Fundamental Nursing Skill and Concept - Barbar

E D I T I O N 1 0
Fundamental Nursing
Skills and Concepts
BARBARA KUHN TIMBY, RN, BC, BSN, MA
Professor Emeritus
Glen Oaks Community College
Centreville, Michigan
LWBK1004-FM_pi-xxii.indd i 2/6/12 8:51 PM

Acquisitions Editor: Elizabeth Nieginski
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Tenth Edition
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Copyright © 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2005, 2001 by Lippincott
Williams & Wilkins. Copyright © 1997 by Lippincott-Raven Publishers. Copyright © 1992, 1988, 1984, 1980, 1976 by J. B.
Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or
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tact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia PA 19103, via email at
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Printed in China
Library of Congress Cataloging-in-Publication Data
Timby, Barbara Kuhn.

Fundamental nursing skills and concepts / Barbara Kuhn Timby. — 10th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60831-787-5 (alk. paper)
I. Title.
[DNLM: 1. Nursing Care. WY 100.1]
610.73—dc23
2011048255
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.
However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from appli-
cation of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness,
or accuracy of the contents of the publication. Application of this information in a particular situation remains the profes-
sional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute
and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing
research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA
f status o
each drug or device planned for use in his or her clinical practice.
LWW.COM
LWBK1004-FM_pi-xxii.indd ii 2/6/12 8:51 PM

his edition of Fundamental Nursing Skills and Concepts is dedicated to all
T student nurses who will join the ranks of practicing nurses to meet the nation’s
health care needs during this time of the nursing shortage.
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LWBK1004-FM_pi-xxii.indd iv 2/6/12 8:51 PM
Contributor & Reviewers
Contributor Tammy McKinney , MSN, FNP-C, RNC

Associate Professor of Nursing
Susan G. Dudek, RN, CDN, BS Danville Community College
Nursing Instructor, Dietetic Technology Program Danville, Virginia
Erie Community College
Williamsville, New York Peggy Penn
San Jacinto College – Central Campus
Pasadena, Texas
Reviewers
Rebecca Romagna
, RN, MSN
Michelle Bennet, RN Practical Nursing Instructor
Nursing Instructor Greater Altoona Career & Technology Center
Nunez Community College Altoona, Pennsylvania
Chalmette, Louisiana
Deborah Shaw, RN, BSN
Pat Clowers, MSN Instructor, Vocational Nursing
Director of Nursing and Allied Health Schreiner University
East Mississippi Community College Kerrville, Texas
Mayhew, Mississippi
Becky Shuttlesworth, RN, BSN
Elizabeth DeMarsh-Smith, RN, BA Skills Lab Coordinator
Curriculum Chairperson San Jacinto College South
Robert T.White LPN School Houston, Texas
Canton, Ohio
Pattie Sunderhaus, RN, MSN, EdD
Theresa Fontaine Director of Faculty Development
Practical Nursing Instructor Brown Mackie College
Arkansas Tech University – Ozark Campus Cincinnati, Ohio
Ozark, Arkansas
Collene Thaxton, RN, MSN
Marion Goodman, BSN Associate Professor of Nursing
Coordinator of Vocational Nursing Mount Wachusett Community College
Lone Star College – CyFair Gardner, Massachusetts
Cypress, T
exas
Olma Weaver, RN
Cynthia Hotaling , RN, MSN Vocational Nursing Instructor
Associate Professor Coastal Bend College – Beeville
Owens Community College Beeville, Texas
Findlay, Ohio
Muriel Zraunig , RN, MSN
Connie Hyde, RN, BSN Practical Nursing Program Director
Practical Nursing Instructor McCann Technical School
Louisiana Technical Colle
ge – Lafayette Campus North Adams,Massachusetts
Lafayette, Louisiana
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LWBK1004-FM_pi-xxii.indd vi 2/6/12 8:51 PM
Preface
Fundamental Nursing Skills and Concepts is designed to throughout the text have been updated according to the latest
assist beginning nursing students in acquiring a foundationNANDA-I publication, Nursing Diagnoses 2012–2014.
of basic nursing theory and developing clinical skills. In • New Content. The entire text has been revised and updated
addition, its content can serve as a ready reference forto refl ect current medical and nursing practice. Additionally,
updating the skills of currently employed nurses or those several skills and sections contain brand new content. The
returning to work after a period of inactive practice. following are some highlights:
• Chapter 1, “Nursing Foundations,” reflects changes to
Nursing: A Social Policy Statement, 3rd edition (2010), in
PHILOSOPHICAL FOUNDATIONS which the American Nurses Association (ANA) provides
OF THE TEXT a current definition of nursing. This chapter introduces the
term evidence-based practice and relates its signicance
fi
Several philosophical concepts are the bases for this text: to current nursing practice. Based on data provided by
the US Bureau of Labor Statistics, this chapter reinforces
• The human experience is a composite of physiologic, emo-
the projected increase in the demand for licensed practical
tional, social, and spiritual aspects that affect health and
nurses in a variety of healthcare settings. Because LPNs,
healing.
as well as RNs, work with unlicensed assistive personnel
• Caring is the essence of nursing and is extended to every
(UAPs), Chapter 1 expands the criteria for appropriate
client.
delegation. Updated statistics on enrollments and numbers
• Each client is unique, and nurses must adapt their care to
of licensed nurses in various nursing programs demon-
meet the individual needs of every person without compro-
strate a continuing shortage of nurses as well as trends
mising safety or achievement of desired outcomes.
toward a demand for higher levels of nursing education,
• A supportive network of health care providers, family, and
specialty certifi cations, and continuing education. The
friends promotes health restoration and health promotion.
content reiterates the crises in health care and how efforts
Therefore, it is essential to include the client’s signi
cant fi
to extend the Nurse Reinvestment Act or create similar
others in teaching, formal discussions, and provision of
federal legislation would somewhat help relieve the short-
services.
age of nurses in the United States.
• Licensed and student nurses are accountable for their
• Chapter 4, “Health and Illness,” includes information on
actions and clinical decisions; consequently, each must be
Healthy People 2020, the newest goals of the national
aware of legislation as it affects nursing practice.
health-promotion effort, which include achieving health
In today’s changing health care environment, nurses face equity among the nation’s citizens. The chapter also
many challenges and opportunities. The tenth edition of includes a discussion of recent Medicare changes.
Fundamental Nursing Skills and Concepts was written to • Chapter 6, “Culture and Ethnicity,” updates the demo-
help nurses meet these challenges and take advantage ofgraphic information on the various ethnic groups that make
expanding opportunities. up the population of the United States, based on the 2010
census data, and discusses the effects these changes might
have on nursing. The chapter also discusses technological
NEW TO THIS EDITION advances for communicating with deaf clients, clients who
do not speak English, or those who speak English as a
• Integration of Gerontologic, Pharmacologic, and Nu- second language.
tritional Considerations. Information that focuses on • Chapter 7, “The Nurse–Client Relationship,” expands its
gerontologic, pharmacologic, and nutritional considerations discussion of special techniques to be used in communi-
is integrated within the text of each chapter where they are cating with deaf clients and with those who are verbally
more applicable to the immediate content rather than appear- impaired or have Alzheimer’s disease.
ing at the end of each chapter. Their location is identi
ed by
fi • Chapter 8, “Client Teaching,” includes new coverage of
unique, recurring icons. the benefits of client teaching, to the client as well as the
• Brand-new NANDA diagnoses and terminology. The nurse, and insights into the concept of “health literacy.”
NANDA diagnoses labels and definitions found in the • Chapter 9, “Recording and Reporting,” updates the crite-
Nursing Implications and accompanying Nursing Care Plans ria of the Joint Commission, formerly known as the The
vii
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viii Preface
Joint Commission on Accreditation of Healthcare begins with Chapter 10, “Asepsis,” to underscore the impor-
Organizations (JCAHO), for record-keeping. tance of hand hygiene and other aseptic practices when pro-
• Chapter 10, “Asepsis” discusses the latest guidelines onviding nursing care.
hand-washing and alcohol-based hand rubs, the agents used • Words to Know. These key terms are listed at the begin-
to achieve surgical asepsis, and the use of protective gear. ning of each chapter and set in boldface type within the text
• Chapter 12, “Vital Signs,” contains new sections on tem- where they appear with or near their nition. defi Additional
poral artery thermometry, including a new Nursing Guide- technical terms are italicized throughout the text.
lines feature for using the temporal artery thermometer. • Learning Objectives. These student-oriented objectives
• Chapter 13, “Physical Assessment,” discusses the newestappear at the beginning of each chapter to serve as guide-
guidelines for breast self-examination, and the impact lines for acquiring specicfi information. They are now
these guidelines have on client teaching. numbered, so that the corresponding student and intructors
• Chapter 15, “Nutrition,” has been thoroughly updated to resources can be easily matched.
refl ect the recent changes recommended by the American • Nursing Process Focus. The focus on the Nursing Process
Dietary Association, including the new MyPlate nutrition continues to be strong. The concepts and paradigm for the
guidelines that replace “MyPyramid.” nursing process appear in Chapter 2. The premise is that
• Chapter 16, “Fluid and Chemical Balance,” contains new early familiarity with its components will reinforce its use
information about oxygen therapeutics and per uorocar-
fl in the Skills and sample Nursing Care Plans throughout the
bons. text. Each skill chapter has the most recent Applicable
• Chapter 18, “Comfort, Rest, and Sleep,” contains a new Nursing Diagnoses that correlate with the types of prob-
box outlining the components of phototherapy. lems recipients of the respective skills may have.
• Chapter 19, “Safety,” includes a new table outlining the lat-• Nursing Care Plans. The diagnostic statements contain
est National Patient Safety Goals, updated in 2009–2010. three parts for actual diagnoses and two parts for potential
• Chapter 22, “Infection Control,” contains the new advice diagnoses. A double-column format lists interventions on
on “cough etiquette,” including an illustration. The chap- one side and corresponding rationales on the other. The
ter also discusses the new Standard Precautions recom- evaluation step is reinforced by evidence indicating expected
mendations and new safe injection practices and infectionoutcome achievement.
control practices in lumbar puncture. • Skills. The Skills continue to be clustered at the end of each
• Chapter 23, “Body Mechanics, Positioning, and Moving,” chapter for ease of access and to avoid interrupting the nar-
explains the newest policies proposed in Congress to pro-rative and distancing related Tables and Boxes to locations
tect the safety of nurses and clients. where they previously seemed out of context. In addition,
• Chapter 32, “Oral Medications,” includes discussion of each illustration within the skills has been closely reviewed
the new technology of barcode medication administration to ensure that it complies with Standard Precautions, infec-
systems. tion control guidelines from the Centers for Disease Control
• Chapter 37, “Resuscitation,” re ects
fl the American Heart and Prevention.
Association’s (AHA’s) International Cardiopulmonary • Nursing Guidelines. These mini-procedures provide direc-
Resuscitation (CPR) and Emergency Cardiovascular tions for performing various kinds of nursing care or sug-
Care (ECC) Guidelines of 2010 for performing basic life gestions for managing client care problems.
support techniques. • Client and Family Teaching boxes. These specially num-
• Chapter 38, “End-of-Life Care,” includes new discussion bered boxes found throughout chapters highlight essential
of multicultural considerations for the nurse caring for cli- education points for nurses to communicate to clients and
ents and their families and they approach the client’s death.their families.
• Art and Photography Program. Contemporary nursing • Critical Thinking Exercises. More critical thinking ques-
practice is illustrated by the many full-color photos and tions have been added at the end of each chapter to facili-
line drawings. These illustrations assist visual learners to tate application of the material, using clinical situations or
become familiar with the latest equipment, techniques, andrhetorical questions.
practices in today’s health care environment. • NCLEX-PN Style Questions. Additional questions have
been added to help students apply their acquired knowl-
edge by answering questions that reflect the formats within
the 2011 NCLEX-PN Test plan.
FEATURES AND LEARNING TOOLS
• End of Unit Exercises. Found at the end of each unit, these
challenging groups of activities consolidate information
Many of the features that long-time users of Timby love are
found in previous chapters to assist students to review and
found in the tenth edition as well:
master critical material. The problems build from simple to
• Table of Contents. Based on market feedback, Section I in complex, with special sections designed to help readers apply
the tenth edition provides chapters that relate to Fundamentaltheir knowledge and prepare for the NCLEX-PN. Answers
Nursing Concepts. Section II, “Fundamental Nursing Skills,” are provided on the Instructor CD-ROM and on .
LWBK1004-FM_pi-xxii.indd viii 2/6/12 8:51 PM

Preface ix
• Glossary. Found at the back of the book, this is a quick Exercises, and End of Unit Exercises allow students to
reference of definitions for Words to Know that are used check their comprehension of textbook presentations as
throughout the text. desired.
• Bibliography. A comprehensive listing of references and
suggested readings, including general recommendations as
well as unit-specific citations, provides a streamlined guide RESOURCES FOR INSTRUCTORS
to current literature about topics discussed in the text.
• Detailed Table of Contents. Located at the beginning of The above student-oriented materials are available for
the textbook, this provides an outline of each unit’s andinstructors on . Additionally, instructors have
chapter’s subject matter. access to the following tools to assist with teaching:
• An extensive collection of materials is provided for each
book chapter:
USE WITH INTRODUCTORY • Pre-Lecture Quizzes and Answers are quick, knowl-
MEDICAL-SURGICAL NURSING edge-based assessments that allow instructors to check
students’ reading and comprehension.
Fundamental Nursing Skills and Concepts may be adopted• PowerPoint presentations provide an easy way to inte-
as a single text for students in a nursing program. Additionally, grate the textbook with students’ classroom experience,
the book may be adopted with Introductory Medical– either via computerized slide shows or handouts.
Surgical Nursing by Timby and Smith. The content, designs, • Guided Lecture Notes walk instructors through the
features, and styles of these two texts have been coordinatedchapters, objective by objective, and provide correspond-
closely to facilitate understanding and to present a consistent ing PowerPoint slide numbers.
approach to learning. • Discussion Topics (and suggested answers) are orga-
nized by learning objective and can be used as classroom
conversation starters.
TEACHING—LEARNING PACKAGE • Assignments (and suggested answers), also organized
by learning objective, include group, written, clinical,
The tenth edition of Fundamental Nursing Skills and Concepts and web-based activities.
features a compelling and comprehensive complement of addi- • An Image Bank provides the photographs and illustra-
tional resources to help students learn and instructors teach. tions from this textbook to be used as best suits instructor
needs, including in PowerPoint slides.
• A sample syllabus provides guidance for structuring an
RESOURCES FOR STUDENTS LPN/LVN course.
• The Test Generator lets teachers assemble exclusive new
Valuable learning tools for students are available on tests from a bank containing more than 900 questions to
: help assess students’ understanding of the material. These
• Concepts in Action animations and Watch and Learn questions are formatted to match the NCLEX, so students
video clips demonstrate important concepts related to vari- can practice preparing for this important examination.
ous topics explored in the accompanying text.
• NCLEX-style review questions that correspond with each
book chapter help students review important concepts and STUDENT WORKBOOK
practice for the NCLEX.
• A Spanish-English glossary lists words commonly encoun-The Workbook for Fundamental Nursing Skills and
tered or needed in the nurse’s practice. Concepts, 10th edition, is available for purchase and pro-
• Journal Articles about relevant topics enable students to vides an engaging review of important material. Featuring
stay aware of the latest research and information available images from the text, review exercises, application activi-
in the current literature. ties, and more NCLEX-PN practice questions, the
• Case Studies help students apply their learning about nurs- Workbook complements this textbook and provides dynam-
ing concepts and skills to client-oriented scenarios. ic reinforcement of everything students need to learn from
• Answer Keys for the Stop, Think, and Respond boxes,it. Answers to the exercises in the Workbook are available
NCLEX-Style Review Questions, Critical Thinking to instructors through .
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LWBK1004-FM_pi-xxii.indd x 2/6/12 8:51 PM
Acknowledgments
It is my belief that this text and its ancillary package will

facilitate learning and produce safe, effective practitioners,
capable of providing quality care for diverse clients in a
variety of settings. Thanks go to the following people at
Lippincott Williams & Wilkins for their help in preparing
this book and for supporting the revision and new ideas and
organization of the text material:
• Elizabeth Nieginski, Executive Editor
• Annette Ferran, Product Manager
xi
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LWBK1004-FM_pi-xxii.indd xii 2/6/12 8:51 PM
Contents
UNIT 1
Exploring Contemporary Nursing 1

1 Nursing Foundations 2 Unique Nursing Skills 15
Assessment Skills 15
Nursing Origins 2
The Nightingale Reformation 3 Caring Skills 15
The Crimean War 3 Counseling Skills 15
Nightingale’s Contributions 4 Comforting Skills 15
Nursing in the United States 4
US Nursing Schools 4 2 Nursing Process 17
Expanding Horizons of Practice 4 Definition of the Nursing Process 17
Contemporary Nursing 5 Characteristics of the Nursing Process 18
Combining Nursing Art With Science 5 Steps of the Nursing Process 18
Integrating Nursing Theory 6 Assessment 18
Defining Nursing 6 Diagnosis 21
The Educational Ladder 6 Planning 23
Practical/Vocational Nursing 6 Implementation 25
Registered Nursing 9 Evaluation 26
Future Trends 11 Use of the Nursing Process 26
Governmental Responses 11 Concept Mapping 26
Proactive Strategies 11 End of Unit Exercises 29
UNIT 2
Integrating Basic Concepts 33

3 Laws and Ethics 34 Ethics 42
Laws 34 Codes of Ethics 42
Constitutional Law 34 Ethical Dilemmas 42
Statutory Laws 34 Ethical Theories 42
Administrative Laws 35 Ethical Principles 45
Common Law 37 Values and Ethical Decision Making 46
Criminal Laws 37 Ethics Committees 46
Civil Laws 37 Common Ethical Issues 46
Professional Liability 40
Liability Insurance 41 4 Health and Illness 50
Reducing Liability 41 Health 50
Malpractice Litigation 42 Health: A Limited Resource 51
Health: A Right 51
Health: A Personal Responsibility 51
Wellness 51
Holism 51
Hierarchy of Human Needs 51
xiii
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xiv Contents
Illness 52 Stress 64
Morbidity and Mortality 52 Physiologic Stress Response 65
Acute, Chronic, and Terminal Illnesses 52 Psychological Stress Responses 67
Primary and Secondary Illnesses 53 Stress-Related Disorders 67
Remission and Exacerbation 53 Nursing Implications 68
Hereditary, Congenital, and Idiopathic Assessment of Stressors 68
Illnesses 53 Prevention of Stressors 68
Health Care System 53 Stress-Reduction Techniques 69
Primary, Secondary, and Tertiary Care 53 Stress Management Techniques 69
Extended Care 54
Health Care Services 54 6 Culture and Ethnicity 72
Access to Care 54 Concepts Related to Culture 72
Financing Health Care 54 Culture 72
Outcomes of Structured Reimbursement 56 Race 73
National Health Goals 56 Minority 73
Nursing Team 57 Ethnicity 73
Functional Nursing 58 Factors that Impact Perception of Individuals 73
Case Method 58 Stereotyping 73
Team Nursing 58 Generalization 74
Primary Nursing 58 Ethnocentrism 74
Nurse-Managed Care 58 Culture and Subcultures in
Continuity of Health Care 58 the United States 74
Transcultural Nursing 75
5 Homeostasis, Adaptation, Cultural Assessment 75
and Stress 60 Culturally Sensitive Nursing 84
Homeostasis 60
Holism 60 End of Unit Exercises 86
Adaptation 61
UNIT 3
Fostering Communication 93
7 The Nurse–Client Relationship 94 Assessing the Learner 106
Learning Styles 106
Nursing Roles Within the
Nurse–Client Relationship 94 Age and Developmental Level 107
The Nurse as Caregiver 95 Capacity to Learn 108
The Nurse as Educator 95 Motivation 109
The Nurse as Collaborator 95 Learning Readiness 109
The Nurse as Delegator 96 Learning Needs 110
The Therapeutic Nurse–Client Relationship 96 Informal and Formal Teaching 110
Underlying Principles 96
Phases of the Nurse–Client Relationship 96 9 Recording and Reporting 114
Barriers to a Therapeutic Relationship 97 Medical Records 114
Communication 97 Uses 115
Verbal Communication 97 Client Access to Records 117
Nonverbal Communication 100 Types of Client Records 117
Communicating With Special Populations 103 Methods of Charting 117
Narrative Charting 117
8 Client Teaching 105 SOAP Charting 117
Focus Charting 119
Importance of Client Teaching 105
Scope and Consequences of Client Teaching 106 PIE Charting 119
Charting by Exception 119
Computerized Charting 119
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Contents xv
Protecting Health Information 121 Communication for Continuity and

Privacy Standards 121 Collaboration 124
Workplace Applications 121 Written Forms of Communication 124
Data Security 122 Interpersonal Communication 126
Documenting Information 122
Using Abbreviations 122 End of Unit Exercises 131
Indicating Documentation Time 123
UNIT 4
Performing Basic Client Care 139

10 Asepsis 140 12 Vital Signs 187
Microorganisms 140 Body Temperature 188
Types of Microorganisms 141 Temperature Measurement 188
Survival of Microorganisms 142 Normal Body Temperature 188
Chain of Infection 142 Assessment Sites 191
Infectious Agents 142 Thermometers 192
Reservoir 143 Elevated Body Temperature 196
Exit Route 144 Subnormal Body Temperature 198
Means of Transmission 144 Pulse 200
Portal of Entry 144 Pulse Rate 200
Susceptible Host 144 Pulse Rhythm 200
Asepsis 145 Pulse Volume 200
Medical Asepsis 145 Assessment Sites 201
Using Antimicrobial Agents 145 Doppler Ultrasound Device 202
Surgical Asepsis 150 Respiration 202
Nursing Implications 153 Respiratory Rate 202
11 Admission, Discharge, Transfer,

Breathing Patterns and
Abnormal Characteristics 203
and Referrals 168 Blood Pressure 203
The Admission Process 168 Factors Affecting Blood Pressure 204
Medical Authorization 169 Pressure Measurements 204
The Admitting Department 169 Assessment Sites 205
Nursing Admission Activities 169 Equipment for Measuring
Initial Nursing Plan for Care 171 Blood Pressure 205
Medical Admission Responsibilities 171 Measuring Blood Pressure 207
Common Responses to Admission 171 Alternative Assessment Techniques 208
The Discharge Process 174 Abnormal Blood Pressure Measurements 208
Discharge Planning 174 Documenting Vital Signs 209
Obtaining Authorization for Medical Nursing Implications 210
Discharge 175
Providing Discharge Instructions 175 13 Physical Assessment 227
Notifying the Business Office 176 Overview of Physical Assessment 227
Discharging a Client 176 Purposes 227
Writing a Discharge Summary 176 Techniques 228
Terminal Cleaning 177 Equipment 229
The Transfer Process 177 Environment 229
Transfer Activities 177
Extended Care Facilities 178
The Referral Process 180
Considering Referrals 180
Home Health Care 181
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xvi Contents
Performing a Physical Assessment

Gathering General Data 229
229 14 Special Examinations and Tests 249
Examinations and Test 249
Draping and Positioning 230 General Nursing Responsibilities 250
Selecting an Approach for Common Diagnostic Examinations 254
Data Collection 231 Diagnostic Laboratory Tests 259
Examining the Client 231 Nursing Implications 263
Data Collection 231
Head and Neck 231 End of Unit Exercises 273
Chest and Spine 236
Extremities 241
Abdomen 242
Genitalia 244
Anus and Rectum 245
Nursing Implications 245
UNIT 5
Assisting With Basic Needs 283

15 Nutrition 284 Common Fluid Imbalances 311
Overview of Nutrition 285 Hypovolemia 311
Human Nutritional Needs 285 Hypervolemia 312
Nutritional Strategies 289 Third-Spacing 313
Nutritional Patterns and Practice 291 Intravenous Fluid Administration 314
Influences on Eating Habits 291 Types of Solutions 314
Vegetarianism 291 Infusion Techniques 318
Nutritional Status Assessment 291 Venipuncture 318
Subjective Data 292 Infusion Monitoring and Maintenance 319
Objective Data 292 Discontinuation of an Intravenous Infusion 322
Management of Problems Interfering With Insertion of an Intermittent Venous
Nutrition 295 Access Device 322
Obesity 295 Blood Administration 323
Emaciation 296 Blood Collection and Storage 323
Anorexia 296 Blood Safety 323
Nausea 297 Blood Compatibility 323
Vomiting 297 Blood Transfusion 323
Stomach Gas 297 Parenteral Nutrition 325
Management of Client Nutrition 298 Peripheral Parenteral Nutrition 325
Common Hospital Diets 298 Total Parenteral Nutrition 325
Meal Trays 299 Lipid Emulsions 325
Feeding Assistance 299 Nursing Implications 326
16 Fluid and Chemical Balance 305 17 Hygiene 345
Body Fluid 305 The Integumentary System 345
Water 305 Skin 346
Fluid Compartments 306 Mucous Membranes 346
Electrolytes 306 Hair 347
Blood 307 Nails 347
Fluid and Electrolyte Distribution Teeth 347
Mechanisms 307 Hygiene Practices 347
Fluid Regulation 308 Bathing 348
Fluid Volume Assessment 308 Shaving 350
Fluid Intake 309 Oral Hygiene 352
Fluid Output 311 Hair Care 354
Nail Care 355
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Contents xvii
Visual and Hearing Devices 355 Pain Assessment Standards 421

Eyeglasses 355 Pain Assessment Data 422
Contact Lenses 355 Pain Intensity Assessment Tools 422
Artificial Eyes 357 Pain Management 423
Hearing Aids 357 Treatment Biases 423
Infrared Listening Devices 359 Pain Management Techniques 423
Nursing Implications 359 Drug Therapy 423
18 Comfort, Rest, and Sleep 374
Surgical Approaches 427
Nondrug and Nonsurgical Interventions 427
Client Environment 374 Nursing Implications 430
Client Rooms 374 Addiction 430
Room Furnishings 375 Placebos 430
Sleep and Rest 377
Functions of Sleep 377 21 Oxygenation 438
Sleep Phases 378 Anatomy and Physiology of Breathing 438
Sleep Cycles 378 Assessing Oxygenation 440
Sleep Requirements 378 Physical Assessment 440
Factors Affecting Sleep 379 Arterial Blood Gases 440
Sleep Assessment 382 Pulse Oximetry 440
Questionnaires 382 Promoting Oxygenation 442
Sleep Diary 382 Positioning 442
Nocturnal Polysomnography 382 Breathing Techniques 442
Multiple Sleep Latency Test 383 Oxygen Therapy 444
Sleep Disorders 383 Oxygen Sources 444
Insomnia 383 Equipment Used in Oxygen Administration 445
Hypersomnia 383 Common Delivery Devices 447
Sleep–Wake Cycle Disturbances 384 Additional Delivery Devices 452
Parasomnia 385 Oxygen Hazards 453
Nursing Implications 385 Related Oxygenation Techniques 453
Progressive Relaxation 387 Water-Seal Chest Tube Drainage 453
Back Massage 387 Hyperbaric Oxygen Therapy 454
19 Safety 399
Age-Related Safety Factors 400 22 Infection Control 467

Infants and Toddlers 400 Infection 467
School-Aged Children and Adolescents 400 Infection Control Precautions 468
Adults 400 Standard Precautions 469
Environmental Hazards 400 New Standard Precaution
Latex Sensitization 401 Recommendations 469
Burns 402 Transmission-Based Precautions 471
Asphyxiation 404 Infection Control Measures 473
Electrical Shock 405 Client Environment 473
Falls 406 Personal Protective Equipment 474
Restraints 408 Discarding Biodegradable Trash 476
Legislation 409 Removing Reusable Items 476
Accreditation Standards 409 Delivering Laboratory Specimens 476
Restraint Alternatives 410 Transporting Clients 476
Use of Restraints 410 Pyschological Implications 477
Nursing Implications 411 Promoting Social Interaction 477
20 Pain Management 417

Combating Sensory Deprivation 477
Pain 417
The Process of Pain 418 End of Unit Exercises 483
Pain Theories 419
Types of Pain 419
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xviii Contents
UNIT 6
Assisting the Inactive Client 493

23 Body Mechanics, Positioning, 25 Mechanical Immobilization 537
and Moving 494 Purposes of Mechanical Immobilization 537
Maintaining Good Posture 495 Mechanical Immobilizing Devices 538
Standing 495 Splints 538
Sitting 496 Slings 540
Lying Down 496 Braces 541
Body Mechanics 496 Casts 541
Ergonomics 497 Traction 543
Positioning Clients 498 External Fixators 544
Common Positions 498 Nursing Implications 546
Positioning Devices 500
Turning and Moving Clients 501
26 Ambulatory Aids 560
Preparing for Ambulation 561
Protective Devices 503
Isometric Exercises 561
Side Rails 503
Upper Arm Strengthening 561
Mattress Overlays 503
Dangling 561
Cradle 504
Using a Tilt Table 561
Specialty Beds 504
Assistive Devices 562
Transferring Clients 506
Ambulatory Aids 563
Transfer Handle 506
Canes 563
Transfer Belt 506
Walkers 565
Transfer Boards 506
Crutches 565
Crutch-Walking Gaits 566
24 Therapeutic Exercise 519 Prosthetic Limbs 566
Temporary Prosthetic Limb 566
Fitness Assessment 519
Body Composition 519 Permanent Prosthetic Components 566
Vital Signs 520 Client Care 568
Fitness Tests 520 Ambulation With a Lower Limb Prosthesis 568
Walk-a-Mile Test 521 Nursing Implications 568
Exercise Prescriptions 521
Target Heart Rate 521
End of Unit Exercises 580
Metabolic Energy Equivalent 522
Types of Exercise 522
Fitness Exercise 522
Therapeutic Exercise 523
UNIT 7
The Surgical Client 587

27 Perioperative Care 588 Intraoperative Period 598
Receiving Room 598
Preoperative Period 589
Inpatient Surgery 589 Operating Room 598
Outpatient Surgery 589 Surgical Waiting Area 599
Informed Consent 590 Postoperative Period 599
Preoperative Blood Donation 591 Immediate Postoperative Care 599
Immediate Preoperative Care 592 Continuing Postoperative Care 600
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Contents xix
28 Wound Care 610 Nasogastric Tube Management 639

Insertion 639
Wounds 610
Wound Repair 611 Use and Maintenance 640
Inflammation 611 Removal 642
Proliferation 611 Nasointestinal Tube Management 642
Remodeling 612 Insertion 642
Wound Healing 612 Checking Tube Placement 643
Wound-Healing Complications 613 Transabdominal Tube Management 643
Wound Management 614 Tube Feedings 643
Dressings 614 Benefits and Risks 643
Drains 615 Formula Considerations 644
Sutures and Staples 616 Tube-Feeding Schedules 645
Bandages and Binders 616 Client Assessment 646
Debridement 617 Nursing Management 647
Heat and Cold Applications 620 Intestinal Decompression 649
Pressure Ulcers 622 Tube Insertion 649
Stages of Pressure Ulcers 622 Removal 649
Prevention of Pressure Ulcers 624 Nursing Implications 650
29 Gastrointestinal Intubation 635
Intubation 635
Types of Tubes 636
Orogastric Tubes 636
Nasogastric Tubes 636
Nasointestinal Tubes 637
Transabdominal Tubes 638
UNIT 8
Promoting Elimination 673

30 Urinary Elimination 674 Catheterization 680
Overview of Urinary Elimination 674 Types of Catheters 680
Characteristics of Urine 675 Inserting a Catheter 682
Factors Affecting Urinary Elimination 675 Connecting a Closed Drainage System 682
Urine Specimen Collection 675 Providing Catheter Care 683
Abnormal Urine Characteristics 676 Catheter Irrigation 684
Abnormal Urinary Elimination Patterns 676 Indwelling Catheter Removal 684
Anuria 677 Urinary Diversions 685
Oliguria 677 Nursing Implications 685
Polyuria 677
Nocturia 677 31 Bowel Elimination 705
Dysuria 677 Defecation 705
Incontinence 677 Assessment of Bowel Elimination 706
Assisting Clients With Elimination Patterns 706
Urinary Elimination 678 Stool Characteristics 706
Commode 678
Urinal 678
Using a Bedpan 678
Managing Incontinence 678
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xx Contents
Common Alterations in Bowel Elimination 707 Ostomy Care 712

Constipation 707 Providing Peristomal Care 712
Fecal Impaction 708 Applying an Ostomy Appliance 713
Flatulence 708 Draining a Continent Ileostomy 713
Diarrhea 708 Irrigating a Colostomy 713
Fecal Incontinence 709 Nursing Implications 714
Measures to Promote
Bowel Elimination 709 End of Unit Exercises 729
Inserting a Rectal Suppository 710
Administering an Enema 710
UNIT 9
Medication Administration 735

32 Oral Medications 736 34 Parenteral Medications 762
Medication Orders 736 Parenteral Administration Equipment 762
Components of a Medication Order 737 Syringes 763
Verbal and Telephone Orders 738 Needles 763
Documentation in the Medication Modified Safety Injection Equipment 763
Administration Record 739 Drug Preparation 764
Methods of Supplying Medications 739 Ampules 764
Storing Medications 739 Vials 764
Accounting for Narcotics 739 Prefilled Cartridges 765
Medication Administration 739 Combining Medications in One Syringe 765
Applying the Five Rights 740 Injection Routes 766
Calculating Dosages 741 Intradermal Injections 766
Administering Oral Medications 741 Subcutaneous Injections 767
Administering Oral Medications by Intramuscular Injections 770
Enteral Tube 743 Reducing Injection Discomfort 774
Documentation 743 Nursing Implications 774
Medication Errors 744
Nursing Implications 744 35 Intravenous Medications 783
Intravenous Medication Administration 784
33 Topical and Inhalant Medications 751 Continuous Administration 784
Intermittent Administration 784
Topical Route 751
Cutaneous Applications 751 Central Venous Catheters 787
Ophthalmic Applications 753 Nontunneled Percutaneous Catheters 788
Otic Applications 754 Tunneled Catheters 788
Nasal Applications 755 Implanted Catheters 789
Sublingual and Buccal Applications 755 Medication Administration Using a Central
Vaginal Applications 755 Venous Catheter 789
Rectal Applications 755 Nursing Implications 790
Inhalant Route 755
Nursing Implications 757 End of Unit Exercises 801
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Contents xxi
UNIT 10
Intervening in Emergency Situations 809

36 Airway Management 810 Chain of Survival 827
Early Recognition and Access of Emergency
The Airway 811
Natural Airway Management 811 Services 828
Liquefying Secretions 811 Early Cardiopulmonary Resuscitation 828
Mobilizing Secretions 812 Early Defibrillation 830
Suctioning Secretions 813 Early Advanced Life Support 832
Artificial Airway Management 814 Recovery 832
Oral Airway 814 Discontinuing Resuscitation 832
Tracheostomy 814 Nursing Implications 832
37 Resuscitation 825
Airway Obstruction 825
Identifying Signs of Airway Obstruction 826
Relieving an Obstruction 826
U N I T 11
Caring for the Terminally Ill 841

38 End-of-Life Care 842 Grieving 851
Terminal Illness and Care 842 Pathologic Grief 851
Stages of Dying 843 Resolution of Grief 851
Promoting Acceptance 843 Nursing Implications 851
Providing Terminal Care 846
Family Involvement 847 End of Unit Exercises 856
Approaching Death 847
Confirming Death 849
Performing Postmortem Care 851
References and Suggested Readings 861
APPENDIX A
Chapter Summaries 875

APPENDIX B
Commonly Used Abbreviations and Acronyms 887
Glossary of Key Terms 889
Index 905
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LWBK1004-FM_pi-xxii.indd xxii 2/6/12 8:51 PM
UNIT 1
Exploring Contemporary Nursing
1 Nursing Foundations 2
2 Nursing Process 17
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1 Nursing Foundations
Wo r d s To K n o w Learning Objectives
active listening
On completion of this chapter, the reader should be able to:
activities of daily living
advanced practice 1. Name one historical event that led to the demise of nursing in
art England before the time of Florence Nightingale.
assessment skills 2. Identify four reforms for which Florence Nightingale is
capitation responsible.
caring skills 3. Describe at least five ways in which early US training schools
clinical pathways deviated from those established under the direction of
comforting skills Florence Nightingale.
counseling skills 4. Name three ways that nurses used their skills in the early
cross-trained history of US nursing.
discharge planning 5. Explain how art, science, and nursing theory have been
empathy incorporated into contemporary nursing practice.
evidence-based practice 6. Discuss the evolution of definitions of nursing.
managed care practices 7. List four types of educational programs that prepare students
multicultural diversity for beginning levels of nursing practice.
nursing skills 8. Identify at least five factors that influence choice of
nursing theory educational nursing program.
primary care 9. State three reasons that support the need for continuing
quality assurance education in nursing.
science 10. List examples of current trends affecting nursing and health
sympathy care.
theory 11. Discuss the shortage of nurses and methods to reduce the
crisis.
12. Describe four skills that all nurses use in clinical practice.
T
his chapter traces the historical development of nursing from its
unorganized beginning to current sophisticated practice. Nurses
in the 21st century owe a debt of gratitude to their pioneering
counterparts who served clients on battlefields, in urban settlement
houses, in Boston’s harbor on a floating “children’s hospital,” and on
horseback in the Appalachian frontier. Ironically, nursing is returning
to its original community-based practice model.
NURSING ORIGINS
Nursing is one of the youngest professions but one of the oldest arts.
It evolved from the familial roles of nurturing and caretaking. Early
responsibilities included assisting women during childbirth, suckling
healthy newborns, and ministering to the ill, aged, and helpless within
households and surrounding communities. Its hallmark was caring
more than curing.
During the Middle Ages in Europe, religious groups assumed
many of the roles of nursing. Christian nuns, priests, and brothers
2
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CHAPTER 1 Nursing Foundations 3
B OX 1- 1 Rules of Employment for Nursing

Attendants—1789
• No dirt, rags, or bones may be thrown from the windows.
• Nurses are to punctually shift the bed and body linen of
patients, viz., once in a fortnight (2 weeks), their shirts once
in 4 days, their drawers and stockings once a week or oftener,
if found necessary.
• All nurses who disobey orders, get drunk, neglect
their patients, quarrel with men shall be immediately
discharged.
From Goodnow, M. (1933). Outlines of nursing history

(5th ed., pp. 57–58).
Philadelphia, PA: W.B. Saunders.
combined their efforts to save souls with a commitment to

care for the sick. Despite their zeal, they were overworked
and overwhelmed because of their limited numbers, espe-
cially during periods when plagues and pestilence spread
quickly in communities. Consequently, some convents and FIGURE 1-1 Florence Nightingale (center), her brother-in-law,
Sir Harry Verney, and Miss Crossland, the nurse in charge of
monasteries engaged conscientious penitent and disadvan-
the Nightingale Training School at St. Thomas Hospital, with a
taged lay people to assist with the burden of physical care. class of student nurses. (Courtesy of The Florence Nightingale
In England, the character and quality of nursing care Museum Trust, London, England.)
changed dramatically when religious groups were exiled
to Western Europe during the schism between King Henry
VIII and the Catholic Church. The management of parochial war correspondents at the front lines made public the dire
hospitals and the ill within them fell to the state. Hospitals circumstances of the soldiers. Reports of high death rates
became poorhouses, which some characterized more accu- and complications among the war casualties caused out-
rately as “pest houses.” The English state recruited the hos- rage among the British people. As a result, the government
pital labor force from the ranks of criminals, widows, and became the object of national criticism.
orphans, who repaid the Crown for their meager food and It was then that Florence Nightingale offered a stra-
shelter by tending to the unfortunate sick. An example of the tegic plan to Sidney Herbert, Britain’s Secretary of War
menial requirements for employment appears in Box 1-1. and an old family friend. She proposed that the sick and
Generally, nursing attendants were ignorant, uncouth, and injured British soldiers at Scutari, a military barracks in
apathetic to the needs of their charges. Without supervision, Turkey, would fare better if a team of women trained in
they rarely performed even minimal duties. Infections, pres- nursing skills could care for them (Fig. 1-1). With Herbert’s
sure sores, and malnutrition were a testimony to their neglect. approval, Nightingale selected women with reputations
beyond reproach. She realized intuitively that only people
with devotion and idealism could accept the discipline and
THE NIGHTINGALE REFORMATION hard work necessary for the looming task.
To the British medical staff at Scutari, the arrival of this
In the midst of deplorable health care conditions, Florence group of women implied that they were incapable of provid-
Nightingale, an Englishwoman born of wealthy parents, ing adequate care. Jealousy and rivalry caused them to refuse
announced that God had called her to become a nurse. any help from Nightingale and her 38 volunteers. When it
Despite her family’s protests, she worked with nursing dea- became clear that the daily death rate, which averaged about
conesses, a Protestant order of women who cared for the 60%, was not subsiding, the medical staff allowed Night-
sick in Kaiserswerth, Germany. After becoming suitably ingale’s nurses to work. Under Nightingale’s supervision,
prepared through her nursing apprenticeship, Nightingale the women cleaned the filth, eliminated the vermin, and
embarked on the next phase of her career. improved ventilation, nutrition, and sanitation. They helped
control infection and gangrene and lowered the death rate
The Crimean War to 1%.
While Nightingale was providing nursing care for resi- Servicemen and their families alike were grateful, and
dents at the Institution for the Care of Sick Gentlewomen England adored Nightingale. To show their appreciation,
in Distressed Circumstances, England found itself allied many donated funds to sustain her great work. Nightingale
with Turkey, France, and Sardinia in defending the Cri- used this money to start the first training school for nurses
mea, a peninsula on the north shore of the Black Sea at St. Thomas Hospital in England. This school became the
(1854 to 1856). The British military suffered terribly, and model for others in Europe and the United States.
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4 UNIT 1 Exploring Contemporary Nursing
Nightingale’s Contributions Applicants also had to submit two letters of recommen-

Nightingale changed the negative image of nursing to a dation attesting to their moral character, integrity, and capac-
positive one. She is credited with the following: ity to care for the sick. Once selected, a volunteer nurse was
to dress plainly in brown, gray, or black and had to agree to
• Training women for future work serve for at least 6 months (Donahue, 1985).
• Selecting only those with upstanding characters as potential
nurses US Nursing Schools
• Improving sanitary conditions for the sick and injured After the Civil War, US training schools for nurses began
• Significantly reducing the death rate of British soldiers to be established. Unfortunately, however, the standards of
• Providing classroom education and clinical teaching these schools deviated substantially from those of the Night-
• Advocating that nursing education should be lifelong ingale paradigm (Table 1-1). While planned and consistent
formal education was the priority in Nightingale’s schools,
➧ Stop, Think, and Respond Box 1-1 the training of US nurses was like an unsubsidized appren-
How did Florence Nightingale convince the English ticeship. Eventually, the curricula and content of US train-
and others that formal education of people who cared ing schools became more organized and uniform. Training
for the sick and injured was essential? periods lengthened from 6 months to 3 full years. Graduate
nurses received a diploma attesting to their successful com-
pletion of training.
NURSING IN THE UNITED STATES
Expanding Horizons of Practice
The American Civil War occurred around the same time as
Diplomas in hand, US nurses began the 20th century by dis-
the Nightingale reformation. Like England, the United States
tinguishing themselves in caring for the sick and disad-
found itself involved in a war with a lack of an organized trained
vantaged outside of hospitals (Fig. 1-2). Some nurses moved
nursing staff to care for the sick and wounded. The military
into communities and established “settlement houses” where
had to rely on untrained corpsmen and civilian volunteers,
they lived and worked among poor immigrants. Others pro-
who were often the mothers, wives, and sisters of soldiers.
vided midwifery services, especially in rural Appalachia.
The Union government appointed Dorothea Lynde Dix,
The success of their public health efforts in administering
a social worker who had proved her worth by reforming
prenatal and obstetric care, teaching child care, and immu-
health conditions for the mentally ill, to select and organ-
nizing children is well documented.
ize women volunteers to care for the troops. In 1862, Dix
Like previous counterparts, nurses continued to volun-
followed Nightingale’s advice and established the following
teer during wars. They offered their services to fight yellow
selection criteria. Applicants were to be
fever, typhoid, malaria, and dysentery during the Spanish-
• Thirty-five to fifty years old American War. They replenished the nursing staff in mili-
• Matronly and plain-looking tary hospitals during World Wars I and II (Fig. 1-3). They
• Educated worked alongside physicians in Mobile Army Surgical Hos-
• Neat, orderly, sober, and industrious, with a serious pitals (MASH) during the Korean War, acquiring knowledge
disposition about trauma care that later would help reduce the mortality
TABLE 1-1 Differences in Nightingale Schools and US Training Schools

NIGHTINGALE SCHOOLS US TRAINING SCHOOLS
• Training schools were affiliated with a few select hospitals. • Any hospital, rural or urban, could establish a training school.
• Training hospitals relied on employees to provide client care. • Students staffed the hospital.
• Education costs were borne by students or endowed from the • Students worked without pay in return for training, which usually
Nightingale Trust Fund. consisted of chores.
• Training of nurses provided no financial advantages to the • Hospitals profited by eliminating the need to pay employees.
hospital. • No formal classes were held; training was an outcome of work.
• Class schedules were planned separately from practical • Curricular content was unplanned and varied according to
experiences. current cases.
• Curricular content was uniform. • Instruction was usually informal, at the bedside, and from a
• A previously trained nurse provided formal instruction, focusing physician’s perspective.
on nursing care. • Students were expected to work 12 hours a day and to live in or
• The number of clinical hours during training was restricted. adjacent to the hospital in case they were needed unexpectedly.
• At the end of training, graduates became paid employees or • At the end of training, students were discharged and new
were hired to train others. students took their places. Most graduates sought private-duty
positions.
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FIGURE 1-2 Community health nurses circa late 1800s to early 1900s. (Courtesy of Visiting
Nurse Association, Inc., Detroit, MI.)
rate of US soldiers in Vietnam. More recently, nurses again

answered the call during the conflicts in Iraq and Afghani-
stan. Whenever and wherever there has been a need, nurses
have put their own lives on the line.
CONTEMPORARY NURSING
Combining Nursing Art With Science

At first, the training of nurses consisted of learning the art
(ability to perform an act skillfully) of nursing. Students
learned this art by watching and imitating the techniques
performed by other, more experienced nurses. In this way,
mentors informally passed skills on to students.
Contemporary nursing practice has added another
dimension: science. The English word “science” comes
from the Latin word scio, which means, “to know.” A science
(body of knowledge unique to a particular subject) develops
from observing and studying the relationship of one phe- FIGURE 1-3 A military nurse comforts a soldier during World
nomenon to another. By developing an accumulating body War II. (Courtesy of the National Archives, Washington, DC.)
LWBK1004-C01_p01-16.indd 5 26/01/12 2:56 AM

of unique scientific knowledge, it is now possible to pre- In Nursing’s Social Policy Statement, 3rd edition (2010),
dict which nursing interventions are most likely to produce the American Nurses Association (ANA) defines nursing
desired outcomes, a process referred to as evidence-based as follows:
practice.
• Protection, promotion, and optimization of health and
abilities
Integrating Nursing Theory
• Prevention of illness and injury
The word theory (opinion, belief, or view) comes from a
• Alleviation of suffering through the diagnosis and treatment
Greek word that means vision. For example, a scientist may
of human response
study the relation between sunlight and plants and derive a
• Advocacy in the care of individuals, families, communities,
theory of photosynthesis that explains how plants grow. Oth-
and populations
ers who believe in the theorist’s view may then apply the
theory for their own practical use. The ANA (2010) further attests that six essential fea-
Nursing has undergone a similar scientific review. Flor- tures characterize nursing: (1) provision of a caring rela-
ence Nightingale and others have examined the relationships tionship that facilitates health and healing, (2) attention to
among humans, health, the environment, and nursing. The the range of human experiences and responses to health
outcome of such analysis becomes the basis for nursing and illness within the physical and social environments,
theory (proposed ideas about what is involved in the proc- (3) integration of objective data with knowledge gained
ess called nursing). Nursing programs then adopt a theory from an appreciation of the client’s or group’s subjective
to serve as the conceptual framework or model for their phi- experience, (4) application of scientific knowledge to the
losophy, curriculum, and most importantly, approach to cli- processes of diagnosis and treatment through the use of
ents. Similarly, psychologists have adopted and used Freud’s judgment and critical thinking, (5) advancement of pro-
psychoanalytic theory or Skinner’s behavioral theory, for fessional nursing knowledge through scholarly inquiry,
example, as a model for diagnostic and therapeutic interven- and (6) influence on social and public policy to promote
tions with clients. social justice.
Table 1-2 summarizes some nursing theories and how Based on statements from the ANA, clearly nursing
each has been applied to nursing practice. These are only has an independent area of practice in addition to tradi-
a few of many; additional information can be found in cur- tional dependent and interdependent functions involving
rent nursing literature and academic courses in nursing physicians. As the role of the nurse evolves, the definition
theory. of nursing and the scope of nursing practice will undergo
further revisions.
Defining Nursing
To clarify for the public, and nurses themselves, what nurs- THE EDUCATIONAL LADDER
ing encompasses, various working definitions have been
proposed. Nightingale is credited with the earliest modern Two basic educational options are available to those inter-
definition: “putting individuals in the best possible condition ested in a nursing career: practical (vocational) nursing and
for nature to restore and preserve health.” registered nursing. Several types of programs prepare gradu-
Other definitions have been offered by nurses who are ates in registered nursing. Each educational track provides
recognized as authorities, and therefore qualified spokesper- the knowledge and skills for a particular entry level of prac-
sons, on the practice of nursing. One such authority was Vir- tice. The following factors influence the choice of a nursing
ginia Henderson (1897 to 1996). Her definition, adopted by program:
the International Council of Nurses, broadened the descrip-
tion of nursing to include health promotion, not just illness • Career goals
care. As stated in 1966: • Geographic location of schools
• Costs involved
The unique function of the nurse is to assist the individual, • Length of programs
sick or well, in the performance of those activities contrib-
• Reputation and success of graduates
uting to health or its recovery (or to a peaceful death) that
he could perform unaided if he had the necessary strength,
• Flexibility in course scheduling
will or knowledge. And to do this in such a way as to help • Opportunity for part-time versus full-time enrollment
him gain independence as rapidly as possible. • Ease of movement into the next level of education
Henderson proposed that nursing is more than carry-

ing out medical orders. It involves a special relationship and Practical/Vocational Nursing
service between the nurse and the client (and his or her fam- During World War II, many registered nurses enlisted in the
ily). According to Henderson, the nurse acts as a temporary military. As a result, civilian hospitals, clinics, schools, and
proxy, meeting the client’s health needs with knowledge and other health care agencies faced an acute shortage of trained
skills that neither the client nor family members can provide. nurses. To fill the void expeditiously, abbreviated programs
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TABLE 1-2 Nursing Theories and Applications

THEORIST THEORY EXPLANATION
Florence Nightingale Environmental Theory
1820–1910 Man An individual whose natural defenses are influenced by a healthy or unhealthy
environment
Health A state in which the environment is optimal for the natural body processes to achieve
reparative outcomes
Environment All the external conditions capable of preventing, suppressing, or contributing to
disease or death
Nursing Putting the client in the best condition for nature to act
Synopsis of theory External conditions such as ventilation, light, odor, and cleanliness can prevent,
suppress, or contribute to disease or death
Application to nursing Nurses modify unhealthy aspects of the environment to put the client in the best
practice condition for nature to act
Virginia Henderson Basic Needs Theory
1897–1996 Man An individual with human needs that have unique meaning and value
Health The ability to independently satisfy human needs composed of 14 basic physical,
psychological, and social elements
Environment The setting in which a person learns unique patterns for living
Nursing Temporarily assisting a person who lacks the necessary strength, will, and knowledge
to satisfy one or more of 14 basic needs
Synopsis of theory People have basic needs that are components of health. The significance and value of
these needs are unique to each person
Application to nursing Nurses assist in performing those activities that the client would perform if he or she
practice had the strength, will, and knowledge
Dorothea Orem Self-Care Theory
1914–2007 Man An individual who uses self-care to sustain life and health, to recover from disease or
injury, or to cope with its effects
Health The result of practices that people have learned to carry out on their own behalf to
maintain life and well-being
Environment External elements with which people interact in the struggle to maintain self-care
Nursing A human service that assists people to progressively maximize their self-care
potential
Synopsis of theory People learn behaviors that they perform on their own behalf to maintain life, health,
and well-being
Application to nursing Nurses assist clients with self-care to improve or to maintain health
practice
Sister Callista Roy Adaptation Theory
1939– Man A social, mental, spiritual, and physical being affected by stimuli in the internal and
external environments
Health A person’s ability to adapt to changes in the environment
Environment Internal and external forces in a continuous state of change
Nursing A humanitarian art and expanding science that manipulates and modifies stimuli to
promote and to facilitate humans’ ability to adapt
Synopsis of theory Humans are biopsychosocial beings; a change in one component results in adaptive
changes in the others
Application to nursing Nurses assess biologic, psychological, and social factors interfering with health; alter
practice the stimuli causing the maladaptation; and evaluate the effectiveness of the action
taken
in practical nursing were developed across the country to organized to form the National Association for Practical
teach essential nursing skills. The goal was to prepare grad- Nurse Education and Service, Inc. This group worked to
uates to care for the health needs of infants, children, and standardize practical nurse education and to facilitate the
adults who were mildly or chronically ill or convalescing so licensure of graduates. By 1945, eight states had approved
that registered nurses who remained stateside could be used practical nurse programs (Mitchell & Grippando, 1993); the
effectively to care for acutely ill clients. current number has grown to 1,500 state-approved schools
After the war, many registered nurses opted for part-time (Bureau of Labor Statistics, 2007). Career centers, voca-
employment or resigned to become full-time housewives. tional schools, hospitals, independent agencies, and com-
Thus, the need for practical nurses persisted. It became munity colleges generally offer practical nursing programs
obvious that the role of practical nurses would not be tem- and arrange clinical experiences at local community hospi-
porary. Consequently, leaders in practical nursing programs tals, clinics, and nursing homes. The length of a practical
LWBK1004-C01_p01-16.indd 7 26/01/12 2:56 AM

175,000
159,128
153,347
LPN/LVN
150,000
RN
125,000
LPN/LVN and RN Enrollments
110,703
99,186
100,000
87,079
76,523 76,688
75,000 71,392 70,692
68,759
61,880 63,394
54,969 56,944
49,283
50,000 44,075
37,372 38,297
35,572 34,650
25,000
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
FIGURE 1-4 Trends in licensed practical nurses/licensed vocational nurses (LPN/LVN) and reg-
istered nurses (RN) enrollments, 1999 to 2008. Numbers are based on US candidates taking
the National Council Licensure Examination (NCLEX) for the first time in respective years, as
reported by the National Council of State Boards of Nursing.
nursing program averages from 12 to 18 months, after which or licensed vocational nurses (LVNs) provide nursing care
graduates are qualified to take their licensing examination. to clients with common health needs that have a predictable
Because this nursing preparatory program is the shortest, outcome. Their scope of practice is described in the nurse
many consider it the most economical. practice act in the state in which the nurse is licensed. Each
After a low ebb in 2001, enrollments in practical and state interprets the limits of practice differently. For exam-
vocational schools continued to rise yearly (Fig. 1-4). In ple, in one state, an LPN may monitor and hang intravenous
2008, a total of 63,394 US educated candidates passed the solutions, discontinue the infusion, and dress the site. The
National Council Licensure Examination-Practical Nurse same may not be true in another state. An LPN also may
(NCLEX-PN) on their first attempt (National Council of delegate tasks to UAPs, who may or may not have acquired
State Boards of Nursing, 2009). Job security for licensed state certification. The LPN, therefore, must know the extent
practical nurses (LPNs) is supported by the Bureau of Labor to which nursing assistants can function and the outcomes of
Statistics’ prediction (2007) that job opportunities in practi- their actions (see guidelines for delegation under “Registered
cal nursing will increase to a projected 854,000 by 2016, an Nursing”). Because of the geographic disparities in LPN
increase of 14%. However, hospitals will not be the primary practice, educational programs, and state regulations, the
employers. Licensed practical nurses will most likely secure National Council of State Boards of Nursing is researching
positions in nursing homes, physicians’ offices, home health and pursuing strategies to promote more consistency (Practi-
agencies, outpatient centers, residential care facilities, correc- cal Nurse Scope of Practice White Paper, 2005). Additional
tional institutions, and government agencies (Larson, 2008). information on nursing practice standards for the licensed
Licensed practical nurses are a vital link between the reg- practical/vocational nurse can be obtained from the National
istered nurse and the unlicensed assistive personnel (UAP). Federation of Licensed Practical Nurses Web site.
They work under the supervision of a registered nurse, phy- Opportunities for post-licensure certifications in phar-
sician, or dentist, but their role may be expanded to include macology and long-term care are available through the
supervision of UAPs in circumstances like long-term care National Association for Practical Nurse Education and Serv-
(National Council of State Boards of Nursing, 2005). LPNs ices, Inc. Achieving certification via testing demonstrates
LWBK1004-C01_p01-16.indd 8 26/01/12 2:56 AM

knowledge above minimum standards. To provide career • Right direction (communication): providing sufficient
mobility, many schools of practical nursing have developed information
“articulation agreements” to help graduates enroll in another • Right supervision: being available for assistance
school that offers a path to registered nursing through associ- • Right follow-up: validating that the task was completed,
ate or baccalaureate degrees. obtaining the results, and analyzing if further actions are
necessary (National Council of State Boards of Nursing,
Registered Nursing 2005)
Registered nurses (RNs) work under the direction of a physi-
Students can choose one of the three paths to become
cian or dentist in various health care settings ranging from
an RN: a hospital-based diploma program, a program that
preventive to acute care. They manage or provide direct care
awards an associate degree in nursing, or a baccalaureate
to clients who are stable but may have complex health needs,
nursing program. All three meet the requirements for taking
or who are unstable with unpredictable outcomes. In addi-
the national licensing examination (NCLEX-RN). A person
tion to managing client care, RNs educate clients and the
licensed as an RN may work directly at the bedside or super-
public about various medical conditions and provide emo-
vise others in managing the care of groups of clients.
tional support to clients and their family members (Bureau
Table 1-3 describes how educational programs prepare
of Labor Statistics, 2007). RNs delegate client care to LPNs
graduates to assume separate but coordinated responsibili-
and UAPs when appropriate.
ties. When hiring new graduates, however, many employ-
Regardless of whether it is an RN delegating to an
ers do not differentiate between these educational programs,
LPN or a UAP or an LPN delegating to an UAP, delegation
arguing that “a nurse is a nurse.”
requires adhering to the following six guidelines:
• Right task: matching the client’s needs with the caregiv- Hospital-Based Diploma Programs
er’s skills Diploma programs were the traditional route for nurses
• Right circumstance: ensuring that the situation is appro- through the middle of the 20th century. Their decline became
priate obvious in the 1970s, and the number of diploma programs
• Right person: knowing the unique competencies of the continues to be lowest in relation to other basic nursing edu-
caregiver cational programs (Fig. 1-5). The reasons for their decline
TABLE 1-3 Levels of Responsibilities for the Nursing Processa

PRACTICAL/VOCATIONAL NURSE ASSOCIATE DEGREE NURSE BACCALAUREATE NURSE
Assessing Gathers data by interviewing, Collects data from people with Identifies the information needed
observing, and performing a basic complex health problems with from individuals or groups to
physical examination of people unpredictable outcomes, their provide an appropriate nursing
with common health problems family, medical records, and other database
with predictable outcomes health team members
Diagnosing Contributes to the development of Uses a classification list to write a Conducts clinical testing of approved
nursing diagnoses by reporting nursing diagnostic statement, nursing diagnoses
abnormal assessment data including the problem, its etiology, Proposes new diagnostic categories
and signs and symptoms for consideration and approval
Identifies problems that require
collaboration with the physician
Planning Assists in setting realistic and Sets realistic, measurable goals Develops written standards for
measurable goals Develops a written individualized nursing practice
Suggests nursing actions that can plan of care with specific nursing Plans care for healthy or sick
prevent, reduce, or eliminate orders that reflects the standards individuals or groups in structured
health problems with predictable for nursing practice health care agencies or the
outcomes community
Assists in developing a written plan
of care
Implementing Performs basic nursing care under Identifies priorities Applies nursing theory to the
the direction of a registered nurse Directs others to carry out nursing approaches used for resolving
orders actual and potential health
problems of individuals or groups
Evaluating Shares observations on the Evaluates the outcomes of nursing Conducts research on nursing
progress of the client in reaching care routinely activities that may be improved
established goals Revises the plan of care with further study
Contributes to the revision of the
plan of care
a
Note that each more advanced practitioner can perform the responsibilities of those identified previously.
LWBK1004-C01_p01-16.indd 9 26/01/12 2:56 AM

Baccalaureate Programs
Although collegiate nursing programs were established at
the beginning of the 20th century, until recently they did not
Diploma attract many students. Their popularity has been increasing
Associate degree 4%
53% at a progressive rate, perhaps because of proposals by the
ANA and the National League for Nursing to establish bac-
calaureate education as the entry level into nursing practice.
The deadline for implementation of this goal, once set for
1985, has been postponed for three reasons:
Baccalaureate • The date coincided with a national shortage of nurses.

43% • There was tremendous opposition from nurses without
degrees, who believed that their titles and positions would
be jeopardized.
• Employers feared that paying higher salaries to personnel
with degrees would escalate budgets beyond their financial
FIGURE 1-5 Enrollments in basic RN programs by program
limits.
type, 2008. (From National League for Nursing [2010]. Nursing Consequently, the adoption of a unified entry level into
Data Review Academic Year 2007 to 2008: Baccalaureate,
Associate Degree, and Diploma Programs. Retrieved from
practice remains in limbo.
http://www.nln.org/research/slides/ndr_0708.pdf.) Although this preparatory program is the longest and
most expensive, baccalaureate-prepared nurses have the great-
est flexibility in qualifying for nursing positions, both staff
are twofold. First, there has been a movement to increase and managerial. Nurses with a baccalaureate degree usually
professionalism in nursing by encouraging education in col- are preferred in areas requiring substantial independent deci-
leges and universities. Second, hospitals can no longer finan- sion making, such as public health and home health nursing.
cially subsidize schools of nursing. Currently, many nurses are returning to school to earn
Diploma nurses were, and are, well trained. Because of baccalaureate degrees. Articulation has been difficult for
their vast clinical experience (compared with students from some because of problems transferring credits for courses
other types of programs), they are often characterized as they took during their diploma or associate degree programs.
more self-confident and more easily socialized into the role To increase enrollment, some collegiate programs are offer-
requirements of a graduate nurse. ing nurses an opportunity to obtain credit by passing “chal-
A hospital-based diploma program generally lasts lenge examinations.” In addition, many colleges and univer-
3 years. Many hospital schools of nursing collaborate with sities provide satellite or outreach programs to accommodate
nearby colleges to provide basic science and humanities nurses who cannot go to school full-time or travel long dis-
courses; graduates can transfer these credits if they choose tances. Despite a renewed interest in acquiring a nursing edu-
to pursue associate or baccalaureate degrees later. cation, approximately 99,000 (26%) qualified applicants for
admission were rejected in 2007 to 2008 (National League
Associate Degree Programs for Nursing, 2008; Fig. 1-6). Qualified applicants are being
During World War II, when qualified nurses were being rejected or waitlisted because (1) very few nursing faculty
used for the military effort, hospital-based schools accel- are available to teach required courses, (2) there is a lack of
erated the education of some RN students through the clinical placements, (3) there is a lack of space, and (4) there
Cadet Nurse Corps. After the end of the war, Mildred Mon- is intense competition for selective admissions.
tag, a doctoral nursing student at the time, began to ques-
tion whether it was necessary for students in RN programs Graduate Nursing Programs
to spend 3 years acquiring a basic education. She believed Graduate nursing programs are available at both the master’s
that nursing education could be shortened to 2 years and and the doctoral levels. Master’s-prepared nurses fill roles as
relocated to vocational schools or junior or community col- clinical specialists, nurse practitioners, administrators, and
leges. The graduate from this type of program would acquire educators. Unfortunately, too few are pursuing advanced
an associate degree in nursing, would be referred to as a degrees in sufficient numbers to fill the positions vacated by
technical nurse, and would not be expected to work in a retiring faculty, 75% of whom will be eligible to retire by
management position. 2019 (Health Resources and Services Administration, 2005).
This type of nursing preparation has proved extremely Nurses with doctoral degrees conduct research and advise,
popular and now commands the highest enrollment administer, and instruct nurses pursuing undergraduate and
among all RN programs. Despite the condensed cur- graduate degrees. Although a graduate degree in nursing is
riculum, graduates of associate degree programs have preferred, some nurses pursue advanced education in fields
demonstrated a high level of competence in passing the outside of nursing, such as business, leadership, and educa-
NCLEX-RN. tion, to enhance their nursing career.
LWBK1004-C01_p01-16.indd 10 26/01/12 2:56 AM

Health care officials hope that enrollment in all nursing

programs and continuing education will reduce the current
and projected critical shortage of nurses. However, the future
looks alarming. The nursing shortage is projected to reach a
Accepted deficit of one million nurses by 2020 (Health Resources and
39% Services Administration, 2005). Besides a retirement rate of
Not qualified
35% nurses that exceeds their replacement and the attrition of
aging faculty, which restricts the numbers of student appli-
cants, some factors contributing to the nursing shortage
include the following:
Qualified
not accepted
• Increased aging population requiring health care
26% • Disappointing salaries for nurses with longevity employment
• Job dissatisfaction as a result of stress and the unrelenting
rigor of working in health care
• Heavier workloads and sicker clients
FIGURE 1-6 Disposition of applications to basic RN programs • Publicity about mandatory overtime
by program type, 2007 to 2008. (From National League for • Downsizing nursing staff from dwindling revenues and
Nursing [2010]. Nursing Data Review Academic Year 2007 to managed care policies
2008: Baccalaureate, Associate Degree, and Diploma
Programs. Retrieved from http://www.nln.org/research/slides/
• Negative stereotypes for traditionally female occupations
ndr_0708.pdf.) like nursing
Governmental Responses
Continuing Education The federal government has addressed the shortage of nurses
Continuing education in nursing is any planned learning by approving the American Recovery and Reinvestment Act
experience beyond the basic nursing program. Nightingale in 2009. This legislation authorizes the following:
is credited with having said, “to stand still is to move back-
wards.” The principle that learning is a lifelong process still 1. Loan repayment programs and scholarships for nursing
applies. Box 1-2 lists reasons why nurses, in particular, pur- students
sue continuing education. Many states now require nurses to 2. Funding for public service announcements to encourage
show proof of continuing education to renew their nursing more people to enter nursing
license. 3. Career ladder programs to facilitate advancement to
higher levels of nursing practice
4. Establishment of nurse retention and client safety
FUTURE TRENDS enhancement grants
5. Grants to incorporate gerontology into nursing curricula
Two major issues dominate nursing today. The first concerns 6. Loan repayment programs for nursing students who agree
methods of eliminating the shortage of nurses. The second to teach after graduation (American Association of
involves strategies for responding to a growing aging popu- Colleges of Nursing, 2009)
lation with chronic health problems.
Proactive Strategies
Rather than taking a “wait-and-see” position about the
B OX 1- 2 Rationales for Acquiring Continuing
nursing shortage and the ramifications of the Nurse Rein-
Education
vestment Act, many nurses are proactively responding
• No basic program provides all the knowledge and skills to the trends affecting their role in health care (Box 1-3).
needed for a lifetime career. Nurses are dealing with the unique challenges of the 21st
• Current advances in technology make previous methods of century by:
practice obsolete.
• Assuming responsibility for self-learning demonstrates per- • Switching from part-time to full-time positions.
sonal accountability. • Delaying retirement.
• To ensure the public’s confidence, nurses must demonstrate • Pursuing post-licensure education.
evidence of current competence. • Training for advanced practice roles (nurse practitioner,
• Practicing according to current nursing standards helps to nurse midwifery) to provide cost-effective health care in
ensure that care is legally safe. areas in which numbers of primary care physicians are
• Renewal of state licensure often is contingent on evidence of
inadequate.
continuing education.
LWBK1004-C01_p01-16.indd 11 26/01/12 2:56 AM

B OX 1- 3 Trends in Health Care and Nursing

Health Care Nursing
• The most underserved health care populations include older • Enrollments and numbers of graduates from LPN/LVN and
adults, ethnic minorities, and the poor, who delay seeking early RN educational programs are not keeping pace with projected
treatment because they cannot afford it. shortages.
• The number of uninsured rose from 37 million in 1995 to 41.2 • More licensed nurses are earning master’s and doctoral
million in 2002. This figure now exceeds 50 million in 2009. degrees.
• Medicare and Medicaid benefits are being modified and • There continues to be a shortage of nurses in various health
reduced. care settings because of decreased enrollments, retirement,
• Chronic illness is the major health problem. attrition, and cost-containment measures.
• Disease and injury prevention and health promotion are • Hospital employment is decreasing.
priorities. • Client-to-nurse ratios in employment settings are higher.
• Medicine tends to focus on high technology, which improves • More high-acuity clients are in previously nonacute settings
outcomes for a select few. such as long-term and intermediate health care facilities.
• Hospitals are downsizing and hiring unlicensed personnel to • Job opportunities have expanded to outpatient services, home
perform procedures once in the exclusive domain of licensed health care, hospice programs, and community health, and
nurses for cost containment. mental health agencies.
• There are fewer primary care physicians in rural areas.
• Changes in reimbursement practices have created a shift in
decision making from hospitals, nurses, and physicians to
insurance companies.
• Health care costs continue to increase despite managed
care practices (cost-containment strategies used to plan
and coordinate a client’s care to avoid delays, unnecessary
services, or overuse of expensive resources).
• Capitation (strategy for controlling health care costs by pay-
ing a fixed amount per member) encourages health providers
to limit tests and services to increase profits.
• Hospitals, practitioners, and health insurance companies
are being required to measure, monitor, and manage quality
of care.
• Becoming cross-trained (able to assume non-nursing jobs, • Providing older adults can receive a variety of nursing ser-
depending on the census or levels of client acuity on any vices such as physical assessment during periods of illness,
given day). For example, nurses may be trained to provide teaching, and managing medications, in assisted-living
respiratory treatments and to obtain electrocardiograms, facilities at less cost than care in nursing homes.
duties that non-nursing health care workers previously • Developing and implementing clinical pathways,
performed. standardized multidisciplinary plans for a specific
• Learning more about multicultural diversity (unique diagnosis or procedure that identify aspects of care
characteristics of ethnic groups) as it affects health beliefs to be performed during a designated length of stay
and values, food preferences, language, communication, (Fig. 1-7).
roles, and relationships. • Participating in quality assurance (process of identifying
• Supporting legislative efforts toward national health insur- and evaluating outcomes).
ance and other health care reforms that involve nurses in • Concentrating on the knowledge and skills to manage
primary care (the first health care worker to assess a per- the health needs of older Americans, whose numbers
son with a health need). will reach 70 million by 2030 (National Center for
• Promoting wellness through home health and community- Chronic Disease Prevention and Health Promotion,
based programs. 2005).
• Helping clients with chronic diseases learn techniques for
living healthier and, consequently, longer lives.
• Referring clients with health problems for early treatment,
Gerontologic Considerations
a practice that requires the fewest resources and thus
minimizes expenses.
■ Currently, 30% or more older adults in nursing homes
• Coordinating nursing services across health care settings— return to community settings, necessitating an increase in
that is, discharge planning (managing transitional needs the need for home care services (Miller, 2009).
and ensuring continuity).
LWBK1004-C01_p01-16.indd 12 26/01/12 2:56 AM

LWBK1004-C01_p01-16.indd 13
FIGURE 1-7 Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.)
(continues)
13
26/01/12 2:56 AM
FIGURE 1-7 (Continued).
14
LWBK1004-C01_p01-16.indd 14 26/01/12 2:56 AM

In addition to strategies that are being pursued by nurses Counseling Skills

themselves, there are suggestions for workplace reforms A counselor is one who listens to a client’s needs, responds
that are believed to attract and promote the retention of more with information based on his or her area of expertise, and
nurses. Some of these include: (1) developing nontraditional facilitates the outcome that a client desires. Nurses implement
and flexible work schedules, (2) offering on-site child care counseling skills (interventions that include communicating
facilities, (3) supporting refresher courses for inactive nurses, with clients, actively listening during exchanges of informa-
(4) abandoning mandatory overtime policies, (5) eliminating tion, offering pertinent health teaching, and providing emo-
understaffing, and (6) improving the salary scale (Oncology tional support) in relationships with clients.
Nursing Society, 2007). To understand the client’s perspective, the nurse uses
therapeutic communication techniques to encourage verbal
expression (see Chap. 7). The use of active listening (dem-
UNIQUE NURSING SKILLS onstrating full attention to what is being said, hearing both
the content being communicated and the unspoken message)
Although employment locations and how they carry out facilitates therapeutic interactions. Giving clients the oppor-
nursing skills (activities unique to the practice of nurs- tunity to be heard helps them organize their thoughts and to
ing) differ according to educational preparation, all nurses evaluate their situation more realistically.
share the same philosophy. In keeping with Nightingale’s When the client’s perspective is clear, the nurse pro-
traditions, contemporary nursing practice continues to vides pertinent health information without offering specific
include assessment skills, caring skills, counseling skills, advice. By reserving personal opinions, nurses promote the
and comforting skills. right of every person to make his or her own decisions and
choices on matters affecting health and illness care. The role
Assessment Skills of the nurse is to share information about potential alterna-
Before the nurse can determine what care a person requires, tives, to allow clients the freedom to choose, and to support
he or she must determine the client’s needs and problems. the final decision.
This requires the use of assessment skills (acts that involve While giving care, the nurse finds many opportuni-
collecting data), which include interviewing, observing, and ties to teach clients how to promote healing processes, stay
examining the client, and in some cases, the client’s family well, prevent illness, and carry out ADLs in the best possible
(family is used loosely to refer to the people with whom the way. People know much more about health and health care
client lives and associates). Although the client and the fam- today, and they expect nurses to share accurate information
ily are the primary sources of information, the nurse also with them.
reviews the client’s medical record and talks with other Because clients do not always communicate their feelings
health care workers to obtain facts. Assessment skills are to strangers, nurses use empathy (intuitive awareness of what
discussed in more detail in Unit 4. the client is experiencing) to perceive the client’s emotional
state and need for support. This skill differs from sympathy
Caring Skills (feeling as emotionally distraught as the client). Empathy
Caring skills (nursing interventions that restore or maintain helps the nurse become effective at providing for the client’s
a person’s health) may involve actions as simple as assisting needs while remaining compassionately detached.
with activities of daily living (ADLs), the acts that people
normally do every day, for example, bathing, grooming, Comforting Skills
dressing, toileting, and eating. Increasingly, however, the Nightingale’s presence and the light from her lamp commu-
nurse’s role is expanding to include the safe care of clients nicated comfort to the frightened British soldiers in the 19th
who require invasive or highly technical equipment. This century. As a result of that heritage, contemporary nurses
textbook introduces beginning nurses to the concepts and understand that illness often causes feelings of insecurity that
skills needed to provide care for clients whose disorders have may threaten the client’s or family’s ability to cope; they may
fairly predictable outcomes. After this foundation has been feel very vulnerable. At this point, the nurse uses comforting
established, students may add to their initial knowledge base. skills (interventions that provide stability and security during
Traditionally, nurses always have been providers of a health-related crisis) (Fig. 1-8). The nurse becomes the cli-
physical care for people unable to meet their own health ent’s guide, companion, and interpreter. This supportive rela-
needs independently. But caring also involves the concern tionship generally increases trust and reduces fear and worry.
and attachment that result from the close relationship of one As a result of one woman’s efforts, modern nurs-
human being with another. Nevertheless, the nurse ultimately ing was born. It has continued to mature and flourish ever
wants clients to become self-reliant. The nurse who assumes since. The skills that Nightingale performed on a very grand
too much care for clients, like a parent who continues to tie a scale are repeated today during each and every nurse–client
child’s shoes, often delays their independence. relationship.
LWBK1004-C01_p01-16.indd 15 26/01/12 2:56 AM

NCLEX-STYLE REVIEW QUESTIONS

1. Before delegating the task of assessing a client’s
blood sugar to a UAP, what should the LPN do first?
1. Review the client’s trends in blood sugar
measurements
2. Check the diabetic medications prescribed for the
client
3. Determine whether the UAP is qualified to check
the blood sugar
4. Assess what the client knows about controlling
blood sugar
2. After receiving an assignment from the RN in charge,
which client should the LPN assess first?
1. Client A, who will be discharged in the morning
FIGURE 1-8 This nurse offers comfort and emotional support. 2. Client B, who returned from surgery an hour ago
(Photo by B. Proud.) 3. Client C, who received recent pain medication
4. Client D, who has not urinated in 4 hours
3. What information is most important for an LPN
➧ Stop, Think, and Respond Box 1-2 to receive when obtaining a report on an assigned
Identify which of the following nursing actions is an postoperative client?
assessment skill, a caring skill, a counseling skill, and 1. The client’s age
a comforting skill: (a) the nurse discusses with a fam- 2. The client’s occupation
ily the progress of a client undergoing surgery; (b) the 3. The client’s last consumption of food
nurse provides information on advanced directives, 4. The client’s most recent blood pressure
which allows a client to identify his or her end-of-life 4. After an LPN delegates the assessment of a client’s
decisions; (c) the nurse asks a client to identify his or
blood pressure to a UAP, what is the most important
her current health problems; (d) the nurse provides
medication for a client in pain.
action to take next?
1. Check the results of the delegated task
2. Recheck the client’s blood pressure
CRITICAL THINKING EXERCISES 3. Teach the client about controlling blood pressure
4. Assess the client’s family history for heart disease
1. Describe some outcomes that may result if the nurs- 5. When an RN determines an LPN’s assignment, which
ing shortage is not reduced or resolved. client assignment is most reasonable for the LPN to
2. There are four major categories of questions on the question?
NCLEX-PN: Safe and Effective Care Environment, 1. Client A, who has unrelieved chest pain
Health Promotion and Maintenance, Psychosocial 2. Client B, whose fractured leg is in traction
Integrity, and Physiological Integrity (refer to 3. Client C, who is recovering after an appendectomy
National Council of State Boards of Nursing, 2011 4. Client D, whose white blood cell count is elevated
NCLEX-PN Detailed Test Plan). Based on your
personal experiences during wellness or illness care,
identify nursing skills (other than those in Stop,
Think, and Respond Box 1-2) that would be examples
of each of the four NCLEX-PN categories.
3. How might the shortage of registered nurses affect
LPNs both positively and negatively?
4. If Florence Nightingale were alive today, how might
she view the current education and practice of nursing?
LWBK1004-C01_p01-16.indd 16 26/01/12 2:56 AM

Photo to
Come
FPO
2# Nursing Process
actual diagnosis
assessment
collaborative problems 1. Define the term nursing process.
concept mapping 2. Describe seven characteristics of the nursing process.
critical thinking 3. List five steps in the nursing process.
database assessment 4. Identify four sources of assessment data.
diagnosis 5. Differentiate between data base, focus, and functional
evaluation assessments.
focus assessment 6. Distinguish between a nursing diagnosis and a collaborative
functional assessment problem.
goal 7. List three parts of a nursing diagnostic statement.
implementation 8. Describe the rationale for setting priorities.
long-term goals 9. Discuss appropriate circumstances for short-term and long-term
nursing diagnosis goals.
nursing orders 10. Identify four ways to document a plan of care.
nursing process 11. Describe the information that is documented in a plan
objective data of care.
planning 12. Discuss three outcomes that result from an evaluation.
possible diagnosis 13. Describe the process of concept mapping as an alternative
risk diagnosis learning strategy for student clinical experiences.
short-term goals
signs
standards for care n the past, nursing practice consisted of actions based mostly on common
subjective data
symptoms
syndrome diagnosis
wellness diagnosis I sense and the examples set by older, more experienced nurses. The actual
care of clients tended to be limited to the physician’s medical orders. Al-
though nurses today continue to work interdependently with physicians
and other health care practitioners, they now plan and implement client care
more independently. In even stronger terms, nurses are held responsible and
accountable for providing client care that is safe and appropriate and
ectsrefl
currently accepted standards for nursing practice.
DEFINITION OF THE NURSING PROCESS
A process is a set of actions leading to a particular goal.nursing

The
process is an organized sequence of problem-solving steps used to
identify and manage the health problems of clients (Fig. 2-1). It is the
accepted standard for clinical practice established by the American
Nurses Association (ANA) (Box 2-1).
The nursing process is the framework for nursing care in all
health care settings. When nursing practice follows the nursing proc-
ess, clients receive quality care in minimal time with maximal
effi ciency.
17
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Assessment B OX 2 - 1 Standards of Clinical Nursing

1. Collect data Practice
2. Organize data
Standard I — Assessment
The nurse collects patient health data.
Evaluation Diagnosis
Standard II — Diagnosis
1. Monitor client 1. Analyze data
outcomes 2. Identify nursing
The nurse analyzes the assessment data to determine diag-
2. Resolve, continue, diagnoses and noses.
and revise the collaborative problems
current plan for care Standard III — Outcome Identification
The nurse identifies expected outcomes individualized to the
patient.
Planning
Standard IV — Planning
Implementation
The nurse develops a plan of care that prescribes interventions
1. Carry out the 1. Prioritize problems
nursing orders 2. Identify measurable to attain expected outcomes.
2. Document the outcomes (goals)
nursing care and 3. Select nursing Standard V — Implementation
client responses interventions The nurse implements the interventions identified in the plan
4. Document the plan of of care.
care
FIGURE 2-1 The steps in the nursing process. Standard VI — Evaluation

The nurse evaluates the patient’s progress toward attainment of
outcomes.
CHARACTERISTICS OF Reprinted with permission from American Nurses Association. (1998).

THE NURSING PROCESS Standards of clinical nursing practice (2nd ed.). Washington, DC:
American Nurses Association.
The nursing process has seven distinct characteristics:

loop. Evaluation, the last step in the nursing process,
• Within the legal scope of nursing. Most state nurse practice involves data collection, beginning the process again.
acts define nursing as an independent problem-solving role
that involves the diagnosis and treatment of human
STEPS OF THE NURSING PROCESS
responses to actual or potential health problems.
• Based on knowledge. The ability to identify and resolve
The steps of the nursing process, each of which is discussed
client problems requires critical thinking, which is a pro-
in detail throughout this chapter, are as follows:
cess of objective reasoning or analyzing facts to reach a
valid conclusion. Critical thinking enables nurses to deter- 1. Assessment
mine which problems necessitate collaboration with the 2. Diagnosis
physician and which fall within the independent domain of 3. Planning
nursing. Critical thinking helps nurses select appropriate 4. Implementation
evidence-based nursing interventions for achieving pre- 5. Evaluation
dictable outcomes.
Licensed practical nurses (LPNs) and registered nurses
• Planned. The steps of the nursing process are organized
(RNs) have different responsibilities related to the nursing
and systematic. One step leads to the next in an orderly
process. For example, RNs may delegate some parts of an
fashion.
initial assessment to an LPN, but the RN is still responsible
• Client-centered. The nursing process makes it easier to for-
for ensuring that data collection is complete. After obtain-
mulate a comprehensive and unique plan of care for each
ing the assessment data, the RN develops the initial plan of
client. Clients are expected, whenever possible, to actively
care. Differences exist in various locales as to whether the
participate in their care.
LPN makes changes to the plan of care independently or col-
• Goal-directed. The nursing process involves a united effort
laboratively with the RN (National Council of State Boards
between the client and the nursing team to achieve desired
of Nursing, 2005, Practical Nurse Scope of Practice White
outcomes.
Paper). Also refer to Table 1-3.
• Prioritized. The nursing process provides a focused way to
resolve the problems that represent the greatest threat to Assessment
health. Assessment, the first step in the nursing process, is the
• Dynamic. Because the health status of any client is con- systematic collection of facts or data. Assessment begins
stantly changing, the nursing process acts like a continuous with the nurse’s first contact with a client and continues as
LWBK1004-C02_p17-32.indd 18 26/01/12 2:59 AM

CHAPTER 2 Nursing Process 19
B OX 2 - 2 Examples of Objective and Sources for Data

Subjective Data The primary source of information is the client. Second-
ary sources include the client’s family, reports, test results,
OBJECTIVE DATA SUBJECTIVE DATA
information in current and past medical records, and discus-
Weight Pain sions with other health care workers.
Temperature Nausea
Skin color Depression Types of Assessments
Blood cell count Fatigue There are three types of assessments: database assessment,
Vomiting Anxiety focus assessment, and functional assessment (Table 2-1).
Bleeding Loneliness
Database Assessment
A database assessment (initial information about the
long as a need for health care exists. During assessment, the client’s physical, emotional, social, and spiritual health) is
nurse collects information to determine areas of abnormal lengthy and comprehensive. The nurse obtains data base
function, risk factors that contribute to health problems, and information during the admission interview and physical
client strengths (Alfaro-LeFevre, 2009). examination (see Chap. 13). Health care facilities generally
provide a form that is printed or available on a computer
Types of Data for use as a guide (Fig. 2-2). Information obtained during
Data are either objective or subjective (Box 2-2). Objective a database assessment serves as a reference for compar-
data are observable and measurable facts and are referred to ing all future data and provides the evidence used to iden-
as signs of a disorder. An example is a client’s blood pres- tify the client’s initial problems. Comparisons of ongoing
sure measurement. Subjective data consist of information assessments with baseline data help determine whether the
that only the client feels and can describe, and are called client’s health is improving, deteriorating, or remaining
symptoms. An example is pain. unchanged.
➧ Stop, Think, and Respond Box 2-1 Focus Assessment

Which of the following represent objective data? A focus assessment is information that provides more details
1. A client rates his pain as 8 on a scale of 0 to about specific problems and expands the original database.
10, with 10 being the most pain he has ever For instance, if during the initial interview the client tells
experienced. the nurse that constipation is the rule rather than the excep-
2. A client has an incisional scar in the right lower tion, more questions follow. The nurse obtains data about
quadrant of the abdomen. the client’s dietary habits, level of activity, fluid intake, cur-
3. A client says she slept very well and feels rested. rent medications, frequency of bowel elimination, and stool
4. A client’s blood pressure is 165/86 mm Hg. characteristics. The nurse may ask the client to save a stool
5. A client’s heart rate is irregular. for inspection.
TABLE 2-1 Comparison of Data Base, Focus, and Functional Assessments

DATABASE ASSESSMENT FOCUS ASSESSMENT FUNCTIONAL ASSESSMENT
Obtained on admission Compiled throughout subsequent care Completed within the first 14 days of admission
Consists of predetermined questions and Consists of unstructured questions and Can follow various assessment tools, one of
systematic head-to-toe examination a collection of physical assessments which is standardized minimum data set
(MDS)
Performed once Repeated each shift or more often Repeated at least every 12 months or immedi-
ately after a significant change in physical or
mental status; reviewed every 3 months
Suggests possible problems Rules out or confirms problems Identifies physical, psychological, and social
factors that affect self-care
Findings documented on an admission Findings documented on a checklist or Findings documented on various assessment
assessment form in progress notes tools, one of which is standardized
MDS
Time-consuming; may take 1 hour Completed in a brief amount of time Labor intensive; may involve a multidisciplinary
or more (about 15 minutes) team with final completion by an RN
Supplies a broad, comprehensive volume Collects limited data Comprehensive evaluation of current strengths
of data and the potential for avoidable decline
Provides breadth for future comparisons Adds depth to the initial database Provides comparative data
Reflects the client’s condition on entering Provides comparative trends for evaluat- Data may also be used as a facility’s quality
the health care system ing the client’s response to treatment indicator
LWBK1004-C02_p17-32.indd 19 26/01/12 2:59 AM

FIGURE 2-2 One page of a multipage admission assessment form is shown. (Courtesy of the
Community Health Center of Branch County, Coldwater, MI.)
LWBK1004-C02_p17-32.indd 20 26/01/12 2:59 AM

B OX 2 - 3 Functional Assessment as It B OX 2 - 4 Organization of Data

Applies to Bathing
Assessment Findings
5: Unable to assist in any way Lassitude; distended abdomen; dry, hard stool passed with
4: Able to cooperate, but cannot assist difficulty; fever; weak cough; thick sputum
3: Able to wash hands, face, and chest with supervision; needs
help with completing the bath
Related Clusters
2: Able to wash face, chest, arms, and upper legs; needs help
Lassitude, fever
with completing the bath
Weak cough, thick sputum
1: Bathes self, but requires devices (e.g., long-handled sponge)
Distended abdomen; dry, hard stool passed with difficulty
0: Bathes self independently
Focus assessments generally are repeated frequently or they take on more significance than when the nurse consid-
on a scheduled basis to determine trends in a client’s con- ers each fact separately or examines the entire group at once.
dition and responses to therapeutic interventions. Examples
include conducting postoperative surgical assessments (see
➧ Stop, Think, and Respond Box 2-2
Chap. 27), monitoring the client’s level of pain before and
after administering medications, and checking the neuro- Organize the following data into two related clusters:
cough, dry skin, infrequent urination, fever, nasal
logic status of a client with a head injury.
congestion, thirst.
Functional Assessment
A functional assessment is a comprehensive evaluation of Diagnosis
a client’s physical strengths and weaknesses in areas such Diagnosis, the second step in the nursing process, is the
as (1) the performance of activities of daily living (see identification of health-related problems. Diagnosis results
Box 2-3 for an example that relates to bathing), (2) cognitive from analyzing the collected data and determining whether
abilities, and (3) social functioning. The results of the func- they suggest normal or abnormal findings.
tional assessment help formulate an individualized plan for Nursing Diagnoses
care that identifies specific interventions for achieving the Nurses analyze data to identify one or more nursing diag-
maximum possible functioning to ensure a better quality of noses. A nursing diagnosis is a health issue that can be pre-
life. Currently, the performance of a functional assessment vented, reduced, resolved, or enhanced through independent
is being promoted by the Joint Commission in all general nursing measures. It is an exclusive nursing responsibility.
health care settings. Nursing diagnoses are categorized into five groups: actual,
risk, possible, syndrome, and wellness (Table 2-2).
TABLE 2-2 Categories of Nursing Diagnoses
Since 1987, all Medicare- and Medicaid-funded nursing
TYPE EXPLANATION AND EXAMPLE
homes must complete a Resident Assessment Instrument
(RAI) to document a client’s functional assessment. It Actual A problem that currently exists
includes a form known as the minimum data set (MDS) for diagnosis Impaired Physical Mobility related to pain
Resident Assessment and Care Screening. When used on a as evidenced by limited range of motion,
cyclical basis, a functional assessment indicates changes— reluctance to move
Risk A problem the client is uniquely at risk for
in both improvement and deterioration—experienced by aging
diagnosis developing
clients over time.
Risk for Deficient Fluid Volume related to
persistent vomiting
Possible A problem may be present, but requires more
Organization of Data diagnosis data collection to rule out or confirm its
Interpreting data is easier if information is organized. Organi- existence
zation involves grouping related information. For example, Possible Parental Role Conflict related to
impending divorce
consider the following list of words: apple, wheels, orchard, Syndrome Cluster of problems predicted to be
pedals, tree, and handlebars. At first glance, they appear to diagnosis present because of an event or situation
be a jumble of terms. If asked to cluster the related terms, (Carpenito-Moyet, 2009)
however, most people would correctly group apple, tree, and Rape Trauma Syndrome and Disuse Syndrome
orchard together, and wheels, pedals, and handlebars together. Wellness A health-related problem with which a healthy
diagnosis person obtains nursing assistance to main-
Nurses organize assessment data similarly. Using knowl- tain or perform at a higher level
edge and past experiences, they cluster related data (Box 2-4). Potential for Enhanced Breastfeeding
Data organized into small groups are easier to analyze and
LWBK1004-C02_p17-32.indd 21 26/01/12 2:59 AM

B OX 2 - 5 Parts of a Nursing Diagnostic

Statement
1. Disturbed Sleep Pattern = problem
2. Related to excessive intake of coffee = etiology
3. As manifested by difficulty in falling asleep, feeling tired
Collaborative
during the day, and irritability with others = signs and Nursing diagnoses Medical diagnoses
problems
symptoms
The NANDA List

The ANA has designated NANDA International (NANDA-
I; formerly the North American Nursing Diagnosis Nursing Other health care professionals
Association) as the authoritative organization for devel- (medicine, social services, etc.)
oping and approving nursing diagnoses. NANDA is the FIGURE 2-3 These two overlapping circles illustrate that the
clearinghouse for proposals suggesting diagnoses that nurse independently treats nursing diagnoses. Doctors, other
fall within the independent domain of nursing practice. health professionals, and nurses work together on
collaborative problems.
NANDA reviews the proposals for appropriateness. While
research is ongoing, NANDA incorporates its findings into
a list published for clinical use. The most recent index, “possible” is used in a diagnostic statement to indicate
which is revised every 2 years, is provided on the inside uncertainty; for example, Possible Sexual Dysfunction
back cover of this book. related to anxiety. Wellness diagnoses are prefaced with the
Although entries in the NANDA list change, most phrase “potential for enhanced.”
authorities believe that nurses should use the language of Risk and possible nursing diagnoses do not include the
the approved diagnoses whenever possible. When a client’s third part of the statement. In risk nursing diagnoses, the
problem does not fit into any of the NANDA-approved cat- signs or symptoms have not yet manifested; in possible nurs-
egories, the nurse can use his or her own terminology when ing diagnoses, the data are incomplete. The factors that place
stating the nursing diagnosis. the client at risk or make the nurse suspect such a diagno-
sis, however, are identified in the nursing assessment docu-
Diagnostic Statements mentation. Syndrome diagnoses and wellness diagnoses are
An actual nursing diagnostic statement contains three parts: one-part statements; they are not linked with an etiology or
signs and symptoms.
1. Name of the health-related issue or problem as identified
in the NANDA list Collaborative Problems
2. Etiology (its cause) Collaborative problems are physiologic complications
3. Signs and symptoms that require both nurse- and physician-prescribed interven-
tions. They represent an interdependent domain of nursing
The name of the nursing diagnosis is linked to the
practice (Fig. 2-3). The nurse is specifically responsible and
etiology with the phrase “related to,” and the signs and
accountable for the following:
symptoms are identified with the phrase “as manifested (or
evidenced) by” (Box 2-5). • Correlating medical diagnoses or medical treatment
Different types of diagnoses have different stems. Risk measures with the risk for unique complications.
diagnoses are prefaced with the term “risk for,” as in Risk • Documenting the complications for which clients are
for Impaired Skin Integrity related to inactivity. The word at risk.
TABLE 2-3 Correlation of Collaborative Problems

MEDICAL DIAGNOSIS OR MEDICAL TREATMENT POSSIBLE CONSEQUENCE COLLABORATIVE PROBLEM
Myocardial infarction (heart attack) Abnormal heart rhythm PC: Dysrhythmias
Heart failure Fluid in the lungs PC: Pulmonary edema
Severe burns Serum moves into tissue, depleting blood volume PC: Hypovolemic shock
HIV positive (infected with AIDS virus) Decreased blood cells that fight infection PC: Immunodeficiency
Gastric decompression (suctioning stomach fluid) Removes acid and electrolytes PC: Alkalosis
PC: Electrolyte imbalance
Cardiac catheterization (inserting a catheter into Arterial bleeding PC: Hemorrhage
the heart)
LWBK1004-C02_p17-32.indd 22 26/01/12 2:59 AM

• Making pertinent assessments to detect complications. TABLE 2-4 Prioritizing Nursing Diagnoses
• Reporting trends that suggest development of complica- HUMAN NEED EXAMPLES OF NURSING DIAGNOSES
tions.
Physiologic Imbalanced nutrition: less than body
• Managing the emerging problem with nurse- and physician- requirements
prescribed measures. Ineffective breathing pattern
• Evaluating the outcomes. Pain
Impaired swallowing
Collaborative problems are identified on a client’s Urinary retention
plan for care with the abbreviation PC, which stands for Safety and security Risk for injury
potential complication (Table 2-3). Because a collabora- Impaired verbal communication
tive problem requires the nurse to use diagnostic processes, Disturbed thought processes
Anxiety
some nursing leaders are proposing the use of the term
Fear
“collaborative diagnosis” instead (Alfaro-LeFevre, 2009). Love and belonging Social isolation
Impaired social interactions
Interrupted family processes
➧ Stop, Think, and Respond Box 2-3 Parental role conflict
Esteem and self- Disturbed body image
Which of the following nursing diagnostic statements esteem Powerlessness
is written correctly based on the data and the infor- Caregiver role strain
mation in this chapter? Ineffective breastfeeding
Data: The client eats only bites of the food served. Self-actualization Delayed growth and development
She has lost 15 lb in the last 3 weeks and currently Spiritual distress
weighs 130 lb, which is more than 10% underweight
for her height. She has been experiencing chronic
vomiting after eating for the last 3 weeks and is Establishing Goals
physically weak. A goal (expected or desired outcome) helps the nursing team
1. Risk for Imbalanced Nutrition: Less than Body know whether the nursing care has been appropriate for
Requirements related to vomiting managing the client’s nursing diagnoses and collaborative
2. Imbalanced Nutrition: Less than Body
problems. Therefore, a written goal accompanies each one.
Requirements related to inadequate intake of food
Although the terms “goal” and “outcome” are sometimes
secondary to vomiting as manifested by caloric
intake below daily requirements, recent weight loss used interchangeably, outcomes are generally more specific
of 15 lb, and current weakness (Box 2-6). What is important is that the goal statement or out-
3. Weight Loss related to vomiting as evidenced by come contains the criteria or objective evidence for verifying
reduced intake of food that the client has improved. Depending on the agency, nurses
4. Possible Malnutrition due to inadequate consump- may identify short-term goals, long-term goals, or both.
tion of nutrients
Short-Term Goals
Nurses use short-term goals (outcomes achievable in a few
days to 1 week) more often in acute care settings because
Planning most hospital stays are no longer than 1 week. Short-term
The third step in the nursing process is planning, or the goals have the following characteristics (Box 2-7):
process of prioritizing nursing diagnoses and collaborative
problems, identifying measurable goals or outcomes, select- • Developed from the problem portion of the diagnostic
ing appropriate interventions, and documenting the plan of statement
care. Whenever possible, the nurse consults the client while • Client-centered, reflecting what the client will accomplish,
developing and revising the plan. not the nurse
• Measurable, identifying specific criteria that provide evi-
Setting Priorities dence of goal achievement
Not all clients’ problems can be resolved in a brief time. • Realistic, to avoid setting unattainable goals, which can be
Therefore, it is important to determine which problems self-defeating and frustrating
require the most immediate attention. This is done by setting • Accompanied by a target date for accomplishment, the
priorities. Prioritization involves ranking, from those that are predicted time when the goal will be met; identifying a
most serious or immediate to those of lesser importance. target date establishes a time line for evaluation.
There is more than one way to determine priorities.
One method nurses frequently use is Maslow’s Hierarchy Long-Term Goals
of Human Needs (see Chap. 4). Problems interfering with Nurses generally identify long-term goals (desirable out-
physiologic needs have priority over those affecting other comes that take weeks or months to accomplish) for clients
levels of needs (Table 2-4). The ranking can change as prob- with chronic health problems that require extended care in
lems are resolved or new problems develop. a nursing home or who receive community health or home
LWBK1004-C02_p17-32.indd 23 26/01/12 2:59 AM

B OX 2 - 6 Goals Versus Outcomes interventions are directed at eliminating the etiologies. The
nurse selects strategies based on evidence-based knowl-
Goal edge that certain nursing actions produce desired effects.
The client will be well hydrated by 8/23. Whatever interventions are planned, they must be safe,
within the legal scope of nursing practice, and compatible
Outcome with medical orders.
The client will have adequate hydration as evidenced by an
Initial interventions generally are limited to selected
oral intake between 2,000 and 3,000 mL/24 hours and a urine
measures with the potential for success. Nurses should
output plus or minus 500 mL of the intake amount by 8/23.
reserve some interventions in case a client does not accom-
plish the goal.
health services. An example of a long-term goal for the client
Documenting the Plan of Care
with a cerebrovascular accident (stroke) is the return of full
Plans of care can be written by hand (Fig. 2-4), standard-
or partial function to a paralyzed limb. The client is unlikely
ized on printed forms, computer generated, or based on an
to have achieved this goal by discharge. If a client achieves
agency’s written standards or clinical pathways. Whatever
short-term goals in the hospital, however, he or she is more
method is used, The Joint Commission requires that every
likely to achieve long-term goals during care at home or in
client’s medical record provide evidence of the planned nurs-
other community settings.
ing interventions for meeting the client’s needs (Carpenito-
Goals for Collaborative Problems Moyet, 2009).
Goals for collaborative problems are written from a nursing Nursing orders (directions for a client’s care) identify
rather than from a client perspective. They focus on what the the what, when, where, and how for performing nursing
nurse will monitor, report, record, or do to promote early interventions. They provide specific instructions so that all
detection and treatment (Alfaro-LeFevre, 2009). health team members understand exactly what to do for the
The format for writing a nursing goal is, “The nurse client (Box 2-8). Nursing orders are also signed to indicate
will manage and minimize (identify complication) by (insert accountability.
evidence of assessment, communication, and treatment activi- Standardized care plans are preprinted. Both computer-
ties),” or “(identify complication) will be managed and mini- generated and standardized plans provide general sugges-
mized by (evidence).” For example, if the nurse identifies gas- tions for managing the nursing care of clients with a particu-
trointestinal bleeding as a PC, he or she may state the goal, lar problem. It is up to the nurse to transform the generalized
“The nurse will examine emesis and stools for blood and report interventions into specific nursing orders and to eliminate
positive test findings, changes in vital signs, and decreased whatever is inappropriate or unnecessary.
red blood cell counts to the physician” or “Gastrointestinal Agency-specific standards for care (policies that indi-
bleeding will be managed and minimized as evidenced by cate which activities will be provided to ensure quality client
negative Hemoccult tests, red blood cell count greater than care) and clinical pathways (see Chap. 1) relieve the nurse
2.5 million/dL, and vital signs within normal ranges.” from writing time-consuming plans. Both tools help nurses
use their time efficiently and ensure consistent client care.
Selecting Nursing Interventions
Planning the measures that the client and nurse will use to Communicating the Plan of Care
accomplish identified goals involves critical thinking. Nursing Clients need consistency and continuity of care to achieve
goals. Therefore, the nurse shares the plan of care with nurs-
B OX 2 - 7 Components of Short-Term Goals ing team members, the client, and the client’s family. In
some agencies, the client signs the plan of care.
Nursing Diagnostic Statement
Constipation related to decreased fluid intake, lack of dietary
fiber, and lack of exercise as manifested by no normal bowel
movement for the past 3 days, abdominal cramping, and
B OX 2 - 8 Nursing Orders
straining to pass stool
Nursing Order
Short-Term Goal Encourage fluids
The client will client-centered
have a bowel movement identifies measurable Weaknesses
criteria that reflect the Lacks specificity
problem portion of the Likely to be interpreted differently
diagnostic statement May result in inconsistent or less than adequate care
in 2 days (specify date) identifies a target date
for achievement within a Improvement
realistic time frame Provide 100 mL of oral fluid every hour while awake
LWBK1004-C02_p17-32.indd 24 26/01/12 2:59 AM

Name: Mrs. Rita Williard Age: 68 Date of Admission: 11/10

Diagnosis on admission: CVA c left-sided weakness
Nursing diagnosis: Impaired Physical Mobility, High Risk for Injury, Situational Low Self-esteem
Long-term goals: Independent mobility using walker or quad cane, record of personal safety, positive self-regard
DATE PROBLEM GOAL TARGET DATE NURSING ORDERS
11/10 #1
Impaired Physical The client will stand 11/24 1) Passive ROM t.i.d. to
Mobility related to left and pivot from bed to left arm and leg
sided weakness as wheelchair or commode. 2) Physical therapy b.i.d.
manifested by decreased for practice at parallel bars
muscle strength in left 3) Apply left leg brace and
leg and arm, slowed sling to left arm when up
gait, dragging foot. 4) Assist to balance on
right leg at bedside before
and after physical therapy
daily
C. Meyer, RN
11/10 #2
Risk for Injury The client will 12/1 1) Keep side rails up and
related to motor transfer from bed to trapeze over bed
deficit wheelchair without 2) Use shoe & nonskid sole
injury on right foot (leg brace
on left) before transfer
3) Dangle for 5 minutes
before attempting to stand
4) Lock wheels on wheelchair
before transfer
5) Obtain help of second
assistant
6) Block left foot to avoid
slipping during pivot
7) Place signal light on
right side within reach
at all times
C. Meyer, RN
12/2 #3
Situational Low The client will 12/18 1.) Allow to express feelings
Self-Esteem related identify one or more without disagreeing or
to dependence on positive feelings regarding interrupting.
others as manifested improved mobility and 2.) Reinforce concept that
by statements, “I need self-care the right side of body is
as much help as a unaffected.
baby; I feel so useless; 3.) Help to set and
How embarrassing to accomplish one realistic
be so dependent.” goal daily.
S. Moore, RN
FIGURE 2-4 Sample nursing care plan.
The plan of care is a permanent part of the client’s medi- Implementation

cal record. It is placed in the client’s chart, kept separately at Implementation, the fourth step in the nursing process,
the client’s bedside, or located in a temporary folder at the means carrying out the plan of care. The nurse implements
nurses’ station for easy access. Wherever it is located, each medical orders as well as nursing orders, which should com-
nurse assigned to the client refers to it daily, reviews it for plement each other. Implementing the plan involves the cli-
appropriateness, and revises it according to changes in the ent and one or more members of the health care team. A wide
client’s condition. circle of care providers with assorted roles may be called on
LWBK1004-C02_p17-32.indd 25 26/01/12 2:59 AM

Evaluation
Evaluation, the fifth and final step in the nursing process,
is the way by which nurses determine whether a client has
reached a goal. Although this is considered the last step, the
Pharmacist Laboratory entire process is ongoing. By analyzing the client’s response,
Technician evaluation helps determine the effectiveness of nursing care
(Table 2-5).
Before revising a plan of care, it is important to discuss
any lack of progress with the client. In this way, both the
nurse and the client can speculate on what activities need
Dietitian
to be discontinued, added, or changed. Other health team
LPN MD members who are familiar with a particular client or prob-
lems similar to those of the client may offer their expertise as
well. The evaluation of a client’s progress may be the subject
RN Physical of a nursing team conference. Some units even invite the cli-
Therapist ent and family to participate.
CLIENT
Unlicensed Respiratory USE OF THE NURSING PROCESS

Assistive Personnel Therapist
FIGURE 2-5 Members of the health care team. Use of the nursing process is the standard for clinical nurs-
ing practice. Nurse practice acts hold nurses accountable for
demonstrating all the steps in the nursing process when car-
to participate, either directly or indirectly, in carrying out
ing for clients. To do less implies negligence. More detailed
one client’s plan of care (Fig. 2-5).
discussions of the nursing process can be found in specialty
The medical record is legal evidence that the plan of
texts and in some of the suggested readings at the end of
care has been more than just a paper trail. The information in
this book. Nursing Guidelines 2-1 reiterate the sequence of
the chart shows a correlation between the plan and the care
the nursing process.
that has been provided. In other words, the nurse’s chart-
ing (see Chap. 9) reflects the written plan. Nurses are just as
accountable for carrying out nursing orders as they are for
physician’s orders. CONCEPT MAPPING
In addition to identifying the nursing interventions that
have been provided, the record also describes the quantity and Concept mapping (also known as care mapping) is a method
quality of the client’s response. Quoting the client helps iden- of organizing information in graphic or pictorial form. This
tify his or her point of view and safeguards against incorrect strategy promotes learning by having the student gather data
assumptions. In short, appropriate documentation maintains from the client and medical record or a written case study,
open lines of communication among members of the health select significant information, and organize related concepts
care team, ensures the client’s continuing progress, complies on a one- or two-page working document. Various formats
with accreditation standards, and helps ensure reimburse- used include a spider diagram with a central theme such as the
ment from government or private insurance companies. client’s medical diagnosis, a hierarchy moving from general
TABLE 2-5 Outcomes from Evaluation

ANALYSIS REASON ACTION
The client has reached Plan was effective and implemented consistently Discontinue the nursing orders
the goals
The client has made Care has been inconsistent Check that nursing orders are clear and specific
some progress Target date was too ambitious Continue care as planned; readjust target date
Client’s response has been less than expected Revise the plan by adding nursing interventions or
more frequent implementation
The client has made no The initial diagnosis was inaccurate Revise problem list; write new goals and nursing orders
progress New problems have occurred Add new problems, goals, and nursing orders
The target date was unrealistic Revise expected date for achievement
Nursing interventions were ineffective Add new nursing orders; discontinue ineffective
measures; readjust target date
LWBK1004-C02_p17-32.indd 26 26/01/12 2:59 AM

NURSING GUIDELINES 2-1

Rationales
Using the Nursing Process
• Collect information about the client. Data collection is the of communication and reference for the nursing team
basis for identifying problems. to follow.
• Organize the data. Organizing related data simplifies the proc- • Discuss the plan with nursing team members, the client, and
ess of analysis. the family. Verbally sharing the plan ensures that everyone is
• Analyze the data for what is normal and abnormal. Abnormali- informed and goal directed.
ties provide clues to the client’s problems. • Put the plan into action. Work produces results.
• Identify actual, risk, possible, syndrome, and wellness nursing • Observe the client’s responses. Evaluating outcomes is the
diagnoses and collaborative problems. Problem identification basis for determining the effectiveness of the plan of care.
directs the nurse to select methods for maintaining or restoring • Chart all nursing activities and the client’s responses. Docu-
the client’s health. mentation demonstrates that planned care has been imple-
• Prioritize the problem list. Setting priorities targets problems mented and provides information about the client’s progress.
that require the most immediate attention. • Compare the client’s responses with the goal criteria. If the
• Set goals with specific criteria for evaluating whether the prob- planned care is appropriate, there should be some measure of
lems have been prevented, reduced, or resolved. Goals predict progress toward accomplishing goals.
the expected outcomes from nursing care. • Discuss the progress, or lack of it, with the client, family, and
• Select a limited number of appropriate nursing interventions. The other nursing team members. Pooling resources may provide
nurse uses evidence-based knowledge to determine which meas- better alternatives when revising the plan of care.
ures will be most effective in accomplishing the goals of care. • Change the plan in areas that are no longer appropriate. The
• Give specific directions for nursing care. Specific directions nursing care plan changes according to the needs of the client.
promote consistency and continuity among caregivers. • Continue to implement and evaluate the revised plan of care.
• Document the plan for care using whatever written The nursing process is a continuous sequence of actions that is
format is acceptable. A written plan provides a means repeated until the goals have been met.
to specific, or a flow chart (Fig. 2-6). With additional knowl- Those who use concept mapping report that the
edge, students draw lines or arrows to link or correlate rela- technique:
tionships within the map. Organizing the data then facilitates
identifying nursing diagnoses, setting goals and expected • Allows students to integrate previous knowledge with
outcomes, and evaluating the results of the care provided. newly acquired information.
A B
FIGURE 2-6 Three formats used in concept mapping.

A. Spider diagram. B. Hierarchical arrangement. C. Linear
C flow chart.
LWBK1004-C02_p17-32.indd 27 26/01/12 2:59 AM

• Enables students to organize and visualize relationships 2. According to most nurse practice acts, if a charge
between their current academic learning and new, unique nurse assigns a licensed practical nurse to admit a
client assignments. new client, what is the practical nurse’s primary role?
• Increases critical thinking and clinical reasoning skills. 1. Create an initial nursing care plan.
• Enhances retention of knowledge. 2. Gather basic information from the client.
• Correlates theoretical knowledge with nursing practice. 3. Develop a list of the client’s nursing diagnoses.
• Helps students recognize information that they must review 4. Report assessment data to the client’s physician.
or learn to promote safe, appropriate client care. 3. At a team conference, staff members discuss a client’s
• Promotes better time management for beginning students nursing diagnoses. Which one of the following nurs-
otherwise focused on the composition requirements of ing diagnoses is of highest priority?
nursing care plans rather than use of the nursing process 1. Ineffective Airway Clearance
itself. 2. Ineffective Coping
3. Deficient Diversional Activity
4. Interrupted Family Processes
4. The licensed practical nurse notes that an expected
CRITICAL THINKING EXERCISES
outcome of bathing independently has not been
1. If an unconscious client is brought to the nursing reached by the target date. What action is most
unit, how can a nurse gather data? appropriate to take at this time?
2. Three nursing diagnoses are on a client’s plan of care: 1. Urge the client to try harder to bathe independ-
ineffective breathing pattern, social isolation, and ently.
anxiety. Which has the highest priority, and why? 2. Limit bathing until the client can bathe independ-
3. While reviewing a client’s plan of care, a nurse ently.
notices that the client has made no progress in 3. Suggest that the staff reduce their assistance with
accomplishing the goal by its projected target date. bathing.
What actions are appropriate at this time? 4. Revise the interventions or target date for achiev-
4. A nurse plans an 1,800 calorie diet to manage an ing the goal.
obese client with the nursing diagnosis of Imbal- 5. When gathering nursing data on a newly admitted
anced Nutrition: More than Body Requirements, client, which of the following is an appropriate source
but the client rejects that intervention in lieu of to consult for additional information?
exercising 30 minutes each day. What nursing action 1. The client’s visitors
is appropriate in this situation? 2. The client’s family
3. The client’s clergy
4. The client’s employer
1. When managing the care of a client, which of the fol-
lowing nursing actions is most appropriate to perform
first?
1. Develop a plan of care.
2. Determine the client’s needs.
3. Assess the client physically.
4. Collaborate on goals for care.
LWBK1004-C02_p17-32.indd 28 26/01/12 2:59 AM

UNIT 1
End of Unit Exercises for Chapters 1 and 2
S e c t i o n I : Reviewing What You’ve Learned
Activity A: Fill in the blanks by choosing the correct word from the options given in parentheses.
1. A ____________________ develops from observing and studying the relationship of one phenomenon to another.
(science, skill, theory)
2. A nursing ____________________ is a health issue that can be prevented, reduced, resolved, or enhanced through
independent nursing measures. (assessment, diagnosis, evaluation)
3. ____________________ defined nursing as “putting individuals in the best possible condition for nature to restore and
preserve health.” (Henderson, Herbert, Nightingale)
4. ____________________ data are observable and measurable facts and are referred to as signs of a disorder. (Historical,
Objective, Subjective)
Activity B: Mark each statement as either T (True) or F (False). Correct any false statements.
1. T____F____ Concept mapping is a method of organizing information in a graphic or pictorial form.
2. T____F____ Nurses with master’s degrees conduct research and advise, manage, and instruct nurses pursuing degrees.
3. T____F____ The primary health care provider refers to the plan of care, reviews it for appropriateness, and revises it
according to changes in the client’s condition.
4. T____F____ Nurses frequently use Maslow’s Hierarchy of Human Needs to determine priorities when caring for clients.
Activity C: Write the correct term for each description that follows.
1. Process of identifying and evaluating outcomes __________________
2. An expected or desired outcome that helps the nursing team know whether nursing care has been appropriate for
managing the client’s nursing diagnoses and collaborative problems __________________
3. The standard for clinical nursing practice __________________
4. Care provided by the first health care worker assessing the person with a health need __________________
Activity D: Match the nursing skills in Column A with their descriptions in Column B.
Column A Column B
1. ____________ Assessment skills A. Assisting with activities of daily living

2. ____________ Caring skills B. Offering pertinent health teaching
3. ____________ Counseling skills C. Providing interventions that allow for stability and security during a
health-related crisis
4. ____________ Comforting skills D. Interviewing, observing, and examining the client
29
LWBK1004-C02_p17-32.indd 29 26/01/12 2:59 AM

Activity E: Differentiate between a database assessment and a focus assessment based on the criteria given.
Database Assessment Focus Assessment
Definition
Purpose
Example
Activity F: The nursing process is an organized sequence of problem-solving steps used to identify and manage the
health concerns of clients. When nursing practice follows the nursing process, clients receive quality care
in minimal time with maximum efficiency. Write in the boxes provided the correct sequence in which the
actions of the nursing process should be performed.
1. Implementation
2. Diagnosis
3. Assessment
4. Evaluation
5. Planning
Activity G: Answer the following questions.

1. How did Florence Nightingale improve the image of nursing?
2. How did Virginia Henderson define nursing?
3. What are the different types of nursing diagnoses?
4. What is a collaborative problem?
LWBK1004-C02_p17-32.indd 30 26/01/12 2:59 AM

UNIT 1 End of Unit Exercises 31
S e c t i o n I I : Applying Your Knowledge
Activity H: Give rationales for the following questions.

1. Why is the use of empathy so important when nurses care for clients?
2. Why are short-term goals most appropriate for clients receiving care in acute care settings?
3. Why should the nurse document and sign a nursing order?
Activity I: Answer the following questions focusing on nursing roles and responsibilities.
1. A family member brings an elderly client with severe back pain following a fall to the health care facility.
a. What should the nurse do before determining the nursing care that the client requires?
b. What skills must the nurse possess to perform the previous intervention?
2. A nurse is providing care to a client with respiratory distress.

a. What are the requirements for preparing a nursing diagnosis?
b. What are the different parts of a nursing diagnosis?
3. A nurse is identifying short-term and long-term goals for a client who has been admitted to the health care facility with a
fractured right leg.
a. What should the nurse keep in mind when setting short-term goals?
b. What are long-term goals?
c. Identify one possible short-term goal and one possible long-term goal for this client.
LWBK1004-C02_p17-32.indd 31 26/01/12 2:59 AM

Activity J: Consider the following questions. Discuss them with your instructor or peers.
1. A client with lung cancer is undergoing chemotherapy. Recently, he has been losing hair, looks pale and tired, and has
significantly reduced his activities. His family members are worried about the drastic changes in his appearance and
health. In the beginning, the client was eager to comply with the treatment, but now he tells the nurse that he would rather
suffer the consequences of the disease than the side effects of the treatment. How might the nurse approach this situation
using assessment, caring, counseling, and comforting skills?
2. A 50-year-old client is in a long-term care facility following a stroke. His left arm is paralyzed. The client is having
problems with urinary incontinence; recently, he has also developed constipation and is not eating well. Full or partial
return of the left limb’s function is one of the long-term goals for this client, who eventually will undergo occupational
therapy.
a. How should the nurse prioritize care given to this client?
b. What client needs require immediate attention?
c. Identify some other short-term and long-term goals for this client.
S e c t i o n I I I : Getting Ready for NCLEX
Activity K: Answer the following questions.

1. A nurse is assessing a client. Which of the following should the nurse record as subjective data?
a. Temperature
b. Abdominal pain
c. Pulse rate
d. Blood pressure
2. Which of the following was the primary factor that contributed to the demise of nursing in England before Florence
Nightingale?
a. Use of untrained workers, some of whom lacked good character, as nurses
b. Recruitment of lay people by monasteries to assist in physical care
c. Engagement of religious groups in many of the roles of nursing
d. Lack of resources during periods of plague and pestilence
3. Which of the following programs qualify students to take the National Council Licensure Examination-Registered Nurse
(NCLEX-RN)? Select all that apply.
a. A practical nurse program
b. A hospital-based diploma program
c. A licensed practical nursing (LPN) program
d. An associate degree in nursing
e. A baccalaureate nursing program
4. Nursing diagnoses for a client with a fractured hip include “impaired skin integrity related to inactivity.” To which of the
following categories does this nursing diagnosis belong?
a. Actual
b. Possible
c. Syndrome
d. Wellness
LWBK1004-C02_p17-32.indd 32 26/01/12 2:59 AM

UNIT 2
Integrating Basic Concepts
3 Laws and Ethics 34
4 Health and Illness 50
5 Homeostasis, Adaptation, and Stress 60
6 Culture and Ethnicity 72
33
LWBK1004-C03_p33-49.indd 33 26/01/12 3:00 AM

3 Laws and Ethics
administrative laws
advance directive
allocation of scarce resources 1. Name six types of laws.
anecdotal record 2. Discuss the purpose of nurse practice acts and the role of the
assault state board of nursing.
autonomy 3. Explain the difference between intentional and unintentional
battery torts.
beneficence 4. Describe the difference between negligence and malpractice.
board of nursing 5. Identify three reasons as to why a nurse should obtain
civil laws professional liability insurance.
code of ethics 6. List five ways that a nurse’s professional liability can be
code status mitigated in the case of a lawsuit.
common law 7. Define the term ethics.
confidentiality 8. Explain the purpose of a code of ethics.
criminal laws 9. Describe two types of ethical theories.
defamation 10. Name and explain six ethical principles that apply to health
defendant care.
deontology 11. List five ethical issues common in nursing practice.
durable power of attorney for health care
duty
ethical dilemma aws, ethics, client rights, and nursing duties affect nurses throughout
ethics
false imprisonment
felony
fidelity
Good Samaritan laws
incident report
L their careers. This chapter introduces basic legal and ethical concepts
and issues that affect the practice of nursing.
intentional tort LAWS

invasion of privacy
justice Laws (rules of conduct established and enforced by government) are
laws intended to protect both the general public and each person. The six
liability insurance
categories of laws are constitutional, statutory, administrative, com-
libel
mon, criminal, and civil (Table 3-1).
living will
malpractice
misdemeanor Constitutional Law
negligence The founders of the United States wrote the country’s first formal laws
nonmaleficence within the Constitution. This document, which has endured with few
nurse licensure compacts amendments, divides power among three branches of government and
nurse practice act establishes checks and balances that protect the entire nation. It also
plaintiff identifi es the rights and privileges to which all US citizens are entitled.
reciprocity Two examples of rights protected by constitutional law are free speech
restraints and privacy.
risk management
slander
statute of limitations
Statutory Laws
statutory laws Statutory laws (laws enacted by federal, state, or local legislatures)
sometimes are identified as public acts, codes, or ordinances. For
34
LWBK1004-C03_p33-49.indd 34 26/01/12 3:00 AM

Wo r d s To K n o w (continued)
telehealth services
telenursing
teleology
tort
truth telling
unintentional tort
values
veracity
whistle-blowing
example, state legislatures are responsible for enacting stat- administrative laws authorize federal and state governments
utes that ensure the competence of health care providers. A to ensure citizen health and safety.
nurse practice act (statute that legally defines the unique
role of the nurse and differentiates it from that of other health
care practitioners, such as physicians) is one example of a State Boards of Nursing
statutory law (Box 3-1). Although each state’s nurse practice The state board of nursing is an example of an administrative
act is unique, all generally contain common elements: agency that enforces administrative law. Each state’s board
of nursing (regulatory agency for managing the provisions
• They define the scope of nursing practice. of a state’s nurse practice act) has a primary responsibility
• They establish the limits to that practice. to protect the public receiving nursing care within the state.
• They identify the titles that nurses may use, such as Some activities of the state’s board of nursing include (1)
licensed practical nurse (LPN), licensed vocational nurse reviewing and approving nursing education programs in the
(LVN), or registered nurse (RN). state, (2) establishing criteria for licensing nurses, (3) over-
• They authorize a board of nursing to oversee nursing seeing procedures for nurse licensing examinations, (4) issu-
practice.
ing and transferring nursing licenses, (5) investigating allega-
• They determine what constitutes grounds for disciplinary
tions against nurses licensed in that state, and (6) disciplining
action.
nurses who violate legal and ethical standards. The state’s
board of nursing is responsible for suspending and revoking
Administrative Laws licenses and reviewing applications asking for reciprocity
Administrative laws (legal provisions through which fed- (licensure based on evidence of having met licensing criteria
eral, state, and local agencies maintain self-regulation) in another state). A license in one state does not give a person
affect the power to manage governmental agencies. Some a right to automatic licensure in another.
TABLE 3-1 Types of Laws

CATEGORY PURPOSE EXAMPLES
Constitutional law Protects fundamental rights and freedoms of US citizens Bill of Rights, freedom of speech
Defines the duties and limitations of the executive, legisla-
tive, and judicial branches of government
Statutory law Identifies local, state, or federal rules necessary for the Public health ordinances, tax laws, nurse
public’s welfare practice acts
Administrative law Develops regulations by which to carry out the mission of State boards of nursing, which enact and
a public agency enforce rules as they relate to nurse practice
acts
Common law Interprets legal issues based on previous court decisions in Tarasoff v. Board of Regents of University of
similar cases (legal precedents) California [1976], which justifies breaching a
client’s confidentiality if he or she reveals the
identity of a potential victim of crime
Criminal law Determines the nature of criminal acts that endanger all of Identifies the differences in first-degree and
society second-degree murder, manslaughter, etc.
Civil law Determines the circumstances and manner in which a Dereliction of duty, negligence
person may be compensated for being the victim of
another person’s action or omission of an action
35
LWBK1004-C03_p33-49.indd 35 26/01/12 3:00 AM

36 UNIT 2 Integrating Basic Concepts
B OX 3 - 1 Scope of Nursing Practice as Defined • Facilitates a cost-effective alternative when a nurse is emp-
in Sample Nurse Practice Act loyed to provide telenursing, health triage, or information
from his or her state through electronic or telephonic
The practice of nursing means the performance of services access to residents in another state.
provided for purposes of nursing diagnosis and treatment of • Responds to the health care delivery trend in which nurses
human responses to actual or potential health problems con-
are employed in small hospitals or satellite agencies that
sistent with educational preparation. Knowledge and skill are
have merged with multistate health care systems.
the basis for assessment, analysis, planning, intervention, and
evaluation used in the promotion and maintenance of health
and nursing management of illness, injury, infirmity, restora-
tion of optional function, or death with dignity. Practice is Gerontologic Considerations
based on understanding the human condition across the human
life span and understanding the relationship of the individual ■ Telehealth services, technology that facilitates the trans-
within the environment. This practice includes execution of the mission of health assessment and monitoring data with
medical regime including the administration of medications audio, video, and Internet-based devices, contribute to the
and treatments prescribed by any person authorized by state welfare of homebound elderly or those who live in rural,
law to so prescribe. remote, or underserved areas for health care.
■ Telehealth, which is reimbursed by Medicare, provides
From Oklahoma Nurse Practice Act, 2003. Oklahoma Statutes, Title 59, quick access of home health nurses with clients, decreases
Chapter 12, Section 567.1 et seq. Retrieved September 2009 from http:// client anxiety, and results in substantial cost-reduction with-
www.ok.gov/nursing/actwp.pdf. out compromising quality of care (Miller, 2008).
Nurse Licensure Compacts

The traditional method of separate licenses for each
Several states are considering nurse licensure compacts,
state of practice provides a legal loophole when one state
agreements between states in which a nurse licensed in
revokes a nurse’s license as a disciplinary measure. Some
one state can practice in another without obtaining an addi-
nurses move to the state where their license is still active and
tional license (Fig. 3-1). Under this agreement, the nurse
continue to work. Legislation has been enacted, however, to
acknowledges that he or she is subject to each state’s nurse
track incompetent practitioners. Since 1989, the names of
practice act and discipline. Advantages include the following:
licensed health care workers who have been disciplined by
• Simplifies the licensing process and removes barriers, thus hospitals, courts, licensing boards, professional associations,
increasing employability and access to nursing care. insurers, and peer review committees are submitted to a com-
• Is more cost-effective than multiple licensing fees. puterized National Practitioner Data Bank. The information
• Decreases barriers for nurses who live in one state and is made available nationwide to licensing boards and health
want to work in another nearby. care facilities that hire nurses, should they choose to check
• Reduces the need for duplicate listings of nurses working it. Under the nurse licensure compact, the state of licensure
in more than one state for disaster planning and prepared- and the state where the client was located during an incident
ness or other times of need for qualified nursing services. may take disciplinary action against a nurse working under
ME
ND
NH
ID SD WI
RI
IA
NE
DE
UT CO MD
VA
MO KY
NC
TN DC
MP AZ NM AR SC
MS
TX FIGURE 3-1 States participating in
AS
the Nurse Licensure Compact (NLC)
as of June 2011. (From National
Council of State Boards of Nursing.
[2011]. Nurse Licensure Compact
GU Administrators. Map of NLC States.
RN and LPN/VN Retrieved June 15, 2011 from https://
VI www.ncsbn.org/2537.htm.)
LWBK1004-C03_p33-49.indd 36 26/01/12 3:00 AM

CHAPTER 3 Laws and Ethics 37
a multistate agreement. Some employers also are requiring Assault

that potential and current employees undergo a state or fed- Assault is an act in which bodily harm is threatened or
eral background check and drug screen. attempted. Such harm may be physical intimidation, remarks,
or gestures. The plaintiff interprets the threat to mean that
force may be forthcoming. A nurse may be accused of assault
Common Law if he or she verbally threatens to restrain a client unnecessar-
Common law (decisions based on prior similar cases) is ily (eg, to curtail the use of the signal light).
also known as judicial law. It is based on the principle of
stare decisis (“let the decision stand”), in which prior out- Battery
comes guide decisions in other jurisdictions dealing with Battery (unauthorized physical contact) can include touch-
comparable circumstances. Common law refers to litigation ing a person’s body, clothing, chair, or bed. A plaintiff can
that falls outside the realm of constitutional, statutory, and claim battery even if contact causes no actual physical harm.
administrative laws. The criterion is that contact happened without the plaintiff’s
consent.
Criminal Laws Sometimes, nonconsensual physical contact can be
Criminal laws (penal codes that protect all citizens from justified. For example, health professionals can use physi-
people who pose a threat to the public good) are used to pros- cal force to subdue clients with mental illness or under the
ecute those who commit crimes. The state represents “the influence of alcohol or drugs if their actions endanger their
people” when prosecuting those accused of crimes. Crimes own safety or that of others. Documentation must show,
are either misdemeanors or felonies. A misdemeanor is a however, that the situation required the degree of restraint
minor criminal offense (eg, shoplifting). If a person is con- used. Excessive force is never appropriate when less would
victed of a misdemeanor, a small fine, a short period of have been effective. When recording information about such
incarceration, or both may be levied. The fine is paid to the situations, nurses must describe the behavior and the client’s
state. A felony is a serious criminal offense, such as mur- response when lesser forms of restraint were used first.
der, falsifying medical records, insurance fraud, and stealing To protect health care workers from being charged with
narcotics. Conviction is punishable by a lengthy prison term battery, adult clients are asked to sign a general permission
or even execution. The state generally prohibits felons from for care and treatment during admission (Fig. 3-2) and addi-
obtaining an occupational license, and the state will revoke tional written consent forms for tests, procedures, or surgery.
such a license if its holder is convicted of a felony. When seeking a client’s consent for specific treatments, the
physician must describe the proposed intervention, potential
benefits, risks involved, expected outcome, available alterna-
Civil Laws tives, and consequences if the intervention is not performed.
Civil laws (statutes that protect personal freedoms and Health care personnel obtain consent from a parent or
rights) apply to disputes between individual citizens. Some guardian if the client is a minor, is developmentally disabled,
examples include laws that protect the right to be left alone, or is mentally incompetent. In an emergency, consent can be
freedom from threats of injury, freedom from offensive con- implied. In other words, it is assumed that in life-threatening
tact, and freedom from character attacks. In civil cases, the circumstances, a client would give consent for treatment if
plaintiff (person claiming injury) brings charges against he or she were able to understand the risks. In most cases,
the defendant (person charged with violating the law). The another physician must concur that the emergency procedure
case is referred to as a tort (litigation in which one person is essential.
asserts that a physical, emotional, or financial injury was a
consequence of another person’s actions or failure to act). A False Imprisonment
tort implies that a person breached his or her duty to another A plaintiff can allege false imprisonment (interference
person. A duty is an expected action based on moral or legal with a person’s freedom to move about at will without legal
obligations. authority to do so) if a nurse detains a competent client from
It does not take the same quality or quantity of evidence leaving the hospital or other health care agency. If a client
to be convicted in a civil lawsuit as in a criminal case. If a wants to leave without being medically discharged, it is
defendant is found guilty of a tort, he or she is required to customary for him or her to sign a form indicating personal
pay the plaintiff restitution for damages. Torts are classified responsibility for leaving against medical advice (AMA)
as intentional or unintentional. (Fig. 3-3). If the client refuses to sign the paper, however,
health care personnel cannot bar him or her from leaving.
Intentional Torts Forced confinement is legal under two conditions: if
Intentional torts are lawsuits in which a plaintiff charges there is a judicial restraining order (eg, a prisoner admitted
that a defendant committed a deliberately aggressive act. for medical care) or if there is a court-ordered commitment
Examples include assault, battery, false imprisonment, inva- (eg, a client with mental illness who is dangerous to self or
sion of privacy, and defamation. others).
LWBK1004-C03_p33-49.indd 37 26/01/12 3:00 AM

FIGURE 3-2 Example of consent for treatment form. (From Timby, B. K., & Smith, N. E. [2010].
Introductory medical-surgical nursing [10th ed., p. 37]. Philadelphia: Lippincott Williams &
Wilkins.)
LWBK1004-C03_p33-49.indd 38 26/01/12 3:00 AM

FIGURE 3-3 Example of a release form for discharging oneself against medical advice.
Restraints are devices or chemicals that restrict move- assessment; provisions for fluids, nourishment, and bowel
ment. They are used with the intention to subdue a client’s and bladder elimination; and attempts to release the client
activity. Types include cloth limb restraints, bedrails, chairs from the restraints for a trial period. When the client is no
with locking lap trays, and sedative drugs. Unnecessary or longer a danger to self or others, nurses must remove the
unprescribed restraints can lead to charges of false imprison- restraints.
ment, battery, or both.
The Nursing Home Reform Act of the Omnibus Budget
Reconciliation Act (OBRA) states that residents in nursing Invasion of Privacy
homes have “the right to be free of, and the facility must Civil law protects citizens from invasion of privacy (failure
ensure freedom from, any restraints imposed or psychoac- to leave people and their property alone). Nonmedical exam-
tive drug administered for purposes of discipline or con- ples include trespassing, illegal search and seizure, wiretap-
venience, and not required to treat the residents’ medical ping, and revealing personal information about someone,
symptoms.” This is not to say that restraints cannot be used; even if true. Examples of privacy violations in health care
rather, they should be used as a last resort. Use must be justi- include photographing a client without consent, revealing a
fied and accompanied by informed consent from the client or client’s name in a public report, and allowing an unauthor-
a responsible relative. ized person to observe the client’s care. To ensure and pro-
Before using restraints, the best legal advice is to tect clients’ rights to privacy, medical records and informa-
try alternative measures for protecting wandering clients, tion are kept confidential. Personal names and identities are
reducing the potential for falls (see Chap. 19), and ensur- concealed or obliterated in case studies or research. Privacy
ing that clients do not jeopardize medical treatment by curtains are used during care; permission is obtained if a
pulling out feeding tubes or other therapeutic devices. If nursing or medical student will observe a procedure.
less restrictive alternatives are unsuccessful, nurses must
obtain a medical order before each and every instance in Defamation
which they use restraints. In acute care hospitals, medi- Defamation (an act in which untrue information harms a
cal orders for restraints are renewed every 24 hours. When person’s reputation) is unlawful. Examples include slander
restraints are applied, charting must indicate regular client (character attack uttered orally in the presence of others)
LWBK1004-C03_p33-49.indd 39 26/01/12 3:00 AM

and libel (damaging statements written and read by others). B OX 3 - 2 Elements in a Malpractice Case
Injury is considered to occur because the derogatory remarks
attack a person’s character and good name. Duty—An obligation existed to provide care for the person
If a client accuses a nurse of defamation of character, who claims to have been injured or harmed
the client must prove that there was malice, misuse of privi- Breach of Duty—The caregiver failed to provide appropriate
care, or the care provided was given negligently, that is, in
leged information, and spoken or written untruths. Nurses
a way that conflicts with how others with similar education
are at risk for defamation of character suits if they make
would have acted given the same set of circumstances
negative comments in public areas (eg, elevators), or assert Causation—The caregiver’s action, or lack of it, caused the
opinions regarding a client’s character in the medical record. plaintiff harm
To avoid accusations of defamation, nurses must avoid mak- Injury—Physical, psychological, or financial harm occurred
ing or writing negative comments about clients, physicians,
or other coworkers.
One of the best methods for avoiding lawsuits is to admin-
Unintentional Torts ister compassionate care. The “golden rule” of doing unto oth-
Unintentional torts result in an injury, although the person ers as you would have them do unto you is a good principle to
responsible did not mean to cause harm. The two types of follow. Clients who perceive the nurse as caring and concerned
unintentional torts involve allegations of negligence and tend to be satisfied with their care. The following techniques
malpractice. communicate a caring and compassionate attitude:
• Smiling
Negligence
• Introducing yourself
Negligence (harm that results because a person did not act
• Calling the client by the name he or she prefers
reasonably) implies that a person acted carelessly. In cases
• Touching the client appropriately to demonstrate concern
of negligence, a jury decides whether any other prudent
• Responding quickly to the call light
person would have acted differently than the defendant,
• Telling the client how long you will be gone if you need to
given the same circumstances. For example, a car breaks
leave the unit; informing the client who will provide care
down on the highway. The driver moves to the side of the
in your absence; alerting the client when you return
road, raises the hood, and activates the emergency flash-
• Spending time with the client other than while performing
ing lights. If another vehicle strikes the disabled car and
required care
the driver of the second car sues, the guilt or innocence of
• Being a good listener
the driver of the disabled car depends on whether the jury
• Explaining everything so that the client can understand it
believes his or her action was reasonable. Reasonableness
• Being a good host or hostess—offering visitors extra chairs,
is based on the jury’s opinion of what constitutes good
letting them know where they can obtain snacks and bever-
common sense.
ages, and directing them to the restrooms and parking areas
• Accepting justifiable criticism without becoming defensive
Malpractice • Saying “I’m sorry”
Malpractice is professional negligence, which differs from Clients can sense when a nurse wants to do a good job,
simple negligence. It holds professionals to a higher stand- rather than just get a job done. The relationship that devel-
ard of accountability. Rather than being held accountable for ops is apt to reduce the potential for a lawsuit, even if harm
acting as an ordinary, reasonable lay person, in a malpractice occurs.
case the court determines whether a health care worker acted
in a manner comparable to that of his or her peers. The plain- ➧ Stop, Think, and Respond Box 3-1
tiff must prove four elements to win a malpractice lawsuit: A nurse warns a weak and debilitated older adult that
duty, breach of duty, causation, and injury (Box 3-2). if she continues to get out of bed during the night
Because the jury may be unfamiliar with the scope of without calling for assistance, it will be necessary to
nursing practice, the plaintiff may present other resources apply wrist restraints. Can the nurse legally restrain
in court to prove breach of duty. Some examples include the the client who may be harmed if the behavior does
employing agency’s standards for care, written policies and not change?
procedures, care plans or clinical pathways, and the testi-
mony of expert witnesses (Fig. 3-4). PROFESSIONAL LIABILITY
The best protection against malpractice lawsuits is
competent nursing. Nurses demonstrate competency by par- All professionals, including nurses, are held responsible and
ticipating in continuing education programs, taking nurs- accountable for providing safe and appropriate care. Because
ing courses at colleges or universities, and becoming certi- nurses have specialized knowledge and proximity to clients,
fied. Defensive nursing practice also involves thorough and they have a primary role in protecting clients from prevent-
objective documentation (see Chap. 9). able or reversible complications.
LWBK1004-C03_p33-49.indd 40 26/01/12 3:00 AM

Stan Standards
da
Care rdized of Practice
P
Critic lan (ANA,
Path al The Joint
w
Prac ay Commission,
Guid tice specialty
eline
organizations)
Hospital Policy
and
Procedure
Manual
Expert
Witness
Previous
FIGURE 3-4 Data that establish standards of Patients Court
Bill of Rulings
care. (From Timby, B. K., & Smith, N. E. [2010].
Rights
Introductory medical-surgical nursing [10th
ed., p. 41]. Philadelphia: Lippincott Williams &
Wilkins.)
The number of lawsuits involving nurses is increasing. Liability insurance is available through the National Fed-
It is to every nurse’s advantage to obtain liability insurance eration for Licensed Practical Nurses, the National Stu-
and to become familiar with legal mechanisms, such as Good dent Nurses’ Association, the American Nurses Association
Samaritan laws and statutes of limitations, that may prevent (ANA), and other private insurance companies.
or relieve culpability, as well as with strategies for providing
a sound legal defense, such as written incident reports and Reducing Liability
anecdotal records. It is unrealistic to think that lawsuits can be avoided com-
pletely. Some avenues protect nurses and other health care
Liability Insurance workers from being sued or provide a foundation for a sound
Liability insurance (a contract between a person or corpo- legal defense. Examples include Good Samaritan laws,
ration and a company willing to provide legal services and statutes of limitations, principles regarding assumption of
financial assistance when the policyholder is involved in a risk, appropriate documentation, risk management, incident
malpractice lawsuit) is necessary for all nurses. Although reports, and anecdotal records.
many agencies have liability insurance with an umbrella
clause that includes its employees, nurses should obtain Good Samaritan Laws
their own personal liability insurance. The advantage is that Most states have enacted Good Samaritan laws, which pro-
a nurse involved in a lawsuit will have a separate attorney vide legal immunity to passersby who provide emergency
working on his or her sole behalf. Because the damages first aid to victims of accidents. The legislation is based on
sought in malpractice lawsuits are so costly, attorneys hired the biblical story of the person who gave aid to a beaten
by health care facilities sometimes are more committed to stranger along a roadside. The law defines an emergency
defending the facility against liability and negative publicity, as one occurring outside of a hospital, not in an emergency
rather than defending an employed nurse whom they also are department.
being paid to represent. Although these laws are helpful, no Good Samaritan law
Student nurses are held accountable for their actions dur- provides absolute exemption from prosecution in the event
ing clinical practice and should also carry liability insurance. of injury. Paramedics, ambulance personnel, physicians,
LWBK1004-C03_p33-49.indd 41 26/01/12 3:00 AM

and nurses who stop to provide assistance are still held to All witnesses are identified by name. Any pertinent
a higher standard of care because they have training above statements made by the injured person, before or after the
and beyond that of average lay people. In cases of gross incident, are quoted. Accurate and detailed documentation
negligence (total disregard for another’s safety), health care often helps to prove that the nurse acted reasonably or appro-
workers may be charged with a criminal offense. priately in the circumstances.
Statute of Limitations Anecdotal Records

Each state establishes a statute of limitations (designated An anecdotal record (personal, handwritten account of an
time within which a person can file a lawsuit). The length incident) is not recorded on any official form, nor is it filed
varies among states and generally is calculated from when the with administrative records. The nurse retains the informa-
incident occurred. When the injured party is a minor, how- tion, which is safeguarded and may be used later to refresh
ever, the statute of limitations sometimes does not commence the nurse’s memory if a lawsuit develops. Anecdotal notes
until the victim reaches adulthood. When the time expires, can be used in court on advice of an attorney.
an injured party can no longer sue, even if his or her claim is
legitimate. Malpractice Litigation
A successful outcome in a malpractice lawsuit depends on
Assumption of Risk many variables, such as physical evidence and attorney exper-
If a client is forewarned of a potential safety hazard and tise. The appearance, demeanor, and conduct of the nurse
chooses to ignore the warning, the court may hold the client defendant inside and outside of the courtroom, however, can
responsible. For example, if a hospitalized client objects help or damage the case. Suggestions in Box 3-3 may help if
to having the side rails up or lowers the rails independ- a nurse becomes involved in malpractice litigation.
ently, the nurse or health care facility may not be held fully
accountable for an injury. It is essential that the nurse docu-
ment that he or she warned the client and that the client dis- ETHICS
regarded the warning. The same recommendation applies
when nurses caution clients about ambulating only with The word “ethics” comes from the Greek word ethos, meaning
assistance. customs or modes of conduct. Ethics (moral or philosophical
principles) direct actions as being either right or wrong. Var-
Documentation ious organizations, such as those representing nurses, have
A major component to limiting liability is accurate, thor- identified standards for ethical practice, known as a code of
ough documentation. Nurses are held responsible or liable ethics, for members within their discipline.
for information that they either include or exclude in reports
and charting. Each health care setting requires accurate Codes of Ethics
and complete documentation. The medical record is a legal A code of ethics (a list of written statements describing
document and is used as evidence in court. Records must ideal behavior) serves as a model for personal conduct. The
be timely, objective, accurate, complete, and legible (see National Association for Practical Nurse Education and Serv-
Chap. 9). The quality of the documentation, including neat- ices, the National Federation for Licensed Practical Nurses,
ness and spelling, can influence a jury’s decision. and the International Council of Nurses all have composed
codes of ethics. Box 3-4 shows the ANA’s current code of
Risk Management ethics. Because of rapidly changing technology, no code is
Risk management (the process of identifying and reduc- ever specific enough to provide guidelines for every dilemma
ing the costs of anticipated losses) is a concept originally that nurses may face.
developed by insurance companies. Health care institutions
now employ risk managers to review all the problems in the Ethical Dilemmas
workplace, identify common elements, and then develop An ethical dilemma (choice between two undesirable alter-
methods to reduce their risk. A primary tool of risk manage- natives) occurs when individual values and laws conflict.
ment is the incident report. This is especially true in relation to health care. Occasion-
ally, nurses find themselves in situations that are legal but are
Incident Reports personally unethical, or are ethical but illegal. For instance,
An incident report is a written account of an unusual, poten- abortion is legal, but some believe it is unethical. Assisted
tially injurious event involving a client, employee, or visitor suicide is illegal (except in Oregon and Washington state),
(Fig. 3-5). It is kept separate from the medical record. Inci- but some believe it is ethical.
dent reports determine how to prevent hazardous situations
and serve as a reference in case of future litigation. They Ethical Theories
must include five important components: (1) when the inci- Nurses generally use one of two ethical problem-solving
dent occurred; (2) where it happened; (3) who was involved; theories to guide them in solving ethical dilemmas. These
(4) what happened; and (5) what actions were taken. are teleology and deontology.
LWBK1004-C03_p33-49.indd 42 26/01/12 3:00 AM

THREE RIVERS AREA HOSPITAL INCIDENT REPORT Addressograph

CONFIDENTIAL—DO NOT DUPLICATE
Forward to Risk Managment within 48 hours
Indentification Sex Age Incident Date Time Shift Department
Inpatient M / / : 1st
Outpatient F 2nd
Visitor 3rd
Reason for hospitalization/presence on premises:
I. Location of Incident: II. Type of Incident:

Patient room # Fall Treatment/procdure
Patient bathroom Medication Equipment
Corridor Infusion Needle/sponge count
Other Lost/found Other
Burn
III. Description of Incident:
IV. Nature of Incident:

A. FALLS:
Activity Order: Pt. Condition Prior to: Fall Involved: Patient/Visitor was:
Restraints Weak, unsteady Chair, W/C Lying
Bedrest only Alert, oriented Stretcher Standing
BRP Disoriented/confused Tub/shower Getting on/off
Up w/asst. Senile Toilet Sitting
Up AD LIB Unconscious Floor condition (below) Ambulating
Medicated/sedated Bed Other
Med. name Side rails up
Last dose Side fails down
B. MEDICATIONS:
Incident Involved: Factors:
Wrong Med, Tx, Adverse reaction Patient I.D not checked Charting
procedure Infiltration Transcription Wrong med from
Wrong patient Other Labeling pharmacy
Wrong time Physician orders Defective equipment
Omission not clear Communications
Incorrect dose Physician orders Other
Incorrect method of not checked
administration Misread label/dose
C. OTHER:
Loss of property Equipment malfuction Patient I.D.
Struck by object, equipment Anesthesia Other
V. Nature of Injury (Injury sustained as a result of incident):
Asphyxia, strangulation, Fracture or dislocation Burn or scald
inhalation Viscera injury Chemical burn
Head injury Sprain or strain No injury
Contagious or infectious Contusion, cut, No apparent injury
disease exposure laceration Other
VI. Actions Taken:
Physician notified: Pt./visitor seen by MD/T&EC: MD Name Time
Yes No Yes No :
Physician’s findings:
Other follow up: No Yes–Specify
/ / / /
Name of Person Reporting Date Department Director Date
/ / / /
Supervisor Date Risk Management Date
FIGURE 3-5 Example of an incident report form.
LWBK1004-C03_p33-49.indd 43 26/01/12 3:00 AM

B OX 3 - 3 Legal Advice B OX 3 - 4 Code of Ethics for Nurses

1. Notify the claims agent of your professional liability insur- 1. The nurse, in all professional relationships, practices with
ance company. compassion and respect for the inherent dignity, worth, and
2. Contact the National Nurses Claims Database through the uniqueness of every individual, unrestricted by considera-
ANA. This confidential service provides information that tions of social or economic status, personal attributes, or the
supports nurses involved in litigation. nature of health problems.
3. Discuss the particulars of the case only with your attorney. 2. The nurse’s primary commitment is to the patient, whether
4. Tell your attorney everything. an individual, family, group, or community.
5. Avoid giving public statements. 3. The nurse promotes, advocates for, and strives to protect the
6. Reread the client’s record, incident sheet, and your anecdo- health, safety, and rights of the patient.
tal notes before testifying. 4. The nurse is responsible and accountable for individual
7. Ask to reread information in court if it will help to refresh nursing practice and determines the appropriate delegation
your memory. of tasks consistent with the nurse’s obligation to provide
8. Dress conservatively, in a businesslike manner. Avoid optimum patient care.
excesses in makeup, hairstyle, or jewelry. 5. The nurse owes the same duties to self as to others, includ-
9. Look directly at whomever asks a question. ing the responsibility to preserve integrity and safety, to
10. Speak in a modulated but audible voice that the jury and maintain competence, and to continue personal and profes-
others in the court can hear easily. sional growth.
11. Tell the truth. 6. The nurse participates in establishing, maintaining, and
12. Use language with which you are comfortable. Do not try improving health care environments and conditions of
to impress the court with legal or medical terms. employment conducive to the provision of quality health
13. Say as little as possible in court under cross-examination. care and consistent with the values of the profession through
14. Answer the prosecuting lawyer’s questions with “Yes” or individual and collective action.
“No”; limit answers to only the questions asked. 7. The nurse participates in the advancement of the profession
15. If you do not know or cannot remember information, through contributions to practice, education, administration,
say so. and knowledge development.
16. Wait to expand on information if asked by your defense 8. The nurse collaborates with other health professionals and
attorney. the public in promoting community, national, and interna-
17. Remain calm, objective, and cooperative. tional efforts to meet health needs.
9. The profession of nursing, as represented by associations
and their members, is responsible for articulating nursing
values, for maintaining the integrity of the profession and its
Teleologic Theory practice, and for shaping social policy.
Teleology is ethical decision making based on final out-
comes. It is also known as utilitarianism because the ultimate Adapted from Fowler, M. D. M., American Nurses Association. (2010).
Guide to the Code of Ethics for Nurses: Interpretation and Application.
ethical test for any decision is based on what is best for the Silver Spring, MD, American Nurses Association.
most people. Stated from a different perspective, teleologists
believe “the end justifies the means.” Thus, the choice that
benefits many people justifies harm that may come to a few. proposes that health care providers have a moral duty to
A teleologist would argue that selective abortion (destroying maintain and preserve life. Thus, deontologists would con-
some embryos in a multiple pregnancy) is ethical because it sider it immoral for a nurse to assist with abortion, suicide
is done to ensure the full-term birth of those that remain. In for the terminally ill, or execution of a convicted prisoner.
other words, termination can be justified in some situations Deontology also proposes that moral duty to others is
but may not be justified in all cases. equally as important as consequences. A duty is an obliga-
Teleologists analyze ethical dilemmas on a case-by-case tion to perform or to avoid an action to which others are enti-
basis. They propose that an action is not good or bad in and tled. For example, deontologists believe that lying is never
of itself. Instead, the consequences determine whether the acceptable because it violates the duty to tell the truth to
action is good or bad. The primary consideration is a desir- those entitled to honest information. Nurses ultimately have
able outcome for those most affected. a professional duty to their clients, and clients have rights to
Deontologic Theory which they are entitled (Box 3-5).
Deontology is ethical decision making based on duty or
moral obligations. It proposes that the outcome is not the pri- ➧ Stop, Think, and Respond Box 3-2
mary issue; rather, decisions must be based on the morality of How might a teleologist and a deontologist approach
the act itself. In other words, certain actions are always right an ethical dilemma such as managing the care of an
or wrong regardless of circumstances. Deontologists would infant with microcephaly (small brain and severe
argue that destroying any fetus is wrong, whether done to cognitive impairment) who develops a very high fever
save others or not, because killing is immoral. Deontology as a result of an infection?
LWBK1004-C03_p33-49.indd 44 26/01/12 3:00 AM

B OX 3 - 5 A Patient’s Bill of Rights Ethical Principles

It is sometimes impossible or impractical to analyze ethical
1. The patient has the right to considerate and respectful care. issues from a teleologic or deontologic point of view. Most
2. The patient has the right to and is encouraged to obtain nurses do not exclusively use one theory’s principles. They
from physicians and other direct caregivers relevant, cur-
also can base ethical decisions on six principles that form
rent, and understandable information concerning diagnosis,
treatment, and prognosis.
a foundation for ethical practice: beneficence, nonmalefi-
3. The patient has the right to make decisions about the cence, autonomy, veracity, fidelity, and justice. These princi-
plan of care prior to and during the course of treatment ples sometimes conflict with each other.
and to refuse a recommended treatment or plan of care to
the extent permitted by law and hospital policy and to be Beneficence and Nonmaleficence
informed of the medical consequences of this action. Beneficence means “doing good” or acting for another’s
4. The patient has the right to have an advance directive (such benefit. To do good, an ethical person prevents or removes
as a living will, health care proxy, or durable power of any potentially harmful factor. For example, if a client has
attorney for health care) concerning treatment or designat- cancer, the beneficent act is to eliminate the cancer with sur-
ing a surrogate decision maker with the expectation that the gery, drugs, or radiation. The difficulty, however, is that a
hospital will honor the intent of that directive to the extent health care worker’s approach to “doing good” may not be
permitted by law and hospital policy. what the client feels is best. The client may prefer no treat-
5. The patient has the right to every consideration of privacy.
ment of the cancer.
Case discussion, consultation, examination, and treatment
should be conducted so as to protect each patient’s privacy.
Nonmaleficence means “doing no harm” or avoid-
6. The patient has the right to expect that all communications ing an action that deliberately harms a person. Sometimes,
and records pertaining to his or her care will be treated however, “harm” is necessary to promote “good.” In the
as confidential by the hospital, except in cases such as previous example of cancer, available treatments can cause
suspected abuse and public health hazards when reporting pain, nausea, vomiting, hair loss, and susceptibility to
is permitted or required by law. infection. Yet, the ultimate benefit is eradicating the can-
7. The patient has the right to review the records pertain- cer. This is an example of the principle of double effect.
ing to his or her medical care and to have the informa- The following criteria can help to resolve cases involving
tion explained or interpreted as necessary, except when double effect:
restricted by law.
8. The patient has the right to expect that, within its capacity • The action itself must not be intrinsically wrong; it must be
and policies, a hospital will make a reasonable response to good or neutral.
the request of a patient for appropriate and medically indi- • Only the good effect must be intended, even though the
cated care and services. The hospital must provide an harmful effect is foreseen.
evaluation, a service, and/or a referral as indicated by the • The harmful effect must not be the means of the good
urgency of the case. effect.
9. The patient has the right to ask and be informed of the
• The good effect must outweigh the harmful effect (Gracyk,
existence of business relationships among the hospital,
educational institutions, other health care providers, or
2008).
payers that may influence the patient’s treatment and care.
10. The patient has the right to consent to or decline to partici- Autonomy
pate in proposed research studies or human experimenta- Autonomy refers to a competent person’s right to make his
tion affecting care and treatment or requiring direct patient
or her own choices without intimidation or influence. For
involvement, and to have those studies fully explained
prior to consent.
a person to make a decision, he or she must have all rel-
11. The patient has the right to expect reasonable continuity of evant information, including treatment options in language
care when appropriate and to be informed by physicians he or she understands. The client always has the option of
and other caregivers of available and realistic patient care obtaining a second opinion from another practitioner. One
options when hospital care is no longer appropriate. outcome may be that the client declines all possible options
12. The patient has the right to be informed of hospital policies for treatment, a decision that must be respected.
and practices that relate to patient care, treatment, and Conflict can arise if the client’s choice poses more risk
responsibilities. The patient has the right to be informed than potential benefit; is illegal (eg, requesting assistance
of available resources for resolving disputes, grievances, with suicide), morally objectionable, or medically inappro-
and conflicts. The patient has the right to be informed of priate; or interferes with the needs of another person whose
the hospital’s charges for services and available payment
case merits higher priority. An example is a young woman
methods.
who seeks the removal of both breasts because she fears
© 1992 American Hospital Association. breast cancer. In such a case, the duty to respect the client’s
wishes can be nullified. One option may be to refer the client
to another practitioner.
LWBK1004-C03_p33-49.indd 45 26/01/12 3:00 AM

Veracity • Make sure that whatever is done is in the client’s best

Veracity means the duty to be honest and avoid deceiving interest.
or misleading a client. This principle causes conflict when • Preserve and support A Patient’s Bill of Rights (see Box 3-5).
the truth may harm the client by interfering with recovery • Work cooperatively with the client and other health
or worsening the present condition. Avoiding the truth, how- practitioners.
ever, is never justified when it is used to shield the caregiver’s • Follow written policies, codes of ethics, and laws.
discomfort with sharing “bad news” (Aiken, 2004). • Follow your conscience.
Fidelity Ethics Committees

Fidelity means being faithful to work-related commitments Ethical decisions are complex, especially when they affect
and obligations. Its application relates to the caregiver’s obli- the lives of clients. Because making a judgment for another
gation to clients. For example, nurses are obligated to be com- is a weighty responsibility, many health care agencies have
petent in performing skills and services required for safe and established ethics committees. These committees consist of
appropriate care. This implies that nurses pursue continuing a broad cross section of professionals and nonprofession-
education and maintain current certification for cardiopulmo- als within the community with varying viewpoints. Their
nary resuscitation (CPR). It also requires that nurses respect diversity encourages healthy debate about ethics issues.
clients, provide compassionate care, protect confidentiality, Ethics committees are best used in a policy-making capac-
honor promises, and follow their employer’s policies. ity before any specific dilemma. They are also called on to
offer advice, however, to protect clients’ best interests and to
Justice avoid legal battles.
Justice mandates that clients be treated impartially with-
out discrimination according to age, gender, race, religion, Common Ethical Issues
socioeconomic status, weight, marital status, or sexual Several ethical issues recur in nursing practice. Examples
orientation. In other words, everyone should have equal dis- include telling the truth, maintaining confidentiality, with-
tribution of goods and services. holding or withdrawing treatment, advocating for ethical
In reality, circumstances may force nurses to devote allocation of scarce resources, and protecting vulnerable
more attention to an unstable client. For example, a person people from unsafe practices or practitioners.
arrives in the emergency department with fever and vomit-
ing. Shortly thereafter, another person presents with chest Truth Telling
pain. The nurse decides to attend to the client with chest pain Truth telling proposes that all clients have the right to com-
first. Another example of inequity is when more than one cli- plete and accurate information. It implies that physicians
ent needs a scarce resource, such as an organ for transplan- and nurses have a duty to tell clients the truth about matters
tation. Although several clients have the right to the organ, concerning their health. Personnel demonstrate respect for
only one can receive it. this right by explaining to the client the status of his or her
When goods and services cannot be allocated equally, health problem, the benefits and risks of treatment, alterna-
decisions are based on need, merit, or potential for contribu- tive forms of treatment, and consequences if the treatment is
tion. In the example of the transplant organ, based on need, not administered.
the most critically ill person would receive it. Based on merit, It is the physician’s duty to inform clients. Conflict
the organ would be given to the person who worked hardest or occurs when the client has not been given full informa-
made the greatest effort at this point in his or her life. Based tion, when facts have been misrepresented, or when a client
on contribution, the person with the greatest potential for posi- misunderstands information. In some cases, physicians are
tively influencing society in the future would receive the organ reluctant to talk honestly with clients or present the proposed
(Petechuk, 2006; Principle of Distributive Justice, 2007). treatment in a biased manner. Often, the nurse is forced to
choose between remaining silent in allegiance to the physi-
Values and Ethical Decision Making cian and providing the client with the truth. Either action
When a nurse has not taken a course in ethics, his or her may have frustrating consequences.
ethical decisions are often the result of values. Values are a
person’s most meaningful beliefs and the basis on which he Confidentiality
or she makes most decisions about right or wrong. Values Confidentiality, or safeguarding a person’s health infor-
commonly are (1) acquired from parental models, life expe- mation from public disclosure, is the foundation for trust.
riences, and religious tenets; (2) reinforced by a person’s Nurses must not divulge health information to unauthorized
world view; (3) modeled in personal behavior; (4) consistent people without the client’s written permission. Even giving
over time; and (5) defended when challenged. medical information to a client’s health insurance company
The following serve as guidelines to ethical decision requires a signed release. Consequently, nurses must use dis-
making: cretion when sharing verbal information so that others do
LWBK1004-C03_p33-49.indd 46 26/01/12 3:00 AM

LIVING WILL
TO: My family, physicians and all those concerned with my care
I, ___________________________, the undersigned “principal”, presently residing at _____________________, ____________,

and being an adult of sound mind, make this declaration as a directive to be followed if for any reason I become unable to make or
communicate decisions regarding my medical care.
I do not want medical treatment that will keep me alive if I am unconscious and there is no reasonable prospect that I will ever be
conscious again (even if I am not going to die soon in my medical condition) or if I am near death from an illness or injury with no
reasonable prospect of recovery. The procedures and treatment to be withheld and withdrawn include, without limitation, surgery,
antibiotics, cardiac and pulmonary resuscitation, respiratory support, and artificially administered feeding and fluids. I direct that
treatment be limited to measures to keep me comfortable and to relieve pain, even if such measures shorten my life.
[OPTIONAL] I wish to live out my last days at home rather than in a hospital, if it does not jeopardize the chance of my recovery to
a meaningful and conscious life and does not impose an undue burden on my family.
[OPTIONAL] If, upon my death, any of my tissue or organs would be of value for transplantation, therapy, advancement of medical
or dental science, research, or other medical, educational or scientific purpose, I freely give my permission to the donation of such
tissue or organs.
These directions are the exercise of my legal right to refuse treatment. Therefore, I expect my family, physicians, health care
facilities and all concerned with my care to regard themselves as legally and morally bound to act in accordance with my wishes,
and in so doing to be free from any liability for having followed my directions.
IN WITNESS WHEREOF, I have executed this declaration, as my free and voluntary act and deed, this _______ day of ________,
2003.
___________________________________________ ___________________________________________
Principal’s name: WITNESS:
FIGURE 3-6 A living will.
not hear it indiscriminately. Now that vast information about use—in a terminal condition, irreversible coma, or persist-
clients is stored on computers, the duty to protect confiden- ent vegetative state with no hope of recovery (Fig. 3-6).
tiality extends to safeguarding written and electronic data. Clients must share advance directives with health care pro-
viders to ensure that they are implemented (see Client and
Withholding and Withdrawing Treatment
Family Teaching 3-1).
Technology often is used to prolong life at all costs, beyond
A durable power of attorney for health care desig-
justifying its benefits. Decisions involving life and death
nates a proxy for making medical decisions when the client
may sometimes continue to circumvent clients, a clear vio-
becomes so incompetent or incapacitated that he or she can-
lation of ethical principles. Completing advance directives
not make decisions independently. The designee can give or
and determining a client’s code status ensure that a person’s
withhold permission for treatments on the client’s behalf in
health care is in accordance with his or her wishes.
end-of-life circumstances or when the client is temporarily
Advance Directives unconscious.
Legislation now mandates the discussion of terminal care Living wills and durable powers of attorney for health
with clients. Since Congress approved the Patient Self- care are not measures reserved for older adults; any compe-
Determination Act in 1990, health care agencies reimbursed tent adult can initiate them. They are best composed before
through Medicare must ask clients whether they have exe- a health crisis develops to assist care providers and signifi-
cuted an advance directive (written statement identifying cant others to comply with the client’s wishes. A living will
a competent person’s wishes concerning terminal care). The and health care proxy can avoid legal expenses, delays in
two types of advance directives are a living will and a dura- obtaining guardianship, or unwanted decisions made by
ble power of attorney for health care. an ethics committee or court. Thus, nurses should inform
A living will is an instructive form of an advance direc- all clients about their right to self-determination, encour-
tive; that is, it is a written document that identifies a person’s age them to compose advance directives, and support their
preferences regarding medical interventions to use—or not decisions.
LWBK1004-C03_p33-49.indd 47 26/01/12 3:00 AM

prematurely. One strategy is “first come, first served.”

Client and Family Teaching 3-1 Another is to project what would produce the most good for
Advance Directives
the most people, although predicting the future is impossible.
The nurse teaches the following points:
Whistle-Blowing
● An advance directive is not required, but it is encouraged.
Whistle-blowing (reporting incompetent or unethical prac-
● A lawyer is not needed to create an advance directive;
tices), as the name implies, calls attention to unsafe or poten-
printed forms are available from health care agencies,
organizations such as the American Association of Retired tially harmful situations. Usually, it occurs in the institution
Persons, and various Internet sites such as http://www. where the reporting person is employed. For instance, a
ama-assn.org/publicbooklets/livgwill.htm. nurse may report another nurse or physician who cares for
● When filling out the form, indicate specific wishes for the clients while under the influence of alcohol or a controlled
initiation or withdrawal of life-sustaining medical treat- substance.
ments such as CPR, kidney dialysis, mechanical ventila- Whenever a problem is identified, the first step is to
tion, use of a tube for administering food and water, report the situation to an immediate supervisor. If the super-
obtaining comfort measures such as pain medication, and visor takes no action, the nurse faces an ethical dilemma
donation of organs. about any further steps. Going beyond the administrative
● Write additional instructions if something is not ad-
hierarchy and making public revelations may be necessary.
dressed in the form; for example, your instructions may
The decision to “blow the whistle” involves personal
be different if you are pregnant.
● Obtain the signatures of two witnesses, other than your risks and may result in grave consequences such as charac-
physician or spouse. ter assassination, retribution in the form of crimes against
● Give a copy to your physician for your medical file. one’s person or property, negative evaluations, demotions,
● Tell family members or your lawyer that you have an or shunning. Nevertheless, the ethical priority is protecting
advance directive and its location. clients in general and the community at large.
● Keep the original advance directive in a place where it can
be found easily.
● Bring a copy of your advance directive whenever you are CRITICAL THINKING EXERCISES
hospitalized or admitted to a health care facility (eg, nurs-
ing home, extended care facility). 1. What actions might protect a nurse from being sued
● Change your advance directive by revoking or adding in- when a client assigned to his or her care falls out of
structions at any time; share the revised copy with those bed?
who will carry out your instructions. 2. A client who fell while ambulating to the bathroom
● A separate or different advance directive is not needed sues the assigned nurse. Based on the elements neces-
for each state; they are generally recognized universally sary in a malpractice lawsuit, what must the client’s
within the United States.
lawyer prove? What defense may the nurse’s lawyer
offer?
3. What criteria justify assisted suicide?
Code Status
4. Two people need a liver transplant; only one liver is
A code status refers to how health care personnel are
available. What information might a teleologist and a
required to manage care in the case of cardiac or respira-
deontologist use to determine who should receive the
tory arrest. Without a written order from the physician to the
organ?
contrary, the client is designated as a full code. A full code
means that all measures to resuscitate the client are used.
After a discussion with the physician, some clients indi-
cate that they want no resuscitative efforts, that is, “no code”
or “do not resuscitate (DNR).” Or they may select a combi- 1. If a nurse suspects that a colleague is stealing narcot-
nation of interventions that constitute less than a full code. ics and recording their administration to assigned
Some clients specify using drugs, but refuse cardiac defibril- clients, what is the first action the nurse should take?
lation or endotracheal intubation for mechanical ventilation. 1. Refer the nurse to the ethics committee
For anything less than a full code, the physician must write 2. Notify the local police department
an order to that effect in the client’s medical record. 3. Share concerns with nursing peers
4. Report suspicions to a supervisor
Allocation of Scarce Resources 2. In a preoperative assessment, what information is
Allocation of scarce resources is the process of deciding most important for the nurse to obtain?
how to distribute limited life-saving equipment or proce- 1. Birth certificate
dures among several who could benefit. Such decisions are 2. Social security number
difficult. In effect, those who receive the resources have a 3. Advance directive
greater chance to live, whereas those who do not may die 4. Proof of insurance
LWBK1004-C03_p33-49.indd 48 26/01/12 3:00 AM

3. After checking the condition of a client who has 5. An agitated and abusive client demands to leave
fallen out of bed, what should be the next nursing the hospital. Which of the following nursing actions
action? places the nurse at highest risk for being charged
1. Institute fall precautions with false imprisonment?
2. Complete an incident report 1. The nurse administers a sedative drug to the client.
3. Call the nursing supervisor 2. The nurse threatens to restrain the unruly client.
4. Notify the client’s family 3. The nurse calls for security to escort the client.
4. An unresponsive client with terminal cancer stops 4. The nurse publicly talks about the client’s behavior.
breathing and has no pulse. There is no advance
directive or “do not resuscitate” order on the chart.
What action should the nurse take next?
1. Note the time of death
2. Notify the physician
3. Perform postmortem care
4. Begin resuscitative efforts
LWBK1004-C03_p33-49.indd 49 26/01/12 3:00 AM

4 Health and Illness
acute illness
beliefs
capitation 1. Describe how the World Health Organization (WHO) defines
case method health.
chronic illness 2. Discuss the difference between values and beliefs, and list
congenital disorder health beliefs common among Americans.
continuity of care 3. Explain the concept of holism.
diagnostic-related group 4. Identify five levels of human needs.
exacerbation 5. Define illness and terms used to describe illness.
extended care 6. Differentiate primary, secondary, tertiary, and extended care.
functional nursing 7. Name two programs that help finance health care for the
health aged, disabled, and poor.
health care system 8. List four methods to control escalating health care costs.
health maintenance organizations 9. Identify two national health goals targeted for the year 2020.
hereditary condition 10. Discuss five patterns that nurses use to administer client care.
holism
human needs
idiopathic illness
N
either health nor illness is an absolute state; rather, there are fluc-
illness
tuations along a continuum throughout life (Fig. 4-1). Because it is
integrated delivery system
impossible to be (or get) well and stay well forever, nurses are com-
managed care organizations
Medicaid mitted to helping people prevent illness and restore or improve their
Medicare health. Nurses accomplish these goals by the following:
morbidity • Helping people live healthy lives
mortality
• Encouraging early diagnosis of disease
nurse-managed care
• Implementing measures to prevent complications of disorders
nursing team
preferred provider organizations
primary care HEALTH
primary illness
primary nursing
The World Health Organization (WHO) is globally committed to
remission
secondary care
“Health for All.” In the preamble to its constitution, WHO defines
secondary illness health as “a state of complete physical, mental, and social well-being,
sequelae not merely the absence of disease or infirmity.” Each person perceives
team nursing and defines health differently. Nurses must recognize the importance
terminal illness of respecting such differences rather than imposing standards that
tertiary care may be unrealistic for the person.
values A person’s behaviors are the outcomes of his or her values and
wellness belief systems. Values are ideals that a person feels are important
(eg, knowledge, wealth, financial security, marital fidelity, health).
Beliefs are concepts that a person holds to be true. Beliefs and values
guide a person’s actions. Both health values and beliefs demonstrate
or affirm what is personally significant. When a person values health,
he or she takes actions to preserve it.
Most Americans believe one or all of the following: health is a
resource, a right, and a personal responsibility.
50
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CHAPTER 4 Health and Illness 51
health. Physical health exists when body organs function

High-Level Wellness normally. Emotional health results when one feels safe and
copes effectively with the stressors of life. Social health is
an outcome of feeling accepted and useful. Spiritual health
Good Health
is characterized as believing that one’s life has purpose. The
four components are collectively referred to as the concept
Levels of Health
Normal Health of holism (Fig. 4-2).
Holism
Illness
Holism (the sum of physical, emotional, social, and spiritual
health) determines how “whole” or well a person feels. Any
Critical Illness change in one component, positive or negative, automati-
cally creates repercussions in the others. Take, for example,
the person who has a heart attack. Obviously, his or her phys-
Death
ical health is immediately impaired. In addition, the heart
Time span (life span) attack affects the emotional, social, and spiritual aspects of
FIGURE 4-1 The health–illness continuum shows the different health. For example, the client may experience psychologi-
levels of health a person experiences over a lifetime. cal anxiety over this health change. His or her social roles
may temporarily or permanently change. The client may
Health: A Limited Resource explore philosophical and spiritual issues as he or she consid-
A resource is a possession that is valuable because its sup- ers the potential for death.
ply is limited and there is no substitute. Given that defini- Nurses profess to be “holistic practitioners” because
tion, health is considered quite precious. People often say, they are committed to restoring balance in each of the four
“as long as you have your health, you have everything,” and spheres that affect health. They base their strategies for
“health is wealth.” doing so on a hierarchy of human needs.
Health: A Right Hierarchy of Human Needs

The United States was founded on the principle that every- In the 1960s, Abraham Maslow, a psychologist, identified
one is equal and entitled to life, liberty, and the pursuit of five levels of human needs (factors that motivate behav-
happiness. Based on this premise, everyone, regardless of ior). He grouped the needs in tiers, or a sequential hierarchy
age, gender, level of education, religion, sexual orientation, (Fig. 4-3), according to their significance: physiologic (first
ethnic origin, social position, or wealth, is entitled to equal level), safety and security (second level), love and belonging
services for sustaining health. Unfortunately, as will be dis-
cussed later, health disparities exist among various groups
within the United States. These groups include the poor,
racial and ethnic minorities, those affected by gender differ-
ences, older adults, and people with disabilities. Efforts are Physical Emotional
under way, however, to eliminate health barriers and to pro-
mote equal access to health care (see discussion of Healthy
People 2020 later in this chapter). If all are equally deserving
of health, it follows that the nation in general and nurses in
particular have a duty to protect and preserve the health of
those who may be unable to assert this right for themselves.
Health: A Personal Responsibility

Health requires continuous personal effort. There is as much
potential for illness as there is for health. Each person is
Social Spiritual
instrumental in the outcome. Pilch (1981) said, “No one can
do wellness to or for another; you alone do it, but you don’t
do it alone.” Nurses stand ready to provide assistance and to
advocate on behalf of others.
WELLNESS
Wellness means a full and balanced integration of all aspects FIGURE 4-2 Holism is a concept that considers all aspects of
of health. It involves physical, emotional, social, and spiritual a person.
LWBK1004-C04_p50-59.indd 51 30/01/12 5:45 PM

a possible change in role performance or spiritual distress,

after the client’s health condition stabilizes.
ILLNESS
Illness (a state of discomfort) results when disease, deterio-

ration, or injury impairs a person’s health. Several terms are
used commonly when referring to illnesses: morbidity and
mortality; acute, chronic, and terminal; primary and second-
ary; remission and exacerbation; and hereditary, congenital,
Need for self- and idiopathic.
actualization
Need for esteem Morbidity and Mortality
and self-esteem Morbidity (incidence of a specific disease, disorder, or
Need for love injury) refers to the rate or the numbers of people affected.
and belonging
Federal statistics are compiled on the basis of age, gender,
Need for safety or per 1,000 people within the population. Mortality (inci-
and security
dence of deaths) denotes the number of people who died
Physiologic needs from a particular disease or condition. Table 4-1 lists the 10
FIGURE 4-3 Maslow’s hierarchy of human needs. leading causes of death among all Americans of all ages in
2006.
(third level), esteem and self-esteem (fourth level), and self-

actualization (fifth level). Gerontologic Considerations
The first-level physiologic needs are the most impor-
tant. They are the activities, such as breathing and eating, ■ Death rates from heart disease and strokes have contin-
necessary to sustain life. Each higher level is less important ued to decrease over the last three decades, whereas deaths
to survival than the previous levels. Maslow believed that from chronic lung disease, cancer, and diabetes increased
until a human satisfies his or her physiologic needs, he or from what some attribute to an aging population that is
she cannot or will not seek to fulfill other needs. By progres- obese and continues to smoke (Reuters, 2005).
sively satisfying needs at each level, however, people will
realize their maximum potential for health and well-being.
Nurses have adopted Maslow’s hierarchy as a tool for Acute, Chronic, and Terminal Illnesses
setting priorities for client care. For example, in the case of An acute illness (one that comes on suddenly and lasts
the client with a heart attack, the nurse considers the cli- a short time) is one method for classifying a change in
ent’s physical needs such as managing pain as a priority. The health. Influenza is an example of an acute illness. Many
nurse addresses other needs, such as assisting the client with acute illnesses are cured. Some lead to long-term problems
TABLE 4-1 Leading Causes of Death in the United States in 2006

PERCENTAGE OF TOTAL DEATHS
RANK CAUSE OF DEATH NUMBER 2006 2004

1 Diseases of the heart 631,636 26.03 27.2
2 Malignant neoplasms (cancer) 559,888 23.07 22.9
3 Cerebrovascular disease 137,119 5.65 6.2
4 Chronic lower respiratory diseases 124,583 5.13 5.1
5 Accidents (unintentional injuries) 121,599 5.01 4.5
6 Diabetes 72,448 2.99 3.0
7 Alzheimer’s disease 72,432 2.98 2.7
8 Influenza and pneumonia 56,326 2.32 2.5
9 Nephritis, nephritic syndrome, and nephrosis 45,344 1.86 1.7
10 Septicemia 34,234 1.41 1.3
From Heron, M., Hoyert, D.L., Murphy, S.L., et al. (2009). Deaths: Final data for 2006. Accessed September 2009,
from http://www.cdc.gov/nchs/data/nvsr57/nvsr57_14.pdf.
LWBK1004-C04_p50-59.indd 52 30/01/12 5:45 PM

because of their sequelae (singular: sequela; ill effects that (German measles) or exposure to toxic chemicals or drugs,
result from permanent or progressive organ damage caused especially during the first 3 months of pregnancy, often pre-
by a disease or its treatment). disposes the fetus to congenital disorders. Several decades
Chronic illness (one that comes on slowly and lasts a ago, many pregnant women took the drug thalidomide and
long time) increases as people age. Arthritis, a joint disease, subsequently gave birth to infants with missing arms and
is an example of a chronic illness. legs. There is a great deal of concern about the role of alco-
hol in producing fetal alcohol syndrome, a permanent but
preventable form of cognitive impairment, and the effects of
Gerontologic Considerations exposure to other environmental toxins. Although the etiolo-
gies for some congenital disorders are well established, they
■ Many older adults live with persistent health problems
can occur randomly.
and disabilities because they survived acute illnesses that
An idiopathic illness is an illness of unknown cause.
killed others years ago.
■ Four and a half million Americans now have
Treatment focuses on relieving the signs and symptoms
Alzheimer’s disease, which costs $100 billion to care for because the etiology is unknown. Examples of idiopathic
them. By the year 2050, the figure is expected to quadru- conditions include hypertension for which there is no known
ple as more people live into their 80s and 90s (Mayo cause or a fever of undetermined origin.
Clinic, 2009).
HEALTH CARE SYSTEM

A terminal illness (one in which there is no potential
for cure) is one that eventually is fatal. The terminal stage The health care system (the network of available health
of an illness is one in which a person is approaching death. services) involves agencies and institutions where people
seek treatment for health problems or assistance with main-
Primary and Secondary Illnesses taining or promoting their health. The health care system,
A primary illness (one that develops independently of any clients, and their diseases have drastically changed during
other disease) differs from a secondary illness (disorder the past 25 years (Box 4-1). Advances in technology and
that develops from a preexisting condition). For example, discoveries in science have created more elaborate meth-
pulmonary disease acquired from smoking is a primary ill- ods of diagnosing and treating diseases, creating a need for
ness. If pneumonia or heart failure occurs as a consequence more specialized care. What was once a system in which
of smoke-damaged lung tissue, it is considered a secondary people sought medical advice and treatment from one phy-
problem. In essence, the primary condition predisposed the sician, clinic, or hospital has now developed into a com-
smoker, in this case, to the secondary condition. plex system involving primary, secondary, tertiary, and
extended care.
Remission and Exacerbation
A remission means the disappearance of signs and symp- Primary, Secondary, and Tertiary Care
toms associated with a particular disease. Although a remis- Primary care (health services provided by the first health
sion resembles a cured state, the relief may be only tem- care professional or agency a person contacts) usually is
porary. The duration of a remission is unpredictable. An given by a family practice physician, nurse practitioner, or
exacerbation (reactivation of a disorder, or one that reverts physician’s assistant in an office or clinic. Cost-conscious
from a chronic to an acute state) can occur periodically in health care reforms advocate the provision of primary care
clients with long-standing diseases. Often, remissions and by advanced practice nurses.
exacerbations are related to how well or how poorly the An example of secondary care (health services to which
immune system is functioning, the stressors the client is fac- primary caregivers refer clients for consultation and addi-
ing, and the client’s overall health status (eg, nutrition, sleep, tional testing) is the referral of a client to a cardiac catheteri-
hydration). zation laboratory. Tertiary care (health services provided
at hospitals or medical centers where complex technology
Hereditary, Congenital, and
and specialists are available) may require that a client travels
Idiopathic Illnesses
some distance from home. The growing trend is to provide
A hereditary condition (disorder acquired from the genetic
as many secondary and tertiary care services as possible on
codes of one or both parents) may or may not produce symp-
an outpatient basis or to require no more than 24 hours of
toms immediately after birth. Cystic fibrosis, a lung disease,
inpatient care.
and Huntington’s chorea, a neurologic disorder, are exam-
ples of inherited illnesses. The first is diagnosed soon after
birth; the second is not manifested until adulthood. ➧ Stop, Think, and Respond Box 4-1
Congenital disorders (those present at birth but which A friend complains of having frequent bouts of indi-
are the result of faulty embryonic development) cannot gestion. Explain how primary, secondary, and tertiary
be genetically predicted. Maternal illness, such as rubella care might be involved in this client’s care.
LWBK1004-C04_p50-59.indd 53 30/01/12 5:45 PM

BOX 4-1 Trends in Health and Health Care Access to Care

According to the U.S. Census Bureau, an estimated
• Increased older adult population 46.3 million citizens do not have access to health care
• Greater ethnic diversity because of the economic burden it poses. This number reflects
• More chronic, but preventable illnesses a rate of 15.8%, a figure that is projected to rise one- or two-
• More older adults with cognitive disorders (eg, Alzheimer’s
tenths of a percent each year. As the number of people cov-
disease)
ered by an employer’s group health insurance has declined,
• Increased incidence of drug-resistant infections
• Decreased incidence of and death rates from HIV with reliance on government plans such as Medicare, Medicaid,
increased life expectancy associated with expensive drug and military health care have increased (DeNavas-Walt et al.,
therapy 2009). Children, older adults, minorities, and the poor are
• Expanded application of genetic engineering (treating dis- likely to be underserved. Many of these people delay seeking
eases by altering genetic codes) early treatment for their health problems because they can-
• Greater success in organ transplantation not afford to pay for services. When an illness becomes so
• Major efforts at cost containment severe that the only choice is to seek medical attention, many
• Continued rising costs of health care despite cost- turn to their local hospital emergency departments for care.
containment measures Inappropriate use of emergency departments is expensive
• Fewer insured and more underinsured citizens
and involves long waits and often no follow-up care.
• More outpatient or ambulatory (1-day stay) care
• Shorter hospital stays
• Less invasive forms of treatment Financing Health Care
• Shift to more home care Historically, private insurance, self-insurance systems,
• Greater focus on disease prevention, health promotion, and and Medicare paid for health care. Hospitals and approved
health maintenance providers received payment for what they charged; more
• Movement toward more self-care and self-testing charges increased income and profits. These plans offered
• Approval of more prescription drugs for nonprescription use
no incentives to control costs. Disparities in access to health
• Greater interest in herbal supplements and other “comple-
care and the high costs prompted evaluation of the entire
mentary” or alternative treatments
• Nationally linked computer information systems health care system. Subsequently, this led to innovative cost-
• Computerized medical record systems cutting approaches in government payment systems and
• Shift to criterion-based treatment (clients must meet estab- those financed by private insurers and corporate health plans.
lished criteria to justify treatment measures)
• Increased litigation against health professionals
Extended Care ■ The challenge that the majority of older adults face is the
Extended care (services that meet the health needs of clients high cost of paying for levels of care in skilled nursing facili-
who no longer require acute hospital care) includes rehabili- ties (Andrews & Boyle, 2007).
tation, skilled nursing care in a person’s home or a nursing ■ For the majority of older American adults, the long-held
home, and hospice care for dying clients. Extended care is value to be independent is so strong that many would
rather live alone even in poor health than be a burden to
an important component of the health care system because
his or her family (Andrews & Boyle, 2007).
it allows earlier discharge from secondary and tertiary care
agencies and reduces the overall expense of health care.
Government-Funded Health Care:
Medicare and Medicaid
Medicare (a federal program that finances health care costs
of persons aged 65 years and older, permanently disabled
■ With growing numbers of older dependent persons, soci-
ety is becoming burdened with providing care for aging workers of any age and their dependents, and those with end-
adults (Eliopoulos, 2010). stage renal disease) is funded primarily through withholdings
■ Older adults who require extended care are those who from an employed person’s income. Medicare has two parts:
have generally exhausted home care and various levels of
• Part A covers acute hospital care, rehabilitative care,
assisted living (Andrews & Boyle, 2007).
hospice, and home care services.
• Part B is purchased for an additional fee and covers physi-
Health Care Services cian services, outpatient hospital care, laboratory tests,
As a whole, health care services include those that offer health durable medical equipment, and other selected services.
prevention, diagnosis, treatment, or rehabilitation. As the types Although Medicare is primarily used by older Americans,
of health services expand, the health care delivery system it does not cover long-term care and limits coverage for
becomes more complex, costly, and in many cases inaccessible. health promotion and illness prevention.
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TABLE 4-2 Medicare Part D Prescription Drug ment, and the surgeries are reimbursed at basically the same
Benefits rate. If actual costs are less than the reimbursed amount, the
ANNUAL PRESCRIPTION COST MEDICARE CONTRIBUTION hospital keeps the difference. If costs exceed the reimbursed
TO PARTICIPANT amount, the hospital is left with the deficit. Hospitals that
Monthly premium of $30, are inefficient in managing clients’ recoveries and early dis-
subject to increase based charges can potentially lose vast revenue, possibly leading to
on date of enrolling closure of the facility.
$275 deductible of initial Since its inception, the DRG system has been largely
drug expenses responsible for marked decreases in hospital lengths of stay.
25% of prescription 75% of prescription drug costs
drugs $275–$2,510 between $275 and $2,510
Subsequently, three major criticisms have surfaced: (1) some
100% of drug costs 0% of drug costs = coverage older clients are discharged prematurely so as not to exceed
$2,510–$4,050 gap (also referred to as the the fixed reimbursement, (2) families have had to assume
“donut hole”) responsibility for the care of clients who cannot function
5% drug costs > $4,050 95% of drug costs > $4,050 independently after discharge, and (3) increased hospital
care costs have been charged to clients with private insur-
Data from Department of Health and Human Services, Centers for Medicare
& Medicaid Services (2009), and Medicare Prescription Drug Plans: Medicare ance to make up for the lost Medicare revenues. In response
Part D. Accessed September 2009, from http://www.webmd.com/medicare/ to cost-shifting and other economic forces, private insurance
medicare-part-d-prescription-plans.
companies have countered by aggressively challenging hos-
pital charges, refusing payment for unjustified billings, and
developing their own cost-containment reimbursement sys-
tem known as managed care.
In 2006, the Medicare drug benefit (Medicare Part
D) became available. This and similar plans are being
Managed Care
promoted as a means of relieving the financial burden on
Managed care organizations (MCOs) (private insurers
older Americans and those with low incomes and disabili-
who carefully plan and closely supervise the distribution of
ties who require prescription drugs. Everyone eligible for
their clients’ health care services) control costs of health care
Medicare can receive prescription drug coverage regardless
and focus on prevention as the best way to manage costs
of income, resources, health status, or current prescription
using the following techniques:
expenses. Part D includes additional cost-sharing assist-
ance for persons with incomes lower than $16,245 and • Using health care resources efficiently
assets less than $12,510 (Kaiser Family Foundation, 2009). • Bargaining with providers for quality care at reasonable
Nevertheless, gaps in the system remain (Table 4-2). People costs
are being advised to compare Medicare benefits with stand- • Monitoring and managing fiscal and client outcomes
alone prescription drug plans offered by private companies. • Preventing illness through screening and health promotion
Some may choose to purchase an additional “Medigap” activities
insurance plan to assist with the cost of deductible and co- • Providing client education to decrease the risk for disease
payments. • Minimizing the number of hospitalizations of clients with
Medicaid (a state-administered program designed chronic illness
to meet the needs of low-income residents) is supported
The two most common types of managed care systems
by funds from federal, state, and local sources. Each state
are health maintenance organizations (HMOs) and preferred
determines how the funds will be spent. In general, Med-
provider organizations (PPOs). Capitation is a third emerg-
icaid programs cover hospitalization, diagnostic tests, phy-
ing MCO financial strategy.
sician visits, rehabilitation, and outpatient care. They may
also cover long-term care when a person exhausts his or her
Health Maintenance Organizations
private funds.
Health maintenance organizations (HMOs) are corpora-
tions that charge preset, fixed, or yearly fees in exchange
Prospective Payment Systems for providing health care for their members. The fee remains
In response to escalating health care costs, the federal gov- the same regardless of the type of health service required or
ernment implemented a system of prospective payment in the frequency of care. These organizations are able to remain
1983 for people enrolled in Medicare. A prospective payment fiscally sound because they offer preventive services, peri-
system uses financial incentives to decrease total health care odic screenings, and health education to keep their members
charges by reimbursing hospitals on a fixed rate basis. Reim- healthy and out of the hospital.
bursement is based on the diagnostic-related group (DRG) HMOs provide ambulatory, hospitalization, and home
(a classification system used to group clients with similar care services. Some HMOs have their own health care facili-
diagnoses). For example, all clients receiving a hip, knee, or ties; others use facilities within the community. A member
shoulder replacement fall into DRG 209, total joint replace- of an HMO must receive permission for seeking additional
LWBK1004-C04_p50-59.indd 55 30/01/12 5:45 PM

care such as second opinions from specialists or unauthor- BOX 4-2 Integrated Delivery Systems’ Services
ized diagnostic tests. Those members who fail to do so are
responsible for the entire bill. In this way, HMOs serve as Integrated delivery systems provide:
gatekeepers for health care services. • Wellness programs
• Preventive care
Preferred Provider Organizations • Ambulatory care
Preferred provider organizations (PPOs) are agents for • Outpatient diagnostic and laboratory services
• Emergency care
health insurance companies that control health care costs on
• Secondary and tertiary services
the basis of competition. PPOs create a network of a com- • Rehabilitation
munity’s physicians who are willing to discount their fees for • Long-term care
service in exchange for a steady supply of referred clients. • Assisted living facilities
The subscriber’s clients can lower their health care costs by • Psychiatric care
receiving care from any of the preferred providers. If they • Home health care services
select providers outside the network, they pay a higher per- • Hospice care
centage of the costs. • Outpatient pharmacies
Capitation
An approach that is fundamentally different from HMOs and
PPOs is capitation, a payment system in which a preset fee
per member is paid to a health care provider (usually a hos-
pital or hospital system) regardless of whether the member
NATIONAL HEALTH GOALS
requires services. Capitation provides an incentive to pro-
A national ongoing health-promotion effort referred to as
viders to control tests and services as a means of making a
Healthy People 2020 is a continuation of the 1979 Surgeon
profit. If members do not receive costly care, the provider
General’s Report, Healthy People, and later, Healthy People
makes money.
2000: National Health Promotion and Disease Prevention,
and Healthy People 2010. The mission of Healthy People
Outcomes of Structured 2020 and its four main goals for promoting the nation’s
Reimbursement health in the 21st century are aimed at improving the quality
In many cases, the changes in reimbursements have shifted of life, not just increasing life expectancy, identifying major
economic and decision-making power from hospitals and factors that affect health and wellness, setting public health
physicians to insurance companies. One criticism is that priorities, and achieving health equity among the nation’s
it is difficult to obtain and provide health care without citizens (Box 4-3).
the economic pressure of insurers. Many claim that the Healthy People 2020’s four main goals are subdi-
profits of insurance companies come at the expense of vided into multiple topic areas, each of which has identi-
quality care. For example, hospitals are using unlicensed fied interventions that consist of programs, policies, and
assistive personnel to perform some duties that practical/ information; determinants that identify social, economic,
vocational and registered nurses once provided. Current environmental factors, and individual traits; and outcomes,
evidence shows that deaths in health care agencies increase such as behaviors, specific risk factors, diseases, mental dis-
as the numbers of licensed nurses decrease (Agency for orders, disabilities, injuries, and qualities of life (Fig. 4-4).
Healthcare Research and Quality of Care, 2004; Aiken Examples of targeted health goals for achievement are as
et al., 2008). follows:
On the other hand, cost-driven changes have had posi-
tive effects as well. As concern for cost meets concern for • Increase the proportion of people with health insurance
quality, health care institutions, nursing personnel, and other • In the health professions, allied and associated health pro-
providers search for ways to ensure that all care, teaching, fessions, and nursing increase the proportion of all degrees
and preparation before the discharge date occur without awarded to members of underrepresented racial and ethnic
overusing expensive resources. groups
In an attempt to reduce duplication of health care serv- • Increase the proportion of health and wellness, and treat-
ices and to increase revenue, hospitals and other health care ment programs and facilities that provide full access for
facilities are forming networks known as integrated delivery people with disabilities
systems. Integrated delivery systems (networks that provide • Reduce the number of new cases of cancer as well as the
a full range of health care services in a highly coordinated, illness, disability, and death caused by cancer
cost-effective manner) offer diverse options to clients (Box • Reduce infections caused by key food-borne pathogens
4-2) and result in shorter hospital stays, fewer complications • Improve the visual and hearing health nationally through
such as hospital-acquired infections, and quicker return to prevention, early detection, treatment, and rehabilitation
self-care. (Healthy People 2020)
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B O X 4 - 3 Healthy People 2020 Mission and The Healthy People 2020 campaign is being carried out
Goals with the combined expertise of the Public Health Service,
each state’s health department, national health organizations,
Mission the Institute of Medicine of the National Academy of Sci-
• Identify nationwide health improvement priorities
ences, and selected individuals from the public at large. To
• Increase public awareness and understanding of the determi-
nants of health, disease, and disability and the opportunities
meet the targeted goals, health care workers are challenged
for progress to implement strategies to improve the overall health of peo-
• Provide measureable objectives and goals that are applicable ple living in the United States.
at the national, state, and local levels
• Engage multiple sectors to take actions to strengthen policies
and improve practices that are driven by the best available NURSING TEAM
evidence and knowledge
• Identify critical research, evaluation, and data collection The goal of the nursing team (personnel who care for cli-
needs ents directly) is to help clients attain, maintain, or regain
health (Fig. 4-5). The team may include several types of pro-
Goals
fessionals as well as allied health care workers with special
• Eliminate preventable disease, disability, injury, and prema-
ture death
training such as respiratory therapists, physical therapists,
• Achieve health equity, eliminate disparities, and improve the and technicians.
health of all groups Nurses use their unique skills in the hospital as well as
• Create social and physical environments that promote good other employment areas. Because they have skills that assist
health for all the healthy, the dying, and all in between, nurses work in
• Promote healthy development and healthy behaviors across various settings such as HMOs, physical fitness centers,
every stage of life weight-loss clinics, public health departments, home health
agencies, and hospices. Wherever nursing personnel work
Fielding, J. E. (2009). Healthy People 2020: Improving our health futures. together, they use one of several patterns for managing client
Retrieved January 11, 2010 from http:www.dialogue4health.org/
webforum/PDFs_10_30_09/FIELDING02Oct2009.pdf. care. The five common management patterns are functional
Disparities/inequity to be assessed by: Determinants can include:

• Race/ethnicity • Social and economic factors
• Gender • Natural and built environments
• Socioeconomic status • Socioeconomic status
• Disability status • Policies and programs
• Lesbian, gay, bisexual, and
transgender status
• Geography
Achieve health Create social

• Life expectancy
equity, eliminate and physical
• Healthy life expectancy • Well-being/satisfaction
disparities, and environments that
• Physical and mental • Physical, mental, and
improve the health promote good
unhealthy days social health-related
of all groups health for all
• Self-assessed health status quality of life
• Limitation of activity • Participation in
• Chronic disease prevalence Attain high Promote common activities
• International comparisons quality, longer Disparities Social quality of life,
(where available) lives free and determinants healthy
of preventable inequity of health development,
disease, disability, and healthy
injury, and Health- behaviors
premature General related across all
Measures of Progress death health quality of life stages of life Measures of Progress
status and well-being
Overarching Goals of Overarching Goals of
Healthy People 2020 Healthy People 2020
Foundation Measures Category
FIGURE 4-4 Components of Healthy People 2020.
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Conferences are an important part of team nursing. They

Licensed may cover a variety of subjects but are planned with certain
Practical/ Registered goals in mind such as determining the best approaches to
Vocational Nurse
each client’s health problems, increasing the team mem-
Nurse
bers’ knowledge, and promoting a cooperative spirit among
nursing personnel.
The Client Primary Nursing

and
Family In primary nursing (a pattern in which the admitting nurse
Nursing Nursing assumes responsibility for planning client care and evaluat-
Assistant Students ing the client’s progress), the primary nurse may delegate the
client’s care to someone else in his or her absence but is con-
sulted when new problems develop or the plan of care requires
modifications. The primary nurse remains responsible and
Nursing accountable for specific clients until they are discharged.
Volunteer
Nurse-Managed Care
Another type of nursing care delivery system is nurse-
FIGURE 4-5 The nursing team.
managed care (a pattern in which a nurse manager plans the
nursing care of clients based on their type of case or medical
diagnosis). A clinical pathway typically is used in a managed
nursing, case method, team nursing, primary nursing, and care approach (see Chap. 1 for more information on man-
nurse-managed care. Each has advantages and disadvan- aged care and an example of a clinical pathway).
tages. Students are likely to encounter one or all of these Nurse-managed care was developed in response to sev-
methods in their clinical experience. eral problems affecting health care delivery today such as
the nursing shortage and the need to balance the costs of
Functional Nursing medical care with limited reimbursement systems. Nurse-
One method used when providing client care is functional managed care is similar to the principles used by successful
nursing (a pattern in which each nurse is assigned specific businesses. In the business world, corporations pay execu-
tasks). For example, one is assigned to give all the medica- tives to forecast trends and determine the best strategies for
tions, another performs all the treatments (such as dressing making profits. In nurse-managed care, a professional nurse
changes), and another works at the desk transcribing physi- evaluates whether predictable outcomes are met on a daily
cians’ orders and communicating with other nursing depart- basis. By meeting the outcomes in a timely manner, the cli-
ments about client care issues. This pattern is being used less ent is ready for discharge by the time designated by prospec-
often because its focus tends to be more on completing the tive payment systems, if not before.
task rather than caring for individual clients. Pilot studies indicate that this approach ensures that
standards of care are met with greater efficiency and cost sav-
ings. Hospitals that are adopting case-managed care report
Case Method that they are operating within their budgets and decreasing
The case method (a pattern in which one nurse manages all their financial losses.
the care a client or group of clients needs for a designated
period of time) should not be confused with managed care,
which is discussed later. The case method is most often used CONTINUITY OF HEALTH CARE
in home health, public health, and community mental health
nursing. Nurses who deliver this type of care are referred to Continuity of care (maintenance of health care from one
as case managers. level of health to another and from one agency to another)
ensures that the client navigates the complicated health care
Team Nursing system with a maximum of efficiency and a minimum of
Team nursing (a pattern in which nursing personnel divide frustration. The goal is to avoid causing a client, whether
the clients into groups and complete their care together) is healthy or ill, to feel isolated, fragmented, or abandoned.
organized and directed by a nurse called “the team leader.” All too often, this occurs when one health practitioner fails
The leader may assist with but usually assigns and supervises to consult or communicate with others involved in the cli-
the care that other team members provide. All team mem- ent’s care. Chapters 9 and 10 give examples of how nurses
bers report the outcomes of their care to the team leader. The communicate among themselves and with personnel in other
team leader is responsible for evaluating whether the goals institutions to ensure that the client’s care is both continuous
of client care are met. and goal directed.
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CRITICAL THINKING EXERCISES 4. All of the following are components of Maslow’s

hierarchy of human needs. Place the categories in
1. If you were asked to participate in planning the goals progressive sequence beginning with that which is
and strategies for Healthy People 2020, what sugges- most basic. Use all the options.
tions would you make to promote health and to 1. Need for love and belonging
reduce chronic illness? 2. Physiologic needs
2. Which pattern for managing client care seems most 3. Need for self-actualization
advantageous for nurses? Which pattern might clients 4. Need for esteem and self-esteem
prefer? Give reasons for your selections. 5. Need for safety and security
3. What arguments would you offer to persuade others 5. Which one of the following client problems is a nurse
that health care reform would be beneficial for pro- correct in identifying as one that compromises the
moting wellness among citizens of the United States? human need for safety and security?
4. Why might people who manage their diabetes 1. Chronic anxiety
effectively profess that they are “healthy”? 2. Labored breathing
3. Severe loneliness
4. Sleep deprivation
1. If all the following client problems exist, which is of
highest priority for nursing management?
1. Low self-esteem
2. Labored breathing
3. Feeling powerless
4. Lack of family support
2. What is the most appropriate initial nursing referral
for a person who is experiencing frequent headaches?
1. Refer to a drug company seeking clinical trial vol-
unteers for a headache medication
2. Refer to a neurologic institute conducting investi-
gational research on headaches
3. Refer to a hospital’s emergency department for
immediate medical treatment
4. Refer to a family practice physician for a baseline
physical examination
3. A hospital nurse’s referral to which type of organiza-
tion is best for promoting continuity of care for a
client with terminal cancer?
1. Preferred provider organization
2. Home health nursing organization
3. Health maintenance organization
4. Managed care organization
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5 Homeostasis,
Adaptation, and
Stress
adaptation
alarm stage
catastrophize 1. Explain homeostasis and list categories of stressors that
coping mechanisms affect homeostasis.
coping strategies 2. Identify two beliefs about the body and mind based on the
endorphins concept of holism.
feedback loop 3. Identify the purpose of adaptation and two possible outcomes
fight or flight response of unsuccessful adaptation.
general adaptation syndrome 4. Trace the structures through which adaptive responses take
homeostasis place.
hypothalamus-pituitary-adrenal (HPA) axis 5. Differentiate between sympathetic and parasympathetic
neurotransmitters adaptive responses.
primary prevention 6. Define stress and list factors that affect the stress response.
secondary prevention 7. Discuss the three stages and consequences of the general
sensory manipulation adaptation syndrome.
stage of exhaustion 8. Name three levels of prevention that apply to reducing or
stage of resistance managing stress-related disorders.
stress 9. Explain psychological adaptation and two possible outcomes.
stress-management techniques 10. Describe the nursing activities helpful to the care of clients
stressors prone to stress and approaches for preventing, reducing, or
stress-reduction techniques eliminating a stress response.
stress-related disorders
tertiary prevention
ealth is a tenuous state. To sustain it, the body continuously adapts
H to stressors (changes with the potential to disturb equilibrium).

As long as stressors are minor, the body’s responses are negligible
and generally unnoticed. When stressors are intense or numerous,
efforts to restore balance may cause uncomfortable signs and symptoms.
With prolonged stress, related disorders and even death may occur.
HOMEOSTASIS
Homeostasis is a relatively stable state of physiologic equilibrium; it

literally means “staying the same.” Although it sounds contradictory,
staying the same requires constant physiologic activity. The body main-
tains constancy by adjusting and readjusting in response to changes in
the internal and external environment that foster disequilibrium.
Holism
Although homeostasis is associated primarily with a person’s physical
status, emotional, social, and spiritual components also affect it. As dis-
cussed in Chapter 4, holism implies that entities in all these areas con-
tribute to the whole of a person. Based on the principles of holism, stres-
sors may be physiologic, psychological, social, or spiritual (Box 5-1).
60
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CHAPTER 5 Homeostasis, Adaptation, and Stress 61
B OX 5 - 1 Common Stressors
PHYSIOLOGIC PSYCHOLOGICAL SOCIAL SPIRITUAL
Prematurity Fear Gender, racial, age discrimination Guilt

Aging Powerlessness Isolation Doubt
Injury Jealousy Abandonment Hopelessness
Infection Rivalry Poverty Conflict in values
Malnutrition Bitterness Conflict in relationships Pressure to join, abandon, or change
Obesity Hatred Political instability religions
Surgery Insecurity Denial of human rights Religious discrimination
Pain Threats to safety
Fever Illiteracy
Fatigue Infertility
Pollution
Holism is the foundation of two commonly held beliefs:

(1) both the mind and the body directly influence humans,
and (2) the relationship between the mind and the body can
potentially sustain health as well as cause illness. Conse-
quently, it is helpful to understand how the mind perceives
information and makes adaptive responses. Both physical
and psychological mechanisms of perception and adaptation
are discussed later in this chapter.
■ What may be a stressor to a younger person is some-

times less so for older adults because their life experiences
help them to put stressful events in a different perspective.
Consequently, older adults may perceive stressors as having
less priority or sense of urgency than younger age groups. Dendrites
Synapse
Axon
List physiologic, psychological, social, and spiritual Dendrite Axon
Direction of
stressors that can affect homeostasis among nursing nerve impulse
students.
Adaptation
Adaptation (the response of an organism to change) requires
the use of self-protective properties and mechanisms for reg- Axon
ulating homeostasis. Neurotransmitters mediate homeostatic
adaptive responses by coordinating functions of the central
Vesicles
nervous system, autonomic nervous system, and endocrine
system. Synaptic
cleft
Neurotransmitters
Neurotransmitters (chemical messengers synthesized in
the neurons) allow communication across the synaptic cleft
between neurons, subsequently affecting thinking, behav- Receptor
ior, and bodily functions. When released, neurotransmitters Neurotransmitters Dendrite sites
temporarily bind to receptor sites on the postsynaptic neuron
and transmit their information. After this is accomplished, FIGURE 5-1 Neurotransmitter activity. (From Timby, B. K., &
the neurotransmitter is broken down, recaptured for later Smith, N. E. [2010]. Introductory medical-surgical nursing
use, or weakened (Fig. 5-1). [10th ed.]. Philadelphia, PA: Lippincott Williams & Wilkins.)
LWBK1004-C05_p60-71.indd 61 26/01/12 3:01 AM

ANTERIOR POSTERIOR the brainstem, includes the basal ganglia, thalamus, and
hypothalamus. The brainstem, so named because it resem-
CEREBRUM
bles a stalk, contains the cerebellum, medulla, and pons. The
Corpus callosum
DIENCEPHALON:
subcortical structures are primarily responsible for regu-
Thalamus
lating and maintaining physiologic activities that promote
survival. Examples include regulation of breathing, heart
Hypothalamus
contraction, blood pressure, body temperature, sleep, appe-
Pituitary gland tite, and stimulation and inhibition of hormone production.
BRAIN STEM:
Midbrain
Pons
Reticular Activating System
Medulla The reticular activating system (RAS), an area of the brain
oblongata
through which a network of nerves pass, is the communica-
Spinal cord CEREBELLUM
tion link between the body and the mind. Information about
a person’s internal and external environment is funneled
FIGURE 5-2 Central nervous system structures. through the RAS to the cortex on both a conscious and an
unconscious level (Fig. 5-3). The cortex processes the infor-
mation and generates behavioral and physiologic responses
through activation by the hypothalamus. The hypothalamus,
Common neurotransmitters include serotonin, dopamine,
in turn, influences the autonomic nervous system and endo-
norepinephrine, acetylcholine, gamma-aminobutyric acid,
crine functions (Fig. 5-4).
and glutamate. Other chemical messengers, called “neuropep-
tides,” are actually a separate type of neurotransmitter. Neu-
ropeptides include substance P, endorphins, enkephalins, and Gerontologic Considerations
neurohormones.
Neurotransmitters and neuropeptides exert different ■ Activity in the RAS is affected by inhibitory neurotrans-
effects. Serotonin stabilizes mood, induces sleep, and regu- mitters, such as gamma-aminobutyric acid (GABA), and
lates temperature. Norepinephrine heightens arousal and excitatory neurotransmitters such as norepinephrine. Drugs,
increases energy. Acetylcholine and dopamine promote like alcohol, narcotic analgesics, and tranquilizers, decrease
coordinated movement. Gamma-aminobutyric acid inhib- brain activity and induce sleep by simulating or increasing
its the excitatory neurotransmitters, such as norepinephrine GABA. Drugs, like caffeine, medications for attention deficit
and dopamine, which are classified as catecholamines. Sub- disorder, and illegal substances like methamphetamine,
stance P transmits the pain sensation, whereas endorphins increase RAS activity, alertness, and the “thinking activity”
and enkephalins interrupt the transmission of substance P of the cortex by stimulating receptors for norepinephrine.
■ Self-medication with alcohol and other sedative drugs
and promote a sense of well-being.
of abuse, such as narcotic analgesics and tranquilizers,
Different brain areas contain different neurons that con-
may decrease arousal and produce relaxation temporarily.
tain specific neurotransmitters. Receptors for these chemi- However, excessive or chronic substance abuse can lead to
cal messengers are found throughout the central nervous, physical impairment, drug dependence, and legal problems
endocrine, and immune systems, suggesting a highly inte- creating more stressors than those for which they were
grated communication system sometimes referred to as the originally intended to relieve.
hypothalamus-pituitary-adrenal (HPA) axis. ■ Because an unrelieved stress response is generally
accompanied by anxiety and depression, short-term pre-
Central Nervous System scription drug therapy with anti-anxiety medication such as
The central nervous system is composed of the brain and alprazolam (Xanax) or antidepressant drugs like fluoxetine
the spinal cord. The brain is divided into the cortex and the (Prozac) may help individuals to more realistically assess
structures that make up the subcortex (Fig. 5-2). and address stressors.
Cortex
The cortex is considered the higher functioning portion Autonomic Nervous System
of the brain. It enables people to think abstractly, use and The autonomic nervous system is composed of peripheral
understand language, accumulate and store memories, and nerves affecting physiologic functions that are largely auto-
make decisions about information received. The cortex also matic and beyond voluntary control. It is subdivided into the
influences other primitive areas of the brain located in the sympathetic and the parasympathetic nervous systems.
subcortex. Both the sympathetic and the parasympathetic divisions
supply organs throughout the body with nerve pathways. Each
Subcortex division takes a turn being functionally dominant, depend-
The subcortex consists of the structures in the midbrain and ing on the appropriate physiologic response. For example,
brainstem. The midbrain, which lies between the cortex and when increased heart rate is needed, the sympathetic division
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Stress
Pituitary
Hypothalamus
Autonomic
nervous system
Thymus
Thyroid
Parathyroid
Heart
and lungs
Catecholamines
Adrenocorticotrophic
hormone (ACTH)
Adrenal
Adrenal medulla
cortex
Kidneys
Liver
Stomach
FIGURE 5-3 The reticular activating system is the link in the Pancreas
Corticosteroids,
mind–body connection. including cortisol Bone marrow
FIGURE 5-4 Homeostatic adaptive pathways.

dominates; when heart rate needs to be slowed, the parasym-
pathetic division takes over.
Sympathetic Nervous System sympathetic nervous system. The parasympathetic nervous

When a situation occurs that the mind perceives as danger- system, however, does not produce an opposite reaction for
ous, the sympathetic nervous system prepares the body for a every sympathetic effect (Table 5-1). For this reason, some
fight or flight response. It accelerates the physiologic func- believe that the parasympathetic nervous system offers an
tions that ensure survival through enhanced strength or rapid alternate but equally effective mechanism for responding
escape. The person becomes active, aroused, and emotion- to threats from the internal or external environment. For
ally charged. example, physiologic deceleration, produced by the para-
sympathetic nervous system, has been likened to the man-
Parasympathetic Nervous System ner in which opossums and other animals “play dead” when
The parasympathetic nervous system restores equilibrium they sense that predators are stalking them. Simulating the
after danger is no longer apparent. It does so by inhibiting appearance of death often causes the predator to leave the
the physiologic stimulation created by its counterpart, the animal alone, thus saving its life. Therefore, it has been
TABLE 5-1 Sympathetic and Parasympathetic Effects

TARGET STRUCTURE SYMPATHETIC EFFECT PARASYMPATHETIC EFFECT
Iris of the eye Dilates pupils Constricts pupils
Sweat glands Increases perspiration None
Salivary glands Inhibits salivation Increases salivation
Digestive glands Inhibits secretions Stimulates secretions
Heart Increases rate and force of contraction Decreases rate and force of contraction
Blood vessels in the skin Constrict, causing pale appearance Dilate causing blush or flushed appearance
Skeletal muscles Increased tone Decreased tone
Bronchial muscles Relaxed (bronchodilation) Contracted (bronchoconstriction)
Digestive motility (peristalsis) Decreased Increased
Kidney Decreased filtration None
Bladder muscle (detrusor) Inhibited (suppressed urination) Stimulated (urge to urinate)
Liver Release of glucose None
Adrenal medulla Stimulated None
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Hypothalamus
Pineal
Pituitary
(hypophysis)
Thyroid
Parathyroid
(posterior)
Thymus
Adrenals
(suprarenals)
Islets of
Langerhans
(in pancreas)
Testes Ovaries
FIGURE 5-5 Endocrine glands.
proposed that humans, too, may respond to stimuli not only STRESS
by speeding physiologic responses, but also by slowing them
down (Nuernberger, 1981). As long as demands on the central nervous, autonomic nerv-
ous, and endocrine systems are within adaptive capacity,
Endocrine System
the body maintains homeostasis. When internal or exter-
The autonomic nervous system provides the initial and imme-
nal changes overwhelm homeostatic adaptation, stress
diate response to a perceived threat through either sympa-
results. Stress is the physiologic and behavioral responses
thetic or parasympathetic pathways. The endocrine system,
to disequilibrium. It has physical, emotional, and cognitive
a group of glands found throughout the body that produce
effects (Box 5-2).
hormones, sustains the response (Fig. 5-5). Hormones are
Although all humans have the capacity to adapt to
chemicals produced in one part of the body, the actions of
stress, not everyone responds to similar stressors exactly
which have physiologic effects on target cells elsewhere.
the same. Differences vary according to (1) the intensity of
Neuroendocrine Control the stressor, (2) the number of stressors, (3) the duration of
The pituitary gland, located in the brain, is considered the
master gland, producing hormones that influence other
endocrine glands. The pituitary gland is connected to the
hypothalamus, a subcortical structure, through both vascu- Releasing
lar connections and nerve endings. For pituitary function to gland
occur, the cortex first stimulates the hypothalamus, which
then activates the pituitary gland.
Feedback Loop
A feedback loop is the mechanism for controlling hormone Inhibition Stimulation
production (Fig. 5-6). Feedback can be negative or positive.
Most hormones are secreted in response to negative feed-
back; when a hormone level decreases, the releasing gland
is stimulated. In positive feedback, the opposite occurs,
High Low
keeping concentrations of hormones within a stable range
level level
at all times. Homeostasis is maintained when hormones are
released as needed or inhibited when adequate. FIGURE 5-6 A feedback loop regulates hormone levels.
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B OX 5 - 2 Common Signs and Symptoms

of Stress
Physical Alarm Stage
Rapid heart rate
Rapid breathing
Increased blood pressure
Difficulty falling asleep or excessive sleep
Loss of appetite or excessive eating
Stiff muscles
Hyperactivity or inactivity
Dry mouth
Constipation or diarrhea
Lack of interest in sex
Emotional
Irritability
Angry outbursts
Hypercritical
Verbal abuse
Withdrawal
Stage of Resistance
Depression
Cognitive
Impaired attention and concentration
Forgetfulness
Preoccupation
Poor judgment
the stressor, (4) physical health status, (5) life experiences,

(6) coping strategies, (7) social support, (8) personal beliefs,
(9) attitudes, and (10) values. Because of unique differences,
outcomes may be adaptive or maladaptive, depending on
each person’s response. Some stress-prone individuals have
a tendency to catastrophize, choosing to focus on all the
potentially negative outcomes that may result from stressors,
thus perpetuating and intensifying their response to stress.
In other words, they see their cup as half empty rather than Stage of Exhaustion
half full.
■ With advanced age, networks of social support tend to

dwindle or disintegrate, diminishing older adults’ ability to
cope. Social losses may provoke the onset of physical or
emotional disorders.
FIGURE 5-7 Stages of the general adaptation syndrome.
Physiologic Stress Response

Hans Selye, a Canadian physician who lived in the early (1) the body’s physical response is always the same, and (2)
1900s, devoted much of his life to researching the collec- it follows a one-, two-, or three-stage pattern: alarm stage,
tive physiologic processes of the stress response, which he stage of resistance, and in some cases, stage of exhaus-
called the general adaptation syndrome. Selye observed tion (Fig. 5-7). The first two stages parallel the adaptation
that this syndrome occurs repeatedly and consistently processes of maintaining homeostasis (discussed earlier).
regardless of the nature of the stressor. He maintained that Therefore, brief stress responses generally have adaptive
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TABLE 5-2 Actions of Cortisol

MAJOR INFLUENCE EFFECT ON BODY
Glucose metabolism Stimulates gluconeogenesis (synthesis of glucose from amino acids and sources other than
carbohydrates)
Decreases glucose use by the tissues
Protein metabolism Increases breakdown of proteins
Increases plasma protein levels
Fat metabolism Increases mobilization and use of fatty acids
Anti-inflammatory action Stabilizes membranes of inflamed cells, preventing release of proinflammatory mediators
Decreases capillary permeability to prevent swelling of tissues
Depresses phagocytosis by white blood cells
Suppresses the immune response
Causes atrophy of lymphoid tissue
Reduces eosinophils (white blood cells active during infectious and allergic reactions)
Decreases cell-mediated immunity
Reduces fever
Inhibits fibroblasts (connective tissue cells that promote wound healing)
Psychic effect May contribute to emotional instability
Adaptive effect Facilitates the response of tissues to physiologic changes, such as increased norepinephrine, during
trauma and extreme stress
From Porth, C. M., Matfin, G. (2010). Essentials of pathophysiology: Concepts of altered health states (3rd ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
outcomes, with restoration of equilibrium. If the stage of Consequently, one or more organs or physiologic processes
resistance is prolonged, however, the process can become may eventually lead to increased vulnerability for stress-
maladaptive and pathologic. It can lead to stress-related dis- related disorders or progression to the stage of exhaustion.
orders and, in some cases, death.
Stage of Exhaustion
Alarm Stage The stage of exhaustion is the last phase in the general
The alarm stage is the immediate physiologic response to adaptation syndrome. It occurs when one or more adap-
a stressor. At its onset, storage vesicles within sympathetic tive or resistive mechanisms are no longer able to protect
nervous system neurons rapidly release norepinephrine. the person experiencing a stressor. Once beneficial mecha-
Shortly thereafter, the adrenal glands secrete additional nisms now become destructive. For example, the effects
norepinephrine and epinephrine. These stimulating neuro- of stress-related neurohormones suppress the immune
transmitters and neurohormones prepare the person for a system. As a result, there are reduced natural killer cells,
“fight or flight” response; that is, to attack the stressor in which attack viruses and cancer cells, and decreased secre-
an effort to overcome the danger it represents, or flee from tory immunoglobulin A, an antibody involved in immune
the stressor to escape its threat. Almost simultaneously, the defense. These changes put the person at risk for frequent or
hypothalamus releases corticotropin-releasing factor (CRF), severe infections or cancer. Additional disruptions to other
which triggers the pituitary gland to secrete adrenocortico- organs include reduced beneficial bowel microorganisms
tropic hormone (ACTH). The result is the release of cortisol, and increased bowel pathogens (Kelly, 1999). As resistance
a stress hormone, from the adrenal cortex. dwindles, there is physical and mental deterioration, illness,
Cortisol plays various important roles in responding to a and death.
stressor such as raising blood glucose as a reserve for meet-
ing increased energy requirements (Table 5-2). Prolonged ➧ Stop, Think, and Respond Box 5-2
elevation of norepinephrine, epinephrine, and cortisol levels,
List the following stress-related responses in
however, can predispose clients to stress-related disorders sequential order:
(discussed later in this chapter). 1. The adrenal cortex releases cortisol.
2. The pituitary gland secretes ACTH.
Stage of Resistance 3. The body prepares for fight or flight.
The stage of resistance, the second phase in the general adap- 4. The blood glucose level rises.
tation syndrome, is characterized by physiologic changes 5. The adrenal glands release norepinephrine and
designed to restore homeostasis. Neuroendocrine hormones, epinephrine.
although temporarily excessive, endeavor to compensate 6. The hypothalamus secretes CRF.
for the physiologic changes of the alarm stage. If stress 7. The immune system becomes suppressed.
is protracted, however, resistance efforts remain activated. 8. Sympathetic neurons release norepinephrine.
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TABLE 5-3 Coping Mechanisms

MECHANISM EXPLANATION EXAMPLE
Repression Forgetting about the stressor Removing the experience of being sexually abused from
conscious memory
Suppression Purposely avoiding thinking about a stressor Resolving to “sleep on a problem” or turn the problem over
to a higher power, such as God
Denial Rejecting information Refusing to believe something like a life-threatening diagnosis
Rationalization Relieving oneself of personal accountability Blaming failure on a test to the manner in which the test was
by attributing responsibility to someone or constructed
something else
Displacement Taking anger out on something or someone else Kicking the wastebasket after being reprimanded by the boss
who is less likely to retaliate
Regression Behaving in a manner that is characteristic of a Wanting to be bottle-fed like a newborn sibling
much younger age
Projection Attributing that which is unacceptable in oneself Accusing a person of another race of being prejudiced
onto another
Somatization Manifesting emotional stress through a physical Developing diarrhea that conveniently excuses one from
disorder going to work
Compensation Excelling at something to make up for a weak- Becoming a motivational speaker although physically
ness of another kind handicapped
Sublimation Channeling one’s energies into an acceptable Turning to sportscasting when an athletic career is not
alternative realistic
Reaction formation Acting just the opposite of one’s feelings Being extremely nice to someone who is intensely disliked
Identification Taking on the characteristics of another Imitating the style of dress, speech, or behavior of another
person
Psychological Stress Responses substances, hostility and aggression, excessive sleep, avoid-
Just as stress requires adaptation from the body, stress also ance of conflict, and abandonment of social activities. Nega-
affects the psyche (mind). The mind, in turn, mounts additive coping strategies may provide immediate temporary
tional defenses. relief from a stressor, but they eventually cause problems.
Coping Mechanisms Stress-Related Disorders

Sigmund Freud posited that humans use coping mecha- Stress-related disorders are diseases that result from pro-
nisms (unconscious tactics to defend the psyche) to pre- longed stimulation of the autonomic nervous and endocrine
vent their ego, or reality base, from feeling inadequate systems (Box 5-3). Many stress-related diseases involve
(Table 5-3). These manipulations of reality act as psycho- allergic, inflammatory, or altered immune responses. They
logical first aid, allowing people to temporarily avoid the are characterized by physical conditions that cycle through
emotional effects of stress. When appropriate and moder- asymptomatic periods (absence of the disorder) to episodes
ate, coping mechanisms enable people to maintain their that usually develop when the person is under stress. The
mental equilibrium. Coping mechanisms that are overused brain–immune connection suggests that changes in body
or overextended may have maladaptive effects, distorting chemistry during periods of stress may trigger the following:
reality to such an extent that the person fails to recognize (1) an autoimmune (self-attacking) response like those asso-
and correct his or her weaknesses. Consequently, the per- ciated with rheumatoid arthritis and other connective tissue
son may avoid taking responsibility for solving personal disorders; (2) failure to respond, as in immunosuppression;
problems.
Coping Strategies
Coping strategies (stress-reduction activities selected con- B OX 5 - 3 Stress-Related Disorders
sciously) help people to deal with stress-provoking events or
situations. They can be therapeutic and nontherapeutic. Ther- • Hypertension • Depressive disorders
apeutic coping strategies usually help the person to acquire • Headaches • Cancer
insight, gain confidence to confront reality, and develop • Gastritis • Low back pain
• Asthma • Irritable bowel syndrome
emotional maturity. Examples include seeking professional
• Rheumatoid arthritis • Allergies
assistance in a crisis, using problem-solving techniques, • Skin disorders • Anxiety disorders
demonstrating assertive behavior, practicing progressive • Hyper/hypoinsulinism • Infertility
relaxation, and turning to a comforting person or higher power. • Hyper/hypothyroidism • Erectile dysfunction
Maladaptation results when people use nonthera- • Bruxism (teeth grinding)
peutic coping strategies such as mind- and mood-altering
LWBK1004-C05_p60-71.indd 67 26/01/12 3:01 AM

or (3) a weakened immune response, which may contribute TABLE 5-4 The Social Readjustment Rating Scale
to infections and cancer. Even psychological variables such
RANK LIFE EVENT LCU VALUE
as prolonged anger, feelings of helplessness, and worry can
potentially influence the onset and progression of immune 1 Death of spouse 100
2 Divorce 73
system-mediated diseases (Cohen & Herbert, 1996; God-
3 Marital separation 65
bout & Glaser, 2006).
4 Jail term 63
5 Death of close family member 63
6 Personal injury or illness 53
NURSING IMPLICATIONS 7 Marriage 50
8 Fired at work 47
9 Marital reconciliation 45
Nurses must be aware of potential stressors affecting clients
10 Retirement 45
because they add to the cumulative effect of other stressful 11 Change in health of family member 44
life events. When a person is experiencing a stressor, nurses 12 Pregnancy 40
do one or several of the following: 13 Sex difficulties 39
14 Gain of new family member 39
• Identify the stressors 15 Business readjustment 39
• Assess the client’s response to stress 16 Change in financial state 38
• Eliminate or reduce the stressors 17 Death of close friend 37
• Prevent additional stressors 18 Change to different line of work 36
• Promote the client’s physiologic adaptive responses 19 Change in number of arguments with 35
• Support the client’s psychological coping strategies spouse
20 Mortgage over $10,000 31
• Assist in maintaining a network of social support
21 Foreclosure of mortgage or loan 30
• Implement stress reduction and stress management 22 Change in responsibilities at work 29
techniques 23 Son or daughter leaving home 29
24 Trouble with in-laws 29
Assessment of Stressors 25 Outstanding personal achievement 28
Holmes and Rahe (1967) developed, the Social Readjust- 26 Wife begins or stops work 26
ment Rating Scale, a tool used to predict a person’s poten- 27 Begin or end school 26
tial for developing a stress-related disorder. The rating scale 28 Change in living conditions 25
is based on the number and significance of social stressors 29 Revision of personal habits 24
a person has experienced within the previous 6 months 30 Trouble with boss 23
31 Change in work hours or conditions 20
(Table 5-4). The risk for a stress-related disorder increases
32 Change in residence 20
as the person’s score rises. Although the dollar amount in 33 Change in schools 20
the mortgage-related item of the scale is outdated, being in 34 Change in recreation 19
debt is still a major stressor. Therefore, with minor modi- 35 Change in church activities 19
fications, the assessment tool continues to have diagnostic 36 Change in social activities 18
value. 37 Mortgage or loan less than $10,000 17
One research study ranked hospital stressors clients 38 Change in sleeping habits 16
39 Change in number of family 15
experience in a list modeled after the Social Readjustment
get-togethers
Rating Scale (Box 5-4). By being aware of how an illness 40 Change in eating habits 15
or interactions with health care personnel and facilities can 41 Vacation 13
affect clients, nurses can be instrumental in supporting those 42 Christmas 12
who are especially vulnerable. 43 Minor violations of the law 11
Social events are ranked from most stressful to least stressful. Each event
Prevention of Stressors is assigned a life change unit (LCU) that correlates with the severity of the
By offering appropriate interventions to people with severe or stressor. The sum of LCUs over the past 6 months is calculated. A score of
less than 150 LCUs is considered low risk, a score between 150 and 199 is
accumulated stressors, nurses can help prevent or minimize an indication of mild risk, moderate risk is associated with a score between
stress-related illness. Prevention takes place at three levels: 200 and 299, and a score over 300 places the person at major risk.
From Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating
• Primary prevention involves eliminating the potential for Scale. Journal of Psychosomatic Research, 11, 216. (Copyright © 1967,
Pergamon Press, Ltd.)
illness before it occurs. An example is teaching principles
of nutrition and methods to maintain normal weight and
blood pressure to adolescents. • Tertiary prevention minimizes the consequences of a dis-
• Secondary prevention includes screening for risk factors order through aggressive rehabilitation or appropriate
and providing a means for early diagnosis of disease. An management of the disease. An example is frequently turn-
example is regularly measuring the blood pressure of a cli- ing, positioning, and exercising a client who has had a
ent with a family history of hypertension. stroke to help restore functional ability.
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B OX 5 - 4 Client-Related Stressors Stress-Reduction Techniques

Stress-reduction techniques are methods that promote
Thinking you might lose your sight physiologic comfort and emotional well-being. Some gen-
Thinking you might have cancer eral interventions appropriate during the care of any client
Thinking you might lose a kidney or some other organ
include providing adequate explanations in understand-
Knowing you have a serious illness
able language, keeping the client and family informed,
Thinking you might lose your hearing
Not being told what your diagnosis is demonstrating confidence and expertise when providing
Not knowing for sure what illness you have nursing care, remaining calm during crises, being availa-
Not getting pain medication when you need it ble to the client, responding promptly to the client’s signal
Not knowing the results or reasons for your treatments for assistance, encouraging family interaction, advocating
Not getting relief from pain medications on behalf of the client, and referring the client and fam-
Being fed through tubes ily to organizations or people who provide post-discharge
Missing your spouse assistance.
Not having your questions answered by the staff
Not having enough insurance to pay for your hospitalization
Not having your call light answered Stress-Management Techniques
Having a sudden hospitalization you were not planning to have People susceptible to intense stressors or those likely to
Being hospitalized far from home experience stressors over a long period may benefit from
Knowing you have to have an operation additional stress management approaches. Stress-manage-
Not having family visit you ment techniques are therapeutic activities used to reestab-
Feeling you are getting dependent on medications lish balance between the sympathetic and the parasympa-
Having nurses or doctors talk too fast or use words you cannot
thetic nervous systems (Table 5-5). Techniques that counter
understand
sympathetic stimulation have a calming effect; stimulating
Having medications that cause you discomfort
Thinking about losing income because of your illness tactics counterbalance parasympathetic dominance. Inter-
Having the staff be in too much of a hurry ventions that cause the release of endorphins, manipulation
Not knowing when to expect things will be done to you of sensory stimuli, and adaptive activities also mediate phys-
Being put in the hospital because of an accident ical and emotional responses to stress. Nurses help clients
Being cared for by an unfamiliar doctor manage stress, for example, by teaching principles of time
Not being able to call family or friends on the phone management and assertiveness techniques.
Having to eat cold or tasteless food
Worrying about your spouse being away from you
Endorphins
Thinking you might have pain because of surgery or test
Endorphins are natural body chemicals that produce effects
procedures
Being in the hospital during holidays or special family occasions similar to those of opiate drugs such as morphine. In addi-
Thinking your appearance might be changed after your tion to decreasing pain, these chemicals promote a sense of
hospitalization pleasantness, tranquility, and well-being.
Being in a room that is too cold or too hot Endorphins are produced in the pituitary gland but
Not having friends visit you are present in the blood and other tissues (Porth & Matfin,
Having a roommate who is unfriendly 2008). Some believe that certain activities, such as massage,
Having to be assisted with a bedpan sustained aerobic exercise, and laughter, trigger the release
Having a roommate who is seriously ill or cannot talk with you of endorphins. Once released, endorphins attach themselves
Being aware of unusual smells around you to receptor sites in the brain—perhaps in the limbic system,
Having to stay in bed or the same room all day
the center where emotions are experienced.
Having a roommate who has too many visitors
Not being able to get newspapers, radio, or TV when you want
them Sensory Manipulation
Having to be assisted with bathing Sensory manipulation involves altering moods, feelings,
Being awakened in the night by the nurse and physiologic responses by stimulating pleasure centers in
Having strange machines around the brain using sensory stimuli. Research is being conducted
Having to wear a hospital gown on the stress-reducing effects of certain colors, full-spectrum
Having to sleep in a strange bed lighting in the home and workplace, music, and specific aro-
Having to eat at different times than you usually do mas that conjure pleasant associations such as the smell of
Having strangers sleep in the same room with you baking bread.
The events in this list are arranged in order of their perceived significance
as a stressor. The first event is the most stressful, and the rest follow in Adaptive Activities
descending order. To enhance adaptation, people experiencing stress may
Copyright © 1975, American Journal of Nursing Company. Reproduced
with permission from Volicer, B.J. & Bohannon, M.W. (1975). A Hospital
adopt techniques from the following categories: alternative
Stress Rating Scale. Nursing Research, 24(5), 352–359. thinking, alternative behaviors, and alternative lifestyles.
LWBK1004-C05_p60-71.indd 69 26/01/12 3:01 AM

TABLE 5-5 Interventions for Stress Management

INTERVENTION EXPLANATION
Modeling Promotes the ability to learn an adaptive response by exposing a person to someone who
demonstrates a positive attitude or behavior
Progressive relaxation Eases tense muscles by clearing the mind of stressful thoughts and focusing on consciously relaxing
specific muscle groups
Imagery Uses the mind to visualize calming, pleasurable, and positive experiences
Biofeedback Alters autonomic nervous system functions by responding to electronically displayed physiologic data
Yoga Reduces physical and emotional tension through postural changes, muscular stretching, and focused
concentration
Meditation and prayer Reduces physiologic activation by placing one’s trust in a higher power
Placebo effect Alters a negative physiologic response through the power of suggestion
Alternative Thinking CRITICAL THINKING EXERCISES

Alternative thinking techniques are those that facilitate a
change in a person’s perceptions from negative to positive. 1. Identify at least five interventions that are both real-
Reframing helps a person to analyze a stressful situation istic and helpful in reducing the stressors associated
from various perspectives and to ultimately conclude that with being a student.
the situation is not as bad as it once seemed. For instance, 2. What stressors are more unique to older adults than
instead of dwelling on the negative consequences of a minor other age groups?
car accident, such as the expense and inconvenience of 3. When faced with comments that a person is an alco-
repairs, the person can choose to focus on the positive aspect holic, explain how the coping mechanism of denial
of being physically unharmed in the accident. can initially protect the drinker’s self-image, but can
eventually cause harm.
4. How can the coping mechanism of identification
Alternative Behaviors or any other example in Table 5-3 be positive or
A behavioral technique for modifying stress is to take con- negative?
trol rather than become immobilized. Making choices and
pursuing actions promote self-confidence over feeling vic-
timized. Procrastination only prolongs and intensifies the NCLEX-STYLE REVIEW QUESTIONS
original stressor.
1. If a client experiences all of the following, which are
In addition, sharing frustrations with others who are
the indications of a stress response? Select all that
both objective and supportive is more therapeutic than
apply.
brooding in isolation. Other behavioral approaches to
1. Rapid heart rate
reduce stress include prioritizing what needs to be accom-
2. Double vision
plished and initially attending to that which is most impor-
3. Indigestion
tant or difficult. Less important activities may be post-
4. Fatigue
poned or delegated to others. And although other positive
5. Thirst
behaviors can be cultivated, it is also important sometimes
2. Which nursing intervention is considered primary
to say “no” to avoid becoming overwhelmed and more
in preventing hypertension in a client with a family
stressed.
history of this disorder?
1. Assess the client’s blood pressure monthly
Alternative Lifestyle 2. Provide information about antihypertensive
People prone to stress can make a conscious effort to medications
improve their diet, become more physically active, cultivate 3. Explain stress-management techniques
humor, and take scheduled breaks throughout the day for lei- 4. Teach the client the health hazards of hypertension
sure, power naps, or listening to uplifting music. Although 3. When caring for an older adult with all the following
pet ownership is not possible for everyone, those who do stressors, which has the highest priority for therapeu-
have pets find it soothing and relaxing to stroke and touch an tic interventions?
animal that responds affectionately regardless of a person’s 1. Death of a spouse
age, physical characteristics, or accomplishments. Pets seem 2. Change in living conditions
to improve a person’s feelings of self-worth in a way that 3. Retirement
extends to human relationships as well. 4. Change in financial state
LWBK1004-C05_p60-71.indd 70 26/01/12 3:01 AM

4. Which coping mechanism is being demonstrated 5. Which one of the following nursing activities would
when a client refuses treatment because she believes have the most benefit toward promoting health and
her breast biopsy indicating cancer is incorrect? wellness?
1. Somatization 1. Encouraging teenagers to never smoke cigarettes
2. Regression 2. Offering suggestions for smoking cessation
3. Displacement 3. Explaining how to apply nicotine patches to the
4. Denial skin
4. Advocating that smokers with a chronic cough
consult a physician
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6 Culture and Ethnicity
acultural nursing care
African Americans
ageism 1. Differentiate culture, race, and ethnicity.
Anglo-Americans 2. Discuss factors that interfere with perceiving others as
Asian Americans individuals.
bilingual 3. Explain why US culture is described as being anglicized.
certified interpreter 4. List at least five characteristics of Anglo-American culture.
cultural shock 5. Define the term “subculture” and list four major subcultures
culturally sensitive nursing care in the United States.
culture 6. List five ways in which people from subcultural groups differ
diversity from Anglo-Americans.
ethnicity 7. Describe four characteristics of culturally sensitive care.
ethnocentrism 8. List at least five ways to demonstrate cultural sensitivity.
folk medicine
generalization
Latinos
lients vary according to age, gender, race, health status, educa-
C
limited English proficiency (LEP)
tion, religion, occupation, and economic level. Culture, the focus
minority
Native Americans of this chapter, is yet another characteristic that contributes to cli-
race ent diversity (differences among groups of people).
stereotypes Nurses have always cared for clients with differences of some sort.
subcultures Despite cultural differences, the traditional tendency has been to treat
telephonic interpreting clients as though none exist. Although equal treatment may be politi-
transcultural nursing cally correct, many nurses now believe that ignoring differences con-
tradicts the best interests of clients. Consequently, there is a movement
toward eliminating acultural nursing care (care that avoids concern
for cultural differences) and promoting culturally sensitive nursing
care (care that respects and is compatible with each client’s culture).
This chapter provides information about cultural concepts, cul-
tural variations among different ethnic and racial groups, and inter-
cultural communication. Although components of culture are speci c fi
to a particular group of people, individual clients within each cultural
group may deviate from the collective norm. Therefore, nurses are
advised to always consider cultural needs from an individual’s per-
spective. Every human being is in some way “like all others, like some
others, and like no other” (Andrews, 2005).
CONCEPTS RELATED TO CULTURE
Culture
Culture (the values, beliefs, and practices of a particular group; Giger
& Davidhizar, 2008) incorporates the attitudes and customs learned
through socialization with others. It includes, but is not limited to,
language, communication style, traditions, religion, art, music, dress,
health beliefs, and health practices.
72
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CHAPTER 6 Culture and Ethnicity 73
A group’s culture is passed from one generation to the men of European ancestry are the current “majority” in the
next. According to Smeltzer and Bare (2010), culture is United States. Slightly more women than men make up
(1) learned from birth; (2) shared by members of a group; (3) the population of the United States, yet women are consid-
influenced by environment, technology, and the availability ered a minority. By the year 2050, the number of Latinos
of resources; and (4) dynamic and ever changing. and Asian Americans living in the United States is expected
Although the United States has been described as to triple, and the number of African Americans will nearly
a “melting pot” in which culturally diverse groups have double (U.S. Census Bureau, 2008). Until these groups
become assimilated, that is not the case. People from vari- acquire more political and economic power in society, they
ous cultural groups have settled, lived, and worked in the will continue to be classified as minorities despite the fact
United States while continuing to sustain their unique identi- that the white population will decrease to only 46% of the
ties (Table 6-1). total population in 2050.
Race
Cultural groups tend to share biologic and physiologic simi- Gerontologic Considerations
larities. Race (biologic variations) is a term used to catego-
rize people with genetically shared physical characteristics. ■ Ethnic populations of color are expected to represent
Some examples include skin color, eye shape, and hair tex- 25% of the elderly by 2030 (Andrews & Boyle, 2008).
ture. Despite wide ranges in physical variations, skin color
has traditionally been the chief, albeit imprecise, method
for dividing races into Mongoloid, Negroid, and Caucasian. Ethnicity
Skin color is just one of a variety of inherited traits. Ethnicity (a bond or kinship a person feels with his or
More importantly, nurses should not equate race with her country of birth or place of ancestral origin) may exist
any particular cultural group. To do so leads to two erroneous regardless of whether or not a person has ever lived outside
assumptions: (1) all people with common physical features of the United States. Pride in one’s ethnicity is demonstrated
share the same culture and (2) all people with physical simi- by valuing certain physical characteristics, giving children
larities have cultural values, beliefs, and practices that differ ethnic names, wearing unique items of clothing, appreciat-
from those of Anglo-Americans (US whites who trace their ing folk music and dance, and eating native dishes.
ancestry to the United Kingdom and Western Europe). Because cultural characteristics and ethnic pride repre-
sent the norm in a homogeneous group, they tend to go unno-
Minority ticed. When two or more cultural groups mix, however, as
The term minority is used when referring to those collec- often happens at the borders of various countries or through
tive people who differ from the dominant group in terms the process of immigration, unique differences become more
of cultural characteristics such as language, physical char- obvious. One or both groups may experience cultural shock
acteristics such as skin color, or both. Minority does not (bewilderment over behavior that is culturally atypical).
necessarily imply that there are fewer group members in Consequently, many ethnic groups have been victimized as
comparison with others in the society. Rather, it refers to the a result of bigotry based on stereotypical assumptions and
group’s status with regard to power and control. For example, ethnocentrism.
TABLE 6-1 Culturally Diverse Groups Within the FACTORS THAT IMPACT PERCEPTION
United States OF INDIVIDUALS
CITY OR REGION PREDOMINANT CULTURAL GROUP
Stereotyping
New England Irish Stereotypes (fixed attitudes about all people who share a
Detroit, Buffalo, Chicago Polish common characteristic) develop with regard to age, gender,
Upper Midwest Scandinavians
race, sexual preference, or ethnicity. Because stereotypes are
(Minnesota, North Dakota)
Ohio and Pennsylvania Amish preconceived ideas usually unsupported by facts, they tend
Washington State and Southeast Asians (Laotian, to be neither real nor accurate. In fact, they can be danger-
Oregon Vietnamese) ous because they interfere with accepting others as unique
New York (Spanish Harlem) Puerto Rican individuals.
Miami (Little Cuba) Cuban
San Francisco (Chinatown) Chinese
Manhattan (Little Italy) Italian
Louisiana Cajun (French/Indian)
Southwest Latin American/Native American ■ Ageism, a form of negative stereotypical thinking about
Hawaiian Islands Pacific Islanders/Japanese/ older adults, is the basis for beliefs that the elderly are
Chinese asexual, cognitively defective, physically incapacitated, and
a burden to families and society.
LWBK1004-C06_p72-92.indd 73 26/01/12 3:02 AM

Generalization B OX 6 - 1 Examples of US Cultural

Generalization (supposition that a person shares cultural Characteristics
characteristics with others of a similar background) is dif-
• English is the language of communication.
ferent than stereotyping. Stereotyping prevents seeing and
• The pronunciation or meaning of some words varies accord-
treating another person as unique, whereas generalizing ing to regions within the United States.
suggests possible commonalities that may or may not be • The customary greeting is a handshake.
individually valid. Assuming that all people who affiliate • A distance of 4 to 12 feet is customary when interacting with
themselves with a particular group behave alike or hold the strangers or doing business (Giger & Davidhizar, 2008).
same beliefs is always incorrect. Diversity exists even within • In casual situations, it is acceptable for women as well as
cultural groups. men to wear pants; blue jeans are a common mode of dress.
A generalization provides a springboard from which to • Most Americans are Christians.
explore a person’s individuality. For example, when a nurse • Sunday is recognized as the Sabbath.
is assigned to care for a terminally ill client whose last name • Government is expected to remain separate from
is Vasquez, the nurse may assume that the client is Roman religion.
• Guilt or innocence for alleged crimes is decided by a jury of
Catholic because Catholicism is the religion of most Latinos.
one’s peers.
Before contacting a priest to assist with the client’s spiritual • Selection of a marriage partner is an individual’s choice.
needs, however, the nurse understands that the generaliza- • Legally, men and women are equals.
tion concerning religion may not be accurate. A culturally • Marriage is monogamous (only one spouse); fidelity is
sensitive nurse strives to obtain information that confirms or expected.
contradicts the original generalization. • Divorce and subsequent remarriages are common.
• Parents are responsible for their minor children.
Ethnocentrism • Aging adults live separately from their children.
Ethnocentrism (belief that one’s own ethnicity is superior • Status is related to occupation, wealth, and education.
to all others) also interferes with intercultural relationships. • Common beliefs are that everyone has the potential for suc-
Ethnocentrism is manifested by treating anyone “different” cess and that hard work leads to prosperity.
• Daily bathing and use of a deodorant are standard hygiene
as deviant and undesirable. This form of cultural intolerance
practices.
was the basis for the Holocaust during which the Nazis • Anglo-American women shave the hair from their legs and
attempted to carry out genocide, the planned extinction of an underarms; most men shave their faces daily.
entire ethnic group (in this case, European Jews). Ethnocen- • Licensed practitioners provide health care.
trism continues to play a role in the ethnic rivalries between • Drugs and surgery are the traditional forms of medical
Shiites, Sunnis, and Kurds in Iraq; Arabs and Jews in the treatment.
Middle East; Tutsis and Hutus in Rwanda; Islamic Arabs • Americans tend to value technology and equate it with
in Sudan; indigenous African tribes in Darfur, and other quality.
regions where culturally diverse groups live in close prox- • As a whole, Americans are time oriented and, therefore,
imity. Similar conflicts also occur among US ethnic groups. rigidly schedule their activities according to clock
hours.
• Forks, knives, and spoons are used, except when eating “fast
CULTURE AND SUBCULTURES IN foods,” for which the fingers are appropriate.
THE UNITED STATES
US culture can be described as anglicized, or English-based, TABLE 6-2 Subcultural Groups in the
United Statesa
because it evolved primarily from its early English settlers.
Box 6-1 provides an overview of some common character- REPRESENTATIVE US POPULATION
istics of US culture. To suggest that everyone who lives in GROUP COUNTRIES ESTIMATE 2008
the United States embraces the totality of its culture, how- Total 304,059,724
ever, would be foolhardy. African American Africa, Haiti, Jamaica, 2.8%
Although it is a gross oversimplification, four major West Indies,
Dominican Republic
subcultures (unique cultural groups that coexist within the Latino Mexico, Puerto Rico, 15.4%
dominant culture) exist in the United States. In addition to Cuba, South and
Anglo-Americans, there are also African Americans, Lati- Central America
nos, Asian Americans, and Native Americans (Table 6-2). Asian American China, Japan, Korea, 4.5%
The 2010 Census allowed individuals to self-select from six Philippines, Thailand,
Cambodia, Laos,
race and ethnicity categories (Table 6-3).
Vietnam, Pacific Islands
The term African Americans is used to identify those Native American Indian and Alaskan tribes 1%
whose ancestral origin is Africa. It is sometimes used inter-
changeably with black Americans. Latinos, a shortened term a
As reported by the U.S. Census Bureau, 2009.
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TABLE 6-3 Categories of Race and Ethnicity for Federal Statistics

CATEGORY DESCRIPTION
White Persons having origins in Europe, the Middle East, or North Africa
Hispanic or Latino Persons with origins in Cuba, Mexico, Puerto Rico, South or Central America, or other
Spanish culture, regardless of race
Asian Persons with origins in East Asia, Southeast Asia, or the Indian subcontinent such as Cambo-
dia, China, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, and Vietnam
Black or African American Persons having origins in any racial groups of Africa including Haiti
American Indian or Alaska Native Persons with origins in any of the peoples of North and South America who maintain tribal
affiliation or community attachment
Native Hawaiian or Other Pacific Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other
Islander Pacific islands
From Revisions to the Standards for Classification of Federal Data on Race and Ethnicity, Office of Management and
Budget, 1997.
for latinoamericano refers to those who trace their ethnic biologic and physiologic variations, promoting health edu-
origin to Mexico, Puerto Rico, Cuba, Central and South cation that will reduce prevalent diseases, and respecting
America, or other Spanish-speaking countries, such as the alternative health beliefs or practices.
Dominican Republic. However, Latinos are sometimes
referred to as Hispanics, a term coined by the U.S. Census Cultural Assessment
Bureau when referring to those residing in the eastern por- To provide culturally sensitive care, the nurse strives to
tion of the United States such as Florida and Texas. The term gather data about the unique characteristics of clients. Perti-
Chicanos is used when referring to people from Mexico, but nent data include the following:
it may have negative connotations to some. Consequently, • Language and communication style
it may be more politically correct to use the term Mexican • Hygiene practices, including feelings about modesty and
Americans. Asian Americans (those who come from China, accepting help from others
Japan, Korea, the Philippines, Thailand, Cambodia, Laos, and • Special clothing or ornamentation
Vietnam) make up the third subculture. Native Americans • Religion and religious practices
include persons who have their origins in North, Central, and • Rituals surrounding birth, passage from adolescence to
South America, as well as Eskimos and Aleuts, all of whom adulthood, illness, and death
belong to 564 federally recognized tribes in the United States • Family and gender roles, including child-rearing practices
(Department of Interior, Bureau of Indian Affairs, 2009). and kinship with older adults
Although Anglo-American culture predominates in the • Proper forms of greeting and showing respect
United States, those of African, Asian, Latino/Hispanic, • Food habits and dietary restrictions
Native Indian, and Hawaiian/Pacific Islander descent will • Methods for making decisions
soon outnumber those who trace their ancestry to the United • Health beliefs and medical practices
Kingdom and Western Europe. As the population of non–
Anglo-Americans rises and becomes more diverse, the need Assessment of these areas is likely to reveal many
for transcultural nursing is increasingly urgent. differences. Examples of variations include language and
communication, eye contact, space and distance, touch,
emotional expressions, dietary customs and restrictions,
TRANSCULTURAL NURSING time, and beliefs about the cause of illness.
Madeline Leininger coined the term transcultural nursing Language and Communication
(providing nursing care within the context of another’s cul- Because language is the primary way to share and gather
ture) in the 1970s. Aspects of transcultural nursing include information, the inability to communicate is one of the big-
the following: gest deterrents to providing culturally sensitive care. For-
eign travelers and many residents in the United States do
• Assessments of a cultural nature not speak English, or they have learned it as their second
• Acceptance of each client as an individual language and do not speak it well. Estimates are that 47 mil-
• Knowledge of health problems that affect particular lion or 18% of those who live in the United States speak a
cultural groups language other than English at home; Spanish is the most
• Planning of care within the client’s health belief system to often spoken language other than English in the United
achieve the best health outcomes States (Fig. 6-1) (Shin & Bruno, 2003). Those who can com-
To provide culturally sensitive care, nurses must become municate in English may still prefer to use their primary lan-
skilled at managing language differences, understanding guage, especially under stress.
LWBK1004-C06_p72-92.indd 75 26/01/12 3:02 AM

Hospital Reported Languages Spoken by Client

(Aggregate)
B OX 6 - 2 Characteristics of a Skilled
Interpreter
• Learns the goals of the interaction
Other 45% • Demonstrates courtesy and respect for the client
• Explains his or her role to the client
Vietnamese 40% • Positions himself or herself to avoid disrupting direct com-
munication between the health care worker and the client
Spanish 88% • Has a good memory for what is said
• Converts the information in one language accurately into the
Russian 38% other without commenting on the content
• Possesses knowledge of medical terminology and vocabulary
Portuguese 17% • Attempts to preserve the emphasis and emotions that both
people express
Polish 18% • Asks for clarification if verbalizations from either party are
unclear
Korean 32% • Indicates instances in which a cultural difference has the
potential to impair communication
Khmer (Cambodian) 15% • Maintains confidentiality
Hmong 32%
own values during communication between the client and
French/French Creole 32%
the health care provider.
The best form of communication with an LEP client
English 88%
is with a certified interpreter. A certified interpreter is a
Chinese
43%
translator who is certified by a professional organization
(Mandarian/Cantonese) through rigorous testing based on appropriate and consistent
American Sign Language 48% criteria. Unfortunately, individuals who meet these qualifi-
cations are few and far between. To comply with the laws
0 20 40 60 80 100 and accreditation requirements, health care agencies are
strongly encouraged to train professional interpreters. A
% of Hospitals (n = 60)
competently trained interpreter demonstrates the skills listed
FIGURE 6-1 Spoken languages other than English in the US. in Box 6-2.
A survey of hospitals in 32 states identified Spanish and
When a trained or certified interpreter is not available in
American Sign Language as the two most commonly spoken
languages other than English. (From Wilson-Stronks, A. & person or by webcam, there are a variety of other options. In
Galvez, E. Hospitals, Language, and Culture: A snapshot descending order of preference, the following may be used:
of the nation. The Joint Commission and The California agency-employed interpreters, bilingual staff, volunteers,
Endowment. Retrieved November 11, 2011 from http://www. and least desirable, family or friends. The Joint Commission
jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-
has not yet specified the type of training and competencies of
BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf.)
individuals who are used as interpreters, but standards may
be forthcoming.
When an on-site interpreter is not available, telephonic
Equal Access. Federal law, specifically Title IV of the
interpreting (over-the-phone translation) can be used
Civil Rights Act of 1994, states that people with limited Eng-
as an alternative. AT&T USADirect In-Language Serv-
lish proficiency (LEP)—an inability to speak, read, write, or
ice provides translators in 140 languages whenever and
understand English at a level that permits interacting effec-
wherever it is needed. This service costs approximately
tively—are entitled to the same health care and social serv-
$2.50 per minute compared to $40 per hour for an on-
ices as those who speak English fluently. In other words, all
site interpreter (Roat, 2005). In addition, although it does
clients have a right to unencumbered communication with a
not meet all the needs of an LEP client, a picture or dual-
health provider. Using children as interpreters or requiring
language communication board may be useful for immedi-
clients to provide their own interpreters is a civil rights vio-
ate bedside interactions between the client and the nursing
lation. The Joint Commission requires that hospitals provide
staff (Fig. 6-2).
effective communication for each client.
The use of untrained interpreters, volunteers, or family Culturally Sensitive Nurse–Client Communication.
is considered inappropriate because it undermines confiden- If the nurse is not bilingual (able to speak a second lan-
tiality and privacy. It also violates family roles and bounda- guage) and a trained interpreter is not available, he or she
ries. It increases the potential for modifying, condensing, must use an alternative method for communicating (see
omitting, adding information, or projecting the interpreter’s Nursing Guidelines 6-1 for more information).
LWBK1004-C06_p72-92.indd 76 26/01/12 3:02 AM

FIGURE 6-2 A picture communication board allows clients to point at appropriate images or
use a wet-erase marker. (Courtesy of Vidatak, LLC. Los Angeles, CA 90069.)
Understanding some unique cultural characteristics and Prevention, 2009). They also have sometimes been
involving aspects of communication may ease the transi- treated as second-class citizens when seeking health care.
tion toward culturally sensitive care. It is helpful to be aware The nurse must demonstrate professionalism by addressing
of general communication patterns among the major US clients by their last names and introducing himself or her-
subcultures. self. He or she should follow-up thoroughly with requests,
respect the client’s privacy, and ask open-ended rather than
Native Americans. Native Americans tend to be private
direct questions until trust has been established. Because
and may hesitate to share personal information with stran-
of their experiences as victims of discrimination, African
gers. They may interpret questioning as prying or meddling.
Americans may hesitate to give any more information than
The nurse should be patient when awaiting an answer and
what is asked.
listen carefully because people of this culture may consider
impatience disrespectful (Lipson & Dibble, 2005). Navajos, Latinos. Latinos are characteristically comfortable sitting
currently the largest tribe of Native Americans, believe that close to interviewers and letting interactions unfold slowly.
no person has the right to speak for another and may refuse Many Latinos speak English but still have difficulty with
to comment on a family member’s health problems. medical terminology. They may be embarrassed to ask the
Because Native Americans traditionally preserved their interviewer to speak slowly, so the nurse must provide infor-
heritage through oral rather than written history, they may mation and ask questions carefully. Latino men generally are
be skeptical of nurses who write down what they say. If pos- protective and authoritarian regarding women and children.
sible, the nurse should write notes after, rather than during, They expect to be consulted in decisions concerning family
the interview. members.
African Americans. African Americans may be mistrust- Asian Americans. Asian Americans tend to respond with
ful of the medical establishment, possibly because of unethi- brief or more factual answers and little elaboration, perhaps
cal practices employed in past research projects such as the because traditionally they value simplicity, meditation, and
Tuskegee syphilis experiment (Centers for Disease Control introspection. Asian Americans may not openly disagree with
LWBK1004-C06_p72-92.indd 77 26/01/12 3:02 AM


Rationales
Communicating With Non–English-Speaking Clients
• Greet or say words and phrases in the client’s language, even if • If the client speaks some English, speak slowly, not loudly,
carrying on a conversation is impossible. Using familiar words using simple words and short sentences. Lengthy or complex
indicates a desire to communicate with the client even if the sentences are barriers when communicating with someone not
nurse lacks the expertise to do so extensively. skilled in a second language.
• Use Web sites with the client that translate English to several • Avoid using technical terms, slang, or phrases with a double or
foreign languages and vice versa. Examples are found at http:// colloquial meaning. The client may not understand the spoken
ets.freetranslation.com and http://babel.altavista.com/tr. A vernacular, especially if he or she learned English from a
computer with Internet access provides sites with easy-to-use, textbook rather than conversationally.
rapid, free translations of up to 150 words at a time. • Ask questions that can be answered by a yes or no. Direct
• Refer to an English/foreign language dictionary or use appen- questions avoid the need to provide elaborate responses in
dices in references such as Taber’s Cyclopedic Medical Dic- English.
tionary. Some dictionaries provide medical words and phrases • If the client appears confused by a question, repeat it without
that may provide pertinent information. changing the words. Rephrasing tends to compound confusion
• Compile a loose-leaf folder or file cards of medical words in because it forces the client to translate yet another group of
one or more languages spoken by clients in the community. unfamiliar words.
Place it with other reference books on the nursing unit. A • Give the client sufficient time to respond. The process of
homemade reference provides a readily available language interpreting what has been said in English and then converting
resource for communicating with others in the local area. the response from the native language back to English requires
• Request a trained interpreter. If that option is impossible, call extra time.
ethnic organizations or church pastors to obtain a list of people • Use nonverbal communication or pantomime. Body language
who speak the client’s language and may be willing to act as is universal and tends to be communicated and interpreted
emergency translators. Someone proficient at speaking the quite accurately.
language is more effective at obtaining necessary information • Be patient. Anxiety is communicated interpersonally and tends
and explaining proposed treatments than is someone relying on to heighten frustration.
a rough translation. • Show the client written English words. Some non–English-
• Contact an international telephone operator in a crisis if there speaking people can read English better than they can under-
is no other option for communicating with a client. Interna- stand spoken English.
tional telephone operators are generally available 24 hours • Work with the health agency’s records committee to obtain
a day; however, their main responsibility is the job for which consent forms, authorization for health insurance benefits, and
they were hired. copies of client’s rights written in languages other than Eng-
• When several interpreters are available, select one who is of lish. Legally, clients must understand what they are consenting
the same gender and approximately the same age as the client. to.
Some clients are embarrassed relating personal information to • Develop or obtain foreign translations describing common pro-
people with whom they have little in common. cedures, routine care, and health promotion. One resource is
• Look at the client, not the interpreter, when asking questions the Patient Education Resource Center in San Francisco, which
and listening for responses. Eye contact indicates that the cli- provides publications in many languages on numerous health
ent is the primary focus of the interaction and helps the nurse topics. All clients are entitled to explanations and educational
to interpret nonverbal clues. services.
authority figures, such as physicians and nurses, because of Space and Distance
their respect for harmony. Such reticence can conceal disa- Providing personal care and performing nursing procedures
greement or potential noncompliance with a particular thera- often intrudes upon personal space, which causes discom-
peutic regimen that is unacceptable from their perspective. fort for some cultural groups. For example, Asian Americans
may feel more comfortable with the nurse at more than an
Eye Contact arm’s length away. The physical closeness of a nurse in an
Anglo-Americans generally make and maintain eye contact effort to provide comfort and support may threaten clients
throughout communication. Although it may be natural for from other cultures. It is best, therefore, to provide expla-
Anglo-Americans to look directly at a person while speak- nations when close contact during procedures and personal
ing, that is not always true of people from other cultures. It care is necessary.
may offend Asian Americans or Native Americans who are
likely to believe that lingering eye contact is an invasion of Touch
privacy or a sign of disrespect. Arabs may misinterpret direct Some Native Americans may interpret the Anglo-American
eye contact as sexually suggestive. custom of a strong handshake as offensive. They may be
LWBK1004-C06_p72-92.indd 78 26/01/12 3:02 AM

more comfortable with just a light passing of the hands. Peo- (Mexican brown sugar), cinnamon, vanilla, and sometimes
ple from Southeast Asia consider the head to be a sacred body chocolate or fruit, as a traditional celebration and comfort
part that only close relatives can touch. Nurses and other food. Atole is also consumed during la cuarentena, a
health care workers should ask permission before touching 40-day period following the delivery of an infant, in the
this area. Southeast Asians also believe that the area between belief that it will help in recovery and increase the volume
a female’s waist and knees is particularly private and should of breast milk.
not be touched by any male other than the woman’s husband. • The diet of some African Americans may include greens,
Before doing so, a male nurse can relieve the client’s anxi- grits, corn bread, and beans cooked with a generous
ety by offering an explanation, requesting permission, and amount of fat or fatty meats, which reflects their Southern
allowing the client’s husband to stay in the room. American roots.
• Some common foods in Asian American diets include rice
Emotional Expression and rice noodles; mixtures containing beef, chicken, fish,
Anglo-Americans and African Americans, in general, freely and soybean products; bok choy cabbage; and bean sprouts.
express positive and negative feelings. Asian and Native Flavors are enhanced with monosodium glutamate (MSG);
Americans, however, tend to control their emotions and soy; oyster, bean, and fish sauce; and peppers resulting in
expressions of physical discomfort (Zborowski, 1952, 1969), food that is both spicy and salty.
especially among unfamiliar people. Stoicism should not be • Native Americans typically consume what is grown locally
interpreted as a lack of feeling or caring (Eliopoulos, 2010). like fry bread made from corn, meat that is hunted on land
Similarly, Latino men may not demonstrate their feelings or or fished from nearby rivers, and chicken, pigs, and cattle
readily discuss their symptoms because they may interpret that are raised within the community. They may also rely
doing so as less than manly (Andrews & Boyle, 2008). The on products available from commercial markets (Schlenker
Latino cultural response can be attributed to machismo, a & Long, 2007).
belief that virile men are physically strong and must deal
with emotions privately. Because this behavior is atypical Time
from an Anglo-American perspective, nurses may overlook Throughout the world, people view clock time and social
the emotional and physical needs of people from these cul- time differently (Giger & Davidhizar, 2008). Calendars and
tural groups. clocks define clock time, dividing it into years, months,
Dietary Customs and Restrictions weeks, days, hours, minutes, and seconds. Social time
Basically, food is a means of survival: it relieves hunger, pro- reflects attitudes concerning punctuality that vary among
motes health, and prevents disease. Eating also has social cultures. Punctuality is often less important to people from
meanings that relate to communal togetherness, celebration, other cultures than it is to Anglo-Americans. Tolerating and
reward and punishment, and relief of stress. Culture dictates accommodating cultural differences related to time facili-
the types of food and how frequently a person eats, the types tates culturally sensitive care.
of utensils used, and the status of individuals, such as who
eats first and who gets larger servings. Beliefs Concerning Illness
Religious practices within some cultures impose certain Generally, people embrace one of three cultural views to
rules and restrictions such as times for fasting and foods that explain illness or disease. The biomedical or scientific per-
can and cannot be consumed (Table 6-4). Nurses can jeop- spective is shared by those from developed countries who
ardize the compliance of clients with a therapeutic diet for base their beliefs about health and disease on research
medical disorders if dietary teaching disregards cultural and findings. An example of a scientific perspective is that
religious food preferences. microorganisms cause infectious diseases, and frequent
handwashing reduces the potential for infection.
Nutrition Notes The naturalistic or holistic perspective espouses that
• Dietary acculturation occurs when people change their eat- humans and nature must be in balance or harmony to remain
ing behaviors after moving to a new area. Some traditional healthy; illness is an outcome of disharmony. Native Ameri-
foods are rejected and new foods are added or used as sub- cans believe that positive outcomes result from living in con-
stitutes for traditional foods. Availability and cost influ- gruence with Mother Earth. Another example includes Asian
ence dietary acculturation. Americans who uphold the Yin/Yang theory, which refers
• Acculturation can have a positive or negative effect on eat- to the belief that balanced forces promote health. Latinos
ing habits. Generally, as immigrants adopt the “typical embrace a similar concept referred to as the hot/cold theory.
American diet” their intake of fat, sugar, and calories It implies that illness is an imbalance between components
increases and their intake of fruit, vegetables, fiber, and ascribed as having hot or cold attributes. Adding or subtract-
protein decreases. New Americans should be encouraged ing heat or cold to restore balance also can restore health.
to retain healthy eating practices from their native culture. Finally, there is the magico-religious perspective in which
• Hispanics and those from Central America drink atole, a there is a cultural belief that supernatural forces contribute to
heated mixture of masa harina (corn meal), piloncillo disease or health. Some examples of the magico-religious
LWBK1004-C06_p72-92.indd 79 26/01/12 3:02 AM

TABLE 6-4 Examples of Religious Beliefs and Practices that Affect Health Care
RELIGION EXAMPLES NURSING IMPLICATIONS
Orthodox Judaism Circumcision is a sacred ritual performed on the Provide information on care following circumcision before
8th day of life. discharge.
Kosher dietary laws allow consumption of Notify dietary department of the client’s food preferences.
animals that chew their cud and have cloven Packaged food labeled kosher indicates it was “properly
hoofs. Animals are slaughtered according to preserved.” Pareve means “made without meat or milk.”
defined procedures; dairy products and meat
are not eaten together. Seafood with fins and
scales are permitted.
Sabbath begins on Friday at sundown and ends Avoid scheduling nonemergency tests or procedures dur-
on Saturday at sundown. ing this time.
Autopsies is are not allowed unless required All organs that are removed and examined during an
by law. autopsy must be returned to the body.
Burial is preferred within 24 hours of death; Contact the family to stay with the dying client. Expect
Judaic law requires that the body not be left a son or relative to close the mouth and eyes of the
alone. deceased.
Catholicism Statues and medals of religious figures provide Leave such items on or near the client; keep items safe
spiritual comfort. and return promptly if removed.
Artificial birth control and abortion are Explain how to avoid pregnancy through methods such as
forbidden. checking basal body temperature and characteristics of
cervical mucus.
Baptism is necessary for salvation. In an emergency, any baptized Christian should perform
baptism by pouring water over the head three times and
saying, “I baptize you in the name of the Father, and of
the Son, and of the Holy Spirit.”
Jehovah’s Witnesses Blood transfusions are refused even in life- Refer to physicians who practice blood conservation strate-
threatening situations because they gies such as autotransfusions and IV volume expanders
believe that blood is the source of the soul. (e.g., Dextran).
Seventh Day Adventist Strict dietary laws are followed based on the Request a consult with the dietitian to facilitate a vegetar-
Old Testament. ian diet without caffeine.
Saturday is the Sabbath. Avoid scheduling medical appointments or procedures at
this time.
Christian Scientist Prayer is the antidote for any illness. Expect that these clients will contact lay practitioners to
assist with healing. Legal procedures may be used as an
option when the well-being of minor children are threat-
ened by parental refusal for medical care.
Church of Jesus Christ Coffee, tea, alcohol, tobacco, illegal drugs, and Notify the dietary department to provide noncaffeinated
of Latter-Day Saints overuse of prescription drugs are prohibited. beverages.
(Mormonism) Male members may anoint the sick with conse- Facilitate anointing rituals before surgery or at the client’s
crated olive oil. request.
Amish Clients may be reluctant to spend money on Assess home remedies and folk healing being used. Home
health care unnecessarily. deliveries are preferred; expect brief overnight stays
following hospital births.
A central belief is that illness must be endured Offer comfort measures and analgesic medications rather
with faith and patience. than waiting for clients to request them.
Clients are formally educated up to 8th grade. Select written health educational materials at the client’s
level of understanding.
Photographs are not permitted. Avoid photographing newborns.
Hinduism Clients highly value modesty and hygiene. Provide a daily bath but not following a meal; add hot water
to cold but not the reverse.
The application of a pundra, a distinctive mark Avoid removing or replace it as soon as possible.
on the forehead, is religiously symbolic.
Hindus value self-control. Offer comfort measures and analgesic medications rather
than waiting for Hindu clients to request them.
Men do not participate during labor and delivery. Keep men informed of the birthing progress
Cleansing of the body after death symbolizes Inquire if the family wishes to wash a deceased client’s
cleansing of the soul. body.
Most clients are vegetarians: beef is forbidden, Request a consult with the dietitian. Clients may refuse
and some do not consume eggs. medication in gelatin capsules because gelatin is made
from animal by-products.
LWBK1004-C06_p72-92.indd 80 26/01/12 3:02 AM

RELIGION EXAMPLES NURSING IMPLICATIONS

Islam (Muslim) Prayer and washing are required five times a Plan care around prayer and washing rituals, which occur at
day. sunrise, mid-morning, noon, afternoon, and sunset. Help
clients face Mecca for prayer.
Pork and alcohol are forbidden. Clients may refuse medication in capsules and pork insulin.
Request that the pharmacist omit alcohol in liquid medi-
cations, which usually contain this ingredient.
Clients prefer to die at home. Expect that life support will be unacceptable if there is no
hope for a reasonable recovery.
Only relatives may touch or wash the body of a Consult the family before performing postmortem care.
deceased Muslim.
Adapted from Andrews, J. D. (2005). Cultural, ethnic and religious reference manual, 3rd ed. Winston-Salem, NC:
JAMARDA Resources.
perspective include cultural groups such as Haitians who accept cyanosis in whites, may be highly pigmented in other groups,
faith healing or practice forms of witchcraft or voodoo. Native and nurses may misinterpret normal findings. The conjunc-
Americans have a strong reverence for the Great Creator’s influ- tiva and oral mucous membranes are likely to provide more
ence on health and illness. They use herbs and spiritual rituals accurate data. The sclera or the hard palate, rather than the
performed by tribal leaders or medicine men known as shamans skin, is a better location for assessing jaundice. In some
to relieve illness (Eliopoulos, 2010). Although nurses may disa- nonwhites, however, the sclera may have a yellow cast from
gree with a client’s beliefs concerning the cause of health or carotene and fatty deposits; nurses should not misconstrue
illness, respect for the person helps to achieve health care goals. this finding as jaundice (Andrews & Boyle, 2008).
As long as a culturally held health belief or practice is not harm- Rashes, bruising, and inflammation may be less obvi-
ful, the nurse should incorporate it into the client’s care. ous among people with dark skin. Palpating for variations
in texture, warmth, and tenderness is a better assessment
technique than inspection. Keloids (irregular, elevated thick
➧ Stop, Think, and Respond Box 6-1 scars) are common among dark-skinned clients (Fig. 6-3).
How might a culturally sensitive nurse respond to They are thought to form from a genetic tendency to pro-
a Vietnamese client who practices coining, which duce excessive transforming-growth factor-beta (TGF-β),
involves rubbing the skin in a symptomatic area with a substance that promotes fibroblast proliferation during
a heated or oiled coin to draw an illness out of the tissue repair.
body? Coining is not painful, but it produces redness
Some nurses, when bathing a dark-skinned person, mis-
of the skin and superficial ecchymosis
interpret the brown discoloration on a washcloth as a sign of
(bruising).
poor hygiene. In reality, this is due to the normal shedding of
dead skin cells, which retain their pigmentation.
Biologic and Physiologic Variations Hypopigmentation and hyperpigmentation are conditions
The biologic characteristics of primary importance to nurses in which the skin is not a uniform color. Hypopigmentation
are those that involve the skin, hair, and certain physiologic may result when the skin becomes damaged. Regardless
enzymes. of ethnic origin, damaged skin characteristically manifests
Skin Characteristics
Skin assessment techniques that are commonly taught are
biased toward white clients. To provide culturally sensitive
care, nurses must modify their techniques to obtain accurate
data on nonwhite clients.
The best technique for observing baseline skin color in a
dark-skinned person is to use natural or bright artificial light.
Because the palms of the hands, the feet, and the abdomen
contain the least pigmentation and are less likely to have
been tanned, they are often the best structures to inspect.
According to Giger and Davidhizar (2008), all skin,
regardless of a person’s ethnic origin, contains an underlying
red tone. Its absence or a lighter appearance indicates pallor, FIGURE 6-3 Keloids are raised, thick scars as is seen in this
a characteristic of anemia or inadequate oxygenation. The client’s earlobe originally punctured to accommodate pierced
color of the lips and nail beds, common sites for assessing earrings. (Photo by B. Proud.)
LWBK1004-C06_p72-92.indd 81 26/01/12 3:02 AM

Hair Characteristics
Hair color and texture are also biologic variants. Dark-
skinned people usually have dark brown or black hair.
Hair texture, also an inherited characteristic, results from
the amount of protein molecules within the hair. Variations
range from straight to very curly. The curlier the hair, the
more difficult it is to comb. In general, using a wide-toothed
comb or pick, wetting the hair with water before combing, or
applying a moisturizing cream makes grooming more man-
ageable. Some clients with very curly hair prefer to arrange
it in small, tightly braided sections.
FIGURE 6-4 Vitiligo of the forearm in an African American. Enzymatic Variations

(Courtesy of Neutrogena Care Institute.) Three inherited enzymatic variations are prevalent among
members of various US subcultures. They involve an
absence or insufficiency of the enzymes lactase, glucose-6-
temporary redness, which then fades to a lighter hue; in dark- phosphate dehydrogenase (G-6-PD), and alcohol dehydro-
skinned clients, the effect is much more obvious. Vitiligo, a genase (ADH).
disease that affects whites as well as those with darker skin, Lactase Deficiency. Lactase is a digestive enzyme that
produces irregular white patches on the skin as a result of an converts lactose, the sugar in milk, into the simpler sugars glu-
absence of melanin (Fig. 6-4). Other than hypopigmentation, cose and galactose. A lactase deficiency, common among Afri-
there are no physical symptoms, but the cosmetic effects can Americans, Hispanics, and Chinese, causes intolerance to
may create emotional distress. Clients concerned about the dairy products. Without lactase, people have cramps, intesti-
irregularity of their skin color may use a pigmented cream to nal gas, and diarrhea approximately 30 minutes after ingest-
disguise noticeable areas. ing milk or foods that contain it. Symptoms may continue for
Mongolian spots, an example of hyperpigmentation, 2 hours (Dudek, 2009). Eliminating or reducing sources of
are dark-blue areas on the lower back and sometimes on the lactose in the diet may prevent the discomfort. Liquid tube-
abdomen, thighs, shoulders, or arms of darkly pigmented feeding formulas and those used for bottle-fed infants can be
infants and children (Fig. 6-5). Mongolian spots are due to prepared using milk substitutes. Because milk is a good source
the migration of melanocytes into fetal epidermis. They are of calcium, which is necessary for health, nurses should teach
rare among whites and tend to fade by the time a child is affected clients to obtain calcium from other sources, such
5 years old. Nurses unfamiliar with ethnic differences can as green leafy vegetables, dates, prunes, canned sardines and
mistake Mongolian spots as a sign of physical abuse or salmon with bones, egg yolks, whole grains, dried peas and
injury. They can differentiate between the two by pressing beans, and calcium supplements. Client and Family Teaching
the pigmented area: Mongolian spots will not produce pain 6-1 provides additional points for education.
when pressure is applied.
Client and Family Teaching 6-1

Reducing or Eliminating Lactose
The nurse teaches the client or the family to do the
following:
● Avoid milk, dairy products, and packaged foods that list
dry milk solids or whey among their ingredients (eg,
some breads, cereals, puddings, gravy mixes, caramels,
chocolate).
● Use nondairy creamers, which are lactose-free, instead of
cream.
● Consume only small amounts of milk or dairy products at
a time.
● Substitute milk that has been cultured with the Acido-
philus organism, which converts lactose into lactic acid.
● Drink Lactaid, a commercial product in which the lactose
has been preconverted into other absorbable sugars.
● Use kosher foods, which are prepared without milk; they
FIGURE 6-5 Mongolian spots. These bluish pigmented areas can be identified by the word pareve on the label.
are common in dark-skinned infants. (Photo by K. Timby.)
LWBK1004-C06_p72-92.indd 82 26/01/12 3:02 AM

TABLE 6-5 Examples of Drugs that Precipitate Glucose 6-Phosphate

Dehydrogenase Anemia
DRUG CATEGORY EXAMPLE USE
Quinine compounds Primaquine phosphate Prevention and treatment of malaria
Uricosurics Probenecid (Benemid) Treatment of gout
Sulfonamides Sulfasalazine (Azulfidine) Treatment of urinary infections
G-6-PD Deficiency. G-6-PD is an enzyme that helps red rate than other groups because of physiologic variations in
blood cells metabolize glucose. African Americans and their enzyme system. The result is that affected clients expe-
people from Mediterranean countries commonly lack this rience dramatic vascular effects, such as flushing and rapid
enzyme. The disorder is manifested in males because the heart rate, soon after consuming alcohol. In addition, mid-
gene is sex linked, but females can carry and transmit the dle metabolites of alcohol (those formed before acetic acid)
faulty gene. remain unchanged for a prolonged period. Many scientists
A G-6-PD deficiency makes red blood cells vulnerable believe that the middle metabolites, such as acetaldehyde,
during stress, which increases metabolic needs. When this are extremely toxic and subsequently play a primary role in
happens, red blood cells are destroyed at a much greater rate causing organ damage. The rate of death from alcoholism
than in unaffected people. If the production of new red blood among Native Americans is five times higher than that of
cells cannot match the rate of destruction, anemia develops. whites and three times the rate in the general population (Sub-
Because several drugs can precipitate the anemic proc- stance Abuse and Mental Health Services Administration,
ess (Table 6-5), it is important for the nurse to intervene 2007; Centers for Disease Control and Prevention, 2008).
if these drugs or those that depress red cell production are
prescribed for ethnic clients who are at greatest risk. At the Disease Prevalence
very least, the nurse must monitor susceptible clients and Several diseases, including sickle cell anemia, hypertension,
advocate for laboratory tests, such as red blood cell count and diabetes, and stroke, occur with much greater frequency
hemoglobin levels, which will indicate any adverse effects. among ethnic subcultures than in the general population.
The incidence of chronic illness affects morbidity differently
Alcohol Dehydrogenase (ADH) Deficiency. When a as well (Table 6-6).
person consumes alcohol, a process of chemical reactions The incidence of some chronic diseases and their com-
involving enzymes, one of which is ADH (not to be confused plications may be related partly to variations in social factors,
with antidiuretic hormone), eventually breaks down the alco- such as poverty. Minority cultural groups tend to be less afflu-
hol into acetic acid and carbon dioxide. Asian Americans ent; consequently, their access to expensive health care often
and Native Americans often metabolize alcohol at a different is limited. Without preventive health care, early detection,
TABLE 6-6 Leading Causes of Death Among US Cultural Groupsa

BLACK OR AFRICAN AMERICAN INDIAN OR ASIAN OR PACIFIC
RANK ALL AMERICANS AMERICAN HISPANIC OR LATINO ALASKA NATIVE ISLANDER
1 Heart disease Heart disease Heart disease Heart disease Heart disease
2 Cancer Cancer Cancer Cancer Cancer
3 Cerebrovascular Cerebrovascular Chronic lower respira- Unintentional injuries Cerebrovascular
diseases diseases tory diseases diseases
4 Chronic lower respira- Diabetes Unintentional injuries Diabetes Unintentional injuries
tory disease
5 Unintentional injuries Unintentional injuries Cerebrovascular Cerebrovascular Diabetes
diseases diseases
6 Diabetes Chronic lower respira- Diabetes Chronic lower respira- Influenza and pneu-
tory diseases tory diseases monia
7 Influenza and pneu- Homicide Influenza and pneu- Chronic liver disease Chronic lower respira-
monia monia and cirrhosis tory diseases
8 Suicide Influenza and pneu- Suicide Influenza and pneu- Chronic liver disease
monia monia and cirrhosis
9 Chronic liver disease Chronic liver disease Chronic liver disease Suicide Suicide
and cirrhosis and cirrhosis and cirrhosis
10 Homicide Suicide Homicide Homicide Homicide
a
Deaths, percentage of total deaths, and rank order for causes of death, by race per 100,000 population,
United States, 2006. Retrieved November 2009, from http://www.cdc.gov/data/hus/hus08.pdf.
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TABLE 6-7 Common Health Beliefs and Practices

CULTURAL GROUP HEALTH BELIEF HEALTH PRACTICES
Anglo-Americans Illness results from infectious microorganisms, organ Physicians are consulted for diagnosis and treatment;
degeneration, and unhealthy lifestyles nurses provide physical care
African Americans Supernatural forces can cause disease and influence Individual and group prayer is used to speed recovery
recovery
Asian Americans Health results from a balance between yin and yang Acupuncture, acupressure, food, and herbs are used to
energy; illness results when equilibrium is disturbed restore balance
Latinos Illness and misfortune are punishment from God Prayer and penance are performed to receive forgive-
(referred to as castigo de Dios) or results from an ness; the services of lay practitioners who are
imbalance of “hot” or “cold” forces within the body believed to possess spiritual healing power are used;
foods that are “hot” or “cold” are consumed to
restore balance
Native Americans Illness occurs when the harmony of nature (Mother A shaman, or medicine man, who has both spiritual and
Earth) is disturbed healing power, is consulted to restore harmony
and treatment, higher death rates are bound to occur. The client’s belief system and integrate scientifically based treat-
United States has, therefore, committed itself to reducing the ment along with folk and quasi-medical practices. Refer to
disparity in health care among all Americans (see Chap. 4). Table 6-7 for additional health beliefs and practices as they
With the knowledge that special populations are at relate to various religions.
increased risk for chronic diseases, culturally sensitive
nurses focus heavily on health education, participate in com-
munity health screenings, and campaign for more equitable CULTURALLY SENSITIVE NURSING
health services.
Accepting that the United States is multicultural is the first
Health Beliefs and Practices step toward transcultural nursing. The following recommen-
Many differences in health beliefs exist among US sub- dations are ways to demonstrate culturally sensitive nursing
cultures. They persist as a result of strong ethnic influ- care:
ences. Health beliefs, in turn, affect health practices
• Learn to speak a second language.
(Table 6-7).
• Use culturally sensitive techniques to improve interactions
Folk medicine (health practices unique to a particular
such as sitting in the client’s comfort zone and making
group of people) has come to mean the methods of disease
appropriate eye contact.
prevention or treatment outside mainstream conventional
• Become familiar with physical differences among ethnic
practice. Generally, lay providers rather than formally
groups.
educated and licensed individuals give such treatments. In
addition to culturally specific health practices, such as those
sought from a curandero (Latino practitioner who is thought
B OX 6 - 3 Examples of Alternative
to have spiritual and medicinal powers), a shaman, or an
Medical Therapy
herbalist, many people in the United States also turn to alter-
native quasi-medical therapy (Box 6-3). • Homeopathy is based on the principle of similars; it uses
Alternative medicine attracts people for various reasons: diluted herbal and medicinal substances that cause similar
the expense of mainstream medical care, dissatisfaction with symptoms of a particular illness in healthy people. For exam-
ple, quinine is used to treat malaria because it causes chills,
prior treatment or progress, or intimidation from the health
fever, and weakness (symptoms of malaria) when adminis-
care establishment. tered to healthy people.
• Naturopathy uses botanicals, nutrition, homeopathy, acu-
puncture, hydrotherapy, and manipulation to treat illness and
Gerontologic Considerations restore a person to optimum balance.
• Chiropractic is based on the belief that illnesses and pain
■ Older adults may prefer their own culture’s traditional result from spinal misalignment; it uses manipulation and
healing practices with which they have been familiar since readjustments of joint articulations, massage, and physi-
childhood. They may implement these practices before, dur- otherapy to correct dysfunction.
ing, and in spite of prescribed care by the scientific health • Environmental medicine proposes that allergies to environ-
care community. mental substances in the home and workplace affect health,
particularly for supersensitive people. It advocates reduced
exposure to chemicals to control conditions that mainstream
Just because a health belief or practice is different does physicians have failed to diagnose or underdiagnosed.
not make it wrong. Culturally sensitive nurses respect the
LWBK1004-C06_p72-92.indd 84 26/01/12 3:02 AM

• Perform physical assessments, especially of the skin, using 2. When interviewing an Asian American during admis-
techniques that provide accurate data. sion to a health agency, what is the best technique
• Learn or ask clients about cultural beliefs concerning for a culturally sensitive nurse to use when asking
health, illness, and techniques for healing. questions?
• Consult the client on ways to solve health problems. 1. Position himself or herself directly next to the client
• Never verbally or nonverbally ridicule a cultural belief or 2. Position himself or herself just beyond an arm’s
practice. length away
• Integrate helpful or harmless cultural practices within the 3. Position himself or herself within the doorway to
plan of care. the room
• Modify or gradually change culturally unsafe health prac- 4. Position himself or herself to facilitate occasional
tices. touching
• Avoid removing religious medals or clothes that hold sym- 3. While assessing an African American infant during
bolic meaning for the client. If they must be removed, keep a home visit, the nurse observes a bluish area on the
them safe and replace them as soon as possible. baby’s buttocks. What is the action that is best for the
• Provide culturally preferred food. nurse to take?
• Advocate routine screening for diseases to which clients 1. Document the information; it is a normal assess-
are genetically or culturally prone. ment finding
• Facilitate rituals by the person the client identifies as a 2. Report suspicion of physical abuse to Child Protec-
healer within his or her belief system. tive Services
• Apologize if cultural traditions or beliefs are violated. 3. Notify the physician in charge of the infant’s care
about the finding
4. Examine any and all children in the home for addi-
CRITICAL THINKING EXERCISES tional signs of abuse
4. A Native American client reports that a tribal elder
1. A nurse working for a home health agency is
used “smudging,” a ritual in which a substance like
assigned to care for a non–English-speaking client
sweet grass is burned and the smoke is fanned about
from Pakistan. How would a culturally sensitive nurse
the body with an eagle feather, to cleanse him of
prepare for this client’s care?
negative energies during his recent illness. Which
2. A pregnant Haitian woman explains to a nurse that
response by the nurse is most appropriate?
she is wearing a chicken bone around her neck to
1. Explain that smudging will not help restore the
protect her unborn child from birth defects. Discuss
client’s health
how it would be best to respond to this woman from
2. Suggest that the client include the physician’s
a culturally sensitive perspective.
treatment regimen
3. Identify characteristics of a cultural group located
3. Report the tribal elder for practicing medicine with-
within your community; include family patterns,
out a license
dietary preferences or restrictions, health beliefs, and
4. Advise the client to avoid treatment prescribed by
practices.
the tribal elder
4. Explore approaches used to meet the health needs
5. Which of the following hospital menu suggestions
of a non–Anglo-American cultural group within the
would be appropriate for a person who practices
community in which you live; include methods for
Orthodox Judaism? Select all that apply.
communicating and provide of non-English printed
1. Breaded pork chop
materials.
2. Crab salad
3. Tuna filet
4. Baked chicken
NCLEX-STYLE REVIEW QUESTIONS 5. Bacon, lettuce, tomato sandwich
1. What is the first step a nurse should take when pre-
paring to teach a Latino client about dietary measures
to control diabetes mellitus?
1. Monitor the client’s blood glucose level each day
2. Review prescribed drug therapy
3. Obtain a copy of a calorie-controlled exchange list
4. Determine the client’s food likes and dislikes
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UNIT 2
End of Unit Exercises for Chapters 3, 4, 5, and 6
1. __________________ means damaging statements written and read by others. (Libel, Misdemeanors, Slander)
2. __________________ is the ethical principle that emphasizes the duty to be honest and to avoid deceiving or misleading
clients. (Autonomy, Justice, Veracity)
3. A(n) __________________ disorder is acquired from the genetic codes of one or both parents. (congenital, hereditary,
idiopathic)
4. Health services to which health care providers refer clients for consultation and additional testing, such as cardiac
catheterization, are an example of __________________ care. (primary, secondary, tertiary)
5. __________________ means physiologic and behavioral responses to disequilibrium. (Adaptation, Holism, Stress)
6. __________________ stabilizes mood, induces sleep, and regulates temperature. (Dopamine, Norepinephrine, Serotonin)
7. __________________ is a bond or kinship that a person feels with his or her country of birth or place of ancestral origin.
(Culture, Ethnicity, Race)
8. A fixed attitude about all people who share a common characteristic related to age, sex, race, sexual orientation, or eth-
nicity is called a __________________. (belief, generalization, stereotype)
1. T____F____ An anecdotal note cannot be used as evidence in court.
2. T____F____ Malpractice is harm that results from acting carelessly in a given circumstance.
3. T____F____ Capitation is a payment system that provides incentives to control the number of tests and services rendered
as a means of making a profit.
4. T____F____ In the case method of nursing, one nurse manages all the care needs of a client or group of clients for a
designated period.
5. T____F____ Coping mechanisms are stress-reduction activities people select consciously to help them deal with
challenging events or situations.
6. T____F____ Receptors for neurotransmitters are found throughout the central nervous, endocrine, and immune systems.
7. T____F____ Ethnocentrism refers to the belief that one’s own ethnicity is superior to all others.
8. T____F____ Florence Nightingale coined the term “transcultural nursing.”
Activity C: Write the correct term for each description below.

1. Unlawful act in which untrue information harms a person’s reputation __________________
2. Person who claims injury and brings charges against another person __________________
3. Sum of physical, emotional, social, and spiritual health, which determines how “whole” or well a person
feels __________________
4. Ill effect that results from permanent or progressive organ damage caused by a disease or its treatment
__________________
86
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5. A relatively stable state of physiologic equilibrium __________________

6. Natural body chemicals that produce effects similar to those of opiate drugs __________________
7. Period during which signs and symptoms of a particular disease temporarily disappear __________________
8. Digestive enzyme that converts lactose into glucose and galactose __________________
Activity D: 1. Match the terms in Column A with their definitions in Column B.

Column A Column B
1. __________________ Morbidity A. The number of people who died from a particular disease or
condition
2. __________________ Mortality B. A change in health that develops slowly and lasts a long time,
increasing with age
3. __________________ Acute illness C. The number of people affected by a specific disease,
disorder, or injury
4. __________________ Chronic illness D. A change in health that happens suddenly and lasts a short
time
2. Match the skin disorders in Column A with their descriptions in Column B.

Column A Column B
1. __________________ Keloids A. Dark-blue areas on the lower backs of darkly pigmented
infants and children
2. __________________ Hypopigmentation B. Irregular, elevated thick scars
3. __________________ Vitiligo C. Damaged skin with temporary redness that fades to a
lighter hue
4. __________________ Mongolian spots D. Irregular white patches on the skin from a lack of melanin
Activity E: 1. Differentiate between teleologic theory and deontologic theory.

Teleologic Theory Deontologic Theory
Definition
Ideology
Example
2. Differentiate between the sympathetic and parasympathetic nervous systems.

Sympathetic Nervous System Parasympathetic Nervous System
Function
Effect on physiologic functions
Example
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Activity F: Consider the following figure.
1. Label the structures in the figure.
Activity G: In the 1960s, Abraham Maslow identified and grouped five levels of human needs in a sequential hierarchy
according to their significance. In the boxes below, sequence the five levels of human needs as defined by
Maslow, moving from those that are most important to those that are least important for survival.
1. Need for esteem and self-esteem
2. Need for self-actualization
3. Need for love and belonging
4. Need for physiologic requirements
5. Need for safety and security
Activity H: Answer the following questions.

1. What are laws? What are the different types of laws?
2. What is the purpose of a nurse practice act?
3. How does the World Health Organization (WHO) define health?
4. What are the five common management patterns that nurses use to administer client care?
5. What is homeostasis? What are the four categories of stressors that affect homeostasis?
6. What factors affect the stress response?
7. What is transcultural nursing care?
LWBK1004-C06_p72-92.indd 88 21/02/12 11:38 PM

Activity I: Answer the following questions.

1. Why is it important for nurses to obtain their own personal liability insurance?
2. Why does the treatment of idiopathic illness focus on relieving signs and symptoms?
3. Why can a nurse be charged with a criminal offense in the case of gross negligence?
4. Why should the nurse refuse the assistance of untrained interpreters, volunteers, or family when caring for a client with
whom the nurse does not share a common language?
5. Why is it important for the nurse to inspect the skin of the palm, foot, and abdomen during a skin assessment of a person
of color?
6. Why must the nurse avoid making or writing negative comments about clients, physicians, or other coworkers?
Activity J: Answer the following questions focusing on nursing roles and responsibilities.
1. An unconscious client has been admitted to the health care facility after a motor vehicle crash. When the client regains
consciousness, he wants to leave the facility without being medically discharged.
a. Can the nurse prevent the client from leaving?
b. What procedure should the nurse follow if the client refuses to stay at the facility?
2. Personnel at a health care facility follow a team nursing pattern of care, with one member as the team leader.
a. What is team nursing?
b. What are the roles and responsibilities of the team leader?
LWBK1004-C06_p72-92.indd 89 26/01/12 3:02 AM

3. A nurse is caring for a client scheduled for minor surgery who is unusually quiet. The nurse believes that the client is
under stress.
a. What can the nurse do if the client is experiencing stress?
b. What stress-reduction techniques can the nurse employ for this client?
4. A nurse is assessing a client who immigrated to the United States years ago and understands English well but does not
speak the language fluently. The client does not want an interpreter.
a. How should the nurse communicate with the client during the assessment?
b. Why is it important for the nurse to be patient when communicating with this client?
5. A nurse who works in a large urban clinic assesses clients from various subcultures.
a. What data should the nurse obtain during an assessment to provide culturally sensitive care?
b. What variations is a nurse likely to observe when assessing these clients?
Activity K: Consider the following questions. Discuss them with your instructor or peers.
1. A client with a fractured left leg is learning how to use crutches. The nurse has asked the client not to leave the room
without assistance. The client ignores this suggestion and falls. How should the nurse handle this situation?
2. A client is unhappy with the lunch served to him at the health care facility. When the nurse arrives to check if the client
has eaten, the client pushes away the tray, spilling its contents on the floor. What should the nurse do in this case?
3. A client who is to undergo chemotherapy expresses concern about the side effects of the drug treatment and the effects
that the cancer is causing on his family roles. The client mentions to the nurse that he tries to combat stress by sleeping
most of the time. What interventions can the nurse suggest to help reduce the client’s stress?
4. A nurse is working at a health care facility where most clients do not speak English. How should the nurse prepare to
meet the challenges of this job?
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Activity L: Answer the following questions.

1. A nurse at a health care facility has been stealing narcotics for personal use and has been attempting to conceal the theft
by altering records of narcotic drug administration. Which of the following would the nurse most likely be charged with
in the case of legal proceedings?
a. Misdemeanor
b. Felony
c. Malpractice
d. Negligence
2. The nurse has asked a client who is likely to experience orthostatic hypotension to use the nurse’s call light if he needs to
use the bathroom. The client refuses to do so. Which of the following actions would be appropriate for the nurse to take to
ensure the client’s safety?
a. Raise the side rails of the bed
b. Obtain a medical order to use a restraint
c. Threaten to use a restraint
d. Use a wanderer alarm
3. A nurse has admitted a client to the health care facility. This same nurse is also responsible for planning the client’s care
and evaluating the client’s progress until discharge. What pattern of nursing is being followed?
a. Primary nursing
b. Functional nursing
c. Nurse-managed care
d. Case method
4. A client who has been diagnosed with cancer refuses to believe this news and wants all the diagnostic tests repeated.
What kind of coping mechanism is the client exhibiting?
a. Displacement
b. Projection
c. Sublimation
d. Denial
5. A nurse is caring for a client whose right hand had to be amputated following an accident. The client, whose employment
involves using a computer keyboard to enter data, may have to look for another job. Which of the following is the highest
contributor to stress in this client’s situation?
a. Moving to a different job
b. Adjusting to a change in financial status
c. Dealing with a personal injury
d. Changing living conditions
6. The nurse is assigned to care for an Asian American woman. Which of the following is appropriate for the nurse to do
when caring for this client?
a. Touch the client’s head gently
b. Avoid touching the client’s hand
c. Provide personal care in the presence of family members
d. Avoid lingering eye contact with the client
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7. When assessing a client who does not speak the same language as the nurse, the nurse seeks the assistance of an
interpreter. Which of the following is a characteristic of a skilled interpreter?
a. Explains the role of an interpreter to the client
b. Expresses personal views on the client’s statement
c. Informs the client’s family about the client’s condition
d. Translates the client’s statements without conveying the client’s emotions
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UNIT 3
Fostering Communication
7 The Nurse–Client Relationship 94
8 Client Teaching 105
9 Recording and Reporting 114
93
LWBK1004-C07_p093-104.indd 93 2/6/12 9:49 PM

7 The Nurse–Client
Relationship
active listening
affective touch
caregiver 1. Name four roles that nurses perform in nurse–client
collaborator relationships.
communication 2. Describe the current role expectations for clients.
delegator 3. List at least five principles that form the basis of the nurse–
educator client relationship.
empathy 4. Identify the three phases of the nurse–client relationship.
intimate space 5. Differentiate between social communication and therapeutic
introductory phase verbal communication.
kinesics 6. Give at least five examples of therapeutic and nontherapeutic
nonverbal communication communication techniques.
paralanguage 7. List at least five factors that affect oral communication.
personal space 8. Describe the four forms of nonverbal communication.
proxemics 9. Differentiate task-related touch from affective touch.
public space 10. List at least five situations in which affective touch may be
relationship appropriate.
silence
social space
task-oriented touch
n intangible factor that helps a client hold a nurse in high
A
terminating phase
regard is the relationship that develops between them. One of
therapeutic relationship
therapeutic verbal communication the primary keys to establishing and maintaining positive
touch nurse–client relationships is the manner and style of the nurse’s
verbal communication communication. This chapter offers information about techniques
working phase for communicating therapeutically, listening empathetically, sharing
information, and providing client education, all of which are
among the most basic processes within the context of nurse–client
relationships.
NURSING ROLES WITHIN

THE NURSE—CLIENT RELATIONSHIP
A relationship (an association between two or more people that

develops over time) is established between the nurse and the client
when nursing services are provided. Nurses provide services or skills
that assist individuals (called clients or patients), promote or restore
health, cope with disorders that will not improve, and die with dignity.
The nurse–client relationship requires the nurse to respond to
the client’s needs. The National Council of State Boards of Nursing,
which develops the National Council Examination-Practical Nurse
(NCLEX-PN), designates four categories of client needs as the struc-
ture for the test plan: (1) safe and effective care environment, (2) health
promotion and maintenance, (3) psychosocial integrity, and (4) physi-
ologic integrity. These four categories apply to all areas of nursing
94
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CHAPTER 7 The Nurse–Client Relationship 95
practice regardless of the stage in the client’s life or the set-

ting for health care delivery. To meet these client needs,
nurses perform four basic roles: caregiver, educator, collabo-
rator, and delegator.
The Nurse as Caregiver Pharmacist Laboratory

A caregiver is one who performs health-related activities technician
that a sick person cannot perform independently. Caregivers
provide physical and emotional services to restore or main-
tain functional independence. Box 7-1 highlights the many Dietitian
differences between the services that nurses provide and
those that other caring people provide.
Although the traditional nursing role is associated with
physical care, it also involves developing close emotional rela- LPN MD
tionships. The contemporary caregiving role incorporates an
understanding that illness and injury cause feelings of insecu-
Physical
rity that may threaten a person’s ability to cope. Nurses use RN
therapist
empathy (an intuitive awareness of what a client is experienc-
ing) to perceive the client’s emotional state and need for sup-
port. Empathy helps nurses become effective at providing for
the client’s needs while remaining compassionately detached. CLIENT
Unlicensed Respiratory
The Nurse as Educator assistive personnel therapist
Being an educator (one who provides information) is a neces- FIGURE 7-1 Collaboration may involve many members of the
sity in today’s complex health care arena. Nurses provide health care team.
health teaching pertinent to each client’s needs and knowledge
or those that offer rehabilitation, financial assistance, or emo-
base (see Chap. 8). Some examples include explanations about
tional support.
diagnostic test procedures, self-administration of medications
after discharge, techniques for managing wound care, and
The Nurse as Collaborator
restorative exercises like those performed after a mastectomy.
The nurse also acts as a collaborator (one who works with
When it comes to treatment decisions, the nurse avoids
others to achieve a common goal) (Fig. 7-1). The most obvi-
giving advice—reserving the right of each person to make
ous example of collaboration occurs between the nurse
his or her own choices on matters affecting health and illness
responsible for managing care and those to whom he or she
care. The nurse shares information on potential alternatives,
delegates care. Collaboration also occurs when the nurse and
promotes the client’s freedom to choose, and supports the
the physician share information and exchange findings with
client’s ultimate decision.
other health care workers.
Nursing is considered a practice “without walls” because
it extends beyond the original treatment facility. Conse-
quently, nurses are resources for information about health
➧ Stop, Think, and Respond Exercise 7-1
services available in the community. This type of information With whom would the nurse collaborate when caring
empowers clients to become involved with self-help groups for an older adult with a fractured hip?
B OX 7- 1 Differentiating Caring Acts from Nursing Acts

CARING ACTS NURSING ACTS
Prompted by observing a person in distress Prompted by a concern for the well-being of everyone
Motivated by sympathy Motivated by altruism
Spontaneous Planned
Goal is to relieve crisis Goal is to promote self-reliance
Outcomes are short term Outcomes are long term
Assume major responsibility for resolving the person’s Expect mutual cooperation in resolving health problems
problem
Experience based Knowledge based
Modeled on a personal moral code Modeled on a formal code of ethics
Guided by common sense Legally defined
Accountability based on acting reasonably prudent Accountability based on meeting professional standards
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96 UNIT 3 Fostering Communication
The Nurse as Delegator B OX 7- 2 Responsibilities Within the

Before the nurse performs the role of delegator (one who Nurse–Client Relationship
assigns a task to someone), he or she must know what tasks
Nursing Responsibilities
are legal and appropriate for particular health care workers
• Possess current knowledge
to perform. It is potentially litigious to delegate a task to • Be aware of unique age-related differences
someone who does not have the knowledge or expertise to • Perform technical skills safely
perform it correctly. Once a task is assigned, it is still the del- • Be committed to client care
egator’s responsibility to check that the task has been com- • Be available and courteous
pleted and determine the resulting outcome. For example, if • Facilitate participation of client and family in decisions
a nurse asks a nursing assistant to change a client’s position, • Remain objective
the nurse verifies that the assistant complied with the nurse’s • Advocate on the client’s behalf
request and obtains additional pertinent information such as • Provide explanations in easily understood language
the condition of the client’s skin. If the delegated task is not • Promote the client’s independence
performed or is performed incorrectly, the nurse is account- Client Responsibilities
able for the inadequate care. • Identify current problem
• Describe desired outcomes
➧ Stop, Think, and Respond Exercise 7-2 • Answer questions honestly
Before delegating the task of taking a client’s vital • Provide accurate historical and subjective data
signs (temperature, pulse, respiratory rate, and blood • Participate to the fullest extent possible
pressure) to a student nurse, how might the nurse • Be open and flexible to alternatives
determine whether the task is appropriate for the • Comply with the plan for care
student, and if appropriate, that it has been performed? • Keep appointments for follow-up care
Phases of the Nurse–Client Relationship

Nurse–client relationships ordinarily are brief. They begin
THE THERAPEUTIC NURSE–CLIENT
when people seek services that will maintain or restore health
RELATIONSHIP
or prevent disease. They end when clients can achieve their
health-related goals independently. This type of relationship
The nurse–client relationship also can be called a therapeu-
generally is described as having three phases: introductory,
tic relationship because the desired outcome of the asso-
working, and terminating.
ciation is almost always moving toward improving health.
A therapeutic relationship differs from a social relationship. Introductory Phase
A therapeutic relationship is client-centered with a focus on The relationship between client and nurse begins with the
goal achievement. It is also time limited: the relationship introductory phase (the period of getting acquainted). Each
ends when goals are achieved. person usually brings preconceived ideas about the other to
The relationship between nurses and clients has changed. the initial interaction. These assumptions eventually are con-
In the past, the role of a sick person was passive; this allowed firmed or dismissed.
others to make decisions and to submit to treatments without Many experts agree that most people form their initial
question or protest. Nurses now encourage and expect peo- opinions within just a few seconds of meeting. Some tech-
ple for whom they care to become actively involved, com- niques for facilitating a positive first impression include:
municate, question, assist in planning their care, and retain
• Dressing appropriately
as much independence as possible (Box 7-2).
• Being well-groomed
• Smiling
Underlying Principles • Making eye contact
A therapeutic nurse–client relationship is more likely to • Greeting with a handshake
develop when the nurse treats each client as a unique person • Projecting confidence
and respects the client’s feelings. The nurse strives to pro- • Avoiding offensive personal odors, such as the smell of
mote the client’s physical, emotional, social, and spiritual cigarette smoke or strong scents of perfume or cologne
well-being, and encourages the client to participate in prob-
lem solving and decision making. The nurse believes that a
client has the potential for growth and change and commu- Gerontologic Considerations
nicates using terms and language the client understands. The
■ Initially, greet the client by giving your name and title.
nurse uses the nursing process to individualize the client’s
Address the older person using formal titles of respect such
care; involves people to whom the client turns for support,
as “Mr.” or “Mrs.” Find an appropriate time to ask the client
such as family and friends when providing care; and imple- how he or she prefers to be addressed. Avoid using familiar
ments health care techniques compatible with the client’s or endearing terms such as “dear,” “sweetie,” or “honey.”
value system and cultural heritage.
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After the initial formalities, the client initiates the rela- B OX 7- 3 Barriers to a Nurse–Client
tionship by identifying one or more health problems for Relationship
which he or she is seeking help. It is important for the nurse
to demonstrate courtesy, active listening, empathy, compe- • Appearing unkempt: long hair that dangles on or over the
tency, and appropriate communication skills to ensure that client during care, offensive body or breath odor, wrinkled or
soiled uniform, dirty shoes
the relationship begins on a positive note.
• Failing to identify oneself verbally and with a name tag
• Mispronouncing or avoiding the client’s name
Working Phase
• Using the client’s first name without permission
The working phase (period during which tasks are per- • Showing disinterest in the client’s personal history and life
formed) involves mutually planning the client’s care and experiences
implementing the plan. Both the nurse and the client partici- • Sharing personal or work-related problems with the client or
pate. Each shares in performing those tasks that lead to the with staff in the client’s presence
desired outcomes mutually identified by the client and the • Using crude or distasteful language
nurse. During the working phase, the nurse tries not to retard • Revealing confidential information or gossip about other
clients, staff, or people commonly known
the client’s independence; doing too much is as harmful as
• Focusing on nursing tasks rather than the client’s responses
doing too little.
• Being inattentive to the client’s requests (eg, food, pain relief,
assistance with toileting, bathing)
• Abandoning the client at stressful or emotional times
Gerontologic Considerations • Failing to keep promises such as consulting with the physi-
cian about a current need or request
■ Promote an older adult’s control over decisions as much • Going on a break or to lunch without keeping the client
as possible. Dependence is often difficult to accept; partici- informed and identifying who has been delegated for the
pation helps maintain self-esteem and dignity. client’s care during the temporary absence
Terminating Phase was understood or requires further clarification (Fig. 7-2).

The nurse–client relationship is self-limiting. The termi- Communication takes place simultaneously on a verbal and
nating phase (the period when the relationship comes to an nonverbal level with the nonverbal level representing the
end) occurs when the nurse and client agree that the client’s stronger component in any interaction. Because no relation-
immediate health problems have improved. A caring attitude ship can exist without verbal and nonverbal communication,
and compassion help facilitate the client’s transition of care nurses develop skills that enhance their therapeutic interac-
to other health care services or to independent living. tions with clients.
Barriers to a Therapeutic Relationship Verbal Communication

It is impossible for a nurse to develop a positive relationship Verbal communication (communication that uses words)
with every client. Box 7-3 lists examples of behaviors that includes speaking, reading, and writing. Both the nurse and
are likely to interfere. The best approach is to treat clients in the client use verbal communication to gather facts. They
the manner one would like to be treated. also use it to instruct, clarify, and exchange ideas.
Many factors affect the ability to communicate by
speech or in writing. Examples include (1) attention and
Gerontologic Considerations concentration; (2) language compatibility; (3) verbal skills;
■ Avoid the “invisible client syndrome.” Talking with some-

one else in the room as if the client is not there demon-
strates disrespect.
■ Never treat older adults as if they are children or are
uneducated. Avoid using terms that are demeaning or that
connote childlike or infantile behavior (eg, referring to incon-
tinence products as “diapers”).
COMMUNICATION
Communication (an exchange of information) involves

both sending and receiving messages between two or more FIGURE 7-2 Communication is a two-way process between a
people followed by feedback indicating that the information sender and a receiver.
LWBK1004-C07_p093-104.indd 97 2/6/12 9:49 PM

(4) hearing and visual acuity; (5) motor functions involv- and promotes recall of situations in which they have dem-
ing the throat, tongue, and teeth; (6) sensory distractions; onstrated coping or adaptation.
(7) interpersonal attitudes; (8) literacy; and (9) cultural
similarities. The nurse promotes the factors that enhance the
communication of verbal content and controls or eliminates
those that interfere with the accurate perception of expressed Therapeutic Verbal Communication
ideas. Communication can take place on a social or therapeu-
tic level. Social communication is superficial; it includes
common courtesies and exchanges about general topics.
Gerontologic Considerations Therapeutic verbal communication (using words and
gestures to accomplish a particular objective) is extremely
■ In the event that it is difficult for older adults to read the
important, especially when the nurse is exploring prob-
name tag or recall the nurse’s name from a previous intro- lems with the client or encouraging expression of feelings.
duction, clients may appreciate if the nurse identifies Techniques that the nurse may find helpful are described
himself or herself by name and title before each interaction in Table 7-1.
or posts them on a dry erase board in the room. For older The nurse must never assume that a quiet, uncommu-
clients with diminished hearing, it may be helpful to nicative client is problem-free or understands everything.
reduce noise in the immediate environment. Identify which It is never appropriate to probe and pry; rather, it may be
ear has the best hearing, and take a position on that side. advantageous to wait and be patient. It is not unusual for
Speak at a normal volume with distinct pronunciation of reticent clients to share their feelings and concerns after they
beginning and ending consonants for each word, yet with- conclude that the nurse is sincere and trustworthy.
out distorting normal patterns of speaking. Because older
Nurses must approach vocal and/or emotional clients
adults with diminished hearing may rely on visual cues,
avoid covering your mouth or turning away from the client
delicately. For instance, when clients are angry or crying,
when interacting verbally. the best nursing response is to remain nonjudgmental, allow
■ Encourage reminiscing. Ask about past events and rela- them to express their emotions, and return later with a follow-
tionships associated with positive experiences and feelings. up regarding their legitimate complaints. Allowing clients to
Giving older adults an opportunity to talk about earlier display their feelings without fear of retaliation or censure
times in their lives reinforces their value and unique identity contributes to a therapeutic relationship.
TABLE 7-1 Therapeutic Verbal Communication Techniques

TECHNIQUE USE EXAMPLE
Broad opening Relieves tension before getting to the real “Wonderful weather we’re having.”
purpose of the interaction
Giving information Provides facts “Your surgery is scheduled at noon.”
Direct questioning Acquires specific information “Do you have any allergies?”
Open-ended questioning Encourages the client to elaborate “How are you feeling?”
Reflecting Confirms that the nurse is following the Client: “I haven’t been sleeping well.”
conversation Nurse: “You haven’t been sleeping well.”
Paraphrasing Restates what the client has said to demonstrate Client: “After every meal, I feel like I will throw
listening up.”
Nurse: “Eating makes you nauseous, but you
don’t actually vomit.”
Verbalizing what has been Shares how the nurse has interpreted a Client: “All the nurses are so busy.”
implied statement Nurse: “You’re feeling that you shouldn’t ask for
help.”
Structuring Defines a purpose and sets limits “I have 15 minutes. If your pain is relieved, we
could discuss how your test will be done.”
Giving general leads Encourages the client to continue “Uh, huh,” or “Go on.”
Sharing perceptions Shows empathy for the client’s feelings “You seem depressed.”
Clarifying Avoids misinterpretation “I don’t quite understand what you’re asking.”
Confronting Calls attention to manipulation, inconsistencies, or “You’re concerned about your weight loss, but
lack of responsibility you didn’t eat any breakfast.”
Summarizing Reviews information that has been discussed “You’ve asked me to check on increasing your
pain medication and getting your diet changed.”
Silence Allows time for considering how to proceed or
arouses the client’s anxiety to the point that it
stimulates more verbalization
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Although nurses often have the best intentions of inter- becoming fully involved in what the client says. To facilitate
acting therapeutically with clients, some fall into traps that active listening, other issues in one’s personal agenda must
block or hinder verbal communication. Table 7-2 lists com- be temporarily blocked in order to focus on the content of
mon examples of nontherapeutic communication. the present interaction.
Giving attention to what clients say provides a stimulus
Listening for meaningful interaction. It is important to avoid giving
Listening is as important during communication as speak- signals that indicate boredom, impatience, or the pretense of
ing. In contrast to hearing, which involves perceiving sounds, listening. For example, looking out a window or interrupt-
active listening is an activity that includes attending to and ing is a sign of disinterest. When communicating with most
TABLE 7-2 Nontherapeutic Verbal Communication Techniques

TECHNIQUE AND CONSEQUENCE EXAMPLE IMPROVEMENT
Giving False Reassurance

Trivializes the client’s unique feelings and “You’ve got nothing to worry about. “Tell me your specific concerns.”
discourages further discussion Everything will work out just fine.”
Using Clichés
Provides worthless advice and curtails “Keep a stiff upper lip.” “It must be difficult for you right now.”
exploring alternatives
Giving Approval or Disapproval
Holds the client to a rigid standard; implies “I’m glad you’re exercising so regularly.” “Are you having any difficulty fitting regular
that future deviation may lead to subse- “You should be testing your blood glucose exercise into your schedule?”
quent rejection or disfavor each morning.” “Let’s explore some ways that will help
you remember to test your blood
glucose each morning.”
Agreeing
Does not allow the client flexibility to “You’re right about needing surgery “Having surgery immediately is one
change his or her mind immediately.” possibility. What others have you
considered?”
Disagreeing
Intimidates the client; makes him or her “That’s not true! Where did you get that “Maybe I can help clarify that for you.”
feel foolish or inadequate idea?”
Demanding an Explanation
Puts the client on the defensive; he or she “Why didn’t you keep your appointment “I see you couldn’t keep your appointment
may be tempted to make up an excuse last week?” last week.”
rather than risk disapproval for an honest
answer
Giving Advice
Discourages independent problem solving “If I were you, I’d try drug therapy before “Share with me the advantages and
and decision making; provides a biased having surgery.” disadvantages of your options as you
view that may prejudice the client’s choice see them.”
Defending
Indicates such a strong allegiance that any “Ms. Johnson is my best nursing “I’m sorry you had to wait so long.”
disagreement is unacceptable assistant. She wouldn’t have let your
light go unanswered that long.”
Belittling
Disregards how the client is responding as “Lots of people learn to give themselves “You’re finding it especially difficult to
an individual insulin.” inject yourself with a needle.”
Patronizing
Treats the client condescendingly (less “Are we ready for our bath yet?” “Would you like your bath now or should I
than capable of making an independent check with you later?”
decision)
Changing the Subject
Alters the direction of the discussion to a Client: “I’m so scared that a mammogram Client: “I’m so scared that a mammogram
safer or more comfortable topic will show I have cancer.” will show I have cancer.”
Nurse: “Tell me more about your family.” Nurse: “It is a serious disease. What
concerns you the most?”
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Nonverbal Communication
Nonverbal communication (an exchange of information
without using spoken or written words) involves what is not
said. The manner in which a person conveys verbal informa-
tion affects its meaning. It is believed that nonverbal com-
munication has about five times the impact of verbal com-
munication (Bennett, 2008b).
A person has less control over nonverbal than verbal
communication. Words can be chosen with care, but a facial
expression and other forms of body language are harder to
control. As a result, people often communicate messages
more accurately through nonverbal communication.
FIGURE 7-3 Appropriate positioning, space, eye contact, and Gerontologic Considerations
attention promote therapeutic communication. (Photo by
B. Proud.)
■ Older adults may have difficulty perceiving nonverbal
forms of communication due to visual impairments.
■ It is important to avoid standing in front of a sunny win-
people in the United States, it is best to position oneself at
dow when communicating with older adults because the
the person’s level and make frequent eye contact (Fig. 7-3).
glare may interfere with looking directly at the nurse, caus-
Refer to Chapter 6 for cultural exceptions. Nodding and ing them to miss the nuances of nonverbal communication.
making comments such as, “Yes, I see” encourages clients
to continue and shows full involvement in what is being said.
People communicate nonverbally through the following
Silence techniques: kinesics, paralanguage, proxemics, and touch.
Silence (intentionally withholding verbal commentary) plays
an important role in communication. It may seem contradic- Kinesics
tory to include silence as a form of verbal communication. Kinesics (body language) includes nonverbal techniques
Nevertheless, one of its uses is to encourage the client to such as facial expressions, posture, gestures, and body
participate in verbal discussions. Other therapeutic uses for movements. Some add that clothing style and accessories
silence include relieving a client’s anxiety just by providing such as jewelry also affect the context of communication.
a personal presence and offering a brief period during which Box 7-4 describes various examples of nonverbal behavior
clients can process information or respond to questions. and their meaning.
Clients may use silence to camouflage fears or to express Knowledge of kinesics is important for the nurse being
contentment. They also use silence for introspection when evaluated by his or her clients and vice versa. To create a pos-
they need to explore feelings or pray. Interrupting someone itive impression during a client interaction, the nurse should:
deep in concentration disturbs his or her thought process. A • Assume a position at eye level with the client; stand or sit
common obstacle to effective communication is ignoring the tall
importance of silence and talking excessively. • Relax arms, legs, and feet; do not cross any body part
B OX 7- 4 Examples of Body Language

POSITIVE INTERPRETATION NEGATIVE INTERPRETATION
Tilt of head Interested Arms crossed Blocking; oppositional

Open hands Sincere Clenched jaw Angry; antagonistic
Brisk, erect walk Confident Downcast eyes Remorseful; bored
Hand to cheek Contemplative Rubbing nose Doubtful; deceitful
Rubbing hands Anticipatory Drumming fingers Impatient
Steepled fingers Authoritative Fondling hair Insecure
Nod Agreement Frown Disagreement
Stroking chin Stalling for time
Shifting from foot to foot Desire to get away
Looking at watch Bored
Adapted from Examples of body language in use. Available at: http://www.bodylanguage training.com/examples.html;
Body language, sending signals without words. Available at: http://www.uwm.edu/~ceil/career/jobs/body.htm;
and Examples of body language. Available at: http://www.deltabravo.net/custody/body.php.
LWBK1004-C07_p093-104.indd 100 2/6/12 9:50 PM

• Maintain eye contact approximately 60% to 70% of the

time or whatever is appropriate for the culture (see Chap. 6);
in a group, focus on the last person who spoke
• Keep the head level, both horizontally and vertically
• Lean forward to demonstrate interest and attention
• Keep the arms where they can be seen
• Strike a balance in arm movements—neither too demon-
strative nor reserved
• Keep the legs as still as possible
Paralanguage
Paralanguage (vocal sounds that are not actually words)
also communicates a message. Some examples include
drawing in a deep breath to indicate surprise, clucking the
tongue to indicate disappointment, and whistling to get
someone’s attention. Vocal inflections, volume, pitch, and FIGURE 7-4 Examining a client involves task-oriented touch.
rate of speech add another dimension to communication. (Photo by B. Proud.)
Crying, laughing, and moaning are additional forms of para-
language. connotations. Approaches that may prevent such misunder-
standing include explaining beforehand how a nursing pro-
Proxemics
cedure will be performed, ensuring that a client is properly
Proxemics (the use and relationship of space to commu-
draped or covered, and asking that another staff person of the
nication) varies among people from different cultural back-
client’s gender be present during a potentially sensitive exam-
grounds. Generally, four zones are observed in interactions
ination or procedure.
between Americans (Hall, 1959, 1963, 1966): intimate space
(within 6 in.), personal space (6 in. to 4 ft), social space (4 to Touch
12 ft), and public space (more than 12 ft; Table 7-3). Touch (a tactile stimulus produced by making personal con-
Most people in the United States comfortably tolerate tact with another person or object) occurs frequently in nurse–
strangers in a 2- to 3-ft area. Venturing closer may cause client relationships. While caring for clients, touch can
some to feel anxious. Understanding the client’s comfort be task-oriented, affective, or both. Task-oriented touch
zone helps the nurse to know how spatial relations affect involves the personal contact required when performing
nonverbal communication. nursing procedures (Fig. 7-4). Affective touch is used to
Closeness is common in nursing because, most often, demonstrate concern or affection (Fig. 7-5).
nurses and clients are in direct physical contact. Therefore, Affective touch has different meanings to different peo-
some clients can misinterpret physical nearness and touch- ple depending on how they were raised and their cultural
ing within intimate and personal spaces as having sexual background. Because nursing care involves a high degree
of touching, the nurse is sensitive to how clients may per-
ceive it. Most people respond positively to touch, but there
TABLE 7-3 Communication Zones are variations among individuals. Therefore, nurses use
ZONE DISTANCE PURPOSE
Intimate space Within 6 in. • Lovemaking

• Confiding secrets
• Sharing confidential
information
Personal space 6 in. to 4 ft • Interviewing
• Physical assessment
• Therapeutic interven-
tions involving touch
• Private conversations
• Teaching one-on-one
Social space 4–12 ft • Group interactions
• Lecturing
• Conversations that
are not intended to be
private
Public space 12 ft or more • Giving speeches
• Gatherings of strangers FIGURE 7-5 This nurse uses affective touch as she talks with
her client. (Photo by B. Proud.)
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FIGURE 7-6 A client who is verbally impaired due to a stroke or intubation can communicate
his or her needs to the nurse using a communication board. (Courtesy of Vidatak, LLC. Los
Angeles, CA 90069.)
LWBK1004-C07_p093-104.indd 102 2/6/12 9:50 PM

affective touch cautiously even though its intention is to will impact their recovery or health maintenance. Regardless
communicate caring and support. In general, affective touch of the obstacles, The Joint Commission is adamant that health
is therapeutic when a client is care workers facilitate communication with all clients.
• Lonely Communicating with Verbally Impaired Clients
• Uncomfortable There are instances when nurses and clients cannot communi-
• Near death cate verbally despite the fact that both are proficient in English.
• Anxious, insecure, or frightened For example, clients who have had a stroke sometimes experi-
• Disoriented ence expressive aphasia, an inability to use verbal language
• Disfigured skills. Clients who have artificial airways (eg, an endotracheal
• Semiconscious or comatose or tracheostomy tube) or who have their jaws wired following
• Visually impaired facial trauma cannot speak. Nevertheless, communication is
• Sensory deprived still a nursing priority as mandated by the Joint Commission’s
National Patient Safety Goals (see Chap. 19). The nurse may
provide the verbally impaired client with a paper tablet and
pencil or “magic slate,” although this approach is time-
consuming. In some cases, the client may not have the use of
■ Although physical touch is an important form of nonver-
the hands or the fine motor skills to use a writing device. Other
bal communication, use it purposefully as the primary
method to reinforce verbal messages. Recognize that touch
communication tools such as those discussed in Chapter 6 or
as a form of communication is usually more important to the example in Figure 7-6 may be used to communicate with
older adults than to those who are younger. verbally impaired clients who may point to common phrases,
■ Gender and age differences between client and care pro- spell with the alphabet, and identify relevant numbers.
vider may determine the acceptability of touch. Appropriate
use of touch, as with eye contact, requires cultural aware- Communicating with Deaf Clients
ness. A person who is deaf is unable to hear well enough to process
spoken information, whereas a person who is hard of hearing
has impaired hearing but is still able to perceive what is being
Communicating With Special said verbally when spoken at a louder level. If a deaf client can
Populations read and write, writing can facilitate communication. How-
Some clients (eg, those who are verbally impaired, deaf, or ever, written communication may not be useful for all clients.
have cognitive deficits such as Alzheimer’s disease) pose Many deaf clients, especially those who were born deaf or
unique challenges for communication. Nurses and other lost their hearing at a very early age, have learned to lip read
health care providers must find ways to help these clients and use American Sign Language (ASL). ASL uses signs
effectively communicate their health problems and needs, made by hand movements and finger spelling, an alphabetical
give informed consent, and understand health practices that substitute for words that have no sign (Fig. 7-7). However,
FIGURE 7-7 The alphabet in sign

language.
LWBK1004-C07_p093-104.indd 103 2/6/12 9:50 PM

not all health care agencies will have someone available who 3. What are the possible explanations when a client
is proficient at ASL. To overcome this barrier, some hospitals does not respond as expected during nurse–client
use a webcam—a video camera that allows two-way viewing interactions?
via a computerized connection. The webcam facilitates video 4. How might a nurse relieve anxiety experienced by
interpreting, in which a person skilled in ASL communicates a client who requires health care in an emergency
with the deaf client in the presence of the nurse. situation?
Communicating with Clients with

Alzheimer’s Disease NCLEX-STYLE REVIEW QUESTIONS
Alzheimer’s disease is a progressive, deteriorating brain dis-
order. Its onset is insidious, with symptoms that may develop 1. A discouraged client says, “I’m sure this surgery
slowly over years. Memory loss is the classic symptom, as won’t help any more than the others.” What is the
well as disturbances in behavior and a loss in the ability to best initial nursing response?
care for oneself. Problems with speaking, reading, and writ- 1. “You’re saying that you doubt you will improve.”
ing affect communication. Clients with this disease have 2. “Do you want to talk to the surgeon again?”
difficulty expressing themselves verbally, such as finding 3. “I’d recommend a more positive attitude.”
correct words, organizing words into logical sentences, fin- 4. “Of course it will; you’ll be up and around in no
ishing sentences, and understanding words. Eventually, they time.”
may become mute. 2. When a terminally ill client does not respond to
Techniques that may facilitate communicating with a medical treatment, which nursing action is most
client who has Alzheimer’s include the following: helpful in assisting the client to deal with his or her
impending death?
• Gain the client’s attention by approaching from the front 1. Providing literature on death and dying
and using the client’s name 2. Allowing the client privacy to think alone
• Smile to convey friendliness 3. Listening to the client talk about his or her feelings
• Maintain eye contact to evaluate the client’s attention and 4. Encouraging the client to get a second opinion
comprehension 3. An alarm caused by a loose cardiac monitor lead star-
• Assume a relaxed posture to avoid agitating the client tles a client with chest pain. What nursing interven-
• Speak naturally at a normal rate and volume; avoid long tion is best to perform next?
sentences and difficult words 1. Identify the client’s current heart rhythm
• Wait for a response while the client processes the informa- 2. Explain the reason the alarm sounded
tion 3. Give the client a prescribed tranquilizer
• Rephrase information if the client does not seem to under- 4. Provide the client with a magazine to read
stand what has been said 4. A 2-year-old child is admitted to the emergency
• Show patience when the client tries to put thoughts into department with a high fever of unknown origin.
words Which of following is the nurse correct to delegate to
• Use visual cues like pantomimes that may clarify verbal a nursing assistant?
meanings 1. Administer an aspirin suppository to reduce the
• Avoid attempts to correct or argue with the client child’s fever
2. Give the toddler a popsicle or other fluid every
30 minutes
CRITICAL THINKING EXERCISES 3. Call the laboratory for the results of diagnostic
tests
1. What specific services might a person expect within 4. Listen to the child’s lungs for sounds of congestion.
a nurse–client relationship which differ from those 5. What is the best nursing response when an 82-year-
within a physician–client relationship? old client with Alzheimer’s disease says he is looking
2. Studies have shown that older adults are not touched forward to a visit from mother later today?
with the same frequency as clients in other age 1. “Your mother has been deceased for years.”
groups. Discuss reasons for this. 2. “Tell me more about your mother.”
3. “Let me call and check on your mother.”
4. “When did you last see your mother?”
LWBK1004-C07_p093-104.indd 104 2/6/12 9:50 PM

Photo to
Come
FPO
8# Client Teaching
affective domain
androgogy
cognitive domain 1. Identify the authoritative bases that mandate client
functionally illiterate teaching.
gerogogy 2. List examples of client teaching provided by nurses.
health literacy 3. List five benefits that result from client teaching.
illiterate 4. Describe the three domains of learning.
literacy 5. Discuss three age-related categories of learners.
pedagogy 6. Discuss at least five characteristics unique to older adult
psychomotor domain learners.
telehome care 7. Identify at least four factors that nurses assess before teaching
clients.
eaching is one of the most important uses of communication for
T nurses. Health teaching promotes the client’s independent ability

to meet his or her health needs. An old proverb that reinforces
how education promotes self-care says, “Give a mansha fi
and he will eat for a day; teach a man to
time.”
sh fi and he will eat for a life-
Teaching is an essential nursing responsibility when caring

for clients in a health care agency, at home, or in community
settings. This chapter offers information on principles of learning and
teaching.
IMPORTANCE OF CLIENT TEACHING
Health teaching is a mandated nursing activity. State nurse practice

acts require health teaching, and The Joint Commission (2010) has
made it a criterion for accreditation. Likewise, the American Nurses
Association’s Social Policy Statement addresses it (Box 8-1).
Lim-
ited hospitalization time demands that nurses begin teaching as soon
as possible after admission rather thanaiting
w until discharge. Early
attention to the client’s learning needs is essential because learning
takes place in four progressive stages:
1. Recognition of what has been taught
2. Recollection or description of information to others
3. Explanation or application of information
4. Independent use of new learning (London, 2009)
105
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B OX 8-1 Social Policy Statement Regarding

Teaching
Nursing practice includes, but is not limited to, initiating and
maintaining comfort measures, promoting and supporting
human functions and responses, establishing an environment
conducive to well-being, providing health counseling and
teaching, and collaborating on certain aspects of the health
regimen.
Excerpted and reprinted with permission from American Nurses Associa-

tion. (2003). Social Policy Statement (2nd ed., p. 8). Washington, DC:
Author.
SCOPE AND CONSEQUENCES OF

CLIENT TEACHING
FIGURE 8-1 A nurse uses pamphlets and a book, which appeal
Client teaching generally focuses on combinations of the
to this client who prefers the cognitive domain of learning.
following subject areas: (Photo by B. Proud.)
• The plan of care, treatment, and services
• Safe self-administration of medications Learning Styles
• The pain assessment process and methods for pain man- Style of learning means how a person prefers to acquire
agement knowledge. Learning styles fall within three general domains:
• Directions and practice in using equipment for self-care cognitive, affective, and psychomotor. The cognitive domain
• Dietary instructions is a style of processing information by listening or reading
• Rehabilitation programs facts and descriptions. It is illustrated in Figure 8-1. The
• Available community resources affective domain is a style of processing information that
• Plan for medical follow-ups appeals to a person’s feelings, beliefs, or values. The psy-
• Signs of complications and actions to take chomotor domain is a style of processing information that
focuses on learning by doing. Box 8-2 lists some activities
Some of the benefits of client teaching include (1) associated with each learning domain.
reduced length of stay, (2) cost-effectiveness of health care, One way to determine the client’s preferred learning style
(3) better allocation of resources, (4) increased client satis- is to ask a question such as, “When you learned to add frac-
faction, and (5) decreased readmission rates. tions, what helped you most: hearing the teacher’s explanation
A delay in teaching retards optimum learning outcomes. or reading about it in a mathematics book (cognitive domain),
If teaching standards are not met and discharged clients are recognizing the value of the exercise (affective domain), or
readmitted or harmed because they were uninformed or actually working sample problems (psychomotor domain)?”
failed to understand information that was taught, nurses are Although most clients favor one domain, nurses can opti-
at risk for being sued. mize learning by presenting information through a combina-
The best proof of compliance with teaching standards is tion of teaching approaches. Although the following figures
to document in the client’s medical record who was taught, (which originated in the National Training Center’s Institute
what was taught, the teaching method, and the evidence of for Applied Behavioral Sciences in Alexandria, Virginia, in
learning. the 1960s) have been challenged, it is proposed that “learners
ASSESSING THE LEARNER

B OX 8-2 Activities that Promote Learning
To implement effective teaching, the nurse must determine
the client’s COGNITIVE PSYCHOMOTOR AFFECTIVE
Listing Assembling Advocating

• Preferred learning style Identifying Changing Supporting
• Age and developmental level Locating Emptying Accepting
• Capacity to learn Labeling Filling Promoting
• Motivation Summarizing Adding Refusing
Selecting Removing Defending
• Learning readiness
• Learning needs
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CHAPTER 8 Client Teaching 107
retain 10% of what they read, 20% of what they hear, 30% of ends of the adult spectrum. Currently, there are three major
what they see, 50% of what they see and hear, 70% of what categories:
they teach/talk, and 90% of what they talk/do” (Smaldino et
• Pedagogy is the science of teaching children or those with
al., 2007; Thalheimer, 2006). The bottom line is that learning
cognitive ability comparable to children.
improves when there is more active involvement.
• Androgogy is the principles of teaching adult learners.
• Gerogogy is the unique techniques that enhance learning
➧ Stop, Think, and Respond Box 8-1 among older adults.
Identify the learning domain that relates to each of
the following teaching methods:
Although most clients with health problems are in their
1. The nurse watches as a client with diabetes prac- later years, nurse educators are advised to prepare them-
tices administering an injection. selves to teach young adults who belong to Generation X,
2. The nurse asks a client who had a mastectomy to Generation Y, and the Net Generation, as they age. Genera-
speak to women attending a health seminar about tion X refers to those born between 1961 and 1981; Genera-
the importance of monthly breast self-examinations. tion Y refers to people who were born after 1981 through
3. The nurse explains the technique for performing the latter part of the 20th century; and Generation Z, the Net
leg exercises to a client scheduled for surgery. Generation or “cyberkids,” refers to those born at the begin-
4. The nurse helps a client self-administer nutritional ning of the 21st century (Skiba & Barton, 2006). In gen-
formula through a gastrostomy tube. eral, those who represent Generations X, Y, and Z may share
5. The nurse gives a client with back strain a pam-
many learning characteristics:
phlet on using good posture and body mechanics.
• Are or will be technologically literate, having used or
grown up with computers, smart phones, and tablet devices
Age and Developmental Level • Crave stimulation and quick responses
Educators emphasize that learning takes place differently • Expect immediate answers and feedback
depending on a person’s age and developmental level. • Become bored with memorizing information and doing
Experts agree that teaching tends to be more effective when it repetitious tasks
is designed to accommodate unique age-related differences. • Prefer a variety of instructional methods from which they
Nurses and all those who provide instruction must can choose
be aware of the learning characteristics of children, adult, • Respond best when information is relevant
and older adult learners (Table 8-1). Recently, a distinc- • Appreciate visualizations, simulations, and other methods
tion has been made between learners at the early and later of participatory learning
TABLE 8-1 Age-Related Differences among Learnersa

PEDAGOGIC LEARNERS ANDROGOGIC LEARNERS GEROGOGIC LEARNERS
Physically immature Physically mature Undergoing degenerative changes

Lack experience Building experience Vast experience
Compulsory learners Voluntary learners Crisis learners
Passive Active Passive/active
Need direction and supervision Self-directed and independent Need structure and encouragement
Motivated to learn by potential rewards Seek knowledge for its own sake or for Motivated by a personal need or goal
or punishment personal interest
Learning is subject centered Learning is problem centered Learning is self-centered
Short attention span Longer attention span Attention affected by low energy level,
fatigue, and anxiety
Convergent thinkers (unidirectional; eg, see Divergent thinkers (process multiple Practical thinkers (process new information
one application for new information) applications for new information) as it applies to a unique personal
problem)
Need immediate feedback Can postpone feedback Respond to frequent feedback
Rote learning Analytical learning Experiential learning
Short-term retention Long-term retention Short-term unless reinforced by immediate
use
Task oriented Goal oriented Outcome oriented
Think concretely Think abstractly Concrete/abstract
Respond to competition Respond to collaboration Respond to family encouragement
a
Each learner is unique and may demonstrate characteristics associated with other age groups.
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➧ Stop, Think, and Respond Box 8-2 information and services needed to make appropriate health
decisions) is obviously a factor in client teaching (Kutner,
Identify the age-related learner for whom the follow-
ing teaching techniques are most appropriate. Explain Greenberg, Jin, et al., 2006). The latter affects a client’s abil-
the basis for your analysis. ity to evaluate information for credibility, analyze risks and
1. The nurse’s goal is to limit the teaching session to benefits, calculate dosages, interpret test results, and locate
no more than 20 minutes. health information (Glassman, 2008).
2. The nurse emphasizes knowledge or techniques Because many illiterate or functionally illiterate peo-
that the client is interested in learning. ple are not apt to volunteer information about their reading
3. The nurse reinforces that the client’s discharge problems, literacy may be difficult to assess. Those who are
from the health agency correlates with becoming illiterate and functionally illiterate usually develop elabo-
competent in self-administering insulin injections. rate mechanisms to disguise or compensate for their learn-
4. The nurse indicates that the client can use a com-
ing deficits. To protect the client’s self-esteem, the nurse can
puterized game for 30 minutes when he or she can
ask, “How do you learn best?” and plan accordingly. Some
name the number of recommended servings in
each category within the food pyramid. useful approaches when teaching clients who are illiterate or
5. The nurse challenges the client to devise a plan for functionally illiterate include the following:
managing her colostomy when she returns to work • Use verbal and visual modes for instruction.
following discharge.
• Repeat directions several times in the same sequence so
that the client can memorize the information.
Capacity to Learn • Provide pictures, diagrams, audio recordings, and videos
For the person to receive, remember, analyze, and apply for future review.
new information, he or she must have a certain amount of
intellectual ability. Illiteracy, sensory deficits, cultural dif- Sensory Deficits
ferences, shortened attention span, and lack of motivation The abilities to see and hear are essential for almost every
and readiness require special adaptations when implement- learning situation. Older adults tend to have visual and
ing health teaching. auditory deficits, although such deficits are not exclusive
to this population. Nursing Guidelines 8-1 presents some
techniques for teaching clients with sensory impairment.
Figure 8-2 shows samples of printing that can be used as
an aid.
■ During an initial assessment, older clients may interact in Cultural Differences
a socially appropriate manner and may indicate that they Because teaching and learning involve language, the nurse
understand the material being taught. Asking a client to must modify approaches if the client cannot speak English
recall what has been discussed after approximately 15 min-
or if English is a second language (see Chap. 6, Nursing
utes have passed may help determine what information
Guidelines 6-1). Language barriers do not justify omitting
has actually been retained. A mental status examination
may be indicated (see Chap. 13). If there is cognitive health teaching. In most cases, if neither the nurse nor the
impairment, a support person or caregiver should be pres- client speaks a compatible language, a translator or accept-
ent for the teaching sessions. able alternative is needed.
Attention and Concentration
The client’s attention and concentration affect the duration,
Literacy
delivery, and teaching methods employed. Some helpful
It is essential to determine a client’s level of literacy (ability
approaches include the following:
to read and write) before developing a teaching plan. Approx-
imately 42 million Americans cannot read at all (American • Observe the client and implement health teaching when he
Institutes for Research, 2009; Education-Portal.com, 2007). or she is most alert and comfortable.
One could infer that these same adults are therefore illiter- • Keep the teaching session short.
ate (cannot read or write). Twenty percent of Americans are • Use the client’s name frequently throughout the instruc-
considered functionally illiterate (possess minimal literacy tional period; this refocuses his or her attention.
skills), which means they can sign their name and perform • Show enthusiasm, which you are likely to communicate to
simple mathematical tasks (eg, make change) but read at or the client.
below a fifth-grade level. Functional illiteracy may be the • Use colorful materials, gestures, and variety to stimulate
consequence of a learning disability, not a below-average the client.
intellectual capacity. • Involve the client in an active way.
Health literacy (the degree to which individuals have • Vary the tone and pitch of your voice to stimulate the client
the capacity to obtain, process, and understand basic health aurally.
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N U R S I N G G U I D E L I N E S 8-1
Rationales
Teaching Clients with Sensory Impairments
Ensure that the client with a visual impairment is wearing pre- • Avoid using materials printed on glossy paper. Glossy paper
scription eyeglasses or that the client with a hearing impairment reflects light, causing a glare that makes reading uncomfort-
is wearing a hearing aid, if available. Visual and auditory aids able.
maximize the ability to perceive sensory stimuli. • Select black print on white paper. This combination provides
maximum contrast and makes letters more legible.
For clients with visual impairment:
For clients with hearing impairment:
• Speak in a normal tone of voice. Clients with visual impair-
ment do not necessarily also have hearing impairment. • Use a magic slate, chalkboard, flash cards, or writing pads to
Increased volume does not compensate for reduced vision. communicate. Writing can substitute for verbal instructions.
• Use at least a 75- to 100-watt light source, preferably in a lamp • Lower the voice pitch. Hearing loss is generally in the higher
that shines over the client’s shoulder. Ceiling lights tend to dif- pitch ranges.
fuse light rather than concentrate it on a small area where the • Try to select words that do not begin with “f,” “s,” “k,” and
client needs to focus. “sh.” These letters are formed with high-pitched sounds and
• Avoid standing in front of a window through which bright are therefore difficult for clients with hearing impairment to
sunlight is shining. It is difficult to look into bright light. discriminate.
• Provide a magnifying glass for reading. Magnification • Rephrase rather than repeat when the client does not under-
enlarges standard or small print to a comfortable size. stand. Rephrasing may provide additional visual or auditory
• Obtain pamphlets in large (12- to 16-point) print and serif clues to facilitate the client’s understanding.
lettering, which has horizontal lines at the bottom and top of • Insert a stethoscope into the client’s ears and speak into the
each letter (see Fig. 8-2). Letters and words are usually more bell with a low voice. The stethoscope acts as a primitive
distinct when set in large print with a style that promotes hearing aid. It projects sounds directly to the ears and reduces
visual discrimination. background noise.
Motivation
Gerontologic Considerations Learning is optimal when a person has a purpose for acquir-
ing new information. Relevance of learning depends on indi-
■ A calm demeanor and a quiet environment can decrease vidual variables. The desire for learning may be to satisfy
anxiety or distractions that prevent new learning. Peer teach- intellectual curiosity, restore independence, prevent com-
ing or reinforcement in support group settings may be helpful. plications, or facilitate discharge and return to the comfort
of home. Less desirable reasons are to please others and to
avoid criticism.
12 pt. Times
Aa Bb Cc Dd Ee Ff Gg Hh Ii Jj Kk Ll ■ Most people are “creatures of habit” and are reluctant to
Oo Pp Qq Rr Ss Tt Uu Vv Ww Xx Yy make changes without understanding the benefit. Older
adults may be creative in methods for incorporating needed
changes in health behavior if the purposes or anticipated
14 pt. Times benefits are made clear at the beginning of the teaching
Aa Bb Cc Dd Ee Ff Gg Hh Ii Jj Kk session.
■ Stating a belief that the older adult can actually make the
Oo Pp Qq Rr Ss Tt Uu Vv Ww Xx recommended health behavioral changes and providing
encouragement may increase the client’s self-confidence
and result in increased learning.
16 pt. Times
Aa Bb Cc Dd Ee Ff
Learning Readiness
Oo Pp Qq Rr Ss Tt When a capacity and motivation for learning exist, the
nurse can determine the final component—learning readi-
FIGURE 8-2 Selecting printed materials with 12- to 16-point
ness. Readiness refers to the client’s physical and psycho-
size type, black print on white paper, and serif lettering help logical well-being. For example, a person who is in pain,
improve visual clarity. is too warm or cold, is having difficulty breathing, or is
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depressed or fearful is not in the best condition to learn. In

these situations, it is best to restore comfort and then attend
to teaching.
■ Beginning the teaching session with a reference to the

older person’s actual experience will help provide a link to
which the new learning can connect.
Learning Needs
The best teaching and learning take place when both are
individualized. To be most efficient and personalized, the
nurse must gather pertinent information from the client.
Second-guessing what the client wants and needs to know
often leads to wasted time and effort.
The following are questions a nurse can ask to assess the
client’s learning needs:
• What does being healthy mean to you? FIGURE 8-3 The nurse teaches about diabetes at the bedside.
• What things in your life interfere with being healthy? Multisensory stimulation is promoted by giving the client expla-
nations and encouraging her to watch the technique for testing
• What don’t you understand as fully as you would like?
blood sugar as it is being performed. (Photo by B. Proud.)
• What activities do you need help with?
• What do you hope to accomplish before being discharged?
• How can I help you at this time? CRITICAL THINKING EXERCISES
1. Identify reasons why health literacy is especially
important in the 21st century.
INFORMAL AND FORMAL TEACHING 2. How would a nurse teach techniques for toothbrush-
ing differently to a child; to a person from the Y, X,
Informal teaching is unplanned and occurs spontaneously or Net generations; to a young adult; to a middle-
at the bedside. Formal teaching requires a plan. Without a aged adult; and to an older adult?
plan, teaching becomes haphazard. Furthermore, without 3. What teaching strategies could the nurse use to teach
some organization of time and content, the potential for toothbrushing within the cognitive, affective, and
reaching goals, providing adequate information, and ensur- psychomotor domains of learning?
ing comprehension is jeopardized. Potential teaching needs 4. Give two examples of how you could determine
are generally identified at the client’s admission, but they whether a client actually learned information you
may be amended as care and treatment progress. If ongo- taught such as toothbrushing.
ing teaching is necessary, furnishing clients with technol-
ogy for telehome care (visiting clients electronically in
their home for the purpose of seeing and communicating in NCLEX-STYLE REVIEW QUESTIONS
real time) may be beneficial, especially for clients located 1. Which of the following are examples of activities that
in rural areas. A student nurse may work with a staff nurse are best performed by a client whose learning style
or instructor in developing a teaching plan. Usually, one or is primarily in the cognitive domain? Select all that
more nurses carry out certain specific parts of a teaching apply.
plan (Fig. 8-3). This approach is the most desirable so that a 1. Assembling equipment
client is not overwhelmed with processing volumes of new 2. Listing needed equipment
information or learning skills that are difficult for novices 3. Identifying pieces of equipment
to perform. Skill 8-1 serves as a model when an adult client 4. Defending the choice of equipment
needs teaching. 5. Summarizing the use of equipment
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2. Arrange the following steps in the order in which 5. Which of the following teaching aids is developmen-
they should occur when teaching a client. Use all the tally appropriate when preparing a preschool child for
options: a diagnostic test such as a bone marrow puncture?
1. Encourage feedback from the client 1. Dolls or puppets
2. Divide information into manageable amounts 2. Pamphlets or booklets
3. Find out what the client wants to know 3. Colored diagrams
4. Document the client’s evidence of learning 4. Commercial videotapes
5. Determine the client’s recall of information
3. Which of the following is most essential before teach-
ing the mother of a 6-year-old child about nutrition?
1. Assess the child’s height and weight
2. Obtain a nutrition guidelines pamphlet
3. Develop a plan for 1 week of menus
4. Collect various nutritional recipes
4. After teaching a client how to perform breathing
exercises, what is the best method for evaluating the
effectiveness of the teaching?
1. Request that the client explain the importance of
breathing exercises
2. Ask the client to perform the breathing exercises as
they were taught
3. Ask the client if he is performing the breathing
exercises as required
4. Monitor the client’s respiratory rate several times a
day
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SKILL 8-1 Teaching Adult Clients
Suggested Action Reason for Action
ASSESSMENT
Find out what the client wants to know. Personal interest facilitates learning.
Establish what the client should know to remain healthy. Clients are not always aware of what information is vital to maintain
their health and safety.
Determine the client’s learning style. Teaching is more effective when techniques support the client’s
preferred learning method.
PLANNING
Collaborate with the client on content, goals, and realistic time Adult learners tend to prefer collaboration and active involvement
frames. in the learning process.
Develop a written plan that builds from simple to complex, Adult learners learn best by applying information from present
familiar to unfamiliar, and normal to abnormal. knowledge or past experiences.
Divide information into manageable amounts. Too much information at once tends to overwhelm learners.
Select teaching strategies and resources that are compatible Adult learners generally prefer one learning style, but multiple
with the client’s preferred style for learning. approaches enhance learning.
Use a variety of instructional methods from the cognitive, affec- Adults tend to retain more knowledge when a variety of instruc-
tive, and psychomotor domains. tional techniques are used.
Review the content that will be used during teaching. Preparation and knowledge evoke self-confidence.
IMPLEMENTATION
Teach when the client appears interested and physically and Learning takes place more easily when the client can focus on
emotionally ready to learn, if possible. the task at hand.
Provide an environment that promotes learning. Learning occurs best in a well-lit room with a comfortable tempera-
ture. Distractions and interruptions interfere with concentration.
Identify how long the teaching session will last. Clarifying the length of time prepares the client for the demands
on his or her time and attention.
Begin with basic concepts. Learning that builds from simple to complex is best.
Review previously taught information. Repetition increases retention of information.
Use vocabulary within the client’s personal level of Teaching at the learner’s level preserves dignity. The nurse is
understanding. accountable for ensuring the client’s comprehension.
Explain any and all new terms. Clients are sometimes embarrassed to admit they do not under-
stand.
Involve the client actively by encouraging feedback and handling Adult learners prefer active rather than passive learning situations.
of equipment.
Stimulate as many senses as possible. Involvement of more than one sense enhances learning.
Invent songs, rhymes, or a series of key terms that correspond Creativity stimulates the right hemisphere of the brain where
with the teaching content. information is retrieved more easily.
Use equipment as similar as possible to what the client will use Becoming familiar with equipment is the best preparation for
at home. self-care at home.
Allow time for questions and answers. Providing this opportunity helps the client clarify information and
prevents misunderstandings.
Summarize the key points covered during the current teaching. Reviewing reinforces important concepts.
Determine the client’s level of learning. The ability to recall or apply information and to demonstrate skills
is proof of short-term learning.
Identify the time, place, and content for the next teaching Planning the next meeting provides a time frame during which
session. the client may review and practice what has been taught.
Arrange an opportunity for the client to use or apply the new Immediate application reinforces learning and promotes long-
information as soon as possible after it was taught. term retention.
Document the information taught and evidence demonstrating Documentation provides a written record of the client’s progress
the client’s understanding. and avoids omissions or duplications during future teaching
sessions.
Review with the client the progress made toward goals. Collaboration keeps the client focused on expected outcomes.
Evaluate the need for further teaching. Evaluation is the basis for revising the teaching plan.
(continues)
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Teaching Adult Clients (continued)
Evaluation
• The planned teaching content was covered.
• The client participated in the teaching process.
• The client recalled at least 50% of the concepts with accuracy.
Document
• Date and time
• Content taught
• Evidence of the client’s learning
SAMPLE DOCUMENTATION
Date and Time Explained the times for taking two drugs that require self-administration after discharge. States, “I take
the yellow pill once in the morning before breakfast and I take one blue pill three times a day when I eat
breakfast, lunch, and supper.” _____________________________________________________ SIGNATURE/TITLE
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9 Recording and
Reporting
auditors
beneficial disclosure
change-of-shift report 1. Identify seven uses for medical records.
chart 2. List six components generally found in any client’s medical
charting record.
charting by exception 3. Differentiate between source-oriented and problem-oriented
checklist records.
computerized charting 4. Identify six methods of charting.
continuous quality improvement 5. Explain the purpose and applications associated with the
documenting Health Insurance Portability and Accountability Act (HIPAA).
double charting 6. List four aspects of documentation required in the medical
flow sheet records of all clients cared for in acute settings.
focus charting 7. Discuss why it is important to use only approved
Kardex abbreviations when charting.
medical records 8. Explain how to convert traditional time to military time.
military time 9. List at least 10 guidelines that apply to charting.
minimum disclosure 10. Identify four written forms used to communicate information
narrative charting about clients.
nursing care plan 11. List five ways that health care workers exchange client
PIE charting information other than by reading the medical record.
problem-oriented record
quality assurance
recording urses must communicate information clearly, concisely, and
rounds
SOAP charting
source-oriented record
total quality improvement
traditional time
N accurately, both when writing and when speaking. This chapter
describes various written and spoken forms of communication
and nursing responsibilities for record keeping and reporting.
MEDICAL RECORDS
Medical records are collections of information about a person’s

health, the care provided by health practitioners, and the client’s
progress. They are also referred to as health records
or client records.
The medical record may consist of various agency-approved paper
forms (Table 9-1), or the forms may be stored on the hard drive of a
computerized electronic medical record. Physicians who provide care
to Medicare and Medicaid clients have an incentive to use electronic
information technology to maintain computerized health records as
early as 2011 and no later than 2015 if they wish to qualify for gov-
ernment funds under the American Recovery and Reinvestment Act
(Amatayakul, 2009).
Hard copy paper forms are placed in a chart (a binder or folder
that promotes the orderly collection, storage, and safekeeping of a
person’s medical records). The paper forms in the chart are-coded
color
or separated by tabbed sheets. A computerized medical record is
114
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CHAPTER 9 Recording and Reporting 115
TABLE 9-1 Common Agency Chart Forms

NAME OF FORM CONTENT
Fact sheet Provides information such as the client’s name, date of birth, address, phone number,
religion, insurer, admitting physician, admitting diagnosis, person to contact in case
of emergency, and emergency phone number
Advance directive Provides instructions about the client’s choices for care should he or she be unable to
make decisions later
History and physical examination Contains the physician’s review of the client’s current and past health problems, results
of a body system examination, medical diagnosis, and tentative plan for treatment
Physician’s orders Identifies laboratory and diagnostic tests, diet, activity, medications, intravenous fluids,
and clinical procedures (instructions for changing a dressing, inserting tubes, and so
forth) on a day-by-day basis
Physician’s or multidisciplinary progress notes Describes the client’s ongoing status and response to the current plan of care, and
potential modifications in the plan
Nursing admission database Documents information concerning the client’s health patterns and initial physical
assessment findings
Nursing or multidisciplinary plan of care Identifies client problems, goals, and directions for care based on an analysis of
collected data
Graphic sheet Displays trends in the client’s vital signs, weight, and daily summary of fluid intake and
output
Daily nursing assessment and flow sheet Indicates focused physical assessment findings by individual nurses during each
24-hour period and the routine care that was provided
Nursing notes Provides narrative details of subjective and objective data, nursing actions, response
of the client, outcomes of communication with other health care personnel, or the
client’s family
Medication administration record Identifies the drug name, date, time, route, and frequency of drug administration as
well as the name of the nurse who administered each medication
Laboratory and diagnostic reports Contains the results of tests in a sequential order
Discharge plan Indicates the information, skills, and referral services that the client may need before
being released from the agency’s care
Teaching summary Identifies content that was taught, evidence of the client’s learning, and need for
repetition or reinforcement
accessed by using a password and selecting the desired form Sharing Information
from a menu. Computerized records can be printed if a hard Because it is impossible for all health care workers to meet
copy is desired. All personnel involved in a client’s health and exchange information on a personal basis at the same
care contribute to the medical record by charting, record- time, the written record becomes central to communication
ing, or documenting (the process of entering information). (ie, sharing information among personnel). The documenta-
tion serves as a way to inform others about the client’s status
Uses and plan for care.
Besides serving as a permanent health record, the collec- Sharing information prevents duplication of care and
tive information about a client provides a means to share helps reduce the chance of error or omission. For example,
information among health care workers, thus ensuring client if a client requests medication for pain, the nurse checks the
safety and continuity of care. Occasionally, medical records client’s record to determine when the last pain-relieving drug
also are used to investigate quality of care in a health agency, was administered. Accurate and timely documentation pre-
demonstrate compliance with national accreditation stand- vents medication from being administered too frequently or
ards, promote reimbursement from insurance companies, withheld unnecessarily. Maintaining immunization records
facilitate health education and research, and provide evi- is an example of how documentation promotes continuity—
dence during malpractice lawsuits. the record ensures the administration of subsequent immuni-
zations according to an appropriate schedule.
Permanent Account
The medical record is a written, chronologic account of Quality Assurance
a person’s illness or injury and the health care provided To maintain a high level of care, hospitals and other health
from the onset of the problem through discharge or death. care agencies use medical records to promote quality
The record is filed and maintained for future reference. assurance, continuous quality improvement, or total
Previous health records often are requested during subse- quality improvement (an agency’s internal process for
quent admissions so that the client’s health history can be self-improvement to ensure that the level of care reflects
reviewed. or exceeds established standards). One quality assurance
LWBK1004-C09_p114-138.indd 115 30/01/12 5:39 PM

method involves investigating the documentation in a sam- B O X 9-1 Criteria for Legally
ple of medical records. If the analyzed data indicate less- Defensible Charting
than-acceptable compliance with standards of care, the com-
When making an entry in a client’s medical record, the nurse
mittee recommends corrective measures and reevaluates the
should:
outcomes later.
• Ensure that the client’s name appears on each page.
• Never chart for someone else.
Accreditation • Use the specified color of ink and ballpoint pen, or enter
The Joint Commission is a private association that has data on a computer.
established criteria reflecting high standards for client • Date and time each entry as it is made.
safety and institutional health care. Representatives of The • Chart promptly after providing care.
Joint Commission periodically inspect health care agencies • Make entries in chronologic order.
to determine whether they demonstrate evidence of quality • Identify documentation that is out of chronologic sequence
care. with the words “late entry.”
The documentation in randomly selected medical • Write or print legibly.
• Use correct grammar and spelling.
records is just one component examined during an accredi-
• Reflect the plan of care.
tation visit. To support a health care agency’s accreditation,
• Describe the outcomes of care.
nursing documentation should include the following: • Record relevant details.
• Initial assessment and reassessments of physical, psycho- • Use only approved abbreviations.
logical, social, environmental, and self-care status; educa- • Never scribble over entries or use correction fluid to oblit-
erate what has been written.
tion; and discharge planning
• Draw a single line through erroneous information so that it
• Identification of nursing diagnoses or client needs
remains readable, add the date, initial, and then document
• Planned nursing interventions or nursing standards of care the correct information.
for meeting the client’s nursing care needs • Record facts, not subjective interpretations.
• Nursing care provided • Quote the client’s verbal comments.
• Client’s response to interventions and outcomes of care, • Write “duplicate” or “recopied” on documentation that is
including pain management, discharge planning activities, not original; include the date, time, initials, and reason for
and the client’s or significant other’s ability to manage the duplication.
continuing care needs • Never imply criticism of another’s care.
• Document the circumstances for notifying a physician,
If documentation is substandard, accreditation may be the specific data reported, and the physician’s recommen-
withheld or withdrawn. dations.
• Identify specific information provided when teaching a
Reimbursement client and the evidence that indicates the client has under-
The costs of most clients’ hospital and home care are billed stood the instructions.
to third-party payers such as Medicare, Medicaid, and pri- • Leave no empty spaces between entries and signature.
vate insurance companies. Auditors (inspectors who exam- • Sign each entry by name and title.
ine client records) survey medical records to determine
whether the care provided meets the established criteria for
reimbursement. Undocumented, incomplete, or inconsistent
documentation of care may result in a denial of payment. agency’s administrator, or other authority whenever a cli-
ent’s record is used for a purpose other than treatment and
Education and Research record keeping.
Published references are primary resources for health edu-
cation. Examining the medical records of clients with spe- Legal Evidence
cific disorders, however, provides a valuable supplement The medical record is considered a legal document. There-
that enhances learning and future problem solving. Client fore, entries in medical records must follow legally defen-
records also facilitate research. For example, some types of sible criteria (Box 9-1). Portions of the medical record can
clinical investigations are difficult to conduct because few be subpoenaed as evidence by the defense or prosecuting
participants are in a particular locale or test facilities are attorney to prove or disprove allegations of malpractice.
limited. Consequently, stored, microfilmed, or computer- It is especially important to document safety precautions
ized medical records serve as an alternative resource for taken to protect the client, individuals who were notified
scientific data. about concerns and issues, and outcomes of the commu-
Nevertheless, to protect confidentiality, only author- nication.
ized persons are allowed access to client records (see Each person who makes entries in the client’s medical
later discussion on protecting health information). Formal record is responsible for the information he or she records
permission must be obtained from the client, the health and can be summoned as a witness to testify concerning
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TABLE 9-2 Common Components of a Problem-Oriented Record

COMPONENT DESCRIPTION
Data base Contains initial health information

Problem list Consists of a numeric list of the client’s health problems
Plan of care Identifies methods for solving each identified health problem
Progress notes Describes the client’s responses to what has been done and revisions to the initial plan
what has been documented. Any written documentation that Problem-Oriented Records
cannot be clearly read or that is vague, scribbled through, A second type of client record is the problem-oriented record
whited out, written over, or erased makes for a poor legal (records organized according to the client’s health problems).
defense. In contrast to source-oriented records that contain numerous
locations for information, problem-oriented records contain
➧ Stop, Think, and Respond Box 9-1 four major components: the database, the problem list, the
Discuss how the nurse could improve each of the plan of care, and the progress notes (Table 9-2). The infor-
following documentation samples: mation is compiled and arranged to emphasize goal-directed
1. 01/11 0800 Ate well. care to promote the recording of pertinent information and
2. 1400 Hygiene provided and ambulated. to facilitate communication among health care professionals.
3. 1500 Depressed all day. S. Rogers.
METHODS OF CHARTING
Client Access to Records
Historically, clients were not allowed to see their medi-
Nurses use various styles to record information within the
cal records. Since the passing of federal legislation in 1996
client’s record. Examples include narrative notes, SOAP
known as the HIPAA, with further revisions in 2001 and
charting, focus charting, PIE charting, charting by excep-
2002, clients now have the right to see their own medical
tion, and computerized charting.
and billing records, request changes to anything they feel is
inaccurate, and be informed about who has seen their medi-
cal records (US Department of Health and Human Services, Narrative Charting
2005). Consequently, many institutions have written policies Narrative charting (the style of documentation generally
that describe the guidelines by which clients can access their used in source-oriented records) involves writing informa-
own medical records. Policies range from complete, unre- tion about the client and client care in chronologic order.
stricted access within 30 days of the client’s written request There is no established format for narrative notations; the
to arranging access in the presence of the client’s physician content resembles a log or journal (Fig. 9-1).
or hospital administrator. Nurses must follow the established Narrative charting is time-consuming to write and read.
agency policy. The caregiver must sort through the lengthy notation for spe-
cific information about care and progress that correlates with
the client’s problems. Depending on the skill of the person
Types of Client Records writing a narrative entry, he or she may omit pertinent docu-
Health records in most agencies contain similar information. mentation or include insignificant information.
They generally are organized in one of two ways: either a
source-oriented or a problem-oriented format. SOAP Charting
SOAP charting (the documentation style more likely to be
Source-Oriented Records used in a problem-oriented record) acquired its name from
The traditional type of client record is a source-oriented the four essential components included in a progress note:
record (records organized according to the source of docu-
• S = subjective data
mented information). This type of record contains separate
• O = objective data
forms on which physicians, nurses, dietitians, physical ther-
• A = analysis of the data
apists, and other health care providers make entries about
• P = plan for care
their own specific activities in relation to the client’s care.
One of the criticisms of source-oriented records is that Some agencies have expanded the SOAP format to
it is difficult to demonstrate a unified, cooperative approach SOAPIE or SOAPIER (I = interventions, E = evaluation, R =
for resolving the client’s problems among caregivers. Fre- revision to the plan of care; Table 9-3).
quently, the fragmented documentation gives the impres- Any variations in the SOAP format tend to focus the doc-
sion that each professional is working independently of the umentation on pertinent information that is required by The
others. Joint Commission. SOAP charting also helps demonstrate
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FIGURE 9-1 Sample of narra-

tive charting. (Courtesy of
Three Rivers Area Hospital,
Three Rivers, MI.)
TABLE 9-3 SOAPIER Charting Format

LETTER EXPLANATION EXAMPLE OF RECORDING
S ⫽ Subjective information Information reported by the client S—“I don’t feel well.”
O ⫽ Objective information Observations made by the nurse O—Temperature 102.4°F
A ⫽ Analysis Problem identification A—Fever
P ⫽ Plan Proposed treatment P—Offer extra fluids and monitor body temperature
I ⫽ Intervention Care provided I—750 mL of fluid intake in 8 hours; temperature assessed every
4 hours
E ⫽ Evaluation Outcome of treatment E—Temperature reduced to 101°F
R ⫽ Revision Changes in treatment R—Increase fluid intake to 1,000 mL per shift until temperature is
ⱕ100°F
LWBK1004-C09_p114-138.indd 118 30/01/12 5:39 PM

6/30/2007 D(ata) – Bladder distended 2 fingers above pubis.

1015 Has not urinated in 8 hrs. since
catheter was removed.
A(ction) – Assisted to toilet. Water turned on at
faucet. Instructed to press over bladder
with hands.
R(esponse) – Voided 525 mL of clear urine. L. Cass, SN
FIGURE 9-2 Example of DAR charting.
interdisciplinary cooperation because everyone involved in the

care of a client makes entries in the same location in the chart.
Focus Charting
Focus charting (a modified form of SOAP charting) uses the
FIGURE 9-4 Portable computers allow for point of care docu-
word focus rather than problem because some believe that the mentation. (From Craven, R.F., Hirnle, C.J. Fundamentals of
word problem carries negative connotations. A focus can be Nursing [6th ed.]. Philadelphia: Lippincott Williams & Wilkins.)
the client’s current or changed behavior, significant events in
the client’s care, or even a North American Nursing Diagno-
that deviates from the standard. Proponents of this efficient
sis Association (NANDA) nursing diagnosis. Instead of using
method say that charting by exception provides quick access
the SOAP format to make entries, focus charting follows a
to abnormal findings because it does not describe normal
DAR model (D = data, A = action, R = response; Fig. 9-2).
and routine information.
DAR notations tend to reflect the steps in the nursing process.
PIE Charting Computerized Charting
PIE charting (a method of recording the client’s progress Computerized charting (documenting client information
under the headings of problem, intervention, and evaluation) electronically) is most efficient for nurses when documenta-
is similar to the SOAPIE format. The PIE style prompts the tion is done at the point of care or bedside (Fig. 9-4). Having
nurse to address specific content in a charted progress note. a terminal at the nursing station is a less desirable option
When nurses use the PIE method, they document assess- because this removes the nurse from the source of the data;
ments on a separate form and give the client’s problems a however, this may be the only alternative when there are lim-
corresponding number. They use the numbers subsequently ited computers for charting available. Centralized terminals
in the progress notes when referring to interventions and the generally are connected to large information systems that
client’s responses (Fig. 9-3). link departments in the institution (eg, pharmacy, laboratory,
admissions office, accounting); therefore, they are less spe-
Charting by Exception cific for nursing use.
Charting by exception is a documentation method in which Although each computer system varies, computerized
nurses chart only abnormal assessment findings or care charting generally is done by using a portable laptop and
keyboard, or touching the monitor screen with a finger or
electronic device such as a light pen to select from a list of
menu options. Some systems allow a combination of key-
boarding and touch-screen technology. Data entry by voice
activation is on the horizon. A single keystroke saves the
information displayed on the monitor to the client’s record
(Fig. 9-5).
Computerized charting has many advantages:
• The information is always legible.
• It automatically records the date and time of the documen-
tation.
• The abbreviations and terms are consistent with agency-
approved lists.
• It eliminates trivia.
• Omissions are fewer because the computer prompts the
nurse to enter specific information.
• It saves time because it eliminates delays in obtaining the
chart.
• It reduces overtime costs for uncompleted end-of-shift
FIGURE 9-3 Sample of PIE charting. charting.
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FIGURE 9-5 Sample of computerized charting.
Computerized documentation and electronic medical the current unit census and client acuity levels, analyze
records have additional advantages for institutions, but there assessment data from monitoring equipment, and reduce
are also disadvantages (Table 9-4). medication errors by calling attention to drugs that have
Besides charting, there are other nursing benefits from been newly ordered or not administered and by alerting
computer applications. Computers are being used to gener- the nurse to incompatibilities or contraindications to pre-
ate nursing care plans, develop staffing patterns that meet scribed drugs.
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TABLE 9-4 Advantages and Disadvantages of Electronic Medical Records

ADVANTAGES DISADVANTAGES
• Increased capacity to store information for longer periods of time • Competency in using the system requires significant learning
• Eliminates loss of entire record or portions thereof due to time
misplacement or misfiling • Passwords must be changed regularly
• Instant access to the record from remote locations when needed • Power or electronic failures can interrupt and delay documentation
by a particular health care worker and access to the full record
• Multiple health care workers can use the medical record simul- • Fewer narrative entries due to structured options that are limited
taneously from many different workstations to multiple lists
• Legibility and spelling are no longer issues • Information is scattered among various files
• Reduces medication errors because the system alerts and • Promotes double charting (repetitious entry of same
prompts the physician regarding miscalculations of drug doses, information)
medication interactions, or the client’s allergies
• Firewalls and passwords prevent breaches in confidentiality by
protecting unauthorized access to confidential information
• Electronic records are periodically backed up on systems else-
where than in the agency of origin and are therefore protected
from destruction should there be a fire or other type of disaster
PROTECTING HEALTH INFORMATION withhold health information for any of these. There are some
exceptions when health information can be revealed with-
Congress enacted the first HIPAA legislation to protect the out the client’s prior approval. Box 9-2 identifies examples
rights of US citizens to retain their health insurance when of beneficial disclosures (exemptions when agencies can
changing employment. To do so required transmitting health release private health information without the client’s prior
records from one insurance company to another. Transmis- authorization).
sion of the information resulted in the disclosure of personal
Workplace Applications
health information to nonclinical individuals, a process that,
In an effort to limit casual access to the identity of clients
in essence, jeopardized the individual’s right to privacy.
and health information, HIPAA legislation has created sev-
Subsequently, the original HIPAA legislation was expanded
eral changes that affect the workplace. Some examples of
in 2001 and 2002 to enact further measures to protect the
these regulations include the following:
privacy of health records and the security of that data. All
health care agencies have been mandated to comply with the • The names of clients on charts can no longer be visible to
newest HIPAA regulations since 2003. the public.
• Clipboards must obscure identifiable names of clients and
Privacy Standards private information about them.
HIPAA regulations require health care agencies to safeguard • Whiteboards must be free of information linking a client
written, spoken, and electronic health information in the fol- with a diagnosis, procedure, or treatment.
lowing ways: • Computer screens must be oriented away from public
view; flat screen monitors are recommended because they
1. Submit a written notice to all clients identifying the uses
are more difficult to read at obtuse angles.
and disclosures of their health information such as to third
• Conversations regarding clients must take place in private
parties for use in treatment or for payment for services.
places where they cannot be overheard. This has led to a
2. Obtain the client’s signature indicating that he or she has
trend of providing private rooms for all hospitalized clients
been informed of the disclosure of information and his or
so that personal health information cannot be overheard by
her right to learn who has seen the records. The law also
someone else sharing the room.
indicates that agencies must limit released information
from a health record to minimum disclosure, or informa-
tion necessary for the immediate purpose only. In other B O X 9-2 Exemptions for Beneficial
words, it is inappropriate to release the entire health Disclosures
record when only portions or isolated pieces of informa- • Reporting vital statistics (births and deaths)
tion are needed. • Informing the US Food and Drug Administration of adverse
reactions to drugs or medical devices
Health care agencies must obtain specific authorization • Disclosing information for organ or tissue donation
from the client to release information to family or friends, • Notifying the public health department about communicable
attorneys, and to other parties for uses such as research, diseases
fundraising, and marketing. The client retains the right to
LWBK1004-C09_p114-138.indd 121 30/01/12 5:39 PM

• Facsimile (fax) machines, filing cabinets, and medical B O X 9-3 Content of Nursing Documentation
records must be located in areas off-limits to the public.
• A cover sheet and a statement indicating that faxed data Nurses or those to whom they delegate client care are
contain confidential information must accompany elec- responsible for documenting:
tronically transmitted information. • Assessment dataa
• Light boxes for examining X-rays or other diagnostic scans • Client care needs
• Routine care such as hygiene measures
on which the client’s name appears must be in private areas.
• Safety precautions that have been used
• Documentation must be kept of people who have accessed • Nursing interventions described in the care plan
a client’s record. • Medical treatments prescribed by the physician
• Outcomes of treatment and nursing interventions
Data Security • Client activity
• Medication administration
Maintaining confidentiality is more difficult with computer-
• Percentage of food consumed at each meal
ized data keeping. Because multiple people who enter and • Visits or consults by physicians or other health professionals
retrieve information from computer files can access elec- • Reasons for contacting the physician and the outcome of
tronically stored data, it has been difficult to monitor use or the communication
to limit access to only authorized people within and outside • Transportation to other departments, like the radiography
a health care institution. department, for specialized care or diagnostic tests, and time
As a result of HIPAA legislation, health agencies are of return
adopting the following methods to ensure the protection of • Client teaching and discharge instructions
electronic data: • Referrals to other health care agencies
• Assigning an access number and password to authorized a

In acute care settings, The Joint Commission requires a registered nurse to
personnel who use a computer for health records. These document the admission nursing assessment findings and develop the initial
plan of care. The registered nurse may delegate some aspects of the initial
are kept secret and changed regularly. data collection to the practical or vocational nurse.
• Using automatic save, use of a screen saver, or return to a
menu if data have been displayed for a specific period.
• Issuing a plastic card or key that authorized personnel use
to retrieve information. Because consistency in charting is important for legal
• Locking out client information except to those who have purposes, nurses must follow the agency’s documentation
been authorized through a fingerprint or voice-activation policy. Deviating from the charting policy reduces a nurse’s
device. protection if the record is subpoenaed (see Chap. 3).
• Blocking the type of information that personnel in various
departments can retrieve. For example, laboratory employ- Using Abbreviations
ees can obtain information from the medical orders, but they Abbreviations shorten the length of documentation and the
cannot view information in the client’s personal history. time required for this task. Brevity, however, must never
• Storing the time and location from which the client’s take priority over completeness and accuracy. It is better
record is accessed in case there is an allegation concerning to write at length than to omit information or make vague
a breach in confidentiality. entries.
• Encrypting any client information transmitted through the Many abbreviations have common meanings; however,
Internet. nurses cannot assume that all abbreviations are interpreted
the same universally. Some may have one meaning in one
locale or agency but may mean something different or be
DOCUMENTING INFORMATION unfamiliar in another. To avoid confusion among caregiv-
ers and misinterpretation if the chart is subpoenaed as
Each agency sets its own documentation policies. In addi- legal evidence, each agency provides a written or compu-
tion to identifying the method for charting, such policies terized list of approved abbreviations and their meanings.
generally indicate the type of information recorded on When documenting, nurses must use only those abbre-
each chart form, the people responsible for charting, and viations on the agency’s approved list. The Joint Commis-
the frequency for making entries on the record. Box 9-3 sion has identified specific abbreviations that should not
lists the general content of nursing documentation. Cur- be used in order to protect the safety of clients (available
rent standards of The Joint Commission require that the via The Joint Commission’s Web site; see Web Resources
medical records of clients cared for in acute care agencies on the Point). There may be future deletions as The Joint
(eg, hospitals) must identify the steps of the nursing proc- Commission monitors and evaluates compliance. Some
ess (assessment, diagnosis, planning, implementation, and common abbreviations are listed in Table 9-5; more can be
evaluation of outcomes). found in Appendix B.
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TABLE 9-5 Commonly Used Abbreviations

ABBREVIATION MEANING ABBREVIATION MEANING
abd. abdomen NSS normal saline solution

a.c. before meals O2 oxygen
ad lib as desired OB obstetrics
AMA against medical advice OOB out of bed
amt. amount OR operating room
approx. approximately per by or through
b.i.d. twice a day P pulse
BM bowel movement p.c. after meals
BP blood pressure p.o. by mouth
bpm beats per minute postop. postoperative
BRP bathroom privileges preop. preoperative
c̄ with pt. patient
C Centigrade PT physical therapy
CCU coronary care unit q every
c/o complains of q.i.d. four times a day
dc discontinue q.s. quantity sufficient
ED emergency department R, Rt, or R right
et and R respirations
H 2O water s̄ without
I&O intake and output SS soap suds
IM intramuscular stat immediately
IV intravenous t.i.d. three times a day
kg kilogram TPR temperature, pulse, respirations
L, Lt, or L left UA urinalysis
L liter via by way of
lb Pound WC wheelchair
NKA no known allergies WNL within normal limits
NPO nothing by mouth Wt. weight
Indicating Documentation Time time (time based on a 24-hour clock), which uses a differ-
The nurse dates and times each entry in the record. Some ent four-digit number for each hour and minute of the day
hospitals use traditional time (time based on two 12-hour (Fig. 9-6 and Table 9-6). The first two digits indicate the hour
revolutions on a clock), which is identified with the hour and within the 24-hour period and the last two digits indicate the
minute, followed by am or pm. Other agencies prefer military minutes.
The use of military time avoids confusion because
no number is ever duplicated, and the labels am, pm, midnight,
2400
and noon are not needed. Military time begins at midnight
2300 1300
1200 (2400 or 0000). One minute after midnight is 0001. A zero is
1100 0100 placed before the hours of one through nine in the morning;
2200 1400 for example, 0700 refers to 7 am and is stated as “oh seven
1000 0200 hundred.” After noon, 12 is added to each hour; therefore,
1 pm is 1300. Minutes are given as 1 to 59. See Skill 9-1.
2100 0900 0300 1500

TABLE 9-6 Examples of Military Time Conversions
TRADITIONAL TIME MILITARY TIME
0800 0400
2000 1600 Midnight 0000 or 2400
12:01 AM 0001
0700 0500
1:30 AM 0130
0600 Noon 1200
1900 1700
1:00 PM 1300
1800 3:15 PM 1515
FIGURE 9-6 The military clock uses one 24-hour time cycle 7:59 PM 1959
instead of two 12-hour cycles (eg, 9:00 AM is 0900 and 10:47 PM 2247
9:00 PM is 2100).
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➧ Stop, Think, and Respond Box 9-2 Written Forms of Communication

Convert the following from traditional time to military Examples of written forms of communication include the nurs-
time: ing care plan, the nursing Kardex, checklists, and flow sheets.
1. 6:30 PM
2. Midnight Nursing Care Plans
3. 8:45 AM A nursing care plan is a written list of the client’s prob-
4. 9:05 PM lems, goals, and nursing orders for client care. It promotes
5. 4:15 AM the prevention, reduction, or resolution of health problems.
The principles and style for writing a diagnostic statement,
goals, and nursing orders are described in Chapter 2.
COMMUNICATION FOR CONTINUITY Presently, The Joint Commission’s standards require
AND COLLABORATION that the record show evidence of a plan of care. Many agen-
cies require a separate nursing care plan as a means of dem-
Although the record serves as an ongoing source of informa- onstrating compliance. Nurses revise the plan of care as the
tion about the client’s status, nurses use other methods of client’s condition changes.
communication to promote continuity of care and collabora- Most nursing care plans are handwritten on a form that
tion among the health personnel involved in the client’s care. the agency develops (Fig. 9-7). Some agencies use pre-
These methods are in written or verbal form. printed care plans, computer-generated care plans, standards
FIGURE 9-7 Sample nursing care plan.
LWBK1004-C09_p114-138.indd 124 30/01/12 5:39 PM

of care, clinical pathways, or cite the plan of care within • Inform staff of a client’s current level of activity
progress notes. • Identify comfort or assistive measures a client may require
Because the nursing care plan is part of the permanent • Provide a tool for estimating the personnel-to-client ratio
record and thus is a legal document, it is compiled and main- for a nursing unit
tained following documentation principles. All entries and
The information in the Kardex changes frequently,
revisions are dated. The written components are clear, con-
sometimes several times in a day. The Kardex is not a part of
cise, and legible. The information is never obliterated; only
the permanent record. Therefore, nurses can write informa-
approved abbreviations are used. Each addition or revision
tion in pencil and erase.
to the plan is signed.
Nursing Kardex Checklists

The nursing Kardex is a quick reference for current infor- A checklist is a form of documentation in which the nurse
mation about the client and his or her care (Fig. 9-8). The indicates with a check mark or initials the performance of
Kardex forms for all clients are centrally located in a folder routine care. It is an alternative to writing a narrative note.
at the nursing station to allow caregivers to flip from one Nurses use paper checklists or a designated file on a compu-
client’s data to another. The Kardex has the following uses: ter primarily to avoid documenting types of care that are reg-
ularly repeated such as bathing and mouth care. This chart-
• Locate clients by name and room number ing technique is especially helpful when the care is similar
• Identify each client’s physician and medical diagnosis each day and the client’s condition does not differ much for
• Serve as a reference for a change of shift report extended periods.
• Serve as a guide for making nursing assignments
• Provide a rapid resource for current medical orders on each Flow Sheets
client A flow sheet is a form of documentation with sections for
• Specify the client’s code or DNR (do not resuscitate) status recording frequently repeated assessment data. It enables
• Check quickly on a client’s diet nurses to evaluate trends because similar information is
• Alert nursing personnel to a client’s scheduled tests or test located on one form. Some flow sheets provide room for
preparations recording numbers or brief descriptions.
3/10/11 539 Page 001 3/10/11 539 Page 002
Stevens, James M 65 Stevens, James M 65

MR #: 00310593 Acct #: 9400037290 MR #: 00310593 Acct #: 9400037290
DR: J. Carrio 2/W 204-01 DR: J. Carrio 2/W 204-01
DX: Unstable angina Date: 3/10/11 DX: Unstable angina Date: 3/10/11
SUMMARY : 3/10 0701 to 1501 SUMMARY: 3/10 0701 to 1501
PATIENT INFORMATION SCHEDULED MEDICATIONS:

3/10 ADVANCE DIRECTIVE: No. 3/10 Nitroglycerin oint 2%, 1-1/2 inches, apply to chest wall
Advance directive does not exist q 8 h, starting on 3/10, 1800 hrs.
3/10 ORGAN DONOR: Yes 3/10 Diltiazem tab 90 mg, #1, P.O., q 6 h 0800, 1400, 2000, 0200
3/10 ADMIT DX: Unstable angina 3/10 Furosemide tab 40 mg, #1, P.O., daily 0900
3/10 MED ALLERGY: None known 3/10 Potassium chloride tab 10 mEq, #1, P.O. daily 0900
3/10 ISOLATION: Standard precautions 3/10 Labetalol tab 100mg, #1/2, P.O. bid 0900, 1800
MISC. PATIENT DATA STAT/NOW MEDICATIONS:

3/10 Furosemide tab 40 mg, #1, P.O. now
NURSING CARE PLAN PROBLEMS 3/10 Potassium chloride tab 10 mEq, #1, P.O., now
3/10 Acute pain R/T: anginal pain
PRN MEDICATIONS:
ALL CURRENT MEDICAL ORDERS 3/10 Procardia nifedipine cap 10 mg, #1, subling. q 6 n, prn
SBP > 170 or DSBP > 105
NURSING ORDERS: 3/10 Acetaminophen tab 325 mg, #2, P.O., q 4 h, prn for pain
3/10 Activity, OOB, up as tol. 3/10 Temazepan cap 15 mg, #1, P.O. q HS, prn
3/10 Routine V/S q & h 3/10 Alprazolam tab 0.25 mg, #1/2, P.O., q 8 h, prn
3/10 Telemetry
3/10 If 1800 PTT < 50, increase heparin drip to 1200 units/hr. If LABORATORY:
50 to 100, maintain 1000 units/hr. If > 100, reduce to 900 3/10 CK & MB 1800 today
units/hr. 3/10 CK & MB 0200 tomorrow
DIET: 3/10 Urinalysis floor to collect
3/10 Diabetic: 1600 cal., start with lunch today 3/10 PTT 1800 today
I.V.s.:
3/10 Peripheral line #1. . . . Start D2W 250 ml with heprin 25,000 LABORATORY:
units: rate, 1000 units/hr. 3/10 Stress test persantine, perp H1, Patient handling:
Wheelchair, Schedule: tomorrow
(continued) Last page
FIGURE 9-8 A computer-generated Kardex. (Used with permission. Holmes, H. N. [Ed.]. [2006].
Documentation in Action [pp. 231–232]. Philadelphia: Lippincott Williams & Wilkins.)
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Interpersonal Communication B O X 9-4 Change of Shift Report

In addition to using written resources (eg, the medical
record) to exchange information, communication also takes A change of shift report usually includes:
• Name of client, age, and room number
place during personal interactions among health profession-
• Name of physician
als. Some examples are as follows:
• Medical diagnosis or surgical procedure and date
• Change of shift reports • Range in vital signs
• Client assignments • Abnormal assessment data
• Team conferences • Characteristics of pain, medication, amount, time last
administered, and outcome achieved
• Rounds
• Type of diet and percentage consumed at each meal
• Telephone calls
• Special body position and level of activity, if applicable
• Scheduled diagnostic tests
Change of Shift Report • Test results, including those performed by the nurse, such
A change of shift report is a discussion between a nursing as blood glucose levels
spokesperson from the shift that is ending and the arriving • Changes in medical orders, including newly prescribed
personnel (Fig. 9-9). It includes a summary of each client’s drugs
condition and current status of care (Box 9-4). • Intake and output totals
To maximize the efficiency of change of shift reports, • Type and rate of infusing intravenous fluid
• Amount of intravenous fluid that remains
nurses should do the following:
• Settings on electronic equipment such as amount of
• Be prompt so that the report can start and end on time. suction
• Come prepared with a pen and paper or clipboard. • Condition of incision and dressing, if applicable
• Avoid socializing during reporting sessions. • Color and amount of wound or suction drainage
• Take notes.
• Clarify unclear information.
• Ask questions about pertinent information that may have or written on a worksheet (Fig. 9-10). Each assignment
been omitted. identifies the clients for whom the staff person is responsible
Some agencies tape-record the report, which saves time and describes their care. Meals and break times also may
because there are no interruptions or digressions. In addition, be scheduled, as well as special tasks such as checking and
nurses can replay portions of the tape if information needs to restocking supplies.
be repeated. A taped report, however, does not allow direct
Team Conferences
questions, elaboration, or clarification with the person who
Conferences are commonly used to exchange informa-
recorded the report.
tion. Topics generally include client care problems, per-
sonnel conflicts, new equipment or treatment methods,
Client Care Assignments and changes in policies or procedures. Team conferences
Client care assignments are made at the beginning of each often include the nursing staff, staff from other depart-
shift. Assignments are posted, discussed with team members, ments involved in client care, physicians, social workers,
personnel from community agencies, and, in some cases,
clients and their significant others. Usually, one person
organizes and directs the conference. Responsibilities for
certain outcomes that result from the team conference
may be delegated to various staff members who attend the
meeting.
Client Rounds
Rounds (visits to clients on an individual basis or as a group)
are used as a means of learning firsthand about clients. The
client is a witness to and often an active participant in the
interaction (Fig. 9-11).
Some nurses use walking rounds as a method of giv-
ing a change of shift report. Giving the report in the cli-
ent’s presence provides oncoming staff with an opportunity
to survey the client’s condition and to determine the status
FIGURE 9-9 Nurses begin their shift by receiving a report on
of equipment used in his or her care. It also tends to boost
their clients. (From Craven, R. F., Hirnle, C. J. Fundamentals of the client’s confidence and security in the transition of care.
Nursing [6th ed.]. Philadelphia: Lippincott Williams & Wilkins.) Since the passage of HIPAA regulations, however, agencies
LWBK1004-C09_p114-138.indd 126 30/01/12 5:39 PM

FIGURE 9-10 Sample of a nursing assignment sheet.
127
LWBK1004-C09_p114-138.indd 127 30/01/12 5:39 PM


1. If a charge nurse does all of the following, which
practice could jeopardize the health agency’s accredi-
tation?
1. The nurse assigns five clients to each person on the
team.
2. The nurse writes the names of clients on a dry
erase board in a public area.
3. The nurse posts the names of the current staff at
the nursing station.
4. The nurse reviews the Kardex of each client on the
nursing unit.
2. All of the following are poor examples of documen-
FIGURE 9-11 Rounds help acquaint oncoming staff with the tation practices. Which one places the writer in the
client. most legal jeopardy?
1. The writer squeezes information into a line written
avoid this type of communication if another client shares hours earlier.
the room or if the client has not authorized family members 2. The writer misspells several words while complet-
or friends who may be visiting to have access to his or her ing documentation.
health information. 3. The writer uses blue rather than black ink as the
agency specifies.
Telephone 4. The writer signs the documentation but omits his or
Nurses use the telephone to exchange information when it is her title.
difficult for people to get together or when they must com- 3. Which method of documentation is used when the
municate information quickly. When using the telephone, nurse charts only abnormal assessment findings or
the nurse does the following: care that deviates from the agency’s standard?
• Answers as promptly as possible 1. PIE (problem, intervention, evaluation) charting
• Speaks in a normal tone of voice 2. Narrative charting
• Identifies himself or herself by name, title, and nursing unit 3. Charting by exception
• Obtains or states the reason for the call 4. Focus charting
• Discretely identifies the client being discussed to avoid 4. For which of the following situations is breaching
being publicly overheard confidentiality appropriate?
• Spells the client’s name if there is any chance of confusion 1. The client is treated for an attempted suicide.
• Converses in a courteous and business-like manner 2. The client has a substance abuse problem.
• Repeats information to ensure it has been heard accurately 3. The client wishes to terminate further treatment.
4. The client has a highly contagious disease.
When notifying a physician about a change in a cli- 5. When using the SOAP method of documentation,
ent’s condition, the nurse documents in the client’s record what does the “A” represent?
the information reported and the instructions received. If the 1. Assessment
nurse believes that the physician has not responded in a safe 2. Analysis
manner to the information given, he or she notifies the nurs- 3. Abnormality
ing supervisor or the head of the medical department. 4. Action
CRITICAL THINKING EXERCISE

1. What are some reasons for protecting the information
within a client’s health record?
2. In your opinion, what is the most important reason for
compiling and maintaining a client’s health record?
3. When initially employed, how can the nurse ensure that
he or she is documenting information appropriately?
4. Explain the possible consequences if a nurse’s docu-
mentation contains illegible writing, unapproved
abbreviations, and misspelled words. How would you
help the nurse improve his or her documentation?
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SKILL 9-1 Making Entries in a Client’s Record
ASSESSMENT
Review the agency’s policy for the charting format it uses. Some agencies require personnel to use a specific style (eg,
SOAP charting, narrative charting, PIE charting) for
documentation.
Locate the agency’s list of approved abbreviations. Abbreviations must be compatible with those that have been
approved for legally defensible reasons.
Determine the paper form that is appropriate to use for docu- Data obtained initially from the client are entered on the admission
menting the information or locate the file within an electronic form; periodic additions about the client’s condition and care
record used for nursing documentation via a computer. are entered on a form commonly called “nurses’ notes” or
on a progress sheet. A graphic sheet or flow sheet is used to
document numbers or trends in assessment data.
Check that the client’s name is identified on the chart form or If a sheet of paper becomes separated from the chart, proper
computer file. identification ensures that it is reinserted into the appropriate
record. Electronic records are opened and stored using the
client’s name.
PLANNING
Resolve to document information as soon as it is obtained or at The potential for inaccuracies or omissions increases when docu-
least every 1–2 hours. mentation is delayed.
Use a pen or keyboard to make entries; use the color of ink Ink is permanent. Black ink photocopies better than other colors.
indicated by the agency’s policy.
IMPLEMENTATION
Record the date and time. Information is recorded in chronologic order. The time of docu-
mentation is when the notation is written. Legal issues often
involve the timing of events.
Write, print, or type information so that it can be read easily. Take The entry loses its value for exchanging information if it is unread-
care that keyboarding is accurate when a computer is used. able. Illegible entries become questionable in a court of law.
Use accurate spelling and grammar. Literacy skills reflect a person’s knowledge and education.
Be brief but complete; delete articles (a, an, the). Extra words add length to the entry.
Do not state the client’s name; do not use pt. as an abbreviation It is understood that all the entries refer to the person identified
for “patient.” on the chart form.
Use only agency-approved abbreviations and symbols. Using approved abbreviations promotes consistent interpretation.
Document information clearly and accurately without any subjec- The chart is a record of facts, not opinions.
tive interpretation. Quote the client if a statement is pertinent.
Avoid phrases such as “appears to be” or “seems to be.” Phrases implying uncertainty suggest that the nurse lacks reason-
able knowledge.
Never use ditto marks. Even if information is repetitious, it must be documented sepa-
rately.
Identify actual or approximate sizes when describing assess- Nonspecific measurements are subject to wide interpretation and
ment data rather than using relative descriptions such as are therefore less accurate and informative.
large, moderate, or small.
Record adverse reactions; include the measures used to man- Documentation may be necessary to demonstrate that the nurse
age them. acted reasonably and that the care was not substandard.
Identify the specific information that is taught and the evidence Ensures continuity in preparing the client for discharge.
of the client’s learning.
Fill all the space on each line of the form; draw a line through Filling space reduces the possibility that someone else will add
any blank space on an unfilled line. information to the current documentation.
Never chart nursing activities before they have been performed. Making early entries can cause legal problems, especially if the
client’s condition suddenly changes.
Follow agency policy for the interval between entries. Frequent charting indicates that the client has been observed and
attended to at reasonable periods.
Indicate the current time when charting a late entry (documenta- Correlating time with actual events promotes logic and order
tion of information that occurred earlier but was unintention- when evaluating the client’s progress.
ally omitted); write “late entry for …,” identifying the date and
time to which the documentation refers.
Draw a line through a mistake rather than scribbling through or Corrections are done in such a way that all words are readable.
in any other way obscuring the original words. Obliterated words can cast suspicion that the record was
tampered with to conceal damaging information.
(continued)
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Making Entries in a Client’s Record (continued)
IMPLEMENTATION (CONTINUED)
Put the word error followed by a date and initials next to the A jury seeing the word error without any explanation might
entry and immediately enter the corrected information. Some assume that the nurse made an error in care rather than in
agencies specify that the nurse must indicate the nature of documentation.
the error (eg, “wrong medical record”).
Sign each entry with a first initial, last name, and title. The signature demonstrates accountability for what has been
written.
Log off the computer after documenting in an electronic client Logging off returns the computer to a home or menu page, which
record. prevents anyone else from entering information under the
name of the person who originally logged in. Exiting to a home
or menu page prevents those who are unauthorized from view-
ing anything confidential on the computer screen.
Evaluation
The writer’s entries are:
• Dated and timed
• Accurate, comprehensive, and up-to-date
• Legibly written according to the agency’s format
• Spelled correctly without grammatical errors
• Objectively written
• Free of unapproved abbreviations
• Identified with the writer’s name and title
Date and Time Dressing changed. Abdominal incision and sutures are intact. No evidence of redness, swelling, or drainage.
__________________________________________________________________________________ SIGNATURE/TITLE
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UNIT 3
End of Unit Exercises for Chapters 7, 8, and 9
1. The __________________ domain is a learning style through which information is presented in such a way as to appeal
to a person’s feelings, beliefs, or values. (affective, cognitive, psychomotor)
2. Charting by exception is a documentation method in which nurses chart only __________________ assessment findings.
(abnormal, physical, psychological)
3. __________________ includes nonverbal components such as facial expressions, posture, gestures, and body
movements. (Kinesics, Paralanguage, Proxemics)
4. __________________ is the technique of restating what the client has said to demonstrate listening. (Paraphrasing,
Reflecting, Structuring)
5. The nursing __________________ is a quick reference for current information about the client and his or her care.
(checklist, Kardex, care plan)
6. __________________ charting follows a data, action, response (DAR) model to reflect the steps in the nursing process.
(Exception, Flow, Focus)
1. T____F____ Health teaching promotes the client’s ability to meet his or her health needs independently.
2. T____F____ People belonging to Generation X are technologically literate, having grown up with computers.
3. T____F____ Therapeutic verbal communication involves the use of words alone to accomplish a particular objective.
4. T____F____ Silence is a form of therapeutic communication that encourages the client to participate in verbal
discussions.
5. T____F____ PIE charting is a method of recording the client’s progress under the headings of patient, implementation,
and education.
6. T____F____ A change-of-shift report is a discussion between a nurse from a shift that is ending and the personnel com-
ing on duty.

1. Learning style in which a person processes information by listening or reading facts and descriptions ________________
2. Science of teaching children or those with cognitive ability comparable to that of children __________________
3. Nursing role that involves assigning a task, checking on completion of that task, and evaluating the resulting outcome
__________________
4. Person who performs health-related activities that a sick person cannot perform independently __________________
5. Written collections of information about a person’s health, the care provided by health practitioners, and the client’s
progress __________________
6. Method of documentation that involves writing information about the client and his or her care in chronologic order
__________________
131
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Activity D: 1. Match the terms in Column A with their descriptions in Column B.

Column A Column B
1. Psychomotor domain A. The principle of teaching adult learners
2. Androgogy B. A style of processing information that focuses on learning by doing
3. Gerogogy C. A term given to a person who possesses minimal literacy skills
4. Functionally illiterate D. A technique that enhances learning in older adults
2. Match the phases of the nurse–client relationship in Column A with the descriptions of what happens during those phases
in Column B.
Column A Column B
1. Introductory phase A. The nurse and client plan and implement the client’s care
2. Working phase B. The nurse and client mutually agree that the client’s immediate health
problems have improved
3. Terminating phase C. The client identifies one or more health problems for which he or she is
seeking help
Activity E: 1. Differentiate between informal and formal teaching based on the components listed below.
Informal Teaching Formal Teaching
Definition
Requirements
Disadvantages
2. Differentiate between source-oriented records and problem-oriented records based on the items listed below.
Source-Oriented Records Problem-Oriented Records
Definition
Components
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Activity F: Consider the following figures.
1.
a. Identify what is happening in the figure shown above.

b. What learning style might this client prefer?
2.
a. Identify what is happening in the figure shown above.

b. What are its benefits?
LWBK1004-C09_p114-138.indd 133 30/01/12 5:39 PM

Activity G: Limited hospitalization time demands that nurses begin teaching as soon as possible after admission
rather than waiting until discharge. Early attention to the client’s educational needs is essential because
learning takes place in four progressive stages. Write down the correct sequence of the progressive stages
of learning in the boxes below:
1. Using new learning independently
2. Recalling or describing information to others
3. Recognizing what has been taught
4. Explaining or applying information

1. What subject areas should the nurse focus on when teaching a client?
2. How can the nurse implement effective teaching?
3. How does task-related touch differ from affective touch?
4. What factors affect the ability to communicate by speech or in writing?
5. What are the seven uses of medical records?
6. What are the steps for converting traditional time into military time?
LWBK1004-C09_p114-138.indd 134 30/01/12 5:39 PM

Activity I: Give rationales for the following questions.

1. Why should the nurse select black print on white paper when providing instructions to a visually impaired client?
2. Why should the nurse document information he or she has taught and evidence demonstrating the client’s
understanding?
3. Why is the nurse–client relationship called a therapeutic relationship?
4. Why is it important for nurses to follow their agency’s documentation policy?
5. Why do some health care agencies use military time instead of traditional time?
1. A nurse at an extended-care facility is caring for a client with impaired hearing who has undergone knee surgery.
How might the nurse approach teaching this client?
2. A nurse at a dermatology clinic is caring for a 12-year-old boy who has just had a cyst removed from the soft tissue on his
forearm.
a. What important first step should the nurse follow after the surgical procedure?
b. Describe skin care techniques that the nurse should explain to this client.
LWBK1004-C09_p114-138.indd 135 30/01/12 5:39 PM

3. A young male client is bedridden with limited use of his arms following a motorcycle accident. A female nurse needs to
assist this client with activities of daily living, such as bathing and shaving.
a. What actions can the nurse take to prevent the client from misinterpreting physical nearness and hands-on nursing
procedures as sexual advances?
b. Why should nurses use affective touch cautiously?
4. A nurse caring for multiple clients in a health care facility has completed shift duties and is preparing to leave for the day.
a. How should the nurse proceed when completing a shift and preparing to leave the facility?
b. What actions should the nurse receiving the shift report take to ensure maximum efficiency during this process?
5. A physician returns a nurse’s call about a change in a client’s health condition.

a. What actions should the nurse take when answering the telephone and reporting information about the client’s
condition?
b. What information should the nurse document following communication with the physician?
Activity K: Think over the following questions. Discuss them with your instructor or peers.
1. A nurse is caring for three clients in a health care facility:
• A functionally illiterate elderly man who has undergone cataract surgery.
• A 58-year-old woman with diabetes who has undergone hand amputation.
• An 18-year-old Asian American girl who cannot speak English and has to learn how to use a hearing aid.
a. How can the nurse determine each client’s preferred learning style and developmental level?
b. How should the nurse provide teaching to these clients?
c. What kind of processes or techniques should the nurse follow?
2. A nurse is caring for a middle-aged client who has been diagnosed with cancer. The client is worried about the expenses
involved in treatment, his future, and his dependent family members.
a. How can the nurse begin to build a therapeutic relationship with this client?
b. What communication techniques should the nurse use with this client?
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3. A nurse is working at a health care facility that has a computer terminal at every client’s bedside. The nurse is required to
use computerized charting for each client.
a. What actions should the nurse take when completing computerized charting?
b. What are the advantages and disadvantages of this documentation system?

1. Which one of the following methods should a nurse use when teaching a client who uses prescription eyeglasses?
a. Provide pamphlets in 12- to 16-point type and serif lettering.
b. Provide teaching material printed on glossy paper.
c. Ensure that the room is well lit by a ceiling light.
d. Stand in front of a window letting in bright sunlight.
2. Which of the following are characteristics of pedagogic learners? Select all that apply.
a. Need direction and supervision
b. Need immediate feedback
c. Think abstractly
d. Learn analytically
e. Respond to competition
3. A nurse is caring for an elderly client who lives alone and is recovering from a fall. The client is in severe pain and angry
that the fall could have been avoided if somebody else has been in the home. Which of the following responses by the
nurse is most appropriate when caring for this client?
a. Ask why the client is living alone.
b. Allow the client to express emotions.
c. Ask the client to stop complaining.
d. Tell the client to stay calm and take pain medication.
4. A nurse is teaching an American-born client about a medication regimen. What is the appropriate distance that the nurse
should maintain from the client during teaching?
a. 12 or more feet
b. 4 to 12 feet
c. 6 inches to 4 feet
d. 6 inches or less
5. A nurse is caring for a client undergoing treatment following a stroke. The nurse needs to document routine care,
such as bathing and oral hygiene. Which of the following forms should the nurse use to document this
routine nursing care?
a. Kardex
b. Flow sheet
c. Care plan
d. Checklist
6. A nurse is caring for a client who cannot have any food or oral fluids for 4 hours before the scheduled surgery. Which of
the following abbreviations should the nurse note on the client’s chart?
a. AMA
b. NKA
c. NPO
d. NSS
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LWBK1004-C09_p114-138.indd 138 30/01/12 5:39 PM
UNIT 4
Performing Basic Client Care
10 Asepsis 140
11 Admission, Discharge, Transfer, and Referrals 168
12 Vital Signs 187
13 Physical Assessment 227
14 Special Examinations and Tests 249
139
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10 Asepsis
aerobic bacteria
anaerobic bacteria
antimicrobial agents 1. Describe microorganisms.
antiseptics 2. Name eight specific types of microorganisms.
asepsis 3. Differentiate between nonpathogens and pathogens, resident
aseptic techniques and transient microorganisms, and aerobic and anaerobic
biologic defense mechanisms microorganisms.
carriers 4. Give two examples of the ways some microorganisms have
chain of infection adapted for their survival.
communicable diseases 5. Name the six components in the chain of infection.
community-acquired infections 6. Cite examples of biologic defense mechanisms.
concurrent disinfection 7. Define nosocomial infection.
contagious diseases 8. Discuss the concept of asepsis.
disinfectants 9. Differentiate between medical and surgical asepsis.
exit route 10. Identify at least three principles of medical asepsis.
fomites 11. List five examples of medical aseptic practices.
hand antisepsis 12. Name at least three techniques for sterilizing equipment.
hand hygiene 13. Identify at least three principles of surgical asepsis.
hand washing 14. List at least three nursing activities that require application of
means of transmission the principles of surgical asepsis.
medical asepsis
microorganisms
nonpathogens reventing infections is one of the most important priorities in
normal flora
nosocomial infections
opportunistic infections
pathogens
portal of entry
reservoir
P nursing. The most effective method is hand hygiene, an essential
nursing activity that must be performed repeatedly when car-
ing for clients. This chapter discusses how microorganisms
survive and how to use aseptic techniques, measures that reduce or
eliminate microorganisms.
resident microorganisms
spore
sterile field MICROORGANISMS
sterile technique
sterilization Microorganisms, living animals or plants visible only through a
surgical asepsis microscope, are commonly called “microbes” or “germs.” What they
surgical hand antisepsis
lack in size, they make up for in numbers. Microorganisms are present
susceptible host
everywhere: in the air, soil, and water, and on and within virtually
terminal disinfection
transient microorganisms everything and everyone.
viral load Once microorganisms invade, one of three events occurs: the
virulence body’s immune defense mechanisms eliminate them, they reside
within the body without causing disease, or they cause an infection
or an infectious disease. Factors that influence whether an infection
develops include the type and number of microorganisms, the charac-
teristics of the microorganism (such as its virulence), and the person’s
state of health.
140
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CHAPTER 10 Asepsis 141
Types of Microorganisms
Microorganisms are divided into two main groups: nonpath-
ogens, or normal flora (harmless, beneficial microorganisms),
and pathogens (microorganisms that cause illness).
Nonpathogens live abundantly and perpetually on and
within the human body, which is their host. They are found
in areas of the body exposed to the external environment,
A B C
such as the skin, nose, mouth, throat, lower urethra, and
FIGURE 10-1 Classification of bacteria according to shape:
intestines. They have adapted to human defense mechanisms cocci (A), bacilli (B), and spirochetes (C).
like acidic sweat and oil secretions on the skin. Most exist in
the large intestine, having been introduced from food or sub-
stances on fingers, pencils, tableware, and other items placed
in the mouth. Nonpathogens assume one of two relationships scope. They are filterable, which means that they can pass
with their human host: mutually beneficial, or neither harm- through very small barriers. Viruses are unique because
ing nor helping the host. They inhibit pathogenic growth and they do not possess all the genetic information necessary to
reproduction by competing for nutrients, vying for space, or reproduce; they require metabolic and reproductive materi-
producing substances that interfere with the pathogens. They als from other living species. Some can remain dormant in a
thus ensure a hospitable habitat for themselves. human and reactivate sporadically, causing recurrence of an
Pathogens have a high potential for causing infectious infectious disorder. An example is the herpes simplex virus,
communicable diseases (diseases that can be transmit- which can cause cold sores (fever blisters) to repeatedly flare
ted to other people), also called contagious diseases and up years after an initial infection.
community-acquired infections. Some examples of com- Some viral infections, such as the common cold, are
municable diseases are measles, streptococcal sore throat, minor and self-limiting, that is, they terminate with or with-
sexually transmitted infections, and tuberculosis (TB). out medical treatment. Others, such as rabies, poliomyelitis,
Although pathogenic infections can result in death, most of hepatitis, and AIDS, are more serious or fatal.
them lead only to temporary illness. They may cause illness
in various ways. They may become established, grow, and Fungi
proliferate when numbers of nonpathogens are reduced when Fungi include yeasts and molds. Only a few types of fungi
broad-spectrum antibiotics are prescribed. Pathogens may produce infectious diseases in humans. The three types of
also cause infections when the host is immunosuppressed fungal (mycotic) infections are superficial, intermediate,
from acquired immunodeficiency syndrome (AIDS), cancer and systemic. Superficial fungal infections affect the skin,
chemotherapy, or steroid drug therapy. mucous membranes, hair, and nails. Examples include
In addition, their structures and functions may pro- tinea corporis (ringworm), tinea pedis (athlete’s foot), and
mote virulence (the extent of dangerousness) of pathogens. candidiasis (a yeast infection that infects mucous mem-
Some have fimbriae, tiny hairs used to attach themselves to branes in the mouth and the vagina). Intermediate fungal
the host’s tissue to avoid expulsion. Fimbriae prevent patho- infections affect subcutaneous tissues such as fungal gran-
gens that reach the bladder from being eliminated during uloma (an inflammatory lesion under the skin). Systemic
urination. Some pathogens use flagella, long tails that pro- fungi infect deep tissues and organs, such as histoplasmo-
mote motility to reach a site less hostile to survival. Others sis in the lungs.
release toxins (harmful chemicals). Many enter the host’s
cells and use their content to support their life cycle. Rickettsiae
Nonpathogens and pathogens include bacteria, viruses, Rickettsiae resemble bacteria; like viruses, however, they
fungi, rickettsiae, protozoans, mycoplasmas, helminths, and cannot survive outside another living species. Consequently,
prions. an intermediate life-form, such as fleas, ticks, lice, or mites,
transmits rickettsial diseases to humans. For example, tiny
Bacteria
deer ticks transmit Lyme disease, a problem found where
Bacteria are single-celled microorganisms. They appear
people live, work, or enjoy activities in wooded areas.
in various shapes: round (cocci), rod-shaped (bacilli), and
spiral (spirochetes) (Fig. 10-1). Aerobic bacteria require
oxygen to live, whereas anaerobic bacteria exist without Protozoans
oxygen; this difference demonstrates how varied these life- Protozoans are single-celled animals classified according to
forms have become. their ability to move. Some use ameboid motion, by which
they extend their cell walls and their intracellular contents
Viruses flow forward. Others move by cilia (hairlike projections)
Viruses, the smallest microorganisms known to cause infec- or flagella (whiplike appendages). Some cannot move inde-
tious diseases, are visible only through an electron micro- pendently at all.
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142 UNIT 4 Performing Basic Client Care
Mycoplasmas B OX 10 -1 Causes of Antibiotic Drug Resistance

Mycoplasmas lack a cell wall. They are referred to as pleo-
morphic because they assume various shapes. Mycoplasmas • Prescribing antibiotics for minor or self-limiting bacterial
are similar, but not related, to bacteria. Primarily, they infect infections
the surface linings of the respiratory, genitourinary, and gas- • Administering antibiotics prophylactically (for prevention) in
trointestinal tracts. the absence of an infection
• Failing to take the full course of antibiotic therapy
• Taking someone else’s prescribed antibiotic without knowing
Helminths
whether it is effective for one’s illness or symptoms
Helminths are infectious worms, some of which are micro- • Prescribing antibiotics for viral infections (antibiotics are
scopic. They are classified into three major groups: nema- ineffective for treating infections caused by viruses)
todes (roundworms), cestodes (tapeworms), and trematodes • Dispersing antibiotic solutions into the environment:
(flukes). Some helminths enter the body in the egg stage, • Depositing partially empty IV bags containing antibiotic
whereas others spend the larval stage in an intermediate drugs in waste containers
life-form before finding their way into humans. Helminths • Releasing droplets while purging IV tubing attached to
mate and reproduce after they invade a species; they are then secondary bags of antibiotic solution
excreted, and the cycle begins again. • Expelling air from syringes before injecting antibiotics
• Administering antibiotics to livestock, leaving traces of drug
Prions residue that humans consume after their slaughter
Until recently, it was believed that all infectious agents con- • Spreading nosocomial pathogens via unwashed or poorly
washed hands
tain nucleic acid—either deoxyribonucleic acid (DNA) or
ribonucleic acid (RNA). The idea of an atypical infectious
agent (initially referred to as rogue proteins) was proposed
in 1967. Dr. Stanley Prusiner won a Nobel Prize in 1997 for microorganisms to form spores. A spore is a temporarily
his discovery of such proteins called prions. inactive microbial life-form that can resist heat and destruc-
A prion is a protein containing no nucleic acid. Research tive chemicals and can survive without moisture. Conse-
suggests that a normal prion, which is present in brain cells, quently, spores are more difficult to destroy than their more
protects against dementia (diminished mental function). biologically active counterparts. When conditions are favo-
When a prion mutates, however, it can become an infectious rable, spores can reactivate and reproduce.
agent that alters other normal prion proteins into similar Another example of adaptation is the development
mutant copies. The mutants, which can result from either of antibiotic-resistant bacterial strains of Staphylococcus
genetic predisposition or transmission between same or aureus, Enterococcus faecalis and E. faecium, and Strepto-
similar infected animal species, cause transmissible spong- coccus pneumoniae. Such strains no longer respond to drugs
iform encephalopathies. These are so named because they that once were effective against them (Box 10-1). Research-
cause the brain to become spongy (ie, full of holes). As a ers speculate that resistant species can transmit their resist-
result, brain tissue withers, leading to uncoordinated move- ant genes to totally different microbial species (National
ments. Examples of transmissible spongiform encephalopa- Institute of Allergy and Infectious Diseases, 2009).
thies include bovine spongiform encephalopathy (mad cow
disease), scrapie in sheep, and Creutzfeldt–Jakob disease
in humans. Researchers are currently trying to determine CHAIN OF INFECTION
whether prions are the cause of neurologic disorders such as
Alzheimer’s disease, Parkinson’s disease, and Huntington’s By interfering with the conditions that perpetuate the trans-
disease; whether people with these disorders lack prions; and mission of microorganisms, humans can avoid acquiring
whether prions in people with these disorders are ineffective. infectious diseases. The six essential components in the chain
of infection (the sequence that enables the spread of disease-
producing microorganisms) must be in place if pathogens are
Survival of Microorganisms
to be transmitted from one location or person to another:
Each species of microorganism is unique, but all microorgan-
isms share one characteristic; that is, although infinitesimally 1. An infectious agent
small, they are powerful enough to cause disease. All they need 2. A reservoir for growth and reproduction
is a favorable environment to survive. Conditions that promote 3. An exit route from the reservoir
survival include warmth, darkness, oxygen, water, and nour- 4. A means of transmission
ishment. Humans offer all these and so are optimal hosts for 5. A portal of entry
supporting the growth and reproduction of microorganisms. 6. A susceptible host (Fig. 10-2)
Many pathogens have mutated to adapt to hostile envi-
ronments and unfavorable living conditions. Such adaptabil- Infectious Agents
ity has ensured that they continue to pose a threat to humans. Some microorganisms are less dangerous than others. Just
One example of biologic adaptation is the ability of some as some animal species coexist symbiotically (for mutual
LWBK1004-C10_p139-167.indd 142 26/01/12 3:05 AM

INFECTIOUS AGENT
• Bacteria
• Viruses
• Fungi
• Rickettsiae
• Protozoans
• Mycoplasmas
SUSCEPTIBLE HOST • Helminths
• Immunosuppression • Prions
• Diabetes
• Surgery RESERVOIRS
• Burns • People
• Old age • Equipment
• Water
PORTAL OF ENTRY
• Mucous membrane
• GI tract
PORTAL OF EXIT
• GU tract
• Excretions
• Respiratory tract
• Secretions
• Broken skin
• Skin
• Droplets
MEANS OF
TRANSMISSION
• Direct contact
• Ingestion
• Fomites
• Airborne
FIGURE 10-2 The chain of infection. GI, gastrointestinal; GU, gastrourinary.
benefit), some normal flora help maintain healthy function- Reservoir

ing. For example, intestinal bacteria help produce vitamin K, A reservoir is a place where microbes grow and reproduce,
which, in turn, helps control bleeding. Vaginal bacteria cre- providing a haven for their survival. Microorganisms thrive
ate an acid environment hostile to the growth of pathogens. in reservoirs such as tissues within the superficial crevices
Unless the supporting host becomes weakened, normal of the skin, on shafts of hair, in open wounds, in the blood,
flora remain controlled. If the host’s defenses are weakened, inside the lower digestive tract, and in nasal passages.
however, even benign microorganisms can cause oppor- Some grow abundantly in stagnant water, in uncooked and
tunistic infections (infectious disorders among people with unrefrigerated food, and on used utensils or equipment. They
compromised health). More commonly, however, infections are present in intestinal excreta and the earth’s organic
result from pathogens that, by their very nature, produce material.
illness after invading body tissues and organs. Asymptomatic clients or animals that harbor pathogens
but do not show evidence of an infectious disease are known
as carriers. Nonliving reservoirs are fomites.
■ Pneumonia, influenza, urinary tract and skin infections, Gerontologic Considerations

and TB are common in older adults. Most cases of TB occur
in people aged 65 years or older living in long-term care ■ Many long-term care residents, older hospitalized
facilities (Toughy & Jett, 2010). The incidence of TB in clients, and health care personnel are colonized with
community-living older adults is twice that of the general antibiotic-resistant bacteria, possibly with few or no
population (Miller, 2008). symptoms.
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TABLE 10-1 Methods of Transmission

ROUTE DESCRIPTION EXAMPLE
Contact transmission
Direct contact Actual physical transfer from one infected person to Sexual intercourse with an infected person
another (body surface to body surface contact)
Indirect contact Contact between a susceptible person and a Use of a contaminated surgical instrument
contaminated object
Droplet transmission Transfer of moist particles from an infected person who is Inhalation of droplets released during sneezing,
within a radius of 3 ft coughing, or talking
Airborne transmission Movement of microorganisms attached to evaporated Inhalation of spores
water droplets or dust particles that have been
suspended and carried over distances greater than 3 ft
Vehicle transmission Transfer of microorganisms present on or in contaminated Consumption of water contaminated with
items such as food, water, medications, devices, and microorganisms
equipment
Vector transmission Transfer of microorganisms from an infected animal carrier Diseases spread by mosquitoes, fleas, ticks,
or rats
Exit Route infections. The two types of biologic defense mechanisms

The exit route is how microorganisms escape from their are mechanical and chemical. Mechanical defense mecha-
original reservoir and move about. When present within nisms are physical barriers that prevent microorganisms
or on humans, they are displaced by handling or touching from entering the body or that expel them before they multi-
objects or whenever blood, body fluids, secretions, and ply. Examples include intact skin and mucous membranes,
excretions are released. In the environment, factors such as reflexes such as sneezing and coughing, and infection-
flooding and soil erosion provide mechanisms for escape. fighting blood cells called “phagocytes” or “macrophages.”
Means of Transmission
The means of transmission is how infectious microorgan- Gerontologic Considerations
isms move to another location. This component is important
to the microorganism’s survival because most microorgan- ■ Thinning, drying, and decreased vascular supply to the
isms cannot travel independently. Microorganisms are trans- skin predispose the older person to infections.
mitted by one of five routes: contact, droplet, airborne, vehi-
cle, and vector (Table 10-1).
Chemical defense mechanisms destroy or incapacitate
microorganisms through natural biologic substances. For
Portal of Entry
example, lysozyme, an enzyme found in tears and other secre-
The portal of entry is where microorganisms find their way
tions, can dissolve the cell wall of some microorganisms.
onto or into a new host, thus facilitating their relocation. One
Gastric acid creates an inhospitable microbial environment.
of the most common ports of entry is an opening in the skin
Antibodies, complex proteins also called “immunoglobu-
or mucous membranes. Microorganisms also can be inhaled,
lins,” form when macrophages consume microorganisms
swallowed, introduced into the blood, or transferred into
and display their distinct cellular markers.
body tissues or cavities through unclean hands or contami-
nated medical equipment.
Susceptible Host
Humans become susceptible to infections when their defense
Gerontologic Considerations mechanisms are diminished or impaired. A susceptible host,
the last link in the chain of infection, is one whose biologic
■ Pathogens may find a portal of entry into vulnerable defense mechanisms are weakened in some way (Box 10-2).
older adults through devices such as indwelling urinary Ill clients are prime targets for infectious microorganisms
catheters, humidifiers, oxygen administration devices, and because their health is already compromised. Health care
tissues compromised by equipment used for administering workers who are ill should stay at home rather than exposing
intravenous fluids, parenteral nutrition, or tube feedings. clients, who are already ill, to infectious microorganisms.
Particularly susceptible clients include those who:
Although microorganisms exist in reservoirs every- • Are burn victims
where, biologic defense mechanisms (anatomic or • Have suffered major trauma
physiologic methods that stop microorganisms from causing • Require invasive procedures such as endoscopy (see Chap. 14)
an infectious disorder) often prevent them from producing • Need indwelling equipment such as a urinary catheter
LWBK1004-C10_p139-167.indd 144 26/01/12 3:05 AM

B OX 10 - 2 Factors Affecting Susceptibility • Microorganisms exist everywhere except on sterilized

to Infections equipment.
• Frequent hand hygiene and maintaining intact skin are the
• Inadequate nutrition best methods for reducing the transmission of microorgan-
• Poor hygiene practices isms.
• Suppressed immune system
• Blood, body fluids, cells, and tissues are considered major
• Chronic illness
• Insufficient white blood cells
reservoirs of microorganisms.
• Prematurity • Personal protective equipment such as gloves, gowns,
• Advanced age masks, goggles, and hair and shoe covers serve as a barrier
• Compromised skin integrity to microbial transmission.
• Weakened cough reflex • A clean environment reduces microorganisms.
• Diminished blood circulation • Certain areas—the floor, toilets, and the insides of sinks—
are more contaminated than others.
• Cleaning should be done from cleaner to dirtier areas.
• Receive implantable devices such as intravenous catheters Examples of medical aseptic practices include using
• Are given antibiotics inappropriately, which promote antimicrobial agents, performing hand hygiene, wearing
microbial resistance hospital garments, confining and containing soiled materials
• Are receiving anticancer drugs and anti-inflammatory drugs appropriately, and keeping the environment as clean as pos-
such as corticosteroids that suppress the immune system sible. Measures used to control the transmission of infectious
• Are infected with HIV microorganisms are discussed in more detail in Chapter 22.
Using Antimicrobial Agents

Gerontologic Considerations Antimicrobial agents are chemicals that destroy or sup-
press the growth of infectious microorganisms (Table 10-2).
■ Older adults are more susceptible to infections because Some antimicrobial agents are used to clean equipment,
of diminished functioning of the immune system. surfaces, and inanimate objects. Others are applied directly
to the skin or administered internally. Examples are antisep-
tics, disinfectants, and anti-infective drugs.
➧ Stop, Think, and Respond Box 10-1 Antiseptics
Use the chain of infection to trace the transmission of Antiseptics, also known as bacteriostatic agents, inhibit
the common cold from one person to another. the growth of, but do not kill, microorganisms. An example
is alcohol. Antiseptics generally are applied to the skin or
mucous membranes. Some are also used as cleansing agents.
ASEPSIS
Disinfectants
Health care institutions are teeming reservoirs of microor- Disinfectants, also called germicides and bactericides,
ganisms because of the sheer numbers of confined sick peo- destroy active microorganisms but not spores. Phenol, house-
ple. Add to this the number of caretakers, equipment, and hold bleach, and formaldehyde are examples. Disinfectants
treatment devices in constant use, and it is easy to under- are rarely applied to the skin because they are very strong;
stand why infection control is so important. Nurses must rather, they are used to kill and remove microorganisms from
understand and practice methods to prevent nosocomial equipment, walls, and floors.
infections (infections acquired while a person is receiving
care in a health care agency). Anti-infective Drugs
Asepsis refers to those practices that decrease or elimi- The two groups of drugs used most often to combat infec-
nate infectious agents, their reservoirs, and vehicles for tions are antibacterials and antivirals.
transmission. It is the major method for controlling infec- The chemical actions of antibacterials, which consist of
tion. Health care professionals use medical and surgical antibiotics and sulfonamides, alter the metabolic processes
asepsis to accomplish this goal. of bacteria but not viruses. They damage or destroy bacterial
cell walls or the mechanisms that bacteria need to repro-
Medical Asepsis duce. When used, the intent is to kill or control pathogens;
Medical asepsis means those practices that confine or however, these drugs have the capacity to similarly affect
reduce the numbers of microorganisms. Also called clean normal nonpathogenic bacteria. Before the advent of anti-
technique, it involves measures that interfere with the chain bacterial therapy, wound infections, dysentery, and many
of infection in various ways. The following principles under- contagious diseases cut short life expectancy. Some believe
lie medical asepsis: that humans will return to the days of epidemics, plagues,
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TABLE 10-2 Antimicrobial Agents

TYPE MECHANISM EXAMPLE USE
Soap Lowers the surface tension of oil on the skin, which holds microor- Dial, Safeguard Hygiene
ganisms; facilitates removal during rinsing
Detergent Acts as soap, except detergents do not form a precipitate when Dreft, Tide Sanitizing eating utensils,
mixed with water laundry
Alcohol Injures the protein and lipid structures in the cellular membrane Isopropyl ethanol Cleansing skin,
of some microorganisms (70% concentration) instruments
Iodine Damages the cell membrane of microorganisms and disrupts Betadine Cleansing skin
their enzyme functions; not effective against Pseudomonas,
a common wound pathogen
Chlorine Interferes with microbial enzyme systems Bleach, Clorox Disinfecting water,
utensils, blood spills
Chlorhexidine Damages the cell membrane of microorganisms, but is ineffective Hibiclens Cleansing skin and
against spores and most viruses equipment
Mercury Alters microbial cellular proteins Merthiolate, Disinfecting skin
Mercurochrome
Glutaraldehyde Inactivates cellular proteins of bacteria, viruses, and microbes that Cidex Sterilizing equipment
form spores
and pestilence if antibacterial agents can no longer control times for a minimum of 15 seconds (Goldmann, 2006). Con-
microorganisms. sidering how often health care personnel use their hands when
Antiviral agents were developed more recently, most touching or using equipment in their care, it is no surprise that
likely in response to the rising incidence of influenza and hand hygiene is the single most effective way to prevent infec-
blood-borne viral diseases such as AIDS. Antivirals do not tions. Skill 10-1 describes the steps of hand washing.
destroy the infecting viruses; rather, they control viral repli- Certain situations require hand washing; in others,
cation (copying) or their release from the infected cells. The nurses may substitute hand antisepsis (Box 10-3).
virus remains alive and can potentially cause reactivation of
the illness. The goal of antiviral therapy is to limit the viral Performing Hand Antisepsis
load (the number of viral copies). Research has shown that approximately 36% to 59% of health
care workers comply with the minimum requirements for
Hand Hygiene hand washing (Boyce & Pittet, 2002) as recommended by
Hand hygiene refers to removing surface contaminants on the Centers for Disease Control and Prevention (CDC). To
the skin by either hand washing or hand antisepsis. Hand improve compliance with hand hygiene, guidelines for hand
washing is a medical aseptic practice that involves clean- antisepsis with alcohol-based hand rubs have been developed.
ing the hands with soap, water, and friction to mechani- Hand antisepsis means the removal and destruction of tran-
cally remove dirt and organic substances. It is the preferred sient microorganisms without soap and water (Skill 10-2). It
method of hand hygiene when the hands are visibly dirty, involves products such as alcohol-based liquids, thick gels,
when the hands are soiled with blood or other body fluids, and foams. Alcohol-based hand rubs are not substitutes for
after using the toilet, or when exposure to potential spore- hand washing in all situations (see Box 10-3). Alcohol does
forming pathogens is strongly suspected or proven (Barclay not remove soil or dirt with organic material; however, it
& Murata, 2009). Hand washing removes resident microor- does produce antisepsis when the hands are visibly clean.
ganisms (generally, nonpathogens constantly present on the Alcohol-based hand rubs remove microorganisms on the
skin) and transient microorganisms (pathogens picked up hands, including gram-positive and gram-negative bacteria,
during brief contact with contaminated reservoirs). fungi, multidrug-resistant pathogens, and viruses (Kovach,
Although transient microorganisms are more pathogenic, 2003; Paul-Cheadle, 2003). Because alcohol formulations have
hand washing more easily removes them. They tend to cling a brief rather than sustained antiseptic effect, however, nurses
to grooves and gems in rings, the margins of chipped nail must reuse them over the course of a day (Kovach, 2003).
polish and broken or separated artificial nails, and long finger- Advantages of alcohol-based hand rubs over hand
nails. Thus, these items are contraindicated when caring for washing are that they (1) take less time considering dry-
clients. Without conscientious hand washing, transient micro- ing does not require the use of paper towels, (2) are more
organisms become residents, thereby increasing the potential accessible because they do not require sinks or water,
for transmission of infection. One possible explanation for the (3) increase compliance because they are easier to per-
increase of antimicrobial-resistant pathogens is that nosoco- form, (4) provide convenience based on their location at
mial pathogens are replacing the normal flora of clients when the client’s point of care, (5) provide the fastest and greatest
health care workers fail to wash their hands at appropriate reduction in microbial counts on the skin, (6) reduce costs
LWBK1004-C10_p139-167.indd 146 26/01/12 3:05 AM

B OX 10 - 3 Hand Washing and Hand Antisepsis Guidelines

Hand washing with either a nonantimicrobial or an antimicro- • Before donning sterile gloves to insert invasive devices such
bial soap and water is performed: as urinary catheters, peripheral vascular catheters, central
• When hands are visibly dirty intravascular catheters, or other devices that do not require a
• When hands are contaminated with proteinaceous material surgical procedure
• When hands are visibly soiled with blood or other body fluids • After contact with body fluids or excretions, mucous mem-
• Before eating and after using the restroom branes, nonintact skin, and wound dressings if hands are not
• If exposure to spore-forming pathogens is suspected or proven visibly soiled
Hand antisepsis with an alcohol-based hand rub can be substi- • If moving from a contaminated body site to a clean body site
tuted for hand washing: during client care
• Before having direct contact with clients • After contact with inanimate objects (including medical
• After contact with a client’s intact skin (eg, when taking a equipment) in the immediate vicinity of the client
pulse or blood pressure and lifting a client) • After taking off gloves because gloves are not an impervious
barrier
Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the
Healthcare Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. Morbidity & Mortality Weekly Report, 51 (RR16), 1–44. Retrieved January 2010, from http://www.cdc.
gov/mmwr/preview/mmwrhtml/rr5116a1.htm
by eliminating paper towels and waste management, and that is performed before donning sterile gloves and garments
(7) are less irritating and drying than soap because they when the nurse is actively involved in an operative or obstet-
contain emollients (Hand Hygiene Resource Center, 2009; ric procedure. The purpose is to more extensively remove
Paul-Cheadle, 2003). The CDC believes that with higher transient microorganisms from the nails, hands, and fore-
compliance, there is a greater potential for reducing the rate arms. In fact, the cleanser should reduce microbial growth
of nosocomial infections. for increasingly longer periods when repeatedly performed.
Table 10-3 lists several differences between surgical hand
➧ Stop, Think, and Respond Box 10-2 antisepsis and routine hand washing.
Discuss actions for ensuring appropriate hand To maximally reduce the number of microorganisms,
washing before and after caring for a client in his or the fingernails must be short—no more than ¼ in. long, a
her home. Use a scenario in which the client has bar
length that does not extend beyond the tip of the fingers
soap that rests on the bathroom sink and terrycloth
hand towels shared among an entire family.
(Arbique, 2006; Gile, 2009). Artificial nails are prohibited.
Nail polish is discouraged, especially if it is chipped, worn,
or on for more than 4 days because it is conducive to har-
Performing Surgical Hand Antisepsis boring an increased number of microorganisms. All rings,
Surgical hand antisepsis, previously referred to as a sur- watches, and jewelry are removed and safeguarded before
gical scrub, is a medically aseptic hand-hygiene procedure surgical hand antisepsis (Skill 10-3).
TABLE 10-3 Differences Between Hand Washing and Surgical Hand Antisepsis
HAND WASHING SURGICAL HAND ANTISEPSIS
Plain wedding band may be worn All hand jewelry, including watches, are removed
Faucets with hand controls are used; elbow, knee, or foot controls Faucets are regulated with elbow, knee, or foot controls
are preferred
Liquid, bar, leaflet, or powdered soap or detergent is used Liquid antibacterial soap is used; devices such as sponges may be
incorporated with antibacterial soap
Washing lasts a minimum of 15 seconds Antisepsis lasts 2–6 min, depending on the antibacterial agent and
time interval between subsequent repetitions
Hands are held lower than the elbows during washing, rinsing, Hands are held higher than the elbows during washing, rinsing,
and drying and drying
Areas beneath fingernails are washed Areas beneath fingernails are cleaned with an orange stick or
similar nail cleaner
Friction is produced by rubbing the hands together Friction is produced by scrubbing with a brush and/or sponge
Hands are dried with paper towels; the paper is used to turn off Hands are dried with sterile towels
hand-regulated faucet controls
Clean gloves are donned if the nurse has open skin or if there is a Sterile gloves are donned immediately after the hands are dried
potential for contact with blood or body fluids
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Wearing Personal Protective Equipment

To reduce the transfer of microorganisms between them-
selves and clients, health care personnel wear various gar-
ments: uniforms, scrub suits or gowns, masks, gloves, hair
and shoe covers, and protective eyewear. They wear some of
these items when caring for any client regardless of diagno-
sis or presumed infectious status (see Chap. 22).
Uniforms
Health care professionals should wear their uniforms only
while working with clients. Some nurses wear a clean labo-
ratory coat over their uniform to reduce the spread of micro-
organisms onto or from the surface of clothing worn from
home. When caring for clients, they wear a plastic apron or
cover gown over the uniform if there is a potential for soiling
it with blood or body fluids. When not wearing a cover, nurses
take care to avoid touching the uniform with any soiled items
such as bed linens. After work, they should change the uni-
form as soon as possible to avoid exposing their family and
the public to the microorganisms present on work clothing.
FIGURE 10-3 Face mask and hair cover. (Photo by B. Proud.)
Scrub Suits and Gowns
Scrub suits and gowns are hospital garments worn instead Respirators
of a uniform. Their use is mandatory in some areas of a To prevent the transmission of TB, the National Institute
hospital, such as the nursery, the operating room, and the for Occupational Safety and Health (NIOSH, 2008) recom-
delivery room. These garments prevent personnel from mends the use of a disposable or replaceable particulate air
bringing microorganisms on their clothes into the working filter respirator that fits snugly to the face (Fig. 10-4). The
environment. Employees in other departments sometimes minimum specification for a particulate air filter respirator
wear their own scrub suits or gowns because they are com- is N-95; N refers to “not resistant to oil” (ie, it is effective at
fortable and practical. Personnel who work in mandatory- blocking particulate aerosols that are free of oil). An N-95 air
wear areas don scrub suits and gowns when they arrive for filter respirator can filter very small particles that may con-
work. They wear cover gowns over the scrubs when taking tain viruses with a minimum efficiency of 95% (CDC, 2009).
coffee or lunch breaks. Nurses discard mandatory-wear Particulate respirators are custom sized and fitted for
scrub suits and gowns in a laundry receptacle and change each health care worker to ensure that there is less than
into street clothes before leaving the place of employment. 10% leakage between the seal of the mask and the wearer’s
Masks face. Once fitted, the health care worker can reuse his or
Masks are disposable, loose-fitting covers for the nose her own N-95 respirator as long as it remains intact and
and mouth (Fig. 10-3). They help prevent droplet and air- clean, and the wearer does not grow facial hair, gain or lose
borne transmission of microorganisms, but not necessarily 10 lb, or incur other facial changes that interfere with a
viruses, by keeping splashes or sprays from reaching the tight facial seal (Nursing Guidelines 10-1).
wearer’s nose and mouth. They are worn once and then In certain high-risk situations, such as when a bronchos-
disposed. copy or autopsy is performed on a client with TB, a respi-
rator that exceeds the minimum standard is used. In those
■ Visitors with respiratory infections need to wear a mask

or avoid contact with older adults in their home or long-
term care settings until their symptoms have subsided. In
addition to the mask, frequent and thorough hand washing
can help prevent the transfer of organisms.
■ Older adults, family members in close contact with older
people, and all personnel in health care settings should
obtain annual immunizations against influenza, a virus
spread via respiratory secretions. Those 65 years and older
Disposable Replaceable
should receive an initial dose of the pneumococcal vaccine.
FIGURE 10-4 Replaceable filters and disposable respirators.
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N U R S I N G G U I D E L I N E S 10 -1
Rationales
Using a Mask or Particulate Filter Respiratory
• Wear a mask if there is a risk for coughing or sneezing within a • Change the mask or respirator every 20 to 30 minutes or when
radius of 3 ft. The mask blocks the route of exit. it becomes damp; particulate filter respirators can be worn
• Wear a mask or particulate filter respirator if there is a multiple times, but they must be rechecked for leakage and fit.
potential for acquiring diseases caused by droplet or airborne Changing the mask preserves its effectiveness.
transmission. The mask blocks the port of entry. • Touch only the strings of the mask or the respirator strap during
• Position the mask or respirator so that it covers the nose and mouth. removal. Touching the mask transfers microorganisms to the hands.
The mask provides a barrier to nasal and oral ports of entry. • Discard used masks into a lined or waterproof waste container.
• Tie the upper strings of a mask snugly at the back of the head Proper disposal reduces the transmission of microorganisms to
and the lower strings at the back of the neck. Proper placement others.
reduces the exit and entry routes for microorganisms. • Perform hand washing or hand antisepsis after removing a
• Avoid touching the mask or respirator once it is in place. mask or respirator. Hand washing and hand antisepsis remove
Touching the mask transfers microorganisms to the hands. microorganisms from the hands.
cases, a powered air-purifying respirator or positive-pressure of wear. By using aseptic techniques, nurses should remove
airline respirator equipped with a half- or full-face mask is gloves without directly touching their more contaminated
required (CDC, 2005). This type of respirator removes air outer surface (see Nursing Guidelines 10-2).
contaminants by blowing them through a high efficiency
Hair and Shoe Covers
particulate air (HEPA) filter, thus providing purified air to
Hair and shoe covers reduce the transmission of pathogens
enter a facepiece, hood, or helmet.
present on the hair or shoes. Health care personnel generally
Gloves wear these garments during surgical or obstetric procedures.
Nurses wear clean gloves, sometimes called “examination Shoe covers are fastened so that they cover the open ends of
gloves,” in the following circumstances: pant legs. Hair covers should envelop the entire head. Men
with beards or long sideburns wear specially designed head
• As a barrier to prevent direct hand contact with blood, covers that resemble a cloth or paper helmet. Even though
body fluids, secretions, excretions, mucous membranes, hair covers are not required during general nursing care,
and nonintact skin health care workers should keep their hair short or contained
• As a barrier to protect clients from microorganisms with a clip, band, or by some other means.
transmitted from nursing personnel when performing pro-
cedures or care involving contact with the client’s mucous Protective Eyewear
membranes or nonintact skin Protective eyewear is essential when there is a possibility that
• When there is a potential transfer of microorganisms from body fluids will splash into the eyes. Goggles are worn along
one client or object to another during subsequent nursing care with a mask, or a multipurpose face shield is used (Fig. 10-6).
Examination gloves are generally made of latex or vinyl, Confining Soiled Articles
although other types are available (see Chap. 19). Latex and Health care agencies use several medically aseptic practices
vinyl gloves are equally protective with nonvigorous use, but to contain reservoirs of microorganisms, especially those on
latex gloves have some advantages. They stretch and mold soiled equipment and supplies. They include using designated
to fit the wearer almost like a second layer of skin, permit- clean and dirty utility rooms and various waste receptacles.
ting greater flexibility with movement. Perhaps most impor-
Utility Rooms
tantly, they can reseal tiny punctures.
Health care agencies have at least two utility rooms: one des-
Unfortunately, some nurses and clients are allergic to
ignated clean and the other considered dirty. Personnel must
latex. Reactions vary and range from annoying symptoms
not place soiled articles in the clean utility room.
such as skin rash, flushing, itching and watery eyes, and
The dirty or soiled utility room contains covered waste
nasal stuffiness to life-threatening swelling of the airway and
receptacles, at least one large laundry hamper, and a flushable
low blood pressure. Nurses who are sensitive to latex can
hopper. This room also houses equipment for testing stool or
wear alternative types of gloves, or they can wear a double
urine. A sink is located in the soiled utility room for hand
pair of vinyl gloves when the risk for contact with blood or
washing and for rinsing grossly contaminated equipment.
body fluids is high.
Nurses should change gloves if they become perforated, Waste Receptacles
after a period of use, and between the care of clients. Vinyl Agencies rely on various methods to contain soiled articles
gloves are not as protective as latex gloves after 5 minutes until they can be discarded. Most clients have a paper bag at the
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N U R S I N G G U I D E L I N E S 10 - 2
Rationales
Removing Gloves
• Grasp one of the gloves at the upper, outer edge at the wrist • Pull the second glove inside out while enclosing the first glove within
(Fig. 10-5). This position maintains a barrier between con- the palm. This action contains the reservoir of microorganisms.
taminated surfaces. • Place the gloves within a lined waste container. Proper disposal
• Stretch and pull the upper edge of the glove downward while confines the reservoir of microorganisms.
inverting the glove as it is removed. This action encloses the • Wash hands or perform hand antisepsis with an alcohol-based
soiled surface, blocking a potential exit route for microorgan- rub immediately after removing gloves. Hand washing and
isms. hand antisepsis remove transient and resident microorganisms
• Insert the fingers of the ungloved hand within the inside edge of that have proliferated within the warm, dark, and moist environ-
the other glove. The inside edge is the cleaner surface of the glove. ment inside the gloves.
bedside for tissues or other small, burnable items. Wastebaskets Terminal disinfection is more thorough than concurrent
generally are lined with plastic. Suction and drainage contain- disinfection and consists of measures used to clean a client’s
ers are kept covered and emptied at least once during each shift. environment after discharge. It includes scrubbing the mat-
Most client rooms have a wall-mounted puncture-resistant con- tress surface and the insides of drawers and bedside stands.
tainer for needles or other sharp objects (Fig. 10-7). Nurses who work in home health care can teach the cli-
ent and the family simple aseptic practices for cleaning con-
Keeping the Environment Clean taminated articles (see Client and Family Teaching 10-1).
Health agencies employ laundry staff and housekeeping per-
sonnel to assist with cleaning. In general, if soiled linen is ➧ Stop, Think, and Respond Box 10-3
bagged appropriately or handled with gloves, the detergents
Describe the methods of medical asepsis that are
and heat from the water and the dryer are sufficient to rid
helpful in controlling the chain of infection of the
linens of pathogenic organisms. common cold.
Housekeeping personnel are responsible for collecting
and disposing of accumulated refuse and for performing
concurrent and terminal disinfection. Housekeepers who fol- Surgical Asepsis
Surgical asepsis refers to those measures that render
low the principles of medical asepsis carry out concurrent
supplies and equipment totally free of microorganisms.
disinfection or measures that keep the client environment
Sterile techniques include practices that avoid contami-
clean on a daily basis, which include:
nating microbe-free items. Both begin with the process of
• They clean less soiled areas before grossly dirty ones. sterilization.
• They wet-mop floors and damp-dust furniture to avoid dis-
persing microorganisms on dust particles and air currents. Sterilization
• They frequently discard solutions used for mopping in a Sterilization consists of physical and chemical techniques
flushable hopper. that destroy all microorganisms, including spores. Steriliza-
• They never place clean items on the floor. tion of equipment is done within the health agency or by
A B C
FIGURE 10-5 A. Pulling at the cuff. B. Inverting the glove. C. Enclosing contaminated surfaces.
(Photo by B. Proud.)
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Cleaning Potentially Infectious Equipment
The nurse teaches the client and the family to do the following:
● Wear waterproof gloves when handling heavily contami-
nated items or if there are open skin areas on the hands.
● Designate one container for the sole purpose of cleaning
contaminated articles.
● Disassemble and rinse reusable equipment as soon as
possible after use.
● Rinse grossly contaminated items first under cool, run-
ning water; hot water causes protein substances in body
fluids to thicken or congeal.
● Soak reusable items in a solution of water and detergent
or disinfectant if a thorough cleaning is not immediately
possible.
● Use a sponge, scrub brush, or cloth to create friction and
loosen dirt, body fluids, and microorganisms from the sur-
face of contaminated articles.
● Force sudsy water through the hollow channels of items
to remove debris.
● Rinse washed items well under running water.
● Drain rinsed equipment and air dry.
FIGURE 10-6 Protective goggles. (Photo by B. Proud.) ● Wash hands for at least 15 seconds after cleaning equip-
ment if the hands are visibly dirty, soiled with blood or other
manufacturers of hospital supplies. Labels on commercially body fluids, or contaminated with proteinaceous material;
sterilized equipment identify a safe use date. substitute an alcohol-based hand rub in other circumstances.
● Store clean, dry items in a covered container or in a clean,
Physical Sterilization folded towel.
Microorganisms and spores are destroyed physically through
radiation or heat, boiling water, free-flowing steam, dry heat,
and steam under pressure. nated equipment needs to be boiled for 15 minutes at 212°F
Radiation. Ultraviolet radiation can kill bacteria, espe- (100°C)—longer in places at higher altitudes.
cially the organism that transmits TB. This process is gen-
erally combined with other aseptic methods, however, its Free-Flowing Steam. Free-flowing steam is a method in
efficacy depends on circulating organisms by air currents which items are exposed to the heated vapor that escapes from
from lower areas of a room to wall- or ceiling-mounted units boiling water. It requires the same time and temperature as the
(CDC, 2008). Exposure to sunlight was used in the past to boiling method. Free-flowing steam is less reliable than boiling
eliminate microorganisms. because exposing all the surfaces of some contaminated items
to the steam is difficult.
Boiling Water. Boiling water is a convenient way to
sterilize items used in the home. To be effective, contami- Dry Heat. Dry heat, or hot air sterilization, is similar to bak-
ing items in an oven. To destroy microorganisms with dry heat,
temperatures of 330° to 340°F (165° to 170°C) are maintained
for at least 3 hours. Dry heat is a good technique for steriliz-
ing sharp instruments and reusable syringes because moist heat
damages cutting edges and the ground surfaces of glass. Dry
heat prevents the rusting of objects that are not made of stain-
less steel.
Steam Under Pressure. Steam under pressure is the

most dependable method for destroying all forms of organ-
isms and spores. The autoclave is a type of pressure steam
sterilizer that most health care agencies use (Fig. 10-8). Pres-
sure makes it possible to achieve much hotter temperatures
than the boiling point of water or free-flowing steam. Heat-
sensitive tape that changes color or displays a pattern when
exposed to high temperatures is used on sterilized packages
FIGURE 10-7 A sharps container. as a visual indicator that the wrapped item is sterile.
LWBK1004-C10_p139-167.indd 151 26/01/12 3:05 AM

• If there is a question about the sterility of an item, it is

considered unsterile.
• The longer the time since sterilization, the more likely it is
that the item is no longer sterile.
• A commercially packaged sterile item is not considered
sterile past its recommended expiration date.
• Once a sterile item is opened or uncovered, it is only a
matter of time before it becomes contaminated.
• The outer 1-in. margin of a sterile area is considered a zone
of contamination.
• A sterile wrapper, if it becomes wet, wicks microorgan-
isms from its supporting surface, causing contamination.
• Any opened sterile item or sterile area is considered con-
taminated if it is left unattended.
FIGURE 10-8 An autoclave. (Photo by B. Proud.) • Coughing, sneezing, or excessive talking over a sterile
field causes contamination.
• Reaching across an area that contains sterile equipment
Chemical Sterilization has a high potential for causing contamination and is there-
Both gas and liquid chemicals are used to sterilize invasive fore avoided.
equipment. Until peracetic acid was perfected as a steriliz- • Sterile items that are located or lowered below waist level
ing agent, sterilization using liquid chemicals was difficult are considered contaminated because they are not within
and some questioned its reliability. The use of peracetic critical view.
acid, however, and performic acid, a second liquid steri-
Health care professionals observe the principles of
lizing agent, is considered a reliable method for sterilizing
surgical asepsis during surgery, when performing invasive
heat-sensitive instruments such as endoscopes (Rutola &
procedures such as inserting urinary catheters, and when
Weber, 2001). Gas sterilization, using ethylene oxide gas, is
caring for open wounds. Practices that involve surgical asep-
a traditional method for destroying microorganisms if heat
sis include creating a sterile field, adding sterile items to the
or moisture is likely to damage items or if no better method
sterile field, and donning sterile gloves.
is available.
Peracetic Acid. Peracetic acid is a liquid sterilizing agent, Creating a Sterile Field
which is a combination of acetic acid and hydrogen perox- A sterile field means a work area free of microorganisms. It is
ide. When compared with other liquid sterilizing agents, formed using the inner surface of a cloth or paper wrapper that
peracetic acid is the most effective agent against bacteria, holds sterile items, much like a table cloth. The field enlarges the
viruses, yeasts, and molds. It sterilizes equipment quickly, is area where sterile equipment or supplies are placed. When open-
effective in the presence of organic material such as blood ing the sterile package, the nurse must be careful to keep the
and stool, and decomposes into environmentally safe by- inside of the wrapper and its contents sterile. Refer to Skill 10-4.
products (Steris Corporation, 2006). Adding Items to a Sterile Field
Ethylene Oxide Gas. Ethylene oxide gas destroys a broad Sometimes it is necessary to add sterile items or sterile solu-
spectrum of microorganisms, including spores and viruses, tions to the sterile field (see Skill 10-4).
when contaminated items are exposed for 3 hours at 86ºF
Sterile Items. Agency-sterilized items or those that
(30ºC). Gassed items, however, must be aired for 5 days at
have been commercially prepared may be added to the ster-
room temperature or 8 hours at 248ºF (120ºC) to remove
ile field. The former are generally wrapped in cloth. The
traces of the gas, which can cause chemical burns.
nurse unwraps the cloth by supporting the wrapped item in
Principles of Surgical Asepsis one hand rather than placing it on a solid surface. He or she
Surgical asepsis is based on the premise that once equipment holds each of the four corners to prevent the edges of the
and areas are free of microorganisms, they can remain in that wrap from hanging loosely. The nurse places the unwrapped
state if contamination is prevented. Consequently, health item on the sterile field and discards the cloth cover.
care professionals observe the following principles: Commercially prepared supplies, such as sterile gauze
squares, are enclosed in paper wrappers. The paper cover
• They preserve sterility by touching one sterile item with usually has two loose flaps that extend above the sealed
another that is sterile. edges. After separating the flaps, the nurse drops the sterile
• Once a sterile item touches something that is not sterile, it contents onto the sterile field.
is considered contaminated.
• Any partially unwrapped sterile package is considered Sterile Solutions. Sterile solutions, such as normal saline,
contaminated. come in various volumes. Some containers are sealed with
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N U R S I N G G U I D E L I N E S 10 - 3
Rationales
Donning a Sterile Gown
• Apply a mask and hair cover. This sequence prevents contami- • Allow the gown to unfold while holding it high enough to
nation of the hands after they are washed. avoid contact with the floor. This prevents contamination.
• Perform surgical hand antisepsis (see Skill 10-3). This removes • Insert an arm within each sleeve without touching the outer
resident and transient microorganisms. surface of the gown. This action maintains sterility.
• Pick up the sterile gown at the inner neckline. This action • Have an assistant pull at the inside of the gown to adjust the fit,
preserves the sterility of the outer gown surface. expose the hands, and then tie it closed (see Fig. 10-9B). This
• Hold the gown away from the body and other unsterile objects action preserves the sterility of the front of the gown.
(see Fig. 10-9A). This prevents contamination. • Don sterile gloves. Wearing sterile gloves ensures the sterile
condition of the hands and cuff of the gown.
a rubber cap or screw top. Either is replaced if the inside ➧ Stop, Think, and Respond Box 10-4
surface is contaminated. To avoid contamination, the nurse
What is the best action to take if while donning sterile
places the cap upside down on a flat surface or holds it dur- gloves, a nurse touches the thumb of an already
ing pouring. gloved finger to his or her ungloved wrist?
Before each use of a sterile solution, the nurse pours
and discards a small amount to wash away airborne con-
Donning a Sterile Gown
taminants from the mouth of the container. This is called
A sterile gown protects the client and the sterile equipment
lipping the container. While pouring, the nurse holds the
from microorganisms that collect on the surface of uniforms,
container in front of himself or herself. The nurse avoids
scrub suits, or scrub gowns. Sterile gowns are required dur-
touching any sterile areas within the field. He or she con-
ing surgery and childbirth. They are used during other sterile
trols the height of the container to avoid splashing the ster-
procedures as well.
ile field, causing a wet area of contamination. Agencies
Sterile gowns usually are made of cloth and are laun-
replace sterile solutions daily even if the entire volume is
dered and sterilized after each use. Before wrapping a gown
not used.
for sterilization, it is folded so that the inside surface can be
Donning Sterile Gloves touched while putting it on. To avoid contamination, the nurse
When applied correctly, nurses can use sterile gloves to han- should follow the steps outlined in Nursing Guidelines 10-3.
dle sterile equipment and supplies without contaminating
them. Sterile gloves also provide a barrier against transmit- NURSING IMPLICATIONS
ting microbes to clients. Some packages of supplies include
sterile gloves; they are also packaged separately in glove Everyone is susceptible to infections, especially if sources of
wrappers (Skill 10-5). microorganisms among personnel, clients, equipment, and
A B
FIGURE 10-9 A. Unfolding a sterile gown. B. Assisting with donning a sterile gown.
LWBK1004-C10_p139-167.indd 153 26/01/12 3:05 AM

the agency are not controlled. Nurses generally identify per- Nursing Care Plan 10-1 illustrates how nurses incorpo-
tinent nursing diagnoses like those that follow when caring rate aseptic principles into a teaching plan for the nursing
for particularly susceptible clients: diagnosis of Deficient Knowledge. The NANDA taxonomy
(2012) defines Deficient Knowledge as an absence or defi-
• Risk for Infection
ciency of cognitive information related to a specific topic.
• Risk for Infection Transmission
Carpenito-Moyet (2008) uses the definition, “the state in
• Ineffective Protection
which an individual or group experiences a deficiency in
• Delayed Surgical Recovery
cognitive knowledge or psychomotor skills concerning the
• Deficient Knowledge
condition or treatment plan.” Some have argued that this
N U R S I N G C A R E P L A N 1 0-1 Deficient Knowledge

Assessment • Listen for statements that reflect inaccurate health information.
• Explore the client’s level of knowledge in a particular area of • Observe if a client performs health-related self-care incor-
health care. rectly.
• Provide opportunities during which a client can request health- • Watch for signs of emotional distress that reflect inaccurate
related information. information.
Nursing Diagnosis. Deficient Knowledge related to unfamiliarity with infectious disease (hepatitis A) transmission as evidenced
by the statements, “The school nurse sent this note home saying there’s been a case of hepatitis in my daughter’s fifth-grade class.
Isn’t that what drug users get? Should I keep my daughter home from school? What will prevent her from catching it?”
Expected Outcome. The client will (1) state the difference in transmission of hepatitis A and hepatitis B, (2) list at least three
signs and symptoms of hepatitis A, (3) verbalize how to avoid infection with hepatitis A, and (4) demonstrate how to wash hands
appropriately by the end of the office visit.
Interventions Rationales
Explain that hepatitis A is primarily transmitted from the stool This discussion provides accurate information concerning the
of an infected person to the oral route of the susceptible mode of disease transmission.
person and that hepatitis B is spread by blood and body
fluids.
Provide health-related information about hepatitis A, which Specific information increases the client’s knowledge, clarifies
includes: misinformation, and helps relieve anxiety.
• The incubation period for hepatitis A is 25–30 days.
• Signs and symptoms that may develop are low-grade fever,
reduced activity, loss of appetite, nausea, abdominal pain,
dark urine, light-colored stool, and yellowing of the skin and
sclera of the eyes.
• Hand washing is an excellent preventive measure especially
when performed before eating and after using the toilet.
• An injection of immune serum globulin is a method of provid-
ing temporary passive immunity when exposed to hepatitis A.
Demonstrate hand washing and observe a return demon- A demonstration provides health teaching by visual
stration emphasizing the following: learning; returning a demonstration reinforces learning
• Turn handles of the faucet on and let the water run. via a psychomotor activity.
• Wet hands and lather with soap.
• Rub lathered hands for at least 15 seconds.
• Rinse, letting the water flow from wrists to fingers.
• Dry hands with a paper towel.
• Use the paper towel to turn the faucet off.
Evaluation of Expected Outcomes

• The client identifies the mode of transmitting hepatitis A as the • The client demonstrates appropriate hand washing and is pre-
fecal/oral route. pared to teach her daughter the same skill.
• The client lists low fever, loss of appetite, and yellow sclera as • The client makes an appointment for her daughter to receive an
indications of hepatitis A infection. injection of immune serum globulin.
• The client states that frequent and thorough hand washing is a
method for preventing the acquisition of hepatitis A.
LWBK1004-C10_p139-167.indd 154 26/01/12 3:05 AM

nursing diagnosis is used erroneously because it is more 3. What is the most important health teaching the nurse
often an etiology than a nursing diagnosis (Carpenito- can provide to a client with an eye infection?
Moyet, 2008). 1. Eat a well-balanced, nutritious diet.
2. Wear sunglasses in bright light.
3. Cease sharing towels and washcloths.
CRITICAL THINKING EXERCISES 4. Avoid products containing aspirin.
4. If the nurse provides the following information to a
1. If the rate of infections increased on your nursing
person who has just had his or her earlobes pierced,
unit, what would you investigate to determine the
which is most important for reducing the potential for
contributing factors?
infection?
2. If the cause of nosocomial infections is related to
1. Use earrings made of 14-carat gold.
inadequate hand washing among health care person-
2. Leave the earrings in place for 2 weeks.
nel, what suggestions would you give for correcting
3. Turn the earrings frequently.
the problem?
4. Swab the earlobes daily with alcohol.
3. What methods could be used to evaluate if health
5. When donning sterile gloves, which actions are
care workers are performing hand hygiene appropri-
correct? Select all that apply.
ately?
1. The nurse performs hand hygiene.
4. What recommendations might you suggest to
2. The finger ends of the opened glove wrapper are
prevent transferring microorganisms from health care
positioned nearest the nurse.
workers’ homes to clients for whom they care?
3. The nurse picks up the first glove cuff at the folded
edge with the fingers and thumb.
4. The nurse pulls the glove on without touching the
glove’s outer surface.
1. What is the minimum amount of time required for 5. The second glove is donned by holding the cuff
performing an alcohol-based hand rub? with the finger and thumb of the first glove.
1. 5 seconds
2. 10 seconds
3. 15 seconds
4. 20 seconds
2. Which of the following are appropriate aseptic
practices in relation to hand hygiene? Select all that
apply.
1. The health care worker has freshly applied artificial
nails.
2. The fingernails are less than ¼ in.
3. The nurse removed all remnants of fingernail
polish.
4. The nurse rubs the tips of the fingers against the
opposite palm containing an alcohol-based
product.
5. The nurse rubs the hands up to, but not including,
the wrists.
LWBK1004-C10_p139-167.indd 155 26/01/12 3:05 AM

SKILL 10-1 Hand Washing
ASSESSMENT
Review the medical record to determine whether it is appropri- Demonstrates concern for immunosuppressed clients, newborns,
ate to perform hand washing for longer than 15 seconds. or other susceptible hosts.
Check that there are soap and paper towels near the sink and a Promotes effective hand washing and disposal of paper towels; bar
waste receptacle nearby. soap is supplied in small cakes, which are changed frequently
and placed on a drainable holder to avoid colonization with micro-
organisms; liquid soap is stored in closed containers that are
replaced, or cleaned, dried, and refilled on a regular schedule.
PLANNING
Trim long fingernails so that they are less than ¼ in. long, a Reduces the reservoir where the majority of hand flora reside;
length at which the nails cannot be seen when the palms are prevents tearing gloves.
held in front of the nose.
Remove all jewelry; a plain, smooth wedding band can be worn; Facilitates removing transient and resident microorganisms; bac-
roll up long sleeves. terial counts are higher when rings are worn during client care.
Explain the purpose for hand washing to the client. Reinforces and demonstrates concern for client safety.
IMPLEMENTATION
Turn on the water using faucet handles; an automated faucet; or Serves as a wetting agent and facilitates lathering; using auto-
elbow, knee, or foot controls (Fig. A). mated faucets, elbow, knee, or foot controls prevents recon-
tamination of hands after they are washed.
Turning on faucet.
If a lever-operated paper towel dispenser is available, activate it Electronic sensors decrease hand contamination before and after
to dispense the paper towel. hand washing, but they are not generally
available in most health care agencies.
Wet your hands with comfortably warm water from the wrists Allows water to flow from the least contaminated area to the
toward the fingers (Fig. B). most contaminated area.
Wetting hands.
Avoid splashing water from the sink onto your uniform. Prevents transferring microorganisms to clothing via a wicking
action.
(continued)
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Hand Washing (continued)
Dispense about 3–5 mL (1 tsp) of liquid soap into your hands, or Provides an agent for emulsifying body oils and releasing micro-
wet a cake of bar soap. organisms.
Work the soap into a lather and generate friction. Expands the volume and distribution of the soap; begins to soften
the keratin layer of the skin; loosens debris and directs soap
into crevices of skin.
Rinse the bar soap, if used, and replace it within a drainable Flushes microorganisms from the surface of the soap; drained
soap dish. bar soap is less likely to support the growth of microorganisms.
Rub the lather vigorously over all surfaces of the hands including Frees microorganisms that are lodged in skin creases and
thumbs and backs of fingers and hands and under the finger- crevices.
nails for a minimum of 15 seconds–the time it takes to sing
two rounds of the song, “Happy Birthday” (Fig. C).
Cleaning backs of fingers.
Rinse the soap from your hands by letting the water run from Avoids transferring microorganisms to cleaner areas.
the wrists toward the fingers (Fig. D).
Rinsing hands.
Stop the flow of water if it is controlled by an elbow or knee Terminates the flow of water without recontaminating the hands.
lever, or a foot pedal.
Hold your draining hands lower than your wrists. Promotes drainage by gravity flow toward the fingers.
(continued)
LWBK1004-C10_p139-167.indd 157 26/01/12 3:05 AM

Hand Washing (continued)
Dry your hands thoroughly with paper towels or similar items Prevents chapping.
(Fig. E). Cloth towels are the least desirable method of drying because
they are prone to contamination. A warm air dryer (rarely
available in client environments) is the best. Paper towels
dispensed from a holder mounted high enough to avoid splash
contamination are acceptable and effective.
Drying hands.
Turn the hand controls of the faucet off using a paper towel. Prevents recontamination of washed hands.
Apply hand lotion from time to time. Maintains the integrity of the skin because skin that becomes
irritated and abraded from frequent hand washing increases
the risk of acquiring pathogens by direct skin contact.
Evaluation
• Hand washing has met time requirements.
• Hands are clean.
• Skin is intact.
Document
Because hand washing is performed so frequently, it is not documented, but it is expected as a standard for care among all health
care personnel.
SKILL 10-2 Hand Antisepsis with an Alcohol-Based Rub
ASSESSMENT
Determine that the hands are not visibly dirty or contaminated Hand washing is required when the hands are visibly soiled.
with proteinaceous material, blood, or other body fluids.
Identify the location of the alcohol-based dispenser. Compliance increases when the dispenser is close to the point
of client care such as at the entrance to the client’s room or at
the bedside.
PLANNING
Prepare to perform routine hand antisepsis with an alcohol- Hands acquire 100–1,000 colony-forming units, a measure of
based product when the hands are not visibly soiled such as microbial load, during “clean activities.” Products containing
before and after touching a client, before and after performing alcohol have better antimicrobial activity than soap (Boyce &
a procedure, after touching within the immediate vicinity of Pittet, 2002).
the client, and after removing gloves. (continued)
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Hand Antisepsis with an Alcohol-Based Rub (continued)
IMPLEMENTATION
Dispense approximately 3 mL of the alcohol-based product into Achieving effective antisepsis is related to a sufficient volume
a cupped palm (Fig. A). necessary to cover all hand and wrist surfaces.
Accessing an alcohol-based product.
Distribute and rub the alcohol-based product over all surfaces of Effective antisepsis requires contact between the alcohol-based
the hands and fingers. product and the skin surfaces where microorganisms reside.
Rub the back of each hand with the opposite palm. Rubbing spreads the alcohol-based product over the dorsum of
the hands and creates friction that loosens surface debris.
Spread the fingers and rub the webbed areas of exposed skin Microorganisms tend to collect and accumulate in the folds of skin.
on each hand.
Rub down the length of each thumb using a rotating motion. A rotational movement ensures that the entire thumb is included.
Rub the tips of the fingers against the opposite palm on each The areas that are cleaned less effectively during hand hygiene
hand in a circular fashion. include the thumbs, fingertips, and webs between the fingers.
Rub the wrists of both hands in a rotating manner. Cleaning the wrists is the final step in reducing surfaces in close
proximity of clients.
Proceed with nursing activities after rubbing the hands for at After sufficient rubbing and evaporation, bacterial counts on the
least 15 seconds and the hands are dry. hands are significantly reduced.
Evaluation
Hand antisepsis is completed when the product containing alcohol has totally evaporated.
Documentation
Hand hygiene is not documented, but it is expected to be performed conscientiously as a standard of care for all health care personnel.
SKILL 10-3 Performing Surgical Hand Antisepsis
ASSESSMENT
Locate the area designated for performing surgical hand antisep- This action reduces the potential for recontamination or repeat-
sis. Verify that the sink is deep and has a faucet with either a ing surgical hand antisepsis because of a lack of necessary
knee or a foot control. Ensure that there is a sufficient supply supplies.
of liquid cleanser that can be dispensed with a foot pump;
also check to see whether a hand sponge and nail cleaner are
available.
PLANNING
Change from uniform or street clothes into a scrub gown or suit. Changing attire decreases the number of microorganisms trans-
ferred from other areas of the health care agency.
Place uniform and valuables, which may include rings and Storage ensures the safekeeping of items that contain abundant
a wristwatch, in a locker. microorganisms.
Don a mask and hair and shoe covers. These items prevent recontaminating the skin after the hands
have been cleaned.
Verify that a sterile towel, gloves, and long-sleeved cover gown Checking ensures that clean hands can be dried and covered
are in the operative or obstetric room adjacent to the quickly to avoid transferring additional microbes to the cleansed
cleansing area. areas. (continued)
LWBK1004-C10_p139-167.indd 159 26/01/12 3:05 AM

Performing Surgical Hand Antisepsis (continued)
IMPLEMENTATION
Turn on the water to a comfortably warm temperature; wet the This measure removes surface debris, oil, and some microorgan-
hands to the forearms and lather the liquid cleanser to all the isms before beginning surgical hand antisepsis.
wet areas, using friction for approximately 15 seconds.
Use a brush, if one is provided, to scrub under the nails, around A brush may be used initially to remove superficial debris from
the cuticles, and the creases in the palms. the hands.
Clean beneath each fingernail with a nail file or orange stick This device removes deeper debris and microorganisms from
(Fig. A); dispose of this item in a foot-operated waste container beneath the nails.
before rinsing.
Cleaning the fingernails.
Rinse the lather while keeping the hands above the elbows. Gravity prevents soiled lather from adhering to the hands.
Dispense the antimicrobial cleanser into the palm of a hand or use Doing so decreases microorganisms.
a wetted sponge that has been presaturated with the cleanser.
Using friction, wash the nails and all surfaces of each finger; These steps follow the principle of cleaning from most to least
proceed to the thumb, palm, and back of the hand (Fig. B). contaminated areas.
Washing all surfaces of the hands using friction.
Go over all areas with at least 10 strokes each; repeat on the This amount ensures adequate cleansing.
other side.
Avoid splashing water or lather onto the surface of the scrub Doing so wicks microorganisms beneath the surface of the cover
gown or suit. gown or suit to the surface.
Proceed to wash the forearms with circular strokes from lower Cleanse in the direction of cleaner areas of the body.
to middle to upper areas.
Ensure that washing continues for the time identified by the Adequate time is necessary to reduce microorganisms. Current
manufacturer of the cleansing agent (generally a total of studies are being conducted to determine whether surgical
2–6 minutes; Boyce & Pittet, 2002). hand antisepsis using hand rubbing products that contain
alcohol or chlorhexidine may be used in lieu of using traditional
hand antiseptics such as povidone iodine or whether the dura-
tion of surgical hand antisepsis could be shortened with their
use (Al Naami & Afzal, 2006; Tanner, 2008).
(continued)
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Drop the soapy sponge in the sink or discard it within a foot- These steps prevent touching unclean surfaces, as well as debris
operated waste container. Rinse lather by allowing the water and loosened microorganisms from dripping over previously
to run from fingers to elbows (Fig. C). cleaned hands.
Rinse water flowing toward the elbows.
Keep the hands elevated above the waist, well in front of the Proceeding this way maintains cleanliness during relocation to
scrub gown or suit with the elbows flexed; enter the room the operating room or obstetric suite.
where the sterile towel, gloves, and gown are located (Fig. D).
Holding the hands and arms upward and away from the body.
D
(continued)
LWBK1004-C10_p139-167.indd 161 26/01/12 3:05 AM

Walk to the table containing an unwrapped sterile towel while This step prevents transferring organisms from the scrub gown or
keeping a slight distance from it. suit to a sterile area.
Pick up the sterile towel by its folded edge. After allowing it to This process avoids transferring organisms from an unclean to a
unfold without touching anything, use one end to dry the clean area.
hands and forearm in that order. Use the other end to dry the
opposite hand and forearm (Fig. E).
Drying the hands with a sterile towel.
Discard the towel within a linen hamper. Such disposal confines soiled items.
Pick up and don a sterile gown with assistance from another This step keeps the front surface of the gown sterile and covers
person (see Nursing Guidelines 10-3) and don sterile gloves. the clean hands.
Evaluation
• Nails, hands, and forearms have been washed for the designated time.
• The sequence of cleansing supports principles of asepsis.
• The procedure and the use of equipment have followed principles to avoid recontamination.
Document
Surgical hand antisepsis is not documented, but it is expected to be performed conscientiously following agency policies and
procedures that are standards of care for all health care personnel.
SKILL 10-4 Creating a Sterile Field and Adding Sterile Items
ASSESSMENT
Inspect the work area to determine the cleanliness and orderli- Working in a clean area is a principle of medical asepsis.
ness of the surface on which you will work.
Obtain the prepared package that contains items needed for Contents within a prepared package contain sterile items.
performing the clinical procedure.
Check that the package is sealed and that its use date has not Items are not used if there is a question as to their sterility.
expired.
Determine whether additional sterile items are needed but not Gathering all necessary items facilitates organization and time
contained in the sterile package. management.
(continued)
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Creating a Sterile Field and Adding Sterile Items (continued)
PLANNING
Explain what is about to take place to the client. Promotes understanding and cooperation.
Plan to perform the procedure that requires a sterile field when Once a sterile field is created, it has a potential for contamination
the client is comfortable and there are no potential interrup- when items are uncovered and the field is exposed for a any
tions. length of time.
Remove objects from the area where the field will be created. Removing unsterile items provides room for working and reduces
the potential for accidental contamination.
IMPLEMENTATION
Perform hand washing or hand antisepsis with an alcohol-based Removes transient microorganisms and reduces the potential for
rub. transmitting infection.
Place the wrapped package on a surface at or above waist level. Placement above the waist keeps the sterile field and its contents
within sight and reduces the potential for contamination.
Position the package so that the outermost triangular edge of the This placement prevents reaching over the sterile area while the
wrapper can be moved away from the front of the body (Fig. A). package is opened and reduces the potential for contamination.
Unfolding away from the body.
Unfold each side of the wrapper by touching the area that will This action maintains a sterile area.
be in direct contact with the table or stand, or touch no more
than the outer 1 in. of the edge of the wrapper (Fig. B).
Unfolding the sides.
B
(continued)
LWBK1004-C10_p139-167.indd 163 26/01/12 3:05 AM

Unfold the final corner of the wrapper by pulling it toward the This action avoids reaching over an uncovered sterile area, which
body (Fig. C). has the potential for contaminating the sterile field and the
items that rest upon it.
Unfolding toward the body.
Add additional wrapped sterile items by unwrapping them, Placing sterile items on a sterile field without touching anything
securing the edges of the wrapper in one hand, and placing that is unsterile preserves a sterile condition.
them on the sterile field (Fig. D).
Adding an agency-sterilized item.
Add additional paper-wrapped sterile items by separating the Placing sterile items on a sterile field without touching anything
sealed flaps and dropping the contents onto the sterile field that is unsterile preserves a sterile condition.
(Fig. E).
Adding sterile gauze.
E
(continued)
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Add a sterile solution to a sterile container, if it is needed, by: Placing sterile items on a sterile field without touching anything
• Opening the cap on the solution without touching the inner that is unsterile preserves a sterile condition.
surface with anything that is unsterile
• Pouring and discarding a small amount into a waste container
• Pouring the amount desired into the container on the sterile
field without splashing the surface of the field (Fig. F)
Adding sterile solution.
Evaluation
• The exposed area of the field is sterile; nothing unsterile has touched the surface inside the 1-in. outer margin.
• Additional items have been added to the sterile field in such a way as to preserve the sterility of the items and the surface of the sterile
field.
Document
Preparation of a sterile field and the addition of sterile items is not documented, but it is expected as a standard for care among all health
professionals. The procedure that required the sterile field and the outcome of the procedure are documented (refer to the sample
documentation that accompanies Skill 10-5).
SKILL 10-5 Donning Sterile Gloves
ASSESSMENT
Determine whether the procedure requires surgical asepsis. Complies with infection control measures.
Read the contents of prepackaged sterile equipment to Indicates whether extra supplies are needed.
determine whether sterile gloves are enclosed.
Discover how much the client understands about the Provides a basis for teaching.
subsequent procedure.
PLANNING
Explain what is about to take place to the client. Promotes understanding and cooperation.
Select a package of sterile gloves of the appropriate size. Ensures ease when donning and using gloves.
Remove unnecessary items from the overbed table or bedside Ensures an adequate, clean work space.
stand.
(continued)
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Donning Sterile Gloves (continued)
IMPLEMENTATION
Perform hand washing or alcohol-rub hand antisepsis. Reduces the potential for transmitting microorganisms.
Open the outer wrapper of the gloves (Fig. A). Provides access to inner wrapper.
Opening the outer package.
Carefully open the inner package and expose the sterile gloves Facilitates donning gloves.
with the cuff ends closest to you (Fig. B).
Positioning the inner wrapper.
Pick up one glove at the folded edge of the cuff using your Avoids contaminating the outer surface of the glove.
thumb and fingers (Fig. C).
Picking up the first glove.
Insert your fingers while pulling and stretching the glove over Avoids contaminating the outer surface of the glove.
your hand, taking care not to touch the outside of the glove to
anything that is unsterile.
Unfold the cuff so that the glove extends above the wrist, but Extends the sterile area.
touch only the surface that will be in direct contact with the skin. (continued)
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Donning Sterile Gloves (continued)
Insert the gloved hand beneath the sterile folded edge of the Maintains the sterility of each glove.
remaining glove (Fig. D).
Picking up the second glove.
Insert the fingers within the second glove while pulling and Facilitates donning the glove.
stretching it over the hand (Fig. E).
Pulling on the second glove.
Take care to avoid touching anything that is unsterile. Maintains sterility.

Maintain your gloved hands at or above waist level. Prevents the potential for contamination.
Repeat the procedure if contamination occurs. Protects the client from acquiring an infection.
Evaluation
• Gloves are donned.
• Sterility is maintained.
Document
• The procedure that was performed.
• The outcome of the procedure.
Date and Time Sterile dressing changed over abdominal incision. Wound edges are approximated, with no evidence of
redness or drainage. SIGNATURE/TITLE
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11 Admission,
Discharge, Transfer,
and Referrals
admission
basic care facility
clinical résumé 1. List four major steps involved in the admission process.
continuity of care 2. Identify four common psychosocial responses when clients
discharge are admitted to a health agency.
discharge planning 3. List the steps involved in the discharge process.
extended care facility 4. Give three examples of the use of transfers in client care.
home health care 5. Explain the difference between transferring clients and
intermediate care facility referring clients.
orientation 6. Describe three levels of care that nursing homes provide.
progressive care units 7. Discuss the purpose of a minimum data set (MDS).
referral 8. Identify two contributing factors to the increased demand for
skilled nursing facility home health care.
stepdown units
transfer
transfer summary
experiences health changes. Several levels of health
E
VERYONE
transitional care units
care are available, depending on the seriousness of the condition
(see Chap. 4). Some people recover with self-treatment or by
following health instructions from nurses or other health care team
members.
This chapter describes skills used in caring for clients who
become seriously ill, are injured, or have chronic health problems that
require admission and temporary care in a facility such as a hospital.
This chapter also addresses nursing skills involved in the subsequent
discharge, transfer, or referral of clients to community agencies that
provide health care.
THE ADMISSION PROCESS
Admission means entering a health care agency for nursing care and
medical or surgical treatment. It involves the following:
• Authorization from a physician that the person requires specialized
care and treatment
• Collection of billing information by the admitting department of the
health care agency
• Completion of the agency’s admission database by nursing personnel
• Documentation of the client’s medical history and ndings
fi from
physical examination
• Development of an initial nursing care plan
• Initial medical orders for treatment
The various types of admissions are listed in Table 11-1.
168
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CHAPTER 11 Admission, Discharge, Transfer, and Referrals 169
TABLE 11-1 Types of Admissions

TYPE EXPLANATION EXAMPLE
Inpatient Length of stay generally more than 24 hours Acute pneumonia

Planned (nonurgent) Scheduled in advance Elective or required major surgery
Emergency admis- Unplanned; stabilized in emergency department and Unrelieved chest pain, major trauma
sion transferred to nursing care unit
Direct admission Unplanned; emergency department bypassed Acute condition such as prolonged vomiting or
diarrhea
Outpatient Length of stay less than 24 hours; possible return on Minor surgery, cancer therapy, physical therapy
a regular basis for continued care or treatment
Observational Monitoring required; need for inpatient admission Head injury, unstable vital signs, premature or early
determined within 23 hours labor
Gerontologic Considerations at this time. They prepare a form with the client’s address,
place of employment (if the client works), insurance carrier
■ Many older adults fear that admission to a hospital or and policy numbers, Medicare information, and other per-
long-term care facility will eventually prevent their return to sonal data. The hospital’s business office uses this informa-
independent living. They may, therefore, minimize symp- tion for record keeping and billing.
toms to protect their independent-living status. Clients who are extremely unstable or in severe discom-
■ Aging directly correlates with increased incidence of fort may bypass the admitting department and go directly
acute disease and exacerbations of chronic conditions. to the nursing unit. Personnel eventually will direct some-
■ Adults 65 years and older accounted for one third of the one from the family to the admitting department on the cli-
hospital admissions in 2007 (Stranges & Friedman, 2009).
ent’s behalf or go to the client’s bedside to obtain the needed
■ Pets are an integral social support system and contribute
information.
to the general well-being of older adults. Those who live
alone may be concerned about the welfare of pets. This Generally, the admissions clerk prepares an identifica-
should be considered during admission, with arrangements tion bracelet for the client, which contains the client’s name,
made for the care of the pet. an identification number, and, in some cases, a bar code for
computerized scanning purposes. Someone in the admitting
department or the admitting nurse applies the bracelet. For
the client’s safety, he or she must wear the bracelet through-
Pharmacologic Considerations out the stay. Other than asking a client’s name, the bracelet is
the single most important method for identifying the client.
■ Nonadherence to medication regimens accounts for more If the identification bracelet is missing or has been removed,
than 10% of older adult hospital admissions, nearly one fourth the nurse is responsible for replacing it as soon as possible.
of nursing home admissions, and 20% of preventable adverse Once personnel have collected preliminary data, they
drug events among older persons in the ambulatory setting notify the nursing unit and escort the client to the site where
(American Society on Aging and American Society of Consult- he or she will receive care. They deliver the form initiated
ant Pharmacists Foundation, 2006). in the admitting department to the nursing unit along with a
plastic card called an addressograph plate. The card identi-
fies the pages within the client’s medical record. Nurses use
Medical Authorization it to stamp laboratory test request forms, forms that accom-
Before admission, a physician determines whether a client’s pany a laboratory specimen, and charge slips for special
condition requires special tests, technical care, or treatment items such as dressing supplies used in the client’s care.
unavailable anywhere other than in a hospital or other health
care agency. Some clients are scheduled for nonurgent care, Nursing Admission Activities
such as some types of surgery, on a mutually agreeable date
Preparing the Client’s Room
and time. Most clients, however, see a primary care or emer-
When the admissions department informs the nursing unit
gency department physician just before admission. The phy-
that the client is about to arrive, nurses check the room to
sician advises both the client and the nursing staff to proceed
ensure it is clean and stocked with basic equipment for initial
with the admission process.
care (Box 11-1). They later provide personal care items such
as soap, skin lotion, a toothbrush, toothpaste, razors, paper
The Admitting Department tissues, and denture containers for clients who do not have
In the admitting department, clerical personnel begin to them. They also place oxygen administration equipment, a
gather information from the prospective client or his or her stand for supporting intravenous fluids, and anything else
family. They initiate the medical record with data obtained required at the time of initial treatment.
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B OX 11-1 Basic Room Supplies

Each bedside stand is generally stocked with the following:
• A wash basin
• A soap dish
• An emesis basin
• A water carafe
• A bedpan and a urinal
Welcoming the Client

One of the most important steps in admission is to make the
client feel welcome. On arrival, the admitting nurse greets
the client warmly with a smile and a handshake. He or she
wears a name tag, introduces himself or herself, and also
introduces other clients sharing the room. Being treated
courteously helps relax the client. A client who feels unex-
pected or unwanted is likely to have a poor, and lasting, first
impression of the unit.
Orienting the Client

Orientation (helping a person become familiar with a new
environment) facilitates comfort and adaptation. When ori-
enting a client, the nurse describes the following:
• The location of the nursing station, toilet, shower or bath-
ing area, and lounge available to the client and visitors
• Where to store clothing and personal items
• How to call for nursing assistance from the bed and bathroom
• How to adjust the hospital bed
• How to regulate the room lights
• How to use the telephone and any policy about diverting
incoming calls to the nursing station during the night FIGURE 11-1 An inventory of a client’s personal belongings.
• How to operate the television
• The daily routine such as meal times Losing a client’s personal items can have serious legal
• When the doctor usually visits implications for both the nurse and the health care agency.
• When surgery is scheduled The client may sue, claiming the belongings were lost or sto-
• When laboratory or diagnostic tests are performed len because of careless handling. Therefore, it is best to have
Some hospitals provide booklets with information about a second nurse’s, supervisor’s, or security person’s signature
the agency, such as gift shop hours, newspaper deliveries, on the envelope containing the secured valuables.
and the location of the chapel or name of the chaplain. Such One method for avoiding discrepancies between the
booklets, however, should never replace a nurse’s individu- items entrusted to the nurse and those eventually returned is
alized explanations. to make an inventory (Fig. 11-1), which both the nurse and
the client sign. The nurse gives one copy to the client and
Safeguarding Valuables and Clothing attaches another copy to the chart. When adding items or
Nurses give certain items, such as prescription and nonpre- returning them to the client, the nurse revises the list and the
scription medications, valuable jewelry, and large sums of client signs the new inventory. Problems with theft or loss
money, to family members to take home. If this is not pos- may occur without subsequent documentation.
sible, the nurse must carefully observe the agency’s policies. The nurse identifies client-owned equipment, such as a
Some institutions provide clients who are not expected to stay walker or wheelchair, with a large, easily read label. Labe-
longer than 24 hours with a locker to store personal effects. ling prevents confusing such equipment with that belonging
The nurse may place the clients’ valuables in the hospital’s to the facility. Most agencies have places in the client’s room
safe temporarily. He or she notes in the medical record the for storing street clothing.
type of valuables and how they have been safeguarded. It is Because clients occasionally remove eyeglasses and
best to be as descriptive as possible. For example, rather than dentures, such items may be lost or broken. Generally, the
indicating that the nurse placed a ring in the safe, it is better health care agency is responsible for replacing these items
to describe the type of metal and stones in the ring. if negligence of the staff causes accidental damage or loss.
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Helping the Client Undress Initial Nursing Plan for Care

To facilitate a physical examination, the client must undress. Once all admission data are collected, the nurse develops
If the client cannot undress without the nurse’s help, the an initial plan for the client’s care as soon as possible but
nurse does the following: no later than 24 hours following admission (see Chap. 2).
• Provides privacy. The initial plan generally identifies priority problems and
• Has the client sit on the edge of the bed, which has already includes the client’s projected needs for teaching and dis-
been lowered. charge planning. The nurse revises the care plan as more
• Removes the client’s shoes. data accumulate or if the client’s condition changes.
• Gathers each stocking, sliding it down the leg and over the
Medical Admission Responsibilities
foot.
The nurse notifies the physician once the admission proce-
• Helps the client lie down if weak or tired.
dure is completed. The physician provides medical orders
• Releases fasteners such as zippers and buttons and removes
for medications and other treatments, laboratory and diag-
the item of clothing in whatever way is most comfortable
nostic tests, activity, and diet. He or she also obtains a
and least disturbing. For example, the nurse folds or gath-
medical history and performs a physical examination within
ers a garment and works it up and over the body. He or she
24 hours of admission. The physician may delegate this task
has the client lift the hips to slide clothes up or down.
to another member of the medical team such as a medical
• Lifts the client’s head to guide garments over it.
student, an intern, or a resident.
• Rolls the client from side to side to remove clothes that
The medical history and physical examination gener-
fasten up the front or back.
ally include identifying data, reason for seeking care, his-
• Covers the client with a bath blanket after removing the
tory of present illness, personal history, past health history,
outer clothing, or puts a hospital gown on the client,
family history, review of body systems, and conclusions
explaining that hospital gowns fasten in the back.
(Box 11-2). If the physician is unsure of the actual medical
diagnosis, he or she uses the term rule out or the abbrevia-
Compiling the Nursing Database tion R/O to indicate that the condition is suspected, but addi-
On admission, the nurse begins assessing the client and col- tional diagnostic data must be obtained before confirmation.
lecting information for the database (Fig. 11-2). Although
the registered nurse is responsible for the admission assess- Common Responses to Admission
ment, he or she may delegate some aspects to the practi- Nurses and physicians must remember that no matter how
cal nurse, nursing student, or other ancillary staff. Physical often they have admitted clients, it is a unique and emo-
assessment skills, which include taking vital signs, are dis- tionally traumatic experience for each client. Leaving the
cussed in more depth in Chapters 12 and 13. security of the home and entering an unfamiliar environment
Skill 11-1 describes the basic steps in admitting a client. compound the stress of physical illness and contribute to
Additions or modifications to the procedure depend largely emotional and social distress.
on the client’s condition and agency policies. Although specific responses to admission are unique,
common reactions include anxiety, loneliness, decreased pri-
➧ Stop, Think, and Respond Box 11-1 vacy, and loss of identity. In addition, the nurse may identify
What aspects of admission could the registered nurse one or more of the following nursing diagnoses as a conse-
delegate to a practical nurse, a nursing student, or a quence of admission:
nursing assistant? What are the responsibilities of the
nurse who has delegated admission tasks? • Anxiety
• Fear
• Decisional conflict
• Situational low self-esteem
• Powerlessness
• Social isolation
• Ineffective self-health managment
Anxiety
Anxiety is an uncomfortable feeling caused by insecurity.
The NANDA International (NANDA-I, 2012, p. 344) has
defined it as “a vague uneasy feeling of discomfort or dread
accompanied by an autonomic response (the source is often
nonspecific or unknown to the individual); a feeling of
apprehension caused by anticipation of danger. It is an alert-
ing signal that warns of impending danger and enables the
FIGURE 11-2 Beginning to compile the nursing database. individual to take measures to deal with threat.”
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B OX 11- 2 Components of a Medical History the nursing process when planning the care of a client with
and Physical Examination anxiety.
Identifying Data
• Age, gender, marital status Loneliness
• General appearance Loneliness occurs when a client cannot interact with family
• Circumstances surrounding physician involvement and friends. Although nurses can never replace significant
• Reliability of client as historian others, they act as temporary surrogates and should make
• Others providing information about the client’s history frequent contact with the client. To help combat loneli-
Chief Complaint
ness, many hospitals and nursing homes have adopted
• Reason for seeking care (from client’s perspective) liberal visiting hours. They also are lifting age restrictions
to allow more contact between children and their sick
Present Illness relatives.
• Chronologic description of onset, frequency, and duration of
current signs and symptoms
• Outcomes of earlier attempts at self-treatment and medical Decreased Privacy
treatment Privacy is at a premium in most health care agencies. Provid-
ing private rooms for all hospitalized clients is becoming a
Personal History
trend because of Health Insurance Portability and Account-
• Occupation
• Highest level of education
ability Act (HIPAA) legislation (see Chap. 9). Although most
• Religious affiliation prefer a private room, not all clients have one; in fact, clients
• Residence may have little more than a few feet that they can consider
• Country of origin their personal space. For most, it is stressful to share a room
• Primary language with a stranger. To ensure privacy, the nurse closes room
• Military service doors unless safety issues require observation. Doors may be
• Foreign travel or residence (date, location, length) open at the client’s request, but this results in being observed
Past Health History by many people who pass by at all hours.
• Childhood disease summary Nurses demonstrate respect for and protect each cli-
• Physical injuries ent’s right to privacy. They always shield clients from the
• Major illnesses and surgeries view of others when giving personal care. If a client’s door
• Previous hospitalizations (medical or psychiatric) is closed or the curtains are pulled, the nurse knocks and
• Drug history asks permission to enter. If the health care agency has a
• Alcohol and tobacco use place where clients can find solitude, such as a chapel or
• Allergy history reading room, the nurse includes this information in the
Family History admission orientation.
• Health problems in immediate family members (living and
deceased) ➧ Stop, Think, and Respond Box 11-2
• Longevity and cause of death among deceased blood rela-
tives (especially parents and grandparents) What actions are appropriate if a family member or
significant other chooses to remain with the client
Review of Body Systems after he or she has been escorted to a room on the
• Results of physical examination nursing unit at admission?
Conclusions
• Primary diagnosis (from chief complaint and physical exami- Loss of Identity
nation) Admission to a health care facility may temporarily
• Secondary diagnoses reflecting stable or preexisting condi- deprive a person of his or her identity. For example, clients
tions possibly affecting client’s treatment required to wear hospital gowns tend to look somewhat
alike. As a result, personnel may treat clients imperson-
ally—simply as a face or a warm body with no name. This
attitude makes clients feel like they are receiving care but
Many adults do not manifest their anxiety in obvi- without caring.
ous ways. Observant nurses may note that adults appear Nurses learn and use the client’s name. They use first
sad or worried, are restless, have a reduced appetite, and names only at the client’s request. They encourage clients
have trouble sleeping (see Chap. 5). Because adults have to display pictures or other small personal objects that reaf-
a greater capacity to process information than children, it firm their unique life and personality. Many long-term care
is helpful to acknowledge their uneasiness and to provide facilities urge clients to dress in their own clothing and
explanations and instructions before any new experience. invite them to furnish their rooms with personal items from
Nursing Care Plan 11-1 provides an example of how to use home.
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N U R S I N G C A R E P L A N 1 1 - 1 Anxiety
Assessment If anxiety exists, ask the client to rate the level of anxiety by
• Observe evidence of anxiety such as rapid heart rate, elevated using a scale from 0 to 10, in which 0 represents no anxiety and
blood pressure, sleep disturbance, restlessness, worry, irritabil- 10 represents the most anxiety the client has ever experienced.
ity, facial tension, impaired attention, difficulty concentrating, • Also ask the client to indicate the level at which he or she can
talking excessively, crying, or being withdrawn. tolerate or cope with anxiety.
• Encourage the client to validate observations by asking • Inquire as to methods the client uses to control anxiety when it
open-ended questions such as “How are you feeling now?” exists and the effectiveness of the identified methods.
Nursing Diagnosis. Anxiety related to the perception of danger as evidenced by a heart rate of 92 beats/minute at rest, elevated
blood pressure of 156/92, awareness of feelings of apprehension in the statement, “I feel like a rubber band that’s stretched and ready
to snap,” and rate of 7 as level of emotional discomfort.
Expected Outcome. The client’s anxiety will be reduced to a self-rated level of tolerance of “5.”
Encourage the client to use methods that have successfully Interventions that the client has relied upon and that have had
relieved anxiety in the past. beneficial outcomes can increase the potential for effective-
ness in current and future episodes of anxiety.
Reduce external stimuli such as bright lights, noise, sudden Numerous stimuli escalate anxiety because they interfere with
movement, and unnecessary activity. attention and concentration. Dealing simultaneously with
multiple stimuli can tax the client’s energy and compromise
the ability to cope.
Maintain a calm manner when interacting with the client. People communicate anxiety to one another; an anxious nurse
can increase anxiety in a client. Modeling a controlled state
promotes a similar response in the client.
Take a position at least an arm’s length away from the Invading an anxious client’s personal space may increase his
client. or her discomfort.
Avoid touching the client without first asking permission. An anxious client may misinterpret unexpected touching as
threatening.
Establish trust by being available to the client and keeping Insecurity can be relieved if the client knows he or she can
promises. depend on assistance from the nurse.
Advise the client to seek out the nurse or another The earlier the anxiety is de-escalated, the sooner the client
supportive person when feeling heightened anxiety. will experience relief of symptoms.
Stay with the client during periods of severe anxiety. The nurse’s presence can help the client stay in control or
restore control to a more comfortable level.
Follow a consistent schedule for routine activities. Unpredictability heightens anxiety; consistency helps a client
manage time and cope with personal demands.
Encourage the client to identify what he or she perceives Processing situations verbally may give the client perspective
to be a threat to emotional equilibrium. on perceived threats so that they are more realistic and less
exaggerated.
Use a soft voice, short sentences, and clear messages Anxious clients have a short attention span and reduced abil-
when exchanging information. ity to concentrate; they may be unable to follow lengthy or
complicated information.
Provide specific, succinct directions for tasks the cli- Anxious clients have difficulty following instructions and
ent should complete or assist the client who becomes performing tasks in correct sequence. Assistance relieves
agitated. unnecessary distress.
Instruct and help the client with moderate or severe anxi-
ety to perform one or more of the following until anxiety
is within a tolerable level:
• Count slowly backward from 100. Distraction redirects the client’s attention from distressing
physiologic symptoms to a simple task.
• Breathe slowly and deeply in through the nose and out Slowing respirations aborts hyperventilation and subsequent
through the mouth. potential for fainting, peripheral tingling, and numbness from
respiratory alkalosis.
• Offer a warm bath or back rub. Sitting in warm running water promotes relaxation; massage
relaxes tense muscles and possibly releases endorphins
(natural chemicals that create a feeling of well-being).
(continued)
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NURSING CARE PLAN 11-1 Anxiety ( c o n ti n u e d )
Help the client to progressively relax groups of muscles Consciously relaxing skeletal muscles relieves tension and
from the toes to the head. fatigue.
Suggest that the client repeat positive statements such as, Positive self-talk can be transformed into reality.
“I am relaxed,” “I am in control,” “I am safe.”
Encourage the client to visualize a pleasant, relaxing place. Imagery can transform a person’s aroused state to one that is
more relaxed.
Have the client listen to a relaxation tape or soothing Distraction helps to refocus attention to less anxiety-provoking
music. stimuli.
Advise the client to reduce dietary intake of substances Caffeine is a central nervous system stimulant that contributes
that contain caffeine such as colas and coffee. to the symptoms the client experiences with anxiety.

• The client deals with anxiety-provoking stimuli realistically • The client has extended periods during which his or her anxi-
and implements interventions that reduce anxiety. ety is at a tolerable level.
• The client has a reduced perception of being apprehensive.
THE DISCHARGE PROCESS homes. Discharge planning for older adults should consider
the needs of caregivers, which may include family, friends,
Regardless of where or why clients are admitted, the goal or paid helpers. Delaying discharge planning or teaching
until immediately before the discharge may not meet the
is to keep the admission brief and to discharge clients to
educational needs of older clients and family members,
the home or to another health care facility of their choice as which can result in readmissions.
soon as possible. Discharge (the termination of care from a ■ Resources available to discharged older adults include
health care agency) generally consists of discharge planning, senior centers, adult day care centers, churches, and care
obtaining a written medical order, completing discharge management services. In addition, support and education
instructions, notifying the business office, helping the client may come from advocacy groups such as the Alzheimer’s
leave the agency, writing a summary of the client’s condition Association, Area Councils on Aging, Parkinson’s support
at discharge, and requesting that the room be cleaned. groups, and the American Cancer Society.
■ Barriers to the use of community-based services by older
Discharge Planning adults include the following:
■ Lack of financial assets to pay for services
Discharge planning is a process that improves client out-
■ Reluctance to spend assets for services
comes by (1) predetermining his or her postdischarge needs
■ Unwillingness to acknowledge or accept the need for
in a timely manner and (2) coordinating the use of appro- services
priate community resources to provide a continuum of care. ■ Mistrust of service providers
If effective, discharge planning shortens the hospital stay, ■ Lack of time, energy, or problem-solving ability to
decreases the cost of in-hospital care, reduces the necessity select appropriate services
for readmission, and eases the transition between the hospi-
tal and the next level of care. Discharge planning usually is simple and routine. Cli-
Activities involved in discharge planning, which are ents with one or more of the following characteristics may
incorporated within the plan of care, ideally begin at admis- have special considerations related to discharge planning:
sion or shortly thereafter (Fig. 11-3). Although the discharge
planner may be a nurse consultant or social worker, the plan- • Age older than 75 years
ning often involves a multidisciplinary team of personnel • Multiple, chronic, or terminal health problems
from a skilled intermediate or basic care nursing facility, home • Cognitive impairment, motivational problems, or confusion
health agency, and hospice provider; a physical, occupational, • Inability to perform self-care
or speech therapist; a medical equipment supplier; and others. • Impaired mobility
• Safety risks associated with independent living or that pose
a burden to potential caregivers
Gerontologic Considerations • A treatment regimen involving multiple medications,
dietary management, or complicated medical equipment
■ Early discharge planning and the appropriate use of com- • History of multiple treatments in the emergency depart-
munity resources may return many older adults to their own ment
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Discharge Care Plan
Date & Plan and Outcome Target Nursing Interventions Date

Sign. (check those that apply) Date: (check those that apply) Achieved:
The client/family’s discharge planning Assess needs of client/family beginning

will begin on day of admission including on the day of admission and continue
preparation for education and/or assessment during hospitalization.
equipment.
Anticipated needs/services:
On the day of discharge, the client/
family will receive verbal and written - Respiratory equipment
instructions concerning: - Hospital bed
- Wheelchair
- Medications - Walker
- Diet - Home health nurse
- Activity - Home PT/OT/ST
- Treatment
- Follow-up appointments Involve client/family in the discharge
- Signs and symptoms to process.
observe for (when to
contact the doctor) Discuss with physician the discharge
- Care of incisions, wounds, etc. plan and obtain orders if needed.
Other: Contact appropriate personnel with

orders.
Provide written and verbal instructions

at the client/family’s level of
understanding.
Verbally explain instructions to client/

family prior to discharge and provide
client/family with a written copy.
Ascertain that client has follow-up care

arranged at discharge.
Provide verbal and written information

on what signs and symptoms to
observe and when to contact the
physician.
Assess if any community resources

should be used (i.e., Home Health
Nurse), and contact appropriate
personnel.
Document all discharge teaching on

Discharge Instruction Sheet and
Nursing notes.
Other: _________________________
_______________________________
_______________________________
_______________________________
FIGURE 11-3 A discharge care

_______________________________________________
plan. (Used with permission of Client/Significant other signature
RN Central. Available at: http://
_______________________________________________
www.rncentral.com/careplans/ RN signature
plans/dc. Accessed January 21,
2010.)
Obtaining Authorization for Medical If the client is determined to leave, the nurse asks
Discharge him or her to sign a special form (see Chap. 3). This signed
The physician determines when the client is well enough form may release the physician and agency from future
for discharge. Generally, he or she waits to write the medi- responsibility for any complications. If the client refuses
cal order until after examining the client. Before leaving the to sign, personnel cannot prevent him or her from leav-
nursing unit, the physician writes the discharge order, pro- ing. They note in the client’s medical record, however, that
vides written prescriptions for the client, and indicates when they presented the form and that the client subsequently
and where a follow-up appointment should occur. refused it.
Leaving against medical advice (AMA) is a term that
applies to situations in which the client leaves before the physi- Providing Discharge Instructions
cian authorizes the discharge. Many times, it happens because When the nurse anticipates that a client will be discharged
the client is unhappy with an aspect of care. In some cases, home, he or she establishes the anticipated knowledge, skills,
the nurse may negotiate a compromise or persuade the client and community resources that the client will need to maintain
to delay such action. In the meantime, the nurse informs the a safe level of self-care. One discharge planning technique uses
physician and nursing supervisor of the client’s wish to leave. the acronym METHOD (Table 11-2). The nurse provides the
LWBK1004-C11_p168-186.indd 175 26/01/12 3:06 AM

TABLE 11-2 The METHOD Discharge Planning Guide

TOPIC NURSING ACTIVITY EXAMPLE
M—Medications Instruct the client about drugs that will be self-administered Insulin
E —Environment Explore how the home environment can be modified to ensure the client’s safety Remove scatter rugs
T —Treatments Demonstrate how to perform skills involved in self-care and provide opportunities Dressing changes
for returning the demonstration
H —Health teaching Identify information that is necessary for maintaining or improving health Signs and symptoms of
complications
O —Outpatient referral Explain what community services are available that may ease the client’s transition Physical therapy
to independent living
D —Diet Arrange for the dietitian to provide verbal and written instructions on modifying or Low-fat diet
restricting certain foods or suggestions for altering their methods of preparation
teaching identified in the discharge plan periodically during Escorting the Client
the client’s stay and documents it in the record (see Chap. 8). When the client is ready, the nurse takes him or her to the
Before the client leaves, the nurse reviews teaching that door in a wheelchair or allows the client to walk there with
has been provided, gives the client prescriptions to have assistance. The client may choose to have discharge prescrip-
filled, and advises the client to make an office appointment tions filled at the hospital’s pharmacy before leaving. Gener-
for the date specified by the physician. He or she provides a ally, the nurse remains with the client until he or she is safely
written summary of discharge instructions. The client signs inside a vehicle or waiting in the lobby for a ride. Skill 11-2
and keeps the original; the nurse attaches a copy to the cli- provides a step-by-step description of the discharge process.
ent’s medical record.
Notifying the Business Office What information is helpful to obtain to ensure a safe
Before the client leaves the agency, the nurse notifies the busi- transition from a health agency to self-management
ness office. At that time, clerical personnel verify that all insur- before discharge?
ance information is complete and that the client has signed a
consent form authorizing the release of medical information Writing a Discharge Summary
to the insurance carrier. If records are incomplete or the cli- After the client has left the health care agency, the nurse doc-
ent has no health insurance, the client may be asked to make uments the discharge activities and client’s condition (see
arrangements for future financial payments before discharge. Skill 11-2).
Discharging a Client
When all the preliminary business is complete, the nurse
helps the client gather his or her belongings, plan for trans-
portation, and actually leave the agency.
Gathering Belongings
If necessary, the nurse helps the client to repack personal
items. The nurse uses the inventory of valuables to ensure
that nothing has been lost or forgotten. Because most hos-
pitals dispose of the plastic supplies (eg, basin, bedpan, uri-
nal), the nurse can offer them to the client; otherwise, he or
she discards them in the soiled utility room. A wheeled cart
is helpful to transport the client’s belongings.
Arranging Transportation
The nurse informs clients about the agency’s “check-out
time”—the time before which they can avoid being charged
for another full day. In most cases, the client contacts a fam-
ily member or friend for assistance with transportation. If no
transportation is available, the client may use public trans-
portation, a taxicab, or an ambulance to get home. Van trans-
portation may be available for older adults through the local
Commission on Aging, but 24-hour advance notification is FIGURE 11-4 Transferring a client rapidly may be a life-saving
usually required. measure.
LWBK1004-C11_p168-186.indd 176 26/01/12 3:06 AM

Terminal Cleaning may facilitate more specialized care in a life-threatening situa-

Except in unusual circumstances, housekeeping personnel tion (Fig. 11-4), or it may reduce health care costs. Many hos-
prepare the client’s room for the next admission. They strip pitals are creating stepdown units, progressive care units, or
the bed of linen and clean it with disinfectant, and they restock transitional care units. These units are for clients who were
the bedside cabinet with basic equipment. They then notify the once in a critical or unstable condition but have recovered suf-
admitting department that the unit is ready. These measures ficiently to require less intensive nursing care.
prevent assigning a client to a room that still requires cleaning.
Transfer Activities
Transferring a client to a different nursing unit is less com-
plex than to another agency. In a transfer within the same
THE TRANSFER PROCESS agency, the nurse does the following:
A transfer (discharging a client from one unit or agency and • Informs the client and family about the transfer
admitting him or her to another without going home in the • Completes a transfer summary (a written review of the
interim) may occur when a client’s condition improves or wors- client’s current status) briefly describing the client’s cur-
ens. Generally, a transfer has some advantage for the client. It rent condition and reason for transfer (Fig. 11-5)
FIGURE 11-5 A transfer summary

provides information that pro-
motes continuity of care.
LWBK1004-C11_p168-186.indd 177 26/01/12 3:06 AM

N U R S I N G G U I D E L I N E S 11- 1
Rationales
Transferring a Client
• Be sure to inform the client and the family of the need for a trans- the transfer agency to inform them to momentarily expect
fer as early as possible. Communication promotes cooperation. the fax. Under the revisions to the HIPAA privacy rules
• If time permits and the client and family have some choice, (2002), agencies must systematically protect the client’s per-
encourage them to investigate various facilities and collaborate sonal health information within and outside of the institution.
on the one they prefer. The people most affected should make • Collect all the client’s belongings. Carelessness can lead to
the decisions. the loss of the client’s clothing or valuables and can cause
• Communicate with the agency or unit where the client will inconvenience in returning them.
be transferred. Other personnel need time to prepare for the • Accompany emergency medical staff or paramedics to the
client’s arrival. client’s room. Seeing a familiar face may reduce the client’s
• Make a photocopy of the medical record. A copy aids in conti- anxiety.
nuity of care and avoids duplicating services. • Help transfer the client onto the stretcher. Assistance reduces
• Provide a written clinical résumé, which is a summary of the physical demands on the client.
previous care (see Fig. 11-5). It should include (1) the reason • Give the transfer personnel a copy of the medical record in a
for the hospitalization, (2) significant findings, (3) the treat- folder or envelope. Enclosing the record protects confidential-
ment rendered, (4) the current condition of the client, and ity and prevents loss.
(5) instructions, if any, to the client and family (JCAHO, 1998). • Complete the original medical record by adding a summary
Check that the client has been notified and given consent for of the client’s discharge. Each medical record includes a dis-
the release of his or her personal health information. To comply charge summary.
with privacy rules and data security standards set by HIPAA • Send the completed chart within a file folder to the
in 1996 and further modified in 2001 and 2002 (see Chap. 9), medical records department. All charts are filed for future
the client must be informed and approve the release of health reference.
information among third parties for routine use in treatment. • Notify the business office, admitting office, and housekeeping
• Place the written information in a large manila envelope or department of the client’s transfer. Each department has its
send it via facsimile (fax) machine with a cover sheet. Call own responsibilities when a client leaves.
• Speaks with a nurse on the transfer unit to coordinate the

transfer (the change of shift report in Chap. 9 can be used Gerontologic Considerations
as a model)
• Transports the client and his or her belongings, medica- ■ Approximately 5% of US adults 65 years or older reside
tions, nursing supplies, and chart to the other unit in long-term care facilities. The range of housing options for
older adults is increasing (Table 11-3).
When transferring the client to a nursing home or other
facility, the nurse conducts the process similarly to a dis-
Nursing homes are classified as skilled nursing facilities
charge: the client is discharged from the hospital and admit-
or those that provide intermediate or basic care.
ted to the transfer facility. See Nursing Guidelines 11-1.
Skilled Nursing Facilities
A nursing home licensed as a skilled nursing facility pro-
Gerontologic Considerations vides 24-hour nursing care under the direction of a regis-
tered nurse. The facility is reimbursed for the care of clients
■ When admitting, discharging, or transferring older adults, who require specific technical nursing skills. To qualify for
nurses should allow additional time because of possible skilled care, the client must be referred by a physician and
functional impairments. must require daily skilled nursing care. The following are
examples of common procedures that qualify:
Extended Care Facilities
• Care for a pressure ulcer
Older adults, in particular, may be transferred directly from
• Enteral feedings or intravenous fluids
an acute care hospital to a facility that provides extended
• Bowel or bladder retraining
care (Fig. 11-6). An extended care facility (a health care
• Injectable medications
agency that provides long-term care) is designed for people
• Sterile dressing changes
who do not meet the criteria for hospitalization. Although
• Tracheostomy care
group homes for assisted living, adult day care centers, sen-
ior residential communities, home health care agencies, and Skilled care is provided from a multidisciplinary per-
hospice organizations (see Chap. 38) all fit this description, spective. In addition to a 24-hour team of nurses, a skilled
extended care is generally associated with nursing homes. nursing facility must provide rehabilitation services such as
LWBK1004-C11_p168-186.indd 178 26/01/12 3:06 AM

Distribution of Inpatient Hospital Stays TABLE 11-3 Housing Options for Older Adults
by Discharge Status, 2007*
TYPE DESCRIPTION
Another
short-term Against Shared housing The older person shares a house or
In-hospital hospital medical apartment and living expenses
deaths 2% advice with one or more unrelated people.
2% 1% Foster care or board- The older person lives in a
and-care home residence where an unrelated
person provides a room, meals,
housekeeping, and supervision or
Home health assistance with activities of daily
care living
9% Congregate housing Older adults occupy individual
apartments and receive supportive
services within a multiunit dwelling
Long-term care Retirement Self-sufficient older people live in
and other facilities community owned or rented units within a
12%
residential development exclusively
for retired people
Life care or continuing Older adults live in a residential
Routine care community complex that provides services
74%
and accommodations as each
resident’s needs change
Assisted living facility Older adults live in their own small
apartments and share common
areas for meals and social
activities. These facilities provide
some support and 24-hour
emergency services
39.5 million discharges (Adapted from Miller, C. A. [2008]. Nursing for wellness in older adults [5th
ed.]. Philadelphia: Lippincott Williams & Wilkins.)
FIGURE 11-6 More than 21% of all clients admitted to hospitals
require additional health care services after discharge. (From
Agency for Healthcare Research and Quality. [2009]. HCUP Facts
and Figures: Statistics on Hospital-based Care in the United
States, 2007. Available at: http://www.hcup-us.ahrq.gov/reports/ care and services to people who, because of their mental or
factsandfigures/2007/hcup_partnersV2.jsp. Accessed November physical condition, require institutional care but not 24-hour
20, 2011.) nursing care. Clients who require intermediate care may
need supervision because they tend to wander or are con-
physical therapy and occupational therapy, pharmaceutical fused. They need assistance with oral medications, bathing,
services, dietary services, diversional and therapeutic activi- dressing, toileting, and mobility.
ties, and routine and emergency dental services. Many of the Medicare does not provide reimbursement for interme-
latter services are provided by qualified people on a contrac- diate care. Clients assume the costs. For impoverished resi-
tual basis rather than through full-time employment. dents, state welfare programs, such as Medicaid, will pay.
To qualify for Medicare benefits in a nursing home, a Some nursing homes do not accept Medicaid clients, how-
person must have been hospitalized for three or more days ever, because states fix the fees for reimbursement at much
within 30 days before needing skilled nursing care. Clients lower amounts than Medicare and private insurance provide.
who meet the criteria are eligible for 100 days of assistance Basic Care Facilities
with the costs. There is no charge for the first 20 days; for the A third type of nursing home is a basic care facility (an
next 80 days, Medicare pays most, but not all of the expenses. agency that provides extended custodial care). The emphasis
Some older adults have private insurance policies that is on providing shelter, food, and laundry services in a group
assist with Medicare co-payments. If not, or if clients con- setting. These clients assume much responsibility for their
tinue to require skilled care beyond 100 days, they must bear own activities of daily living such as hygiene and dressing,
the cost personally until they are considered indigent. After preparing for sleep, and joining others for meals. Intermedi-
clients have exhausted their own financial resources and ate and basic care may be provided at a skilled nursing facil-
those of their spouse, they may apply to the state for Medic- ity but usually in separate wings.
aid or its equivalent.
Determining the Level of Care
Intermediate Care Facilities The level of care is determined at or prior to admission. Each
A nursing home also may be licensed as an intermediate client is assessed using a standard form developed by the Health
care facility. This type of agency provides health-related Care Financing Association called a Minimum Data Set for
LWBK1004-C11_p168-186.indd 179 26/01/12 3:07 AM

Nursing Home Resident Assessment and Care Screening. By THE REFERRAL PROCESS
federal law, the MDS is repeated every 3 months or whenever
a client’s condition changes. The MDS requires an assessment A referral is the process of sending someone to another
of the following: person or agency for special services. Referrals generally
• Cognitive patterns are made to private practitioners or community agencies.
• Communication and hearing patterns Table 11-4 lists some common community services to which
• Vision patterns people with declining health, physical disabilities, or special
• Physical functioning and structural problems needs are referred.
• Continence patterns in the last 14 days
• Psychosocial well-being Considering Referrals
• Mood and behavior patterns Considering referrals is part of good discharge planning.
• Activity pursuit patterns For example, a nurse, a case manager, or an agency dis-
• Disease diagnoses charge planner may help refer clients for home health care.
• Health conditions Because planning, coordinating, and communicating take
• Oral and nutritional status time, personnel initiate referrals as soon as possible once a
• Oral and dental status need is identified. Early planning helps to ensure continu-
• Skin condition ity of care (uninterrupted client care despite a change in
• Medication use caregivers), thus avoiding any loss of progress that has been
• Special treatments and procedures made.
Problems identified on the MDS are then reflected in the
nursing care plan.
Selecting a Nursing Home

TABLE 11-4 Common Community Services
When the need arises, family members are often ill-
prepared for selecting a nursing home. A discharge planner ORGANIZATION SERVICE
can assist with arranging nursing home care. Brochures Commission on Aging Assists older adults with
on selection are available from the American Association transportation to medical
of Retired Persons, the Commission on Aging, and each appointments, outpatient
state’s public health and welfare departments. Web sites therapy, and community
meal sites
also provide valuable information. See Client and Family Hospice Supports the family and
Teaching 11-1. terminally ill clients who
choose to stay at home
Visiting Nurses’ Association Offers intermittent nursing care
Client and Family Teaching 11-1 to homebound clients
Selecting a Nursing Home Meals on Wheels Provides one or two hot meals
per day delivered either at
The nurse teaches the client or family to do the following: home or at a community
● Find out the levels of care (skilled, intermediate, or basic) meal site
that the nursing home is licensed to provide. Homemaker Services Sends adults to the home to
● Review inspection reports on each home. This information assist in shopping, meal
preparation, and light
is available from the state’s public health department on a
housekeeping
fee-per-page basis. Home health aides Assist with bathing, hygiene,
● Ask others in the community, including the family physi- and medications
cian, for recommendations. Adult protective services Investigates and pursues
● Visit nursing homes with, and again without, an appoint- accountability of individuals
ment. Go at least once during a meal. who are physically, socially,
● Note the appearance of residents and how staff mem- emotionally, or financially
bers respond to their needs. victimizing vulnerable
● Observe the cleanliness of the surroundings and any adults
Respite care Provides short-term, temporary
unpleasant odors.
relief to full-time caregivers
● Request brochures that identify medical care, nursing
of homebound clients
services, rehabilitation therapy, social services, activities Older Americans’ Ombuds- Investigates and resolves
programs, religious observances, and residents’ rights man complaints made by or on
and privileges. behalf of nursing home
● Clarify charges and billing procedures. residents; at least one
● Analyze if the overall impression of the home is positive full-time ombudsman is
or negative. mandated for each state
LWBK1004-C11_p168-186.indd 180 26/01/12 3:07 AM

2005) (Fig. 11-8). Types of assistance older adults may need

include basic activities of daily living (bathing, dressing, eat-
ing, and getting around the house), preparing meals, shop-
ping, housework, managing money, using the phone, and
taking medications.
■ Medicare requires that a client meet all the following

eligibility criteria for coverage of home care services:
1. A physician has signed or will sign a care plan.
2. The person is homebound. Homebound status is met if
leaving home requires a considerable and taxing effort,
such as needing personal assistance or the help of a
wheelchair, crutches, etc. Occasional but infrequent “walks
around the block” are allowable. Attendance at an adult day
care center or religious services is not an automatic bar to
FIGURE 11-7 A home health care assessment. meeting the homebound requirement.
3. The person needs skilled nursing care or physical or
speech therapy intermittently. Intermittency may vary from
Home Health Care every day to once every 60 days.
Home health care is health care provided in the home by 4. The care must be provided by, or under arrangements
an employee of a home health agency (Fig. 11-7). Public with, a Medicare-certified provider.
■ Some older adults have difficulty accepting help from
agencies (regional, state, or federal, such as the public health
others even though they recognize the need for it. They
department) or private agencies may provide home health
may resist changes related to how they accomplish
care. familiar tasks. Nurses should consider methods to facili-
The number of clients who receive home health care tate required changes and minimize any unnecessary
continues to rise, partly as an outcome of limitations imposed alterations when planning a transition to an institutional
by Medicare and insurance companies on the number of hos- setting.
pital and nursing home days for which they reimburse care.
Another factor is the growing number of chronically ill older
adults in the population in need of assistance. Home care nursing services help shorten the time spent
According to the Administration on Aging (2008), 52% recovering in the hospital, prevent admissions to extended
of older Americans reported having some type of disability. care facilities, and reduce readmissions to acute care facili-
Almost 35% of those over the age of 80 with disabilities ties. Box 11-3 identifies the responsibilities assumed by
need assistance (American Association of Retired Persons, home health nurses who provide community-based care.
50
45
65–74 yr
40
75–84 yr
35
≥ 85 yr
30
25
FIGURE 11-8 The percentage of people 20
with limitations in activities of daily
15
living (ADLs) by age: 2008. (From
Administration on Aging, Department 10
of Health and Human Services. [2008]. 5
A profile of older Americans: 2008.
Available at: http://www.aoa.gov/ 0
Bathing/ Dressing Eating Getting in/out Walking Using
AoARoot/Aging_Statistics/Profile/
Showering of bed/chairs toilet
2008/16.aspx. Accessed January 20,
2010.) Type of ADL
LWBK1004-C11_p168-186.indd 181 26/01/12 3:07 AM

B OX 11- 3 Responsibilities of Home Health 2. Which of the following information is essential for
Nurses the nurse to obtain at the time of a client’s admission
to a health care agency?
• Assess the readiness of the client and the home environment 1. Social security number
• Treat each client with respect regardless of the person’s
2. Medicare status
standard of living
• Identify health or social problems that require nursing, allied 3. Advance directive
health, or supportive care services 4. Health insurance policy
• Plan, coordinate, and monitor home care 3. Which of the following observations is most sugges-
• Give skilled care to clients requiring part-time nursing tive that a newly admitted client is anxious?
services 1. The client is unusually quiet and withdrawn.
• Teach and supervise the client in self-care activities and 2. The client is restless and awakens frequently.
family members who participate in the client’s home care 3. The client eats very little food at each meal.
• Assess the safety of health practices that are being used 4. The client misses his or her spouse and children.
• Observe, evaluate, and modify environmental and social 4. If there is a suspicion that an older adult in the com-
factors that affect the client’s progress
munity is the target of abuse, what agency would be
• Evaluate the urgency and complexity of each client’s
appropriate to contact?
changing health needs
• Keep accurate written records and submit documentation to 1. The Commission on Aging
the agency for the purpose of reimbursement 2. Visiting Nurses Association
• Arrange for referrals to other health care agencies 3. Older Americans’ Ombudsman
• Discharge clients who have reached a level of self-reliance 4. Adult Protective Services
5. Which type of extended care facility referral would
be appropriate for an older adult who needs further
rehabilitation for mobility at the time of discharge
CRITICAL THINKING EXERCISES from an acute care facility?
1. Discuss how the admission of a child might differ 1. Skilled care facility
from that of an adult. 2. Intermediate care facility
2. Compare and contrast admission to a hospital and to 3. Basic care facility
a nursing home. 4. Assisted living facility
3. Describe the criteria you would use when selecting a
nursing home for a relative.
4. If it becomes apparent that a relative cannot continue
to live independently, what options would
you pursue?

1. Which of the following is essential for complying
with federal regulations that ensure the client’s right
to privacy?
1. Addressing clients by their first names only
2. Obtaining consent for releasing information
3. Referring to the client as the person in Room 201
4. Using a code number rather than a name in the
medical record
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SKILL 11-1 Admitting a Client
ASSESSMENT
Obtain the name, admitting diagnosis, and condition of the Provides preliminary data from which to plan the activities that
client and the room to which he or she has been assigned. may be involved in admitting the client.
Check the appearance of the room and the presence of basic Demonstrates concern for cleanliness, order, and client conven-
supplies. ience.
PLANNING
Assemble the needed equipment: admission assessment form, Enhances organization and efficient time management.
thermometer, blood pressure cuff (if not wall mounted),
stethoscope, scale, urine specimen container.
Obtain special equipment, such as an intravenous pole or oxy- Facilitates immediate care of the client without causing unneces-
gen, that may be needed according to the client’s needs. sary delay or discomfort.
Arrange the height of the bed to coordinate with the expected Reduces the physical effort in moving from a wheelchair or
mode of arrival. stretcher to the bed.
Fold the top linen to the bottom of the bed if the client will be Reduces obstacles that may interfere with the client’s comfort
immediately confined to bed. and ease of transfer.
IMPLEMENTATION
Greet the client by name and demonstrate a friendly smile; Promotes feelings of friendliness and personal regard to help
extend a hand as a symbol of welcome. reduce initial anxiety.
Introduce yourself to the client and those who have accompa- Establishes the nurse–client relationship on a personal basis.
nied the client.
Observe the client for signs of acute distress. Determines if the admission process requires modification.
Attend to urgent needs for comfort and breathing. Demonstrates concern for the client’s well-being.
Introduce the client to his or her roommate, if there is one, and Promotes a sense of familiarity to relieve social awkwardness;
anyone else who enters the room. demonstrates concern for the client’s emotional comfort.
Offer the client a chair unless the client requires immediate bed Demonstrates concern for the client’s physical comfort.
rest.
Check the client’s identification bracelet. Enhances safety by accurately identifying the client.
Orient the client to the physical environment of the room and Aids in adapting the client to unfamiliar surroundings.
the nursing unit.
Demonstrate how to use the equipment in the room such as the Promotes comfort and self-reliance; ensures safety.
adjustments for the bed, how to signal for a nurse, and use of
the telephone and television.
Explain the general routines and schedules that are followed for Reduces uncertainty about when to expect activities.
visiting hours, meals, and care.
Explain the need to examine the client and ask personal health Prepares the client for what will follow next.
questions.
Ask if the client would like family members to leave or remain. Promotes a sense of control over decisions and outcomes.
Make provisions for privacy. Demonstrates respect for the client’s dignity.
Request that the client undress and don a hospital or examina- Facilitates physical assessment.
tion gown; assist as necessary.
Ask the client about the need to urinate at the present time, and Shows concern for the client’s immediate comfort; facilitates
obtain a urine specimen if ordered. physical assessment of the abdomen.
Weigh the client before helping him or her into bed. Avoids disturbing the client once settled in bed.
Assist the client to a comfortable position in bed. Shows concern for the client’s comfort; facilitates the examina-
tion.
Take care of the client’s clothing and valuables according to Provides safeguards for the client’s possessions.
agency policy.
Ask the client to identify allergies to food, drugs, or other sub- Aids in preventing the potential for an allergic reaction during
stances and to describe the type of symptoms that accom- care; prepares staff for the manner in which the client reacts to
pany a typical allergic reaction. the allergen.
Apply a second bracelet that is color-coded to the client’s arm Calls staff’s attention to the fact that the client has allergies.
that identifies the client’s allergies.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the direct transmission of microorganisms from the
Chap. 10). nurse’s hands to the client.
Obtain the client’s temperature, pulse, respiratory rate, and Contributes to the initial database assessment.
blood pressure.
Place the signal cord where it can be conveniently reached. Reduces the potential for accidents by ensuring that the client
can make his or her needs known.
(continued)
LWBK1004-C11_p168-186.indd 183 26/01/12 3:07 AM

Admitting a Client (continued)
Make sure the bed is in low position, and follow agency policy Promotes safety. Side rails are considered a form of physical
about raising the side rails on the bed. restraint in a nursing home; their use may require written
permission from the client.
Remove the urine specimen if obtained at this time, attach a Ensures proper identification of the specimen, specifies the test
laboratory request form, and place it in the refrigerator or take to be performed, and prevents changes that may affect test
it to the laboratory. results.
Wash hands or perform hand antisepsis with an alcohol rub (see Removes microorganisms acquired from contact with the client
Chap. 10). or the urine specimen.
Report the progress of the client’s admission to the registered Complies with The Joint Commission standards; the entire admis-
nurse, who may perform the nursing interview and physical sion assessment must be completed within 24 hours; parts of
assessment or delegate components at this time. the assessment may be performed at periodic intervals until it
is completed.
Inform family or friends that they may resume visiting when the Facilitates the client’s network of support.
nursing activities are completed.
Evaluation
• Client is comfortable and oriented to the room and to routines.
• Safety measures are implemented.
• Database assessments are initiated.
• Status and progress are communicated to nursing team.
Document
• Date and time of admission
• Age and gender of client
• Overall appearance
• Mode of arrival to unit
• Room number
• Initial vital signs and weight
• List of allergies, if any; quote the client’s description of a typical reaction or indicate if the client has no allergies by using the abbreviation
NKA (no known allergies) or whatever abbreviation is acceptable
• Disposition of urine specimen
• Present condition of client
Date and Time Sixty-eight-year-old female admitted to Room 258 by wheelchair from admitting dept. with moderate dysp-
nea. O2 running at 2 L per nasal cannula. Weighs 173 lb on bed scale wearing only a hospital gown. T 98.4°,
P 92, R 32, BP 146/68 in R arm while sitting up. Cannot void at present. Allergic to penicillin, which causes
“hives and difficulty breathing.” In high Fowler’s position at this time with a respiratory rate of 24 at rest.
SIGNATURE/TITLE
SKILL 11-2 Discharging a Client
ASSESSMENT
Determine that a medical order has been written. Provides authorization for discharging the client.
Check for written prescriptions and other medical discharge Enables the client to continue self-care.
instructions.
Note if any new medical orders must be carried out before the Ensures that the client will leave in the best possible condition.
client’s discharge.
Review the nursing discharge plan. Determines if the client needs more health teaching or if instruc-
tions have been completed.
(continued)
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Discharging a Client (continued)
PLANNING*
Discuss the client’s time frame for leaving the hospital. Helps coordinate nursing activities within the client’s schedule.
Coordinate the discharge with the home health care agency, Facilitates continuity of care.
hospice organization, or company supplying oxygen or other
medical equipment.
Determine the client’s mode of transportation. Clarifies if the client needs the services of a cab company or
other resource.
*Notify the business office of the client’s impending discharge. Allows time for the clerical department to review the client’s bill-
ing information and determine the necessity for further actions.
*Inform the housekeeping department that the client will be Alerts cleaning staff that the unit will need terminal cleaning.
leaving.
*Cancel any meals that the client will miss after discharge. Avoids wasting food.
*Notify the pharmacy of the approximate time of discharge. Eliminates wasted drugs.
Plan to provide hygiene and medical treatments early. Prevents delays in the client’s departure.
IMPLEMENTATION
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces transmission of microorganisms.
Chap. 10).
Provide for hygiene but omit changing the bed linen. Eliminates unnecessary work.
Complete medical treatment and nursing interventions accord- Promotes continuation of nursing care.
ing to the plan for care.
Help the client dress in street clothing or clothing appropriate for Demonstrates concern for the client’s appearance and appropri-
leaving the agency. ateness for the weather.
Review discharge instructions and complete health teaching. Promotes safe self-care.
Have the client sign the discharge instruction sheet, paraphrase Validates that the client has understood instructions for maintain-
the information it contains, and provide the client with the ing health and can refer to the information at a future time.
original form containing the discharge instructions and pre-
scriptions that should be filled.
Assist the client with packing personal items; if appropriate, Reduces claims that personal items were lost or stolen; signing a
have the client sign the clothing inventory or valuables list. clothing inventory or valuables list is more likely to apply when
a client is discharged from a nursing home or rehabilitation
center.
Obtain a cart for the client’s belongings. Eases the work of transporting multiple or heavy items.
Assist the client into a wheelchair when transportation is avail- Reduces the potential for a fall if the client is weak or unsteady.
able.
Stop, if necessary, at the business office. Complies with billing procedures.
Escort the client to the waiting vehicle. Promotes safety while still in the hospital.
Return any forms from the business office. Confirms that the client has left the hospital.
Replace the wheelchair in its proper location on the nursing unit. Makes equipment available for others to use.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the transmission of microorganisms.
Chap. 10).
Complete a discharge summary in the medical record. Closes the medical record for this admission.
Evaluation
• Health condition is stable (if being transferred in unstable condition, is accompanied by qualified personnel who have the knowledge
and skills to intervene in emergencies).
• Client can paraphrase discharge instructions accurately.
• Business office indicates that billing records are in order.
• Client experiences no injuries during transport from room to vehicle.
Document
• Date and time of discharge
• Condition at the time of discharge
• Include a copy of discharge instructions
• Mode of transportation
• Identity of person(s) who accompanied the client
(continued)
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Discharging a Client (continued)
Date and Time No fever or wound tenderness at this time. Sutures removed. Abdominal incision intact. No dressing applied.
Given prescription for Keflex. Can repeat how many capsules to self-administer per dose, appropriate times
for administration, and possible side effects. Repeated signs and symptoms of infection and the need to
report them immediately. Instructed to shower as usual and temporarily avoid lifting objects over 10 lb. In-
formed to make follow-up appointment in 1 week with physician as indicated on discharge instruction sheet.
Given copy of written discharge instructions. Escorted to automobile in wheelchair accompanied by spouse.
Assisted into private car without any unusual events. ------------------------------------------------------------------ SIGNATURE/TITLE
*Activities marked with asterisk may be delegated to a clerk.
LWBK1004-C11_p168-186.indd 186 26/01/12 3:07 AM

Photo to
Come
FPO
12# Vital Signs
afebrile
afterload On completion of this chapter, the reader should be able to:
antipyretics 1. List four physiologic components measured during
apical heart rate an assessment of vital signs.
apical–radial rate 2. Differentiate between shell and core body temperature.
apnea 3. Identify the two scales used to measure temperature.
arrhythmia 4. List four temperature assessment sites and indicate the sites
auscultatory gap considered the closest to core temperature.
automated monitoring devices 5. Name four types of clinical thermometers.
blood pressure 6. Discuss the difference between fever and hyperthermia.
bradycardia 7. Name the four phases of a fever.
bradypnea 8. List at least four signs or symptoms that accompany a fever.
cardiac output 9. Give two reasons for using an infrared tympanic thermometer
centigrade scale when body temperature is subnormal.
cerumen 10. List at least four signs and symptoms that accompany
clinical thermometers subnormal body temperature.
core temperature 11. Identify three characteristics noted when assessing a client’s
diastolic pressure pulse.
Doppler stethoscope 12. Name the most commonly used site for pulse assessment and
drawdown effect three other assessment techniques that may be used.
dyspnea 13. Explain the difference between systolic and diastolic blood pres-
dysrhythmia sure.
Fahrenheit scale 14. Name and explain at least four terms used to describe
febrile abnormal breathing characteristics.
fever 15. Discuss the physiologic data that can be inferred from a blood
frenulum pressure assessment.
hypertension 16. Name three pieces of equipment for assessing blood
hyperthermia pressure.
hyperventilation 17. Describe the five phases of Korotkoff sounds.
hypotension 18. Identify three alternative techniques for assessing blood
hypothalamus pressure.
hypothermia
hypoventilation
Korotkoff sounds
metabolic rate
V
ital signs (body temperature, pulse rate, respiratory rate, and blood
offsets pressure) are four objective assessment data that indicate how well
orthopnea or how poorly the body is functioning. Pain assessment is considered
orthostatic hypotension a fifth vital sign. A subjective pain assessment is performed at least
palpitation daily and whenever vital signs are taken (see Chap. 20).
piloerection
Vital signs are very sensitive to alterations in physiology; therefore,
postural hypotension
nurses measure them at regular intervals (Box 12-1) or whenever they
preload
pulse determine it is appropriate to assess a client’s health status. This chapter
pulse deficit describes how to obtain each component of the vital signs and explains
pulse pressure what findings indicate based on established norms.
pulse rate
pulse rhythm
187
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pulse volume
pyrexia
respiration
respiratory rate
set point
shell temperature
speculum
sphygmomanometer
stertorous breathing
stethoscope
stridor
systolic pressure
tachycardia
tachypnea
temperature translation
thermistor catheter
thermogenesis
training effect
ventilation
vital signs
white-coat hypertension
BODY TEMPERATURE which core temperature can fluctuate without resulting in

negative outcomes.
Body temperature refers to the warmth of the human body.
Temperature Measurement
Body heat is produced primarily from exercise and metabo-
Physicists studying thermokinetics, or heat in motion, have
lism of food. Heat is lost through the skin, the lungs, and the
developed various scales for measuring heat and cold.
body’s waste products through the processes of radiation,
Some examples include Kelvin (K), Rankine (R), Fahren-
conduction, convection, and evaporation (Table 12-1).
heit (F), and centigrade (C) scales, all of which are based
The body’s shell temperature (warmth at the skin
on increments at which water freezes and boils. The cen-
surface) is usually lower than its core temperature
tigrade temperature scale is also known as Celsius. Health
(warmth in deeper sites within the body like the brain and
care professionals commonly use the Fahrenheit and cen-
heart). Core temperature is much more significant than
tigrade scales.
shell temperature because there is a narrow range within
The Fahrenheit scale (a scale that uses 32°F as the
temperature at which water freezes and 212°F as the point
at which it boils) generally is used in the United States
B OX 1 2 - 1 Recommendations for Measuring to measure and report body temperature. The centigrade
Vital Signs scale (a scale that uses 0°C as the temperature at which
Vital signs are taken: water freezes and 100°C as the point at which it boils)
• On admission, when obtaining database assessments is used more often in scientific research and in countries
• According to written medical orders that use the metric system. Nurses are required to use both
• Once per day when a client is stable scales occasionally and to convert between the two meas-
• At least every 4 hours when one or more vital signs are urements (Box 12-2).
abnormal
• Every 5 to 15 minutes when a client is unstable or at risk
Normal Body Temperature
for rapid physiologic changes such as after surgery
In normal, healthy adults, shell temperature generally ranges
• Whenever a client’s condition appears to have changed
• A second time, or more frequently, when there is a signifi- from 96.6° to 99.3°F or 35.8° to 37.4°C (Porth & Matfin,
cant difference from the previous measurement 2008). Core body temperature, according to Nicholl (2002),
• When a client is feeling unusual ranges from 97.5° to 100.4°F (36.4° to 37.3°C). If a client’s
• Before, during, and after a blood transfusion temperature is above or below normal, the nurse records and
• Before administering medications that affect any of the reports the temperature, implements nursing and medical
vital signs and after to monitor the drug’s effect interventions for restoring a normal body temperature when
appropriate, and reassesses the client frequently.
188
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CHAPTER 12 Vital Signs 189
TABLE 12-1 Mechanisms of Heat Transfer

RADIATION CONVECTION EVAPORATION CONDUCTION
Definition The diffusion or The dissemination of heat The conversion of a liquid The transfer of heat to
dissemination of heat by motion between to a vapor. another object during
by electromagnetic areas of unequal density. direct contact.
waves.
Example The body gives off An oscillating fan blows Body fluid in the form of The body transfers heat to
waves of heat from currents of cool air perspiration and insen- an ice pack, causing the
uncovered surfaces. across the surface of a sible loss is vaporized ice to melt.
warm body. from the skin.
Illustration
Gerontologic Considerations various structural and physiologic adaptations keep their

body temperature within a narrow stable range regardless of
■ Older adults tend to have lower “normal” or baseline the environmental temperature.
temperatures; therefore, a temperature in the normal range In humans, the hypothalamus (a structure within the
may actually be elevated for an older adult. An older per- brain that helps control various metabolic activities) acts as
son’s usual temperature should be assessed and docu- the center for temperature regulation. The anterior hypotha-
mented to enable accurate comparison when assessing for lamus promotes heat loss through vasodilation and sweating.
elevations. Nevertheless, with changes in an older adult’s The posterior hypothalamus promotes two functions: heat
thermoregulation system, temperature elevations may not conservation and heat production. It produces heat conser-
accompany infections. vation in the following ways:
1. Adjusting where blood circulates
Temperature Regulation 2. Causing piloerection (the contraction of arrector pili
The temperature of poikilothermic animals, such as reptiles, muscles in skin follicles), which stiffens body hairs and
fluctuates widely depending on environmental tempera- gives the appearance of what commonly is described as
ture. Humans, on the other hand, are homeothermic; that is, “goose flesh”
3. Promoting a shivering response
The hypothalamus promotes heat production by increas-
B OX 1 2 - 2 Temperature Conversion Formulas ing metabolism through secretion of thyroid hormone as well
as epinephrine and norepinephrine from the adrenal medulla.
To convert Fahrenheit to centigrade, use the formula: When functioning appropriately, the hypothalamus
(° F − 32) maintains the core temperature set point (an optimal body
°C =
1.8 temperature) within 1°C by responding to slight changes in
the skin surface and blood temperatures. Other physiologic
Example: Step 1: 98.6⬚F ⫺ 32 ⫽ 66.6 responses accompany the temperature-regulating mecha-
Step 2: 66.6 ⫼ 1.8 ⫽ 37⬚C
nisms of the hypothalamus, as shown in Figure 12-1.
To convert centigrade to Fahrenheit, use the formula: Temperatures above 105.8°F (41°C) and below 93.2°F
⬚F ⫽ (⬚C ⫻ 1.8) ⫹ 32 (34°C) indicate impairment of the hypothalamic regulatory
center. According to Porth and Matfin (2008), the chance
Example: Step 1: 15⬚C ⫻ 1.8 ⫽ 27
of survival is diminished when body temperatures exceed
Step 2: 27 + 32 ⫽ 59⬚F
110°F (43.3°C) or fall below 84°F (28.8°C).
LWBK1004-C12_p187-226.indd 189 26/01/12 3:07 AM

Climate
Climate affects mechanisms for temperature regulation.
Heat and cold produce neurosensory stimulation of thermal
receptors in the skin, which transmit information through the
autonomic nervous system to the hypothalamus. Cool envi-
ronmental temperatures result in vasoconstriction of surface
blood vessels with subsequent shunting of blood to vital
35.8
organs. This physiologic phenomenon helps to explain how
brain cells are protected temporarily in cold-water drown-
ings.
Mechanisms Mechanisms
for for People who live in predominately cold climates have
Heat Production Heat Loss more brown adipocytes (fat cells uniquely adapted for ther-
mogenesis) (Austgen & Bowen, 2009). Thermogenesis from
brown fat occurs when norepinephrine triggers lipolysis
(the breakdown of fat). Those who live in arctic regions are
highly cold adaptive because they have increased brown adi-
pocytes. They tend to have an overall 10% to 20% higher
FIGURE 12-1 The hypothalamus regulates body temperature. metabolic rate compared with those who live in geographic
areas with less severe environmental temperatures (Lichten-
belt et al., 2009; Iatropoulos & Williams, 2004). Conversely,
Factors Affecting Body Temperature those who live in the tropics have a 10% to 20% lower meta-
Various factors affect body temperature. Examples include bolic rate than those in milder climates.
food intake, age, climate, gender, exercise and activ-
ity, circadian rhythm, emotions, illness or injury, and Gender
medications. Body temperature increases slightly in women of childbear-
ing age during ovulation. This probably results from hormo-
Food Intake nal changes affecting metabolism or tissue injury and repair
Food intake, or lack of it, affects thermogenesis (heat pro- after the release of an ovum (egg). The change in body
duction). When a person consumes food, the body requires temperature is so slight that most women are unaware of it
energy to digest, absorb, transport, metabolize, and store unless they are monitoring their temperature daily (to plan
nutrients. The process is sometimes described as the specific or avoid pregnancy).
dynamic action of food or the thermic effect of food because
it produces heat. Protein foods have the greatest thermic Exercise and Activity
effect. Thus, both the amount and the type of food eaten Both exercise and activity involve muscle contraction. As
affect body temperature. Dietary restrictions can contribute muscle groups and tendons repeatedly stretch and recoil, the
to decreased body heat as a result of reduced processing of friction produces body heat. Shivering is another example of
nutrients. contractile thermogenesis.
Muscles also are the largest mass of metabolically
Age active tissue. This means that muscle activity generates
Infants and older adults have difficulty maintaining normal additional heat from chemical reactions during the muscle
body temperature for several reasons. Both have limited cells’ combustion of nutrients for cellular functions. To pro-
subcutaneous white adipocytes (fat cells that provide heat vide adequate calories that will give the energy necessary for
insulation and cushioning of internal structures). The ability muscle activity, the body adjusts its metabolic rate through
of both young and old to shiver and perspire also may be endocrine hormones released from the pituitary, thyroid, and
inadequate, putting them at risk for abnormally low or high adrenal glands. In contrast, inactivity and reduced metabo-
body temperatures. Another problem for both populations is lism or nutrient intake may lead to a lower body temperature.
an inability to independently forestall or reverse heat loss or
gain without the assistance of a caretaker. Circadian Rhythm
Newborns and young infants tend to experience tem- Circadian rhythms are physiologic changes, such as fluctua-
perature fluctuations because they have a three times greater tions in body temperature and other vital signs, over 24-hour
surface area from which heat is lost (Nicholl, 2002) and a cycles. Body temperature fluctuates from 0.5° to 2.0°F
metabolic rate (use of calories for sustaining body func- (0.28° to 1.1°C) during a 24-hour period. It tends to be
tions) twice that of adults. Older adults are compromised lowest from midnight to dawn and highest in the late after-
further by progressively impaired circulation, which inter- noon to early evening. People who routinely work at night
feres with losing or retaining heat through the dilation or and sleep during the day have temperature fluctuations that
constriction of blood vessels near the skin. cycle in reverse.
LWBK1004-C12_p187-226.indd 190 26/01/12 3:07 AM

Emotions TABLE 12-2 Equivalent Thermometer

Emotions affect metabolic rate by triggering hormonal Measurements According to Site
changes through the sympathetic and parasympathetic path- ASSESSMENT SITE FAHRENHEIT CENTIGRADE
ways of the autonomic nervous system (see Chap. 5). People
Oral 98.6⬚ 37.0⬚
who tend to be consistently anxious and nervous are likely to
Rectal equivalent 99.5⬚ 37.5⬚
have slightly increased body temperatures. Conversely, peo- Axillary equivalent 97.5⬚ 36.4⬚
ple who are apathetic or depressed are prone to have slightly Tympanic membrane 99.5⬚ 37.5⬚
lower body temperatures. Temporal artery 99.4⬚ 37.4⬚
Illness or Injury Rectal and arterial temperatures are generally 1⬚F (0.5⬚C) higher than oral
temperatures and 2⬚F (1⬚C) higher than axillary temperatures; axillary temper-
Diseases, disorders, or injuries that affect the function of ature is lower than any measured site. Report the temperature and site used.
the hypothalamus or mechanisms for heat production and
loss alter body temperature, sometimes dramatically. Some
examples include tissue injury, infections and inflammatory arteries containing warm blood, enclosed areas where heat loss
disorders, fluid loss, injury to the skin, impaired circulation, is minimal, or both. Of the four sites, the ear is the peripheral
and head injury. site that most closely reflects core body temperature.
Temperature measurements vary slightly depending on
the assessment site (Table 12-2). To evaluate trends in body
Gerontologic Considerations temperature, the nurse documents the assessment site as O
for oral, R for rectal, AX for axillary, and T for tympanic
■ Some older adults have a delayed and diminished febrile membrane, and TA for temporal artery. He or she takes the
response to illnesses. A careful assessment is essential to temperature by the same route each time.
identify temperature elevations or disease symptoms other
than increased temperature. Often, a change in cognitive The Ear
function, restlessness, or anxiety are initial signs of illness. Research indicates that the temperature within the ear near the
tympanic membrane and behind the ear over the path of the
Medications temporal artery have the closest correlation to core temperature.
Various medications affect body temperature by increas-
Tympanic Membrane Thermometry
ing or decreasing metabolic rate and energy requirements.
The tympanic membrane is just 1.4 in. (3.8 cm) from the
Drugs, such as aspirin, acetaminophen, and ibuprofen,
hypothalamus; blood from the internal and external carotid
directly lower body temperature by acting on the hypotha-
arteries, the same vessels that supply the hypothalamus, also
lamus itself. In the absence of fever, however, their use will
warms the tympanic membrane. For these reasons, tempera-
not lower body temperature to subnormal levels. Stimulant
tures obtained at this site, if the thermometer is inserted cor-
drugs, like those containing dextroamphetamine (Dexedrine)
rectly (Fig. 12-2), are considered more reliable than those
or ephedrine, increase metabolic rate and body temperature.

Explain how infants and older adults are particularly Probe tip
vulnerable to alterations in temperature regulation.
Ear canal
Assessment Sites
Body temperature can be assessed at various locations, some
of which are more practical than others. The most accurate
locations for measuring core body temperature are the brain, 36.9
heart, lower third of the esophagus, and the urinary bladder. 37.3
Measuring the temperature in the brain is currently prohibitive
36.6
because of a lack of technology. The temperature of blood cir- 34.5
culating through the heart, esophagus, or bladder is measured
using a thermistor catheter (heat-sensing device at the tip of
an internally placed tube). The required skill for insertion and Tympanic
risks associated with the use of thermistor catheters, however, membrane
restricts their use to clients with highly acute illnesses.
The most practical and convenient temperature assess-
ment sites are the ear (tympanic membrane and temporal FIGURE 12-2 Obtain the most accurate tympanic temperature
artery on the forehead and behind the ear lobe), mouth, rectum, by aiming the probe toward the anterior inferior third of the
and axilla. These areas are anatomically close to superficial ear canal.
LWBK1004-C12_p187-226.indd 191 26/01/12 3:07 AM

obtained at the oral and axillary sites. They also correlate

closely with those taken at the rectal site. Also, because the 36.88 36.77
tympanic membrane is fairly deep within the head, warm or
cool air temperatures affect it less.
X X
Temporal Artery Thermometry
The superficial branch of the temporal artery, which receives
36.88 36.77
blood from the aorta, lies less than 2 mm below the skin sur-
face at the forehead. Because of this anatomic relationship, 36.66 36.66
the temperature of blood flowing through the temporal artery
is analogous to the temperature of blood within the heart, 36.33 36.22
that is, core body temperature. In research studies, tempera- 36.0
tures measured with an infrared temporal artery thermom- 36.66 36.77
eter demonstrated measurements that were more accurate 36.0
than the tympanic membrane thermometry; as accurate, or
more so, than rectal measurements; interchangeable with
esophageal probes; and similar to measurements obtained
with pulmonary artery catheters (Medical News Today, 2007; FIGURE 12-3 Temperature measurements vary with the
placement of the oral thermometer. A thermometer placed
Pompei & Pompei, 2004). Besides its accuracy, the tempo-
at the rear sublingual pockets provides the most accurate
ral artery thermometer is the most noninvasive device when measurement.
compared with others because it scans the artery at the skin
surface, poses no risk for injury, and is suitable for nearly
all ages. However, continuing research is reporting mixed Axillary Site
reviews concerning the use of these thermometers in certain The axilla, or underarm, is an alternative site for assessing
populations (Holzhauer et al., 2009; Langham et al., 2009; body temperature. Temperature measurements from this site
Marable et al., 2009). Before adopting their use universally, are generally 1°F (0.6°C) lower than those obtained at the
practitioners should investigate continuing scientific data. oral site and reflect shell rather than core temperature (except
in newborns). Because infants can be injured internally with
Oral Site rectal thermometers and because they lose heat through their
The oral site, or mouth, is convenient. It generally measures skin at a greater rate than other age groups, the axilla and the
temperatures 0.8° to 1.0°F (0.5° to 0.6°C) below the core groin, areas where there is skin-to-skin contact, have tradi-
temperature. The area under the tongue is in direct proximity tionally been the preferred sites for temperature assessment
to the sublingual artery. As long as the client keeps the mouth in this age group.
closed and breathes normally, the tissue remains at a fairly The axillary site has several advantages for all age
consistent temperature. Valid measurement also depends on groups. It is readily accessible in most instances. It is safe.
accurate placement and maintenance of an oral thermometer There is less potential for spreading microorganisms than
in the rear sublingual pocket at the base of the tongue (Fig. with the oral and rectal sites, and it is less disturbing psycho-
12-3). Poor placement or premature removal of the ther- logically than the rectal site. This route, however, requires the
mometer can result in inaccurate measurements, deviating longest assessment time of 5 minutes or longer depending on
by as much as 1.5°F (0.9°C) from the actual temperature. the electronic monitoring mode being used (discussed later).
The oral site is contraindicated for clients who are uncoop- Poor circulation, recent bathing, or rubbing the axillary area
erative, very young, unconscious, shivering, prone to seizures, dry with a towel also affects the accuracy of the axillary site.
or mouth breathers; those who have had oral surgery; and those
who continue to talk during temperature assessment. To ensure Thermometers
accuracy, the nurse delays the oral temperature assessment There are several types of clinical thermometers (instru-
for at least 30 minutes after the client has been chewing gum, ments used to measure body temperature): electronic, infra-
smoking a cigarette, or eating hot or cold food or beverages. red, chemical, digital, and glass (Table 12-3).
Rectal Site Electronic Thermometers

A rectal temperature differs only about 0.2°F (0.1°C) from An electronic thermometer (Fig. 12-4) uses a temperature-
the core temperature. Rapid fluctuations in temperature may sensitive probe covered with a disposable sheath attached by
not be identified for as long as 1 hour, however, because this a coiled wire to a display unit. Electronic thermometers are
area retains heat longer than other sites. In addition, this site portable. They are recharged when not in use.
can be embarrassing and emotionally traumatic for alert cli- Electronic thermometers generally have two types of
ents. Furthermore, stool in the rectum, improper placement probes: one for oral or axillary use and the other for rectal
of the thermometer, and premature removal affect the accu- use. Some models offer the option of providing the measure-
racy of rectal temperature assessment. ment in Fahrenheit or centigrade.
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TABLE 12-3 Types of Clinical Thermometers

TYPE ADVANTAGES DISADVANTAGES
Electronic Faster than glass Expensive
Accurate Recharging is necessary
No sterilization or disinfection needed Probe needs to be held by the client or nurse
Easy to use Interference with simultaneously taking the client’s pulse
while holding the probe with one hand and unit in the other
Infrared Fast Expensive in comparison with others
(tympanic) Convenient Battery recharging is necessary
Close approximation of core temperature Accuracy is affected by improper placement and probe size
Less invasive Actual ear and core temperature ranges are slightly different
Accuracy unaffected by eating, drinking, or breathing from oral, rectal, and axillary sites
Sanitary Tip requires cleaning with a paper tissue or alcohol swab
Extreme hot or cold environmental temperatures may
affect electronics
No sterilization or disinfection is required
Infrared (tem- Closest approximate of core temperature User error if the thermometer is moved too quickly across
poral artery) Most sanitary the skin
Most convenient for clients Hair, clothing, or bandages between the probe and the
Records within 2 seconds skin can result in falsely high readings
Initial cost is similar to other types of electronic and Infrared probe requires cleaning between uses with an
tympanic membrane thermometers alcohol prep pad and dry swab
Probe covers are not needed; decreases volume of
disposal waste
Can be used over the femoral artery or lateral thoracic
artery if the temporal artery is inaccessible due to
bandaging or trauma
Chemical Inexpensive Varying measurements at different body sites depending
Safe; nonbreakable on blood flow and room temperature
Sanitary
Temperature registers in approximately 45 seconds to
3 minutes
Resets in 30 seconds
Cleans easily in hot soapy water
Easily used by untrained people
Digital Inexpensive Requires a battery (1.55 V)
Safe; no glass to break or potential mercury spill Accuracy of ⫾0.2⬚F compared with glass thermometer at
Memory displays last temperature 95–102.2⬚F
Fast; records in 1–3 minutes Accuracy is ⫾0.4⬚F compared with glass thermometer at
Audible signal during or after assessment <95 or >102.2⬚F
Automatic shut-off to prolong battery
Battery life of 200 hours
Water resistant, which facilitates cleaning
Large, lighted numerical display for ease of reading
Glass Inexpensive Breakable
Small Difficult to read
Portable Cleaning necessary before use by another client
Cannot sterilize using heat
Time-consuming
Accuracy affected by eating, drinking, smoking, talking,
mouth breathing, stool in rectum, vasoconstriction of
skin and mucous membranes
Porous; possible inaccuracy from mercury evaporation
High risk for injury if broken during use
Environmental pollution from mercury is possible if not
properly disposed
LWBK1004-C12_p187-226.indd 193 26/01/12 3:07 AM

A tympanic membrane thermometer converts the heat

it detects into a temperature measurement in 2 to 5 seconds.
The potential for transferring microorganisms from one cli-
ent to another is reduced because the probe cover is changed
after each use and because the ear does not contain mucous
membranes or their accompanying secretions.
Despite the advantages of tympanic thermometers,
infrared thermometers can produce inaccurate measure-
ments in the following circumstances:
• The ear canal is not straightened appropriately.
• The probe, which measures 6 to 8 mm, is too large for the
ear canal (a problem with infants and small children
whose ear canals are 5 mm or smaller). The size differ-
ence alters the location where infrared light must be
precisely directed. Consequently, use of a tympanic
thermometer is contraindicated for children younger than
FIGURE 12-4 An electronic thermometer. (Copyright B. Proud.) 2 years.
• The sensor is directed at the ear canal rather than directly
Electronic thermometers operate in either a predictive at the tympanic membrane.
mode or a monitor mode. If used in the predictive mode, the • There is impacted cerumen (ear wax), a common problem
thermometer takes multiple measurements that a computer among older adults.
chip processes in only a few seconds to determine what • There is fluid behind the tympanic membrane, a problem
the temperature would be if the thermometer was left in that occurs with middle-ear infections.
place for several minutes. The monitor mode requires that • The drawdown effect (cooling of the ear when it comes in
the thermometer remain at the assessment site for a longer, contact with the probe) occurs.
more steady time to obtain the actual temperature. There is no The first use of a tympanic thermometer after recharg-
significant difference in temperature measurements obtained ing is not always as accurate as a second reading. Another
by the predictive versus the monitor mode (Nicholl, 2002). criticism of the tympanic temperature measurement is that
The electronic unit senses when the temperature ceases to currently there is no standard for actual ear or core tem-
change and emits a beep. The audible signal alerts the nurse peratures. At present, tympanic thermometers use internally
to remove the probe and read the displayed measurement. calculated offsets (predictive mathematical conversions)
for oral and rectal temperatures. These offsets vary among
Infrared (Tympanic) Thermometers manufacturers.
An infrared tympanic thermometer is a battery-operated
device that contains an infrared sensor for detecting the Infrared Temporal Artery Thermometer
warmth radiating from the tympanic membrane (eardrum) The temporal artery thermometer (Fig. 12-6) contains an
when a handheld covered probe is inserted into the ear canal infrared sensor that uses computerized algorithms to com-
(Fig. 12-5). When not in use, it rests in a base-charging unit, pute temperature measurements. It does so by calculating
referred to as its cradle.
FIGURE 12-5 An infrared tympanic thermometer. (Copyright B.

Proud.) FIGURE 12-6 A temporal artery thermometer.
LWBK1004-C12_p187-226.indd 194 26/01/12 3:07 AM


Rationales
Using a Temporal Artery Thermometer
• Perform hand hygiene. • Slide the probe to the depression behind the ear lobe.
• Place the probe at the center of the forehead. • Release the button.
• Depress the sensing button on the thermometer throughout the • Read and record the displayed temperature.
procedure. • Wait 30 seconds if a sequential measurement is needed or use
• Slide the thermometer laterally across the forehead to the the opposite side.
hairline. • Clean the thermometer probe with an alcohol pad and a dry swab.
• Lift the probe while keeping the button depressed. • Replace the 9 V alkaline battery when “BATT” display
• Relocate the probe behind the ear. indicates the battery is low.
the difference between the heat radiating from the tempo- 109th Congress, 2002, 2005). Health care institutions are
ral artery at the center of the forehead and the heat loss at making their facilities mercury free.
the skin. Because there may be evaporative cooling on the Nurses may be required to use a client’s glass thermom-
exposed skin on the forehead, the thermometer is secondar- eter or to teach a client to use one because that is all the client
ily moved to scan the skin behind the ear lobe, which tends to has available. If a glass thermometer is the only option, the
remain relatively dry (Nursing Guidelines 12-1). An assess- nurse teaches clients and their family members how to clean
ment over the temporal artery alone is sufficient for infants. the glass thermometer (see Client and Family Teaching 12-1).
If a glass thermometer breaks, the mercury is disposed of
Glass Thermometers following the actions discussed in Nursing Guidelines 12-2.
Electronic and infrared tympanic thermometers have
replaced glass mercury thermometers in health care agen- Chemical Thermometers
cies. Glass thermometers contain mercury and are consid- Various chemical thermometers are available. One exam-
ered environmentally toxic and obsolete because safer alter- ple is a paper or plastic strip with chemically treated dots
natives are available and preferred. (Fig. 12-7). The temperature is determined by noting how
The Mercury Reduction Act, passed in 2002 and many dots change color after the strip is held in the mouth.
amended in 2005, prohibits the sale or supply of mercury Chemical dot thermometers are discarded after one use. They
fever thermometers to consumers, except by prescription. It are used to assess the temperature of clients who require iso-
further requires manufacturers to provide clear instructions lation precautions for infectious diseases. Their use elimi-
on handling mercury thermometers to avoid breakage and nates the need to clean a multiuse electronic or infrared ther-
proper cleanup in the event of a breakage (United States mometer. Some physician’s offices also use chemical dot
thermometers because they are disposable.
A second type of chemical thermometer is made of
Client and Family Teaching 12-1 heat-sensitive tape or patch applied to the abdomen or fore-
Cleaning Glass Thermometers head (Fig. 12-8). The tape or patch changes color according
The nurse teaches the client or the family the following:
to body temperature. Heat-sensitive tapes and patches can be
reused several times before being thrown away.
● Don gloves if there is the potential for contact with blood
or stool (as with a rectal assessment).
● Hold the thermometer at the tip of the stem. Keep the
bulb downward and away from your hand.
● Using a firm twisting motion and a clean, soft tissue,
wipe the soiled thermometer toward the bulb.
● Wash the thermometer with soap or detergent solution,
again using friction, while holding the thermometer over
a towel or other soft material to reduce the potential for
breaking if dropped.
● Rinse the thermometer under cold running water.
● Dry the thermometer with a soft towel.
● Soak the thermometer in 70% to 90% isopropyl alcohol
or a 1:10 solution of household bleach (1 part bleach to 10
parts water).
● Rinse the thermometer after disinfecting it.
● Store the thermometer in a clean, dry container.
FIGURE 12-7 A chemical thermometer.
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Rationales
Disposing of Heavy Metals Safely
• Don gloves. • Seal the mercury in a glass or plastic jar or sturdy plastic bag.
• Pick up shards of glass and place in a puncture-resistant • Affix a label identifying the contents as “mercury spill debris.”
container. • Deliver the mercury spill debris to the waste manager of
• Use an index card to pool the droplets of mercury. the health care institution or the county public health
• Collect the droplets with a syringe, pipette, adhesive tape, or department (Princeton University Environmental Health and
wet paper towel. Safety, 2004).
Digital Thermometers Continuous Monitoring Devices

A plastic digital thermometer looks similar to a glass ther- Continuous temperature monitoring devices are used prima-
mometer (Fig. 12-9) and can be used at oral, axillary, and rily in critical care areas. They measure body temperature
rectal sites. It has a sensing tip at the end of the stem, an on/ using internal thermistor probes within the esophagus of
off button, and a display area that lights up during use. The anesthetized clients, inside the bladder, or attached to a pul-
battery used to operate the thermometer requires occasional monary artery catheter. These measurements are generally
replacement. required when caring for clients with extreme hypothermia
Digital thermometers are designed for multiple uses; for or hyperthermia. Warming or cooling blankets are also gen-
this reason, they require cleaning after use. Digital thermom- erally used at the same time (see Chap. 28). Temperature
eters are cleaned similarly to glass thermometers except that assessments aid in evaluating the effectiveness of these treat-
they are wiped rather than soaked with isopropyl alcohol. ment devices.
Disposable plastic sheaths can be used to cover the probe Skill 12-1 describes how to assess body temperature
with each use as an alternative sanitary measure. using electronic, infrared tympanic membrane, and glass
thermometers. Some agencies also use automated and con-
Automated Monitoring Devices tinuous monitoring devices.
Some agencies use automated monitoring devices (equip-
ment that allows for the simultaneous collection of multiple ➧ Stop, Think, and Respond Box 12-2
data). They may measure the temperature, blood pressure,
When caring for an older adult who has chronic
and pulse, as well as other information such as heart rhythm
disorders but is currently stable, what type of
and pulse oximetry (Fig. 12-10). Some models can store and thermometer and site is best for a temperature
display the trends in vital signs. Their chief advantage is that assessment? Explain your choice.
they save time and money. Agencies favor the use of auto-
mated monitors for potentially unstable clients who require
frequent assessments. To ensure reliable data, the accuracy Elevated Body Temperature
of automated devices is compared with data measured with A fever (a body temperature that exceeds 99.3°F [37.4°C])
manual devices on a regular basis. is a common indication of illness. Pyrexia (Greek word for
FIGURE 12-8 A disposable chemical thermometer with heat- FIGURE 12-9 A digital thermometer is a nonmercury alterna-
sensitive liquid crystals. (Photo by B. Proud.) tive considered as accurate as a glass mercury thermometer.
LWBK1004-C12_p187-226.indd 196 26/01/12 3:07 AM

• Convulsions in infants and children (when the temperature

is very high)
• Fever blisters around the nose or lips in clients who harbor
the herpes simplex virus
Hyperthermia (excessively high core temperature)
describes a state in which the temperature exceeds 105.8°F
(40.6°C). At this level, the person is at extremely high risk
for brain damage or death from complications associated
with increased metabolic demands.
Phases of a Fever
A fever generally progresses through four distinct phases:
FIGURE 12-10 An automated monitoring device. (Photo by B. 1. Prodromal phase: The client has nonspecific symptoms
Proud.) just before the temperature rises.
2. Onset or invasion phase: Obvious mechanisms for
fire) is a term used to describe a warmer-than-normal set increasing body temperature, such as shivering, develop.
point. A person with a fever is said to be febrile (a condition 3. Stationary phase: The fever is sustained.
in which the temperature is elevated) as opposed to afebrile 4. Resolution or defervescence phase: The temperature
(no fever). returns to normal (Fig. 12-11).
The following are common signs and symptoms associ- Common variations in fever patterns are described in
ated with a fever: Table 12-4. Fevers also subside in different ways. If an ele-
• Pinkish, red (flushed) skin that is warm to the touch vated temperature suddenly drops to normal, it is referred
• Restlessness or, in others, excessive sleepiness to as a resolution by crisis. If the descent is gradual, it is
• Irritability referred to as a resolution lysis.
• Poor appetite
• Glassy eyes and a sensitivity to light Nursing Management
• Increased perspiration A fever is considered an important body defense for destroy-
• Headache ing infectious microorganisms. Therefore, as long as a fever
• Above-normal pulse and respiratory rates remains below 102°F (38.9°C) and the person does not have
• Disorientation and confusion (when the temperature is a chronic medical condition, fluids or rest may be all that is
very high) necessary.
FIGURE 12-11 Phases of a fever and physiologic changes.
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TABLE 12-4 Variations in Fever Patterns thermometers do not have the capacity to measure tempera-
TYPE OF FEVER DESCRIPTION
tures in hypothermic ranges. Second, the blood flow in the
mouth, rectum, or axillae generally is so reduced that meas-
Sustained fever Remains elevated with little fluctuation
urements taken from these sites are inaccurate.
Remittent fever Fluctuates several degrees but never
reaches normal between fluctuations
The following are common signs and symptoms associ-
Intermittent fever Cycles frequently between periods of ated with hypothermia:
normal or subnormal temperatures and
spikes of fever
• Shivering until body temperature is extremely low
Relapsing fever Recurs after a brief but sustained period • Pale, cool, and puffy skin
during which temperature has been • Impaired muscle coordination
normal • Listlessness
• Slow pulse and respiratory rates
• Irregular heart rhythm
• Decreased ability to think coherently and use good judgment
Pharmacologic Considerations • Diminished ability to feel pain or other sensations
In some illnesses, such as hypothyroidism and star-
■ Antipyretics (drugs that reduce fever), such as aspirin, vation, the client typically has a subnormal temperature.
acetaminophen, or ibuprofen, are helpful when a tempera- Therefore, the nurse must assess clients just as closely
ture is 102° to 104°F (38.9° to 40°C). when body temperature falls below normal ranges as when
it is elevated.
Physical cooling measures are used for temperatures
between 104° and 105.8°F (40° to 40.6°C). If the temperature
is higher than 105.8°F (40.6°C) or if a high temperature is
unchanged after a sufficient response time with conventional ■ Older adults are more susceptible to hypothermia and
interventions, more aggressive treatment is warranted. heat-related conditions. Environmental factors, such as
Nursing Care Plan 12-1 describes nursing actions used for extreme heat and cold conditions and inadequately heated
a client with a nursing diagnosis of Hyperthermia. NANDA-I or cooled living environments, pose additional risk factors
(2012; p. 468) defines hyperthermia as a “body temperature for developing hypothermia and heat-related illnesses.
elevated above normal range.” If the fever is so severe that it
requires medical interventions, it is a collaborative problem.
Clients with severe hypothermia usually die. Neverthe-
Subnormal Body Temperature less, clients have been known to live even with very low tem-
There are several ranges of hypothermia (a core body temperatures, as in near-drowning in cold water and exposure
perature less than 95°F [35°C]). A person is considered in extremely cold environments. This phenomenon has led
mildly hypothermic at temperatures of 95° to 93.2°F (35° to the saying among paramedics and emergency department
to 34°C), moderately hypothermic at 93° to 86°F (33.8° to personnel that “a person isn’t dead until he or she is warm
30°C), and severely hypothermic below 86°F (30°C). and dead.” Various supportive measures are implemented
Cold body temperatures are best measured with a when clients have subnormal body temperatures (see Nurs-
tympanic thermometer for two reasons. First, other clinical ing Guidelines 12-3).

Rationales
The Client With a Subnormal Temperature
• Raise the room temperature. Doing so warms the body surface. • Cover the head with a cap or towel. Covering the head reduces
• Remove wet clothing. This measure reduces heat loss. heat loss.
• Apply layers of dry clothing and loosely woven blankets. • Provide warm fluids. Fluids conduct heat to internal organs.
Layers trap body heat next to the skin. • Massage the skin unless it has been frostbitten. Massage pro-
• Warm blankets and clothing in an oven or microwave if body duces mechanical friction, which produces warmth.
temperature is quite low. Heating raises the temperature of • Apply bags filled with warm water between areas of skin
woven fabrics above ambient (room) temperature. folds, or place an electronic warming pad beneath the back
• Position the client so that the arms are next to the chest and and hips (see Chap. 28) according to medical orders. These
the legs are tucked toward the abdomen. This position prevents measures transfer heat to the blood as it circulates through the
heat loss. skin.
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N U R S I N G C A R E P L A N 1 2 - 1 The Client With a F ev er

Assessment • Additional assessment data such as if the client is flushed,
Determine the following: restless, sleepy, confused, shivering, perspiring, or sensitive to
• Current temperature light, or has an accompanying headache or poor appetite
• Contributing factors such as dehydration, illness, inability to • Results of latest white blood cell count and thyroid hormone
perspire, exposure to warm environment or excessive layers of levels
clothing, prolonged physical activity, current drug history • Exposure to others with similar symptoms
• Trend in temperature measurements to determine whether the
fever is sustained, remittent, intermittent, or relapsing
Nursing Diagnosis. Hyperthermia related to imbalance between heat production and heat loss secondary to known or unknown
etiology.
Expected Outcome. The client’s body temperature will be between 96.6⬚ and 99.3⬚F (35.8⬚ to 37.4⬚C) within 24 hours following
implementation of fever-relieving interventions.
Cover a client who is shivering. Covering prevents heat loss; shivering will not cease until the
hypothalamus readjusts to a higher set point.
Keep the client in a warm but not hot environment. A warm environment provides comfort while the client’s body
adapts to the new set point.
Remove blankets or heavy clothing once shivering Decreasing layers of insulating fabric facilitates heat loss by
subsides. radiation and convection.
Limit activity. Restriction of activity reduces contractile thermogenesis from
muscle movement.
Provide liberal oral fluids. They replace fluid loss from perspiration and increased
metabolism.
Provide light but high-calorie nourishment. Modifying dietary intake compensates for increased metabolic
rate, delayed gastric emptying, and decreased intestinal
motility.
Administer antipyretics according to medical orders; aspirin Antipyretics block the set point elevation in the hypothalamus.
is contraindicated for children with fevers because it is
associated with Reye’s syndrome.
Apply cool cloths or an ice pack to the forehead, behind Cooling the skin lowers the temperature of blood by
the neck, and between the axillary and the inguinal skin conduction as the warmer blood flows near the
folds. peripheral skin surface.
Promote room ventilation or use an electric fan if an air Convection disperses heat via air currents.
conditioner is not available.
Keep the humidity level low. Reducing environmental moisture facilitates heat loss via
evaporation.
Apply tepid water to the skin, as in a sponge bath, Heat loss via convection and evaporation after an antipyretic
30 minutes after administering an antipyretic. helps to alter the set point in the hypothalamus.
Discontinue physical cooling measures if the client begins Shivering raises body heat and defeats the purpose of the
to shiver. sponge bath.
Apply an electronically regulated cooling pad beneath the A cooling pad lowers the body temperature by conduction as
client as directed by a physician (see Chap. 28). blood circulates through vessels in the skin.
Evaluation of Expected Outcome

The client’s temperature returns to normal range.
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PULSE • Exercise and activity. Rates increase with exercise and

activity and decrease with rest. With regular aerobic exer-
A pulse, a wavelike sensation that can be palpated in a cise, however, a training effect occurs, in which the heart
peripheral artery, is produced by the movement of blood dur- rate and, consequently, the pulse rate become consistently
ing the heart’s contraction. In most adults, the heart contracts lower than average. This effect develops because the heart
60 to 100 times per minute at rest. muscle becomes more efficient at supplying body cells with
sufficient oxygenated blood with fewer beats. Those who
Pulse Rate are physically fit exhibit slower pulse rates even during
The pulse rate (the number of peripheral pulsations pal- exercise.
pated in 1 minute) is counted by compressing a superficial • Stress and emotions. Stimulation of the sympathetic ner-
artery against an underlying bone with the tips of the fingers. vous system and emotions such as anger, fear, and excite-
ment increase heart and pulse rates. Pain, which is stressful
Rapid Pulse Rate (especially when moderate to severe), can trigger faster
The pulse rate of adults is considered rapid if it exceeds 100 rates.
beats per minute (bpm) at rest. Tachycardia (100 to 150 bpm) • Body temperature. For every degree of Fahrenheit eleva-
is a fast heart rate, but heart and pulse rates can exceed 150 bpm. tion, the heart and pulse rates increase by 10 bpm. A 1°
Rapid contraction, if sustained, tends to overwork the heart and increase in centigrade measurement causes a 15-bpm
may not oxygenate cells adequately because the heart has such increase (Porth, 2004). With a fall in body temperature, the
little time between contractions to fill with blood. opposite effect occurs.
The term palpitation (awareness of one’s own heart • Blood volume. Excessive blood loss causes the heart and
contraction without having to feel the pulse) can accompany pulse rates to increase. With decreased red blood cells or
tachycardia. Clients with rapid pulse rates are monitored inadequate hemoglobin to distribute oxygen to cells, the
closely, and the results are reported and recorded according heart rate accelerates in an effort to keep cells adequately
to agency policy. supplied.
• Drugs. Certain drugs can slow or speed the rate of heart
Slow Pulse Rate
contraction. Digitalis preparations and sedatives typically
The pulse rate of adults is considered slower than normal if
slow the heart rate. Caffeine, nicotine, cocaine, thyroid
it falls below 60 bpm. Bradycardia (less than 60 bpm) is
replacement hormones, and epinephrine increase heart
less common than tachycardia; it merits prompt reporting
contractions and subsequently, pulse rates.
and continued monitoring.
Factors Affecting Pulse and Heart Rates

Any factors that affect the rate of heart contraction also cause Pharmacologic Considerations
comparable effects in pulse rate. Because one depends on the
other, the pulse rate can never be faster than the actual heart rate. ■ Older adults generally have more profound responses to
Heart and pulse rates may vary depending on the following: cardiovascular medications than younger adults. Changes
such as dizziness or fainting, diminished appetite, nausea,
• Age. Some common rates are listed in Table 12-5. or visual changes may indicate the need for evaluation of
• Circadian rhythm. Rates tend to be lower in the morning cardiovascular medications.
and increase later in the day.
• Gender. Men average approximately 60 to 65 bpm at rest;
the average rate for women is about 7 or 8 bpm faster. Pulse Rhythm
• Body build. Tall, slender people usually have slower heart The pulse rhythm (the pattern of the pulsations and the
and pulse rates than short, stout people. pauses between them) is normally regular. That is, the beats
and the pauses occur similarly throughout the time the pulse
is palpated.
TABLE 12-5 Normal Pulse Rates Per Minute at
An arrhythmia or dysrhythmia (an irregular pattern
Various Ages
of heartbeats) with a consequently irregular pulse rhythm
APPROXIMATE APPROXIMATE is reported promptly. Some types indicate potentially life-
AGE RANGE AVERAGE
threatening cardiac dysfunctions that may warrant more
Newborn 120–160 140 sophisticated monitoring and treatment. Details about dys-
1–12 months 80–140 120 rhythmias and their causes can be found in textbooks that
1–2 years 80–130 110
discuss cardiac disorders.
3–6 years 75–120 100
7–12 years 75–110 95
Adolescence 60–100 80 Pulse Volume
Adulthood 60–100 80 Pulse volume (the quality of pulsations felt) is usually related
to the amount of blood pumped with each heartbeat, or the
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TABLE 12-6 Identifying Pulse Volume Assessment Sites

NUMBER DEFINITION DESCRIPTION The arteries used for pulse assessment lie close to the skin.
Most, but not all, are named for the bone over which they
0 Absent pulse No pulsation is felt despite
extreme pressure.
are located (Fig. 12-12). These pulse sites are collectively
1+ Thready pulse Pulsation is not easily felt; called “peripheral pulses” because they are distant from the
slight pressure causes it to heart. Of all the peripheral pulses, the radial artery, located
disappear. on the inner (thumb) side of the wrist, is the site most
2+ Weak pulse Pulse is stronger than thready; often used for pulse assessment. Three alternative assess-
light pressure causes it to
ment techniques can be used instead of or in addition to the
disappear.
3+ Normal pulse Pulsation is felt easily; moder-
assessment of a peripheral pulse. These techniques include
ate pressure causes it to counting the apical heart rate, obtaining an apical–radial
disappear. rate, and using a Doppler ultrasound device over a periph-
4+ Bounding Pulsation is strong and does eral artery.
pulse not disappear with moderate
pressure.
The apical heart rate (the number of ventricular contrac-
tions per minute) is considered more accurate than the radial
pulse for two reasons. First, the sound of each heartbeat is
force of the heart’s contraction. When a pulse can be felt obvious and distinct. Second, sometimes the heart contrac-
with mild pressure over the artery, it is described as being tion is not strong enough to be felt at a peripheral pulse site.
strong. A feeble, weak, or thready pulse refers to a pulse Counting the apical rate, however, is less convenient than
that is difficult to feel or, once felt, is obliterated easily with counting a radial pulse. An apical heart rate generally is
slight pressure. A rapid, thready pulse is usually a serious assessed when the peripheral pulse is irregular or difficult to
sign and reported promptly. A bounding or full pulse pro- palpate because of a rapid rate or thready quality or when it
duces a pronounced pulsation that does not easily disappear is necessary to obtain an actual heart rate.
with pressure. The apical heart rate is counted by listening at the chest
Another way to describe the volume or quality of the with a stethoscope or by feeling the pulsations in the chest
pulse is with corresponding numbers (Table 12-6). When for 1 full minute at an area called the “point of maximum
documenting pulse volume, the nurse should follow the impulse”. As the name suggests, the heartbeats are best
agency policy about using descriptive terms or a number- heard or felt at the apex, or lower tip, of the heart. The apex
ing system. in a healthy adult is slightly below the left nipple in line with
the middle of the clavicle (Fig. 12-13).
When assessing the apical heart rate by listening to the
chest—which is generally the more accurate technique—
the nurse listens for the “lub/dub” sound. The lub sound is
louder if the stethoscope has been correctly applied. These
Temporal
Carotid
Clavicle
Apex of
heart
Brachial
1
Radial
2
3
4
Femoral
5
Popliteal
Apical
Posterior
tibialis impulse
Dorsalis
pedis
FIGURE 12-13 Assess the apical heart rate to the left of the
sternum at the interspace below the fifth rib in midline with
FIGURE 12-12 The peripheral pulse sites. the clavicle.
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FIGURE 12-15 Using a Doppler ultrasound device. (Photo by

FIGURE 12-14 One nurse counts the radial pulse while the
B. Proud.)
other counts the apical rate. (Photo by B. Proud.)
two sounds equal one pulsation at a peripheral pulse site. RESPIRATION

The apical heart rate is counted for 1 full minute, and the
rhythm is also evaluated. Respiration is the exchange of oxygen and carbon diox-
ide. When it occurs between the alveolar and the capillary
Apical–Radial Rate
membranes, it is called “external respiration.” The exchange
The apical–radial rate (the number of sounds heard at the
of oxygen and carbon dioxide between the blood and the
heart’s apex and the rate of the radial pulse during the same
body cells is called “internal” or “tissue respiration.”
period) is counted by separate nurses at the same time using
Ventilation (the movement of air in and out of the
one watch or clock (Fig. 12-14). The apical and radial rates
chest) involves inhalation or inspiration (breathing in)
should be the same, but in some clients, they are not. The
and exhalation or expiration (breathing out). The medulla,
pulse deficit (the difference between the apical and the radial
which is the primary respiratory center in the brain, con-
pulse rates) is noted. If a pulse deficit is significant—and the
trols ventilation. The medulla is sensitive to the amount of
rates have been counted accurately—the nurse reports the
carbon dioxide in the blood and adapts the rate of ventila-
findings promptly and documents them in the client’s medi-
tions accordingly. Breathing can be voluntarily controlled
cal record.
to a certain extent.
DOPPLER ULTRASOUND DEVICE Respiratory Rate

The respiratory rate (the number of ventilations per minute)
A Doppler ultrasound device is an electronic instrument that varies considerably in healthy people, but normal ranges
detects the movement of blood through peripheral blood ves- have been established (Table 12-7). Factors that influence
sels and converts the movement to a sound. This instrument pulse rate generally also affect respiratory rate. The faster
is most helpful when slight pressure occludes pulsations or the pulse rate, the faster the respiratory rate, and vice versa.
when arterial blood flow is severely compromised. The ratio of one respiration to approximately four or five
When the device is used, conductive gel is applied over heartbeats is fairly consistent in healthy adults.
the arterial site, and the probe is moved at an angle over the
skin until a pulsating sound is heard (Fig. 12-15). The pulsat-
ing sounds are counted, much like the palpated pulsations. The TABLE 12-7 Normal Respiratory Rates at
nurse documents the assessment site and the rate, followed by Various Ages
the abbreviation D to indicate the use of a Doppler device. AGE AVERAGE RANGE
Skill 12-2 describes how to assess the rate, rhythm, and
Newborn 30–80
volume of the pulse at the radial artery. Early childhood 20–40
Late childhood 15–25
➧ Stop, Think, and Respond Box 12-3 Adulthood
If assessing the radial pulse is difficult or impossible, Men 14–18
what alternatives could be taken? Women 16–20
LWBK1004-C12_p187-226.indd 202 26/01/12 3:07 AM

Rapid Respiratory Rates air moving through the chest. The assessment technique and
Resting respiratory rates that exceed the standards for a cli- the characteristics of lung sounds are described in Chapter 13.
ent’s age are considered abnormal. Tachypnea (a rapid res- Skill 12-3 lists techniques to use when counting the res-
piratory rate) often accompanies an elevated temperature or piratory rate.
diseases that affect the cardiac and respiratory systems.
Slow Respiratory Rates What nursing actions are appropriate if a client has
Bradypnea (a slower-than-normal respiratory rate at rest) an abnormal respiratory rate?
can result from medications; for instance, morphine sulfate
slows the respiratory rate. Slow respirations also may be
observed in clients with neurologic disorders or who are BLOOD PRESSURE
experiencing hypothermia.
Blood pressure is the force that the blood exerts within the
Breathing Patterns and arteries. Several physiologic variables create blood pressure:
Abnormal Characteristics
• Circulating blood volume averages 4.5 to 5.5 L in adult
Various breathing patterns and abnormal characteristics
women and 5.0 to 6.0 L in adult men. Lower-than-normal
may be identified when assessing respiratory rates. Cheyne–
volumes decrease blood pressure; excess volumes increase it.
Stokes respiration refers to a breathing pattern in which
• Contractility of the heart is influenced by the stretch of
the depth of respirations gradually increases, followed by a
cardiac muscle fibers. Based on Starling’s law of the heart,
gradual decrease, and then a period when breathing stops
the force of heart contraction is related to preload (the
briefly before resuming again. Cheyne–Stokes respiration is
volume of blood that fills the heart and stretches the heart
a serious sign that may occur as death approaches.
muscle fibers during its resting phase). A common analogy
Hyperventilation (rapid or deep breathing or both) and
is to compare the effect of preload and contractility with
hypoventilation (diminished breathing) affect the volume
the snap of a rubber band stretched to various lengths—the
of air entering and leaving the lungs. Changes in ventilation
longer the rubber band is stretched, the greater it snaps
may occur in clients with airway obstruction or pulmonary
when released. Tissue damage that scars the heart, such as
or neuromuscular diseases.
after a heart attack, impairs stretching and reduces contrac-
Dyspnea (difficult or labored breathing) is almost
tility. Regular aerobic exercise increases the tone of the
always accompanied by a rapid respiratory rate as clients
heart muscle, making it an efficient muscular pump.
work to improve the efficiency of their breathing. Clients
• Cardiac output (the volume of blood ejected from the left
with dyspnea usually appear anxious and worried. The
ventricle per minute) is approximately 5 to 6 L (slightly
nostrils flare (widen) as they fight to fill the lungs with air.
more than a gallon) in adults at rest. It is estimated by
They may use the abdominal and neck muscles to assist
multiplying the heart rate by the stroke volume (amount of
other muscles in breathing. When observing these clients,
blood that leaves the heart with each contraction). The
the nurse should note how much and what type of activ-
average stroke volume in adults is 70 mL. With exercise,
ity brings on dyspnea. For example, walking to the bath-
cardiac output can increase as much as five times the rest-
room may bring on dyspnea in a client but sitting in a chair
ing volume. Bradycardia can severely reduce cardiac out-
may not.
put and thus, blood pressure.
Orthopnea (breathing facilitated by sitting up or stand-
• Blood viscosity (thickness) creates a resisting force when
ing) occurs in clients with dyspnea who find it easier to
the heart contracts. The resistance compromises stroke
breathe this way. The sitting or standing position causes
volume and cardiac output. Blood thickens when there are
organs in the abdominal cavity to fall away from the dia-
more cells and proteins than water in plasma. Circulating
phragm with gravity. This gives more room for the lungs to
viscous blood also causes cardiac fatigue and weakens the
expand within the chest cavity, allowing the person to take in
heart’s ability to contract.
more air with each breath.
• Peripheral resistance, referred to as afterload (the force
Apnea (the absence of breathing) is life threatening if
against which the heart pumps when ejecting blood),
it lasts more than 4 to 6 minutes. Prolonged apnea leads to
increases when the valves of the heart and arterioles (small
brain damage or death. Brief periods of apnea lower oxygen
subdivisions of arteries) are narrowed or calcified.
levels in the blood and can trigger serious abnormal cardiac
Afterload is decreased when arteries dilate.
rhythms (see Chap. 21 for more on sleep apnea).
Terms such as “stertorous breathing” (noisy ventila- In healthy people, the arterial walls are elastic and eas-
tion) and “stridor” (a harsh, high-pitched sound heard on ily stretch and recoil to accommodate the changing vol-
inspiration when there is laryngeal obstruction) are used ume of circulating blood. Measuring the blood pressure
to describe sounds that accompany breathing. Infants and helps to assess the efficiency of the circulatory system.
young children with croup often have stridor when breath- Blood pressure measurements reflect (1) the ability of the
ing. The nurse uses a stethoscope to listen to the sounds of arteries to stretch, (2) the volume of circulating blood, and
LWBK1004-C12_p187-226.indd 203 26/01/12 3:07 AM

(3) the amount of resistance the heart must overcome when

it pumps blood.
Systolic pressure
Factors Affecting Blood Pressure (heart contracts)
Besides the physiologic variables that create blood pressure,
other factors that cause temporary or permanent alterations 120
are as follows: 200
• Age. Blood pressure tends to become elevated with age as 60 240
a result of arteriosclerosis, a process in which arteries lose
their elasticity and become more rigid, and atherosclerosis, 40 280
a process in which the arteries become narrowed with fat
deposits. The rate of these conditions depends on heredity
and lifestyle habits such as diet and exercise.
Diastolic pressure
• Circadian rhythm. Blood pressure tends to be lowest after
(heart at rest)
midnight, begins rising at approximately 4 or 5 AM, and
peaks during late morning or early afternoon.
• Gender. Women tend to have lower blood pressure than Sphygmomanometer
men of the same age.
• Exercise and activity. Blood pressure rises during exercise
and activity, when the heart pumps more blood. Regular
exercise, however, helps to maintain blood pressure within FIGURE 12-16 The pressure of blood in the arteries is higher
during systole when the heart contracts and is lower during
normal levels. diastole when the heart muscle relaxes, hence the terms
• Emotions and pain. Strong emotional experiences and pain systolic and diastolic pressure.
tend to increase blood pressure from sympathetic nervous
system stimulation.
the kilopascal (kPa), a measurement from the European Sys-
• Miscellaneous factors. As a rule, a person has lower blood
tème International (SI) in which 1 mm Hg equals 0.133 kPa.
pressure when lying down than when sitting or standing,
Using this system, the equivalent of a normal blood pressure
although the difference in most people is insignificant.
such as 118/78 mm Hg would be 16/11 kPa when rounded
Blood pressure also seems to rise somewhat when the uri-
to the nearest decimal point. Although the conversion to kPa
nary bladder is full, when the legs are crossed, or when the
for measuring blood pressure has been discussed by experts
person is cold. Drugs that stimulate the heart such as nico-
from the National Heart, Lung, and Blood Institute and the
tine, caffeine, cocaine, and methamphetamine also tend to
American Heart Association (NHLBI, 2002), it has not been
constrict the arteries and raise blood pressure.
adopted as yet.
The pulse pressure (the difference between systolic
Pressure Measurements and diastolic blood pressure measurements) is computed by
When assessing blood pressure, nurses obtain both systolic and subtracting the smaller measurement from the larger. For
diastolic measurements. Systolic pressure (pressure within example, when the blood pressure is 126/88 mm Hg, the
the arterial system when the heart contracts) is higher than pulse pressure is 38. A pulse pressure between 30 and 50 is
diastolic pressure (pressure within the arterial system when considered normal, with 40 being a healthy average.
the heart relaxes and fills with blood). Blood pressure measure-
ments are expressed as a fraction. The numerator is the systolic
pressure, the pressure during systole, and the denominator is Gerontologic Considerations
the diastolic pressure, the pressure during diastole (Fig. 12-16).
Currently, blood pressure measurement is expressed in ■ Some older adults have a wide pulse pressure because
millimeters of mercury (mm Hg) because the mercury sphyg- of a rising systolic pressure exceeding the rate of diastolic
momanometer, an instrument for measuring blood pressure elevation. Such people have a higher incidence of hyperten-
using a graduated column of mercury, has been the standard sion.
for use. Thus, a recording of 118/78 means the systolic blood
pressure measured 118 mm Hg and the diastolic blood pres- Studies of healthy people show that blood pressure can
sure measured 78 mm Hg. Because mercury within the sphyg- fluctuate within a wide range and still be normal. Because
momanometer is a toxin that persists and accumulates within individual differences can be considerable, analyzing the
the environment and living species, mercury sphygmomanom- usual ranges and patterns of blood pressure measurements
eters have been eliminated. As a result, some propose that the for each person is important. A rise or fall of 20 to 30 mm
pressure measurements should be changed to something other Hg in usual pressure is significant, even if it is well within
than millimeters of mercury. One possible alternative is to use the generally accepted range for normal.
LWBK1004-C12_p187-226.indd 204 26/01/12 3:07 AM

Assessment Sites Aneroid Manometer

Blood pressure usually is assessed over the brachial artery An aneroid manometer, named from the French word
at the inner aspect of the elbow. It is also possible to use the aneroide, which means “no liquid,” measures pressure
lower arm and radial artery. There are situations in which using a spring mechanism. Its gauge features a needle that
the nurse must use an alternative to brachial or radial meas- moves around a numbered dial. The numbers correspond
urement, such as in the following circumstances: to the measurements obtained with a mercury manometer.
Before using an aneroid manometer, the needle on the
• When the client’s arms are missing gauge must be positioned at zero to ensure an accurate
• When both of a client’s breasts have been removed measurement.
• When a client has had vascular surgery (such as that which
permits dialysis treatments for kidney failure) Electronic Oscillometric Manometer
• When dressings or plaster or fiberglass casts obscure the An electronic oscillometric manometer is battery operated
brachial and radial sites or uses power from an electrical outlet. Unlike an aneroid
In these and other unusual circumstances, blood pres- manometer, an electronic oscillometric manometer does
sure is measured over the popliteal artery behind the knee not require a stethoscope for auscultating sounds that cor-
(see sections “Alternative Assessment Techniques” and respond to pressure measurements. It measures blood pres-
“Measuring Thigh Blood Pressure”). Documentation of the sure with a transducer within the cuff. The transducer is a
site is essential because measurements vary depending on device that receives sound waves, in this case, from the flow
the site used. of blood within the artery. The device actually measures the
mean arterial pressure and then electronically calculates the
systolic and diastolic pressure using a preprogrammed for-
Equipment for Measuring mula. The calculated pressures are visually displayed. Mod-
Blood Pressure els vary from those used in intensive care settings to others
Blood pressure most often is measured with a sphygmoma- intended for home use.
nometer (a device for measuring blood pressure), an inflat- Aneroid and electronic monitors have advantages and
able cuff, and a stethoscope. disadvantages (Table 12-8). Either can be used to assess
blood pressure, provided they are working properly and are
Sphygmomanometer used correctly.
A sphygmomanometer may be portable or wall mounted.
It contains a gauge for measuring the pressure of a gas or
Inflatable Cuff
liquid. Mercury manometers have always been considered
The cuff of a sphygmomanometer contains an inflatable
the gold standard; however, health care agencies have elim-
bladder to which two tubes are attached. One is connected
inated devices containing mercury. Presently, two types of
to the manometer, which registers the pressure. The other is
devices are available for measuring blood pressure nonin-
attached to a bulb that is used to inflate the bladder with air.
vasively: the aneroid and electronic oscillometric manom-
A screw valve on the bulb allows the nurse to fill and empty
eters (Fig. 12-17).
the bladder. As the air escapes, the pressure is measured.
Cuffs come in various sizes. A common guide
(Fig. 12-18) is to use a cuff that has a bladder width of at
least 40% and a length that is 80% to 100% of midlimb cir-
cumference (Pickering et al., 2005). Note that it is not the
width and length of the cuff itself, but rather the inflatable
bladder that must be the correct size.
If the cuff is too wide, the blood pressure reading will
be falsely low. If the cuff is too narrow, the blood pres-
sure reading will be falsely high. At the working meeting
on blood pressure measurement under the auspices of the
National High Blood Pressure Education Program, the
National Heart, Lung, and Blood Institute, and the American
Heart Association in April 2002, it was noted that the mean
arm circumference of US adults is increasing because of the
growing trend toward obesity. This means that the standard
adult blood pressure cuff no longer corresponds to a “stand-
ard adult” because more and more adults require a “large
A B adult” cuff when the blood pressure is measured. The nurse
FIGURE 12-17 An aneroid (A) and an electronic oscillometric must select a cuff with an appropriate bladder size for the
manometer (B). body proportions of each client.
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TABLE 12-8 Comparisons of Sphygmomanometer Equipment

Aneroid Inexpensive Delicate
Easy to carry and store Periodic equipment checking against a second sphygmomanometer
Ability to read the gauge from any position necessary for accuracy
Gauge possibly clumsy to attach to cuff
Stethoscope and accurate hearing necessary
Calibration check and readjustment recommended yearly
Manufacturer repair required
Electronic Digital display of measurement Expensive depending on quality
No stethoscope required Batteries necessary
Accurate for people with hearing loss Body movements and improper cuff application can influence
Facilitation of blood pressure measurement of accuracy
newborns and infants in whom auscultation Calibration check and readjustment recommended every
(listening with a stethoscope) is difficult 6 months
Manufacturer repair needed
Adapted from Blood pressure: Buying and caring for home equipment. American Heart Association, 1999.
Stethoscope between uses. Personal stethoscopes also need periodic

A stethoscope (an instrument that carries sound to the ears) cleaning to keep the eartips free of cerumen and dirt.
is composed of eartips, a brace and binaurals, and tubing The brace and binaurals are generally made of metal.
leading to a chest piece that may be a bell, diaphragm, or They connect the eartips to the tubing and chest piece. The
both (Fig. 12-19). The eartips are generally rubber or plas- brace prevents the tubing from kinking and distorting the
tic. When the stethoscope is used, the eartips are positioned sound. Stethoscope tubing is rubber or plastic. The best
downward and forward within the ears to produce the best length for good sound conduction is about 20 in. (50 cm).
sound perception. If various people are using stethoscopes The bell, or cup-shaped chest piece, is used to detect
in common, they must clean the eartips with alcohol pads low-pitched sounds such as those produced in blood vessels.
80%–100%
Bladder
length
40%
Cuff Bladder
width
Bladder
40%
80% –100%
Bell side Diaphragm side

FIGURE 12-18 To determine the appropriate size of blood B
pressure cuff, the width of the bladder should be 40% of the
midarm circumference and the length should be at least 80%. FIGURE 12-19 A stethoscope (A) and a chest piece (B).
LWBK1004-C12_p187-226.indd 206 26/01/12 3:07 AM

The diaphragm, or disk-shaped chest piece, detects high- 150 mm Hg 120 mm Hg 80 mm Hg 0 mm Hg

pitched sounds such as those in the lungs, heart, or abdo-
men. A cracked diaphragm must be replaced. When the bell
is used, care is taken to position it lightly over the anatomic Phase I Phase II Phase III Phase IV Phase V
area because pressure flattens the skin and creates the same Faint tapping Swishing Loud knocking Muffled Silence
effect as a diaphragm.
FIGURE 12-20 Characteristics of Korotkoff sounds.
Measuring Blood Pressure

The first time blood pressure is measured, it is assessed in The first sound, which is heard for at least two consecu-
each arm. The two blood pressure measurements should not tive beats, may be missed if the cuff pressure is not initially
vary more than 5 to 10 mm Hg unless pathology (disease) pumped high enough. Palpating for the disappearance of a
is present. Some agencies include a blood pressure assess- distal pulse when inflating the cuff helps to ensure that the
ment of the client in lying, sitting, and standing positions for cuff pressure is above arterial pressure.
the initial database. Several variables can result in inaccurate Phase I sounds may disappear briefly before they become
blood pressure measurements (Table 12-9). reestablished, especially in older adults and in clients with high
blood pressure or peripheral arterial disease. An auscultatory
Korotkoff Sounds gap (a period during which sound disappears) can range as
Most blood pressure recordings are obtained indirectly. much as 40 mm Hg. Failure to identify the first sound preced-
That is, they are determined by applying a blood pressure ing an auscultatory gap results in an inaccurate blood pressure
cuff, briefly occluding arterial blood flow, and listening for assessment from undermeasurement of the systolic pressure.
Korotkoff sounds (sounds that result from the vibrations Consequently, many clients with hypertension may be uniden-
of blood within the arterial wall or changes in blood flow). tified and thus, undiagnosed and untreated.
Blood pressure measurements are determined by correlat- Phase II is characterized by a change from tapping
ing the phases of Korotkoff sounds with the numbers on sounds to swishing sounds. At this time, the diameter of the
the sphygmomanometer. If Korotkoff sounds are difficult artery is widening, allowing more arterial blood flow.
to hear, they can be intensified in one of two ways: Phase III is characterized by a change to loud and distinct
sounds described as crisp knocking sounds. During this phase,
• Have the client elevate the arm before and during cuff
blood flows relatively freely through the artery once more.
inflation, then lower the arm after full inflation.
Phase IV sounds are muffled and have a blowing qual-
• Have the client open and close the fist after cuff inflation.
ity. The sound change results from a loss in the transmission
Korotkoff sounds have five unique phases (Fig. 12-20). of pressure from the deflating cuff to the artery. The point
Phase I begins with the first faint but clear tapping sound at which the sound becomes muffled is considered the first
that follows a period of silence as pressure is released from diastolic pressure measurement. It is generally preferred
the cuff. When the first sound occurs, it corresponds to the when documenting blood pressure measurements in children.
peak pressure in the arterial system during heart contraction, Phase V is the point at which the last sound is heard, or
or the systolic pressure measurement. It is recorded as the the second diastolic pressure measurement. This is considered
first number in the fraction. the best reflection of adult diastolic pressure because phase IV
TABLE 12-9 Common Causes of Blood Pressure Assessment Errors

CAUSE EFFECT CORRECTION
Inaccurate manometer calibration False high or low readings Recalibrate, repair, or replace gauge
Loosely applied cuff High reading Wrap snugly with equal pressure about
extremity
Cuff too small for extremity High reading Select appropriate size
Cuff too large for extremity Low reading Select appropriate size
Cuff applied over clothing Creates noise or interferes with Remove arm from sleeve or have client don a
sound perception gown
Tubing that leaks Rapid loss of pressure Replace or repair
Improper positioning of eartips Poor sound conduction Reposition and retake blood pressure
Impaired hearing Altered sound perception Use an alternative assessment technique or
equipment
Loud environmental noise Interferes with sound perception Reduce noise and reassess
Impaired vision Inaccurate observation of gauge Correct vision; reposition gauge in adequate
range
Rapid cuff deflation Inaccurate observation of gauge Reassess and deflate at 2 to 3 mm Hg/second
Number bias Falsely high or low measurements Use an electronic sphygmomanometer
LWBK1004-C12_p187-226.indd 207 26/01/12 3:07 AM

is often 7 to 10 mm Hg higher than direct diastolic pressure vessel. The sounds of moving blood cells are reflected
measurements. When recording adult blood pressure meas- toward the ultrasound receiver, producing a tone. The nurse
urements, the pressures at phases I and V are used. notes the pressure at which the sound occurs. The onset of
Studies have shown that some health care workers do sound represents the peak pressure of arterial blood flow. A
not record auscultated measurements accurately because description of how Doppler is used was given earlier in this
they have a number bias. In other words, they prefer record- chapter. When documenting the pressure measurement, the
ing auscultated measurements in even numbers or zero. nurse writes a D to indicate the use of Doppler.
Blood pressure measurements using an electronic sphyg-
momanometer or other nonauscultatory hybrid sphygmoma- Automatic Blood Pressure Monitoring
nometers that are being developed could eliminate number An automatic electronic blood pressure monitoring device
biases and provide more accurate measurements (National consists of a blood pressure cuff attached to a microprocess-
Institutes of Health, Working Meeting on Blood Pressure ing unit. Such devices diagnose unusual fluctuations in blood
Measurement, 2002). pressure that single or sporadic monitoring cannot identify.
Directions for standard auscultatory blood pressure When used, the device records the client’s blood pressure
measurements are given in Skill 12-4. every 10 to 30 minutes or as needed over 24 hours. It stores
the data in the microprocessor’s memory. Measurements are
Alternative Assessment Techniques printed or transferred by hand to a flow sheet for vital signs.
When Korotkoff sounds are difficult to hear in the usual man- Outpatients can wear a portable model supported either at
ner no matter how conscientious the effort to augment them, the shoulder or waist to help diagnose conditions in which
nurses can assess blood pressure using alternative methods. blood pressure is altered.
They can measure blood pressure by palpation or by using
a Doppler stethoscope. When blood pressure requires fre- Measuring Thigh Blood Pressure
quent or prolonged assessment, an automated blood pressure The thigh is a structure that corresponds anatomically to the
machine is necessary. When the brachial or radial artery is upper arm. Nurses use this site for blood pressure assessment
inaccessible in both arms or assessing blood pressure at these when they cannot obtain readings in either of the client’s arms.
sites is contraindicated, the thigh is an optional alternative. The systolic measurement tends to be 10% to 20% higher than
that obtained in the arms, but the diastolic measurement is
Palpating the Blood Pressure similar (Brownfield, 2004). Skill 12-5 describes the technique
When palpating the blood pressure, the nurse applies a blood for obtaining a thigh blood pressure measurement.
pressure cuff. Instead of using a stethoscope, however, he
or she positions the fingers over the artery while releasing ➧ Stop, Think, and Respond Box 12-5
the cuff pressure. The point at which the nurse feels the first What suggestions would you offer to a nurse who has
pulsation corresponds to the systolic pressure. The diastolic difficulty hearing Korotkoff sounds when assessing a
pressure cannot be measured because there is no perceptible client’s blood pressure?
change in the quality of pulsations like there is in the sounds.
When recording a blood pressure taken this way, it is impor- Abnormal Blood Pressure Measurements
tant to indicate that palpation was used. Blood pressures above or below normal ranges may indicate
significant health problems.
Doppler Stethoscope
A Doppler stethoscope (Fig. 12-21) helps to detect sounds High Blood Pressure
created by the velocity of blood moving through a blood Hypertension (high blood pressure) exists when the systolic
pressure, diastolic pressure, or both are sustained above nor-
mal levels for the person’s age. For adults 18 years or older,
the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (2004)
considers a systolic pressure of 140 mm Hg or greater and a
diastolic pressure of 90 mm Hg or greater to be abnormally
high (Table 12-10); these guidelines are due to be updated
in Spring 2012. An occasional elevation in blood pressure
does not necessarily mean a person has hypertension. It does
mean that the blood pressure should be monitored at various
intervals depending on the significance of the measurements
(Table 12-11). Monitoring is especially important to deter-
mine whether the elevated blood pressure is sustained or is
the result of white-coat hypertension (a condition in which
FIGURE 12-21 A Doppler stethoscope is used when Korotkoff the blood pressure is elevated when taken by a health care
sounds are difficult to hear. worker but normal at other times).
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TABLE 12-10 Classification of Adult Blood Nutrition Notes

Pressure Measurements
■ Individuals who are prehypertensive or who have hyper-
CATEGORY SYSTOLIC (MM HG) DIASTOLIC (MM HG)
tension may lower their blood pressure by adopting the
Normala <120 and <80 Dietary Approaches to Stop Hypertension (DASH) eating
Prehypertension 120–139 or 80–89 plan. It features generous amounts of fruits, vegetables, and
Hypertensionb low-fat or nonfat milk and milk products, and encourages
Stage 1 140–159 or 90–99 whole grains, fish, poultry, and nuts. Red meats, sweets, and
Stage 2 160 or higher or 100 or higher foods with added sugars are limited. Reducing sodium intake
a
to 2,300 mg (the amount in 1 teaspoon of salt) or lower
Normal blood pressure with respect to cardiovascular risk is below 120/80 mm
Hg. However, unusually low readings should be evaluated for clinical significance. (1,500 mg/day) improves the blood pressure lowering effect
b
Based on the average or two or more readings taken at each of two or more of DASH (National Heart Lung and Blood Institute, 2006).
visits after an initial screening.
Classification terms and measurements from the seventh report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure, 2004. Low Blood Pressure
Hypotension (low blood pressure) is when blood pres-
sure measurements are below the normal systolic values
for the person’s age. Having a consistently low pressure,
Gerontologic Considerations 96/60 mm Hg, for example, seems to cause no harm. In
fact, low blood pressure usually is associated with efficient
■ Older adults may use self-monitoring devices or blood functioning of the heart and blood vessels. People with low
pressure monitors at community settings, but these moni- blood pressure, however, should continue to be monitored
tors should be validated for accuracy. to evaluate its significance. Low blood pressure measure-
ments may indicate shock, hemorrhage, or side effects
Hypertensive blood pressure measurements often are from drugs.
associated with the following:
• Anxiety Postural Hypotension
• Obesity Postural or orthostatic hypotension (a sudden but tem-
• Vascular diseases porary drop in blood pressure when rising from a reclining
• Stroke position) is most common in those with circulatory prob-
• Heart failure lems, those who are dehydrated, and those who take diuret-
• Kidney diseases ics or other drugs that lower blood pressure. A consequence
of a sudden drop in blood pressure is dizziness and faint-
ing. Skill 12-6 describes an assessment of postural hypo-
TABLE 12-11 Recommendations for Follow- tension for clients in high-risk categories or who become
up Based on Initial Set of Blood symptomatic during care.
Pressure Measurements
INITIAL BLOOD PRESSURE (MM HG)a RECOMMENDED FOLLOW-UPb Gerontologic Considerations
Systolic Diastolic
■ Older adults are more susceptible to postural and post-
⬍120 ⬍80 Recheck in 2 years prandial hypotension (a drop in blood pressure of 20 mm
120–139 80–89 Recheck in 1 yearc
Hg within 1 hour of eating a meal). If hypotension is
140–159 90–99 Confirm within 2 monthsd
assessed in a client, plan for limited activities during the
160–179 100–109 Evaluate or refer to source
hour following eating or for frequent, smaller food con-
of care within 1 month
ⱖ180 ⱖ110 Evaluate or refer to source
sumption throughout the day.
of care immediately or
within 1 week depending
on clinical situation
a
If systolic and diastolic categories are different, follow recommendations DOCUMENTING VITAL SIGNS
for shorter follow-up (eg, client with 160/86 mm Hg should be evaluated or
referred to source of care within 1 month).
b
Once nurses have obtained vital sign measurements, they
Modify the scheduling of follow-up according to reliable information about
past blood pressure measurements, other cardiovascular risk factors, or are documented in the medical record for analysis of pat-
target organ disease. terns and trends (Fig. 12-22). They also may be entered as
c
Provide advice about lifestyle modifications. data, along with any other subjective or objective informa-
From the seventh report of the Joint National Committee for the Detection,
Evaluation, and Treatment of High Blood Pressure, National Heart, Lung, and
tion, elsewhere in the client’s record such as in the narrative
Blood Institute, National Institutes of Health, 2004. nursing notes.
LWBK1004-C12_p187-226.indd 209 26/01/12 3:07 AM

FIGURE 12-22 A graphic

recording of vital signs.
NURSING IMPLICATIONS CRITICAL THINKING EXERCISES

1. When visiting a friend with a fever, you see that the
Vital sign assessment is part of every client’s care and forms
only thermometer available is made of glass and
the basis for identifying problems. Based on the analysis of
contains mercury. What suggestions for replacement
assessment data, the nurse may identify one or more of the
would you offer when your friend feels better?
following nursing diagnoses:
2. A neighbor with no medical experience asks how to
• Hyperthermia tell if her 4-year-old child has a fever. What advice
• Hypothermia would you give?
• Ineffective thermoregulation
• Decreased cardiac output
• Risk for injury
• Ineffective breathing pattern
LWBK1004-C12_p187-226.indd 210 26/01/12 3:07 AM

3. An 80-year-old client explains that, as an economy 3. While assessing a client’s radial pulse, the nurse notes
measure, she keeps her thermostat set at 65°F. What that it disappears with very slight pressure. What is
health information would be appropriate, considering the best description for the nurse to use when docu-
this woman’s age? menting the quality of the pulse?
4. While participating in a community health assess- 1. Normal
ment, you discover a person with a blood pressure 2. Weak
that measures 190/110 mm Hg. What actions are 3. Thready
appropriate at this time? 4. Diminished
4. Before assessing an adult client’s blood pressure, the
nurse is most correct in selecting a blood pressure
NCLEX-STYLE REVIEW QUESTIONS cuff with a bladder width that is 40% and a bladder
length that encircles at least what percent of the cli-
1. Upon observing a nursing assistant taking a client’s
ent’s upper arm?
vital signs (oral temperature, pulse rate, respiratory
1. 40%
rate, and blood pressure) immediately after breakfast,
2. 60%
what instruction should the nurse give the nursing
3. 80%
assistant?
4. 100%
1. Obtain the client’s apical–radial heart rate.
5. If the nurse detects that a client has symptoms associ-
2. Wait 15 minutes to assess the client’s pulse.
ated with orthostatic hypotension, what is the best
3. Assess the client’s temperature in 30 minutes.
instruction the nurse can offer the client?
4. Take the blood pressure with the client lying down.
1. Limit consumption of fluids during the day.
2. What nursing action is best when a client with a tem-
2. Rise slowly from a lying or sitting position.
perature of 103.6°F is shivering?
3. Remain on bed rest throughout care in the health
1. Offer the client a cup of hot soup.
agency.
2. Cover the client with a light blanket.
4. Ambulate about the health agency at least four
3. Direct a fan in the client’s direction
times a day.
4. Darken the room to provide rest.
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SKILL 12-1 Assessing Body Temperature
ASSESSMENT
Determine when and how frequently to monitor the client’s Demonstrates accountability for making timely and appropriate
temperature (see Box 12-1) and the type of thermometer assessments; ensures consistency in the technique for gather-
previously used. ing data.
Review previously recorded temperature measurements. Aids in identifying trends and analyzing significant patterns.
If using an oral electronic or digital thermometer:
Observe the client’s ability to support a thermometer within the Shows consideration for accuracy because thermal energy is
mouth and breathe adequately through the nose with the transferred from the oral cavity to the thermometer probe;
mouth closed. escape of heat invalidates the measurement.
Read the client’s history for any reference to recent seizures or Shows consideration for safety and identifies possible
a seizure disorder. contraindication for oral site.
Determine whether the client consumed any hot or cold sub- Shows consideration for accuracy because the temperature in the
stances or smoked a cigarette within the past 30 minutes. oral cavity can be temporarily altered from substances recently
placed within the mouth.
PLANNING
Arrange to take the client’s temperature as near to the sched- Ensures consistency and accuracy.
uled routine as possible.
Gather supplies including a thermometer, watch, and probe Promotes efficiency, accuracy, and safety.
cover or disposable sleeve if needed. Include lubricant, paper
tissues, and gloves if using the rectal site or other route if
there is a potential for contact with body secretions.
(Use of gloves is determined on an individual basis. The virus
that causes AIDS has not been shown to be transmitted
through contact with oral secretions unless they contain
blood; thorough handwashing or hand antisepsis is always
appropriate after any client contact.)
IMPLEMENTATION
Introduce yourself to the client if you have not done so during Demonstrates responsibility and accountability.
earlier contact.
Explain the procedure to the client. Reduces apprehension and promotes cooperation.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the spread of microorganisms.
Chap. 10).
Electronic Thermometer
Remove the electronic unit from the charging base. Promotes portability.
Select the oral or rectal probe depending on the intended site Ensures appropriate use.
for assessment.
Insert the probe into a disposable cover until it locks into place Protects the probe from contamination with secretions containing
(Fig. A). microorganisms.
Inserting the probe into a disposable cover. (Photo by Rick Brady.)
A
(continued)
LWBK1004-C12_p187-226.indd 212 26/01/12 3:07 AM

Assessing Body Temperature (continued)
Oral Method
Place the covered probe beneath the tongue to the right or left Locates the probe near the sublingual artery to ensure correct
of the frenulum (structure that attaches the underneath sur- location.
face of the tongue to the fleshy portion of the mouth) (Fig. B).
Location for oral temperature assessment.
Frenulum
of tongue
B
Hold probe in place (Fig. C). Supports the probe so that it does not drift away from its
intended location; ensures valid data collection.
Maintaining the probe in position. (Photo by Rick Brady.)
Maintain the probe in position until an audible sound occurs. Signals when the sensed temperature remains constant.
Observe the numbers displayed on the electronic unit. Indicates temperature measurement.
(continued)
LWBK1004-C12_p187-226.indd 213 26/01/12 3:07 AM

Remove the probe and eject the probe cover into a lined recep- Confines contaminated objects to an area for proper disposal
tacle (Fig. D). without direct contact.
Releasing the probe cover. (Photo by Rick Brady.)
Replace the probe in the storage holder within the electronic Prevents damage to the probe attachment.
unit.
Rectal Method
Provide privacy. Demonstrates respect for the client’s dignity.
Lubricate approximately 1″ (2.5 cm) of the rectal probe cover. Promotes comfort and ease of insertion.
Position the client on the side with the upper leg slightly flexed Helps to locate the anus and facilitate probe insertion.
at the hip and knee (Sims’ position).
Instruct the client to breathe deeply. Relaxes the rectal sphincter and reduces discomfort during
insertion.
Insert the thermometer approximately 1.5 in. (3.8 cm) in an
adult, 1 in. (2.5 cm) in a child, and 0.5 in. (1.25 cm) in an infant
(Fig. E).
Rectal thermometer insertion.
Observe the numbers displayed on the electronic unit. Indicates temperature measurement.
Remove the probe and eject the probe cover into a lined Confines contaminated objects to an area for proper disposal
receptacle (see Fig. D). without direct contact.
unit.
Wipe lubricant and any stool from around the client’s rectum. Demonstrates concern for the client’s hygiene and comfort.
Remove and discard gloves, if worn; wash hands or perform Reduces the transmission of microorganisms.
hand antisepsis with an alcohol rub (see Chap. 10). (continued)
LWBK1004-C12_p187-226.indd 214 26/01/12 3:07 AM

Axillary Method
Insert the thermometer into the center of the axilla and lower Confines the tip of the thermometer so that room air does not
the client’s arm to enclose the thermometer between the two affect it.
folds of skin (Fig. F).
Placement for an auxiliary temperature assessment.
Hold the probe in place. Supports the probe so it does not drift away from its intended
location; ensures valid data collection.
Remove the probe and eject the probe cover into a lined recep- Confines contaminated objects to an area for proper disposal
tacle (see Fig. D). without direct contact.
unit.
Return the electronic unit to its charging base. Facilitates reuse.
Record the assessment measurement on the graphic sheet or Provides documentation for future comparisons.
flow sheet, or in the narrative nursing notes.
Verbally report elevated or subnormal temperatures. Alerts others to monitor the client closely and make changes in
the care plan.
Infrared Tympanic Thermometer
Remove the thermometer component from its holding cradle Facilitates insertion of the tympanic speculum (funnel-shaped
(Fig. G). instrument used to widen and support an opening in the body).
A tympanic thermometer and cradle. (Photo by Rick Brady.)
Inspect the tip of the thermometer for damage and the lens for Promotes safety and hygiene.
cleanliness.
Replace a cracked or broken tip; clean the lens with a dry wipe Ensures accurate data collection.
or lint-free swab moistened with a small amount of isopropyl
alcohol, and then wipe to remove the alcohol film.
(continued)
LWBK1004-C12_p187-226.indd 215 26/01/12 3:07 AM

Wait 30 min after cleaning with alcohol. Allows the thermometer to readjust after the cooling effect
created by alcohol evaporation.
Cover the speculum with a disposable cover until it locks in Maintains cleanliness of the tip.
place.
Press the mode button to select the choice of temperature Adjusts the tympanic measurement, norms for which have not
translation (conversion of tympanic temperature into an oral, been established, into more common frames of reference. The
rectal, or core temperature). rectal equivalent is recommended for children younger than
3 years.
Depress the mode button for several seconds to select either Eliminates the need to calculate conversion measurements by
Fahrenheit or centigrade. hand.
Hold the probe in your dominant hand. Improves motor skill and coordination.
Position the client with the head turned 90 degrees, exposing Promotes proper probe placement; if the right hand is holding the
the ear with the hand holding the probe. probe, the left ear is assessed.
Wait for display of a “Ready” message. Indicates offset has been programmed.
Pull the external ear of adults up and back by grasping the Straightens the ear canal.
external ear at its midpoint with your nondominant hand; for
children 6 years and younger, pull the ear down and back.
Insert the probe into the ear, advancing it with a gentle Seals the tip of the probe within the ear canal and confines the
back-and-forth motion until it seals the ear canal. radiated heat within the area of the probe.
Point the tip of the probe in an imaginary line between the Positions the probe in direct alignment with the tympanic
sideburn hair and the eyebrow on the opposite side of the membrane; if pointed elsewhere, the infrared sensor detects
face (Fig. H). the temperature of surrounding tissue rather than membrane
temperature.
The placement of a probe for accurate tympanic assessment. (Photo by Rick Brady.)
Press the button that activates the thermometer as soon as the Initiates electronic sensing; for some models, this action must be
probe is in position. done within 25 seconds of having removed the thermometer
from its holding cradle.
Keep the probe within the ear until the thermometer emits a Indicates that the procedure is complete.
sound or flashing light. (continued)
LWBK1004-C12_p187-226.indd 216 26/01/12 3:07 AM

Repeat the procedure after waiting 2 minutes if this is the first Ensures accuracy with a second assessment.
use of the tympanic thermometer since it was recharged.
Read the temperature, remove the thermometer from the ear, Controls the transmission of microorganisms.
and release the probe cover into a lined receptacle (Fig. I).
Disposing of the probe cover. (Photo by Rick Brady.)
Record the assessment measurement on the graphic sheet or Provides documentation for future comparisons.
flowsheet, or in the narrative nursing notes.
Verbally report elevated or subnormal temperatures. Alerts others to monitor the client closely and make changes in
the plan for care.
Evaluation
• Thermometer remained inserted the appropriate time.
• Level of temperature is consistent with accompanying signs and
symptoms.
• Thermometer and surrounding tissue remain intact.
Document
• Date and time
• Degree of heat to the nearest tenth
• Temperature scale
• Site of assessment
• Accompanying signs and symptoms
• To whom abnormal information was reported and the outcome
of the interaction
Date and Time T 102.4⬚F (O). States, “I feel cold and my throat hurts.” Pharynx looks beefy red. Reported to Dr. Washington.
New orders for throat culture. ____________________________________________________ SIGNATURE/TITLE
LWBK1004-C12_p187-226.indd 217 26/01/12 3:07 AM

SKILL 12-2 Assessing the Radial Pulse
ASSESSMENT
pulse (see Box 12-1). assessments.
Review data collected in previous assessments of the pulse or Aids in identifying trends and analyzing significant patterns.
abnormalities in other vital signs.
Read the client’s history for any reference to cardiac or vascular Demonstrates an understanding of factors that may affect the
disorders. pulse rate.
Review the list of prescribed drugs for any that may have Helps in analyzing the results of assessment findings.
cardiac effects.
PLANNING
Arrange to take the client’s pulse as near to the scheduled Ensures consistency and accuracy.
routine as possible.
Make sure a watch or wall clock with a second hand is available. Ensures accurate timing when counting pulsations.
Plan to assess the client’s pulse after 5 minutes of inactivity. Reflects the characteristics of the pulse at rest rather than data
that may be influenced by activity.
Plan to use the right or left radial pulse site unless it is Provides consistency in evaluating data.
inaccessible or difficult to palpate.
IMPLEMENTATION
Introduce yourself to the client, if you have not done so earlier. Demonstrates responsibility and accountability.
Raise the height of the bed. Reduces musculoskeletal strain.
Wash hands or perform hand antisepsis with an alcohol rub Reduces the spread of microorganisms.
(see Chap. 10).
Help the client to a position of comfort. Avoids stress or pain from influencing the pulse rate.
Rest or support the client’s forearm with the wrist extended Provides access to the radial artery and relaxes the arm.
(Fig. A).
Locating the radial pulse.
Press the first and second fingertips toward the radius while Ensures accuracy because the nurse may feel his or her own
feeling for a recurrent pulsation. pulse if using the thumb; light palpation should not obliterate
the pulse.
Palpate the rhythm and volume of the pulse once it is located. Provides comprehensive assessment data.
Note the position of the second hand on the clock or watch. Identifies the point at which the assessment begins.
Count the number of pulsations for 15 or 30 seconds and multi- Provides pulse rate data. A regular pulse rate should not vary
ply the number by 4 or 2, respectively. If the pulse is irregular, whether it is counted for a full minute or some portion thereof,
count for a full minute. whereas the rate of an irregular pulse may be significantly
inaccurate if assessed for less than a full minute.
Write down the pulse rate. Ensures accurate documentation.
Restore the client to a therapeutic position or one that provides Demonstrates responsibility for client care, safety, and comfort.
comfort, and lower the bed.
Record the assessed measurement on the graphic sheet or the Provides documentation for future comparisons.
Verbally report rapid or slow pulse rates. Alerts others to monitor the client closely and to make changes in
the plan for care.
(continued)
LWBK1004-C12_p187-226.indd 218 26/01/12 3:07 AM

Assessing the Radial Pulse (continued)
Evaluation
• Pulse rate remained palpable throughout the assessment.
• Pulse rate is consistent with the client’s condition.
Document
• Date and time
• Assessment site
• Rate of pulsations per minute, pulse volume, and rhythm
• Accompanying signs and symptoms, if appropriate
• To whom abnormal information was reported and the outcome of the interaction
Date and Time Radial pulse 88 bpm full and regular. ___________________________________________ SIGNATURE/TITLE
SKILL 12-3 Assessing the Respiratory Rate
ASSESSMENT
respiratory rate (see Box 12-1). assessments.
Review data collected in previous assessments of the respira- Aids in identifying trends and analyzing significant patterns.
tory rate and other vital signs.
Read the client’s history for any reference to respiratory, cardiac, Demonstrates an understanding of factors that may affect the
or neurologic disorders. respiratory rate.
respiratory or neurologic effects.
PLANNING
Arrange to count the client’s respiratory rate as close to the Ensures consistency and accuracy.
scheduled routine as possible.
Make sure a watch or wall clock with a second hand is available. Ensures accurate timing.
Plan to assess the client’s respiratory rate after a 5-minute period Reflects the characteristics of respirations at rest rather than
of inactivity. under the influence of activity.
IMPLEMENTATION
Introduce yourself to the client, if you have not done so Demonstrates responsibility and accountability.
previously.
(see Chap. 10).
Help the client to a sitting or lying position. Facilitates the ability to observe breathing.
Note the position of the second hand on the clock or watch. Identifies the point at which assessment begins.
Choose a time when the client is unaware of being watched; Discourages conscious control of breathing or talking during the
it may help to count the respiratory rate while appearing to assessment of the rate of breathing.
count the pulse or while the client holds a thermometer in
the mouth.
Observe the rise and fall of the client’s chest for a full minute, Determines the respiratory rate per minute.
if breathing is unusual. If breathing appears noiseless and
effortless, count ventilations for a fractional portion of
1 minute and then multiply to calculate the rate.
Write down the respiratory rate. Ensures accurate documentation.
Record the assessed measurement on the graphic sheet or Provides documentation for future comparisons.
flow sheet, or in the narrative nursing notes. (continued)
LWBK1004-C12_p187-226.indd 219 26/01/12 3:07 AM

Assessing the Respiratory Rate (continued)
Verbally report rapid or slow respiratory rates or any other Alerts others to monitor the client closely and make changes in
unusual characteristics. the plan for care.
Evaluation
• Respiratory rate is counted for an appropriate time.
• Respiratory rate is consistent with the client’s condition.
Document
• Date and time
• Rate per minute
Date and Time Respiratory rate of 20/minute at rest. Breathing is noiseless and effortless. --------------------------- SIGNATURE/TITLE
SKILL 12-4 Assessing Blood Pressure
ASSESSMENT
blood pressure (see Box 12-1). assessments.
Review the data collected in previous assessments. Aids in identifying trends and analyzing significant patterns.
Determine in which arm and in what position previous Ensures consistency when evaluating data.
assessments were made.
disorders. blood pressure.
cardiovascular effects.
PLANNING
Gather the necessary supplies: blood pressure cuff, sphyg- Promotes efficient time management. A recently calibrated aner-
momanometer, and stethoscope. oid or a validated electronic device can be used.
Select an appropriately sized cuff for the client. Ensures valid assessment findings.
Arrange to take the client’s blood pressure as near to the Ensures consistency.
scheduled routine as possible.
Plan to assess the blood pressure after at least 5 minutes of Reflects the blood pressure under resting conditions.
inactivity unless it is an emergency.
Wait 30 minutes after the client has ingested caffeine or used Avoids obtaining a higher-than-usual measurement from arterial
tobacco. constriction.
Plan to use the right or left arm unless inaccessible. Provides consistency in evaluating data.
IMPLEMENTATION
Introduce yourself to the client if you have not done so earlier. Demonstrates responsibility and accountability.
Chap. 10).
Help the client to a sitting position or one of comfort. Relaxes the client and reduces elevations caused by stress or
discomfort.
Support the client’s forearm at the level of the heart with the Ensures collecting accurate data and facilitates locating the
palm of the hand upward. brachial artery.
Expose the inner aspect of the elbow by removing clothing or Facilitates application of the blood pressure cuff and optimum
loosely rolling up a sleeve. sound perception.
(continued)
LWBK1004-C12_p187-226.indd 220 26/01/12 3:07 AM

Assessing Blood Pressure (continued)
Center the cuff bladder so that the lower edge is about 1–2 inches Places the cuff in the best position for occluding the blood flow
(2.5–5 cm) above the inner aspect of the elbow (Fig. A). through the brachial artery.
Applying the blood pressure cuff. (Photo by B. Proud.)
Wrap the cuff snugly and uniformly about the circumference of Ensures the application of even pressure during inflation.
the arm.
Make sure the aneroid gauge can be clearly seen. Prevents errors when observing the gauge.
Palpate the brachial pulse (Fig. B). Determines the most accurate location for assessing and hearing
Korotkoff sounds.
Palpating the brachial artery. (Photo by B. Proud.)
Tighten the screw valve on the bulb (Fig. C). Prevents loss of pumped air.
Tightening the screw valve. (Photo by B. Proud.)
C
(continued)
LWBK1004-C12_p187-226.indd 221 26/01/12 3:07 AM

Compress the bulb until the pulsation within the artery stops Provides an estimation of systolic pressure.
and note the measurement at that point.
Deflate the cuff and wait 15–30 seconds. Allows the return of normal blood flow.
Place the eartips of the stethoscope within the ears and Ensures accurate assessment.
position the bell of the stethoscope lightly over the location of
the brachial artery (Fig. D). The diaphragm may be used, but it
is not preferred.
Placing the stethoscope. (Photo by B. Proud.)
Keep the tubing free from contact with clothing. Reduces sound distortion.
Pump the cuff bladder to a pressure that is 30 mm Hg above Facilitates identifying phase I of Korotkoff sounds.
the point where the pulse previously disappeared (Fig. E).
Pumping the bulb. (Photo by B. Proud.)
Loosen the screw on the valve. Releases air from the cuff bladder.
Control the release of air at a rate of approximately 2–3 mm Ensures an accurate assessment between the perception of a
Hg/second. sound and noting the numbers on the gauge.
Listen for the onset and changes in Korotkoff sounds. Aids in determining the systolic and diastolic pressures.
Read the manometer gauge to the closest even number when Follows recommended standards for children or adults.
phase I, IV, or V is noted.
Release the air quickly when there has been silence for at least Indicates phase V is complete.
10 mm Hg.
Write down the blood pressure measurements. Ensures accurate documentation.
Repeat the assessment after waiting at least 1 minute if unsure Allows time for the arterial pressure to return to baseline before
of the pressure measurements. another assessment.
Chap. 10). (continued)
LWBK1004-C12_p187-226.indd 222 26/01/12 3:08 AM

Record the assessed measurement on the graphic sheet or Provides documentation for future comparisons.
Verbally report elevated or low blood pressure measurements. Alerts others to monitor the client closely and make changes in
the plan for care.
Evaluation
• Korotkoff sounds are heard clearly.
• Blood pressure is consistent with the client’s condition.
Document
• Date and time
• Systolic and diastolic pressure measurements
• Assessment site
• Position of the client
Date and Time BP 136/72 in R arm while in sitting position. ____________________________________ SIGNATURE/TITLE
SKILL 12-5 Obtaining a Thigh Blood Pressure
ASSESSMENT
Determine on which thigh previous assessments were made. Ensures consistency when evaluating data.
Read the client’s history for any reference to cardiac or vascular Demonstrates an understanding of factors that may affect blood
disorders. pressure.
cardiovascular effects.
PLANNING
Gather the necessary supplies: thigh blood pressure cuff, Promotes efficient time management and ensures an accurate
sphygmomanometer, and stethoscope (Fig. A). measurement when a wider and longer blood pressure cuff is
used.
Application of blood pressure cuff to the thigh.
A
(continued)
LWBK1004-C12_p187-226.indd 223 26/01/12 3:08 AM

Obtaining a Thigh Blood Pressure (continued)
PLANNING (CONTINUED)
Plan to assess blood pressure after the client has been reclining Promotes conditions for obtaining accurate measurements.
for at least 10 minutes.
Wait 30 minutes from the time the client has ingested caffeine, Eliminates factors that contribute to the constriction or dilation of
used tobacco, consumed a heavy meal, exercised vigorously, blood vessels.
or taken a hot shower or bath.
IMPLEMENTATION
(see Chap. 10).
Place the client in either the supine or the prone position, with Facilitates application of the blood pressure cuff.
the knee slightly flexed and the hip abducted.
Make sure the manometer can be seen clearly. Prevents observational errors.
Palpate the popliteal pulse. Determines the most accurate location for hearing Korotkoff
sounds.
Warn the client that he or she may experience discomfort Prepares the client for sensation and provides an explanation for
when the cuff is inflated but that remaining still will facilitate its necessity.
accuracy.
Tighten the screw valve on the bulb. Prevents the loss of air from the cuff bladder.
and note the pressure measurement.
Deflate the cuff and wait 15 to 30 seconds. Allows the return of normal blood flow.
Place the eartips of the stethoscope within the ears, and posi- Ensures an accurate assessment.
tion the bell of the stethoscope lightly over the location of the
popliteal artery. (Note: The diaphragm of the stethoscope may
be used, but it is not preferred.)
Keep the tubing free from contact with clothing and bed linens. Reduces sound distortion.
the point where the pulse previously disappeared.
Control the release of air at a rate of approximately Ensures accurate assessment between perception of the sound
2 to 3 mm Hg/second. and noting the numbers on the gauge.
Listen for the onset and changes in Korotkoff sounds. Aids in determining systolic and diastolic pressure.
Read the manometer when phase I, IV, and V are noted. Follows recommended standards for adults or children.
Release the air quickly when there has been silence for at least Indicates that phase V is complete.
10 mm Hg.
comfort.
Chap. 10).
Record assessed measurements on the graphic sheet or the Provides documentation for future comparisons.
Verbally report blood pressure measurements to the nurse in Alerts others to monitor the client closely or to modify the client’s
charge. plan of care.
Evaluation
• Korotkoff sounds are heard clearly.
• Blood pressure is consistent with the client’s condition.
Document
• Date and time
• Systolic and diastolic pressure measurements
• Assessment site
• To whom abnormal information was reported, and the outcome of the interaction
Date and Time BP 176/88 at popliteal artery of left thigh. States, “It hurts when the blood pressure cuff gets tight.”
--------------------------------------------------------------------------------------------------------------------------------------------------------------------- SIGNATURE/TITLE
LWBK1004-C12_p187-226.indd 224 26/01/12 3:08 AM

SKILL 12-6 Assessing for Postural Hypotension
ASSESSMENT
Determine in which arm previous assessments were made. Ensures consistency when evaluating data.
disorders. blood pressure.
Review the list of prescribed drugs for any that may have cardio- Helps in analyzing the results of assessment findings.
vascular effects.
PLANNING
Gather the necessary supplies: blood pressure cuff, sphyg- Promotes efficient time management.
momanometer, and stethoscope.
Select a cuff that is an appropriate size for the client. Ensures valid assessment findings.
Arrange to take the client’s blood pressure as near to the sched- Ensures consistency.
uled routine as possible.
Plan to assess the blood pressure after the client has been Promotes conditions for obtaining accurate baseline measure-
reclining for at least 5 minutes. ments for comparison.
Wait 30 minutes from the time the client has ingested caffeine, Eliminates factors that contribute to constriction or dilation of
used tobacco, consumed a heavy meal, exercised vigorously, blood vessels.
or taken a hot shower or bath.
IMPLEMENTATION
Chap. 10).
Assess the client’s pulse. Provides a baseline for evaluating heart rate in relation to postural
changes.
Support the client’s forearm at the level of the heart with the Ensures collecting accurate data and facilitates locating the
palm of the hand upward. brachial artery.
Expose the inner aspect of the elbow by removing clothing or Facilitates the application of the blood pressure cuff and optimum
loosely rolling up a sleeve. sound perception.
Center the cuff bladder so that the lower edge is about Places the cuff in the best position for occluding blood flow
1–2 inches (2.5–5 cm) above the inner aspect of the elbow. through the brachial artery.
Wrap the cuff snugly and uniformly about the circumference of Ensures the application of even pressure during inflation.
the arm.
Make sure the manometer can be clearly seen. Prevents observational errors.
Palpate the brachial pulse. Determines the most accurate location for hearing Korotkoff
sounds.
Tighten the screw valve on the bulb. Prevents loss of air from the cuff bladder.
and note the pressure measurement.
Deflate the cuff and wait 15–30 seconds. Allows the return of normal blood flow.
Place the eartips of the stethoscope within the ears and posi- Ensures accurate assessment.
tion the bell of the stethoscope lightly over the brachial artery.
(Note: The diaphragm of the stethoscope may be used, but it
is not preferred.)
Keep the tubing free from contact with clothing. Reduces sound distortion.
the measurement where the pulse previously disappeared.
Control the release of air at a rate of approximately 2–3 mm Ensures accurate assessment between the perception of a sound
Hg/second. and noting of numbers on the gauge.
Listen for the onset and changes in pressure. Aids in determining systolic and diastolic Korotkoff sounds.
Read the manometer when phase I, IV, and V are noted. Follows the recommended standards for adults or children.
Release the air quickly when there has been silence for at least Indicates that phase V is complete.
10 mm Hg.
Assist the client with standing or sitting. Stimulates reflexes for maintaining blood flow to the brain.
(continued)
LWBK1004-C12_p187-226.indd 225 26/01/12 3:08 AM

Assessing for Postural Hypotension (continued)
Be prepared to steady or assist the client should he or she Promotes safety and reduces the potential for injury.
become dizzy or faint.
Repeat the blood pressure and pulse measurement within Provides data for comparison.
3 minutes of quiet standing (Pickering et al., 2005).
Use a head-up tilt at 60 degrees if the client cannot stand Provides an alternative for unstable or mobility challenged clients.
(Pickering et al., 2005).
Determine if the systolic blood pressure falls 20 mm Hg or Hypotension accompanied by tachycardia is an abnormal
more, the diastolic blood pressure falls 10 mm Hg or more, or response (Carlson, 1999).
the pulse rises 20 beats or more.
comfort.
Instruct the client to rise slowly from a sitting or lying position if Allows time for the physiologic adaptation in blood flow to the
the data indicate the client experiences postural hypotension. brain.
Chap. 10).
Record assessed measurements on the graphic or flow sheet, Provides documentation for future comparisons.
or in the narrative nursing notes.
Verbally report blood pressure measurements to the nurse in Alerts others to monitor the client closely or to modify the client’s
charge. plan of care.
Evaluation
The data validate or disprove that the client experiences postural hypotension.
Document
• Date and time
• Systolic and diastolic pressure measurements and pulse rate in lying and standing or sitting positions
• Assessment site
• To whom abnormal information was reported, and the outcome of the interaction
Date and Time P-68, BP 136/72 in R arm while lying down. BP 110/60 and P-90 in standing position. States, “I feel very light-
headed.” Assisted to lie down in bed. Cautioned to call for assistance when there is a need to ambulate or
get out of bed. Signal cord attached to bed. __________________________________________ SIGNATURE/TITLE
LWBK1004-C12_p187-226.indd 226 26/01/12 3:08 AM

13 Physical Assessment
accommodation
audiometry
auscultation 1. List four purposes of a physical assessment.
body systems approach 2. Name four assessment techniques.
capillary refill time 3. List at least five items needed when performing a basic physical
cerumen assessment.
consensual response 4. Discuss at least three criteria for an appropriate assessment
drape environment.
edema 5. Identify at least five assessments that can be obtained during
extraocular movements the initial survey of clients.
head-to-toe approach 6. State two reasons for draping clients.
hearing acuity 7. Differentiate a head-to-toe and a body systems approach to
inspection physical assessment.
Jaeger chart 8. List six ways in which the body may be divided for organizing
mental status assessment data collection.
palpation 9. Identify two self-examinations that nurses should teach their
percussion adult clients.
physical assessment
Rinne test
smelling acuity
T
Snellen eye chart he first step in the nursing process is assessment, or gathering of
turgor information. The physical assessment (a systematic examination of
visual acuity body structures) is one method for gathering health data. This chapter
visual field examination describes how to perform a physical assessment from a generalist’s
Weber test or beginning nurse’s point of view and identifies common assessment
findings. Students can learn advanced physical assessment skills through
additional education and experience or by consulting specialty texts.
OVERVIEW OF THE PHYSICAL ASSESSMENT
Health care practitioners use various techniques and equipment to

perform the physical assessment. Although the settings for a physical
assessment vary, each environment must facilitate accurate data collec-
tion and be conducive to the client’s privacy and comfort.
Purposes
The overall goal of a physical assessment is to gather objective data
about a client. To achieve this goal, nurses thoroughly examine clients
on admission, briefly at the start of each shift, and any time a client’s
condition changes. The purposes of assessment are as follows:
• To evaluate the client’s current physical condition
• To detect early signs of developing health problems
• To establish a baseline for future comparisons
• To evaluate the client’s responses to medical and nursing interventions
227
LWBK1004-C13_p227-248.indd 227 31/01/12 1:30 AM

■ The nurse shows consideration for alterations in hearing,

vision, or movement before starting the examination.
Before the physical assessment, the nurse may ask, “Is
there anything you want me to know before we begin?” or
“How can I make you as comfortable as possible during
this examination?”
■ If limitations are identified, the nurse makes appropriate
adjustments to the examination such as speaking into the
ear with the best hearing or modifying positions to reduce
discomfort.
■ Physical limitations from chronic diseases (eg, difficulty
breathing, limited movement, weakness) may require modi-
fying assessment techniques during the examination.
A
Techniques
The four basic physical assessment techniques are inspec-
tion, percussion, palpation, and auscultation.
Inspection
Inspection (purposeful observation) is the most frequently
used assessment technique. It involves examining particular
body parts and looking for specific normal and abnormal
characteristics (Fig. 13-1A). With advanced instruction, some
nurses learn to use special instruments to inspect parts of the
body, such as the interior of the eyes, that are potentially inac-
cessible to ordinary vision and inspection techniques.
Percussion B
Percussion, the least used assessment technique by nurses, is
FIGURE 13-1 A. Inspection. (Copyright B. Proud.) B. Percussion.
the striking or tapping a part of the client’s body with the fin- (Copyright Ken Kasper.)
gertips to produce vibratory sounds (see Fig. 13-1B) (Table
13-1). The quality of the sounds aids in determining the
location, size, and density of underlying structures. A sound and vibrations in the chest. Deep palpation is performed by
different from expected suggests a pathologic change in the depressing tissue approximately 1 in. (2.5 cm) with the fore-
area being examined. If percussion is performed correctly, fingers of one or both hands (Fig. 13-2B).
the client experiences no discomfort. Pain could indicate a Palpation provides information about the following:
disease process or tissue injury.
• The size, shape, consistency, and mobility of normal tissue
Palpation and unusual masses
Palpation involves lightly touching or applying pressure to • The symmetry or asymmetry of bilateral (both sides of the
the body. Light palpation involves using the fingertips, the body) structures such as the lobes of the thyroid gland
back of the hand, or the palm of the hand (Fig. 13-2A). It is • Skin temperature and moisture
best used when feeling the surface of the skin, structures that • Any tenderness
lie just beneath the skin, pulsations from peripheral arteries, • Unusual vibrations
TABLE 13-1 Percussion Sounds

SOUND INTENSITY DESCRIPTIVE TERM COMMON LOCATIONS
Muted Soft Flat Muscle, bone
Thud Soft to moderate Dull Liver, full bladder, and tumorous mass
Empty Moderate to loud Resonant Normal lung
Cavernous Loud Tympanic Intestine filled with air
Booming Very loud Hyperresonant Barrel-shaped chest overinflated with trapped air as a result of
chronic lung disease
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CHAPTER 13 Physical Assessment 229
B OX 1 3 - 1 Physical Assessment Equipment

For a basic physical assessment, the nurse needs:
• Gloves
• Examination gown
• Cloth or paper drapes
• Scale
• Stethoscope
• Sphygmomanometer
• Thermometer
• Pen light or flashlight
• Tongue blade
• Assessment form and pen
A
with intestinal hyperactivity, are audible with gross hearing

(ie, listening without any instrumentation).
Nurses must practice auscultation repeatedly on various
healthy and ill people to gain proficiency with the equipment
and experience in interpreting data. To ensure the accuracy
of findings, it is best to eliminate or reduce environmental
noise as much as possible.
Equipment
The items generally needed for a basic physical assessment
are listed in Box 13-1. More advanced practitioners use
B additional examination equipment.
FIGURE 13-2 Palpation techniques. A. Light palpation. B. Deep
palpation. (From Craven, 2009.)
Environment
Nurses assess clients in a special examination room or at
the bedside. Regardless of the assessment location, the area
should have easy access to a restroom; a door or curtain that
Auscultation
ensures privacy; adequate warmth for client comfort; a pad-
Auscultation (listening to body sounds) is used frequently,
ded, adjustable table or bed; sufficient room for moving to
most often to assess the heart, lungs, and abdomen. A stetho-
either side of the client; adequate lighting; facilities for hand
scope is required to hear most internal sounds (Fig. 13-3),
hygiene; a clean counter or surface for placing examination
but in some cases, loud sounds, such as those associated
equipment; and a lined receptacle for soiled articles.
PERFORMING A PHYSICAL
ASSESSMENT
Basic activities involved in a physical assessment include

gathering general data, draping and positioning the client,
selecting a systematic approach for collecting data, and
examining the client.
Gathering General Data

The nurse obtains general data during the first contact with
the client. At this time, the nurse appraises the client’s over-
all condition. By observing and interacting with the client
before the actual physical examination, the nurse notes the
following:
• Physical appearance with regard to clothing and hygiene
FIGURE 13-3 Auscultation. (Photo by B. Proud.) • Level of consciousness
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FIGURE 13-5 A bed-sling scale. (From Craven, 2009.)
body size. The recorded measurements are extremely important

in assessing trends in future weight loss or gain. For hospital-
ized clients, health care practitioners also use weight and height
to calculate dosages of some drugs. In most cases, nurses weigh
and measure adult clients and older children using a standing
scale (Fig. 13-4) (see Nursing Guidelines 13-1.)
Nurses use an electronic bed or chair scale to weigh
medically unstable clients, clients who are extremely obese,
FIGURE 13-4 An assessment of height and weight. (From and clients who cannot stand (Fig. 13-5). Battery-powered
Taylor, 2011.) electronic scales can weigh people who are 400 to 500 lb
(181 to 227 kg) while protecting against a client’s fall or
injury to the nurse. Several models store the client’s weight
• Body size
in its memory, allowing it to be automatically recalled until
• Posture
another client is weighed. Electronic scales can be trans-
• Gait and coordinated movement (or lack of it)
ported from storage to a client’s room when needed.
• Use of ambulatory aids
• Mood and emotional tone
Draping and Positioning
The nurse also gathers some preliminary data, such as Because assessment takes place while clients are naked (or
vital signs (see Chap. 12), weight, and height, at this time. wearing only a loose examination gown), they generally
The nurse documents the client’s weight and height because appreciate being covered with a drape (a sheet of soft cloth
they provide more reliable data than a subjective assessment of or paper). A drape provides more modesty than warmth.
N U R S I N G G U I D E L I N E S 1 3 -1
Rationales
Obtaining Weight and Height
• Check to see that the scale is calibrated at zero. Doing so • Move the lighter weight across the calibrations for individual
ensures accuracy. pounds and ounces until the bar balances in the center of the
• Ask or assist the client to remove shoes and all but a scale. This positioning correlates with the actual weight.
minimum of clothing. Doing so facilitates measuring body • Read the weight and write it down. Doing so ensures accurate
weight. documentation.
• Place a paper towel on the scale before the client stands on it in • Raise the measuring bar well above the client’s head. This
bare feet. This helps to reduce contact with microorganisms on provides room for positioning the client without injury.
equipment that other people use. • Ask the client to stand straight and look forward. Doing so
• Assist the client onto the scale. Doing so helps to prevent facilitates measuring height.
injury should the client become dizzy or unstable. • Lower the measuring bar until it lightly touches the top of the
• Position the heavier weight in a calibrated groove of the scale client’s head. This positioning correlates with actual height.
arm. Doing so provides a rough approximation of the gross • Note the height and write it down. This ensures accurate
body weight. documentation.
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Body Systems Approach

A body systems approach means assessing the client
according to the functional systems of the body. It involves
examining the structures in each system separately. For
example, the nurse assesses the skin, mucous membranes,
nails, and hair because they are all parts of the integumen-
tary system. When assessing the cardiovascular system, the
nurse palpates peripheral pulses, listens to heart sounds, and
so on. One advantage of this method is that findings tend
to be clustered, making problems more easily identifiable.
Disadvantages are that the nurse examines the same areas
of the body several times before completing the assessment;
also, frequent position changes during the examination may
tire the client.
Examining the Client

The procedure for performing a physical assessment is
described in Skill 13-1. Specific assessment techniques,
their purpose, and the data they provide are described later
in the chapter.

FIGURE 13-6 A client is prepared for examination. (Photo by
You have been asked to assess two new clients. One
B. Proud.)
arrived by wheelchair and has been walking around
the nursing unit. The other was transported by ambu-
The examination usually begins with the client stand- lance, has intravenous fluid infusing, and is receiving
oxygen. Which client would you assess first? Why?
ing or sitting (Fig. 13-6). Some components of the physi-
What differences might you use in the physical
cal assessment require the client to recline and turn from assessment of each client?
side to side. Specific positions for special examinations are
described and illustrated in Chapters 14 and 23.
DATA COLLECTION
Selecting an Approach for
Data Collection When collecting data, the nurse may divide the body into six
Once the client is draped and positioned, selection of a general areas: the head and neck, the chest, the extremities,
systematic, organized pattern facilitates further data col- the abdomen, the genitalia, and the anus and rectum. The fol-
lection. Two common approaches are the head-to-toe lowing discussion identifies structures commonly assessed,
approach and the body systems approach. The objective specific techniques used, and common findings.
of both methods is to obtain the same basic data. Con-
sequently, each nurse develops his or her own order and
sequence for examining clients or uses an assessment form Head and Neck
as a guide. Nurses should conduct the assessment consist- Head
ently each time to avoid omitting essential information. The nurse begins at the client’s head by assessing his or her
mental status and the symmetry and function of craniofacial
Head-to-Toe Approach structures (eyes, ears, nose, mouth). The nurse also assesses
A head-to-toe approach means assessing the client from the client’s skin, oral and nasal mucous membranes, hair,
the top of the body to the feet. This has three advantages: and scalp.
1. It helps to prevent overlooking some aspect of data col-
lection. Mental Status Assessment
2. It reduces the number of position changes required of the A mental status assessment (a technique for determining
client. the level of a client’s cognitive functioning) provides infor-
3. It generally takes less time because the nurse is not con- mation about a client’s attention, concentration, memory,
stantly moving around the client in what may appear to be and ability to think abstractly. For most clients, documenting
a haphazard manner. that they are alert and oriented is all that is necessary. More
LWBK1004-C13_p227-248.indd 231 31/01/12 1:30 AM

objective assessment data are important, however, when car- Wheel

ing for the following clients:
• Clients who were previously unconscious
• Clients who were recently resuscitated Detachable
• Clients with periods of confusion head (contains
• Clients with a head injury magnifying
lens)
• Clients who took an overdose of drugs
• Clients with a history of chronic alcoholism
• Clients with a psychiatric diagnosis
Eyes. When examining the head, one of the most obvious A Body (contains light source)
assessments is the appearance of the eyes, which generally
are of similar size and distance from the center of the face.
Each iris is the same color, the sclerae (plural of sclera)
appear white, the corneas are clear, and eyelashes are present
along the margins of each eye. More advanced practition-
ers use an instrument called an ophthalmoscope (Fig. 13-7)
to examine structures within the eye. After gross inspection,
the nurse assesses functions such as visual acuity, pupil size
and response, and ocular movements.
Visual acuity (the ability to see both far and near) is not
assessed in every client. It is always appropriate, however,
to ask if a client wears glasses or contact lenses, has a pros-
thetic eye, or considers himself or herself blind.
To assess far vision grossly, the nurse asks the client to
cover one eye at a time and, from a distance of approximately
20 ft, count the number of fingers the nurse raises. Clients
can wear corrective lenses during this assessment. For close
vision, the nurse asks literate clients to read newsprint from
approximately 14 in. away.
A Snellen eye chart (a tool for assessing far vision)
is a more objective technique (Fig. 13-8). Each line on the B
chart is printed in progressively smaller letters or symbols. FIGURE 13-7 A. Components of an ophthalmoscope.
The nurse asks the client to read the smallest line he or she B. Performing an ophthalmoscopic examination. (From Craven,
can see comfortably from a distance of 20 ft, both with and R. F, Hirnle, C. J. (2008). Fundamentals of Nursing (6th ed.).
without any corrective lenses. The nurse then compares the
client’s vision against norms. tion lenses. This number is written as a fraction (eg, 20/20).
Normal vision is the ability to read printed letters that If, at 20 ft from the chart, a person sees only the first line—
most people can see at a distance of 20 ft without prescrip- one that people with normal vision can see from 200 ft
FIGURE 13-8 Three examples of

Snellen eye charts. (Photo by
Ken Timby.)
LWBK1004-C13_p227-248.indd 232 31/01/12 1:30 AM

Pupil Gauge (mm)
1 2 3 4 5 6 7
FIGURE 13-10 Pupil size assessment guide.
The nurse documents normal findings using the abbreviation

PERRLA: pupils equally round and react to light and accom-
modation (see Nursing Guidelines 13-2).
The nurse observes extraocular movements, which are
eye movements controlled by several pairs of eye muscles.
He or she asks the client to focus on and track the nurse’s
finger or some other object as it moves in each of six posi-
tions (see Fig. 13-11C). During the assessment, both eyes
should move in a coordinated manner. No movement in one
eye may indicate cranial nerve damage; irregular or uncoor-
dinated movement may suggest other neurologic pathology.
FIGURE 13-9 A Jaeger reading test card used for assessing A visual field examination is the assessment of periph-
near visual acuity. (Source: Western Ophthalmics, Lynnwood, eral vision and continuity in the visual field. The nurse may
WA http://www.west-op.com) perform a gross assessment or test using more sophisticated
ophthalmic equipment. For gross assessment, the nurse stands
directly in front of the client, and each person covers his or her
eye. The nurse instructs the client to look straight ahead and
away—the client’s visual acuity is recorded as 20/200. The
indicate when he or she sees a light or the nurse’s finger as the
nurse tests near vision using a Jaeger chart, a visual assess-
nurse brings it from several sectors of the periphery toward the
ment tool with small print (Fig. 13-9).
center. If the client’s and the nurse’s visual fields are normal,
The size of each pupil is estimated in millimeters under
they see the object at the same time. Certain eye and neuro-
normal light conditions (Fig. 13-10). Normal pupils are round
logic disorders are associated with changes in the visual field.
and equal in size. There is also a consensual response (a brisk,
equal, and simultaneous constriction of both pupils when one Ears. The nurse inspects and palpates the external ears.
eye then the other is stimulated with light) (Fig. 13-11A). In More advanced practitioners use an otoscope to examine the
addition, the nurse assesses the pupils for accommodation tympanic membrane, or eardrum.
(the ability to constrict when looking at a near object and dilate The nurse performs a gross examination of the ear by
when looking at an object in the distance) (see Fig. 13-11B). observing the appearance of the ears. Both should be similar
A B C
FIGURE 13-11 A. Testing pupil response to light. B. Testing accommodation. C. Assessing
extraocular movements.
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Rationales
Assessing Pupillary Response
• Dim the lights in the examination area and instruct the client to • Repeat the assessment by directly stimulating the opposite eye.
stare straight ahead. Doing so facilitates pupil dilation. Doing so provides comparative data.
• Bring a narrow beam of light, like that from a pen light or • Ask the client to look at a finger or object approximately
small flashlight, from the temple toward the eye. This step 4 inches (10 cm) from his or her face. This measure produces a
provides a direct stimulus for pupil constriction. situation in which the pupils should get smaller.
• Observe the pupil of the stimulated eye as well as the unstimu- • Tell the client to look from the near object to another that is
lated pupil. The response should be the same. This assessment more distant. This measure produces a situation in which the
indicates the status of brain function. pupils should get larger.
in size, shape, and location. He or she moves the skin behind He or she then asks the client if the sound is audible equally
and in front of the ears as well as the underlying cartilage to in both ears. A positive response indicates either a normal
determine whether there is any tenderness. The nurse shines finding or that hearing in both ears is equally diminished.
a penlight or other light source within each ear to illuminate Hearing the sound louder in one ear is a sign of unequal
the ear canal. For optimal visualization, the nurse straightens hearing (hearing loss greater in one ear).
the curved ear canal as much as possible. For children, this is A tuning fork is also necessary in the Rinne test (an
done by pulling the ear down and back; for an adult, the ear assessment technique for comparing air versus bone conduc-
is pulled up and back (Fig. 13-12). Cerumen (a yellowish- tion of sound). First, the nurse strikes the tuning fork and
brown, waxy secretion produced by glands within the ear) is then places the stem on the client’s mastoid area behind the
a common finding. Any other drainage is abnormal, and the ear (Fig. 13-15). This test is for bone conduction of sound
nurse describes and reports its characteristics. waves in the tested ear. The client reports when the sound
If the client relies on a hearing aid to amplify sound, the stops. The nurse then moves the tines of the still-vibrating
nurse notes that information on the assessment form. The tuning fork near the ear canal and asks the client if he or
nurse may discover changes in hearing acuity (the ability she perceives sound. This tests air conduction of sound in
to hear and discriminate sound) by performing a voice test the tested ear. Both ears are assessed separately. Normally,
or the Weber or Rinne test (see Nursing Guidelines 13-3 and sound is heard longer by air conduction. If the client does
Fig. 13-13). not continue to hear sound when the tuning fork is beside the
The Weber and Rinne tests help to determine hearing ear, it indicates a problem with the ear structures that collect
impairment resulting from sensory nerve damage or disor- and transmit sound through the ear.
ders that interfere with sound conduction through the ear. To Audiometry measures hearing acuity at various sound
perform the Weber test (an assessment technique for deter- frequencies. An audiologist is a professional trained to test
mining equality or disparity of bone-conducted sound), the hearing with standardized instruments. Audiometric hearing
nurse strikes a tuning fork on his or her palm and places the tests measure exact pitch and volume deficits. They meas-
vibrating stem in the center of the client’s head (Fig. 13-14). ure hearing in decibels (intensity of sound)—the greater the
FIGURE 13-12 Technique for straightening the ear canal of an

adult and child. FIGURE 13-13 Voice test. (Photo by B. Proud.)
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Rationales
Performing a Voice Test for Hearing Acuity
• Stand approximately 2 ft behind and to the side of the client. • Instruct the client to repeat the whispered word. This reveals
This placement simulates the distance between most people the client’s ability to discriminate sound.
during social interaction and prevents the client from observ- • Continue the same pattern using several more words; increase
ing visual cues. the volume from a soft to medium to loud whisper or spoken
• Instruct the client to cover the ear on the opposite side (see Fig. voice if the client’s response is inaccurate. Variations provide
13-13). This step facilitates sound conduction to the tested ear more reliable data.
only. • Repeat the test on the opposite ear. Doing so provides separate
• Whisper a color, number, or name toward the uncovered ear. assessment findings for each ear.
Doing so delivers a high-pitched sound, the most common type
of hearing loss, toward the tested ear.
intensity of sound that can be heard by the client, the more Mouth and Oral Mucous Membranes
impaired the hearing (Table 13-2). The lips surround the mouth, which contains the tongue and
teeth. The nurse inspects these structures by having the cli-
Nose. The nurse inspects the nose and nasal passages by
ent open the mouth widely. The protruding tongue is nor-
having the client assume a “sniffing” position. The septum
mally in midline. The nurse documents any dentures, miss-
(the tissue that divides the nose in half) should be in mid-
ing or malpositioned teeth, or a partial plate. Some unusual
line with equal-sized nasal passages. Pressing at the tip
breath odors are diagnostic. For example, the odor of alcohol
of the nose facilitates deeper inspection. Air should move
or acetone suggests additional health problems.
fairly quietly through the nose during breathing. Normal
Normal oral mucous membranes are pink, intact, and
nasal mucous membrane is pink, moist, and free of obvious
kept moist by salivary glands located below the tongue.
drainage. The nurse documents a deviated septum, lesions,
When the client smiles, purses the lips as though preparing
growths, flaring of the nostrils, or unusual drainage.
to whistle, or shows the teeth, the lips should look the same.
Smelling acuity (the ability to smell and identify odors)
The tongue contains many taste buds that detect partic-
is not commonly checked unless impairment is suspected.
ular taste characteristics. Although assessing taste is rarely
To test smelling acuity:
1. Have the client occlude one nostril and close his or her eyes.
2. Place substances with strong odors, such as lemon, vanilla
extract, coffee, peppermint, or alcohol, one at a time
beneath the patent (open) nostril.
3. Ask the client to sniff and identify the substance.
FIGURE 13-15 For the Rinne test, the tuning fork base is
placed first on the mastoid process (top), after which the
FIGURE 13-14 The Weber test assesses sound conducted prongs are moved to the front of the external auditory canal
through bone. (Photo by B. Proud.) (bottom). (Photo by B. Proud.)
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TABLE 13-2 Hearing Acuity Levels TABLE 13-3 Common Skin Color Variations
HEARING LEVEL DECIBEL RANGE (dB) COLOR TERM POSSIBLE CAUSES
Normal 0–25 Pale, regard- Pallor Anemia, blood loss
Mildly impaired 26–30 less of race
Moderately impaired 31–55 Red Erythema Superficial burns, local inflam-
Moderately to severely impaired 56–70 mation, carbon monoxide
Severely impaired 71–90 poisoning
Profoundly impaired 91 or greater Pink Flushed Fever, hypertension
Purple Ecchymosis Trauma to soft tissue
Blue Cyanosis Low tissue oxygenation
Yellow Jaundice Liver or kidney disease,
destruction of red blood
done, it is facilitated by placing substances on the tongue cells
Brown Tan Ethnic variation, sun expo-
and asking the client to identify them with the eyes closed.
sure, pregnancy, Addison’s
To ensure valid results, the nurse instructs the client to sip disease
water between assessments.
Facial Skin. The nurse notes characteristics of the facial
skin while assessing the head. Although skin assessment
begins here, it continues as the nurse examines other body
areas. Regardless of location, skin should be smooth, unbro- Neck
ken, of uniform color consistent with the client’s ethnicity The neck supports the head in midline. The client should be
or race, warm, and resilient. It should not be wet or unu- able to bend the head forward, backward, and to either side,
sually dry. Diagnostic variations in skin color are listed in as well as to rotate it 180 degrees. The trachea (windpipe)
Table 13-3. should be in the center of the neck. Pulsations in the carotid
While examining the skin, the nurse may detect one or arteries (see Chap. 12) are visible and easy to palpate. There
more alterations in its integrity: should be no unusual bulges or fullness in the neck. Some
nurses lightly palpate the lymph nodes in the neck area or
• A wound is a break in the skin. assess anteriorly for an enlarged thyroid gland.
• An ulcer is an open, crater-like area.
• An abrasion is an area that has been rubbed away by
friction.
Chest and Spine
The chest is a cavity surrounded by the ribs and verte-
• A laceration is a torn, jagged wound.
brae and houses the heart and lungs. The nurse observes
• A fissure is a crack in the skin especially in or near mucous
the chest’s shape and movement with breathing, notes the
membranes.
curved appearance of the spine, and assesses skin turgor,
• A scar is a mark left by the healing of a wound or lesion.
breasts, heart sounds, and lung sounds.
Other common skin lesions and their characteristics are Turgor (the resiliency of the skin) is a combination of the
described in Table 13-4. Additional skin assessments are elastic quality of the skin and the pressure exerted on it by the
described later as related to other body areas. fluid within. To assess skin turgor, the nurse grasps the client’s
skin between the thumb and fingers in an attempt to lift it from
the underlying tissue. The area over the chest is a good assess-
A nurse has documented that a client has maculopa- ment location because the skin in other areas tends to loosen
pular skin lesions over her body. Describe how these
with age. When the nurse releases the tissue, it should return
would appear.
immediately to its original position. Prolonged “tenting” indi-
cates dehydration.
Hair. Assessment of the hair includes scalp hair, eyebrows,
and eyelashes. The nurse notes the color, texture, and distri-
Chest Shape and Movement
bution (presence or absence in unusual locations for gender
In normal adults, the lateral dimension of the chest is
or age). He or she also inspects the hair for debris such as
approximately twice the anterior–posterior dimension. Vari-
blood in a client with head trauma, nits (eggs from a lice
ous musculoskeletal abnormalities, cardiac or respiratory
infestation), or scales from scalp lesions. As the physical
diseases, or trauma can cause changes in shape (Fig. 13-16).
assessment progresses, the nurse also observes the charac-
With normal breathing, the chest expands equally on both
teristics of body hair.
sides. To assess chest expansion, the nurse places his or her
Scalp. The nurse assesses the scalp by randomly separating thumbs side by side over the client’s posterior vertebrae at
the hair and inspecting the skin. He or she looks for signs about the level of the 10th rib (Fig. 13-17). As the client
that the scalp is smooth, intact, and free of lesions. The nurse inhales, the nurse notes how far the thumbs separate; nor-
also palpates the skull for any unusual contour. mally the distance is 1 to 2 in. (3 to 5 cm).
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TABLE 13-4 Common Skin Lesions

TYPE OF LESION DESCRIPTION EXAMPLE ILLUSTRATION
Macule Flat, round, colored, nonpalpable area Freckles
Papule Elevated, palpable, solid Wart
Vesicle Elevated, round, filled with serum Blister
Wheal Elevated, irregular border, no free fluid Hives
Pustule Elevated, raised border, filled with pus Boil
Nodule Elevated, solid mass, deeper and firmer Enlarged lymph node
than papule
Cyst Encapsulated, round, fluid-filled or solid Tissue growth

mass beneath the skin
Spine Breasts
The spine, or vertebral column, appears in midline with gen- Although breast abnormalities such as tumors can occur
tle concave and convex curves when viewed from the side. in men, they are more common in women. Usually, more
The shoulders are at equal height. Some common devia- advanced practitioners examine the breasts manually. In
tions may be noted (Fig. 13-18). Lordosis is an exaggerated November 2009, the U.S. Preventive Services Task Force
natural lumbar curve of the spine. Kyphosis is an increased made several controversial recommendations: (1) that teach-
thoracic curve. Scoliosis is a pronounced lateral curvature ing breast self-examination (BSE) is unnecessary because
of the spine. there is no net benefit and (2) that routine mammography
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A B C D
FIGURE 13-16 A. Normal chest size and shape; anterolateral dimension is twice the
anteroposterior dimension. B. Barrel chest. C. Pigeon chest. D. Funnel chest.
screening should begin at age 50 and every 2 years thereafter Heart Sounds
because earlier screenings rarely saved lives and more often When assessing the anterior chest, the nurse listens to the
resulted in misdiagnoses (Agency for Health Care Research heart sounds, which presumably are caused by the closing
and Quality, 2009). However, the Society of Breast Imag- of the atrial and ventricular valves. A beginning nurse may
ing, the American College of Radiology, and the American limit assessment to the apical area (see Chap. 12). Experi-
Cancer Society continue to advocate that mammography enced nurses expand their skills to auscultate at the aortic,
screening should begin at age 40. Furthermore, the Ameri- pulmonic, tricuspid, and mitral areas (Fig. 13-20).
can Cancer Society recommends that although BSE plays a
small role in finding breast cancer, its benefit lies in help- Normal Heart Sounds
ing women assess the look and feel of their breasts to detect The two normal heart sounds are S1 and S2. S1, the first
changes (American Cancer Society, 2009). For those women heart sound, correlates with the “lub” sound and is louder at
who wish to perform BSE, nurses are the ideal health prac- the apex or mitral area when using the diaphragm of a steth-
titioner to teach this self-assessment technique (Client and oscope. Although the second heart sound, S2 or the “dub”
Family Teaching 13-1, Table 13-5, and Fig. 13-19). sound, can be heard in the mitral area, it is louder over the
aortic area.
Sometimes there is a slight slurring, or splitting, of one
or both sounds that lasts just a fraction of a second longer.
It may sound like “lubba-dub” or “lub-dubba.” Split sounds
generally are attributed to the fact that the valves between
the atria (or ventricles) do not always close in exact unison.
Splitting, if heard at all, generally is noted with the stetho-
scope at point P or T on the chest.
Inspiration
Expiration
FIGURE 13-17 Palpation of thoracic excursion. In the posterior

A B C D
approach, the nurse places the hands at the level of the 10th FIGURE 13-18 Variations in spinal curves: normal (A), scoliosis
rib and observes for equal movement as the client inhales. (B), lordosis (C), and kyphosis (D).
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TABLE 13-5 Breast Examination Guidelines

Breast Self-Examination TECHNIQUE AGE FREQUENCY
Self-examination (optional) ≥20 years Once per month
The nurse teaches the client as follows:
Clinical examination by a 20–39 Every 3 years
● Examine the breasts monthly about 1 week after the nurse or physician years
menstrual period or on a specific date postmenopause. ≥40 years Every year
● Begin the examination in the shower. Mammography 40 years First examina-
● Use the right hand to examine the left breast and the left tion and yearly
hand to examine the right breast. thereafter
● Place the hand on the side that will be examined behind Clinical exam, mammogra- Any age, Yearly
phy, magnetic reso- high risk
the head.
nance imaging (MRI)
● Glide the flat portion of the fingers over each breast up
to the collarbone, out to the armpit, to the middle of the Source: American Cancer Society, 2009.
chest, and down to the bottom of the rib cage (see Fig.
13-19) in an up-and-down or vertical pattern.
● Determine if there are any lumps, hard knots, or thick-
ened areas. Abnormal Heart Sounds
● Next, stand in front of a mirror. The nurse may hear two additional sounds, S3 and S4, when
● Look at both breasts with the arms relaxed at the side,
auscultating the chest. S3, which is normal in children but
with the hands pressing on the hips, and with the hands
abnormal in most adults, appears after S2. S3 sounds like
elevated above the head.
● Look for dimpling in the skin or retraction of either nipple. “lub-dub-dub” or the cadence of sounds in “Ken-tuck-y.”
● Lie down for the remainder of the examination. An S3 is much more pronounced than a split second sound.
● Put a pillow or folded towel under the shoulder on the S4 is heard just before S1. It may sound like “lub-lub-dub”
side where the first breast will be examined; reverse the or the syllables in “Ten-nes-see.”
pillow before examining the second breast. Identifying abnormal heart sounds—S3, S4, heart mur-
● Again, place the arm behind the head. murs, clicks, and rubs—is a skill that nurses master after they
● Press the flat surface of the fingers in small circular become proficient at distinguishing S1 from S2. A beginning
motions from the outer margin of the breast toward the nurse should consult with an experienced nurse or physician
nipple, feeling for changes in any area of the breast (see if there are any unusual characteristics in a client’s S1 and
Fig. 13-19).
S2 heart sounds.
● Feel upward toward the axilla of each arm.
● Complete at least three revolutions about the breast. Lung Sounds
● Squeeze the nipple gently between the thumb and index Listening to the lungs is another skill that requires frequent
finger to determine if there is any clear or bloody discharge.
and repeated practice because some sounds are normal
● Repeat the examination on the opposite breast and axilla.
and others are abnormal (see Nursing Guidelines 13-4 and
● Report any unusual findings or changes to a physician.
● Breast self-examination may be combined with
Figure 13-21).
a clinical examination and mammography to ensure
early diagnosis and treatment of cancerous tumors (see Normal Lung Sounds
Table 13-5). Normal lung sounds are created by air moving in and out
of passageways. The sounds vary in pitch and duration in
FIGURE 13-19 Patterns for assessment of breast tissue. The vertical up-and-down pattern start-
ing at an imaginary line drawn straight down the side from the underarm and moving across
the breast from the clavicle to the base of the ribs is the most effective pattern for covering
the entire breast without missing any breast tissue (American Cancer Society, 2009). (From
Taylor, 2011.)
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• Bronchial sounds, heard over the upper sternum and between

the scapulae, are harsh and loud. They are shorter on inspira-
tion than expiration with a pause between them.
• Bronchovesicular sounds are heard on either side of the central
chest or back. These medium-range sounds of equal length dur-
ing inspiration and expiration have no noticeable pause.
• Vesicular sounds are located in the periphery of all the lung
fields. Their soft, rustling quality is longer on inspiration
than expiration, with no pause between.
Abnormal Lung Sounds

Abnormal lung sounds, known as adventitious sounds, are
those heard in addition to normal lung sounds. Most adven-
titious sounds are created by air moving through secretions
or narrowed airways. Adventitious sounds are divided into
four categories:
• Crackles, also called rales, are intermittent, high-pitched,
popping, and heard in distant areas of the lungs, primarily
FIGURE 13-20 Locations for assessing heart sounds: M, mitral during inspiration. They resemble the sound of crisped rice
area; T, tricuspid area; P, pulmonic area; A, aortic area. cereal when milk is added. They are attributed to the open-
ing of partially collapsed alveoli (terminal air sacs) or the
relation to the size and location of the air passages (Fig.
movement of air over minute amounts of fluid in the
13-22). There are four normal lung sounds:
periphery of the lungs during deep inspiration.
• Tracheal sounds are loud and coarse. They are equal in • Gurgles, also called rhonchi, are low-pitched, continuous,
length during inspiration and expiration and are separated bubbling, and heard in larger airways. They are more
by a brief pause. prominent during expiration. Some describe gurgles as

Rationales
Assessing Lung Sounds
• Wash hands or perform hand antisepsis with an alcohol rub • Listen for one complete ventilation (inspiration and expiration)
(see Chap. 10). These measures reduce the spread of infection. at each area auscultated. This method ensures hearing charac-
• Provide privacy. Doing so demonstrates concern for client teristics during each phase of ventilation.
modesty. • If body hair causes noise, wet it or press harder with the chest
• Raise the bed to a comfortable position for you. Doing so piece. This technique reduces sound distortion.
reduces strain on the musculoskeletal system. • Move the diaphragm from side to side from the apices (top) to
• Assist the client to a sitting position, if possible. This posi- the bases (bottom) of the lungs (see Fig. 13-21). This sequence
tion facilitates auscultating the anterior, posterior, and lateral facilitates comparison of sounds.
aspects of the chest with minimal client exertion. • Auscultate the lateral and anterior chest in a similar fashion.
• Remove or loosen the client’s upper clothing. Doing so aids in Doing so ensures a comprehensive assessment.
identifying anatomic landmarks. • Ask the client to cough or breathe deeply if crackles or gurgles
• Reduce or eliminate environmental noise such as suction are audible. This method helps to clear the air passages and
motors and oxygen equipment. Quiet conditions promote the open the alveoli.
accurate identification of lung sounds. • Reapply clothing and lower the bed. Doing so restores comfort
• Ask the client to refrain from talking. Talking interferes with and safety.
concentration and distorts lung sounds. • Wash hands or perform hand antisepsis with an alcohol rub
• Warm the diaphragm of the stethoscope in the palm of your (see Chap. 10). Doing so reduces the spread of microorgan-
hand. Warmth reduces discomfort when the diaphragm is isms.
applied to the chest. • Record assessment findings. Documented data can be used for
• Instruct the client to breathe in and out through an open mouth future comparisons.
deeply but slowly. This type of breathing reduces noise from • Repeat lung sound assessments according to agency policy or
air turbulence and prevents hyperventilation. the client’s condition. Doing so demonstrates responsibility,
• Apply the chest piece to the upper back, but avoid placement accountability, and good clinical judgment.
over the scapulae or ribs. This method facilitates hearing
sounds in the upper and lower lobes and reduces competing
sounds from the heart.
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A B C
FIGURE 13-21 The auscultation sequence: anterior (A), lateral (B), and posterior (C).
sounding like wet snoring. Gurgles may clear with deep Extremities
breathing or coughing. The nurse notes the alignment, mobility, and strength of the
• Wheezes are whistling or squeaking sounds caused by air extremities and compares their size. He or she feels the skin
moving through a narrowed passage. They can be heard temperature, notes the characteristics of the nails, times the
anywhere in the chest during inspiration or expiration. capillary refill, palpates local peripheral pulses (see Chap.
Wheezes may be audible without a stethoscope. Coughing 12), checks for edema, and may test the perception of skin
and deep breathing do not usually alter a wheeze; in fact, sensations. Advanced practitioners assess deep tendon
if wheezing suddenly stops, it may mean that the air pas- reflexes with a reflex hammer.
sage is totally occluded.
• Rubs are grating, leathery sounds caused by two dry pleu- Muscle Strength
ral surfaces moving over each other. The nurse assesses all four extremities separately to deter-
mine muscle strength. He or she asks the client to grasp,
Whenever adventitious sounds are heard, the nurse also
squeeze, and release the nurse’s fingers. As the nurse pulls
assesses the characteristics of any cough and the appearance
and pushes on the forearm and upper arm, he or she instructs
of raised sputum.
the client to resist. To test strength in the lower extremi-
➧ Stop, Think, and Respond Box 13-3 ties, the nurse has the client push and pull against resistance
What physical assessments are appropriate when a (Fig. 13-23).
client is coughing frequently?
Fingernails and Toenails
Changes in the shape and thickness of the fingernails and
toenails are often signs of chronic cardiopulmonary dis-
ease (Fig. 13-24) or fungal infections. The nurse docu-
ments any unusual characteristics of the nails or surround-
ing tissues.
Capillary refill time (the time it takes blood to resume
flowing in the base of the nail beds) is normally less than 3
seconds after compression and release of the nail bed. To
assess capillary refill time:
1. Observe the color in the nail bed.
2. Depress the nail bed, displacing capillary blood.
3. Release the pressure.
4. Note how many seconds it takes for the preassessment
color to reappear. Watching a clock would interfere with
an accurate assessment, so count, “one-one thousand,
two-one thousand, three-one thousand” to estimate the
time in seconds.
FIGURE 13-22 Locations of normal lung sounds. The symbols
indicate the ratio of time they may be heard during inspiration Edema
and expiration, as well as the presence or absence of pauses Edema is excessive fluid within tissue and signifies abnor-
between the two. mal fluid distribution. Clients with cardiovascular, liver,
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Diamond-
shaped
space
FIGURE 13-24 A technique for assessing clubbed fingernails. A

diamond-shape space between the nails of the ring fingers is
normal.
Skin Sensation
During a comprehensive rather than a basic assessment, the
nurse tests the client’s ability to differentiate between light
touch, warmth, cold, sharp, dull, and vibration (see Nursing
Guidelines 13-5).
B
FIGURE 13-23 Assessing muscle strength of lower extremities. ABDOMEN

A. Resisting the push of a nurse. B. Resisting the pull by a nurse.
Most gastrointestinal and accessory digestive organs lie

within the abdomen. The bladder, if distended, may rise into
and kidney dysfunction are prone to edema. Subtle signs the abdomen.
of edema include weight gain, tight rings, and patterns in For assessment purposes, the abdomen is divided
the skin after removing socks or shoes. To determine the into four quadrants (Fig. 13-25). The abdomen is always
extent of any edema, the nurse presses a thumb or finger inspected and then auscultated—in that sequence—before
into the tissue over a bone. If an indentation remains (pit- using palpation or percussion techniques. Touching or
ting edema), the nurse attempts to quantify its severity manipulating the abdomen can alter bowel sounds, thus pro-
(Box 13-2). ducing invalid findings.
Assessing Sensory Skin Perception

• Gather a cotton ball, a safety pin, or other pointed object; • Touch the client with the test objects in a random pattern. A
a small container of warm water and one of ice water; and random pattern prevents the potential for correct guessing.
a tuning fork. These materials provide for a variety of test • Use both the pointed and curved ends of the safety pin to deter-
resources. mine if the client can discriminate between sharp and dull. Take
• Instruct the client to shut both eyes. Doing so reduces the care not to puncture the skin. Doing so prevents injury.
potential for gathering invalid data. • Stroke the skin with the cotton ball; touch areas with the warm
• Explain that you will touch the skin with test objects at various and cold containers. These tests assess the client’s ability to
places and on both sides of the body and that you will ask the identify fine touch and differences in temperature.
client to identify the location and characteristics of the sensa- • Strike a tuning fork and place the stem against bony areas such
tion. This information identifies the test method and how the as the wrists and along the length of the shins. This tests the
client is expected to respond. client’s ability to sense vibration.
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B OX 1 3 - 2 Criteria for Estimating Pitting Edema
1+ Pitting Edema 2+ Pitting Edema

• Slight indentation (2 mm) • Deeper pit after
• Normal contours pressing (4 mm)
• Associated with interstitial • Lasts longer than 1+
2 mm 4 mm
fluid volume 30% above • Fairly normal contour
normal
3+ Pitting Edema 4+ Pitting Edema

• Deep pit (6 mm) • Deep pit (8 mm)
• Remains several seconds • Remains for a prolonged
after pressing time after pressing,
6 mm 8 mm
• Skin swelling obvious by possibly minutes
general inspection • Frank swelling
5+ Brawny Edema
• Fluid can no longer be displaced secondary
to excessive interstitial fluid accumulation
• No pitting
• Tissue palpates as firm or hard
• Skin surface shiny, warm, moist
Midline
Right Upper Quadrant Left Upper Quadrant

Pylorous Stomach
A B Duodenum Spleen
Liver Left kidney and
Right kidney and adrenal gland
adrenal gland Splenic flexure of colon
Hepatic flexure of colon Body of pancreas
RUQ LUQ
Head of pancreas
Right Lower Quadrant Left Lower Quadrant

RLQ LLQ
Cecum Sigmoid colon
C D Appendix Left ovary and
Right ovary and fallopian tube (female)
fallopian tube (female) Left ureter and
Right ureter and lower kidney pole
FIGURE 13-25 The four abdominal lower kidney pole Left spermatic cord
quadrants. A. The right upper Right spermatic cord (male)
quadrant (RUQ). B. The left (male)
upper quadrant (LUQ). C. The right
lower quadrant (RLQ). D. The left Midline
lower quadrant (LLQ). (From Taylor, Urinary bladder
2011.) Urethra (female)
LWBK1004-C13_p227-248.indd 243 31/01/12 1:30 AM


Rationales
Assessing Bowel Sounds
• Have the client recline. This position provides access to the (LUQ), and ending at the left lower quadrant (LLQ)). If
abdomen. no sounds are audible initially, listen for 2 to 5 min. This
• Reduce noise. A quiet environment facilitates an accurate sequence follows the anatomic areas of the upper to lower
assessment. bowel.
• Warm the diaphragm of the stethoscope. Warmth promotes • Document the frequency and character of the bowel sounds.
comfort. Doing so provides data for problem identification and future
• Place the diaphragm lightly in the right lower quadrant comparisons.
(RLQ) and listen for clicks or gurgles. Move the chest piece • Once you have finished the auscultation, note the softness or
over all four quadrants in a clockwise pattern from the RLQ firmness of the abdomen and feel for palpable masses (see
to the right upper quadrant (RUQ) to the left upper quadrant Box 13-3).
Bowel Sounds the largest diameter. To ensure that he or she always meas-
Wave-like muscular contractions of the large and small ures from the same location, the nurse makes guide marks on
intestines that move fluid and intestinal contents toward the skin with an indelible pen (Fig. 13-26).
the rectum produce bowel sounds. The nurse routinely
assesses a client’s bowel sounds on admission and once Genitalia
per shift. In most cases, the nurse only inspects the genitalia. If contact
Normal bowel sounds resemble clicks or gurgles and with genital structures or secretions is required, the nurse
occur 5 to 34 times a minute (Bickley, 2008). They are more dons gloves. To eliminate the possibility of being falsely
frequent after eating. Bowel sounds are described as hyper- accused of sexual impropriety, it is a good practice to ask
active if they are frequent, hypoactive if they occur after long someone of the client’s gender to be present when the nurse
intervals of silence, and absent if no sound is heard for 2 to touches the genitalia.
5 minutes. Occasionally, the nurse also detects the sound of During inspection, the nurse notes the condition of
blood pulsating through the abdominal aorta (see Nursing the skin and the distribution and characteristics of pubic
Guidelines 13-6 and Box 13-3). hair (lice may infest pubic hair). A physician or nurse with
advanced skills examines females internally with an instru-
Abdominal Girth ment called a speculum (see Chap. 14); in men, the prostate
If the abdomen appears unusually large, the nurse checks its gland is palpated during a digital rectal examination.
girth (circumference) daily by using a tape measure around The nurse observes if the male is circumcised and if the
scrotum appears to be of normal size. Whenever possible,
he or she instructs male clients how to examine their testi-
cles (see Client and Family Teaching 13-2 and Fig. 13-27).
B OX 1 3 - 3 Characteristics of Palpated Masses
CHARACTERISTIC DESCRIPTION
Mobility Fixed—does not move

Mobile—can be moved with palpation
Shape Round—resembles a ball Largest diameter Markings on
Tubular—is elongated abdomen
Ovoid—resembles an egg
Irregular—has no definite shape
Consistency Edematous—leaves indentation when
palpated
Nodular—feels bumpy to touch
Granular—feels gritty to touch
Spongy—feels soft to touch
Hard—feels firm to touch
Size Measured in centimeters (1 cm = approxi-
mately 0.4 in.)
Tenderness Amount of discomfort when palpated—
none, slight, moderate, or severe
FIGURE 13-26 Measuring abdominal girth.
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Testicular Self-Examination
The nurse teaches the client as follows:
● Examine the testes monthly at a time when the testicles
are warm and positioned loosely within the scrotum (eg,
during bathing or showering).
● Elevate the penis with one hand.
● Gently roll each testicle within the scrotum between the
thumb and index finger.
● Feel each testicle vertically and horizontally
(see Fig. 13-27).
● Check for any unusual lumps; cancerous lumps are
located most often on the upper and outer sides of the
testes. FIGURE 13-28 An inspection of the anus.
● Continue palpation following the spermatic cord from the
testicle to where it ascends into the abdomen.
● Report any unusual findings to a physician as soon as
possible; an early diagnosis carries a better prognosis.
Anus and Rectum
Unless a client has specific symptoms, the nurse inspects
only the anus. If touching is required, gloves are necessary.
To examine the anus, the nurse positions the client on the
side with the knees bent. He or she separates the client’s
buttocks and inspects the external orifice (Fig. 13-28). The
area should appear intact but more pigmented than adjacent
skin; it should be moist and hairless. External hemorrhoids
(saccular protrusions filled with blood) may extend beyond
the external sphincter muscle. There may be rectal fissures
(cracks) if the client has a history of chronic constipation.
Trauma also may be present if the client has anal inter-
course.
NURSING IMPLICATIONS
Assessment findings form the basis for identifying health
problems. Often during a physical assessment, clients reveal
A situations that caused their health to fail, or they indicate a
desire for more health information. The following are some
nursing diagnoses that may apply:
• Readiness for Enhanced Knowledge
• Ineffective Health Maintenance
• Ineffective Self-Health Management
• Noncompliance
• Readiness for Enhanced Self-Health Management
Nursing Care Plan 13-1 is an example of how the nurs-
ing process is used when a client has the nursing diagnosis of
Readiness for Enhanced Self-Health Management, defined
B C by NANDA-I (2012, p. 164) as “a pattern of regulating and
FIGURE 13-27 A testicular self-examination. A. Horizontal pal- integrating into daily living a therapeutic regimen … that
pation. B. Vertical palpation. C. Palpation of spermatic cord. is sufficient for meeting health-related goals and can be
(From Taylor, 2011.) strengthened.”
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N U R S I N G C A R E P L A N 1 3 - 1 Readiness for Enhanced Self-Health Management
Assessment • Other evidence that validates the nursing diagnosis of Readi-
• Interact with the client to determine if he or she expresses a ness for Enhanced Self-Health Management is that the client
desire to seek a higher level of wellness or manifests a lack of voices an interest in making choices in daily living that are
knowledge about health promotional activities. appropriate for meeting goals that reduce health risk factors
and prevent illness.
Nursing Diagnosis. Readiness for Enhanced Self-Health Management related to prevention of sexually transmitted diseases
(STDs) and pregnancy as evidenced by the following statements, “I’ve been having sex with many women. None of them has gotten
pregnant, and I haven’t caught any diseases as far as I know. But I don’t want to take chances anymore.”
Expected Outcome. The client will describe safer sexual practices within 24 hours (time of anticipated discharge), following a
surgical repair of an inguinal hernia.
Determine the client’s knowledge regarding various com- Effective health teaching builds on a foundation of knowledge
mon STDs and how they are transmitted. that the client already has acquired.
Explore the client’s views concerning nonpermanent meas- The client’s ability to incorporate new health behaviors depends
ures that men can implement to reduce the potential for on his acceptance of and willingness to integrate such
pregnancy. changes.
Provide pamphlets titled “Choices” and “Understanding Information from an authoritative resource provides scientifically
Safer Sex” from the Reproductive Control Clinic. These based information.
describe birth control measures and illustrate the tech-
nique for applying a condom to prevent STDs.
Give the client a supply of free condoms from the Repro- An initial supply of condoms facilitates implementation of new
ductive Control Clinic. health behaviors until the client acquires his own personal supply.
Review the following health information and illustrations
(A and B) in the pamphlets.
A. To apply, roll the condom completely over the erect penis

while pinching the space at the condom tip. B. Hold the
condom at the base of the penis during its removal from the
vagina.
A B
Reduce sexual partners to one noninfected, faithful person. Sex with a monogamous, disease-free partner reduces the
potential for acquiring an STD.
Use a latex condom and apply nonoxynol-9 either over the A condom provides a barrier for sperm and microorganisms.
tip of the condom or as a vaginal application. Nonoxynol-9 is a chemical spermicide.
Roll the condom completely over the erect penis while Leaving a space provides an area where semen can collect
pinching a space at the condom tip. without breaking the condom.
Hold the condom at the base of the penis and promptly Prompt removal of a condom reduces the potential for leaking
remove the condom-covered penis from the vagina before sperm within the vagina, which can lead to pregnancy.
the penis becomes limp.
Do not have sexual contact again unless you apply another For maximum effectiveness, condoms are recommended for
condom. single use.
If a condom breaks or leaks, urinate immediately and wash Urination helps to eliminate microorganisms that cause STDs
the penis with soap and water. through the male urethra. Washing with soap and water
removes microorganisms from the surface of the penis.

• The client reads the pamphlets provided. I plan to use them from now on until I find the right life part-
• The client states, “Condoms are inconvenient, but they’re ner.”
better than getting a disease. They’re also cheaper than babies.
246
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CRITICAL THINKING EXERCISES 3. A nurse caring for a client with a head injury per-
forms all of the following assessments. Which one is
1. A client reports that he has not had a bowel move- most important at this time?
ment for 3 days, which is unusual for him. Discuss 1. Assessing the client’s lung sounds
the physical assessments important to perform at this 2. Assessing the client’s skin integrity
time. 3. Assessing the client’s urine characteristics
2. Describe the characteristics of lung sounds normally 4. Assessing the client’s pupillary responses
heard at the midchest area below the nipple line. 4. Where is the best location for the nurse to auscultate
3. What action is appropriate if an older adult becomes an S1 heart sound?
fatigued during a physical assessment? 1. The fifth intercostal space in the left midclavicular
4. What information could the nurse provide to a female line
client who is confused about the change in the breast 2. The fourth intercostal space to the left of the
examination guidelines? sternum
3. The second intercostal space to the right of the
sternum
NCLEX-STYLE REVIEW QUESTIONS 4. The second intercostal space to the left of the
1. Although all the following information is appropri- sternum
ate to gather when assessing a client with a cough, 5. What is the most accurate instruction a nurse can
besides documenting the characteristics of the cough, provide before using a Snellen chart to assess a cli-
what other assessment information is essential? ent’s vision?
1. The client’s family history of respiratory disease 1. “Read the words in a sample newsprint.”
2. A current assessment of the client’s heart rate 2. “Read the letters standing at a distance of 20 feet.”
3. The appearance of respiratory secretions 3. “Look at the colored picture and identify the
4. Any self-treatment that the client is using image.”
2. Which explanation is best when teaching a client 4. “Look at the screen and indicate when you see an
how to palpate breast tissue during a breast self- object.”
examination?
1. Move up and down beginning in the axilla
2. Move in small circles from the nipple outward
3. Move laterally from the sternum across the breast
4. Move diagonally in four breast quadrants
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SKILL 13-1 Performing a Physical Assessment
ASSESSMENT
Identify the client. Ensures that the assessment is being performed on the correct
person.
Determine the client’s age, gender, and race. Forms the basis for planning techniques for physical assessment.
Observe the client’s state of alertness and ability to move. Aids in determining the best location for the assessment and if
the nurse, client, or both will require assistance.
Ask the client’s opinion about his or her health status and any Helps to focus attention during the assessment on particular
current or recent signs and symptoms. structures and their functions.
PLANNING
Give the client a specimen container, if a urine sample is Takes advantage of an opportunity when the client’s bladder
needed. contains urine.
Have the client empty his or her bladder before undressing. Facilitates the examination and reduces discomfort.
Pull the curtain or close the door and give the client a drape or Prepares the client for an accurate assessment and ensures
examination gown to put on after undressing. privacy.
Gather assessment equipment and supplies (see Box 13-1 for Promotes organization and efficient time management.
basic necessities).
Decide to examine the client using either a head-to-toe or a Establishes the plan for assessment and ensures that comprehen-
body systems approach. sive data will be gathered.
IMPLEMENTATION
Explain how the assessment will be conducted. Reduces anxiety.
Explain that all information will be kept confidential among those Encourages the client to be honest and open in identifying health
involved in the client’s care. problems.
Wash hands or perform hand antisepsis with an alcohol rub Provides reassurance that the nurse is clean and conscientious
(see Chap. 10), preferably in the client’s presence. about controlling the spread of microorganisms.
Warm your hands before touching the client. Demonstrates concern for the client’s comfort.
Obtain the client’s height, weight, and vital signs. Contributes to the general survey of the client.
Assist the client to sit at the bottom of the examination table. Facilitates examination of the upper body without requiring the
client to change positions.
Modify the client’s position if the examination is being con- Demonstrates adaptability.
ducted in locations other than an examination room.
Explain each assessment technique before performing it. Reduces anxiety.
Try to avoid tiring the client and apologize if the client experi- Demonstrates concern for the client’s comfort.
ences discomfort.
Help the client to resume sitting after the examination. Places the client in the best position for communicating.
Wash hands or perform hand antisepsis with an alcohol rub (see Shows responsibility for controlling the spread of microorganisms.
Chap. 10) once again.
Review pertinent findings, both normal and abnormal, without Demonstrates compliance with the client’s right to information.
making medical interpretations.
Offer the client an opportunity to ask questions. Encourages active participation in learning and decision making.
Begin organizing assessment findings outside the examination Ensures privacy.
room while the client dresses or dons a bathrobe.
Help the client leave the examination room. Demonstrates courtesy and concern for the client’s safety.
Dispose of soiled equipment, restore cleanliness and order to Shows consideration for the next person who uses the examina-
the examination room, and restock used supplies. tion room.
Evaluation
• All aspects of the assessment have been carried out, and comprehensive data have been collected.
• The client remained safe, warm, and comfortable.
• The client’s questions or concerns have been addressed.
Document
• Date and time
• Normal and abnormal findings
• Any unexpected outcomes during the procedure and the nursing actions taken
• To whom abnormal findings were verbally reported, and the outcome of the interaction
Date and Time A 67-year-old man transported from bed to examination room by wheelchair for physical assessment. Can
cooperate without distress. Refer to assessment form for examination findings. SIGNATURE/TITLE
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14 Special Examinations
and Tests
cold spot
computed tomography
contrast medium 1. Differentiate between an examination and a test.
culture 2. List 10 general nursing responsibilities related to assisting with
diagnostic examination special examinations and tests.
dorsal recumbent position 3. Name five positions commonly used during tests or examina-
echography tions.
electrocardiography 4. Explain what is involved in a pelvic examination and a Pap test.
electroencephalography 5. List six commonly performed categories of tests or examina-
electromyography tions.
endoscopy 6. Identify four word endings and their meanings that provide clues
fluoroscopy as to how tests or examinations are performed.
glucometer 7. Explain the following procedures: sigmoidoscopy, paracentesis,
Gram staining lumbar puncture, throat culture, and measurement of capillary
hot spot blood glucose.
knee–chest position 8. Discuss at least three factors to consider when performing
laboratory test examinations and tests on older adults.
lithotomy position
lumbar puncture
magnetic resonance imaging
n addition to obtaining a health history and performing a physical
I
modified standing position
nuclear medicine department assessment, the nurse gains assessment data by evaluating the results
Pap (Papanicolaou) test of special examinations and tests. This chapter gives an overview of
paracentesis some common diagnostic examinations and tests and related nursing
pelvic examination responsibilities. Tests involving the collection of urine and stool speci-
positron emission tomography mens are discussed in Chapters 30 and 31, respectively.
radiography
radionuclides
roentgenography
Sims’ position EXAMINATIONS AND TEST
specimens
speculum A diagnostic examination is a procedure that involves the physical
spinal tap inspection of body structures and evidence of their functions. It is facili-
transducer tated through the use of technical equipment and techniques, such as the
ultrasonography following:
• Radiography (X-rays)
• Endoscopy (optical scopes)
• Radionuclide imaging (radioactive chemicals)
• Ultrasonography (high-frequency sound waves)
• Electrical graphic recordings
By learning root words and suffixes (word endings), which are pri-
marily of Latin and Greek origin, it is possible to decipher many unfa-
miliar names of diagnostic examinations and tests (Table 14-1).
249
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TABLE 14-1 Deciphering Diagnostic Terms

SUFFIX MEANING EXAMPLES DESCRIPTION
-graphy To record Angiography Test that records an image of blood vessels
-gram An image Angiogram The actual image recorded during angiography
-scopy To see Sigmoidoscopy Test in which the lower intestine is inspected
-scope Examination instrument Sigmoidoscope A tube with a light and lens for looking within the lower intestine
-centesis To puncture Thoracentesis Procedure in which a needle is used to puncture the thorax and
withdraw fluid
-metry To measure Pelvimetry Procedure in which the pelvis is measured
-meter Instrument for obtaining Glucometer Instrument for measuring glucose
measurements
A laboratory test is a procedure that involves the General Nursing Responsibilities

examination of body fluids or specimens. It involves com- When clients undergo diagnostic examinations and labora-
paring the components of a collected specimen with normal tory tests, nurses have specific responsibilities before, dur-
findings. A diagnostic examination may or may not include ing, and after the procedures (Box 14-1).
the collection of specimens.
Preprocedural Care
Before a client agrees to a procedure, the nurse deter-
Gerontologic Considerations mines whether the client understands its purpose and
the activities involved. Once the client’s consent for a
■ Some laboratory values change minimally or not at all diagnostic test is obtained, the nurse prepares the cli-
with age. Parameters are often determined by using ent, obtains the equipment and supplies, and readies the
averaged statistics. Failure to appreciate age-related differ- examination area.
ences in laboratory test results can lead to overdiagnoses
or underdiagnoses and, therefore, inappropriate treat- Clarifying Explanations. In some cases, a signed consent
ment. form is required before performing examinations or tests.
■ Many prescription and over-the-counter medications, as To be legally sound, consent must contain three elements:
well as herbal therapies, may affect laboratory values. capacity, comprehension, and voluntariness (Box 14-2).
Therefore, nurses must take care to review and evaluate all Although physicians are responsible for giving clients
medications and alternative therapies before any laboratory sufficient information to obtain their informed consent, not
procedures. all clients fully understand the information. Some are too
■ Knowing the usual range of laboratory results for older
anxious to process details, others feel too insecure to ask
adults who have chronic conditions is important. A
chronic disorder or its treatment can cause abnormal test
questions, and still others express additional concerns after
findings that may be normal or acceptable for older the physician has left. Often the nurse must repeat, simplify,
adults. It is also important to know the client’s previous clarify, or expand the original explanation.
results for the diagnostic test being done as a baseline There are no exact rules for clarifying explanations. In
for comparison. general, it is best to find out how much of the physician’s
B OX 1 4 - 1 General Nursing Responsibilities for B OX 1 4 - 2 Elements of Informed Consent

Examinations and Tests
Capacity Indicates that the client has the ability to
• Determine the client’s understanding of the procedure. make a rational decision; if not, a spouse,
• Witness the client’s signature on a consent form. parent, or legal guardian must do so.
• Teach or follow test preparation requirements. Comprehension Indicates that the client understands the
• Obtain equipment and supplies. physician’s explanation of the risks, ben-
• Arrange the examination area. efits, and alternatives that are available.a
• Position and drape the client. Voluntariness Indicates that the client is acting on his or
• Assist the examiner. her own free will without coercion or the
• Provide the client with physical and emotional support. threat of intimidation.
• Care for specimens.
• Record and report appropriate information. a
Sedative drugs or the effects of anesthesia may temporarily affect capacity
and comprehension.
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CHAPTER 14 Special Examinations and Tests 251
explanation the client understands and use the client’s ques- Client and Family Teaching 14-1
tions as a guide for providing further information. Nurses Preparation for Special Examinations or Tests
should follow the suggestions for teaching and providing
emotional support given in Chapter 8. The nurse teaches the client who is not hospitalized to:
● Call (specify the number) if test preparation instructions
Preparing Clients. Some examinations and tests require
are not clearly understood or cannot be followed.
special preparation of the client such as withholding food ● Refrain from eating or drinking anything for at least
and fluids or modifying the diet. 8 hours before a test or examination that requires a
fasting state.
● Follow all dietary specifications for eating or omitting
certain foods exactly as directed.
● Check with the physician about taking or readjusting the
■ When working with an older adult who is cognitively com-
time schedule for taking prescribed medications on the
promised (eg, dementia), consult the person who has a medi- day of the test or examination.
cal durable power of attorney. Include the caregiver or family ● Bathe or shower as usual on the day of the test or exami-
member in the procedure as much as possible. nation.
■ Older adults, especially those who are medically frail, ● Dress casually and in layers so that items of clothing can
may not be able to tolerate the withholding of food or fluids be removed or added to maintain comfort in the test
for long periods before tests or examinations. Assessing environment.
urinary output, blood pressure, and mental status provides ● Ask a friend or family member to provide transportation
data on how well an older adult is tolerating a fasting state. to and from the site if there is a potential for drowsiness,
■ When older adults must abstain from food or fluid before
lingering pain, or weakness after the procedure.
a test or examination, administration of their prescribed ● Arrive at least 30 minutes before the test is scheduled.
medications with a small amount of water may be allowed ● Identify oneself at the information or appointment desk
based on consultation with the physician. upon arrival.
■ Frail older adults fatigue easily; therefore, coordinate ● Bring information to verify insurance or Medicare
tests and examinations with diagnostic personnel to elimi- coverage.
nate long periods of fasting or waiting in uncomfortable
environments.
Because test preparation requirements vary among

Obtaining Equipment and Supplies. If an examina-
health care agencies, the nurse refers to written protocols in
tion or test is performed at the bedside or in an examination
the agency’s manual rather than relying on memory.
room on the nursing unit, the nurse obtains equipment and
Once he or she understands the specific requirements
supplies ahead of time. Nurses are relieved of this responsi-
for a test, the nurse provides directions to the client, nurs-
bility if the examination or test is carried out in other loca-
ing staff, and other hospital departments, such as the dietary
tions or when a special technician performs the procedure.
department, involved in the test. Everyone involved must
Some items that nurses may need are in packaged
cooperate to ensure test accuracy. The nurse reports any
kits (such as a lumbar puncture kit) kept in a clean util-
incorrect test preparations promptly because the procedure
ity room (Fig. 14-1) or may be obtained from a central
may need to be canceled and rescheduled.
supply department (also called “materials management”
Because many tests and examinations are done on an
in some health care agencies). If using a packaged kit,
outpatient basis, the nurse must understand the client’s
the nurse checks the list of contents to determine what, if
responsibilities and instruct him or her accordingly (see Client
any, additional items are needed. Clean gloves, goggles,
and Family Teaching 14-1).
masks, and gowns are required to prevent direct contact
Regardless of the type of examination or test, the nurse
with blood or body secretions (see section on “Standard
helps the client to change into an examination gown, applies
Precautions” in Chap. 22).
an identification bracelet, takes vital signs, and suggests that
the client empty his or her bladder. The nurse continues to Arranging the Examination Area. If the procedure is
monitor the condition of waiting clients who can experience performed at the bedside, the nurse removes unnecessary
adverse effects from fatigue, delayed food consumption, or articles from the area and provides privacy. Many nursing
medical symptoms. units contain an examination room that is clean, well lit, and
stocked with frequently used equipment. The nurse covers the
examination table with a sheet or paper dispensed from a roll.
A lined receptacle is nearby for the disposal of soiled items.
The nurse arranges equipment and supplies for easy
■ Older adults are likely to need additional clothing, slip-
pers, and extra covers to keep them warm in waiting access by the examiner (Fig. 14-2). Sterile items remain
rooms and examination areas. wrapped or covered until just before their use. Before the
examiner arrives, nurses check instruments that require
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FIGURE 14-1 Obtaining equipment from the supply room.

FIGURE 14-2 The nurse arranges supplies and equipment in
(Photo by Sharon Gynup.)
an endoscopic examination room. (Photo by B. Proud.)
electric power, batteries, or lights so that they can replace that caused by arthritis. This position also provides access to
nonfunctioning equipment. the anus and rectum when the client requires rectal adminis-
tration of medication or the instillation of an enema solution.
Procedural Responsibilities In the knee–chest position, also called a “genupectoral
During the examination or test, the nurse positions and drapes position,” the client rests on the knees and chest. He or she
the client, provides the examiner with technical assistance, turns the head, which is supported on a small pillow, to one
and supports the client physically and emotionally. side. The nurse places a pillow under the client’s chest for
added comfort. The arms are above the head or bent at the
Positioning and Draping. Five positions are commonly
elbows so that they rest alongside the client’s head. The
used depending on the type of examination, the condition of
nurse places a drape to cover the client’s back, buttocks,
the client, and the preference of the examiner. They include
and thighs. This position is very difficult for most clients—
the dorsal recumbent position, Sims’ or left lateral position,
especially older adults—to assume for any length of time.
lithotomy position, knee–chest or genupectoral position, and
Therefore, the nurse waits to place the client in this position
modified standing position (Table 14-2).
until just before the examination. Some examination tables
The dorsal recumbent position is a reclining position
have movable sections that facilitate maintaining this posi-
with the knees bent, hips rotated outward, and feet flat. It is
tion without much client effort.
commonly used for various examinations. The nurse uses a
In the modified standing position, the client stands
bath blanket to drape the client and places examination paper
with the upper half of the body leaning forward. It is used
or a disposable pad under the client’s buttocks to absorb
primarily for examining the prostate gland in men. For com-
drainage.
fort and safety, the draped client stands in front of the exami-
The lithotomy position is a reclining position with the
nation table and leans forward from the waist.
feet in metal supports called “stirrups.” It is used to facilitate
gynecologic (female reproductive), urologic, and sometimes Assisting the Examiner. The nurse must be familiar
rectal examinations. The nurse uses a drape to cover the cli- with the examination equipment and the order of its use.
ent’s exposed perineum and legs. He or she places instruments and equipment on the side of
In the Sims’ position, the client lies on the left side with the examiner’s dominant hand, if possible. If not, the nurse
the chest leaning forward, the right knee bent toward the anticipates what will be needed during the procedure and
head, the right arm forward, and the left arm extended behind hands the examiner one item at a time.
the body. Indications are similar to those for the lithotomy If the skin and underlying tissue require local anesthesia,
position. It is an alternative gynecologic or urologic position the nurse holds a container of the medication as the physi-
when a client cannot abduct the hips (move the legs outward cian withdraws some of its contents. The nurse always care-
from midline) because of restricted joint movement such as fully checks the drug name and concentration on the label.
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TABLE 14-2 Indications for Common Examination Positions

POSITION USES
A. Dorsal recumbent position • External genitalia inspection

• Vaginal examination
• Rectal examination
• Urinary catheter insertion
B. Lithotomy position • Internal pelvic examination (female)

• Obstetric delivery
• Cystoscopic (bladder) examination
• Rectal examination
C. Sims’ position • Rectal examination

• Vaginal examination
• Rectal temperature assessment
• Suppository insertion
• Enema administration
D. Knee–chest position • Rectal and lower intestinal examinations

• Prostate gland examination
E. Modified standing position • Prostate gland examination
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A second method for ensuring the use of the correct drug is B OX 1 4 - 3 Common Factors That Invalidate
to hold the container so that the examiner can read the label. Examination or Test Results
If the nurse is responsible for performing the test or
examination, he or she cannot leave the client to obtain • Incorrect diet preparation
equipment and supplies. If he or she needs assistance or • Failure to remain fasting
• Insufficient bowel cleansing
additional equipment, the nurse summons help with a tele-
• Drug interactions
phone or call light in the examination room.
• Inadequate specimen volume
Providing Physical and Emotional Support. Through- • Failure to deliver specimen in a timely manner
out any examination or test, the nurse continuously observes • Incorrect or missing test requisition
the client’s physical and emotional reactions and responds
accordingly. For example, comfort measures are in order if
the client is cold or in pain. Holding the client’s hand and
offering words of encouragement help the client to endure special examination or test. General information includes
temporary discomfort. The nurse communicates assessments the following:
of the client to the examiner, who may choose to shorten or • Date and time
modify the examination in some manner. • Pertinent pre-examination assessments and preparations
• Type of test or examination
Postprocedural Care • Who performed the test or examination
After the completion of an examination and/or test, the nurse • Where the test or examination was performed
attends to the client’s comfort and safety, cares for speci- • Response of client during the examination and afterward
mens, and records and reports pertinent data. • Type of specimen obtained, if any
Attending to the Client. First, the nurse helps the client • Appearance, size, or volume of specimen
to a position of comfort. He or she rechecks vital signs to • Where the specimen was transported
verify that the client’s condition is stable. The nurse cleans In addition to the documented account of the examina-
any substances from the client that caused soiling. He or she tion, the nurse reports significant information to other nurs-
offers hospitalized clients a clean gown or directs outpatients ing team members. This may include that the examination
to dress in their own clothing. When it is safe to do so, the has been completed, the client’s reactions during and imme-
nurse escorts clients to their rooms or to the discharge area diately after the procedure, and any delayed reactions. When
and provides instructions for follow-up care. the nursing team stays aware of current events and changes
in the client’s condition, they can revise and keep the plan of
care current.
Common Diagnostic Examinations
■ After a diagnostic examination, offer older adults food Many types of diagnostic examinations are performed com-
and fluid and a period of rest before they resume physically monly to assess and evaluate clients. Some of the most
taxing activities. Encourage fluids because older adults may
common are discussed in this section. Additional infor-
have a diminished thirst sensation and may not realize the
need for fluid replacement.
mation can be found in laboratory and test manuals and
courses in which specific diseases are studied; beginning
nurses also gain experiences with these examinations in the
Caring for Specimens. Sometimes specimens (samples clinical setting.
of tissue or body fluids) are collected during an examination
Pelvic Examination
or test. To ensure their accurate analysis, the nurse does the
A pelvic examination is the physical inspection of the
following:
vagina and the cervix with palpation of the uterus and the
• Collects the specimen in an appropriate container ovaries. A physician, a physician’s assistant, or a nurse prac-
• Labels the specimen container with the correct information titioner usually performs it. He or she often collects a speci-
• Attaches the proper laboratory request form men of cervical secretions for a Pap (Papanicolaou) test.
• Ensures that the specimen does not decompose before it This test, also called a Pap smear, screens for abnormal cer-
can be examined vical cells, the status of reproductive hormone activity, and
• Delivers the specimen to the laboratory as soon as possible normal or infectious microorganisms within the vagina or
uterus (Table 14-3).
Box 14-3 lists factors that often interfere with accurate
When a pelvic examination is being used to screen for
examinations or that invalidate test results.
cervical cancer, recommendations from the American Can-
Recording and Reporting Data. The nurse must docu- cer Society, the Association of Reproductive Health Profes-
ment certain information whenever a client undergoes a sionals, and the American Congress of Obstetricians and
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TABLE 14-3 Pap Test Results a pelvic examination and collecting cervical secretions for
TEST COMPONENT INTERPRETATION
a Pap test.
Cellular Examination Radiography
Class I Negative; no abnormal cells Radiography, or roentgenography (a general term for pro-
Class II Unusual, but not cancerous cedures that use roentgen rays, or X-rays), produces images
Class III Suggestive of cancer, but not definite
of body structures. The actual film image is technically
Class IV Strongly suggestive of cancer
Class V Definitely cancerous called a “roentgenogram,” but is commonly known as an
X-ray. Roentgen rays produce electromagnetic energy that
Hormonal Effects (on a 6-point scale)
passes through body structures, leaving an image of dense
1 Marked estrogen effect
2 Moderate estrogen effect tissue on special film. Table 14-4 lists common radiographic
3 Slight estrogen effect examinations and indications for their use.
4 Absent estrogen effect X-rays cannot be seen or felt, but cells absorb the
5 Compatible with pregnancy energy. Repeated exposure to X-rays, even at small doses,
6 Too bloody, inflamed, or scanty to analyze or a single exposure to a high dose causes cell damage that
Identifiable Microorganisms (on a 5-point scale) can lead to cancerous cell changes. Consequently, practitio-
1 Normal microorganisms ners tend to be cautious about the number of X-ray studies
2 Scanty or absent microorganisms that they request. X-rays are avoided during pregnancy if at
3 Trichomonas vaginalis (protozoan organism) all possible because a developing fetus is at greater risk for
4 Candida (yeastlike fungus)
cellular damage from X-rays. Magnetic resonance imaging
5 Other or mixed collection of microorganisms
(MRI) is a technique for producing an image by using atoms
Adapted from Fischbach F. (2008). A manual of laboratory and diagnostic subjected to a strong electromagnetic field. This diagnostic
tests (8th ed.). Philadelphia: Lippincott, Williams & Wilkins. alternative does not involve exposure to the type of radiation
produced with roentgenography (Fig. 14-3).
Gynecologists (ACOG) have slight variations. ACOG’s lat- Some hospitals are offering open MRIs that eliminate
est (2009) recommendations are that women: being enclosed within a tube. Claustrophobic and anxious cli-
ents prefer the open system, which also is ideal for pediatric
1. Receive their first Pap test approximately 3 years after the clients and clients weighing more than 500 lb. Some metal
onset of vaginal intercourse, but no later than 21 years of
age. TABLE 14-4 Common Radiographic Examinations
2. Have annual Pap tests thereafter until 30 years of age.
EXAMINATION EXAMPLES OF INDICATIONS FOR USE
3. Be screened every 2 to 3 years at or after 30 years of age
when three prior consecutive tests were normal or nega- Chest X-ray (anterior, pos- Detects pneumonia, broken ribs,
terior, lateral views) lung tumors, enlarged heart
tive. More frequent screenings are advocated for women
Upper gastrointestinal Aids in diagnosis of ulcers, GI
who have a history of risk factors for cervical cancer, such X-ray (upper GI or tumors, narrowing of the
as being HIV positive, immunosuppressed secondary to barium swallow) esophagus
an organ transplantation, exposed to diethylstilbestrol as a Lower gastrointestinal Helps in diagnosis of polyps or
fetus, or previously diagnosed with cervical cancer, or X-ray (lower GI or tumors of the bowel, intesti-
continuing to shed abnormal cells after a hysterectomy. barium enema) nal obstruction, and structural
changes within the intestine
As an alternative, physicians may opt to perform a Pap Cholecystography (X-ray Facilitates determining the pres-
test and a second test on women 30 years and older to of the gallbladder and ence of gallstones and obstruc-
detect human papillomavirus DNA. If both yield negative ducts) tion in the flow of bile
results, the client can be retested, using the same two tests Intravenous pyelography Helps identify urinary malforma-
every 3 years; if one test is positive, the client is screened (IVP) tions, tumors, stones, cysts, and
obstructions in the kidneys and
more frequently.
ureters
4. At or beyond age 65, women should continue to have Retrograde pyelography Same as for IVP, but the contrast
gynecologic examinations, but the physician determines medium is instilled through a
the frequency of cervical cancer screening on a case-by- urinary catheter
case basis. When three prior Pap tests within the previous Angiography (X-ray of Determines the location where
10 years were normal or negative, screening guidelines blood vessels) and the extent to which blood
vessels have narrowed, or
may be relaxed because cervical cancer in women older evaluates improvement after
than 70 years is almost entirely confined to women who treatment
have not been previously screened or who have deviated Myelography (X-ray of Detects spinal tumors, ruptured
from screening guidelines in the previous 10 years. spinal canal) intervertebral disks, and bony
changes in the vertebrae
Related Nursing Responsibilities. Skill 14-1 identi-
fies the nursing responsibilities involved in assisting with GI, gastrointestinal.
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FIGURE 14-3 Magnetic resonance imaging.
FIGURE 14-4 Cross-sections of a cranial computed tomogra-

devices that are within the body prohibit performing an phy (CT) scan. (Photo by Ken Timby.)
MRI; metal objects on a client’s person must be removed
before an MRI (Box 14-4). MRIs can now be done on clients
with metal joint implants, but it requires that the radiologist
use an adjustment called metal artifact reduction sequence Related Nursing Responsibilities. For the client
(MARS) to avoid radiographic distortion of the image. undergoing a radiographic examination, nursing responsibi-
lities include the following:
Contrast Medium. A contrast medium is a substance,
such as barium sulfate or iodine, that adds density to a body • Assess vital signs before the examination to provide a
organ or cavity. It makes hollow body areas appear more dis- baseline and to help detect changes in the client’s condi-
tinct when imaged on X-ray film. Some people are sensitive tion during or after the procedure.
to substances used in contrast media and have an immediate • Remove any metal items such as a religious medal or
allergic reaction to them. clothing that contains metal such as the hooks and eyes on
Contrast media are administered orally or rectally or a bra. Metal produces a dense image that may be confused
injected intravenously. Fluoroscopy is a form of radiography with a tissue abnormality.
that displays an image in real time. It is used to observe the • Request a lead apron or collar to shield a fetus or vulner-
movement of contrast media—for example, as it is being swal- able body parts during X-rays (Fig. 14-5).
lowed, instilled, or injected. Computed tomography (CT)
scanning is a form of roentgenography that shows planes of
tissue. This and other types of X-ray examinations use contrast
media. The CT contrast medium makes it possible to identify
differences in tissue density when obtaining X-ray images
from various angles and levels in the body (Fig. 14-4).
B OX 1 4 - 4 Metal Devices That Prohibit an MRI

ON THE BODY
WITHIN THE BODY (MUST BE REMOVED)
Wound staples Watch

Implanted pacemaker Jewelry
Artificial heart valve Hearing aid
Metallic pins, screws, plates Hair clips or pins
Implanted drug delivery device Pocket knives
Metal intrauterine device Keys
Aneurysm clips Credit cards or bank cards
Implanted cardiac defibrillator
Implanted brain stimulator
Tattooed eyeliner
FIGURE 14-5 A lead thyroid collar, apron, and skirt. (Photo by
B. Proud.)
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• If the radiographic study involves administration of a con- B OX 1 4 - 5 Examples of Endoscopic

trast medium, ask the client about allergies, especially to Examinations
seafood or iodine, or previous adverse reactions during a
diagnostic examination. A reaction can range from mild • Bronchoscopy—inspection of the bronchi
nausea and vomiting to shock and death. • Gastroscopy—inspection of the stomach
• Colonoscopy—inspection of the colon
• Know the location of emergency equipment and drugs in
• Esophagogastroduodenoscopy—inspection of the esophagus,
case there is an unexpected allergic reaction to the contrast
stomach, and duodenum
medium. • Laparoscopy—inspection of the abdominal cavity
• To avoid interference with subsequent visual imaging, • Cystoscopy—inspection of the urinary bladder
schedule procedures requiring iodine before those that use
barium.
• To promote urinary excretion, encourage the client to drink
a large amount of fluid after an examination involving withhold food or fluids for at least 2 hours after the proce-
iodine to promote its excretion. dure and until swallow, cough, and gag reflexes return.
• Check on bowel elimination and stool characteristics for at • Relieve the client’s sore throat with ice chips, fluids, or
least 2 days after the administration of an oral barium con- gargles when it is safe to do so.
trast medium. Barium retention can lead to constipation • Confirm that a bowel preparation using laxatives and ene-
and bowel obstruction. Report an absence of bowel elimi- mas has been completed before endoscopic procedures of
nation beyond 2 days. The administration of a prescribed the lower intestine.
laxative is often necessary. • Report difficulty in arousing a client or any sharp pain,
fever, unusual bleeding, nausea, vomiting, or difficulty
Endoscopic Examinations with urination after any endoscopic examination.
Endoscopy (a visual examination of internal structures) is
performed using optical scopes. Endoscopes have lighted
mirror-lens systems attached to a tube and are quite flex-
ible so that they can be advanced through curved structures.
Endoscopic examinations are named primarily for the
■ Some older adults become exhausted by preparations for
structure being examined (Box 14-5). In addition to allow-
gastrointestinal examinations that require the use of laxa-
ing the examiner to inspect the appearance of a structure, tives and enemas. Harsh laxatives or multiple enemas may
endoscopes also have attachments that permit various forms also deplete electrolyte balance, leading to weakness or
of treatment or the collection of specimens for microscopic dizziness. Providing a bedside commode and hands-on
analysis. Endoscopic examinations that produce discomfort assistance is helpful for older adults, especially those with
or anxiety are performed under a light, short-acting form impaired mobility, when they are undergoing preparation
of anesthesia, sometimes referred to as conscious sedation. for gastrointestinal examinations.
When conscious sedation is used, clients may have no mem-
ory of having had the test even though they communicate
and interact with staff during its performance. Skill 14-2 describes the nurse’s role when assisting with
Endoscopic examinations are being performed more a sigmoidoscopy.
frequently on an outpatient basis and in the physician’s
office. They are an economical alternative to invasive tests ➧ Stop, Think, and Respond Box 14-1
and procedures that previously required surgery to deter- Explain why it is important for clients to have a sig-
mine a diagnosis. moidoscopy.
Related Nursing Responsibilities. For the client under-

Radionuclide Imaging
going an endoscopy, nursing responsibilities include the fol-
Radionuclides are elements whose molecular structures are
lowing:
altered to produce radiation. They are identified by a number
• To prevent aspiration, withhold food and fluids or advise followed by a chemical symbol, such as 131I (radioactive
the client to do so for at least 6 hours before any procedure iodine) and 99Tc (radioactive technetium). When radionuclides
in which an endoscope is inserted into the upper airway or are instilled in the body, usually by the intravenous route, par-
upper gastrointestinal tract. ticular tissues or organs absorb them. A scanning device that
• If conscious sedation is used, monitor the client’s vital detects radiation creates an image of the size, shape, and con-
signs, breathing, oxygen saturation (using pulse oximetry; centration of the organ containing the radionuclide. The terms
see Chap. 21), and cardiac rhythm. Have oxygen and “hot spot” (area where the radionuclide is intensely concen-
resuscitation equipment readily available. trated) and “cold spot” (area with little if any radionuclide
• If topical anesthesia is used to facilitate the passage of an concentration) refer to the amount of radiation that the tissue
endoscope into the airway or upper gastrointestinal tract, absorbs. Positron emission tomography (PET) combines the
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technology of radionuclide scanning with the layered analysis during pregnancy is sometimes visible on ultrasound, alert-
of tomography. ing the client to the gender of the fetus. Because ultrasound
Radionuclide imaging offers two advantages over examinations do not involve radiation or contrast media,
standard radiography: it visualizes areas within organs and they are extremely safe diagnostic tools.
tissues that are not possible with standard X-rays, and it
involves less exposure to radiation than with roentgenogra-
going ultrasonography, nursing responsibilities include the
phy. Tests using radionuclides, however, are contraindicated
following:
for women who are pregnant or breast-feeding; the energy
released is harmful to the rapidly growing cells of an infant • Schedule abdominal and pelvic ultrasonography before any
or fetus. examinations that use barium for the best visualization.
• Instruct clients undergoing an abdominal ultrasonography
to drink five to six full glasses of fluid approximately 1 to
going radionuclide imaging, nursing responsibilities include
2 hours before the test. To ensure a full bladder, urination
the following:
should be avoided until after the test is completed.
• Inquire about a woman’s menstrual and obstetric history. • Explain that acoustic gel is applied over the area where the
Notify the nuclear medicine department (the unit respon- transducer is placed.
sible for radionuclide imaging) if the client is pregnant,
could possibly be pregnant, or is breast-feeding. Electrical Graphic Recordings
• Ask about the allergy history because iodine commonly is Machines can record electrical impulses from structures
used in radionuclide examinations. such as the heart, brain, and skeletal muscles. These tests are
• Assist the client with a gown, robe, and slippers. Make identified by the prefix “electro-” as in electrocardiography
sure that the client has no internal metal devices or external (ECG or EKG; an examination of the electrical activity in
metal objects because these interfere with diagnostic find- the heart), electroencephalography (EEG; an examination
ings. of the energy emitted by the brain), and electromyography
• Obtain an accurate weight because the dose of radionu- (EMG; an examination of the energy produced by stimulated
clide is calculated according to weight. muscles).
• Inform the client that he or she will be radioactive for a To detect electrical activity, wires called electrodes are
brief period (usually less than 24 hours) but that body flu- attached to the skin (or muscle in the case of an EMG). They
ids, such as urine, stool, and emesis, can be safely flushed transmit electrical activity to a machine that converts it into
away. a series of waveforms (Fig. 14-6). Except for an awareness
• Instruct premenopausal women to abstain from intercourse of the electrodes, the client undergoing an ECG or EEG usu-
or use an effective contraceptive method for the short ally does not experience any other sensations. Occasionally,
period during which radiation continues to be present. there is slight discomfort during an EMG.
Ultrasonography
Ultrasonography (a soft tissue examination that uses sound
going an ECG, nursing responsibilities include the
waves in ranges beyond human hearing) is also known as
following:
echography. During ultrasonography, which is similar to
the echolocation used by bats, dolphins, and sonar devices • Clean the skin and clip hair in the area where the electrode
on submarines, a hand held probe called a transducer tabs will be placed to ensure adherence and to reduce dis-
projects sound through the body’s surface. The sound waves comfort on removal.
cause vibrations within body tissues, producing images • Attach the adhesive electrode tabs to the skin where the
as the waves are reflected back toward the machine. The electrode wires will be fastened.
reflected sound waves are converted into a visual image • Avoid attaching the adhesive tabs over bones, scars, or
called an ultrasonogram, sonogram, or echogram, which can breast tissue.
be viewed in real time on a monitor and recorded for future For the client undergoing an EEG, nursing responsibili-
analysis. Doppler ultrasound, discussed in Chapter 12, is a ties include the following:
variation of this type of technology.
Ultrasound examinations are used to visualize breast, • Instruct the client to shampoo the hair the evening before
abdominal, and pelvic organs; male reproductive organs; the procedure to facilitate firm attachment of the elec-
structures in the head and neck; the heart and valves; and trodes. He or she should shampoo the hair after the test to
structures within the eyes. Air-filled structures such as the remove adhesive from the scalp.
lungs or the intestines and extremely dense tissue such as • Withhold coffee, tea, and cola beverages for 8 hours before
bones do not image well. This type of examination is used the procedure. Consult with the physician about withhold-
in obstetrics to determine fetal size, more than one fetus, ing scheduled medications, especially those that affect
and location of the placenta. The outline of fetal anatomy neurologic activity.
LWBK1004-C14_p249-282.indd 258 31/01/12 1:31 AM

• If a sleep-deprived EEG is scheduled, instruct the client

that he or she must stay awake after midnight before the
examination.
For the client undergoing an EMG, nursing responsibili-
ties include the following:
• Tell the client he or she will be instructed to contract and
relax certain muscles during the examination.
• Explain that electrical current is applied to muscles during
an EMG but that the sensation is not usually painful. Also,
a muscle electrode is inserted with a small-gauge needle in
10 or more locations, but the experience is painless unless
A it touches a terminal nerve in the area.
Supplemental right Diagnostic Laboratory Tests

precordial leads
Nurses, laboratory personnel, and physicians collect speci-
mens such as blood, urine, stool, sputum, intestinal secretions,
spinal fluid, and drainage from wounds or infected tissue.
They repeat tests on collected specimens at intervals to mon-
itor the progress of clients. Students can refer to laboratory
manuals to learn the purpose of specific tests and the associ-
V5R V4R V3R V2R V1R ated nursing responsibilities.
Several examples of specimen collection are discussed
in future chapters where they are more pertinent. Nursing
responsibilities for assisting with a paracentesis and a lum-
Mid-clavicle bar puncture, collecting a specimen for a throat culture, and
measuring capillary blood glucose follow.
Anterior axillary line
Horizontal Assisting With a Paracentesis

plane of V4–V6 A paracentesis is a procedure for withdrawing fluid from
RA LA
the abdominal cavity. A physician always performs it with
the assistance of a nurse. A paracentesis is done most com-
monly to relieve abdominal pressure and to improve breath-
V1 V2 V3 V4 V5
ing, which generally becomes labored when fluid crowds the
lungs. Sometimes, paracentesis removes 1 L (approximately
1 quart) or more of fluid. The physician may send a speci-
men of the fluid to the laboratory for microscopic examina-
ECG
strip tion (see Nursing Guidelines 14-1 and Fig. 14-7).
Assisting With a Lumbar Puncture

The physician requires nursing assistance when performing
a lumbar puncture or spinal tap. This procedure involves
ECG machine inserting a needle between lumbar vertebrae in the spinal canal
RL LL
but below the spinal cord itself. The physician advances the
tip of the needle until it is beneath the middle layer of the
membrane surrounding the spinal cord. He or she measures
the spinal fluid pressure and then withdraws a small amount
B of fluid.
This test is performed for various reasons. It is used to
FIGURE 14-6 The nurse attaches electrodes to the patient’s
chest and limbs before an ECG. diagnose conditions that raise the pressure within the brain,
such as brain or spinal cord tumors, or infections such as
meningitis. Spinal fluid also is withdrawn before instilling
a contrast medium for X-rays of the spinal column. Finally,
the treatment of some conditions requires the instillation of
drugs directly into the spinal fluid after withdrawing a simi-
lar amount (see Nursing Guidelines 14-2 and Fig. 14-8).
LWBK1004-C14_p249-282.indd 259 31/01/12 1:31 AM

N U R S I N G G U I D E L I N E S 1 4 -1
Rationales
Assisting With a Paracentesis
• Explain the procedure or clarify the physician’s explanation to • Offer the client support as an area of the abdomen is anes-
the client. Explanations prepare the client for an unfamiliar thetized then pierced with an instrument called a trocar and
experience or promote a clearer understanding. a hollow sheath called a cannula is inserted (see Fig. 14-7).
• Ensure that the client has signed the consent form, if needed. Empathetic concern helps to relieve anxiety.
A consent form provides legal protection. • Reassess the client periodically after the cannula insertion;
• Measure and record the client’s weight, blood pressure, and expect that blood pressure and respiratory rate may decrease.
respiratory rate; measure abdominal girth at its widest point with Assessment indicates the client’s response.
a tape measure. These data serve as a basis for postprocedural • Place a Band-Aid or small dressing over the puncture site after
comparisons. withdrawal of the cannula. The dressing acts as a barrier to
• Obtain a prepackaged paracentesis kit along with a vial of local microorganisms and absorbs drainage.
anesthetic. Gathering supplies promotes efficient time management. • Assist the client to a position of comfort. Doing so demon-
• Make sure that extra gloves, gown, mask, and goggles are avail- strates concern for the client’s welfare.
able. These items protect against contact with microorganisms, • Measure the volume of fluid withdrawn. This measurement
such as HIV, that may be in the blood or other body fluids. contributes to an accurate assessment of fluid volume.
• Encourage the client to empty the bladder just before the pro- • Label the specimen, if ordered, and send it to the laboratory
cedure. An empty bladder prevents accidental puncture of the with the appropriate requisition form. Doing so facilitates an
bladder. appropriate analysis.
• Place the client in a sitting position. This position pools • Document pertinent information such as the appearance and
abdominal fluid in the lower areas of the abdomen and dis- volume of the fluid, client assessments, and disposition of the
places the intestines posteriorly. specimen. Such documentation adds essential data to the cli-
• Hold the container of local anesthetic so the physician can ent’s medical record.
withdraw a sufficient amount. Doing so prevents contaminat-
ing the physician’s sterile gloves.
Collecting a Specimen for a Throat Culture

A culture (an incubation of microorganisms) is performed by
collecting body fluid or substances suspected of containing
infectious microorganisms, growing the living microorgan-
isms in a nutritive substance, and examining their character-
istics with a microscope. Cultures are performed commonly
on urine, blood, stool, wound drainage, and throat secretions.
To identify and treat the cause of a throat infection (com-
monly streptococcal bacteria), the nurse obtains a specimen
from the throat. An abbreviated test that takes approximately
10 minutes is performed on throat specimens in many doctors’
offices and student health clinics. A rapid preliminary diag-
nosis is made so that appropriate treatment can be initiated
immediately. If the quick test is not clearly negative and symp-
toms strongly suggest a streptococcal infection, a follow-up
specimen is obtained and sent to the laboratory for culturing.
Conclusive results of a bacterial culture generally require 24
to 72 hours for sufficient microbial growth to take place.
Once bacteria grow within the nutritive medium, they
are identified microscopically by their shape and by the color
they acquire when stained with special dyes. Gram stain-
ing (a process of adding a dye to a microscopic specimen)
is named for the Danish physician who developed the tech-
nique. The Gram stain helps determine whether bacteria are
gram-positive or gram-negative. Gram-positive bacteria
appear violet after staining. Those that repel the violet dye
but appear red, the color of a counterstain, are called gram-
FIGURE 14-7 The nurse offers support during an abdominal negative bacteria (Fischbach & Dunning, 2008). Streptococci
paracentesis. are round, grow in chains, and are gram-positive bacteria.
LWBK1004-C14_p249-282.indd 260 31/01/12 1:31 AM


Rationales
Assisting With a Lumbar Puncture
• Explain the procedure or clarify the physician’s explanation to • Tell the client that it is not unusual to feel pressure or a shoot-
the client. Explanations prepare the client for an unfamiliar ing pain down the leg. This information prepares the client for
experience or promote a clearer understanding. expected sensations.
• Ensure that the client has signed the consent form, if needed. • Perform Queckenstedt’s test, if asked, by compressing each
A consent form provides legal protection. jugular vein separately for approximately 10 seconds while
• Perform a basic neurologic examination including the client’s pressure is being measured. Queckenstedt’s test helps dem-
pupil size and response and muscle strength and sensation in onstrate if there is an obstruction in the circulation of spinal
all four extremities. This information provides a baseline for fluid. If so, the pressure remains unchanged, rises slightly, or
future comparisons. takes longer than 20 seconds to return to baseline.
• Encourage the client to empty the bladder. An empty bladder • Observe that the physician fills three separate numbered con-
promotes comfort during the procedure. tainers with 5 to 10 mL in their appropriate sequence if labora-
• Administer a sedative drug if ordered. Sedatives reduce tory analysis is desired. In this way, if blood is present but in
anxiety. the least amount in the third container, its source is most likely
• Obtain a prepackaged lumbar puncture kit along with a vial trauma from the procedure rather than central nervous system
of local anesthetic. Gathering supplies promotes efficient time pathology.
management. • Place a Band-Aid or small dressing over the puncture site after
• Make sure that extra gloves, gown, mask, and goggles are the needle has been withdrawn. The dressing acts as a barrier
available. These items offer protection from contact with micro- to microorganisms and absorbs drainage.
organisms, such as HIV, that may be present in the blood or • Position the client flat on the back or abdomen; instruct the
other body fluids. client to remain flat and roll from side to side for the next 6
• Place the client on his or her side with the knees and neck to 12 hours. These measures reduce the potential for severe
acutely flexed (see Fig. 14-8) or in a sitting position, bent from headache.
the hips. These positions separate the bony vertebrae. • Reassess the client’s neurologic status. Check the puncture
• Instruct the client that once the needle is inserted, he or she site for bleeding or clear drainage. Comparative data help the
must avoid movement. This measure prevents injury. nurse to evaluate changes in the client’s condition.
• Hold the container of local anesthetic so the physician can • Offer oral fluids frequently. They restore the volume of spinal
withdraw a sufficient amount. Doing so prevents contaminat- fluid.
ing the physician’s sterile gloves. • Label the specimens, if ordered, and send them to the labora-
• Stabilize the client’s position at the neck and knees. This rein- tory with the appropriate requisition form. Doing so facilitates
forces the need to remain motionless. an appropriate analysis.
• Support the client emotionally as the needle is inserted and • Document pertinent information such as the appearance of
the skin is injected with local anesthesia. Empathetic concern the fluid, client assessments, and disposition of the specimen.
helps to relieve anxiety. Doing so adds essential data to the client’s medical record.
When there is evidence of microbial growth and the

infectious microorganism is identified, the most appropri-
ate treatment can be provided. A throat culture is performed
most often on young children who are susceptible to com-
plications from upper respiratory infections and infection of
the tonsils. Adults who tend to harbor infectious microor-
ganisms in their pharynx, however, also are tested. A culture
may be repeated after a course of treatment to determine its
effectiveness (see Nursing Guidelines 14-3 and Fig. 14-9).
Measuring Capillary Blood Glucose

Glucose is the type of sugar in blood that results from eating
carbohydrates. A certain amount is always present to supply
cells with a source of instant energy. The American Diabetes
Association (2008, 2010) recommends that the amount of blood
glucose before meals should range between 70 and 130 mg/dL
(milligrams per deciliter) and less than 180 mg/dL within 1 to
FIGURE 14-8 Positioning for lumbar puncture. (Photo by 2 hours after eating when using a blood sample drawn from a
B. Proud.) finger. The body produces the hormones glucagon and insulin,
LWBK1004-C14_p249-282.indd 261 31/01/12 1:31 AM


Rationales
Collecting a Specimen for a Throat Culture
• Check with the physician about proceeding with the throat • Be prepared for the client’s gagging. Stroking the back of the
culture if the client is taking antibiotics. Antibiotics affect test throat stimulates the gag reflex.
results. • Remove the swab and discard the tongue blade in a lined recep-
• Delay collecting a specimen if the client has recently used an tacle. This measure controls the spread of microorganisms.
antiseptic gargle. Such gargles affect the test’s diagnostic value. • Spread the secretions on the swab across the glass slide. Doing
• Explain the purpose of and the technique for obtaining the culture. so prepares a specimen for quick staining and microscopic
Explanations help to reduce anxiety and promote cooperation. examination.
• Collect supplies: sterile culture swab, glass slide, tongue blade, • Replace the swab securely within the tube, taking care not to
gloves, mask if the client is coughing, paper tissues, and an touch the outside of the container. This method avoids collect-
emesis basin if the client gags. Doing so facilitates organiza- ing unrelated microorganisms and provides containment for
tion and efficient time management. the collected specimen.
• Have the client sit where light is optimum. Light enhances • Crush the packet in the bottom of the tube. Crushing releases
inspection of the throat anatomy. nourishing fluid to promote bacterial growth.
• Don gloves and a mask, if necessary. Their use reduces the • Remove gloves, discard them in a lined receptacle, and wash
potential for transferring microorganisms. your hands or perform hand antisepsis with an alcohol rub (see
• Loosen the cap on the tube in which the swab is located. Doing Chap. 10). These steps reduce the transmission of microorgan-
so facilitates hand dexterity. isms.
• Tell the client to open the mouth wide, stick out the tongue, • Label the culture tube with the client’s name, the date and
and tilt the head back. This position promotes access to the time, and the source of the specimen. These steps provide
back of the throat. laboratory personnel with essential information.
• Depress the middle of the tongue with a tongue blade in your • Attend to the staining and examination of the prepared glass
nondominant hand (see Fig. 14-9). Doing so opens the path- slide, if appropriate. Doing so provides tentative identification
way for the swab. of streptococcal bacteria.
• Rub and twist the tip of the swab around the tonsil areas and • Deliver the sealed culture tube to the laboratory or refrigerate
the back of the throat without touching the lips, teeth, or it if there will be a delay of longer than 1 hour. These steps
tongue. Doing so transfers microorganisms from the inflamed ensure that the microorganisms will grow when transferred to
tissue to the swab. other culture media.
which regulate glucose metabolism and maintain normal blood People with diabetes have an impaired ability to pro-
glucose levels. duce insulin and have difficulty regulating blood glucose
levels. They control their disease with diet, exercise, and in
some cases, medications. People with diabetes may experi-
Gerontologic Considerations ence low or high blood glucose levels, both of which can
have life-threatening consequences. Therefore, many clients
■ Older adults are more susceptible to dehydration. The with diabetes measure their own capillary blood glucose
resulting concentration of blood can cause false elevations levels rather than having venous blood drawn for laboratory
of laboratory blood tests.
analysis.
FIGURE 14-9 A throat culture.

A. Depressing the tongue.
A B B. Obtaining a specimen.
LWBK1004-C14_p249-282.indd 262 31/01/12 1:31 AM

2. The blood glucose level usually is measured about 30 min-

B D utes before eating and before bedtime to determine what are
C likely to be the lowest levels of glucose. This allows time for
A
the client to increase or decrease food consumption or, if
insulin-dependent, to administer additional prescribed insu-
lin (see Chap. 34), referred to as coverage.
E 3. Measuring blood glucose involves a risk for contact with
blood. Because blood may contain infectious viruses,
nurses always wear gloves when performing this test.
Researchers are working on developing noninvasive
devices that will not require piercing the skin with a lancet,
but such devices are not available at present.
F
Skill 14-3 presents the steps involved in using a Life-
scan glucometer.
FIGURE 14-10 Equipment used to perform capillary blood
glucose testing: a glucometer (A), control solution (B), a lancet
(C), a lancet holder (D), a test strip (E), and a container of test NURSING IMPLICATIONS
strips (F). (Photo by B. Proud.)
Most clients who undergo special examinations and tests
have emotional needs from the stress of a potential diagnosis
or the anxiety created by undergoing something unfamiliar.
A glucometer is an instrument that measures the
The following are some nursing diagnoses that nurses may
amount of glucose in capillary blood. It operates by assess-
identify during preprocedural and postprocedural stages of
ing the amount of light reflected through a chemical test strip
examinations and tests:
(Fig. 14-10). Based on the amount of measured glucose in
the blood, clients with diabetes adjust their intake of food or • Anxiety
medication. • Fear
Because diabetes is so common, nurses frequently are • Decisional conflict
called on to teach people who have been recently diagnosed • Readiness for enhanced self-health management
with this problem how to test their own blood glucose levels. • Powerlessness
Nurses measure blood glucose levels for clients with diabe- • Spiritual distress
tes who are hospitalized or being cared for in long-term care
Nursing Care Plan 14-1 illustrates the nursing process
facilities.
as it relates to the nursing diagnosis of Decisional Conflict,
There are several important points to remember about
defined in the NANDA-I taxonomy (2012, p. 396) as “uncer-
measuring blood glucose:
tainty about the course of action to be taken when choice
1. Several types of glucometers are available. The user must among competing actions involves risk, loss, or challenge to
follow the manufacturer’s instructions for accurate use. values and beliefs.”
A Client Undergoing Amniocentesis to Diagnose a

N U R S I N G C A R E P L A N 1 4 - 1 Possible Fetal Genetic Disorder
Assessment • Remarks indicating uncertainty about subsequent choices

Determine the following: pending the outcome of the amniocentesis
• Signs of distress such as restlessness, tachycardia, increased • Feelings of anguish or ambivalence regarding the decision to
muscle tension, and rapid respirations either carry the fetus to term or abort it
• Values and beliefs about terminating a pregnancy
Nursing Diagnosis. Decisional conflict related to birthing options as evidenced by tearfulness, sleep disturbance, heart rate of 90
to 100 beats/min at rest, request for visitation from a clergyperson, reading her Bible, and statement, “I don’t feel I can make a deci-
sion about this.”
Expected Outcome. The client will make an informed choice about the outcome of the current pregnancy within 1 week of when
the results of the amniocentesis are known.
(continued)
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A Client Undergoing Amniocentesis to Diagnose a Possible

N U R S I N G C A R E P L A N 1 4 - 1 Fetal Genetic Disorder ( c o n ti n u e d )
Acknowledge the client’s distress. Empathy demonstrates awareness of the client’s emotional
state.
Convey an accepting nonjudgmental attitude. Trust enhances the open expression of feelings.
Offer referrals to pro-choice and right-to-life groups and organi- Consulting others helps to clarify issues and decreases
zations that provide information about the disorder that may feelings of helplessness.
affect the client’s child.
Encourage the client to discuss concerns with other signifi- Sharing concerns with others helps the client to perceive
cant people. conflicts more realistically and facilitates implementation of
a subsequent plan.
Suggest that the client compose a written list of the advan- Identifying the pros and cons of alternatives is the first step in
tages and disadvantages to possible choices before the formulating a decision.
return appointment.
Give verbal recognition for efforts made to reach a solution. Acknowledgment improves the client’s ability to cope with the
burden of a difficult decision.
Support the client’s decision even if it is not your personal Clients have the right to autonomy and self-determination.
choice.

Client makes a decision with support of significant others to continue pregnancy carrying a fetus that will have cystic fibrosis.
CRITICAL THINKING EXERCISES 3. Which of the following instructions is most appropri-

ate if a specimen for a Pap (Papanicolaou) test will be
1. Discuss how the procedure for a sigmoidoscopy or obtained at the time of a pelvic examination?
another test or examination may differ if performed 1. Do not douche for several days before your
on an outpatient basis rather than in a hospital. appointment.
2. How might diminished mentation (the capacity to under- 2. Stop using any and all forms of contraception tem-
stand), reduced strength and stamina, and pain affect the porarily.
performance of a diagnostic examination or test? 3. Drink at least 1 quart of liquid 1 hour before your
3. How might a pelvic examination be different if the appointment.
person being examined is a victim of rape? 4. Take a mild laxative the night before your sched-
4. How would you respond to a client who is uncertain uled appointment.
about having a lumbar puncture because of a fear of 4. Which of the following actions are correct when
paralysis from trauma to the spinal cord? measuring a client’s capillary blood glucose? Select
all that apply.
1. Plan to perform the test 1 hour before a meal.
2. Check that the test strip code matches the one pro-
1. Which of the following indicates that a client needs grammed in the glucometer.
more teaching before a sigmoidoscopy? 3. Have the client wash his or her hands with soap
1. The client says an anesthetic will be given before and water before the test.
the examination. 4. Puncture the central pad of the thumb or fingers
2. The client says a light meal is allowed the evening with the lancet.
before the examination. 5. Cover the test spot on the test strip completely with
3. The client says a flexible scope will be inserted into a drop of blood.
the rectum. 5. When assisting with a pelvic examination during
4. The client says prescribed medications may be which a Pap smear will be obtained, place the follow-
taken in the morning. ing steps in the order in which they are performed.
2. Which nursing action is essential before performing a Use all the statements.
chest roentgenogram (X-ray)? 1. Hand the examiner a brush applicator.
1. Make sure that the client does not eat food. 2. Apply a chemical fixative to the specimen slide.
2. Remove the client’s metal necklace. 3. Place the client in a lithotomy position.
3. Have the client swallow contrast dye. 4. Lubricate the examiner’s gloved fingers.
4. Administer a dose of pain medication. 5. Provide the examiner with a vaginal speculum.
LWBK1004-C14_p249-282.indd 264 31/01/12 1:31 AM

SKILL 14-1 Assisting With a Pelvic Examination
ASSESSMENT
Determine the identity of the client on whom the examination Prevents errors.
will be performed.
Determine whether a Pap test is needed. Indicates the need for additional equipment and supplies.
Find out whether the client has had a pelvic examination before. Provides a basis for teaching.
Ask whether the client is currently menstruating or has had Blood, semen, and lubricant are three substances that obscure
intercourse within the last 48 hours. and distort cells, making it difficult to determine whether they
are atypical and interfering with the microscopic examination of
collected specimens. The examiner may wish to delay obtain-
ing a specimen.
Inquire whether the client has douched or used vaginal hygiene Suggests a need to reschedule the Pap test because an adequate
products in the last 24 hours. sample of cells and secretions may not be available.
Ask the client’s age, date of the last menstrual period, number Provides data to determine the possibility of pregnancy, to com-
of pregnancies and live births, and description of symptoms pare cellular specimens with hormonal activity, and to provide
such as bleeding or drainage, itching, or pain. clues as to possible pathology and the need for additional tests.
Determine if and what type of birth control the client is using Correlates the influence of prescribed hormones on cellular
if she is premenopausal. For oral contraceptives, identify the specimens.
name of the drug and the dosage.
Ask menopausal women whether they are taking hormone Correlates the influence of prescribed hormones on cellular
replacement, and the brand name and dosage. specimens.
Observe for impaired strength or joint limitation. Suggests the need to modify the examination position.
PLANNING
Explain the procedure and give the client an opportunity to ask Tends to reduce anxiety.
questions.
Provide an examination gown and direct the client to empty her Facilitates palpation of the uterus and ovaries.
bladder.
Place a speculum (a metal or a disposable plastic instrument Promotes efficient time management. Metal specula (plural of
for widening the vagina), gloves, examination light, lubricant, speculum) are reused after sterilization. Select an appropriate
and the following materials for the Pap smear: long soft appli- size according to the individual client.
cators and spatula and at least three glass slides, a chemical
fixative, and a container for holding the slides on the counter
or on a tray in the examination room (Fig. A).
Equipment used for a pelvic examination.
(The liquid-based cytology [ThinPrep Pap Test], an alterna-

tive technique of specimen preservation approved by the
US Food and Drug Administration, eliminates using slides;
instead it involves rinsing the collection tool within a liquid
transport medium.)
Mark one slide with an E for endocervical, another with a C for Identifies the location from which the specimens are taken;
cervical, and the last with a V for vaginal. endocervical means inside the cervix. The cervix is the lower
portion of the uterus, or womb.
(continued)
LWBK1004-C14_p249-282.indd 265 31/01/12 1:31 AM

Assisting With a Pelvic Examination (continued)
Arrange for a female nurse to be with the client during the Reduces the potential for claims of sexual impropriety.
examination, especially if the examiner is a man.
Plan to assist with the collection of the vaginal and cervical Prevents lubricant used during palpation from interfering with a
secretions for the Pap test before the examiner proceeds to microscopic examination of the specimens.
palpate the internal organs.
IMPLEMENTATION
Place the client’s legs in stirrups to facilitate a lithotomy position Provides access to the vagina
(Fig. B); use an alternative position, such as Sims’ or dorsal
recumbent, if the client is disabled.
Lithotomy position.
Cover the client with a cotton or paper drape. Maintains modesty and privacy.
Introduce the examiner to the client if the two are strangers. Tends to reduce anxiety.
Fold back the drape just before the examination begins. Exposes the genitalia while minimizing client exposure.
Direct the examination light from behind the examiner’s shoul- Illuminates the area, facilitating inspection.
der toward the vaginal opening.
Wet the speculum with warm water; if a Pap smear will not Eases and provides comfort during insertion.
be obtained, apply water-soluble lubricant to the speculum
blades.
Prepare the client to expect the momentary insertion of the Tends to reduce anxiety and aids in relaxation.
speculum. Explain that she will hear a loud click as it locks in
place.
Hand the examiner a soft-tipped applicator, spatula, and brush Facilitates collection of secretions for the Pap smear.
applicator in that order.
Hold the slide marked E so that the examiner can roll or slide Deposits intact cells and secretions according to their source;
the specimen across the slide; follow a similar pattern as the excessive manipulation of the cells while being obtained or
second and third samples are collected from the cervix and applied to the slide can make normal cells look like atypical
vagina (see Fig. C). cells.
Transferring secretions to a glass slide.
Position the lined receptacle so the examiner can dispose of the Controls the spread of microorganisms.
collection device and the speculum after use.
(continued)
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Assisting With a Pelvic Examination (continued)
Place each slide in a chemical fixative solution or spray it with a Preserves the integrity of the specimens; a delay in applying a
similar chemical (see Fig. D). fixative leads to air drying, distortion of cells, and loss of details
in the nucleus, thus making it difficult to determine whether
cells are atypical.
Preserving the specimen.
If using the liquid-based cytology technique, immerse the sam- Disperses the cells and breaks up blood, mucus, and nondiagnos-
pling device in the container of solution, cap it, and discard tic debris.
the tool.
Lubricate the gloved fingers of the examiner’s dominant hand Reduces friction; keeps the client informed of the progress of the
and prepare the client for an internal vaginal (and in some examination.
cases, rectal) examination.
Don gloves and clean the skin of lubricant when the examina- Prevents the transmission of microorganisms; promotes comfort
tion is completed; then, remove the gloves. and hygiene.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces microorganisms on the hands.
Chap. 10).
Lower both feet simultaneously from the stirrups and assist the Reduces strain on abdominal and back muscles.
client to sit up.
Assist the client from the room after she has dressed. Maintains client safety.
Evaluation
• Client demonstrated understanding of the purpose for the examination.
• Client assumed and was maintained in a satisfactory position for examination.
• Client privacy, comfort, and safety were maintained.
• Specimens were collected, identified, and preserved.
Document
• Date and time
• Pertinent preassessment data, if any
• Type of examination, including any specimens collected
• Examiner and/or location
• Condition of the client after the examination
• Disposition of specimens
Date and Time Taken to examination room by wheelchair for pelvic examination by Dr. Wood. Able to assume lithotomy
position without difficulty. Smears of endocervical, cervical, and vaginal specimens obtained and sent to
lab. Returned to room by wheelchair and assisted into bed. SIGNATURE/TITLE
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SKILL 14-2 Assisting With a Sigmoidoscopy
ASSESSMENT
Identify the client on whom the examination will be performed. Prevents errors.
Check for a signed consent form. Provides legal protection.
Ask the client to describe the procedure. Indicates the accuracy of the client’s understanding and provides
an opportunity to clarify the explanation.
Inquire about the client’s current symptoms and family history Provides information about the purpose for performing the pro-
of significant diseases. cedure and an opportunity for reinforcing the need for future
regular sigmoidoscopic examinations.
Ask for a description of the client’s dietary and fluid intake and Indicates whether the client complied with proper preparation for
bowel cleansing protocol and results. the procedure.
Assess the client’s vital signs and obtain other physical assess- Provides a baseline for future comparisons.
ments according to agency policy, such as weight or bowel
sounds.
Ask for an allergy history and a list of medications being taken. Influences drugs that may be prescribed and alerts staff to other
medical problems.
PLANNING
Direct the client to undress, don an examination gown, and use Facilitates the examination and gives the client an opportunity to
the restroom. empty the bowel and bladder again.
Prepare for the examination by placing a sigmoidoscope (Fig. A), Promotes efficient time management.
gloves, gown, mask, goggles, lubricant, suction machine, and
containers for biopsied tissue in the examination room.
Flexible sigmoidoscope.
Check that the light at the end of the sigmoidoscope and the Avoids delay, inconvenience, and discomfort once the examina-
suction equipment are operational. tion is in progress.
IMPLEMENTATION
Help the client to assume a Sims’ position if a flexible sig- Facilitates passage of the scope; an endoscopic table may be
moidoscope will be used, or a knee—chest position if a rigid used in lieu of a self-maintained knee—chest position.
sigmoidoscope, which is less common, is used.
Cover the client with a cotton or paper drape. Maintains modesty and privacy.
Introduce the examiner to the client if the two are strangers. Tends to reduce anxiety.
Lubricate the examiner’s gloved fingers. Reduces discomfort when the fingers are used to dilate the anal
and rectal sphincters.
Prepare the client for the introduction of the examiner’s fingers, Tends to reduce anxiety by keeping the client informed of each
followed by the insertion of the sigmoidoscope. step and the progress being made.
Acknowledge any discomfort that the client may be experienc- Indicates that the nurse empathizes with the client’s distress.
ing; explain that it should be short-lived.
Inform the client if, and before, suction is used, air is intro- Prepares the client for unexpected sensations or temporary
duced, or a sample of tissue is obtained. increase in discomfort.
Open the specimen container, cover the specimen with pre- Prevents the loss and decomposition of the specimen.
servative, and recap the container.
(continued)
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Assisting With a Sigmoidoscopy (continued)
Inform the client when the scope will be withdrawn. Keeps the client informed of progress.
Don gloves and clean the skin of lubricant and stool after the Prevents the transmission of microorganisms; promotes comfort
examination is completed; remove the gloves. and hygiene.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces microorganisms.
Chap. 10).
Assist the client from the room to an area where his or her Maintains client safety and dignity.
clothing is located or provide a clean gown.
Explain that there may be slight abdominal discomfort until the Provides anticipatory health teaching.
instilled air has been expelled and that the client may observe
some rectal bleeding if a biopsy was taken.
Stress that if severe pain occurs or bleeding is excessive, the Identifies significant data to report.
client should notify the physician.
Advise that the client may consume food and fluids as desired. Clarifies dietary guidelines.
Clean the sigmoidoscope and any other soiled equipment Prevents the transmission of microorganisms.
according to agency and infection control guidelines.
Restore order and cleanliness to the examination room; restock Prepares the room for future use.
supplies.
Complete the laboratory requisition form, label the specimen, Facilitates microscopic examination.
and ensure that the specimen is transported to the laboratory
for analysis.
Evaluation
• Client demonstrated understanding of the purpose for the examination.
• Appropriate dietary and bowel preparations were carried out.
• Client assumed required position.
• Comfort and safety were maintained.
• Postprocedural instructions were given.
• Specimen was preserved, identified, and delivered appropriately.
Document
• Date and time
• Type of examination and specimen collected, if any
• Examiner and/or location
• Condition of the client after the examination
• Instructions provided
• Disposition of specimens
Date and Time Arrived ambulatory for routine sigmoidoscopic examination. No current symptoms, no known allergies.
Takes atenolol (Tenormin) for hypertension. Last dose was @0700. BP 142/90 in right arm while sitting.
T–98.2; P–90; R–22. Bowel sounds active in all four quadrants. Has eaten lightly this morning and self-
administered two enemas last night with good results and one this morning with very little stool expelled.
Placed in Sims’ position for examination. Biopsy omitted. Instructed to resume eating and taking fluid as
desired. Explained that gas pains are possible and that walking about will help, but to notify Dr. Ross if the
discomfort is prolonged or severe. Discharged ambulatory accompanied by wife. ______ SIGNATURE/TITLE
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SKILL 14-3 Using a Glucometer
ASSESSMENT
Determine that a test using one or more control solutions has Determines that the glucometer is functioning accurately;
been performed on the glucometer since midnight in a health complies with an agency’s policies for quality assurance and
agency. Identify the client on whom the examination will be prevents errors.
performed.
Find out whether the client has ever had a blood glucose level Provides a basis for teaching.
measured with a glucometer or whether the client has any
questions.
Review previous blood glucose level and trends that may be Helps evaluate the reliability of the assessed measurement when
obvious. it is obtained.
Check to see whether insulin coverage has been ordered if Aids in quickly reducing high blood glucose levels.
glucose levels are higher than normal.
Check the date on the container of test strips; discard if the Determines whether test strips are still appropriate for use.
date has expired.
Discard unused test strips stored in a vial 4 months after they Ensures accuracy.
are opened.
Observe the code number on the container of test strips; com- Code numbers range from 1 to 16; if the numbers do not match,
pare it with the code number programmed into the glucom- the meter number is changed.
eter (Fig. A).
Comparing the code number on a test strip bottle to the

glucometer code number. (Photo by B. Proud.)
Inspect the client’s fingers and thumb for a nontraumatized area; Avoids secondary trauma.
also inspect the earlobes, which is an acceptable alternative.
PLANNING
Test the machine’s calibration with a control strip or solution Verifies the machine’s accuracy.
supplied by the manufacturer if it has not been done since
midnight.
Arrange care so that the test is performed approximately Ensures consistency in obtaining data and facilitates the detection
30 minutes before a meal and at bedtime. of trends.
Collect the necessary equipment and supplies: a glucometer, Promotes efficient time management.
lancets, a lancet holder, test strips, and gloves.
IMPLEMENTATION
Ask the client to wash his or her hands with soap and warm Reduces microorganisms on the skin; warmth dilates the capil-
water and towel dry. laries and increases blood flow. Swabbing with alcohol is not
necessary and can alter the results if not totally evaporated.
Turn on the machine; observe the last blood glucose reading, Prepares the machine for testing the blood sample. The machine
current test strip code, and the message “Insert strip.” retains the last glucose measurement in its memory.
Place the notched end of one test strip into the holder with the Locates the strip in position for the application of blood.
test spot up.
(continued)
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Using a Glucometer (continued)
Assemble the lancet within the spring-loaded lancet holder (Fig. B). Loads, holds the lancet in place, and prepares the lancet for a
rapid thrust into the skin.
Lancet insertion.
Don clean gloves after washing your hands or performing hand Provides a barrier against contact with blood.
antisepsis with an alcohol rub (see Chap. 10).
Select a nontraumatized side of a client’s finger or thumb; avoid Avoids puncturing an area with sensitive nerve endings.
the central pads (Fig. C).
Appropriate puncture sites.
C
Apply the lancet firmly to the side of the finger and press the Thrusts the lancet into the skin.
release button.
Release lancet and holder. Opens a path for blood.
Hold the finger or thumb so that a large hanging drop of blood Uses gravity to aid in collecting blood.
forms.
Touch the hanging drop of blood to the test spot on the strip, Saturates the test spot to ensure accurate test results.
making sure that the spot is completely covered and stays
wet during the test (Fig. D).
One large drop of blood is placed in the center of the test strip.
(continued)
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Using a Glucometer (continued)
Listen for the meter to beep, followed by a series of beeps Activates the timing mechanism.
45 seconds later.
Read the display on the meter after the series of beeps. Identifies the client’s blood glucose level.
Turn the machine off. Extends the life of the battery.
Offer the client a Band-Aid or paper tissue. Absorbs blood and controls bleeding.
Release the lancet into a puncture-resistant container. Prevents the potential for a needlestick injury and transmission of
blood-borne infectious microorganisms.
Clean the window of the glucometer and the hole of the test Keeps the equipment free of debris that can impair light detection.
strip holder with a cotton swab or damp cloth to remove dirt,
blood, or lint at least once a week.
Remove gloves and immediately wash your hands or perform Reduces microorganisms.
hand antisepsis with an alcohol rub (see Chap. 10).
Remove equipment from the bedside if it does not belong to Facilitates the use of equipment that may be needed for other
the client. clients.
Store the test strips in a cool dry place at 37° to 85°F (1.7° to Prevents decomposition from heat and humidity.
30°C).
Record the glucose measurement in the client’s diabetic record. Documents essential data.
Report the blood glucose level to the nurse in charge. Communicates information for making treatment decisions.
Evaluation
• Client demonstrates understanding of the purpose for the examination.
• Adequate blood is obtained.
• Results are consistent with the client’s present condition, previous trends, and concurrent treatment.
• Additional treatment is provided depending on glucose measurement.
Document
• Date and time
• Results obtained when using the glucometer; in most agencies, the test data are recorded on a diabetic flow sheet rather than charted
in narrative nursing notes
• Treatment provided based on abnormal test results
Date and Time Blood glucose level 210 mg/dL per glucometer. 5 units of Humulin R insulin given subcutaneously as
coverage. SIGNATURE/TITLE
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UNIT 4
End of Unit Exercises for Chapters 10, 11, 12, 13, and 14
1. __________________ bacteria exist without oxygen. (Aerobic, Anaerobic, Mycoplasmic)
2. Tinea corporis is a/an __________________ type of fungal infection. (intermediate, superficial, systemic)
3. Various anatomical and physiologic adaptations keep human body temperature within a narrow stable range regardless
of environmental temperature; hence, humans are __________________. (heterothermic, homeothermic, poikilothermic)
4. A __________________ is the process of sending someone to another person or agency for special services. (discharge,
referral, transfer)
5. Prolonged __________________ leads to brain damage or death. (apnea, dyspnea, orthopnea)
6. __________________ is a heart rate below 60 beats per minute. (Bradycardia, Palpitation, Tachycardia)
7. A/An __________________ is a crack in the skin, especially in or near mucous membranes. (abrasion, fissure, lacera-
tion)
8. __________________ sounds are located normally in the periphery of all the lung fields. (Bronchial, Bronchovesicular,
Vesicular)
9. __________________ is a procedure for withdrawing fluid from the abdominal cavity. (Fluoroscopy, Paracentesis,
Roentgenography)
10. The __________________ is the brain’s temperature-regulating center that initiates processes that promote heat conser-
vation and production. (cerebellum, hypothalamus, medulla)
1. T____F____ A spore is a temporarily inactive microbe that can resist heat and destructive chemicals and survive
without moisture.
2. T____F____ Some pathogens have tiny hairs called flagella that enable them to attach to the host’s tissue and avoid
expulsion.
3. T____F____ For every degree of Fahrenheit that temperature is elevated, heart and pulse rates increase 15 beats per
minute.
4. T____F____ The apical heart rate can be counted by listening at the chest with a stethoscope.
5. T____F____ Orientation helps the client become familiar with and adapt to a new environment.
6. T____F____ The nurse performs light palpation by depressing tissue approximately 1 in. (2.5 cm) with the forefingers
of one or both hands.
7. T____F____ Normal vision is the ability to read without prescription lenses printed letters that most people can see at a
distance of 20 feet.
8. T____F____ Lordosis causes an increased curve in the thoracic area.
9. T____F____ A developing fetus is at increased risk for cellular damage from X-rays.
10. T____F____ Electroencephalography is an examination of the energy produced by stimulated muscles.
273
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1. Practices that decrease or eliminate infectious agents, their reservoirs, and their vehicles for transmission
__________________
2. A haven in which microbes survive, grow, and reproduce __________________
3. Using atoms subjected to a strong electromagnetic field to produce an image __________________
4. A handheld probe used during an ultrasonography to project sound through the body’s surface __________________
5. A pronounced lateral curvature of the spine __________________
6. An assessment technique used to listen to body sounds __________________
7. Rapid or deep breathing, or both, affecting the volume of air entering and leaving the lungs __________________
8. The termination of care from a health care agency __________________
Activity D: 1. Match the type of microorganism in Column A with its characteristics in Column B.
Column A Column B
1. __________________ Bacterium A. Smallest microorganism known to cause infectious disease;
visible only with an electron microscope
2. __________________ Virus B. Protein that does not contain nucleic acid
3. __________________ Protozoan C. Single-celled microorganism; may be round, rod-shaped, or spiral
4. __________________ Prion D. Single-celled animal classified according to its ability to move
2. Match the terms indicating alterations in skin integrity in Column A with their descriptions in Column B.
Column A Column B
1. __________________ Wound A. Open crater-like area
2. __________________ Ulcer B. Mark left by the healing of a lesion
3. __________________ Scar C. Break in the skin
3. Match the positions used for physical examinations in Column A with their descriptions in Column B.
Column A Column B
1. __________________ Dorsal recumbent position A. The client lies on the left side with the chest leaning forward, the
right knee bent toward the head, the right arm forward, and the
left arm extended behind the body
2. __________________ Lithotomy position B. The client rests on the knees and chest
3. __________________ Sims’ position C. The client reclines with the feet in metal supports called stirrups
4. __________________ Genupectoral position D. The client reclines with the knees bent, the hips rotated outward,
and the feet flat
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Activity E: 1. Differentiate between medical and surgical asepsis.

Medical Asepsis Surgical Asepsis
Definition
Technique
Methods of Obtaining Asepsis
2. Differentiate between fever and hyperthermia.

Fever Hyperthermia
Definition
Complications or Concerns
3. Differentiate between the head-to-toe and the body-systems approaches to physical assessment.
Head-to-Toe Approach Body-Systems Approach
Definition
Advantages
Disadvantages
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1.
a. Identify the figure shown above.

b. Which of the two methods for assessing the pulse rate is more accurate? Why?
2.
B D
C
A
a. Identify the equipment shown in the figure.

b. What is this equipment used for?
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Activity G: A surgical scrub extensively removes transient microorganisms from the nails, hands, and forearms before
an operative procedure. Write in the boxes provided below the correct sequence in which the nurse should
perform the actions of a surgical scrub.
1. Use friction to scrub all surfaces of the hands.
2. Use friction to lather the liquid cleanser.
3. Hold the hands and arms up and away from the body.
4. Put on a mask, hair, and shoe covers.
5. Rinse the lather while keeping the hands above the elbows.
6. Dry hands with a sterile towel.
7. Wet hands to the forearms.
8. Clean under each fingernail.

1. What is a nosocomial infection?
2. What are the six components of the chain of infection?
3. What is the purpose of a minimum data set (MDS)?
4. What are the nurse’s duties when a client must be transferred within the same health care agency?
5. What are the phases of a fever?
6. What is postural hypotension?
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7. Why is a physical assessment of the client upon admission to the health care facility important?
8. What is a Snellen eye chart?
9. How is a culture performed?
10. What is the purpose of a lumbar puncture or a spinal tap?

1. Why does the nurse pour out and discard a small amount of sterile solution before each use?
2. Why is it good practice for the nurse to remove chipped or peeling nail polish before working at a health care facility?
3. Why should the nurse have a second nurse’s, supervisor’s, or security person’s signature on the envelope containing a
client’s secured valuables?
4. Why is it important for a nurse to measure a client’s vital signs at regular intervals?
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5. When should the nurse use clean gloves during nursing care?
6. Why should the nurse ensure that the client’s garments are free of all metallic objects, such as hooks or medals, before a
radiographic examination?
7. Why should the nurse drape the client during physical examinations?
8. Why is it better to assess skin turgor in the area over the chest in an elderly client?
1. A nurse at an extended-care facility is caring for an elderly client with a hip fracture who has developed pulmonary
congestion and respiratory distress during his stay.
a. What could have caused the pulmonary congestion and respiratory distress?
b. What care should the nurse take to prevent nosocomial infections at the facility?
2. A client at the health care facility is ready to give birth. A nurse is preparing to assist the obstetrician.
a. What steps should the nurse follow before the procedure?
b. What is the purpose of the previous steps?
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3. A nurse at a health care facility is asked to proceed with admission procedures for a client scheduled for surgery.
a. What is the nurse’s responsibility during the admission of the client to the facility?
b. What should the nurse include in the initial nursing care plan?
4. A nurse caring for a newborn at a health care facility is required to measure and document the baby’s temperature at
regular intervals.
a. Which are the preferred routes for measuring the temperature of newborns or infants?
b. Why do newborns and young infants tend to experience temperature fluctuations?
5. A child arrives at the clinic with complaints of pain in his right ear. A nurse is assisting the physician during the
assessment.
a. How does the nurse perform a gross examination of the ear?
b. What kind of substance within the ear is considered normal?
6. A nurse is caring for a client who is to undergo an electrocardiography (ECG).

a. How should the nurse explain to the client what to expect during the procedure?
b. What are the nursing responsibilities for a client undergoing an ECG?
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Activity K: Think over the following questions. Discuss them with your instructor or peers.
1. A nurse is caring for three different clients in a health care facility. The first is an immunosuppressed 68-year-old client
undergoing chemotherapy. The second is a 40-year-old client with tuberculosis. The third is a teenager with a wound
infection.
a. What considerations are involved when caring for the older client undergoing chemotherapy?
b. What techniques of asepsis should the nurse follow when caring for clients with infectious disorders?
2. A 34-year-old client with diabetes has undergone a foot amputation secondary to an untreated injury. Although the client
is receiving occupational therapy and rehabilitation at the health care facility, he is severely depressed about the loss of
his foot and its implications. He tells the nurse that he regrets his carelessness and fears that he will never be able to lead
a normal life again. He has been very quiet and refuses to interact with his family. The client is to be discharged soon.
a. What may be some special considerations for this client during discharge?
b. What special referral services might be appropriate to help improve the client’s condition?
c. How can the nurse help the client deal with his loss?
3. A nurse employed in the rehabilitative care unit of a health care facility is required to measure the blood pressure of a
severely obese client who is recovering from a motor vehicle collision. The client’s right arm is in a cast. He has just
returned to his room after actively exercising by ambulating in the hall.
a. Should the nurse assess blood pressure soon after the client has exercised?
b. What factors should be considered when using a sphygmomanometer to assess blood pressure in this client?
4. The nurse needs to perform a routine assessment for a client recovering from a head injury as directed by the primary
health care provider. How can the nurse avoid making any subjective assessments of the client’s mental status?

1. A nurse is caring for a client scheduled for electromyography (EMG). Which of the following instructions should the
nurse give the client regarding the procedure?
a. Stay awake after midnight before the examination.
b. Avoid cola beverages for 8 hours before the procedure.
c. Pain will be felt if the electrode touches a terminal nerve in the area.
d. Consult with the physician about withholding scheduled medications.
2. A nurse is caring for a client with an infection at a health care facility. What precautions should the nurse take after leav-
ing the client’s room? Select all that apply.
a. Scrub the hands thoroughly, giving special attention to the nails.
b. Use a wet towel to turn off faucets.
c. Avoid touching any part of the sink or the faucets.
d. Discard paper towels appropriately after drying the hands.
e. Apply hand sanitizer to keep the hands free from odor.
3. During the physical assessment of a client, the nurse listens to lung sounds. How should the nurse document squeaking
sounds caused by air moving through a narrowed passage in the lung?
a. Crackle
b. Gurgle
c. Rub
d. Wheeze
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4. A fever generally goes through four distinct phases. Arrange the phases in the order in which they occur. Use all the
options.
a. Stationary
b. Defervescence
c. Invasion
d. Prodromal
5. A nurse is assigned to measure and document the vital signs of a client recovering from an accident. The client is receiv-
ing intravenous medication in the right arm. The left arm and left lower leg are severely injured. Which of the following
would be the best site for measuring the client’s blood pressure?
a. Right lower arm
b. Right upper arm
c. Left thigh
d. Right thigh
6. During a physical assessment, the nurse taps the fingers against the client’s abdomen. Which of the following techniques
involves tapping or striking fingers on the client’s body?
a. Auscultation
b. Palpation
c. Percussion
d. Observation
7. A nurse uses an alcohol rub after the physical assessment of each client. Which of the following is true about alcohol
rubs?
a. They remove dirt with organic material.
b. They remove 80% of microorganisms.
c. They can substitute for handwashing if the hands are visibly clean.
d. They have a prolonged antiseptic effect after an initial use.
8. While taking a client’s vital signs, the nurse identifies that the pulse is difficult to feel and easily obliterated with slight
pressure. Which of the following is the most accurate description of the pulse?
a. Thready
b. Bounding
c. Full
d. Strong
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UNIT 5
Assisting With Basic Needs
15 Nutrition 284
16 Fluid and Chemical Balance 305
17 Hygiene 345
18 Comfort, Rest, and Sleep 374
19 Safety 399
20 Pain Management 417
21 Oxygenation 438
22 Infection Control 467
283
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15 Nutrition
abdominal circumference
anorexia
anthropometric data 1. Define nutrition and malnutrition.
body mass index 2. List six components of basic nutrition.
cachexia 3. List at least five factors that influence nutritional needs.
calorie 4. Discuss the purpose and components of the MyPlate food
carbohydrates guidelines.
cellulose 5. Describe three facts available on nutritional labels.
complete proteins 6. Explain protein complementation.
diet history 7 . Identify four objective assessments for determining a
dysphagia person’s nutritional status.
emaciation 8. Discuss the purpose of a diet history.
emesis 9. List five common problems that can be identified from a
eructation nutritional assessment.
essential amino acids 10. Plan nursing interventions for resolving problems caused or
fats affected by nutrition.
fat-soluble vitamins 11. List seven common hospital diets.
flatus 12. Discuss four nursing responsibilities for meeting clients’
incomplete proteins nutritional needs.
kilocalorie 13. Identify three facts a nurse must know about a client’s diet.
lipoproteins 14. Describe and demonstrate techniques for feeding clients.
malnutrition 15. Explain how to meet the nutritional needs of clients with
megadoses visual impairment or dementia.
metabolic rate 16. Discuss at least three unique aspects of nutrition that apply to
midarm circumference older adults.
minerals
nausea
H
nonessential amino acids ealthy people, in general, are becoming increasingly selective
nutrition about the quantity and quality of their daily food intake. In a
obesity country of affluence, Americans are both undernourished and
projectile vomiting overnourished. According to the Centers for Disease Control and
protein Prevention (Ervin, 2009), 34% of adults meet the criteria for metabolic
protein complementation syndrome, which is characterized by obesity, abdominal fat, hyperten-
regurgitation sion, and elevated blood glucose (insulin resistance) and fat levels.
retching
saturated fats
triceps skinfold measurement Gerontologic Considerations
trans fats
unsaturated fats ■ Male and female adults who are 60 years and older are four times
vegans and six times more likely, respectively, than younger adults to have
vegetarians metabolic syndrome (Ervin, 2009).
vitamins ■ The escalating incidence of this syndrome indicates the critical
vomiting need to control the epidemic of obesity in the United States.
vomitus
water-soluble vitamins
This chapter includes information about normal nutrition for
promoting health. It also provides suggestions that nurses may offer
clients about what and how much to eat, the dangers of food fads
284
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CHAPTER 15 Nutrition 285
and unsafe dieting, and techniques for managing the care of Calories
clients whose ability to eat, digest, absorb, or eliminate food Food is the source of energy for humans. Some nutrients
is impaired. produce more energy than others. By using a calorimeter, a
device for measuring heat, the nutrients in food are burned in
a laboratory and then analyzed to quantify their energy value.
OVERVIEW OF NUTRITION The energy, or heat equivalent, of food is measured in
calories. A calorie (cal) (the amount of heat that raises the
Eating is a basic need. It is the mechanism by which nutri- temperature of 1 g of water by 1°C) is one way to express the
ents are obtained. An optimal nutritional status provides energy value of food. Sometimes, the energy equivalent of food
(1) sufficient energy for daily activities, (2) maintenance and is expressed in kilocalories (kcal) (1,000 cal, or the amount
replacement of body cells and tissues, and (3) restoration of of heat that raises the temperature of 1 kg of water by 1°C).
health following illness or injury. Because the type and amount When proteins, carbohydrates, and fats are metabolized,
of nutrients consumed affect health, it is important to under- they produce energy. Proteins yield 4 kcal/g, carbohydrates
stand basic nutrition, or the process by which the body uses yield 4 kcal/g, and fats yield 9 kcal/g. Alcohol yields 7 kcal/g
food. Chronic, inadequate nutrition leads to malnutrition (a but is not considered an essential nutrient.
condition resulting from a lack of proper nutrients in the diet). The number of calories a person needs depends on age,
Evidence of malnutrition is common among people living in body size, physical condition, and physical activity. On aver-
poor, developing countries; however, it also occurs among age, healthy adult women require 1,600 to 2,400 cal/day and
people living in countries known for their affluence, like the adult men require 2,000 to 3,000 cal/day; the lower end of
United States. Examples of those in the United States at risk the range is for sedentary individuals, whereas the higher
for an inadequate nutritional intake include the following: end is for active individuals (U.S. Department of Agricul-
ture, 2010). Unless the caloric intake includes an appropriate
• Older adults who are socially isolated or living on fixed
mix of proteins, carbohydrates, and fats, the person may be
incomes
marginally nourished or malnourished. In other words, con-
• Homeless people
suming 2,000 cal of chocolate, exclusive of any other food,
• Children of economically deprived parents
is not adequate to sustain a healthy state! Fortunately, most
• Pregnant teenagers
foods contain a variety of nutrients, vitamins, and minerals.
• People with substance abuse problems, such as alcoholism
• Clients with eating disorders, such as anorexia nervosa and
bulimia nervosa Gerontologic Considerations
Human Nutritional Needs ■ Older adults require fewer calories and, therefore, should
Increasing data support the connections between nutritional be taught to select nutrient-dense foods such as meat,
status and health and well-being. Consequently, an emphasis fruits, vegetables, dairy products, and whole-grain breads
on improving nutrition to prevent and treat disease also is and cereals.
growing. All humans have basic nutritional needs. Through
scientific study, researchers have determined standards for
Proteins
the recommended daily amounts of the following:
Protein, a component of every living cell, is a nutrient com-
• Calories that provide the body with energy posed of amino acids, or chemical compounds composed
• Proteins, carbohydrates, and fats that supply calories and are of nitrogen, carbon, hydrogen, and oxygen. Amino acids
substances needed for the growth and repair of body structures are responsible for building and repairing cells. Twenty-two
• Vitamins and minerals that do not supply calories but are amino acids have been identified so far. Of these, nine are
essential for regulating and maintaining physiologic pro- referred to as essential amino acids, which are protein com-
cesses necessary for health ponents that must be obtained from food because the body
• Water, which is also necessary for life (discussed in Chapter cannot synthesize them. Nonessential amino acids are pro-
16) tein components manufactured within the body; however, this
term is misleading. “Nonessential” refers to the fact that these
Although standards have been established for the types
amino acids are not dependent on dietary intake, not that they
and amounts of dietary components necessary to sustain
are unnecessary for health.
health, individual nutritional needs are influenced by and
The body uses proteins primarily to build, maintain, and
may require adjustment according to the following:
repair tissue. The body spares protein from being used for
• Age energy as long as calories are available from carbohydrates
• Weight and height and fats.
• Growth periods Dietary proteins are obtained from animal and plant food
• Activity sources, which include milk, meat, fish, poultry, eggs, soy,
• Health status legumes (peas, beans, and peanuts), nuts, and components of
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286 UNIT 5 Assisting With Basic Needs
Legumes Fats
Grains
Beans Peas Fats, nutrients that contain molecules composed of glyc-
Generally Breads
Peanuts complementary erol and fatty acids called glycerides, are part of a family
Cereals
Lentils Tofu of compounds known collectively as lipids. Depending on
the number of fatty acids that make up a fat molecule, fats
Generally Generally are referred to as monoglycerides, diglycerides, or triglyc-
complementary complementary
Also: Rice with Sesame erides.
Brazil nuts with Milk Fats are a concentrated energy source, supplying more
Sesame with Milk
Seeds Milk than twice the calories per gram than either proteins or car-
Nuts Products bohydrates. Although fats are high in calories, they should
not be eliminated from the diet. Fats provide energy and are
necessary for many chemical reactions in the body. They are
FIGURE 15-1 A complementary protein guide for meatless
meals.
also necessary for the absorption of some vitamins. Fats also
add flavor to food, and because they leave the stomach
slowly, they promote a feeling of having satisfied appetite
grains. Generally, animal sources provide complete proteins and hunger.
(proteins that contain adequate amounts and proportions of The following food sources contain fat: meat, fish, and
all the essential amino acids); plant sources contain incom- poultry; butter, margarine, and vegetable oils; egg yolks;
plete proteins (proteins that contain insufficient quantities whole milk and cheese; peanut butter; salad dressings; avo-
of one or more essential amino acids). Protein complemen- cados; chocolate; nuts; salty snacks; and most desserts.
tation (combining plant sources of protein) helps a person
Role of Cholesterol. Cholesterol is transported through
to acquire all essential amino acids from nonanimal sources
the blood in molecules of lipoproteins (a combination of
(Fig. 15-1). Protein complementation is discussed later in
fats and proteins). Lipoproteins vary in their proportions of
relation to vegetarian diets.
protein to cholesterol. The more protein a molecule contains,
Carbohydrates the higher is its density. High-density lipoprotein (HDL) is
Carbohydrates are nutrients that contain molecules of car- referred to as “good cholesterol,” because the cholesterol is
bon, hydrogen, and oxygen, and are generally found in plant delivered to the liver for removal. Low-density lipoprotein
food sources. They are classified according to the number is called “bad cholesterol” because the cholesterol is depos-
of sugar (saccharide) units they contain. Carbohydrates ited within the walls of arteries, which can eventually result
are subdivided into monosaccharides, disaccharides, and in cardiovascular disease.
polysaccharides (starches). Types of Fats. All fats in food are a mixture of saturated
Carbohydrates, the chief component of most diets, are and unsaturated fats. Saturated fats are lipids that contain as
the body’s primary source for quick energy. In addition to much hydrogen as their molecular structure can hold and are
providing calories, carbohydrates may contain fiber (com- generally solid. Saturated fats are the predominate type of fat
plex polysaccharides that humans are unable to digest). Cel- in red meats, full fat dairy products, and palm and coconut
lulose is a type of fiber in the stems, skins, and leaves of oils. Cholesterol is only present in foods of animal origin,
fruits and vegetables, which forms intestinal bulk to promote but the body also synthesizes cholesterol. Unsaturated fats
bowel elimination. Other types of fiber help lower serum are missing some hydrogen. They are a healthier form of
cholesterol levels and delay the rise in serum glucose after fats and are liquid at room temperature or congeal slightly
eating. when refrigerated. Unsaturated fats are the predominate type
Sources of carbohydrates include cereals and grains
such as rice, wheat and wheat germ, oats, barley, corn, and
corn meal; fruits and vegetables; and sweeteners. Milk is the
only significant animal source of carbohydrates. Box 15-1
lists terms on food labels that identify ingredients that are, in B OX 1 5 - 1 Label Ingredients That
essence, sugar. Foods containing added sugar as a major ingre- Represent Sugar
dient tend to supply calories but few, if any, other nutrients. • Sucrose (table sugar) • Invert sugar
• Fructose • Lactose
• Glucose (dextrose) • Maltose
Gerontologic Considerations • Brown sugar • Molasses
• Corn sweetener • Raw sugar
■ Older adults often consume diets high in carbohydrates. • Corn syrup • Syrup
Reasons include changes in taste; changes in the ability to • High fructose corn syrup • Evaporated cane juice
prepare or obtain foods; or financial considerations of pay- • Fruit juice concentrate • Malt
ing for medications, groceries, and living expenses on a • Honey
fixed income.
LWBK1004-C15_p283-304.indd 286 31/01/12 1:33 AM

of fat in fish, poultry, nuts, and most plant oils, such as corn, ➧ Stop, Think, and Respond Box 15-1
safflower, olive, peanut, and soybean. Trans fats are unsatu-
Which client has the lowest cardiac risk factor?
rated fats that have been hydrogenated, a process in which • Client A: Total cholesterol level is 224 mg/dL; HDL
hydrogen is added to the fat. Hydrogenation changes the level is 38 mg/dL
unsaturated fat to a more saturated form that remains solid at • Client B: Total cholesterol level is 198 mg/dL; HDL
room temperature. An example includes the hydrogenation level is 35 mg/dL
of vegetable oil to create margarine or shortening. Hydro- • Client C: Total cholesterol level is 210 mg/dL; HDL
genation reduces the rate at which a fat becomes rancid, thus level is 55 mg/dL
increasing the shelf life of food items that contain it (eg, cake
mixes).
Minerals
Health Risks Related to Fat and Cholesterol. Gener- Minerals (noncaloric substances in food that are essential
ally, Americans consume more fats than people do in most to all cells) help regulate many of the body’s chemical proc-
other countries. The relationship between fat consumption esses such as blood clotting and the conduction of nerve
and obesity to disorders such as metabolic syndrome, heart impulses. Table 15-2 lists some of the body’s major and
disease, hypertension, diabetes, and some cancers is well trace minerals, their chief functions, and common dietary
documented. In an effort to improve national health, the sources.
Department of Health and Human Resources is continuing As a national policy, specified amounts of certain min-
its initiative, Healthy People 2020. One goal the government erals and vitamins are added to some processed foods. For
advocates is for at least 50% of people 2 years and older to example, enriched flour and bread contain thiamine, ribofla-
consume no more than 29.8% of their daily calories from fat; vin, niacin, and iron to replace what is lost when the grain is
of that, less than 9.5% should be saturated fat. ground into flour. Fortified foods have nutrients added that
Although the creation of trans fats has improved the were either not naturally present in the food or were present
marketing of convenience foods, health-concerned agencies in insignificant amounts.
like the American Heart Association (AHA, 2010) indicate
that consumption of trans fats increases the risk for coro-
nary heart disease. The U.S. Food and Drug Administration
(FDA, 2010) now requires the listing of the amount of trans
fatty acid content on food labels. TABLE 15-2 Common Dietary Minerals
Health care providers use cholesterol and lipoprotein COMMON DIETARY
levels to assess clients’ risks for cardiac and vascular dis- MINERAL CHIEF FUNCTIONS SOURCES
eases (Table 15-1). Cardiac risk also can be estimated by Sodium Maintenance of water and Table salt
dividing the total serum cholesterol level, which should be electrolyte balance Processed meat
less than 200 mg/dL, by the HDL level. A result greater Potassium Maintenance of electrolyte Bananas
balance Oranges
than 5 suggests that a client has a potential for coronary Neuromuscular activity Potatoes
artery disease. Enzyme reactions
Chloride Maintenance of fluid and Table salt
electrolyte balance Processed meat
Calcium Formation of teeth and Milk
bones Milk products
Neuromuscular activity
TABLE 15-1 Cardiac Risk Associated With Blood Blood coagulation
Fat Levels Cell wall permeability
SUBSTANCE VALUE INTERPRETATION Phosphorus Buffering action Eggs
Formation of bones and Meat
Total cholesterol <200 mg/dL Desirable teeth Milk
200–239 mg/dL Borderline high Iodine Regulation of body Seafood
≥240 mg/dL High metabolism Iodized salt
Low-density lipoprotein <100 mg/dL Optimal Promotion of normal
100–129 mg/dL Near optimal growth
130–159 mg/dL Borderline high Iron Component of hemoglobin Liver
160–189 mg/dL High Assistance in cellular Egg yolks
≥190 mg/dL Very high oxidation Meat
High-density lipoprotein <40 mg/dL Low Magnesium Neuromuscular activity Whole grains
40–59 mg/dL Acceptable Activation of enzymes Milk
≥60 mg/dL Optimal Formation of teeth and Meat
bones
Source: Adult Treatment Panel (ATPIII). (2001). Clinical guidelines for choles-
Zinc Constituent of enzymes Seafood
terol testing and management. The National Cholesterol Education Program,
a division of the National Heart, Lung, Blood Institute. (Online): http://rover. and insulin Liver
nhlbi.gov/guidelines/cholesterol/atp3_rpt.htm
LWBK1004-C15_p283-304.indd 287 31/01/12 1:33 AM

TABLE 15-3 Vitamins

VITAMIN CHIEF FUNCTIONS COMMON DIETARY SOURCES
A (Retinol) Growth of body cells Animal fats: butter, cheese, cream,
Not destroyed by ordinary cooking Promotion of vision, healthy hair and skin, and integrity of egg yolks, whole milk
temperatures epithelial membranes Fish liver oil and liver
Prevention of xerophthalmia, a condition characterized by Dark green leafy vegetables; deep
chronic conjunctivitis orange fruits and vegetables
B1 (Thiamine) Carbohydrate metabolism Fish
Not readily destroyed by ordinary Functioning of the nervous system Pork
cooking temperatures Normal digestion Lean meat and poultry
Prevention of beriberi, a condition characterized by Glandular organs
neuritis Milk
Whole, fortified, and enriched
breads, cereals, and grains
Peas, beans, and peanuts
B2 (Riboflavin) Formation of certain enzymes Eggs
Not destroyed by heat except in Normal growth Green leafy vegetables
the presence of alkali Light adaptation in the eyes Lean meat
Milk
Whole grains
Dried yeast
B3 (Niacin) Carbohydrate, fat, and protein metabolism Lean meat and liver
Enzyme component Fish
Prevention of appetite loss Peas, beans
Prevention of pellagra, a condition characterized by Whole-grain cereals
cutaneous, gastrointestinal, neurologic, and mental Peanuts
symptoms Yeast
Eggs
Liver
B6 (Pyridoxine) Healthy gums and teeth Whole-grain cereals and wheat germ
Destroyed by heat, sunlight, and air Red blood cell formation Vegetables
Carbohydrate, fat, and protein metabolism Yeast
Meat
Bananas
Blackstrap molasses
B9 (Folic acid) Protein metabolism Green leafy vegetables
Red blood cell formation Glandular organs
Normal intestinal tract functioning Yeast
B12 (Cyanocobalamin) Protein metabolism Liver and kidney
Red blood cell formation Dairy products
Healthy nervous system tissues Lean meat
Prevention of pernicious anemia, a condition Milk
characterized by decreased red blood cells Saltwater fish and oysters
C (Ascorbic acid) Healthy bones, teeth, and gums Citrus fruits and juices
Readily destroyed by cooking Formation of blood vessels and capillary walls Tomatoes
temperatures Proper tissue and bone healing Berries
Facilitation of iron and folic acid absorption Cabbage
Prevention of scurvy, a condition characterized by bleed- Green vegetables
ing and abnormal bone and teeth formation Potatoes
D (Calciferol) Absorption of calcium and phosphorus Fish liver oils, salmon, tuna
Relatively stable with refrigeration Prevention of rickets, a condition characterized by weak Milk
bones Egg yolks
Butter
Liver
Oysters
Formed in the skin by exposure to
sunlight
E (Alpha-tocopherol) Red blood cell formation Green leafy vegetables
Heat stable in the absence of Protection of essential fatty acids Wheat germ oil
oxygen Important for normal reproduction in experimental Margarine
animals (ie, rats) Brown rice
Pantothenic acid Metabolism Liver
Egg yolks
Milk
LWBK1004-C15_p283-304.indd 288 31/01/12 1:33 AM

VITAMIN CHIEF FUNCTIONS COMMON DIETARY SOURCES

H (Biotin) Enzyme activity Egg yolks
Heat sensitive Metabolism of carbohydrates, fats, and proteins Green vegetables
Milk
Liver and kidney
Yeast
K (Menadione) Production of prothrombin Liver
Eggs
Green leafy vegetables
Synthesized in the gastrointestinal
tract by bacteria
Vitamins MyPlate
Vitamins are chemical substances necessary in minute MyPlate, introduced in 2011 by the U.S. Department of
amounts for normal growth, the maintenance of health, and Agriculture, replaces the previously used food pyramid
the functioning of the body (Table 15-3). They were origi- and MyPyramid. MyPlate is an improved simplified tool
nally named with letters; numbers were subsequently added for promoting a healthful daily intake of food (Fig. 15-2).
to some letters as more vitamins were identified. Chemical Its advantage is that the recommended percentages of con-
names are now replacing the letter-number system of iden- sumed food from among five food group categories promote
tification. healthy nutrition. Nutritionists also advocate reducing salt
Water-soluble vitamins (B complex and C) are elimi- consumption and substituting water for sugary beverages.
nated with body fluids and so require daily replacement. Fat- Following MyPlate guidelines promotes the achievement
soluble vitamins (A, D, E, and K) are stored in the body as of the dietary recommendations set by the U.S. Department
reserves for future needs. of Health and Human Services and the U.S. Department of
With the exception of vitamin D, vitamin K (menadi- Agriculture’s Dietary Guidelines for Americans (see Web
one), and biotin, the body does not manufacture vitamins. Resources on ).
People can easily meet their vitamin requirements, however, Children, adolescents, pregnant women, and breast-
by eating a variety of foods. Cooking, processing, and not feeding mothers require more servings per day of certain
refrigerating can deplete the content of some vitamins in food groups, particularly the milk group. Recommenda-
food. Various commercially packaged foods such as marga-
rine, milk, and flour have been vitamin enriched or fortified
to promote health.
Generally, vitamin and mineral supplements are not
necessary if a person eats a well-balanced diet. Consuming
megadoses (amounts exceeding those considered adequate
for health) of vitamins and minerals can be dangerous. Some
athletes and people with terminal diseases choose to follow
unconventional diets and take large doses of nutritional sup-
plements. Athletes are motivated by a desire to alter their
muscle mass, strength, and endurance; people with terminal
diseases seek attempts for cure. Although various deficiency
diseases develop from inadequate nutrition, no conclu-
sive evidence at this time supports that consuming exces-
sive nutrients, vitamins, or minerals is a safe substitute for
healthy eating or works as a singular established treatment
for disease.
Nutritional Strategies
Healthy People 2020, a national effort to improve the health
of Americans, provides recommendations to enhance nutri-
tion and weight status (Box 15-2). Other nutritional strat- FIGURE 15-2 MyPlate is color-coded to show the five groups of
egies include using the U.S. Department of Agriculture’s foods that should be consumed each day in the following pro-
portions: 30% grains, of which half are preferably whole grains;
MyPlate, referring to labels about nutrition on processed and 30% vegetables; 20% fruits; 20% protein; which are accompa-
packaged foods, and understanding standard definitions for nied by low-fat/nonfat milk or other reduced fat dairy products.
the terms used on food labels. (USDA, ChooseMyPlate.gov.)
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B OX 1 5 - 2 Nutrition and Weight Status Gerontologic Considerations

Objectives for Healthy People 2020
■ Some older adults have difficulty obtaining and preparing
Healthier Food Access
nutritious meals because of socioeconomic barriers such as
Increase the number of states with nutrition standards for
low income and an inability to get to the grocery store. In
foods and beverages provided to preschool-aged children
addition, appropriate food storage (including food expiration
in child care.
dates, proper storage temperature, and access to cup-
Increase the proportion of schools that offer nutritious foods
boards if arthritic changes are present) should be evaluated.
and beverages outside of school meals.
Increase the number of states that have state-level policies
that incentivize food retail outlets to provide foods that are
encouraged by the USDA’s Dietary Guidelines for Americans. ➧ Stop, Think, and Respond Box 15-2
Increase the proportion of Americans that have access to a Using MyPlate, what percentage of whole grains
food retail outlet that sells a variety of foods that are encour- should an adult consume each day?
aged by the USDA’s Dietary Guidelines for Americans.
Healthcare and Work Site Settings Nutritional Labeling
Increase the proportion of primary care physicians who regu- Nutritional information has appeared on food labels since
larly measure the body mass index (BMI) of their patients. 1974. Today, all packages of fresh meat and poultry must
Increase the proportion of physician office visits that include provide printed disease prevention guidelines. There have
counseling or education related to nutrition or weight. also been major changes in the way nutritional information is
Increase the proportion of work sites that offer nutrition or
provided on approximately 90% of processed and packaged
weight management classes or counseling.
food labels (Fig. 15-3). The labels identify the amounts of
Reduce the proportion of children and adolescents who are
considered obese. each nutrient per serving, which is identified in household
Prevent inappropriate weight gain in youth and adults. measurements. To interpret the information accurately,
however, consumers must become familiar with a variety
Food Insecurity of terms, such as daily value (DV). DVs are calculated in
Eliminate very low food security (a state in which people
percentages based on standards set for total fat, saturated fat,
have access at all times to sufficient, safe, nutritious food to
maintain a healthy and active life) among children.
Reduce household food insecurity and, in doing so, reduce hunger.
Food and Nutrient Consumption
Increase the contribution of fruits to the diets of the population
Nutrition 12
Facts
Serving Size / cup (114g)
aged 2 years and older. Servings Per Container 4
Increase the variety of vegetables to the diets of the population
Amount Per Serving
aged 2 years and older.
Calories 90 Calories from Fat 30
Increase the contribution of whole grains to the diets of the
% Daily Value*
population aged 2 years and older.
Total Fat 3 g 5
Reduce consumption of calories from solid fats and added
Saturated Fat 0 g 0
sugars in the population aged 2 years and older.
Reduce consumption of saturated fat in the population aged Trans Fat 1 g
2 years and older. Cholesterol 0 mg 0
Reduce consumption of sodium in the population aged 2 years Sodium 300 mg 13
and older. Total Carbohydrate 13 g 4
Increase consumption of calcium in the population aged 2 years Dietary Fiber 3 g 12
and older. Sugars 3 g
Iron Deficiency Protein 3 g
Reduce iron deficiency among young children and females of Vitamin A 80% • Vitamin C 60%
Calcium 4% • Iron 4%
childbearing age. * Percent Daily Values are based on a 2,000
Reduce iron deficiency among pregnant females. cal diet. Your daily values may be higher
or lower depending on your caloric needs:
Calories 2,000 2,500
U.S. Department of Health and Human Services. (2010). Healthy People Total Fat Less than 65 g 80 g
2020, Nutrition and Weight Status. http://www.healthypeople.gov/2020/ Sat Fat Less than 20 g 25 g
topicsobjectives2020/overview.aspx?topicid=29, accessed March 1, 2011. Cholesterol Less than 300 mg 300 mg
Sodium Less than 2,400 mg 2,400 mg
Total Carbohydrate 300 g 375 g
Fiber 25 g 30 g
tions for specific populations can be accessed at the Web Calories per gram:
site for the Department of Health and Human Resources: Fat 9 • Carbohydrate 4 • Protein 4
Dietary Guidelines for Americans (see Web Resources on FIGURE 15-3 A sample label with nutritional information
). (Taylor, 2010).
LWBK1004-C15_p283-304.indd 290 31/01/12 1:33 AM

cholesterol, sodium, carbohydrate, and fiber in a 2,000-cal

diet. The standards are as follows:
• Total fat: less than 65 g
• Saturated fat: less than 20 g
• Cholesterol: less than 300 mg
• Sodium: less than 2,400 mg
• Total carbohydrate: 300 g
• Dietary fiber: 25 g
People consuming diets of more or less than 2,000 cal
must adjust the percentage of DVs. The required calculation
may be difficult for the average consumer. An expanded table
showing the DV equivalents for both a 2,000- and a 2,500-cal
diet appears on some, but not all, food labels. Because the
requirements for vitamins and minerals do not depend on cal-
ories, those amounts are uniform to all consumers.
Additional regulations affect food labels. For example, the FIGURE 15-4 Cultural influences affect eating habits.
federal Nutrition Labeling and Education Act requires compa- (Copyright Charles Gupton/Stock Boston.)
nies to comply with standard definitions if they use health-
related claims such as “low-fat” on their labels (Box 15-3).
• Knowledge of nutrition
NUTRITIONAL PATTERNS AND • Income level
PRACTICE • Time available for food preparation
• Number of people in the household
Influences on Eating Habits • Access to food markets
Most people learn their eating habits early in life. Cultural • Use of food for comfort, celebration, or symbolic reward
(Fig. 15-4), economic, emotional, and social variables influ- • Satisfaction or dissatisfaction with body weight
ence the kinds of food a person consumes and his or her eat- • Religious beliefs
ing habits. Some influential factors include the following:
Vegetarianism
• Food preferences acquired during childhood Vegetarians are people who restrict their consumption of
• Established patterns for meals animal food sources, modifying their diets for religious
• Attitudes about nutrition or personal reasons. Vegetarianism is practiced in vari-
ous forms. For example, vegans rely exclusively on plant
B OX 1 5 - 3 Regulations for Labeling Terms sources for protein. Semi-vegetarians exclude only red meat.
Overall, vegetarians have a lower incidence of colorectal
• Calorie-free: <5 cal cancer and fewer problems with obesity and diseases associ-
• Low calorie: ≤40 cal ated with a high-fat diet (American Dietetic Association, 2009;
• Reduced calorie: at least 25% fewer calories than the stand-
American Heart Association, 2010). Nevertheless, a vegan diet,
ard product
unless skillfully planned, can be inadequate in protein, calcium,
• Light or “lite”: one third fewer calories or 50% less fat than
the regular product vitamins B12 and D, iron, zinc, and omega-3 fatty acids. Thus,
• Fat-free: <0.5 g fat; example: skim milk it is helpful to teach vegans about protein complementation if
• Low fat: ≤3 g fat; example: 1% milk they are unfamiliar with the practice. Protein complementation
• Reduced fat: at least 25% less fat than the regular product; involves eating a variety of incomplete plant proteins over the
for example: 2% milk course of the day to provide adequate amounts and propor-
• Cholesterol-free: <2 mg cholesterol and ≤2 g saturated fat tions of all the essential amino acids present in animal protein
• Low cholesterol: ≤20 mg cholesterol and ≤2 g saturated fat sources (see Fig. 15-1 and Client and Family Teaching 15-1 for
• Sugar-free: <0.5 g sugar more information).
• Fruit drink/beverage: <100% fruit juice
• Imitation: new food that resembles a traditional food and
contains less protein or less of any essential vitamin or min- NUTRITIONAL STATUS ASSESSMENT
eral than the traditional food; example: imitation cheese
Because eating is a basic need, nurses must identify any cur-
Figures per serving. rent or potential client problems associated with nutrition.
Food and Drug Administration. Guidance for industry: A food labeling They obtain subjective information by asking clients focused
guide. Washington, DC: FDA, 2011. http://www.fda.gov/Food/Guidance-
ComplianceRegulatoryInformation/GuidanceDocuments/FoodLabeling- questions on a diet history. Nurses gather objective data
Nutition/FoodLabelingGuide, accessed November 30, 2011. using physical assessment techniques.
LWBK1004-C15_p283-304.indd 291 31/01/12 1:33 AM

Client and Family Teaching 15-1 Subjective Data

Vegetarian Diets A diet history is an assessment technique for obtaining
facts about a client’s eating habits and factors that affect
The nurse teaches the vegetarian client and his or her nutrition. The findings add to the database of nutritional
family as follows: information. Common components in a diet history
● Plan menus 1 day or week at a time. include the following:
● Eat a wide variety of foods.
● Eat a variety of different plant proteins every day. • The level of appetite
● Include fortified ready-to-eat cereals, soy foods, dried • Unintentional weight loss or gain of 10% in the past 6 months
fruit, molasses, and dried peas for iron. • The number of meals the client eats per day
● Enhance absorption of iron by including a good source of • Foods (in approximate household measurements) that the
vitamin C (eg, orange juice) with each meal. client has eaten in the previous 24 hours
● Use fortified ready-to-eat cereals and fortified soy milk to • Time when the client generally eats meals
obtain vitamin B12, vitamin D, and zinc. • Frequency with which the client eats meals alone
● Choose calcium-fortified orange juice, fortified soy yogurt,
• Food likes, dislikes, allergies, intolerances, and cultural
milk, and tofu; and bok choy, broccoli, collards, kale, okra,
beliefs about food
and turnip greens for calcium.
● Select plant sources of omega-3 fatty acids, such as
• The amount of alcohol the client consumes daily or weekly
canola oil, ground flaxseed, walnuts, and soybeans. • Vitamin or mineral supplements the client takes rou-
● Select good sources of calcium such as broccoli, collard tinely
and mustard greens, kale, and tofu. • Any problems with eating, digestion, or elimination
● Breast-feed infants, if possible. • Special diets that have been medically prescribed or self-
● Consider taking cod liver oil as a source of vitamin D. imposed
● Purchase meat analogues, products with the taste and • The use of OTC drugs, such as antacids or laxatives
appearance of meat, poultry, or fish that are made from • Food supplements or restrictions and the reason for them
textured vegetable protein. Such analogues are available • The desire to improve nutritional intake or to gain or lose
in health food and grocery stores. weight
● Contact a Seventh-Day Adventist church, whose
members practice vegetarianism, for information on
sources for meatless products and food preparation Objective Data
classes. The body is composed of water, fat, bone, and muscle. The
nurse uses physical assessments and laboratory data, anthro-
pometric data, and a person’s body measurements to help
determine a client’s nutritional status.
Anthropometric Data
Anthropometric data are measurements pertaining to
■ Medical conditions, adverse medication effects, func-
body size and composition. The nurse obtains them by
tional impairments, and psychosocial conditions (eg,
dementia, depression, social isolation) commonly affect measuring height and weight, calculating body mass
the nutritional status of older adults. index (BMI), and measuring midarm circumference, tri-
■ Oral and dental problems are common in older adults, ceps skinfold thickness, and abdominal circumference.
which interfere with adequate nutrition. Encourage older Eating disorder clinics and fitness centers use more
adults to get dental care every 6 months and to practice sophisticated tests such as bioelectrical impedance analy-
good dental hygiene daily. Malfitting dentures may contrib- sis that calculate lean body mass, body fat, and total body
ute to weight change. water based on changes in conduction of an applied elec-
trical current.
Obtaining the client’s height and weight generally
provides sufficient anthropometric data unless a severe
Pharmacologic Considerations nutritional problem is suspected or long-term therapy
is anticipated. An actual weight, rather than the client’s
■ Taking multiple medications increases the incidence of estimate, is essential. The nurse uses a standing, chair, or
food–drug interactions. Some medications cause constipa- bed scale depending on the client’s condition. He or she
tion, diarrhea, a loss of appetite, and other problems that records the date and time, the type of scale, and the cloth-
interfere with nutrition. Teaching regarding medication
ing the client wears. It is important to duplicate all these
dosage should include the potential side effects as well as
factors when taking subsequent weights for comparison.
the recommended timing of administration in relation to
food intake. Also, over-the-counter (OTC) or herbal therapies The nurse measures the client’s height without shoes. A
can interfere with nutrient absorption. gross assessment tool using weight and height is shown in
Figure 15-5.
LWBK1004-C15_p283-304.indd 292 31/01/12 1:33 AM

Healthy Weight Overweight Obese

BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
4'10'' 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
4'11'' 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
5' 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
5'1'' 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
5'2'' 104 109 115 120 125 131 136 142 147 153 158 164 169 175 180 186 191
5'3'' 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197
5'4'' 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204
5'5'' 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
5'6'' 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
Height
5'7'' 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
5'8'' 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230
5'9'' 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
5'10'' 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243
5'11'' 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
6' 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
6'1'' 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
6'2'' 148 156 164 171 179 186 194 202 210 218 225 233 241 249 256 264 272
6'3'' 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
Weight in Pounds
FIGURE 15-5 A tool for determining weight status. (NIH, 2005, http://www.health.gov/
dietaryguidelines/dga2005/report/HTML/figure_e1.htm.)
is located in anatomic areas such as the biceps. When meas-

uring midarm circumference:
■ Age-related changes are usually gradual; therefore, • Use the nondominant arm
include evaluation of nutritional status in annual examina- • Find the midpoint of the upper arm between the shoulder
tions or more frequently if indicated by weight gain or loss and the elbow
of 10% within 6 months or 5% within 1 month. • Mark the midarm location
• Position the arm loosely at the client’s side
Body mass index (BMI) provides numeric data to com- • Encircle the arm with a tape measure at the marked posi-
pare a person’s size in relation to established norms for the tion
adult population. It is calculated using height and weight • Record the circumference in centimeters
(Box 15-4).
Triceps skinfold measurement adds additional data
for estimating the amount of subcutaneous fat deposits (Fig.
➧ Stop, Think, and Respond Box 15-3 15-6). The skinfold thickness measurement relates to total
Using the graph in Figure 15-5 and the formula in body fat. To measure triceps skinfold thickness:
Box 15-4, what is your analysis of a person who is
5 ft 7 in. and weighs 185 lb? • Use the same arm as for the midarm circumference mea-
surement
Midarm circumference helps determine skeletal mus- • Grasp and pull the skin separate from the muscle at the
cle mass. This technique, combined with other body meas- previously marked location
urements, helps assess a client’s nutritional status. The • Place the calipers around the skinfold
measurement is based on the assumption that muscle usually • Record the measurement in millimeters
LWBK1004-C15_p283-304.indd 293 31/01/12 1:33 AM

B OX 1 5 - 4 TABLE 15-4 Anthropometric Measurements

Body Mass Index Calculation
for Adults
and Interpretation
MEASUREMENT GENDER NORMAL RANGEa
Calculation
1. Divide pounds by 2.2 = kilograms (kg). Midarm circumference Male 29.3–17.6 cm
2. Divide height in inches by 39.4 = meters (m). Female 28.5–17.1 cm
3. Square the answer in step 2 by multiplying the number times Midarm muscle Male 25.3–15.2 cm
circumference Female 23.2–13.9 cm
itself.
Triceps skinfold Male 12.5–7.3 mm
4. Divide weight in kg by m2.
Female 16.5–9.9 mm
INTERPRETATION BMI
a
If measurements are below the lowest range for normal, nutritional support
Underweight <18.5 may be indicated.
Normal 18.5–24.9 Adapted from Jelliffe, D.B. (1986). The assessment of the nutritional status
Overweight 25.0–29.9 of the community. World Health Organization Monograph No. 53. Geneva:
World Health Organization.
Obese 30.0–34.9
Severely obese 35.0–39.9
Extremely obese ≥40 the client at the iliac crest of the pelvis without compressing
the soft tissue, and read to the nearest quarter inch (Fig. 15-7).
Increases or decreases in abdominal measurements correlate
with changes in risk factors for diabetes and cardiovascular
To calculate how much of the midarm circumference is disease. Health risks increase for males whose abdominal cir-
actual muscle (midarm muscle circumference), multiply the cumference measures more than 40 in. and for females whose
triceps skinfold measurement by 0.314. abdominal circumference is greater than 35 in. (National Heart,
To interpret the significance of the midarm circumference Lung, and Blood Institute, 2000).
measurement and triceps skinfold thickness, the nurse com-
pares measurements with averages provided in standardized
charts (Table 15-4). Skinfold thickness norms do not exist for
adults older than 75 years.
Abdominal circumference is an indirect measurement of
fatty (adipose) tissue that is distributed in and about the viscera
of the abdomen. Accumulation of centrally located adipose tis-
sue indicates a predisposition for diabetes and cardiovascular
disease. To facilitate accuracy, the client should be (1) wearing
underwear or light clothing to avoid including bulky fabric in
the measurement, and (2) standing upright with the legs spread
10 to 12 in. apart. The tape measure should be placed around
FIGURE 15-6 Measuring triceps skinfold thickness with FIGURE 15-7 The location for measuring abdominal circumfer-
calipers. (Photo by B. Proud.) ence in adults (Taylor, 2010).
LWBK1004-C15_p283-304.indd 294 31/01/12 1:33 AM

proportion of abdominal fat is associated with a higher inci-

Gerontologic Considerations dence of heart and vascular disease, hypertension, and dia-
betes mellitus. Severely obese people are medically evalu-
■ The circumference of the abdomen may be a more accu- ated to determine whether there are physical etiologies for
rate anthropometric measurement for older adults, but the disorder or health risks associated with a weight-loss
standardized norms have not been established for specific program.
age groups. To lose 1 lb, the client must reduce his or her caloric
intake by 3,500 cal/week. Thus, decreasing one’s intake of
food by 500 cal/day will produce a 1-lb weight loss per week.
Physical Assessment By omitting 1,000 cal/day, the person will lose 2 lb/week.
In addition to anthropometric data, the nurse assesses the Generally, a sustained loss of 1 to 2 lb/week is a healthy
following in the client: goal. The nurse advises clients trying to lose weight about
healthy eating and the hazards of unsupervised weight-loss
• General appearance
techniques such as fasting, fad diets, or diet drugs (see Client
• Integrity of the mouth
• Condition of the teeth
• Ability to chew and swallow
• Gag reflex
• Characteristics of skin and hair
• Joint flexibility
• Hand strength Client and Family Teaching 15-2
• Attention and concentration Promoting Weight Loss
The nurse teaches the client who needs to lose weight and
Laboratory Data his or her family as follows:
Laboratory tests used in nutritional assessment include hemo- ● When using MyPlate, follow the food plan for the appro-
globin and hematocrit, glucose; serum albumin and transfer- priate calorie allowance based on the individual’s gender,
rin levels that indicate protein status; and cholesterol, triglyc- age, and activity level.
eride, and lipoprotein levels that may reflect a need to adjust ● Count portions from each group based on MyPlate
the amount of fat the client eats. serving sizes:
● Grains—one slice of bread, 1 cup of ready-to-eat cereal,
or a half-cup of cooked pasta, rice, or cooked cereal is a
MANAGEMENT OF PROBLEMS 1 oz equivalent
INTERFERING WITH NUTRITION ● Vegetables—2 cups of raw leafy vegetables, 1 cup of
other raw or cooked vegetables, or 1 cup of vegetable
Based on the assessment data, the nurse may identify one or juice counts as 1 cup
● Fruits—one cup of fruit or 100% fruit juice or half cup
more of the following nursing diagnoses:
dried fruit counts as 1 cup
• Imbalanced Nutrition: Less Than Body Requirements ● Milk—1 cup of milk or yogurt, 1.5 oz of natural cheese,
• Imbalanced Nutrition: More Than Body Requirements or 2 oz of processed cheese counts as 1 cup
• Deficient Knowledge: Nutrition ● Meat and Beans—1 oz of lean meat, poultry, or fish,
• Self-Care Deficit: Feeding one-quarter cup of cooked dry beans, one egg, 1 table-
• Impaired Swallowing spoon of peanut butter, or one-half oz of nuts or seeds
• Risk for Aspiration equals 1 oz of meat
● Use fats, oils, and sugar sparingly.
If a nutritional problem is beyond the scope of independ- ● Eliminate junk food (contributes calories but not much
ent nursing practice, the nurse consults with the physician. nutrition) and alcoholic beverages.
If the problem can be resolved through independent nurs- ● Eat small but more frequent meals rather than three large
ing measures, the nurse may proceed by collaborating with meals per day. Any nutrients not used from large meals
the dietitian, selecting the appropriate nursing interventions, are stored as fat.
and continuing to monitor the client to evaluate the effective- ● Sit at the table to eat. Do not read or do other tasks while
ness of the nursing care plan. eating; distraction often fools the brain into thinking that
food has not been consumed.
Obesity ● Increase fiber in the diet from fresh fruits, vegetables,
Obesity is a condition in which a person’s BMI equals and whole grains. Fiber is not digested and may provide a
full feeling without a large numbers of calories.
or exceeds 30 or the triceps skinfold measurement exceeds
● Participate in some regular, active form of exercise. Exer-
15 mm. Obesity indicates the need for healthy weight-
cise raises the metabolic rate (the speed at which the
reduction measures. Research (Mayo Clinic, 2009; National body uses calories) while suppressing appetite. Informa-
Institutes of Health, 2008, Vega et al., 2006) indicates that tion on activity and exercise is located in Chapter 23.
excess abdominal fat is a great health risk factor. An increased
LWBK1004-C15_p283-304.indd 295 31/01/12 1:33 AM

Pharmacologic Considerations
■ Psychosocial impairments such as dementia or depres-
■ Currently, the only FDA-approved medication for pro-
sion interfere with food preparation, consumption, and
moting weight loss or preventing weight gain following enjoyment. An important initial sign of these changes may
weight loss is orlistat (Xenical, and a reduced strength form be weight loss.
called Alli). Weight loss occurs by decreasing the number
■ Homebound older adults may benefit from home-
of dietary calories by blocking the absorption of dietary
delivered meals. The nutrition of older adults who are
fat. The action is a result of inhibiting the enzyme lipase.
isolated, depressed, or cognitively impaired may improve
The function of lipase is to break down ingested fat into an
with participation in a group meal program. Home-delivered
absorbable form. The unabsorbed fat is excreted in stool.
meals and group meal programs are widely available and
Due to a reduction in absorbed fat, it is essential to supple-
are funded through the Older Americans Act. The National
ment fat-soluble vitamins 2 hours before or several hours
Eldercare Locator (800-667-1116) provides information.
after taking orlistat. There are several drug–drug interactions
■ Refer low-income older adults to their local Council on
that can occur with drugs for diabetes and anticoagulants,
Aging for assistance in obtaining food stamps.
for example. Some side effects include oily spotting of stool
in underwear, flatulence, urgent bowel movements, and
bowel incontinence. Pharmacologic Considerations
■ The Mayo Clinic (2010) reports that one can only
expect modest weight loss when taking this drug.
■ There are many drugs whose side effects include weight
Modest weight loss is defined as 5 to 7 lb greater
gain. However, the drug megestrol (Megace) is prescribed
than diet and exercise after 1 year of taking Xenical or
for the primary purpose of promoting weight gain. Its pre-
3 to 5 lb with Alli.
scription is generally reserved for clients who are cachectic
(emaciated due to a serious illness like cancer or AIDS).
Emaciation
Anorexia
Progressive or prolonged weight loss resulting in a BMI less
Anorexia (a loss of appetite) is associated with multiple factors:
than 16 can have serious consequences. Emaciation (exces-
illness, altered taste and smell, oral problems, and tension and
sive leanness) and cachexia (general wasting away of body
depression. Simple anorexia is generally a short-lived symp-
tissue) are consistent with severe malnourishment. States of
tom that requires no medical or nursing intervention. Anorexia
severe malnourishment require collaboration with a physi-
nervosa, a psychobiologic disorder, is associated with a 20% to
cian, who will prescribe measures to ensure the client’s
25% loss in previously stable body weight. No matter what the
nutrition using gastric or enteral tube feedings or parenteral
etiology, the nurse never ignores that a client is not eating. If
nutrition if oral intake is inadequate (see Chap. 29).
food is uneaten, the nurse assesses for physiologic, emotional,
Independent nursing interventions, including client
cultural, or social etiologies that may be the contributing fac-
teaching, are appropriate for people who are approximately
tors (see Nursing Guidelines 15-1).
10% below their ideal body weight. To gain 1 lb, a person
must consume 3,500 cal more than his or her metabolic
needs per week. This is best done gradually (see Client and Gerontologic Considerations
■ Diminished senses of smell and taste, which may occur
with normal aging, can interfere with appetite and intake.
■ When attempting to increase an older client’s intake,
Promoting Weight Gain nutritional supplements should be evaluated. Protein-based
liquid supplements will not provide the needed fiber and
The nurse teaches the client who needs to gain weight and should not be relied on as the main source of protein.
his or her family as follows: ■ Decreased exercise may lead to decreased appetite
● Eat a variety of foods from MyPlate, but increase the among sedentary older adults. Sitting exercises may be
number of servings or serving sizes. indicated if balance or functional abilities decline.
● Eat small amounts frequently.
● Eat with others.
● Snack on high-calorie but nutritious foods such as hard Pharmacologic Considerations
cheese, milkshakes, and nuts.
● Disguise extra calories by fortifying foods with powdered ■ Anorexic clients such as those with cancer may experience
milk, gravies, or sauces. a stimulation in appetite by using medical marijuana, which
● Garnish food with cubed or grated cheese, diced meat, can be purchased in states where it is legally available, or
nuts, or raisins. by taking its prescription form, dronabinol (Marinol), in states
● Rest after eating. where possession of the natural marijuana plant is illegal.
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Rationales
Overcoming Simple Anorexia
• Cater to the client’s food preferences. The client will more • Arrange for the client to eat with others. Because eating
likely consume food he or she selects. is a social activity, the client may eat more when with a
• Serve nutrient-dense foods (foods loaded with calories). They group.
may compensate for a low intake of food. • Serve food attractively. A visual presentation of food stimulates
• Offer small servings of food frequently. Eating small amounts appetite.
frequently may result in a cumulative intake within acceptable • Suggest adding spices and herbs to foods. Intensifying flavors
nutritional levels. and aromas may stimulate a desire to eat; however, it may
• Ensure that the client is rested before meals. A lack of energy have the opposite effect as well. When experimenting, add new
may overpower the desire to eat. seasonings to small amounts of food.
• Provide an opportunity for oral hygiene before meals. Mouth care • Serve foods at their appropriate temperature. The client may
stimulates salivation and potentiates the pleasure from eating. eat more food if hot foods are hot and cold foods are cold.
• Help the client to a sitting position. Seeing food stimulates the • Serve cool, bland foods to clients with a mouth irritation. Hot
appetite center; sitting also promotes access to the food. or spicy foods intensify the irritation of oral structures.
➧ Stop, Think, and Respond Box 15-4 Vomiting

Vomiting (a loss of stomach contents through the mouth)
How can the nurse make food and its presentation
visually attractive to entice a client to eat? commonly accompanies nausea. Emesis or vomitus (the sub-
stance that is vomited) is readily visible. Retching (the act of
vomiting without producing vomitus) may occur if the stom-
Nausea ach is empty. Regurgitation (bringing stomach contents to
Nausea usually precedes vomiting and is produced when the throat and mouth without the effort of vomiting) occurs
gastrointestinal sensations, sensory data, and drug effects commonly among infants after eating. Projectile vomiting
stimulate a portion of the medulla that contains the vomiting (vomiting that occurs with great force) is associated with
center. Nausea may be associated with feeling faint or weak. certain disease conditions such as increased pressure in the
Often, dizziness, perspiration, skin pallor, a rapid pulse rate, brain or gastrointestinal bleeding. Nausea may be present,
and headache are present. The nurse consults the physician but it often is not (see Nursing Guidelines 15-3).
when the measures presented in Nursing Guidelines 15-2 The nurse describes the emesis in the client’s medical
are unsuccessful for overcoming nausea. Prescribed medica- record. If possible, he or she measures the amount of emesis
tions may be necessary. and records the volume. Documentation includes the amount,
Once nausea is relieved, assisting the client to resume color, appearance, and any unusual odor such as the odor of
fluid intake and nourishment becomes a priority. The nurse fecal material or alcohol. If the characteristics of the emesis are
starts this process gradually, offering sips of clear fluids first. unusual, the nurse saves a specimen for the physician to exam-
If the client tolerates fluids, the nurse adds soft, bland foods ine. If there are any doubts about whether to discard or save
in small amounts. the emesis, it is best to check with a more experienced nurse.
The nurse always consults the physician when vomiting
is prolonged. It may be necessary to administer prescribed
NURSING GUIDELINES 15-2 medications for relief.
Relieving Nausea
• Check to see if something as simple as an annoying odor or Pharmacologic Considerations
sight is contributing to nausea. Offensive sensory data can
stimulate the vomiting center in the brain. ■ Short-term bouts of nausea and vomiting can be
• Assist the client to take deep breaths. Distraction can over- treated with OTC nonprescription drugs such as Pepto-
come nausea by directing conscious attention away from the Bismol. Although prescription chlorpromazine (Thorazine)
unpleasant sensation. and prochlorperazine (Compazine) have been used for
• Limit the client’s abrupt movements and activities. Move- many years to relieve vomiting, many prescribers now are
ment may shift gastrointestinal structures and their contents, using drugs like metoclopramide (Reglan) and granisetron
intensifying stimulation of the vomiting center. (Kytril) for a variety of conditions that are accompanied by
• Limit the client’s intake of food and fluid temporarily until vomiting, such as emesis due to cancer chemotherapy.
nausea subsides. Distention of the stomach is a common
trigger of the vomiting center.
• Avoid making negative comments about food. Verbal Stomach Gas
comments create visual images that may cause psychogenic Gas in the stomach is primarily a result of swallowing air. It
stimulation of the vomiting center. becomes a problem only when it accumulates. Eructation
(belching) is a discharge of gas from the stomach through
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Rationales
Managing the Care of a Vomiting Client
• Temporarily limit the client’s food intake. Adding contents to rather than remain in the throat, where the client could aspi-
an already upset stomach may prolong episodes of vomiting. rate it into the lungs.
• Lean the client’s head forward over a container or the toilet. • Use a suction machine to clear vomitus from the mouth and
Tilting the chin toward the chest reduces the possibility that throat of a weak or unconscious client. Suctioning pulls fluid
vomitus will enter the lungs. from the oral cavity and airway, thus preventing choking and
• Adjust light, sound, ventilation, and temperature to a comfort- aspiration (see Chap. 36).
able level. Minimizing sensory stimulation may reduce the urge • Provide firm support with the hands or a pillow to the
to vomit. abdominal incision if the client has had abdominal surgery. An
• Apply a cool washcloth to the client’s forehead or back of the abdominal binder also may help to support the incision (see
neck. Increased perspiration and a clammy feeling to the skin Chap. 28). Strong muscle contractions may pull on stitches and
may accompany vomiting. increase pain and discomfort.
• Help the client rinse the mouth, offer mouthwash, or provide • Remove the container of emesis from the bedside as soon as
mouth care as soon as possible after vomiting. Gastric acid is possible. Provide ventilation to remove any lingering odors.
harmful to tooth enamel. Emesis usually produces an unpleas- The appearance and odor of vomitus may stimulate more
ant aftertaste. vomiting.
• Turn a vomiting client who is unconscious or weak onto the
abdomen or side. Gravity helps emesis to drain from the mouth
the mouth. Flatus is gas formed in the intestine and released MANAGEMENT OF CLIENT
from the rectum when eructation does not occur. Nursing NUTRITION
guidelines for relieving intestinal gas are discussed in Chap-
ter 31 (see Nursing Guidelines 15-4). Common Hospital Diets
Some common hospital diets include the following:
Pharmacologic Considerations • Regular or general: allows unrestricted food selections
• Light or convalescent: differs from regular diet in prepara-
■ Avoiding gas-forming food in the diet is one of the first tion; typically omits fried, fatty, gas-forming, and raw foods
steps in preventing the accumulation of stomach and and rich pastries
intestinal gas. However, there are several nonprescription • Soft: contains foods soft in texture; is usually low in residue
products available for this purpose. For example, Beano and readily digestible; contains few or no spices or condiments;
contains an enzyme that breaks down vegetables contain-
provides fewer fruits, vegetables, or meats than a light diet
ing polysaccharides that are difficult to digest and helps
• Mechanical soft: resembles a light diet but is used for cli-
reduce the formation of gas in the colon. Another option
is to take one of several products containing simethicone ents with chewing difficulties; provides cooked fruits and
such as Gas-X, Flatulex, Mylicon, and Mylanta Gas. vegetables and ground meats

Rationales
Preventing and Relieving Stomach Gas
• Suggest that the client chew food with the mouth closed. • Recommend that when under stress, the client should avoid
Laughing and talking while eating increase the amount of eating. Emotions delay stomach emptying, which prevents the
swallowed air. movement of gas to the intestine.
• Advise against using a straw. Each swallow of liquid also • Propose walking if uncomfortable. Activity helps gas to rise
contains the air in the straw. to its highest point in the stomach, making belching
• Advise against chewing gum and smoking cigarettes. Chew- easier.
ing gum increases salivation and results in swallowing both • Consult with the physician about the use of medications that
secretions and air. The client actually may swallow a portion relieve gas accumulation. Instruct clients who purchase OTC
of inhaled cigarette smoke. drugs to follow label directions for their use. Simethicone is an
• Limit or restrict foods that contain large volumes of air such as ingredient in several nonprescription antacids. Drugs contain-
soufflés, yeast breads, and carbonated beverages. Swallowing ing simethicone facilitate the elimination of gas by reducing
air trapped within food and drinking beverages that contain the surface tension of gas bubbles trapped in the gastrointesti-
dissolved gas distend the stomach. nal tract.
LWBK1004-C15_p283-304.indd 298 31/01/12 1:33 AM

• Full liquid: contains fruit and vegetable juices, creamed or • Place the client in a sitting position.
blended soups, milk, ices, ice cream, gelatin, junket, cus- • Ensure that the client is rested and that you have his or her
tards, and cooked cereals attention.
• Clear liquid: consists of water, clear broth, clear fruit juices, • Give short, simple instructions to prompt the client to eat
plain gelatin, tea, and coffee; may or may not include car- and swallow.
bonated beverages • Limit distracting stimuli; turn off the television and reduce
• Special therapeutic: consists of foods prepared to meet or eliminate activities taking place in the area.
special needs, such as low in sodium, fat, calories, or fiber • Request a full liquid or mechanically soft diet for the client
• Most health care agencies have a dietitian who plans the who has missing teeth or has recently had oral surgery.
meals and a centralized food service that prepares clients’ • Provide small frequent meals if efforts to eat and swallow
meals tire the client.
• Modify eating or feeding equipment to facilitate the client’s
Nurses are generally responsible for ordering and can-
safety and independence.
celing diets for clients, serving and collecting meal trays,
• Determine that the client has swallowed one portion of
helping clients to eat, and recording the percentage of food
food before offering another.
that clients eat. Nurses must know the type of diet prescribed
• Encourage repeated swallowing attempts if there is wet,
for each client, the purpose for the diet, and its characteris-
gurgly vocalization, a sign that food is in the esophagus
tics. They take care to ensure that clients receive the correct
and not the stomach.
diet and that restricted foods are withheld.
Meal Trays Gerontologic Considerations

Meals are usually served at the bedside, but some health care
institutions have dining rooms or cafeterias for ambulatory ■ Dysphagia among older adults often results from neuro-
clients. Clients in nursing homes generally eat together in logic conditions including stroke, esophageal disorders, or
small groups unless they physically cannot. Nurses and die- increased pressure from abdominal disorders. Swallowing
tary personnel work together to ensure that clients receive studies may allow for the appropriate teaching of strategies
food at mealtimes and that trays are collected afterward. The to promote swallowing effectiveness.
nursing responsibilities for serving and removing trays are
identified in Skill 15-1. Nursing Care Plan 15-1 is an example of how the nurse
manages the care of a client who has a nursing diagnosis of
Feeding Assistance impaired swallowing. This diagnostic category is defined in
Some clients need help with eating. Skill 15-2 provides sug- the NANDA-I taxonomy (2012, p. 178) as “abnormal func-
gested actions for feeding clients who can bite, sip, chew, tioning of the swallowing mechanism associated with defi-
and swallow but cannot cut food or use utensils for eating. cits in oral, pharyngeal, or esophageal structure or function.”
Suggestions for helping clients with dysphagia (difficulty
swallowing), for helping clients who are blind or have both
eyes patched, and for promoting self-feeding in those with Gerontologic Considerations
dementia (impairment of intellectual functioning) follow.
■ Dry mouth (xerostomia), a common problem in older
adults and often results from medications or the effects of
Gerontologic Considerations disease. It interferes with chewing, swallowing, and enjoy-
ing meals. Encourage people with dry mouth to drink ade-
■ Older adults are likely to have chronic conditions such as quate noncaffeinated and nonalcoholic beverages or to
arthritis and sensory impairments that affect their ability to chew sugarless gum to promote salivation.
meet their nutritional needs. Modifications such as plates ■ Oral infections, poorly fitting dentures, or vitamin defi-
with sides and large-handled utensils may help the older ciencies can cause a painful or burning tongue, ulcers on
person maintain self-care ability in feeding. the gums, or other difficulties that interfere with eating.
Feeding the Client With Dysphagia Feeding the Visually Impaired Client
Nurses use the following techniques when caring for clients When caring for clients who are temporarily or permanently
who have difficulty chewing and swallowing food: sightless:
• Always have equipment for oral and pharyngeal suctioning • Place a thick towel across the client’s chest and over the
at the bedside (see Chap. 36). lap.
• Remain with the client throughout eating when there is a • If the client can eat independently, consider using dishes
potential for aspiration. with rims or bowls to prevent spilling.
• If the client has a tracheostomy tube or endotracheal tube, • Arrange as much as possible to have finger foods (foods
make sure the cuff is inflated (see Chap. 36). that may be eaten with the hands) prepared for the client.
LWBK1004-C15_p283-304.indd 299 31/01/12 1:33 AM

N U R S I N G C A R E P L A N 1 5 - 1 Impair ed Swallowing
Assessment • Inspect the mouth and buccal cavities for retained food, the
• Note that if there is coughing, choking, or drooling from the condition of the teeth, and evidence of tissue irritation, swell-
mouth when the client swallows saliva, liquids, or food. ing, or injury.
• Look for asymmetry of the mouth. • Observe the client’s ability to understand and follow verbal
• Ask the client to extend the tongue; observe if it deviates from instructions.
a midline position. • Review the results of a fluoroscopic swallowing study as
• Determine if the oral mucous membranes are moist or dry. ordered by the physician.
• Check for the gag reflex by stimulating the posterior oral phar-
ynx with a cotton-tipped swab.
Nursing Diagnosis. Impaired swallowing related to left hemiparesis secondary to cerebrovascular accident (stroke) as mani-
fested by incomplete swallowing of food, occasional coughing while eating, and the statement, “I’m losing weight. I’ve almost given
up trying to eat. I get more on me than in me since my stroke.”
Expected Outcome. The client will swallow more effectively as evidenced by an empty mouth after each mastication and attempt
at swallowing.
Maintain a suction machine, a suction catheter, and an oxygen Equipment for suctioning the airway and improving oxygenation
mask at the bedside. may be necessary if the airway becomes obstructed.
Place the client in a sitting position. An upright position uses gravity to move food from the pharynx
to the esophagus and stomach.
Provide oral hygiene before each meal. Oral hygiene moistens the mouth, making it easier to swallow a
bolus of food.
Request that the dietary department initially avoid dry foods Dry and sticky foods are more difficult for a client to masticate
such as crackers and sticky foods such as bananas. and swallow.
Request semisolid foods with some texture such as oat- Semisolids are easier to swallow than liquids and watery pureed
meal, poached eggs, and mashed potatoes. food.
Add a commercial thickener to oral liquids. Thickeners create a consistency that the tongue can manipulate
more easily against the pharynx.
Help the client load a spoon or fork with a 1/4 to 1/2 tsp of Smaller amounts of food are more easily swallowed; the
food. amount of food increases as the client demonstrates effective
swallowing.
Place the food on the nonparalyzed (right) side of the mouth. Chewing and swallowing require neuromuscular function.
Encourage the client to chew food thoroughly. Chewing compresses food and mixes it with saliva to facilitate
swallowing.
Instruct the client to lower the chin to the chest and swallow A chin-to-chest position closes the pathway to the trachea and
repeatedly without breathing in between. reduces the potential for aspiration. Repeated swallowing
uses muscular contraction to move the food bolus into the
esophagus.
Have the client raise the chin after swallowing efforts, clear Raising the chin, clearing the throat, and breathing improve
the throat, and resume breathing. ventilation.
Inspect the client’s mouth after each swallowing attempt; Inspection helps identify retained food.
encourage the client to do so as well by looking in the
mouth with a handheld mirror.
Have the client use the tongue or finger to sweep retained Mechanical movement relocates the food to an area of the
food from the cheek and repeat the swallowing technique; mouth where it can be manipulated and swallowed.
if the client is unsuccessful, apply finger pressure on the
outside of the client’s cheek.
Keep the client in a sitting or semisitting position for at least The potential for aspiration is reduced once food leaves the
a half hour. stomach.

• The client demonstrates techniques for clearing the mouth • The client swallows food completely.
of food. • The client consumes sufficient calories to maintain weight.
LWBK1004-C15_p283-304.indd 300 31/01/12 1:33 AM

• Describe the food and indicate its location on the tray. 2. A client tells the nurse that she eats the following
• Guide the client’s hand to reinforce the location of food every day: cereal, milk, and banana for breakfast;
and utensils. a sandwich made with processed meat, mayon-
• Prepare the food by opening cartons, cutting bite-size naise, and a soft drink for lunch; a candy bar in
pieces, adding salt and pepper, buttering bread, and pour- the late afternoon; and meat, potatoes, a vegetable,
ing coffee. and a glass of milk for supper. In the late evening,
• Use the analogy of a clock when describing where the she snacks on potato chips. What recommendations
client may find food on the plate. For example, “The pota- would you make to improve this client’s nutrition?
toes are at 3 o’clock.” 3. When a client reports experiencing nausea for the last
• If the client needs to be fed, tell him or her what kind of few weeks, what questions would be appropriate for
food you are offering with each mouthful. the nurse to ask to determine possible causes?
• Devise a system by which the client can indicate when he 4. After calculating that a client’s BMI is 32 and meas-
or she is ready for more food or drink, such as asking or ured abdominal circumference is 42 in., what infor-
raising a finger. mation is appropriate for the nurse to provide?
Do not rush the client; eating should be done at a lei-
surely pace.
Assisting the Client With Dementia 1. When caring for a client whose oral mucous mem-
Dementia refers to the deterioration of previous intellectual branes are irritated and sore, which of the following
capacity. It is a common problem among those with neuro- items is best to withhold from the dietary tray?
logic conditions such as Alzheimer’s disease. These clients 1. Tomato soup
often can retain their ability to carry out activities of daily 2. Lime gelatin
living, such as self-feeding, by maintaining attention and 3. Canned peaches
concentration and repeating actions. Therefore, the follow- 4. Rice pudding
ing are useful nursing actions: 2. A nurse notes that a client coughs and chokes while
eating. What initial nursing recommendation is best?
• Have the same staff person help the client, if possible, to
1. Have the dietary department send baby foods from
develop a rapport with the client and promote a continuity
now on.
of care.
2. Tell the client to chew his or her food very thor-
• Be consistent with the time and place for eating.
oughly.
• Reduce or eliminate environmental distractions to promote
3. Advise the client to avoid drinking beverages with
concentration on the task at hand.
meals.
• Place the food tray close to the client, not the staff person,
4. Withhold milk and other dairy products in the future.
to communicate visually and spatially that the client is to
3. Which of the following is the best evidence that a cli-
eat the food.
ent with anorexia as a result of cancer is responding
• Remove wrappers, containers, and food covers to reduce
to the nutritional regimen developed by the nurse and
confusion.
dietitian?
• Pour milk from the carton into a glass so that it is easily
1. The client remains alert.
recognizable.
2. The client gains weight.
• Encourage the client’s participation by offering finger
3. The client feels hungry.
foods and utensils to stimulate awareness and memory.
4. The client is pain free.
• Ensure that the client can see at least one other person
4. When a client on a clear liquid diet asks for some
who is also eating. This serves as a model for the desired
nourishment, which of the following is appropriate
behavior.
for the nurse to provide?
• Guide the hand with food to the client’s mouth.
1. Milk
• Reinforce a desired response by praising, touching, and
2. Pudding
smiling at the client.
3. Gelatin
• Remain with the client. Do not begin feeding, leave, and
4. Custard
then return because this interrupts the client’s attention
5. The nurse is most correct in recommending which
and concentration.
of the following food sources of iron to a client with
chronic anemia?
1. Dairy products
CRITICAL THINKING EXERCISES 2. Citrus fruits
1. Describe appropriate nursing actions if a client eats 3. Red meat
none or only some food served. 4. Yellow vegetables
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SKILL 15-1 Serving and Removing Meal Trays
ASSESSMENT
Check on the usual time for meals. Facilitates planning nursing care.
Determine which clients are undergoing tests or must have Ensures that eating does not affect therapeutic outcomes.
food withheld for some other reason.
Note the type of diet currently prescribed for each client. Follows the client’s therapeutic management plan.
Review the Kardex for information concerning clients’ food aller- Reduces the potential for adverse reactions.
gies or food intolerances.
PLANNING
Prepare clients so that they are ready to eat at the designated time. Ensures food is served at its appropriate temperature.
Meet clients’ needs for comfort, hygiene, and elimination before Promotes appetite and eating.
the meal arrives.
Help clients to a sitting position. Assists ambulatory clients to a comfortable position.
IMPLEMENTATION
Wash hands or perform hand antisepsis with an alcohol rub (see Prevents the transmission of microorganisms.
Chap. 10) before serving trays.
Deliver trays, one by one, as soon as possible. Facilitates the enjoyment of eating through prompt delivery of
food at its intended temperature.
Compare the name on the tray with the name on the client’s Avoids dietary errors.
identification bracelet, or ask the client to identify himself or
herself by name.
Place the tray in such a way that the client can see it. Provides ease of access to food.
Uncover the food and check its appearance. Ensures that the tray is complete, orderly, and tidy.
Assist the client, if necessary, to open cartons and prepare food. Demonstrates consideration and facilitates independence.
Replace food that is objectionable or request special additional Demonstrates respect for unique needs.
items from the dietary department.
Before leaving the room, check whether the client has any further Reduces inconveniences during meal time.
requests like an adjustment of pillows or donning eyeglasses.
Make sure the signal cord is handy in case a need arises later. Provides a means for summoning assistance.
Check the client’s progress from time to time. Indicates a willingness to provide assistance.
Remove the food tray after the client has finished eating. Restores order and cleanliness to the environment.
Record the amount of fluid consumed from the dietary tray on Ensures accurate fluid assessment.
the bedside flow sheet if the client’s fluid intake is being
monitored.
Note the percentage of food that the client has eaten.a Ensures documentation of dietary intake according to Joint
Commission standards rather than vague terms such as good,
fair, and poor.
Assist the client to brush and floss the teeth, if desired. Removes food residue that may support microbial growth.
Place the client in a position of comfort. Demonstrates care and concern.
Evaluation
• Client states that hunger is satisfied.
• Most food is consumed.
Document
Type of diet and percentage of food consumed
SAMPLE DOCUMENTATIONa
Date and Time Ate 100% of mechanical soft diet with need for assistance. __________________________ SIGNATURE/TITLE
a
Many agencies mandate that nurses should record the percentage of consumed food on a flow sheet or checklist. Nurses record other
pertinent data within the medical record.
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SKILL 15-2 Feeding a Client
ASSESSMENT
Compare the dietary information on the Kardex with the medical Ensures accuracy in therapeutic management.
record.
Verify that food or fluids are not being temporarily withheld. Prevents delaying or having to cancel diagnostic tests.
Determine whether the client’s fluid intake is being measured. Ensures the accurate documentation of data.
Assess the client to determine what or how much assistance is Aids in identifying specific problems and selecting nursing
necessary. interventions.
Review the medical record to see how well and how much the Helps to establish realistic goals and to evaluate progress.
client has eaten during previous meals; note weight trends.
Review the characteristics of the diet order. Helps to determine whether the correct food is being served.
Analyze the purpose for the prescribed diet. Assists in evaluating therapeutic responses.
Assess the client’s needs for elimination or relief from pain, Identifies unmet physiologic needs.
nausea, and fatigue.
Check the medication record for drugs that must be adminis- Facilitates optimal drug absorption and reduces drug side effects.
tered before or with meals.
PLANNING
Set realistic goals for how much food the client will eat and how Establishes criteria for evaluating client responses.
much the client will participate with self-feeding.
Select appropriate nursing measures to promote client comfort, Helps resolve problems that, if ignored, may interfere with eating.
such as administering an analgesic.
Complete priority responsibilities for assigned clients. Allows a period of uninterrupted feeding.
Provide oral hygiene and handwashing before serving the tray. Controls the transmission of microorganisms; promotes appetite
and aesthetics.
Prepare medications that must be given before or with meals, Coordinates drug and nutritional therapy.
or delegate that responsibility.
Clear clutter and soiled articles from the eating area. Promotes orderliness and a sanitary environment.
IMPLEMENTATION
Wash hands or perform hand antisepsis with an alcohol rub (see Prevents the transmission of microorganisms.
Chap. 10) before preparing food.
Obtain or clean special utensils or containers that have been Promotes independence and self-reliance.
adapted for use by a client with a physical disability, for
example a fork to which a hand grip has been attached.
Raise the head of the bed to a sitting position, or assist the Promotes safety by facilitating swallowing.
client to a chair (Fig. A).
Feeding a client.
Check that you serve the correct diet and tray to the correct Indicates responsibility and accountability for therapeutic
client. management.
Cover the client’s upper chest and lap with a napkin or towel. Protects bedclothes and linen.
Sit beside or across from client. Promotes socialization and communication.
Uncover the food, open cartons, and season food. Increases gastric secretions and motility.
Encourage the client to assist to the limit of his or her abilities. Maintains or supports independence and self-care.
Avoid rushing. Communicates a relaxed atmosphere while eating.
Collaborate with the client on which foods he or she desires Accommodates individual preferences.
before loading a fork or spoon. (continued)
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Feeding a Client (continued)
Provide manageable amounts of food with each bite. Prevents choking or airway obstruction.
For a client with a stroke, direct the food toward the nonpara- Places food in an area where there is feeling and muscle control
lyzed side of the mouth. for chewing and swallowing.
Give the client time to chew thoroughly and swallow. Chewing aids digestion by grinding the food and mixing it with
saliva and enzymes.
Let the client indicate when he or she is ready for more food or Promotes an independent locus of control.
a sip of beverage.
Talk with the client about pleasant subjects. Combines eating with socialization.
Record fluid intake if the client’s intake is being measured. Documents essential assessment data.
Remove the tray and make the client comfortable. It is best for A sitting position prevents the reflux of stomach contents into the
clients to remain sitting or semisitting for at least 30 min esophagus and reduces the potential for aspiration.
after eating unless there is a medical reason to do otherwise.
Offer the client an opportunity for oral hygiene. Removes sugar and starches that support microbial growth and
tooth decay.
Estimate the amount of food that the client has eaten. Provides data for determining current and future nutritional needs.
Evaluation
• Client eats approximately 75% of meal.
• Client maintains body weight.
• Client participates at maximum capacity.
Document
• Type of diet
• Percentage of food consumed
• Tolerance of food
• Client’s ability to participate
• Problems encountered with chewing or swallowing
• Approaches taken to resolve problems
Date and Time Stated “I’m full” after consuming 75% of full liquid diet. Unable to hold spoon or glass but could direct
straw into mouth. _________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C15_p283-304.indd 304 31/01/12 1:33 AM

Photo to
Come
FPO
16# Fluid and Chemical
Balance
active transport
air embolism
anions 1. Name four components of body fluid.
blood substitutes 2. List five physiologic transport mechanisms for distributing fluid
cations and its constituents.
circulatory overload 3. Name 10 assessments that provide data about a client’s fluid
colloids status.
colloid solutions 4. Describe three methods for maintaining or restoring fluid
colloidal osmotic pressure volume.
crystalloid solutions 5. Describe four methods for reducing fluid volume.
dehydration 6. List six reasons for administering intravenous (IV) fluids.
drop factor 7. Differentiate between crystalloid and colloid solutions, and give
edema examples of each.
electrochemical neutrality 8. Explain the terms isotonic, hypotonic, and hypertonic when used
electrolytes in reference to IV solutions.
emulsion 9. List four factors that affect the choice of tubing used to
extracellular fluid administer IV solutions.
facilitated diffusion 10. Name three techniques for infusing IV solutions.
filtration 11. Discuss at least five criteria for selecting a vein when
fluid imbalance administering IV fluid.
hydrostatic pressure 12. List seven complications associated with IV fluid administration.
hypertonic solution 13. Discuss two purposes for inserting an intermittent venous
hypervolemia access device.
hypoalbuminemia 14. Identify three differences between administering blood and
hypotonic solution crystalloid solutions.
hypovolemia 15. Name at least five types of transfusion reactions.
infiltration 16. Explain the concept of parenteral nutrition.
infusion pump
intake and output
intermittent venous access device
B
interstitial fluid ody fluid is a mixture of water, chemicals called electrolytes and
intracellular fluid nonelectrolytes, and blood cells. Water, the vehicle for transport-
intravascular fluid ing the chemicals, is the very essence of life. Because water is not
intravenous fluids stored in any great reserve, daily replacement is the key to main-
ions taining survival. This chapter discusses the mechanisms for maintain-
isotonic solution ing fluid balance and restoring fluid volume and the components in body
needleless systems
fluid.
nonelectrolytes
osmosis
oxygen therapeutics
parenteral nutrition BODY FLUID
passive diffusion
peripheral parenteral nutrition Water
phlebitis
Depending on age and gender, the human body comprises approximately
ports
45% to 75% water. Body water normally is supplied and replenished
from three sources: drinking liquids, consuming food, and metabolizing
305
LWBK1004-C16_p305-344.indd 305 2/6/12 7:21 PM

pulmonary embolus
third-spacing
thrombus formation
total parenteral nutrition
venipuncture
volumetric controller
nutrients. Once the water is absorbed, it is distributed among absorbed, and distributed in body fluid. They are obtained
various locations, called compartments, within the body. from dietary sources of food and beverages, but may be pro-
vided through pharmaceutical supplements for clients who
Fluid Compartments are not eating or cannot do so, or lose electrolytes because
Body fluid is located in two general compartments. Intrac- of an altered state of health. They are essential for maintain-
ellular fluid (fluid inside cells) represents the greatest pro- ing cellular, tissue, and organ functions. For example, elec-
portion of water in the body. The remaining body fluid is trolytes affect fluid balance and complex chemical activities
extracellular fluid (fluid outside cells). Extracellular fluid such as muscle contraction and the formation of enzymes,
is further subdivided into interstitial fluid (fluid in the tis- acids, and bases (see discussion of minerals in Chap. 15).
sue space between and around cells) and intravascular fluid
(the watery plasma, or serum, portion of blood) (Fig. 16-1).
The percentage of water in these compartments varies Gerontologic Considerations
according to age and gender (Table 16-1).
■ Mobility limitations, cognitive impairments, and an
Electrolytes impaired ability to perform activities of daily living can lead
Electrolytes are chemical compounds, such as sodium and to fluid and electrolyte deficits in older adults who cannot
maintain adequate food and fluid intake independently.
chloride, that possess an electrical charge when dissolved,
Collectively, electrolytes are called ions (substances

that carry either a positive or a negative electrical charge).
Cations (electrolytes with a positive charge) and anions
(electrolytes with a negative charge) are present in equal
amounts overall, but their distribution varies in each body
fluid compartment (Table 16-2). For example, more potas-
sium ions are present inside the cells than outside.
Electrolytes are measured in the serum of blood speci-
mens, and the amount is reported in milliequivalents (mEq).
When one or more cations or anions become excessive or
deficient, an electrolyte imbalance occurs. Significant imbal-
Cellular fluid ances can lead to dangerous physiologic problems. In many
(about 50% of
body weight)
situations, electrolyte imbalances accompany changes in
fluid volumes.
Interstitial fluid
(about 15% of Nonelectrolytes
body weight) Nonelectrolytes are chemical compounds that remain bound
together when dissolved in a solution and do not possess an
Plasma or
intravascular fluid TABLE 16-1 Percentages of Body Fluid According
(about 5% of to Age and Gender
body weight)
FLUID ADULT ADULT ELDERLY
COMPARTMENT INFANTS (%) MEN (%) WOMEN (%) (%)
Intravascular 4 4 5 5
Interstitial 25 11 10 15
Intracellular 48 45 35 25
Total 77 60 50 45
FIGURE 16-1 The average distribution of body fluid.
306
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CHAPTER 16 Fluid and Chemical Balance 307
TABLE 16-2 Major Serum Electrolytes

NORMAL SERUM PREDOMINANT
ELECTROLYTE CHEMICAL SYMBOL CATION/ANION LEVEL (mEq/L) COMPARTMENT
Sodium Na Cation 135–148 ECF
Potassium K Cation 3.5–5.0 ICF
Chloride Cl Anion 90–110 ECF
Phosphate PO4 Anion 1.7–2.6 ICF
Calcium Ca Cation 2.1–2.6 ICF
Magnesium Mg Cation 1.3–2.1 ICF
Bicarbonate HCO3 Anion 22–26 ICF
ECF, extracellular compartment; ICF, intracellular compartment.
electrical charge. The chemical end products of carbohydrates, throughout all areas of the body. Physiologic transport mecha-
proteins, and fat metabolism–namely glucose, amino acids, nisms such as osmosis, filtration, passive diffusion, facilitated
and fatty acids–provide a continuous supply of nonelectrolytes. diffusion, and active transport govern the movement and relo-
In the absence of metabolic disease, a stable amount of cation of water and substances within body fluid (Fig. 16-2).
nonelectrolytes circulate in body fluid as long as a person
consumes adequate nutrients. Deficiency states occur when Osmosis
body fluid is lost or when the ability to eat is compromised. Osmosis helps regulate the distribution of water by controlling
the movement of fluid from one location to another. Under the
Blood influence of osmosis, water moves through a semipermeable
On average, blood consists of 3 L of plasma, or fluid, and 2 L membrane like those surrounding body cells, capillary walls,
of blood cells for a total circulating volume of 5 L. Blood cells and body organs and cavities, from an area where the fluid is
include erythrocytes, or red blood cells; leukocytes, or white more dilute to another area where the fluid is more concentrated
blood cells; and platelets, also known as thrombocytes. For (see Fig. 16-2A). Once the fluid is of equal concentration on both
every 500 red blood cells, there are approximately 30 plate- sides of the membrane, the transfer of fluid between compart-
lets and 1 white blood cell (Fischbach & Dunning, 2008). ments does not change appreciably except volume for volume.
Any disorder that alters the volume of body fluid, whether The presence and quantity of colloids on either side of
it is fluid retention or loss, also affects the plasma volume of the semipermeable membrane influence osmosis. Colloids
blood. Examples include chronic bleeding or hemorrhage, are undissolved protein substances such as albumin and
infection, chemicals or conditions that destroy the blood cells blood cells within body fluids that do not readily pass through
once they have been produced, and disorders that affect the membranes. Their very presence produces colloidal osmotic
bone marrow’s production of blood cells. Deficits in either pressure (the force for attracting water) that influences fluid
fluid or cell volume are treated by administering fluid, whole volume in any given fluid location.
blood or packed cells, or individual blood components.
Filtration
Fluid and Electrolyte Filtration regulates the movement of water and substances
Distribution Mechanisms from a compartment where the pressure is higher to one
Although fluid compartments are identified separately, water where the pressure is lower. It is another mechanism that
and the substances dissolved therein continuously circulate influences fluid distribution. The force of filtration is referred
Na
Arteriole Na
(32 mm Hg) Sodium Na
ATP Na
Na
Na
Na
Carrier Na
Capillary
K
K ATP K
K
Venule K K
(25 mm Hg) K K
Semipermeable K
membrane Potassium
A B C D E
FIGURE 16-2 A. Osmosis. B. Filtration. C. Passive diffusion. D. Facilitated diffusion. E. Active
transport. ATP, adenosine triphosphate.
LWBK1004-C16_p305-344.indd 307 2/6/12 7:21 PM

to as hydrostatic pressure (the pressure exerted against a in the extracellular fluid into cells where it is more highly
membrane). For example, because of contraction of the left concentrated. It also moves sodium, which has a lower con-
ventricle, the fluid pressure is higher at the arterial end of a centration within the cells, to extracellular fluid where it is
capillary than at the venous end. Consequently, fluid and dis- more abundant.
solved substances are forced into the interstitial compartment
at the capillary’s arterial end. Water is then reabsorbed from Fluid Regulation
the interstitial fluid in comparable amounts at the venous end In healthy adults, fluid intake generally averages approxi-
of the capillary because of colloidal osmotic pressure (see mately 2,500 mL/day, but it can range from 1,800 to
Fig. 16-2B). Filtration also governs how the kidney excretes 3,000 mL/day with a similar volume of fluid loss (Table
fluid and wastes and then selectively reabsorbs water and 16-3). Normal mechanisms for fluid loss are urination,
substances that need to be conserved. bowel elimination, perspiration, and breathing. Losses from
the skin in areas other than where sweat glands are located
Passive Diffusion and from the vapor in exhaled air are referred to as insensible
Passive diffusion is the physiologic process in which dis- losses because they are, for practical purposes, unnoticeable
solved substances, such as electrolytes and gases, move and unmeasurable.
from an area of higher concentration to an area of lower Under normal conditions, several mechanisms maintain
concentration through a semipermeable membrane (see Fig. a match between fluid intake and output. For example, as
16-2C). It occurs without an expenditure of energy—hence body fluid becomes concentrated, the brain triggers the sen-
the word passive. Passive diffusion facilitates electrochemi- sation of thirst, which then stimulates the person to drink. As
cal neutrality (an identical balance of cations with anions) fluid volume expands, the kidneys excrete a proportionate
in any given fluid compartment. Like osmosis, passive diffu- volume of water to maintain or restore proper balance.
sion remains fairly static once equilibrium is achieved. There are circumstances, however, in which oral intake
or fluid losses are altered. Therefore, nurses assess clients
Facilitated Diffusion
for signs of fluid deficit or excess, particularly in those prone
Facilitated diffusion is the process in which certain dis-
to fluid imbalances (Box 16-1).
solved substances require the assistance of a carrier mol-
ecule to pass from one side of a semipermeable membrane
to the other (see Fig. 16-2D). It also regulates chemical bal- FLUID VOLUME ASSESSMENT
ance. Facilitated diffusion distributes substances from an
area of higher concentration to one that is lower. Glucose Nurses assess fluid status using a combination of a physical
is an example of a substance distributed by facilitated diffu- assessment (Table 16-4) and a measurement of intake and
sion. Insulin is the carrier substance for glucose. output volumes.
Intake and output (I&O) is one tool to assess fluid sta-
Active Transport
tus by keeping a record of a client’s fluid intake and fluid loss
Active transport, a process of chemical distribution that
over a 24-hour period. Agencies often specify the types of
requires an energy source, involves a substance called ade-
clients that are placed automatically on I&O; generally, they
nosine triphosphate (ATP) (see Fig. 16-2E). ATP provides
energy to drive dissolved chemicals against the concentra-
tion gradient. In other words, it allows chemical distribution • Clients who have undergone surgery until they are eating,
from an area of low concentration to one that is higher—the drinking, and voiding in sufficient quantities
opposite of passive diffusion. • Clients receiving IV fluids
An example of active transport is the sodium– • Clients receiving tube feedings
potassium pump system on cellular membranes, which regu- • Clients with some type of wound drainage or suction
lates the movement of potassium from lower concentrations equipment
TABLE 16-3 Daily Fluid Intake and Losses

SOURCES OF FLUID MECHANISMS OF FLUID LOSS
Oral liquids 1,200–1,500 mL/day Urine 1,200–1,700 mL/day
Food 700–1,000 mL/day Feces 100–250 mL/day
Metabolism 200–400 mL/day Perspiration 100–150 mL/day
Insensible losses:
Skin 350–400 mL/day
Lungs 350–400 mL/day
Total 2,100–2,900 mL/day Total 2,100–2,900 mL/day
Average intake 2,500 mL/day Average loss 2,500 mL/day
LWBK1004-C16_p305-344.indd 308 2/6/12 7:21 PM

B OX 1 6 - 1 Conditions That Predispose to risk for a fluid imbalance problem. The nurse discontinues
Fluid Imbalances the nursing order when the assessment is no longer indi-
cated but consults with the physician if it has been medi-
Fluid Deficit cally ordered.
• Starvation
Each agency has a specific I&O form kept at the bed-
• Impaired swallowing
• Vomiting
side so that nurses can conveniently record the type of fluid
• Gastric suction and amounts that are consumed and lost throughout the day
• Diarrhea (Fig. 16-3). The nurse subtotals the amounts at the end of
• Laxative abuse each shift or more frequently in critical care areas. He or she
• Potent diuretics documents the grand total in a designated area in the medical
• Hemorrhage record, for example, on the graphics sheet with other vital
• Major burns sign information.
• Draining wounds
• Fever and sweating Fluid Intake
• Exercise and sweating Fluid intake is the sum of all fluid volume that a client con-
• Environmental heat and humidity
sumes or is instilled into the client’s body, including the
Fluid Excess
following:
• Kidney failure • All the liquids a client drinks
• Heart failure • The liquid equivalent of melted ice chips, which is half of
• Rapid administration of IV fluid or blood the frozen volume
• Administration of albumin
• Foods that are liquid by the time they are swallowed, such
• Corticosteroid drug therapy
• Excessive intake of sodium
as gelatin, ice cream, and thin cooked cereal
• Pregnancy • Fluid infusions such as IV solutions
• Premenstrual fluid retention • Fluid instillations such as those administered through feed-
ing tubes or tube irrigations
Fluid volumes are recorded in milliliters (mL). The
• Clients with urinary catheters until it can be determined approximate equivalent for 1 oz is 30 mL, a teaspoon is
that output is adequate or they are voiding well after removal 5 mL, and a tablespoon is 15 mL. Packaged beverage con-
of the catheter tainers such as milk cartons usually indicate the specific
• Clients undergoing diuretic drug therapy fluid volume on the label. Hospitals and nursing homes
commonly identify the volume equivalents contained in the
In addition, many agencies allow nurses to independ-
cups, glasses, and bowls used to serve food and beverages
ently order an I&O assessment for clients who have or are at
from the dietary department (Box 16-2). If an equivalency
chart is not available, the nurse uses a calibrated container
TABLE 16-4 Signs of Fluid Imbalance (Fig. 16-4) to measure specific amounts; estimated volumes
ASSESSMENT FLUID DEFICIT FLUID EXCESS
are considered inaccurate.
Weight Weight loss Weight gain
≥2 lb/24 hr ≥2 lb/24 hr
Blood pressure Low High
Temperature Elevated Normal
Pulse Rapid, weak, Full, bounding
B OX 1 6 - 2 Volume Equivalents for Common
thready Containers
Respirations Rapid, shallow Moist, labored CONTAINER VOLUME (mL)
Urine Scant, dark yellow Light yellow
Teaspoon 5
Stool Dry, small volume Bulky
Tablespoon 15
Skin Warm, flushed, dry Cool, pale, moist
Juice glass 120
Poor skin turgor Pitting edema
Drinking glass 240
Mucous Dry, sticky Moist
Coffee cup 210
membranes
Milk carton 240
Eyes Sunken Swollen Water pitcher 900
Lungs Clear Crackles, gurgles Paper cup 180
Breathing Effortless Dyspnea, orthopnea Soup bowl 200
Energy Weak Fatigues easily Cereal bowl 120
Jugular neck veins Flat Distended Ice cream cup 120
Cognition Reduced Reduced Gelatin dish 90
Consciousness Sleepy Anxious
LWBK1004-C16_p305-344.indd 309 2/6/12 7:21 PM

FIGURE 16-3 Intake and output volumes are recorded throughout a 24-hour period and
subtotaled at the end of each 8-hour shift.
Gerontologic Considerations ■ Older adults may consume more fluid if the nurse offers
it, rather than if the nurse asks the older adult if he or she
■ Dehydration in older adults may be a consequence or would like a drink. Offering a small amount of liquid hourly
indicator of abuse or neglect. throughout the day will assist in keeping oral mucosa moist
■ Older adults may need to be encouraged to drink fluids, and providing hydration needs. Types of fluid and tempera-
even at times when they do not feel thirsty, because age- ture preferences (which may vary at different times of the
related changes may diminish the sensation of thirst. day) should be determined.
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• Blood loss
• Diarrhea
• Wound or tube drainage
• Aspirated irrigations
In cases in which an accurate assessment is critical to
a client’s treatment, the nurse weighs wet linens, pads, dia-
pers, or dressings and subtracts the weight of a similar dry
item. An estimate of fluid loss is based on the equivalent: 1
lb (0.47 kg) ⫽ 1 pint (475 mL).
Client cooperation is needed for accurate I&O records.
Therefore, the nurse informs clients whose I&O volumes are
being recorded about the purpose and goals for fluid replace-
ment or restrictions and the ways they can assist in the proce-
dure (Client and Family Teaching 16-1). Suggested actions
for maintaining an I&O record are provided in Skill 16-1.
FIGURE 16-4 Calibrated containers used to measure liquid vol-
umes. (Photo by B. Proud.)
COMMON FLUID IMBALANCES
Fluid imbalance is a general term describing any of sev-

■ To maintain adequate consumption of nutrients, it is eral conditions in which the water content of the body is not
best to offer fluids to older adults at times other than
in the proper volume or location within the body. It can be
meals. Distending the stomach with liquids creates a sen-
life-threatening. Common fluid imbalances include hypovo-
sation of satiety (fullness) and reduces the consumption of
food. lemia, hypervolemia, and third-spacing.
■ When older adults must fast before certain procedures,
emphasize the need to increase oral fluid intake in the Hypovolemia
hours before beginning fluid restrictions to prevent dehy- Hypovolemia refers to a low volume of extracellular fluid. If
dration. untreated, it may result in dehydration (a fluid deficit in both
■ Encourage older adults to drink noncaffeinated beverages extracellular and intracellular compartments). Mild dehydra-
because of the diuretic effect of caffeine or to replace the tion is present when there is a 3% to 5% loss of body weight;
volume of caffeinated beverages by consuming the same moderate dehydration is associated with a 6% to 10% loss
volume of noncaffeinated fluids per day. of body weight; and severe dehydration, a life-threatening
■ Diuretic medications, often prescribed for adults with Recording Intake and Output
cardiovascular disorders, increase the risk for fluid and elec-
The nurse teaches the client or family as follows:
trolyte imbalances. Laxatives, enemas, antihistamines, or
tricyclic antidepressants may also alter fluid and electrolyte ● Write down the amount or notify the nurse whenever oral
balance. fluid is consumed.
● Use a common household measurement, such as 1 glass
or cup, to describe the volume consumed, or refer to an
equivalency chart.
➧ Stop, Think, and Respond Box 16-1 ● Do not let a staff person remove a dietary tray until the
Use Box 16-2 to calculate the volume of fluid intake fluid amounts have been recorded.
for the following: a glass of orange juice, a half-pint ● Do not empty a urinal or urinate directly into the toilet
carton of milk, a bowl of tomato soup, a dish of lime bowl.
gelatin, a cup of coffee, a 100-mL infusion of IV antibi- ● Make sure that a measuring device is in the toilet bowl if
otic solution. the bathroom is used for voiding (Fig. 16-5).
● If a urinal needs to be emptied, call the nurse or empty
its contents into a calibrated container.
Fluid Output ● Use a container such as a bedpan or bedside commode
Fluid output is the sum of liquid eliminated from the body, if diarrhea occurs. Notify the nurse to measure the
including the following: contents before it is emptied.
● If vomiting occurs, use an emesis basin rather than the
• Urine toilet.
• Emesis (vomitus)
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■ Older adults may restrict their fluid intake under the

mistaken notion that this will reduce urinary inconti-
nence. This practice actually contributes to the problem
by increasing bladder irritability and increases the risks
for urinary tract infection, postural hypotension, falls, and
injuries. An assessment of fluid and electrolyte imbal-
ances is important for any older adult who has a change
in mental status.
Causes of fluid volume deficits include the following:

• Inadequate fluid intake
• Fluid loss in excess of fluid intake
• Translocation of large volumes of intravascular fluid to the
FIGURE 16-5 Urine is collected in a calibrated container some- interstitial compartment or to areas with only potential
times referred to as a “hat”. (Photo by B. Proud.) spaces such as the peritoneal cavity, pericardium, and pleu-
ral space
emergency, occurs with a loss of more than 9% to 15% of Fluid balance is restored by treating the cause of hypo-
body weight. In addition to weight loss, dehydration is evi- volemia, increasing oral intake, administering IV fluid
denced by decreased skin turgor. replacements, controlling fluid losses, or a combination of
these measures (see Nursing Guidelines 16-1).
Gerontologic Considerations Hypervolemia

Hypervolemia means a higher-than-normal volume of water
■ Skin elasticity diminishes with aging as subcutaneous fat in the intravascular fluid compartment and is another exam-
deposits decrease. Therefore, an assessment of skin turgor ple of a fluid imbalance. Edema develops when excess fluid
over the sternum is essential. Additional indicators of dehy-
is distributed to the interstitial space (Fig. 16-6). When fluid
dration in older adults include mental status changes;
increases in pulse and respiration rates; a decrease in blood
accumulates in dependent areas of the body (those influ-
pressure; dark, concentrated urine with a high specific enced by gravity), the tissue pits (forms indentations) when
gravity; dry mucous membranes; warm skin; furrowed compressed (see Chap. 13). Edema does not usually occur
tongue; low urine output; hardened stools; and elevated unless there is a 3 L excess in body fluid. Hypervolemia can
hematocrit, hemoglobin, serum sodium, and blood urea lead to circulatory overload (severely compromised heart
nitrogen. function) if it remains unresolved.

Rationales
Increasing Oral Intake
• Explain to the client the reasons for increasing consumption of a bar graph or pie chart. Positive reinforcement encourages
oral fluids. Knowledge facilitates client cooperation. compliance and maintains goal-directed efforts.
• Compile a list of the client’s preferences for beverages. Involv- • Keep fluids handy at the bedside and place them in containers
ing the client facilitates individualized collaboration with the the client can handle. Availability and convenience promote
dietary department. compliance.
• Obtain a variety of beverages on the client’s list. Catering to • Vary the types of fluid, serving glass, or container frequently.
client preferences promotes compliance. Variety reduces boredom and maintains interest in working
• Develop a schedule for providing small portions of the toward the goal.
total fluid volume over a 24-hour period. Scheduling • Serve fluids in small containers and in small amounts. Small
ensures that the final goal is reached by meeting short- portions avoid overwhelming the client.
term goals. • Ensure that fluids are at an appropriate temperature. Palatabil-
• Plan to provide the bulk of the projected fluid intake at times ity promotes pleasure and enjoyment.
when the client is awake. Providing a higher proportion of • Include gelatin, popsicles, ice cream, and sherbet as alterna-
fluid during waking hours avoids disturbing sleep. tives to liquid beverages (if allowed). Varying the liquid’s con-
• Offer verbal recognition and frequent feedback, or design a sistency and techniques for consumption offers an alternative
method for demonstrating the client’s progress; for example, to items that are sipped from a glass.
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B OX 1 6 - 3 Foods High in Salt (Sodium)

• Processed meats such as frankfurters and cold cuts
• Smoked fish
• Frozen egg substitutes
• Peanut butter
• Dairy products, especially hard cheese
• Powdered cocoa or hot chocolate mixes
• Canned vegetables, especially sauerkraut
• Pickles
• Tomato and tomato-vegetable juice
• Canned soup and bouillon
• Boxed casserole mixes
FIGURE 16-6 Foot care is very important for the client with • Baking mixes
edema. The edema and reddened areas can easily break down. • Salted snack foods
• Seasonings such as ketchup, gravy mixes, soy sauce, mono-
sodium glutamate, pickle relish, tartar sauce
Control of edema is an important nursing priority. Fluid

balance is restored by the following:
• Treating the disorder contributing to the increased fluid
with disorders in which albumin levels are low. Causes of
volume
hypoalbuminemia (a deficit of albumin in the blood)
• Restricting or limiting oral fluids
include liver disease, chronic kidney disease, and disorders
• Reducing salt consumption (Box 16-3)
in which capillary and cellular permeability are altered such
• Discontinuing IV fluid infusions or reducing the infusing
as burns and severe allergic reactions.
volume
Depletion of fluid in the intravascular space may lead to
• Administering drugs that promote urine elimination
hypotension and shock; thus, fluid therapy becomes critical.
• Using a combination of these interventions
The priority is to restore the circulatory volume by providing
See Nursing Guidelines 16-2. IV fluids, sometimes in large volumes at rapid rates. Blood
transfusions or the administration of albumin by IV infusion
Third-Spacing also are used to restore colloidal osmotic pressure and to pull
Third-spacing is the movement of intravascular fluid to the trapped fluid back into the intravascular space. When this
nonvascular fluid compartments, where it becomes trapped occurs, clients who were previously hypovolemic can sud-
and useless. It generally is manifested by tissue swelling or denly become hypervolemic. The nurse closely monitors
fluid that accumulates in a body cavity such as the perito- clients who receive albumin replacement for signs of circu-
neum (Fig. 16-7). Third-spacing is associated commonly latory overload.

Rationales
Restricting Oral Fluids
• Explain the purpose for the restrictions. Knowledge facilitates • Serve liquids at their proper temperature. This demonstrates
client cooperation. concern for the client’s pleasure and enjoyment.
• Identify the total amount of fluid the client may consume, • Offer ice chips as an occasional substitute for liquids. Ice chips
using measurements with which the client is familiar. An appear to contain more liquid than they actually do, and hold-
explanation helps the client to understand the extent of the ing them within the mouth prolongs the time over which the
restrictions. fluid is consumed.
• Work out a plan for distributing the permitted volume over a • Provide water or other fluid in a plastic squeeze bottle or
24-hour period with the client. Including the client in planning spray atomizer. These devices provide only a small volume
promotes cooperation. of fluid.
• Ration the fluid so that the client can consume beverages • Help the client with frequent oral hygiene. Oral hygiene
between meals as well as at mealtimes. Distributing opportuni- relieves thirst, moistens oral mucous membranes, and prevents
ties to drink fluid helps minimize thirst. drying and chapping of lips.
• Avoid sweet drinks and foods that are dry or salty. This reduces • Allow the client to rinse his or her mouth with water but not
thirst and the desire for fluid. swallow it. Rinsing reduces thirst and keeps the mouth moist.
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Types of Solutions
There are two types of IV solutions: crystalloid and colloid.
Crystalloid solutions are made of water and other uniformly
dissolved crystals such as salt and sugar. Colloid solutions
are made of water and molecules of suspended substances
such as blood cells and blood products (such as albumin).
Tympany
(air) Crystalloid Solutions
Crystalloid solutions are classified as isotonic, hypotonic,
Dullness and hypertonic (Table 16-5), depending on the concentra-
(fluid) tion of dissolved substances in relation to plasma. The con-
centration of the solution influences the osmotic distribution
of body fluid (Fig. 16-8).
FIGURE 16-7 Fluid accumulation within the peritoneal cavity.

Isotonic Solutions. An isotonic solution contains the
Dullness on percussion indicates fluid, whereas tympany indi- same concentration of dissolved substances normally found
cates air. in plasma. It generally is administered to maintain fluid bal-
ance in clients who may not be able to eat or drink for a short
INTRAVENOUS FLUID ADMINISTRATION period. Because of its equal concentration, an isotonic solu-
tion does not cause any appreciable redistribution of body
Policies and practices vary concerning how much respon- fluid.
sibility practical/vocational nurses assume with IV fluid
Hypotonic Solutions. A hypotonic solution contains
therapy. The discussion that follows is provided to meet the
fewer dissolved substances than normally found in plasma.
needs of those nurses who have been trained and have dem-
It is administered to clients with fluid losses in excess of
onstrated competencies for administering IV fluids.
fluid intake, such as those who have diarrhea or vomiting.
Intravenous fluids are solutions infused into a client’s
Because hypotonic solutions are dilute, the water in the solu-
vein to:
tion passes through the semipermeable membrane of blood
• Maintain or restore fluid balance when oral replacement is cells, causing them to swell. This temporarily increases
inadequate or impossible blood pressure as it expands the circulating volume. The
• Maintain or replace electrolytes water also passes through capillary walls and becomes dis-
• Administer water-soluble vitamins tributed within other body cells and the interstitial spaces.
• Provide a source of calories Hypotonic solutions, therefore, are an effective way to rehy-
• Administer drugs (see Chap. 35) drate clients experiencing fluid deficits.
• Replace blood and blood products
TABLE 16-5 Types of Crystalloid Intravenous Solutions

SOLUTION COMPONENTS SPECIAL COMMENTS
Isotonic Solutions
0.9% saline, also called 0.9 g of sodium chloride/100 mL of water Amounts of sodium and chloride are physiologically equal
normal saline to those found in plasma.
5% dextrose and water, also 5 g of dextrose (glucose/sugar)/100 mL Isotonic when infused but the glucose metabolizes
called D5W of water quickly, leaving a solution of dilute water.
Ringer’s solution or lactated Water and a mixture of sodium, chloride, Electrolyte replacement in amounts similar to those found
Ringer’s calcium, potassium, bicarbonate, and in plasma. The lactate, when present, helps maintain
in some cases lactate acid–base balance.
Hypotonic Solutions
0.45% sodium chloride, also 0.45 g of sodium chloride/100 mL of Smaller ratio of sodium and chloride than found in plasma,
called half-strength saline water causing it to be less concentrated in comparison.
5% dextrose in 0.45% saline 5 g of dextrose and 0.45 sodium chloride/ A quick source of energy from sugar, leaving a hypotonic
100 mL of water salt solution.
Hypertonic Solutions
10% dextrose in water, also 10 g of dextrose/100 mL of water Twice the concentration of glucose as in plasma.
called D10W
3% saline 3 g of sodium chloride/100 mL of water Dehydration of cells and tissues from the high concentra-
tion of salt in the plasma.
20% dextrose in water 20 g of dextrose/100 mL water Rapid increase in the concentration of sugar in the blood,
causing a fluid shift to the intravascular compartment.
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and are preferred for clients who need cellular replacement

but do not need, or may be harmed by, the administration of
additional fluid.
Most blood given to clients comes from public donors.
In some cases, for example, when a person anticipates the
potential need for blood in the near future or when proce-
dures are used to reclaim blood from wound drainage, the
A B client’s own blood may be reinfused (see Chap. 27).
Blood Products. Several blood products are available for

clients who need specific substances but do not need all the
fluid or cellular components in whole blood (Table 16-6).
Blood Substitutes. Blood substitutes are fluids that

when transfused carry and distribute oxygen to cells, tissues,
C
FIGURE 16-8 A. Isotonic solutions. B. Hypotonic solutions.
and organs. Many practitioners feel blood substitutes should
C. Hypertonic solutions. be more accurately called oxygen therapeutics because
they do not replace all the functions of human blood.
Finding a safe blood substitute could have many advan-
Hypertonic Solutions. A hypertonic solution is more tages: (1) it would be an acceptable alternative for people,
concentrated than body fluid and draws cellular and inter- such as Jehovah’s Witnesses, who object to receiving blood
stitial water into the intravascular compartment. This causes transfusions based on their religious beliefs, (2) the risks
cells and tissue spaces to shrink. Hypertonic solutions are for blood-borne diseases, such as hepatitis and AIDS, and
used infrequently except in extreme cases when it is neces- transfusion reactions from transfused human blood could be
sary to reduce cerebral edema or to expand the circulatory eliminated, (3) there would be a greater potential for saving
volume rapidly. the lives of military casualties in primitive locations, and (4)
it could be used in disasters and major trauma cases while
➧ Stop, Think, and Respond Box 16-2 awaiting transfusable human blood.
Currently, oxygen therapeutics fall into two categories:
Identify the net effect when the following IV solutions
are infused: 0.45% sodium chloride, Ringer’s solution, perfluorocarbons (PFCs) and hemoglobin-based oxygen
and 50% glucose. carriers (HBOCs). PFCs are solutions containing fluorine
and carbon that have the potential to carry 50 times more
oxygen than plasma (Whitehead, 2010). HBOCs are derived
Colloid Solutions
from three sources: hemoglobin (1) harvested from outdated
Colloid solutions are used to replace circulating blood vol-
human blood or (2) bovine (cattle) blood, and (3) cultured
ume because the suspended molecules pull fluid from other
from bacteria in which the gene for human hemoglobin is
compartments. Examples are blood, blood products, and
inserted (recombinant technology), much like human insulin
solutions known as plasma expanders.
is produced.
Blood. Whole blood and packed cells are probably the Because PFCs have a smaller molecular size than red
most common colloid solutions. One unit of whole blood blood cells, it is possible that they could deliver oxygen-
contains approximately 475 mL of blood cells and plasma carrying molecules to blood vessels that have been narrowed
plus 60 to 70 mL of preservative and anticoagulant (Smeltzer, as a result of blood clots, thus relieving impaired circulation
et al., 2008). Packed cells have most of the plasma removed after a stroke or heart attack. That same property could be
TABLE 16-6 Types of Blood Products

BLOOD PRODUCT DESCRIPTION PURPOSE FOR ADMINISTRATION
Platelets Disk-shaped cellular fragments that promote Restores or improves the ability to control bleeding
coagulation of blood
Granulocytes Types of white blood cells Improves the ability to overcome infection
Plasma Serum minus blood cells Replaces clotting factors or increases intravascular fluid volume
by increasing colloidal osmotic pressure
Albumin Plasma protein Pulls third-spaced fluid by increasing colloidal osmotic
pressure
Cryoprecipitate Mixture of clotting factors Treats blood clotting disorders such as hemophilia
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used to treat clients during a sickle cell crisis; their pain Solution Selection
could be relieved by oxygenating tissues in which sickled IV solutions are commonly stored in plastic bags containing
red blood cells have obstructed blood flow. In addition, PFCs 1,000, 500, 250, 100, and 50 mL of solution. A few solutions
could prolong the preservation of organs for transplantation are stocked in glass containers. The physician specifies the
and could improve the oxygenation of cancer cells, making type of solution, additional additives, the volume (in mL),
them more vulnerable to standard treatments. and the duration of the infusion. To reduce the potential for
PFCs are now in the second generation of develop- infection, IV solutions are replaced every 24 hours even if
ment; use of first-generation PFCs has been placed on hold the total volume has not been completely instilled.
or abandoned because of safety issues. Oxycyte, a second- Before preparing the solution, the nurse inspects the
generation PFC is undergoing clinical trials. There are five container and determines that:
HBOCs in clinical trials, most outside the United States.
• The solution is the one prescribed by the physician.
PolyHeme, an HBOC made from outdated human blood, is
• The solution is clear and transparent.
being tested in the United States. All of the oxygen therapeu-
• The expiration date has not elapsed.
tics, and particularly the HBOCs, have been associated with
• No leaks are apparent.
adverse effects. Many believe that the best benefit to risk
• A separate label is attached, identifying the type and
is to use them when blood is needed, but none is available
amount of other drugs added to the commercial solution.
(Moore, et al., 2009).
Tubing Selection
Plasma Expanders. Various nonblood solutions are
All IV tubing consists of a spike for accessing the solution, a
used to pull fluid into the vascular space. Two examples
drip chamber for holding a small amount of fluid, a length of
are dextran 40 (Rheomacrodex) and hetastarch (Hespan).
plastic tubing with one or more ports for adding IV medica-
These two substances are polysaccharides—large, insoluble
tions (see Chap. 35), and a roller or slide clamp to regulate
complex carbohydrate molecules. When mixed with water,
the rate of infusion (Fig. 16-9). The nurse then selects from
they form colloidal solutions. Because the suspended parti-
several options:
cles cannot move through semipermeable membranes when
given intravenously, they attract water from other fluid • Primary (long) or secondary (short) tubing
compartments. The desired outcome is to increase the blood • Vented or unvented tubing
volume and raise the blood pressure. Consequently, plasma • Microdrip (small drops) or macrodrip (large drops)
expanders are used as economical and virus-free substitutes chamber
for blood and blood products when treating hypovolemic • Unfiltered or filtered tubing
shock. • Needle or needleless access ports
Preparation for Administration Primary Versus Secondary Tubing. Primary tubing is

Regardless of the prescribed solution, the nurse prepares approximately 110 in. (2.8 m) and secondary tubing is 37 in.
the solution for administration, performs a venipuncture, (94 cm) long. These measurements vary among manufactur-
regulates the rate of administration, monitors the infusion, ers. Primary tubing is used when the tubing must span the
and discontinues the administration when fluid balance is distance from a solution that hangs several feet above the
restored. infusion site. Secondary tubing, which is shorter, is used to
Spike Slide clamp
Connector
Drip chamber
Roller clamp
FIGURE 16-9 Basic intrave-
Injection port nous tubing. (Courtesy of
Abbott Laboratories, North
Chicago, IL.)
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administer smaller volumes of solution into a port within the

primary tubing.
Vented Versus Unvented Tubing. Vented tubing draws
air into the container, whereas unvented tubing does not
(Fig. 16-10). The choice depends on the type of container
in which the solution is packaged. Vented tubing is nec-
essary for administering solutions packaged in rigid glass
containers; if unvented tubing is inserted into a glass bottle,
the solution will not leave the container. Plastic bags of IV
solutions do not need vented tubing because the container
collapses as the fluid infuses.
Drop Size. Drop size refers to the size of the opening
through which the fluid is delivered into the tubing. The
nurse determines whether it is more appropriate to use mac-
rodrip tubing, which produces large drops, or microdrip
tubing, which produces very small drops. When a solution
infuses at a fast rate, such as 125 mL/hr, it is generally easier
to count fewer, larger drops than many smaller ones. When
the solution must infuse very precisely or at a slow rate,
smaller drops are preferred.
Microdrip tubing, regardless of the manufacturer, deliv-
ers a standard volume of 60 drops/mL. Macrodrip tubing
manufacturers, however, have not been consistent in design-
ing the size of the opening. Therefore, the nurse must read FIGURE 16-11 An in-line filter. (Photo by K. Timby.)
the package label to determine the drop factor (number

of drops/mL). Some common drop factors are 10, 15, and
20 drops/mL. The drop factor is important in calculating the
infusion rate when it is instilled by gravity (eg, without an
electronic infuser) and is discussed later in this chapter.
Filters. An in-line filter (Fig. 16-11) removes air bubbles
as well as undissolved drugs, bacteria, and large substances.
Filtered tubing generally is used when:
• Administering parenteral nutrition
• The client is at high risk for infection
• Infusing IV solutions to pediatric clients
• Administering blood and packed cells
Needle or Needleless Access Ports. Traditionally, the

ports (sealed openings) in an IV tubing were designed for
access with a needle. This method, however, contributes
to the estimated 385,000 needle stick injuries among US
health care workers each year (U.S. Department of Labor,
2008) and approximately 2 million annually worldwide
(World Health Organization, 2005). To reduce the incidence
of work-related injuries and the potential for infection with
blood-borne pathogens, needleless systems (IV tubing that
eliminates the need for access needles) are preferred.
With a needleless system, the nurse uses a blunt can-
nula to pierce the resealable port each time it is necessary to
FIGURE 16-10 Unvented (left) and vented (right) tubing. (Photo enter the tubing (Fig. 16-12; and see Chap. 35). A needleless
by K. Timby.) access port can be pierced with a needle a limited number of
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Secondary IV tubing
Primary IV
tubing
Blunt tip
tubing
connector
Needleless
access port
Blunt tip
syringe
FIGURE 16-13 Special tubing with a cassette is inserted into
the electronic infusion pump. (Photo by B. Proud.)
Needleless
access port
special tubing that contains a device such as a cassette to cre-

ate sufficient pressure to push fluid into the vein (Fig. 16-13).
FIGURE 16-12 Needleless systems allow resealable ports to
The machine adjusts the pressure according to the resistance
be punctured with a blunt tip syringe or secondary IV tubing it meets. This can be a disadvantage because if the catheter
connector. or needle within the vein becomes displaced, the pump con-
tinues to infuse fluid into the tissue until the machine’s maxi-
mum preset pressure limit is reached.
times without altering its integrity, but a port that requires a Volumetric Controllers. A volumetric controller (an
needle for access cannot be punctured with a blunt cannula. electronic infusion device that instills IV solutions by grav-
ity) mechanically compresses the tubing at a certain fre-
Infusion Techniques quency to infuse the solution at a precise, preset rate. Volu-
IV infusions are administered either by gravity alone or with metric controllers may or may not require special tubing.
an infusion device–an electric or battery-operated machine Some models allow the nurse to program the infusion of
that regulates and monitors the administration of IV solu- more than one simultaneous infusion of solutions. In some
tions. The use of an infusion device may affect the type of cases, when one container of fluid finishes infusing, the con-
tubing used. troller automatically resumes infusing another solution. The
solution and tubing are prepared before accessing the vein
Gravity Infusion
with a needle or catheter. Skill 16-2 describes how to prepare
Generally, most basic types of tubing can be used for infus-
an IV solution for administration.
ing a solution by gravity. The height of the IV solution rather
than the tubing is the most important factor affecting gravity
Venipuncture
infusions.
Venipuncture (accessing the venous system by piercing a
To overcome the pressure within the client’s vein, which
vein with a needle) is a nursing responsibility when a periph-
is higher than atmospheric pressure, the solution is elevated at
eral vein (one distant from the heart) is used. When perform-
least 18 to 24 in. (45 to 60 cm) above the site of the infusion.
ing a venipuncture, the nurse assembles the needed equip-
The height of the solution affects the rate of flow: the higher
ment, inspects and selects an appropriate vein, and inserts
the solution, the faster the solution infuses, and vice versa.
the venipuncture device.
Electronic Infusion Devices
Venipuncture Devices
The two general types of electronic infusion devices are infu-
Several devices are used to access a vein: a butterfly needle,
sion pumps and volumetric controllers. Both are programmed
an over-the-needle catheter (most common), or a through-
to deliver a preset volume per hour. They trigger audible and
the-needle catheter (Fig. 16-14).
visual alarms if the infusion is not progressing at the rate
Venipuncture devices are available in various diam-
intended. They also sound an alarm when the infusion con-
eters or gauges; the larger the gauge number, the smaller the
tainer is nearly empty, air is detected within the tubing, or an
diameter. The diameter of the venipuncture device always
obstruction or resistance occurs in delivering the fluid.
should be smaller than the vein into which it is inserted to
Infusion Pumps. An infusion pump (an electronic infu- reduce the potential for occluding blood flow. An 18-, 20-, or
sion device that uses pressure to infuse solutions) requires 22-gauge is the size most often used for adults.
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Needle
Catheter
Needle tip Catheter
A B-1 C-1
Needle guard
Needle removed attached
Needle
Catheter
B-2 C-2
FIGURE 16-14 Venipuncture devices. A. A butterfly needle. B-1. An over-the-needle catheter.
B-2. The needle removed. C-1. A through-the-needle catheter. C-2. A needle guard covers the
tip of the needle, which remains outside the skin.
In addition to a device for puncturing the vein, the fol- Once the general site is selected, the nurse applies a
lowing items are needed: clean gloves, a tourniquet, antisep- tourniquet to select a specific vein (Fig. 16-16). Box 16-4
tic swabs to cleanse the skin, a transparent dressing to cover identifies several techniques for promoting vein distention.
the puncture site, and adhesive tape to secure the venipunc- A blood pressure cuff can be substituted for a rubber tour-
ture device and tubing. The use of antibiotic or antimicrobial niquet. Whichever technique is used, the radial pulse should be
ointment at the site varies; the nurse follows agency policy. palpable to indicate that arterial blood flow is being maintained.
An armboard may be needed to prevent the client from dis-
lodging the venipuncture device.
Vein Selection
The veins in the hand and forearm are used most commonly ■ It may be possible and advantageous to avoid using a
for inserting a venipuncture device (Fig. 16-15); scalp veins tourniquet when accessing a vein that is visually prominent
are used for infants and small children (see Nursing Guide- on an older adult. Use of a tourniquet may result in bursting
lines 16-3). the vein, sometimes referred to as “blowing the vein,”
when it is punctured with a needle.
Basilic Venipuncture Device Insertion

vein Skill 16-3 describes the technique for inserting an over-the-
Cephalic needle catheter within a vein.
Cephalic
vein vein
Infusion Monitoring and Maintenance
Median
Once the venipuncture is performed and the solution is
Dorsal
metacarpal cubital vein infusing, the nurse regulates the rate of infusion, assesses for
veins complications, cares for the venipuncture site, and replaces
Accessory equipment as needed.
cephalic
veins Regulating the Infusion Rate
The nurse is responsible for calculating, regulating, and
maintaining the rate of infusion according to the physician’s
Basilic
vein
B OX 1 6 - 4 Techniques for Promoting Vein
Medial
antebrachial Distention
vein
• Apply a tourniquet or blood pressure cuff tightly around the
Radial arm.
vein • Have the client make a fist and pump the fist intermittently.
• Tap the skin over the vein several times.
• Lower the client’s arm to promote distal pooling of blood.
• Stroke the skin in the direction of the fingers.
• Apply warm compresses for 10 minutes to dilate veins, and
then reapply the tourniquet.
FIGURE 16-15 Potential venipuncture sites.
LWBK1004-C16_p305-344.indd 319 2/6/12 7:21 PM


Rationales
Selecting a Venipuncture Site
• Use veins on the nondominant side. This reduces the poten- • Look for a large vein if a large-gauge needle or catheter is
tial for dislodging the device as a result of movement and necessary. Matching the needle and vein size prevents compro-
use. mising circulation.
• Do not use foot and leg veins. Using foot and leg veins • Avoid using veins on the inner surface of the wrist. This pre-
restricts mobility and increases the potential for blood clots. vents pain and discomfort.
• If possible, do not use a vein on the side of previous breast • Look for a vein proximal to the current site or in the opposite
surgery or in which vascular surgery has been performed hand or arm. This promotes healing and decreases the risk of
for kidney dialysis. Using such veins further compromises fluid leaking from the vein into the tissue.
circulation and increases the potential for infection and poor • Feel and look for a fairly straight vein. It is easier to thread the
healing. device into a straight vein.
• Choose a vein in a location unaffected by joint movement. A • Do not use a vein that appears inflamed or if the skin over
venipuncture device in such a location could become displaced the area looks impaired in any way. Use of such a site creates
more easily. additional trauma.
order. If an infusion device is used, the electronic equip- the container at hourly intervals to ensure that the infusion is
ment is programmed in milliliters per hour. If the solu- instilling at the prescribed rate.
tion is infused without an electronic infusion device (ie,
by gravity), the rate is calculated in drops (gtt) per minute. ➧ Stop, Think, and Respond Box 16-3
Formulas for calculating infusion rates are provided in Calculate the rate of infusion for the following two
Box 16-5. medical orders:
For gravity infusions, the nurse counts the number of 1. Infuse 1,000 mL of 0.9% NaCl over 12 hours using
drops falling into the drip chamber per minute. By adjust- an electronic infusion device.
ing the roller clamp, the number of drops is increased or 2. Infuse 500 mL of 5% dextrose and 0.45% NaCl in
decreased until the infusion rate matches the calculated rate. 8 hours by gravity infusion; your tubing delivers
15 gtt/mL.
Thereafter, the nurse monitors the time strip on the side of
A C
FIGURE 16-16 A. To apply a tourniquet, the ends are pulled

tightly in opposite directions. B. Then one end is tucked
beneath the other. C. This allows it to be released easily by
B
pulling one of the free ends. (Photo by B. Proud.)
LWBK1004-C16_p305-344.indd 320 2/6/12 7:21 PM

B OX 1 6 - 5 Formulas for Calculating embolus (a blood clot that travels to the lung), infection
Infusion Rates (growth of microorganisms at the site or within the blood
stream), and air embolism (a bubble of air traveling within
When using an infusion device: the vascular system).
Total volume in mL The minimum quantity of air that may be fatal to humans
= mL/hr
Total hours is not known. Animal research indicates that fatal volumes
of air are much larger than the quantity present in the entire
When infusing by gravity: length of infusion tubing. The average infusion tubing holds
Total volume in mL about 5 mL of air, an amount not ordinarily considered dan-
f or a
× drop fact gtt/min
Total time in minutes gerous. Clients, however, are often frightened when they see
air in the tubing, and nurses make every effort to remove air
Example: bubbles (see Nursing Guidelines 16-4).
1,000 mL
= 125 mL/hr
8 hr
1,000 mL
× 20 = 42 gtt/min
480 min ■ Nurses need to closely monitor the response of
older adults to IV infusions who may be unable to toler-
a
The macrodrip drop factor varies among manufacturers. ate volumes that may be safely administered to younger
adults.
Assessing for Complications

Complications associated with the infusion of IV solutions Caring for the Site
(Table 16-7) are circulatory overload (an intravascular vol- Because the venipuncture is a type of wound, it is impor-
ume that becomes excessive), infiltration (the escape of tant to inspect the site routinely. The nurse documents its
IV fluid into the tissue), phlebitis (inflammation of a vein), appearance in the client’s record. A common practice is to
thrombus formation (a stationary blood clot), pulmonary change the dressing over the venipuncture site every 24 to
TABLE 16-7 Complications of Intravenous (IV) Therapy

COMPLICATION SIGNS AND SYMPTOMS CAUSE(S) ACTION
Infection Swelling Growth of microorganisms Change site
Discomfort Apply antiseptic and dressing to
Redness at site previous site
Drainage from site Report findings
Circulatory overload Elevated blood pressure Rapid infusion Slow the IV rate
Shortness of breath Reduced kidney function Contact the physician
Bounding pulse Impaired heart contraction Elevate the client’s head
Anxiety Give oxygen
Infiltration Swelling at the site Displacement of the venipunc- Restart the IV
Discomfort ture device Elevate the arm
Decrease in infusion rate
Cool skin temperature at the site
Phlebitis Redness, warmth, and discomfort Administration of irritating fluid Restart the IV
along the vein Prolonged use of the same vein Report findings
Apply warm compresses
Thrombus formation Swelling Stasis of blood at the catheter, Restart the IV
Discomfort needle tip, or vein Report findings
Slowed infusion Apply warm compresses
Pulmonary embolus Sudden chest pain Movement of a previously Stay with the client
Shortness of breath stationary blood clot to the Call for help
Anxiety lungs Administer oxygen
Rapid heart rate
Drop in blood pressure
Air embolism Same as a pulmonary embolus Failure to purge air from the Same as for a pulmonary embolus,
tubing but also place the client’s head
lower than the feet
Position the client on his or her left side
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Rationales
Removing Air Bubbles From IV Tubing
• Flush the line with IV solution before inserting the adaptor into the air physically to an area where it can be trapped or
the venipuncture device. This action purges air from the tubing. released.
• Tighten the roller clamp if small bubbles are observed. This • Wrap the tubing around a circular object, like a pencil, start-
action prevents continued forward movement of the air. ing below the trapped air. This moves the air toward the drip
• Tap the tubing below the air bubbles (Fig. 16-17). Doing so chamber where it can escape from the liquid into the empty air
promotes upward movement of the air above the fluid in the space.
drip chamber. • Insert the barrel of a syringe within a port below the air, and
• Milk the air in the direction of the drip chamber or filter, open the roller clamp. This siphons fluid and air from the tub-
if one is incorporated within the tubing. Doing so pushes ing as it passes by the bevel of the needle.
72 hours, according to the agency’s infection control policy Insertion of an Intermittent Venous
(see Chap. 28). Access Device
An intermittent venous access device (a sealed chamber that
Replacing Equipment provides a means for administering IV medications or solu-
Solutions are replaced when they finish infusing or every tions periodically; Fig. 16-18) is inserted into a venipuncture
24 hours, whichever occurs first (Skill 16-4). IV tubing is device. An intermittent peripheral venous access device also
changed every 72 hours, depending on agency policy, with is called a “saline lock” because the chamber is filled and
some exceptions. Tubing used to instill parenteral nutrition periodically flushed with sterile normal saline to prevent
is replaced daily. Tubing used to administer whole blood blood from clotting at the tip of the catheter or needle. Cen-
can be reused for a second unit if one unit is administered tral venous catheters are usually kept patent by flushing the
immediately after the other. Whenever tubing is changed, it device with heparinized saline. Intermittent venous access
is more convenient to replace both the solution and the tub- devices are used when the client:
ing at the same time. Skill 16-5 describes how to replace just
the tubing, which is generally more difficult. • No longer needs continuous infusions of fluid
• Needs intermittent administrations of IV medication
• May need emergency IV fluid or medications if his or her
Discontinuation of an condition deteriorates
Intravenous Infusion
IV infusions are discontinued when the solution has infused These devices are replaced when the venipuncture site
and no more is scheduled to follow. Skill 16-6 is a procedure is changed. Skill 16-7 describes how to insert an intermittent
for removing a venipuncture device when IV infusions are venous access device and ensure its patency. The use of a
no longer needed. When the client needs occasional infu-
sions of solutions or the administration of IV medications,
the venipuncture is temporarily capped but kept patent with
the use of an intermittent venous access device also known
as a medication lock.
A B
FIGURE 16-17 Removing air bubbles. A. Tapping the tubing
may help air bubbles rise into the drip chamber. B. Twisting the
tubing around a pencil or other object may displace air bub- FIGURE 16-18 An intermittent venous access device. (Photo by
bles toward the drip chamber. B. Proud.)
LWBK1004-C16_p305-344.indd 322 2/6/12 7:21 PM

medication lock when administering IV drugs is discussed TABLE 16-8 Blood Groups and Compatible Types
in Chapter 35. PERCENTAGE OF COMPATIBLE
BLOOD GROUPS POPULATION BLOOD TYPES
A 41% A and O
BLOOD ADMINISTRATION B 9% B and O
O 47% O
AB 3% AB, A, B, and O
Blood is collected, stored, and checked for safety and com- Rh+ 85% whites Rh+ and Rh–
patibility before it is administered as a transfusion. 95% African Americans
Rh– 15% whites Rh– only
5% African Americans
Blood Collection and Storage
Blood donors are screened to ensure that they are healthy
and will not be endangered by the temporary loss in blood
volume. Refrigerated blood can be stored for 21 to 35 days,
after which it is discarded. Before donated blood is administered, the blood of the
potential recipient is typed and mixed, or cross-matched,
with a sample of the stored blood to determine whether the
Blood Safety two are compatible. To avoid an incompatibility reaction, it
Once collected, the donated blood is tested for syphilis, hep- is best to administer the same blood group and Rh factor.
atitis, and HIV antibodies to exclude administering blood Exceptions are listed in Table 16-8.
that may transmit these blood-borne diseases. Blood that Type O blood is considered the universal donor because
tests positive is discarded. Unfortunately, disease-carrying it lacks both A and B blood group markers on its cell mem-
viruses may remain undetected if the antibodies have not brane. Therefore, type O blood can be given to anyone
reached a level high enough to be measured. because it will not trigger an incompatibility reaction when
The U.S. Blood Safety Council, a division of the given to recipients with other blood types. Persons with type
Department of Health and Human Services, has policies AB blood are referred to as universal recipients because their
regarding potential hepatitis C infection by blood trans- red blood cells have proteins compatible with types A, B,
fusions. All blood collection agencies must notify people and O. Rh-positive persons may receive Rh-positive or Rh-
who received blood before 1987 if the donation came from negative blood because the latter does not contain the sensi-
a donor who has tested positive for hepatitis C since 1990. tizing protein. Rh-negative persons, however, should never
This policy is being implemented to promote early diagno- receive Rh-positive blood.
sis and treatment of infected but asymptomatic transfusion
recipients. ➧ Stop, Think, and Respond Box 16-4
The American Red Cross has a policy concerning blood Which blood type or types are compatible for cli-
donations to eliminate the potential transmission of neuro- ents who are blood types B (Rh) positive and O (Rh)
logic infectious microorganisms known as prions. Prions negative?
cause various brain disorders, one of which is bovine spong-
iform encephalopathy (“mad cow disease”) detected in peo- Blood Transfusion
ple who live in the United Kingdom (UK). Because blood Before administering blood, the nurse obtains and docu-
is one possible mode of transmitting prions from animals to ments the client’s vital signs to provide a baseline for com-
humans and humans to humans, the collection of blood is parison should the client have a transfusion reaction. Each
banned from anyone who has lived in the UK for a total of client who receives blood has a color-coded bracelet with
3 months or longer since 1980, lived anywhere in Europe for identifying numbers that must correlate with those on the
a total of 6 months since 1980, or received a blood transfu- unit of blood. IV medications are never infused through tub-
sion in the UK (American Red Cross, 2005). ing being used to administer blood.
Blood Transfusion Equipment

Blood Compatibility
There are certain standards for the gauge of the catheter or
There are several hundred differences among the proteins in
needle and the type of tubing used to transfuse blood.
the blood of a donor and a recipient. They can cause minor
or major transfusion reactions. One of the most dangerous Catheter or Needle Gauge. Because blood contains
differences involves the antigens, or protein structures, on cells in addition to water, it generally is infused through a 16-
membranes of red blood cells. Antigens determine the char- to 20-gauge—preferably an 18-gauge—catheter or needle.
acteristic blood group—A, B, AB, and O—and Rh factor. Rh Using a smaller gauge increases the potential for prolonging
positive means the protein is present; Rh negative means the the infusion beyond 4 hours, and 4 hours is the maximum
protein is absent. safe period for administering one unit of blood.
LWBK1004-C16_p305-344.indd 323 2/6/12 7:21 PM

Blood Transfusion Tubing. Blood is administered

through tubing referred to as a Y-set (Fig. 16-19). Two
branches are at the top of the tubing: one is used to admin-
ister normal saline solution and the other is used to adminis-
ter blood. Normal saline (0.9% sodium chloride) is the only
solution used when administering blood because other solu-
tions destroy red blood cells. The two branches of the Y-set
join above a filter that removes clotted blood and dead cell
debris. The normal saline always is administered before the
blood is hung and follows after the blood has been infused. It
also is used during the infusion if the client has a transfusion
reaction (Skill 16-8).
Transfusion Reactions
Life-threatening transfusion reactions generally occur
within the first 5 to 15 minutes of the infusion, so the nurse
or someone designated by the nurse usually remains with
the client during this critical time. Because a transfusion
reaction can occur at any time, however, nurses monitor
clients frequently during a transfusion and instruct them
to call for assistance if they feel any unusual sensations
(Table 16-9).
FIGURE 16-19 Blood transfusion tubing.
TABLE 16-9 Transfusion Reactions

TYPE OF REACTION SIGNS AND SYMPTOMS CAUSE(S) ACTION
Incompatibility Hypotension, rapid pulse rate, Mismatch between donor Stop the infusion of blood
difficulty breathing, back pain, and recipient blood groups Infuse saline at a rapid rate
flushing Call for assistance
Administer oxygen
Raise the feet higher than the head
Be prepared to administer emergency drugs
Send first urine specimen to laboratory
Save the blood and tubing
Febrile Fever, shaking chills, headache, Allergy to foreign proteins in Stop the blood infusion
rapid pulse, muscle aches the donated blood Start the saline
Check vital signs
Report findings
Septic Fever, chills, hypotension Infusion of blood that con- Stop the infusion of blood
tains microorganisms Start the saline
Report findings
Save the blood and tubing
Allergic Rash, itching, flushing, stable Minor sensitivity to sub- Slow the rate of infusion
vital signs stances in the donor blood Assess the client
Report findings
Be prepared to give an antihistamine
Moderate chilling No fever or other symptoms Infusion of cold blood Continue the infusion
Cover and make the client comfortable
Overload Hypertension, difficulty breathing, Large volume or rapid rate Reduce the rate
moist breath sounds, bounding of infusion; inadequate Elevate the head
pulse cardiac or kidney function Give oxygen
Report findings
Be prepared to give a diuretic
Hypocalcemia Tingling of fingers, hypotension, Multiple blood transfusions Stop the blood infusion
(low calcium) muscle cramps, convulsions containing anticalcium Start saline
agents Report findings
Be prepared to give antidote (calcium chloride)
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PARENTERAL NUTRITION B OX 1 6 - 6 Candidates for Total Parenteral

Nutrition
The term parenteral means “a route other than enteral or
• Clients who have not eaten for 5 days and are not likely to
intestinal.” Therefore, parenteral nutrition (nutrients such
eat during the next week
as protein, carbohydrate, fat, vitamins, minerals, and trace • Clients who have had a 10% or more loss of body weight
elements, administered intravenously) is provided by other • Clients exhibiting self-imposed starvation (anorexia nervosa)
than the oral route. Depending on the concentration of these • Clients with cancer of the esophagus or stomach
substances, parenteral nutrition is administered through an • Clients with postoperative gastrointestinal complications
IV catheter in a peripheral vein or through a catheter that • Clients with inflammatory bowel disease in an acute stage
terminates in a central vein near the heart. • Clients with major trauma or burns
• Clients with liver and renal failure
Peripheral Parenteral Nutrition
Peripheral parenteral nutrition (an isotonic or hypotonic IV
nutrient solution instilled in a vein distant from the heart) is
not extremely concentrated and consequently can be infused Because TPN solutions are extremely concentrated,
through peripheral veins. It provides temporary nutritional they must be delivered to an area where they are diluted in a
support of approximately 2,000 to 2,500 cal daily. It can fairly large volume of blood. This excludes peripheral veins.
meet a person’s metabolic needs when oral intake is inter- TPN solutions are infused through a catheter inserted into
rupted for 7 to 10 days, or it can be used as a supplement the subclavian or jugular vein; the tip terminates in the supe-
during a transitional period as the client begins to resume rior vena cava. This type of a catheter is referred to as a cen-
eating. tral venous catheter (Fig. 16-20A). Sometimes a peripherally
inserted central catheter is used; this long catheter is inserted
Total Parenteral Nutrition into a peripheral arm vein, but its tip terminates in the supe-
Total parenteral nutrition (TPN; a hypertonic solution of rior vena cava (Fig. 16-20B) (see Nursing Guidelines 16-5).
nutrients designed to meet almost all caloric and nutritional
needs) is preferred for clients who are severely malnour- Lipid Emulsions
ished or may not be able to consume food or liquids for a An emulsion (a mixture of two liquids, one of which is insol-
long period. Box 16-6 lists clients who may benefit from uble in the other) can be administered parenterally. The
TPN. combination allows a vehicle for administering lipids, or fat,
Insertion site
FIGURE 16-20 A. A central venous
catheter inserted into the subclavian
vein and threaded into the superior
vena cava. B. A peripherally inserted
central catheter with the distal tip in
the superior vena cava. A B
LWBK1004-C16_p305-344.indd 325 2/6/12 7:21 PM

Administering TPN
• Weigh the client daily. A record of the client’s weight assists • Infuse initial TPN solutions gradually (25 to 50 mL/hr). Gradual
with monitoring his or her response to treatment. administration allows time for physiologic adaptation.
• Use tubing that contains a filter. Filters absorb air and bac- • Never increase the rate of infusion to make up for an uninfused
teria, two potential complications associated with the use of volume unless the physician has been consulted. Speeding up
central venous catheters. the infusion tends to increase blood glucose levels.
• Change TPN tubing daily. Doing so reduces the potential for • Monitor intake and especially urine output. High blood glucose
infection. levels can trigger diuresis (increased urine excretion), resulting
• Tape all connections in the tubing and central catheter. Taping in output greater than intake.
prevents accidental separation and reduces the potential for • Monitor capillary blood glucose levels (see Chap. 14). Blood
an air embolism. glucose may not be adequately metabolized without the addi-
• Clamp the central catheter and have the client bear down tional administration of insulin.
whenever separating the tubing from its catheter connection. • Wean the client from TPN gradually. Weaning prevents a sud-
This action prevents an air embolism. den drop in blood glucose levels.
• Use an infusion device to administer TPN solution. An infusion
device monitors and regulates precise fluid volumes.
which is often missing from parenteral nutritional solutions. catheter, the lipid molecules tend to “break” and separate in
A parenteral lipid emulsion is a mixture of water and fats in the solution.
the form of soybean or safflower oil, egg yolk phospholipids, The client receiving an administration of lipids may
and glycerin. have an adverse reaction within 2 to 5 hours of the infu-
Lipid solutions, which look milky white (Fig. 16-21), sion (Dudek, 2009). Common manifestations include fever,
are given intermittently with TPN solutions. They provide flushing, sweating, dizziness, nausea, vomiting, headache,
additional calories and promote adequate blood levels of chest and back pain, dyspnea, and cyanosis. Delayed reac-
fatty acids. Lipid solutions are administered peripherally or tions (up to 10 days later) are characterized by enlargement
in a port in the central catheter below the filter and close to of the liver and spleen accompanied by jaundice, reduced
the vein. If the lipid solution is squeezed or mixed with TPN white blood cell and platelet counts, elevated blood lipid lev-
solutions in larger volumes than those moving through the els, seizures, and shock.
Clients who have fluid, electrolyte, blood, and nutritional

imbalances are likely to have one or more of the following
nursing diagnoses:
• Feeding Self-Care Deficit

• Deficient Fluid Volume
• Excess Fluid Volume
• Impaired Oral Mucous Membrane
• Risk for Impaired Skin Integrity
Nursing Care Plan 16-1 illustrates the nursing proc-

ess as applied to a client with Deficient Fluid Volume. The
NANDA-I (2012, p. 186) defines this diagnostic category
FIGURE 16-21 Administration of lipid emulsion. (Photo by as “decreased intravascular, interstitial, and/or intracellular
B. Proud.) fluid.”
LWBK1004-C16_p305-344.indd 326 2/6/12 7:22 PM

N U R S I N G C A R E P L A N 1 6 - 1 Deficient Fluid Volume

Assessment • Assess skin turgor over the sternum each shift.
• Monitor intake and output (I&O) each shift and total the sum • Note the color and warmth of the skin and the degree of mois-
every 24 hr. ture in the mucous membranes each shift.
• Assess for unusual loss of fluid via emesis, diarrhea, wound • Ask the client to identify any thirst, weakness, or fatigue.
drainage, intestinal suction, blood loss, etc. • Determine the client’s level of consciousness and evidence of
• Weigh the client consistently on the same scale, at the same confusion or disorientation.
time, and in similar clothing and compare the findings. • Review laboratory data such as specific gravity of urine, hema-
• Note the color and odor of urine. tocrit, and electrolyte concentration.
• Check vital signs every 4 hr while the client is awake.
Nursing Diagnosis. Deficient Fluid Volume related to inadequate oral fluid intake and increased fluid loss as manifested by in-
take of 1,000 mL in previous 24 hr, urine output of 750 mL in previous 24 hr, dry oral mucous membranes, dark yellow urine with
strong odor, oral temperature of 100°F, weak pulse rate of 100 beats/min, respiratory rate of 28 breaths/min, BP of 118/68 mm Hg,
and dry skin that tents for more than 3 seconds.
Expected Outcome. The client’s fluid volume will be adequate as evidenced by an oral intake of 1,500 to 3,000 mL in the next
24 hr (8/15) with a urine output nearly the same volume as oral intake.
Explain the need to increase oral fluid intake to the client Teaching helps facilitate the client’s cooperation in reaching
and the process of recording the volume of fluid intake and the goal.
output.
Place an I&O record form at the client’s bedside. Having a form for recording I&O promotes an accurate assess-
ment.
Put a hat for collecting urine inside the bowl of the toilet; Placing a device for collecting voided urine helps prevent acci-
explain its purpose to the client. dental flushing of urine that needs to be measured.
Instruct the client to record fluids and amounts consumed and Periodic recording facilitates accuracy.
to remind nursing personnel to do likewise.
Ask the client to turn on the signal light after each use of the Measuring urine output after each voiding and recording the
toilet or urinal. amount ensure accuracy.
Compile a list of fluid likes and dislikes. Catering to the client’s personal preferences facilitates
increasing oral fluid intake.
Provide a minimum of 100 to 200 mL of preferred oral fluid An oral fluid intake of 100 mL/hr for 16 hr will meet the mini-
every hour over the next 16 hr (day and evening shifts). mum target of 1,500 mL.
Offer oral fluid if the client awakens during the night, but avoid Ensuring sleep is a priority as long as the goals for fluid intake
disturbing the client if asleep and if the oral intake from the are met.
previous shifts is adequate.
Request a regular diet from the dietary department that con- Sodium attracts water.
tains foods that are good sources of sodium such as milk,
cheese, bouillon, and ham.

• Total oral intake for 24 hr is 2,250 mL. • Urine is light yellow and free of strong odor.
• Total urine output for 24 hr is 1,975 mL. • Oral mucous membranes are pink and moist.
• Oral temperature is 98.2°F, pulse is 88 beats/min and • Skin is warm and elastic.
strong, respirations are 18 breaths/min at rest, and BP is • The client is alert and oriented.
128/84 mm Hg in right arm while lying down. • The client is not thirsty, weak, or unusually fatigued.
• Weight remains at admission weight of 157 lb.
LWBK1004-C16_p305-344.indd 327 2/6/12 7:22 PM

CRITICAL THINKING EXERCISES 3. When a client asks how a transfusion of packed red
blood cells differs from the usual whole blood trans-
1. When calculating a client’s I&O, you find that she has fusion, which nursing explanation is most correct?
had a total 24-hour intake of 1,000 mL and output 1. A unit of packed red blood cells has the same
of 750 mL. What other assessment findings are you number of red blood cells in less fluid volume.
likely to observe? 2. A unit of packed red blood cells contains more
2. A client whose oral intake is being limited to 1,000 red blood cells in the same amount of fluid
mL/24 hours is experiencing thirst and asks for volume.
assistance in relieving his discomfort. What nursing 3. A unit of packed red blood cells is less likely to
actions could be taken? cause an allergic transfusion reaction.
3. While assessing a client’s IV infusion that is instilling 4. A unit of packed red blood cells will stimulate the
by gravity, you note that it is infusing at a signifi- bone marrow to make more red blood cells.
cantly slower rate than when it was originally regu- 4. If all the following units of blood are available, which
lated. What actions are appropriate to take? is the nurse correct to refuse for a client with type A,
4. A client will be receiving a blood transfusion. The Rh-positive blood because it is incompatible for this
registered nurse who hangs the unit of blood and client?
initiates the administration of the blood asks you to 1. Type A, Rh negative
assess the client during its infusion. What assess- 2. Type O, Rh positive
ments are appropriate to monitor? 3. Type O, Rh negative
4. Type AB, Rh positive
5. During the first 15 minutes of infusing a unit of
NCLEX-STYLE REVIEW QUESTIONS blood, which of the following is most indicative
1. When the nursing care plan indicates that a client is that the client is experiencing a transfusion
to be weighed regularly, which is most important to reaction?
consider? 1. The client feels an urgent need to urinate.
1. When the client was weighed before 2. The client’s blood pressure becomes low.
2. When the client last took a drink of fluid 3. Localized swelling develops at the infusion
3. How much the client has eaten so far today site.
4. Whether the client feels like being weighed 4. The skin is pale at the site of the infusing
2. Which item in the following list, if identified by the blood.
client, is the best evidence that the client understands
dietary restrictions for a low-sodium diet?
1. Soy sauce
2. Lemon juice
3. Maple syrup
4. Onion powder
LWBK1004-C16_p305-344.indd 328 2/6/12 7:22 PM

SKILL 16-1 Recording Intake and Output
ASSESSMENT
Check the Kardex or listen in report to determine whether an Ensures compliance with the plan for care.
assigned client is on I&O.
Verify during the report how much IV fluid has been accounted Indicates the credited volume for calculating fluid intake at the
for from any currently infusing solution. end of the shift.
Review the nursing care plan for any previously identified fluid Promotes continuity of care.
problem and nursing orders for specific interventions.
Review the client’s medical record and analyze trends in I&O, Aids in analyzing trends in fluid status.
vital sign measurements, laboratory findings, and weight
records.
Perform a physical assessment to obtain data that reflect the Provides current data.
client’s fluid status (see Table 16-4).
Inspect all tubings and drains to ensure they are patent (open). Ensures that methods for instilling or removing fluids are
functional.
Notice whether all suction containers or drainage containers Ensures accurate record keeping.
were emptied at the end of the previous shift.
Determine how much the client understands about I&O meas- Verifies whether additional teaching is needed.
urements, fluid intake goals, or fluid restrictions.
Look for a calibrated container and bedside I&O record. Facilitates keeping accurate data.
Obtain a collection device for inside the toilet if the client has Facilitates measuring voided urine.
none and uses the toilet for urinary elimination.
Measure the amount of water in the client’s bedside carafe at Provides a baseline for measuring fluid consumed in addition to
the beginning of the shift. that served at regular meal times.
PLANNING
Place the client on I&O or plan to measure I&O if the client is at Demonstrates safe and appropriate nursing care.
high risk for fluid imbalance or the assessment data suggest
a problem.
Identify the goal for fluid intake or restriction. A minimum of Provides a target for client care.
1,000 mL in 8 hr is not unrealistic for a client in fluid deficit.
An amount prescribed by the physician or an intake equal to
the client’s previous hourly output may be used as a guideline
for fluid restrictions.
IMPLEMENTATION
Explain or reinforce the purpose and procedures that will be Facilitates client cooperation.
followed for measuring I&O.
Record the volume for all fluids consumed from the dietary tray Contributes to accurate assessment records.
and other sources of oral liquids.
Make sure that all IV fluids or tube feedings are being adminis- Ensures compliance with medical therapy.
tered at the prescribed rate.
Ensure that the nurse who adds additional IV fluid containers Ensures accurate record keeping.
also records the volume when the infusion is complete or
replaced.
Keep track of the fluid volumes used to irrigate drainage tubes Ensures accurate record keeping.
or flush feeding tubes.
Measure and record the volume of voided urine. Although Ensures accurate record keeping and reduces the transmission of
urine is not considered a vehicle for the transmission of microorganisms.
blood-borne microorganisms, gloves are worn as standard
precautions.
(continued)
LWBK1004-C16_p305-344.indd 329 2/6/12 7:22 PM

Recording Intake and Output (continued)
Measure and record the volume of urine collected in a catheter Ensures accurate record keeping.
drainage bag near the end of the shift (Fig. A).
Urine drainage bag. (Photo by B. Proud.)
Wear gloves to measure liquid stool or other body fluids and Prevents the transmission of microorganisms and provides
record their measured amounts. assessment data.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the presence and potential transmission of microorgan-
Chap. 10) after removing and disposing of the gloves. isms.
Check the volume remaining in currently infusing IV fluids; Ensures accurate assessment data.
subtract the remaining volume from the credit provided at the
beginning of the shift.
Total all fluid intake volumes and all fluid output volumes for the Ensures accurate record keeping.
current 8-hr shift; record the amounts.
Compare the data to determine whether the I&O are approxi- Demonstrates concern for safe and appropriate care.
mately the same and if the goals for fluid intake or restric-
tions have been met.
Report major differences in I&O to the nurse in charge or the Demonstrates concern for safe and appropriate care.
client’s physician.
Review the plan of care and make revisions if the goals have Demonstrates responsibility and accountability.
not been met or if additional nursing interventions seem
appropriate.
Report the I&O volumes, IV fluid credit amount, and any other Demonstrates responsibility and accountability.
pertinent data to the nurse who will be assuming responsibil-
ity for the client’s care.
Evaluation
• Intake approximates output.
• Goals for fluid intake or restriction have been met.
• Significant data have been reported.
• The client’s fluid status justifies continuing the care as planned, or the care plan has been revised.
Document
• Date and time
• Intake and output volumes for the previous 8 hours
Date and Time Fluid intake for the previous 8 hours is 1,200 mL and output is 1,000 mL. _________________ SIGNATURE/TITLE
LWBK1004-C16_p305-344.indd 330 2/6/12 7:22 PM

SKILL 16-2 Preparing Intravenous Solutions
ASSESSMENT
Check the medical order for the type, volume, and projected Ensures accuracy and guides the selection of equipment.
length of fluid therapy.
Determine if the solution is in a bag or bottle and if the infusion Affects the selection of tubing.
will be administered by gravity or infusion device.
Review the client’s medical record for information on the risk for Determines need for filtered tubing.
infection.
Read the label on the solution at least three times. Helps prevent errors.
PLANNING
Mark a time strip and attach it to the side of the container Facilitates monitoring.
(see Fig. A).
Marking a time strip. (Photo by B. Proud.)
IMPLEMENTATION
Wash hands or perform hand antisepsis with an alcohol rub Reduces the transmission of microorganisms.
(see Chap. 10).
Select the appropriate tubing and stretch it once it has been Straightens the tubing by removing bends and kinks.
removed from the package.
Tighten the roller clamp (see Fig. B). Aids in filling the drip chamber.
Tightening the roller clamp. (Photo by B. Proud.)
B
(continued)
LWBK1004-C16_p305-344.indd 331 2/6/12 7:22 PM

Preparing Intravenous Solutions (continued)
Remove the cover from the access port. Provides access for inserting the spike.
Insert the spike by puncturing the seal on the container Provides an exit route for fluid.
(see Fig. C).
Inserting the spike. (Photo by B. Proud.)
Hang the solution container from an IV pole or suspended hook. Inverts the container.
Squeeze the drip chamber, filling it no more than half full Leaves space to count the drops when regulating the rate of
(see Fig. D). infusion.
Squeezing the drip chamber. (Photo by B. Proud.)
Release the roller clamp. Flushes air from the tubing.

(continued)
LWBK1004-C16_p305-344.indd 332 2/6/12 7:22 PM

Preparing Intravenous Solutions (continued)
Invert ports within the tubing as the solution approaches. Displaces air that may be trapped in the junction.
Tighten the roller clamp when all the air has been removed. Prevents a loss of fluid.
Attach a piece of tape or a label on the tubing giving the date, Provides a quick reference for determining when the tubing
time, and your initials (see Fig. E). needs to be changed.
Attaching label on the tubing. (Photo by B. Proud.)
Take the solution and tubing to the client’s room. Facilitates administration.
Evaluation
• Solution and tubing are properly labeled.
• Tubing has been purged of air.
Document
• Date and time
• Type and volume of solution
• Rate of infusion once venipuncture has been performed
• Location of venipuncture site
Date and Time 1,000 mL of 5% D/W infusing at 125 mL/hr through IV in L. forearm. ___________________ SIGNATURE/TITLE
LWBK1004-C16_p305-344.indd 333 2/6/12 7:22 PM

SKILL 16-3 Starting an Intravenous Infusion
ASSESSMENT
Check the identity of the client. Prevents errors.
Review the client’s medical record to determine whether there Influences supplies that will be used and modifications in the
are any allergies to iodine or tape. procedure.
Inspect and palpate several potential venipuncture sites (see Provides an alternative if the first attempt is unsuccessful.
Fig. A).
Palpating veins. (Photo by B. Proud.)
PLANNING
Bring all the necessary equipment to the bedside. Promotes organization and efficient time management.
Position the client on his or her back or in a sitting position. Promotes comfort and facilitates inspection of the arm.
Place an absorbent pad beneath the hand or arm. Prevents having to change the bed linen if the site bleeds.
Select a site most likely to facilitate the purpose for the infusion Facilitates continuous fluid administration and minimizes potential
and comply with the criteria for vein selection. complications.
Clip body hair at the site if it is excessive. Facilitates visualization and reduces discomfort when adhesive
tape is removed.
Apply topical anesthetic such as Numby Stuff™ or EMLA cream. Provides local anesthesia to insertion site to minimize pain associ-
ated with a needle stick.
Tear strips of tape, open the package with the venipuncture Saves time and ensures that the venipuncture device is not
device and transparent dressing, or place antiseptic oint- displaced once inserted. Transparent dressings facilitate site
ment on an opened Band-Aid or gauze square, based on the assessment. Use of a nontransparent cover and antimicrobial
agency’s policy. ointment is controversial and is dependent on agency policy.
IMPLEMENTATION
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the number of microorganisms.
Chap. 10).
Apply a tourniquet or a blood pressure cuff 2 to 4 in. (5 to 10 cm) Distends the vein.
above the vein that will be used.
Use an antimicrobial solution such as Betadine and/or alcohol to Reduces the potential for infection.
cleanse the skin, starting at the center of the site outward 2
to 4 in. (see Fig. B).
Swabbing the site. (Photo by B. Proud.)
B
(continued)
LWBK1004-C16_p305-344.indd 334 2/6/12 7:22 PM

Starting an Intravenous Infusion (continued)
Allow the antiseptic to dry. Potentiates the effectiveness of antiseptic and prevents burning
when the needle is inserted.
Don clean gloves. Provides a barrier for blood-borne viruses.
Use the thumb to stretch and stabilize the vein and soft Helps straighten the vein and prevents it from moving around
tissues about 2 in. (5 cm) below the intended site of underneath the skin.
entry (see Fig. C).
Stabilizing the vein. (Photo by B. Proud.)
Position the venipuncture device with the bevel up and at Facilitates piercing the vein.
approximately a 45-degree angle above or to the side of the
vein (see Fig. D).
Placing the bevel up.
D
Warn the client just before inserting the needle. Prepares the client for discomfort.
Feel for a change in resistance and look for blood to appear Indicates the vein has been pierced.
behind the needle.
Once blood is observed, advance the needle about 1⁄8 in. to Positions the catheter tip within the inner wall of the vein.
¼ in. (see Fig. E).
Advancing the needle tip. (Photo by B. Proud.)
E
(continued)
LWBK1004-C16_p305-344.indd 335 2/6/12 7:22 PM

Withdraw the needle slightly so that the tip is within the catheter. Prevents puncturing the outside of the vein wall.
Slide the catheter into the vein until only the end of the infusion Ensures full insertion of the catheter.
device can be seen.
Release the tourniquet. Reduces venous pressure and restores circulation.
Apply pressure over the internal tip of the catheter. Limits blood loss.
Remove the protective cap covering the end of the IV tubing Facilitates infusing the solution.
and insert it into the end of the venipuncture device.
Release the roller clamp and begin infusing the solution slowly. Clears blood from the venipuncture device before it can clot.
Remove gloves when there is no longer a potential for direct Facilitates handling tape.
contact with blood.
Reduces the potential for infection.
Secure the catheter by criss crossing a piece of tape from Prevents catheter displacement.
beneath the tubing. Cover the site according to agency policy
(see Fig. F).
Stabilizing the catheter. (Photo by B. Proud.)
Apply additional strips of tape, taking care to loop and secure Prevents tension on the tubing that may cause displacement.
the tubing (see Fig. G).
Securing the tubing. (Photo by B. Proud.)
G
(continued)
LWBK1004-C16_p305-344.indd 336 2/6/12 7:22 PM

Write the date, time, gauge of the catheter, and your initials on Provides a quick reference for determining when the site must be
the site dressing or the outer piece of tape. changed.
Tighten or release the roller clamp to regulate the rate of fluid Facilitates compliance with the medical order.
infusion.
Evaluation
• A flashback of blood was observed before advancing the catheter.
• Minimal discomfort and blood loss occurred.
• Fluid is infusing at the prescribed rate.
Document
• Date and time
• Gauge and type of venipuncture device
• Site of venipuncture
• Type and volume of solution
• Rate of infusion
Date and Time No. 20 gauge over-the-needle catheter inserted into vein in L. forearm. 1,000 mL 0.9% saline infusing at
42 gtt/min. ______________________________________________________________________ SIGNATURE/TITLE
SKILL 16-4 Changing Intravenous Solution Containers
ASSESSMENT
Assess the volume that remains in the infusing container and Helps establish when the solution will need to be replaced.
the rate at which it is infusing.
Check the medication record or physician’s orders to determine Ensures compliance with the medical order.
what solution is to follow the current infusion.
PLANNING
Obtain the replacement solution well in advance of needing it. Ensures that the infusion will be uninterrupted.
Attach a time strip to the new container indicating the date, Avoids having to complete this responsibility later.
your initials, and the hourly infusion volumes.
Organize client care to change the container when the current Demonstrates efficient time management.
infusion becomes low.
IMPLEMENTATION
Check the identity of the client. Prevents errors.
Chap. 10).
Tighten the roller clamp slightly or slow the rate of infusion on Slows the rate of infusion so that the drip chamber remains filled
an infusion device. with solution.
Remove the almost empty solution container from the suspen- Facilitates separating the tubing from the container.
sion hook with the tubing still attached.
Invert the empty solution container and pull the spike free. Prevents minor loss of remaining solution.
Deposit the empty bag in a lined waste receptacle. Keeps the environment clean and orderly.
Remove the seal from the replacement solution container. Provides access to the port.
Insert the spike into the port of the new container. Provides a route for infusing fluid.
Hang the new container from the suspension hook on the IV Restores height to overcome venous pressure.
standard or infusion device.
Inspect for the presence of air within the tubing; remove it if Reduces the potential for air embolism or an alarm from an infu-
present. sion device detecting air.
Readjust the roller clamp or reprogram the infusion device to Demonstrates compliance with the medical order.
restore the prescribed rate of infusion.
(continued)
LWBK1004-C16_p305-344.indd 337 2/6/12 7:22 PM

Changing Intravenous Solution Containers (continued)
Evaluation
• Solution container is replaced.
• Infusion continues.
Document
• Volume infused from previous container on I&O record
• Time, volume, type of solution, and signature on the medication record or wherever the agency specifies documenting the administra-
tion of IV solutions
• Condition of the client
Date and Time 1,000 mL lactated Ringer’s instilling at 42 gtt/min. Dressing over venipuncture is dry and intact. No swell-
ing or discomfort in the area of the infusing fluid. __________________________________ SIGNATURE/TITLE
SKILL 16-5 Changing Intravenous Tubing
ASSESSMENT
Determine the agency’s policy for changing IV tubing. Demonstrates responsibility for complying with infection control
policies.
Check the date and time on the label attached to the tubing. Determines the approximate time when the tubing must be
changed.
Determine whether the solution container will need to be Facilitates changing both the container and the tubing at the
replaced before the time expires on the tubing. same time.
PLANNING
Obtain appropriate replacement tubing and supplies for chang- Ensures that equipment will be available and ready when needed.
ing the dressing.
Attach a new label to the tubing indicating the date and time the Provides a quick reference for determining when the tubing must
tubing is changed and your initials. be changed again.
IMPLEMENTATION
Chap. 10).
Tear strips of adhesive tape and prepare dressing materials and Facilitates dexterity later in the procedure.
place them in a convenient location.
Open the new package containing the tubing, stretch the tub- Prepares the tubing for insertion into the solution container.
ing, and tighten the roller clamp.
Remove the solution container from the suspension hook with Facilitates separating the tubing from the container.
the tubing still attached.
Invert the solution container and pull the spike free. Prevents the minor loss of remaining solution.
Secure the spike to the IV pole with a strip of previously torn Facilitates continued infusion.
tape.
Insert the spike from the new tubing into the container of Provides a route for the fluid.
solution.
Squeeze the drip chamber to fill it half full, open the roller Prepares the tubing for use.
clamp, and purge the air from the tubing.
Remove the tape and dressing from the venipuncture site. Provides access to the venipuncture device.
Don gloves. Provides a barrier from contact with blood.
Tighten the roller clamp on the expired tubing. Temporarily interrupts the infusion.
Stabilize the hub of the venipuncture device and separate the Prevents accidental removal of the catheter or needle from the
tubing from it. vein.
Remove the cap from the end of the new tubing and attach it to Connects the venipuncture device to the tubing without contami-
the end of the venipuncture device. nating the tip of the tubing.
Continue to hold the venipuncture device with one hand while Reestablishes the infusion.
releasing the roller clamp on the new tubing.
(continued)
LWBK1004-C16_p305-344.indd 338 2/6/12 7:22 PM

Changing IV Tubing (continued)
Replace the dressing on the venipuncture site and secure the Covers the site and keeps the tubing and venipuncture device
tubing. from being pulled out.
Readjust the rate of infusion. Complies with the medical order.
Write the date, time, and your initials on the new dressing, and Provides a quick reference for determining future nursing respon-
include the gauge of the venipuncture device and original sibilities for infection control.
date of insertion.
Dispose of the expired tubing in a lined receptacle. Maintains a clean and orderly environment.
Evaluation
• Tubing is replaced.
• Solution continues to infuse at the prescribed rate.
Document
• Date and time
• Assessment findings of venipuncture site
• Dressing change
Date and Time No redness, swelling, or tenderness at venipuncture site in L. forearm. Dressing changed following
replacement of IV tubing. _____________________________________________________ SIGNATURE/TITLE
SKILL 16-6 Discontinuing an Intravenous Infusion
ASSESSMENT
Confirm that the physician has written an order to discontinue Demonstrates responsibility and accountability for carrying out
the infusion of IV fluid. medical orders.
Check the client’s identity. Prevents errors.
PLANNING
Assemble necessary equipment, which includes clean gloves, Promotes organization and efficient time management.
sterile gauze, and tape.
IMPLEMENTATION
(see Chap. 10).
Clamp the tubing and remove the tape that holds the dressing Facilitates removal without leaking fluid.
and venipuncture device in place.
Don gloves. Prevents contact with blood.
Press a gauze square gently over the site where the venipunc- Helps absorb blood.
ture device enters the skin.
Remove the catheter or needle by pulling it out without hesita- Prevents discomfort and injury to the vein.
tion following the course of the vein.
(continued)
LWBK1004-C16_p305-344.indd 339 2/6/12 7:22 PM

Discontinuing an Intravenous Infusion (continued)
Apply pressure to the site of the venipuncture for 30 to Pressure and elevation control bleeding.
45 seconds while elevating the forearm (Fig. A).
Applying pressure to the venipuncture site. (Photo by B. Proud.)
Secure the gauze with tape. Acts as a dressing to reduce the potential for infection.
Dispose of the venipuncture device in a sharps container if it is Prevents accidental needle-stick injuries and the transmission of
a needle. blood-borne infectious microorganisms.
Enclose a catheter used for venipuncture within a glove as they Facilitates disposal and prevents contact with blood.
are removed and discarded within a lined waste container.
Wash hands or perform hand antisepsis with an alcohol rub Removes transient microorganisms.
(see Chap. 10) after glove disposal.
Encourage the client to flex and extend the arm or hand several Helps the client to regain sensation and mobility.
times.
Record the amount of intravenous fluid that the client received Contributes to an accurate record of fluid intake.
before discontinuing the infusion on the I&O sheet.
Document the time the infusion was discontinued and the Demonstrates responsibility and accountability for the client’s
condition of the venipuncture site. care.
Evaluation
• Site appears free of inflammation.
• Bleeding is controlled.
• Discomfort is minimized or absent.
• Equipment is disposed in a manner to prevent injury and transmission of infection.
Document
• Date and time
• Condition of venipuncture site
• Volume of infused solution
Date and Time Infusion of Ringer’s lactate discontinued per physician’s order following administration of 1,000 mL. No.
22 gauge angiocatheter removed from left forearm. No redness, swelling, or drainage evident at site of
venipuncture. Venipuncture site covered with a dry sterile dressing. _______________ SIGNATURE/TITLE
LWBK1004-C16_p305-344.indd 340 2/6/12 7:22 PM

SKILL 16-7 Inserting a Medication Lock
ASSESSMENT
Confirm that the physician has written an order to discontinue Demonstrates responsibility and accountability for carrying out
the continuous infusion of IV fluid and insert a medication medical orders.
lock.
Inspect the site for signs of redness, swelling, or drainage. Provides data indicating whether the site can be maintained or a
new venipuncture should be performed.
Observe whether the infusion is instilling at the predetermined rate. Indicates whether the vein and catheter are patent (open).
Determine whether the client understands the purpose and Indicates the need for client teaching.
technique for inserting a medication lock.
PLANNING
Assemble necessary equipment, which includes the medication Promotes organization and efficient time management.
lock, syringe containing 2 mL of sterile normal saline (0.9%
sodium chloride, depending on the agency’s policy), alcohol
swabs, gloves, and supplies for changing or reinforcing the
dressing over the site.
IMPLEMENTATION
(see Chap. 10).
Fill the chamber of the medication lock with saline solution. Displaces air from the empty chamber.
Loosen the tape over the dressing to expose the connection Facilitates removing the tubing from the client.
between the hub of the catheter or needle and the tubing
adapter; also remove the tape that is stabilizing the tubing to
the client’s arm.
Loosen the protective cap from the end of the medication Maintains sterility while preparing for the insertion of the lock.
lock.
Don clean gloves. Provides a barrier from contact with blood.
Tighten the roller clamp on the tubing and stop the infusion Prevents leakage of fluid when the tubing is removed.
pump or controller if one is being used.
Apply pressure over the tip of the catheter or needle Controls or prevents blood loss.
(see Fig. A).
Applying pressure over the catheter tip. (Photo by B. Proud.)
Remove the tip of the tubing from the venipuncture device and Seals the opening in the catheter or needle.
insert the medication lock (see Fig. B).
(continued)
LWBK1004-C16_p305-344.indd 341 2/6/12 7:22 PM

Inserting a Medication Lock (continued)
Inserting the device. (Photo by B. Proud.)
Screw the lock onto the end of the catheter or needle. Stabilizes the connection.
Swab the rubber port on the medication lock with alcohol. Cleanses the port.
Pierce the port with the blunt needleless adapter and gradually instill Clears blood from the venipuncture device and lock before it can
2 mL of saline until the syringe is almost empty (see Fig. C). clot.
Instilling saline solution. (Photo by B. Proud.)
Begin to remove the syringe from the port as the last volume Continues the application of positive pressure (pushing effect)
of solution is instilled; clamp or pinch the tubing, or press rather than negative pressure (pulling effect) during the time
over the venipuncture device before removing a needleless the syringe is removed. Negative pressure pulls blood into the
adapter. catheter or needle tip, which may cause an obstruction.
Retape or secure the dressing. Reduces the possibility that the lock and catheter may be acci-
dentally dislodged.
Plan to flush the lock after each use or at least every 8 hours Ensures continued patency.
with 1 or 2 mL of flush solution depending on agency policy.
Evaluation
• Site appears free of inflammation.
• Patency is maintained.
• Flush solution instills easily.
• Device is stabilized.
Document
• Date and time
• Discontinuation of infusing solution
• Volume of infused IV solution
• Insertion of medication lock
• Volume and type of flush solution
• Assessment findings
Date and Time Infusion of 5% D/W discontinued. 700 mL of IV solution infused. Medication lock inserted into IV
catheter in R. hand and flushed with 2 mL of normal saline. No redness, swelling, or discomfort
at site. ____________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C16_p305-344.indd 342 2/6/12 7:22 PM

SKILL 16-8 Administering a Blood Transfusion
ASSESSMENT
Determine whether a special signed consent is required. Complies with legal responsibilities.
Check the gauge of the current venipuncture device if an IV is Indicates whether another venipuncture must be performed.
infusing.
Review the medical record for results of type and cross-match. Indicates whether blood is available in the blood bank.
Take temperature, pulse, respirations, and blood pressure within Provides a baseline for comparison during the transfusion.
30 minutes of obtaining blood.
PLANNING
Complete major nursing activities before starting the infusion of Avoids disturbing the client once the blood is administered.
saline unless the blood must be given immediately.
Plan to perform a venipuncture or start the infusion of saline just Prevents administering fluid unnecessarily.
before obtaining the blood.
Obtain necessary equipment including a 250-mL container of Complies with the standards of care for administering blood.
normal saline (0.9% NaCl) and a Y-set.
Tighten the roller clamp on one branch of the Y-tubing and the Prepares the tubing for purging with saline.
roller clamp below the filter.
Insert the unclamped branch of the Y-set into the container of Moistens the filter and fills the upper portion of the tubing with
saline; squeeze the drip chamber until it and the filter are half saline.
full.
Release the lower clamp and flush air from the remaining section Reduces the potential for infusing a bolus of air.
of tubing.
IMPLEMENTATION
Perform the venipuncture or connect the Y-set to the present Provides access to the venous circulation and ensures that blood
venipuncture device if it is a 16–20 gauge. will move freely through the catheter or needle.
Begin the infusion of saline. Ensures that the site is patent and that there will be no delay
once the unit of blood is obtained.
Go to the blood bank to pick up the unit of blood, making sure to Prevents mistaken identity when releasing the matched blood.
take a form identifying the client.
Double check the information on the blood bag with the cross- Prevents releasing the wrong unit of blood or blood that is not a
matched information on the lab slip with the blood bank compatible blood group and Rh factor.
personnel.
Check that the blood has not passed the expiration date. Ensures maximum benefit from the transfusion.
Inspect the container of blood and reject the blood if it appears Indicates deteriorated or tainted blood.
dark black or has obvious gas bubbles inside.
Plan to give the blood as soon as it is brought to the unit. Demonstrates an understanding that blood must be totally
infused within 4 hours after being released from the blood
bank.
Rotate the blood, but do not shake or squeeze the container if Avoids damaging intact cells.
the serum has separated from the cells.
At the bedside, check the label on the blood bag with the num- Reduces the potential for administering incompatible blood.
bers on the client’s wristband with a second nurse; sign in the
designated areas on the transfusion record.
Spike the container of blood. Provides a route for administering the blood.
Tighten the roller clamp on the saline branch of the tubing and Fills the tubing and filter with blood.
release the roller clamp on the blood branch.
Regulate the rate of infusion at no more than 50 mL/hr for the Establishes a slow rate of infusion so that the nurse can monitor
first 15 minutes (check the drop factor to determine the rate in for and respond to signs of a transfusion reaction.
gtt/min).
Increase the rate after the first 15 minutes to complete the infu- Increases the rate of administration to infuse the unit within a
sion in 2 to 4 hours if a second assessment of vital signs is safe period.
basically unchanged and no signs of a reaction have occurred.
Assess the client at 15- to 30-minute intervals during the Ensures client safety.
transfusion.
Clamp the tubing from the blood and release the clamp on the Flushes blood cells from the tubing.
saline when the blood has infused.
Take vital signs one more time. Documents the condition of the client at the completion of the
blood administration.
Tighten the roller clamp below the filter when the tubing looks Prevents leaking when the IV is discontinued.
reasonably clear of blood.
(continued)
LWBK1004-C16_p305-344.indd 343 2/6/12 7:22 PM

Administering a Blood Transfusion (continued)
Don gloves. Provides a barrier from contact with blood.
Loosen the tape covering the venipuncture site and remove the Discontinues the infusion or restores previous fluid therapy.
catheter, or remove the blood tubing and reconnect the previ-
ously infusing solution.
Apply a dressing or Band-Aid over the venipuncture site if the IV Prevents infection.
is discontinued.
Dispose of the blood container and tubing according to agency Blood is a biohazard and requires special bagging to ensure that
policy. others will not accidentally come in direct contact with the
blood.
Evaluation
• Entire unit of blood is administered within 4 hours.
• Client demonstrates no evidence of transfusion reaction
• Reactions have been minimized by appropriate interventions.
• Infusion is discontinued or previous orders are resumed.
Document
• Venipuncture procedure, if initiated for the administration of blood
• Preinfusion vital signs
• Names of nurses who checked armband and blood bag container
• Time blood administration began
• Rate of infusion during first 15 minutes and remaining period of
time
• Signs of reaction, if any, and nursing actions
• Periodic vital sign assessments
• Time blood infusion completed
• Volume of blood and saline infused
Date and Time No. 18 gauge over-the-needle catheter inserted into L. forearm and connected to 250 mL of 0.9% saline
infusing at 21 mL/hr. T—98ºF (tympanic), P—90, R—22, BP 116/64 in R. arm while lying flat. One unit of type
O+ whole blood No.684381 obtained from the blood bank and checked by E. Rogers, RN, and D. Baker, RN.
Blood bag and wrist band information found to be compatible. Blood infusing at 50 mL/hr for 15 minutes.
Rate increased to 125 mL/hr during remainder of infusion. Blood transfusion completed at 1,600. No evi-
dence of transfusion reaction. T—98ºF (tympanic), P—86, R—20, BP 122/70 in R. arm at end of transfusion.
Total of 100 mL of saline and 500 mL of blood infused before IV discontinued. ___________ SIGNATURE/TITLE
LWBK1004-C16_p305-344.indd 344 2/6/12 7:22 PM

Photo to
Come
FPO
17# Hygiene
bag bath On completion of this chapter, the reader should be able to:
bed bath
bridge 1. Define hygiene.
caries 2. Name five hygiene practices that most people perform regularly.
cuticles 3. Give two reasons why a partial bath is more appropriate than a
dentures daily bath for older adults.
gingivitis 4. List at least three advantages of towel or bag baths.
hygiene 5. Name two situations in which shaving with a safety razor is
integument contraindicated.
ophthalmologist 6. Name three items recommended for oral hygiene.
optometrist 7. Identify two methods to prevent the chief hazard when
oral hygiene providing oral hygiene to an unconscious client.
partial bath 8. Describe two techniques for preventing damage to dentures
perineal care during cleaning.
periodontal disease 9. Describe two methods for removing hair tangles.
plaque 10. Name two types of clients for whom nail care is provided with
podiatrist extreme caution.
sordes 11. Name four visual and hearing devices.
tartar 12. List two alternatives for clients who cannot insert or care for
towel bath their own contact lenses.
13. Discuss four reasons for sound disturbances experienced by
people who wear hearing aids.
14. Describe an infrared-listening device.
H
ygiene means those practices that help in promoting health through
personal cleanliness. People foster hygiene through activities such
as bathing, performing oral care, cleaning and maintaining finger-
nails and toenails, and shampooing and grooming hair. Hygiene
also includes care and maintenance of devices such as eyeglasses and
hearing aids to ensure continued and proper function. Hygiene practices
and needs differ according to age, inherited characteristics of the skin
and hair, cultural values, and the state of health.
This chapter provides suggestions to nurses for carrying out
hygiene practices when providing client care. Principles that refer to
the client’s environment, such as bed-making skills, are discussed in
Chapter 18.
THE INTEGUMENTARY SYSTEM
The word integument (covering) refers to the collective structures that

cover the surface of the body and its openings. Most hygiene practices
are based on maintaining or restoring a healthy integumentary system,
which includes the skin, mucous membranes, hair, and nails. Because the
345
LWBK1004-C17_p345-373.indd 345 2/6/12 7:23 PM

Sweat pore
Hair
Stratum corneum
Epidermis
Arrector pili muscle
Sebaceous gland
Eccrine sweat gland

Dermis
Hair follicle Nerve
Papilla
Arteriole
Venule
Subcutaneous
tissue
FIGURE 17-1 A cross-section of the skin.
mouth, or oral cavity (which is lined with mucous mem- • Provide sensory information such as pain, temperature,
brane), contains teeth, this chapter also discusses this acces- touch, and pressure
sory structure. • Assist in converting precursors to vitamin D when exposed
to sunlight
Skin
The skin consists of the epidermis, dermis, and subcutane-
ous layer (Fig. 17-1). The epidermis, or outermost layer, Gerontologic Considerations
contains dead skin cells that form a tough protein called
keratin. Keratin protects the layers and structures within ■ Benign skin lesions such as seborrheic keratoses (tan to
the lower portions of the skin. The cells in the epidermis are black raised areas on the trunk) and senile lentigines
shed continuously and replaced by the dermis, or true skin, (brown, flat patches on the face, hands, and forearms) are
which contains most of the secretory glands (Table 17-1). common in older adults.
The subcutaneous layer separates the skin from skeletal
muscles. It contains fat cells, blood vessels, nerves, and the
roots of hair follicles and glands.
Mucous Membranes
Skin structures carry out the following functions:
The mucous membranes are continuous with the skin. They
• Protect inner body structures from injury and infection line body passages such as the digestive, respiratory, urinary,
• Regulate body temperature and reproductive systems. Mucous membranes also line the
• Maintain fluid and chemical balance conjunctiva of the eye. Goblet cells in the mucous membranes
TABLE 17-1 Types of Skin Glands

GLAND LOCATION SECRETION PURPOSE
Sudoriferous Throughout the dermis and subcutaneous Sweat Regulate body temperature
layers, especially in the axilla and groin Excrete body waste
Ceruminous Ear canals Cerumen Perform protective functions; cerumen
has antimicrobial properties
Sebaceous Throughout the dermis Sebum Lubricate skin and hair
Ciliary Eyelids Sweat and sebum Protect lid margin and lubricate
eyelash follicles
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CHAPTER 17 Hygiene 347
secrete mucus, a slimy substance that keeps the membranes texture. Fingernails and toenails provide some protection to
soft and moist. the digits. Normal nails are thin, pink, and smooth. The free
margin ordinarily extends from the end of each finger or toe,
Hair and the skin around the nails is intact. Changes in the shape,
Each hair is a thread of keratin. Hair is formed from the color, texture, thickness, and integrity of the nails provide
cells at the base of a single follicle. Although hair covers evidence of local injury or infection and even systemic dis-
the entire body, its amount, distribution, color, and texture eases (see Chap. 13).
vary considerably according to location and among males
and females, infants and adults, and ethnic groups.
In addition to contributing to a person’s unique appearance, Teeth
hair basically helps prevent heat loss. As heat escapes from the Teeth, the enamel of which is a keratin structure, are present
skin, it gets trapped in the air between the hairs. The contraction beneath the gums at birth. The exposed portion of each tooth
of small arrector pili muscles around hair follicles, commonly is referred to as the crown; the portion within the gum is the
described as goose bumps, further generates body heat. root (Fig. 17-3).
Sebaceous glands in the hair follicles release sebum, an The teeth begin to erupt at about 6 months of age and
oily secretion that adds weight to the shafts of hair, causing continue to do so for 2 or 2½ more years. As the jaw grows,
them to flatten against the skull. Oily hair further attracts the deciduous teeth (baby teeth) are replaced by permanent
dust and debris. teeth. Adults have 28 to 32 permanent teeth, depending on
The texture, elasticity, and porosity of hair are inherited whether the third molars (wisdom teeth) are present.
characteristics influenced by the amount of keratin and sebum Healthy teeth are firmly fixed within the gums. Their
produced. To alter the basic genetically inherited structure, alignment, which is related to jaw structure, generally is a
some people use chemicals to curl, relax, or lubricate their hair. result of heredity. Although the teeth are white originally,
they become discolored from chronic consumption of cof-
Nails fee or tea, tobacco use, or certain drugs such as tetracycline
Fingernails (Fig. 17-2) and toenails also are made of kera- antibiotics taken during childhood.
tin, which in concentrated amounts, gives them their tough The integrity of the teeth largely depends on the per-
son’s oral hygiene practices, diet, and general health. Saliva,
Free edge Nail plate Lunula Cuticle which moistens food and begins the digestive processes,
tends to keep the teeth clean and inhibits bacterial growth.
The accumulation of food debris, especially sugar, and
plaque (a substance composed of mucin and other gritty
substances in saliva) supports the growth of mouth bacteria.
The combination of sugar, plaque, and bacteria may eventu-
ally erode the tooth enamel, causing caries (cavities).
Tartar (hardened plaque) is more difficult to remove
and may lead to gingivitis (inflammation of the gums).
Pockets of gum inflammation promote periodontal dis-
ease, a condition that results in the destruction of the tooth-
supporting structures and bones that make up the jaw.
A External nail structures
Nail bed Lunula

Nail plate Cuticle Nail root
■ Tooth loss is common in older adults as a result of peri-

odontal disease.
HYGIENE PRACTICES
The integument contains many secretory glands that produce

odors and attract debris, and the teeth are prone to decay if
Distal bone Growth region
uncared for. Therefore, hygiene measures are beneficial for
of finger (nail matrix)
maintaining personal cleanliness and healthy integumentary
B Internal and external nail structures structures. Although hygiene practices vary widely, most
FIGURE 17-2 The external and cross-sectional views of a nail. Americans routinely perform bathing, shaving, brushing
A. External nail structures. B. Internal and external nail structures. teeth, shampooing, and caring for nails.
LWBK1004-C17_p345-373.indd 347 2/6/12 7:23 PM

FIGURE 17-3 A cross-section of a tooth.

(From Cohen B. [2010] Medical terminology:
An illustrated guide [4th ed.]. Philadelphia:
Lippincott Williams & Wilkins.)
• Stimulating circulation
Gerontologic Considerations • Providing a refreshed and relaxed feeling
• Improving self-image
■ Poor hygiene and grooming in older adults are often
In addition to bathing for hygiene purposes, other types
signs of visual impairment, functional changes, dementia,
depression, abuse, or neglect.
of bathing serve different functions (Table 17-2). In general,
however, most bathing is done in a tub or shower, at a sink,
or at the bedside.
Bathing
Bathing is a hygiene practice in which a person uses a ➧ Stop, Think, and Respond Box 17-1
cleansing agent such as soap and water to remove sweat, How might a nurse respond to a client who believes
oil, dirt, and microorganisms from the skin. Although restor- that daily bathing is unnecessary or even unhealthy?
ing cleanliness is the primary objective, bathing has several
Tub Bath or Shower
other benefits:
If the safety risks are negligible and there are no contraindi-
• Eliminating body odor cations, the nurse encourages clients to bathe independently
• Reducing the potential for infection in a tub or shower (Skill 17-1). Most hospitals and nursing
TABLE 17-2 Therapeutic Baths

TYPE DESCRIPTION PURPOSE
Sitz bath Immersion of the buttocks and perineum in a small basin of continuously Removes blood, serum, stool, or urine
circulating water Reduces local swelling
Relieves discomfort
Sponge bath Applications of tepid water to the skin Reduces a fever
Medicated bath Soaking or immersing in a mixture of water and another substance, such Relieves itching or a rash
as baking soda (sodium bicarbonate), oatmeal, or cornstarch
Whirlpool bath Warm water that is continuously agitated within a tub or tank Improves circulation
Increases joint mobility
Relieves discomfort
Removes dead tissue
LWBK1004-C17_p345-373.indd 348 2/6/12 7:23 PM

homes equip bathing facilities with various rails and handles

to promote client safety.
What suggestions can you make to promote the
dignity of clients who need nursing assistance with
Gerontologic Considerations perineal care?
■ To reduce the risk of falls in older adults when bathing, Bed Bath
nonskid strips on the floor of tubs and showers are helpful. Clients who cannot take a tub bath or cannot shower inde-
Grab bars should be placed at arm level and within reach of pendently may be given any one of three types of baths: a bed
the dominant hand. bath, a towel bath, or a bag bath. During a bed bath (washing
■ A tub or shower seat is an important safety measure for
with a basin of water at the bedside), the client may actively
adults who have mobility limitations or difficulty maintain-
assist with some aspects of bathing. Skill 17-3 explains how
ing balance.
■ Diminished ability to sense temperature changes may
to give a bed bath (also see Nursing Guidelines 17-1).
occur with aging. The temperature of bath water should be
checked with the wrist before immersing older adults.
■ Long-handled bath sponges or hand held shower attach- Gerontologic Considerations
ments help older adults with limited range of motion
maintain independence. ■ Bath oils can be added to a water basin when adminis-
■ Older adults should use soap sparingly because it is tering a bed bath to an older adult. Oils are not used in
extremely drying to the skin. A mild, superfatted, nonper- showers or bathtubs, however, because they increase the
fumed soap such as Castile, Dove, Tone, or Basis may be risk of falls.
preferable. ■ It is best to avoid the use of skin care products contain-
■ Because older adults have thin skin, decreased skin elas- ing alcohol or perfumes when caring for older adults
ticity, and increased fragility of blood vessels in the dermis, because they tend to aggravate dry skin conditions, cause
gentle patting motions rather than harsh rubbing motions allergic reactions, and over time, lotions may be a medium
should be used when drying the skin. for bacterial growth.
■ One should thoroughly inspect the feet of older adults ■ Increasing oral fluid intake or adding humidity to the air
for ulcerations or other lesions of which they are unaware. reduces the discomfort of dry skin experienced by older
adults.
Partial Bath
A daily bath or shower is not always necessary—in fact, Some agencies use two variations of the traditional bed
for older adults, who perspire less than younger adults and bath—the towel bath and the bag bath—because they save
are prone to dry skin, frequent washing with soap further time and expense. Box 17-1 lists their advantages.
depletes oil from the skin. Therefore, partial or less frequent
bathing sometimes is appropriate. A partial bath means Towel Bath
washing only those body areas that are subject to greatest With a towel bath, the nurse uses a single large towel to cover
soiling or that are sources of body odor: generally, the face, and wash a client. It requires a towel or bath sheet measuring
hands, axillae, and perineal area. Partial bathing is done at a 3 ⫻ 7.5 ft but no basin or soap. The nurse prefolds and mois-
sink or with a basin at the bedside. tens the towel or bath sheet with approximately one-half gal-
Sometimes the perineum, the area around the genitals lon (2 L) of water heated to 105° to 110°F (40° to 43°C) and
and rectum, requires special or frequent cleansing in addi- 1 oz (30 mL) of no-rinse liquid cleanser. He or she unfolds
tion to bathing. Perineal care (peri-care; techniques used to the towel so that it covers the client and uses a separate sec-
cleanse the perineum) is especially important after a vaginal tion to wipe each part of the body, beginning at the feet and
delivery or gynecologic or rectal surgery so that the impaired moving upward. The nurse folds the soiled areas of the towel
skin remains as clean as possible. It is also appropriate when- to the inside as he or she bathes each area and allows the
ever male or female clients have bloody drainage, urine, or skin to air-dry for 2 to 3 seconds. After washing the front
stool collected in this area. side of the body, the nurse positions the client on the side
When providing perineal care, nurses must: and repeats the procedure. He or she unfolds the towel so
• Prevent direct contact between themselves and any secre- that the clean surface covers the client. The nurse bathes the
tions or excretions; this is generally accomplished by wear- client’s back, and then the buttocks. When the towel bath is
ing clean gloves (see Standard Precautions in Chap. 22). complete, the nurse changes the bed linens.
• Cleanse so that secretions and excretions are removed
Bag Bath
from less soiled to more soiled areas.
A bag bath involves the use of a commercially packaged
These principles help prevent the transfer of infectious kit with 8 to 10 premoistened, disposable cloths in a plas-
microorganisms to the nurse and to uncontaminated areas on tic bag or container and is another form of a bed bath. The
or within the client (Skill 17-2). cloths contain a no-rinse surfactant (a substance that reduces
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N U R S I N G G U I D E L I N E S 1 7-1
Rationales
Bathing Clients
• Ask the client if he or she uses special soap, lotion, or other • Wash one part of the body at a time. Exposing only one part
hygiene products. Determining the client’s preferences indi- prevents chilling.
vidualizes care. • Place a towel under the part of the body being washed. A towel
• Wear gloves if there is any potential for direct contact with absorbs moisture.
blood, drainage, or other body fluid. Gloves reduce the poten- • Use firm but gentle strokes. Gentle strokes avoid friction that
tial for acquiring an infection. can damage the skin.
• Keep the client covered during the bath. Covering the client • Wash and dry well between folds of skin. Effective washing
demonstrates respect for modesty. removes debris and microorganisms from areas where they are
• Wash cleaner areas of the body first and dirtier areas last. This apt to breed.
reduces the spread of microorganisms. • Keep the washcloth wet, but not so wet that it drips. This dem-
• Encourage the client to participate at whatever level is appro- onstrates concern for the client’s comfort.
priate. Participation promotes independence and self-esteem. • Wash more soiled areas, such as the anus, last. Doing so pre-
• Monitor the client’s tolerance of activity. If activity becomes vents transferring microorganisms to cleaner areas of the body.
too strenuous, it should be discontinued and resumed later. • Remove all soap residues. This prevents drying of the skin and
• Inspect the body during washing for skin disorders (see possible itching.
Table 17-3). Bathing provides an excellent opportunity for • Dry the skin after it has been rinsed. Drying the skin prevents
physical assessment. chilling.
• Communicate with the client and use the occasion to do infor- • Replace the water as it cools. Using warm water shows con-
mal health teaching. Talking demonstrates respect for the client cern for the client’s comfort.
as a person rather than an object being washed; teaching • Apply an emollient lotion to the skin after bathing. A lotion
promotes health. restores lubrication to the skin.
surface tension between the skin and surface contaminants) man with frequent seizures; (3) a 65-year-old man
and an emollient/humectant (a substance that attracts and who becomes short of breath with exertion; and
traps moisture in the skin), but no soap. The nurse warms (4) a 72-year-old woman recovering from pneumonia?
the container and its contents in a microwave or warming Explain the reasons for your answers.
unit or sets them in a container of warm water before use.
At the bedside, the nurse uses a separate cloth to wash each
part of the client’s body. Rinsing is not required. Air-drying
Shaving
Shaving removes unwanted body hair. In the United States,
circumvents the need for a towel.
most men shave their face daily, and most women shave their
➧ Stop, Think, and Respond Box 17-3 axillae and legs regularly. The nurse respects personal or cul-
tural differences and asks each client about his or her prefer-
Which method of bathing (shower, tub bath, bed/
towel/bag bath) is appropriate for (1) a 75-year-old ences before assuming otherwise.
woman with arthritis of the hips; (2) a 60-year-old Shaving is accomplished with an electric or a safety
razor. In some circumstances, use of a safety razor is con-
traindicated (Box 17-2), and an electric or battery-operated
B OX 1 7- 1 Advantages of Towel or Bag Baths
• Reduce the potential for skin impairment because the nonrin-
B OX 1 7- 2 Contraindications to Using a
sable cleanser lubricates rather than dries the skin
Safety Razor
• Prevent the transmission of microorganisms that may be
growing in wash basins Use of a safety razor is contraindicated for clients:
• Reduce the spread of microorganisms from one part of the • Receiving anticoagulants (drugs that interfere with
body to another because separate cloths or regions of the clotting)
towel are used • Receiving thrombolytic agents (drugs that dissolve blood
• Preserve the integrity of the skin because friction is not used clots)
while drying the skin • Taking high doses of aspirin
• Promote self-care among clients who may lack the strength • With blood disorders such as hemophilia
or dexterity to wet, wring, and lather a washcloth • With liver disease who have impaired clotting
• Save time compared to conventional bathing • With rashes or elevated or inflamed skin lesions on or near
• Promote comfort because the moist towel or cloths are used the face
so quickly, and they are warmer when applied • Who are suicidal
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TABLE 17-3 Examples of Integumentary Disorders

CONDITION DESCRIPTION CLIENT TEACHING
Acne Inflammation of sebaceous glands and hair fol- Keep the face clean
licles on the face, upper chest, and back Refrain from touching or squeezing lesions
Avoid the use of oily cosmetics
Contact dermatitis Allergic sensitivity evidenced by red skin rash Avoid scratching or wearing clothing made of irritating
and itching fibers, such as wool
Use tepid water and hypoallergenic or glycerin soap
when bathing
Pat the skin dry; do not rub
Furuncle (boil) Raised pustule, usually in the neck, axillary, or Keep hands away from the infected lesion
groin area that feels hard and painful Use separate face cloth and towels from the rest of the
family; launder personal bath items in hot water and
bleach
Wash hands thoroughly before and after applying medica-
tion to the skin
Psoriasis Noninfectious chronic skin disorder that appears Follow medical regimen, which may be lifelong
as elevated silvery scales that shed over Be wary of advertised remedies that promise a cure or
elbows, knees, trunk, and scalp; acute epi- quick relief, because they rarely do
sodes occur between periods of relief
Pediculosis (lice Brown crawling insects that move over the scalp Inspect the skin carefully as adult lice move quickly from
infestation) and skin and deposit yellowish-white eggs light
on hair shafts including pubic area; skin bite Look for eggs (nits) on hairs ¼ in. to ½ in. from the scalp
causes itching or skin surface
Do not share clothing, combs, and brushes; lice are
spread by direct contact
Use a pediculicide (chemical that kills lice), in addition to
a lice comb and manual removal
Do not use hair conditioner: it coats the hair and protects
the nits
Scabies Infestation with an itch mite that burrows within Bathe thoroughly in the morning and at night
the webs and sides of fingers, around arms, Apply prescribed medication after bathing
axilla, waist, breast, lower buttocks, and Don clean clothes after bathing
genitalia Avoid skin-to-skin contact with uninfected people
Tinea capitis, pedis, Fungal infection in the scalp, feet, body, or groin Use separate bathing and grooming articles
corporis, and cruris that appears as a ring or cluster of papules Keep body areas dry, especially in folds of skin
or vesicles that cause itching, become scaly, Wear clothing that promotes evaporation of perspiration
cracked, and sore
Skin cancer Newly pigmented growth or change in existing See a physician for examination and possible biopsy
skin lesion, especially where skin is chronically Avoid direct sun exposure between 10 AM and 4 PM
exposed to sun Recommend using a sunscreen with an SPF ≥15
Wear a wide-brimmed hat on sunny days
Do not use artificial tanning facilities
Fungal nail infection Thick, yellowed, rough-appearing toenails or Consult a physician about prescription drugs, which are
fingernails that can spread from one nail to approximately 50% effective
others Wear leather shoes, and alternate pairs to reduce damp
shoe conditions
Be aware that unsanitary utensils used in the application
of artificial fingernails can spread the fungus
Seek professional nail care from a podiatrist
Candidiasis Yeast infection of the mouth or vagina; oral Follow directions for oral or topical antifungal medications
candidiasis appears as white patches or red Swish antifungal mouth rinses, retain the solution in the
spots on the tongue, gums, or throat; vaginal mouth as long as possible, and then swallow the rinse
candidiasis appears as a thick, cottage cheese- Avoid simple sugars and alcohol because they promote
like discharge that causes itching and burning the growth of yeast
Eat yogurt that contains live Lactobacillus acidophilus to
restore a balance of helpful to harmful microbes
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N U R S I N G G U I D E L I N E S 1 7- 2
Rationales
Shaving Clients
• Prepare a basin of warm water, soap, a face cloth, and a towel. • Use short strokes. They provide more control of the razor.
These supplies are necessary for wetting, rinsing, and lather- • Rinse the razor after each stroke or as hair accumulates. Rins-
ing the face (or other area that requires shaving). ing keeps the cutting edge of the razor clean.
• Wash the skin with warm, soapy water. Washing removes oil, • Rinse the remaining soap or shaving cream from the skin.
which helps raise hair shafts. Rinsing reduces the potential for drying the skin.
• Lather the skin with soap or shaving cream. Use of soap or • Apply direct pressure to areas that bleed, or apply alum sulfate
shaving cream reduces surface tension as the razor is pulled (styptic pencil) at the site of bleeding. Pressure or alum helps
across the skin. to promote clotting.
• Start at the upper areas of the face (or other area that requires • Apply aftershave lotion, cologne, or cream to the shaved
shaving) and work down (see Fig. 17-4). This progression area if the client desires it. The alcohol in lotion and cologne
provides more control of the razor. reduces and retards microbial growth in the tiny abrasions
• Pull the skin taut below the area to be shaved. This evens the caused by the razor; cream restores oil to the skin.
level of the skin.
• Pull the razor in the direction of hair growth. Shaving with the
hair reduces the potential for irritation.
razor is used. When the client cannot shave, the nurse assumes Tooth Brushing and Flossing
responsibility for this hygiene practice (see Nursing Guide- Clients who are alert and physically capable generally attend
lines 17-2 and Fig. 17-4). to their own oral hygiene. For clients confined to a bed,
the nurse assembles the necessary items—a toothbrush,
toothpaste, a glass of water, an emesis basin, and floss.
Pharmacologic Considerations Most dentists recommend using a soft-bristled or elec-
tric toothbrush and toothpaste twice a day. For the advan-
■ Anticoagulants—even daily low-dose aspirin therapy— tages of electric toothbrushes, see Box 17-3. Flossing
increase the potential for bleeding. An electric shaver may removes plaque and food debris from the surfaces of teeth
be substituted for a safety razor.
that a manual or electric toothbrush may miss. The choice of
unwaxed or waxed floss is personal. Waxed floss is thicker
and more difficult to insert between teeth; unwaxed floss
Oral Hygiene frays more quickly.
Oral hygiene consists of those practices used to clean the Although conscientious oral hygiene does not prevent
mouth, especially brushing and flossing the teeth. Dentures dental problems completely, it reduces the incidence of tooth
and bridges also require special cleaning and care. and gum disease. Therefore, clients need to learn how to
maintain the structure and integrity of their natural teeth (see
Client and Family Teaching 17-1 and Fig. 17-5).
B OX 1 7- 3 Advantages of Electric Toothbrushes

• Last longer than manual toothbrushes
• Promote a full 2 min of toothbrushing with a built-in timer
• Remove 30% more plaque than manual toothbrushing
• Have a higher reduction of gingivitis compared with manual
toothbrushing
• Decrease gingival trauma and gum recession because of less
force used in brushing
• Facilitate self-care among clients with disabilities or reduced
manual dexterity
Electric vs. manual toothbrushes. (2008). http://tips4dentalcare.

com/2008/07/29/electric-vs-manual-toothbrushes. Accessed March 9,
FIGURE 17-4 Shaving a client’s face. 2010.
LWBK1004-C17_p345-373.indd 352 2/6/12 7:23 PM


Reducing Dental Disease and Injuries
The nurse teaches the client or family as follows:
● Brush and floss the teeth as soon as possible after each
meal, using the following techniques:
● Moisten the toothbrush and apply toothpaste.
● Hold a manual toothbrush at a 45-degree angle to the
teeth.
● Brush the front and back of all teeth from gum line
toward crown, using circular motions (see Fig. 17-5). A
● Brush back and forth over the chewing surfaces of the
molars.
● Rinse the mouth periodically to flush loosened debris.
● Wrap an 18-inch length of floss around the middle fingers
of each hand.
● Slide the floss between two teeth until it is next to the
gum.
● Move the floss back and forth.
● Repeat flossing with new sections of the floss until all
the teeth have been flossed including the outer surface
B
of the last molar.
● Use a tartar-control toothpaste or rinse containing
fluoride.
● If brushing is impossible, rinse the mouth with water
after eating.
● Use a battery-operated oral irrigating device, which uses
pulsating jets of water to flush debris from teeth, bridges,
or braces.
● Eat fewer sweets such as soft drinks containing sugar,
candy, gum that contains fructose or another form of
sugar, pastries, and sweet desserts.
● Eat more raw fruits and vegetables that naturally remove
C
plaque and other food as they are chewed.
● Eat two or three servings of dairy products per day to
provide calcium.
● If antacids are used, select ones with calcium.
● Use frozen orange juice concentrate fortified with
calcium.
● Do not use the teeth to open packages or containers.
● Use scissors rather than the teeth to cut thread.
● Do not chew ice cubes or crushed ice.
● Avoid chewing unpopped or partially popped kernels of
popcorn.
● Have dental checkups at least every 6 months.
D
FIGURE 17-5 A. Brushing toward the crown of the teeth.
B. Rinsing the mouth. C. Using floss. About 1¼ in. of approximately
18 in. of wrapped floss is used at any one time. D. Inserting floss
Oral Care for Unconscious Clients between the teeth.
Oral hygiene cannot be neglected because the client is uncon-
scious. In fact, because unconscious clients are not salivat-
ing in response to seeing, smelling, and eating food, they saliva and liquid oral hygiene products into their lungs.
need oral care even more frequently than conscious clients. Aspirated liquids predispose clients to pneumonia. There-
Sordes (dried crusts containing mucus, microorganisms, fore, the nurse uses special precautions to avoid getting fluid
and epithelial cells shed from the mucous membrane) are in the client’s airway.
common on the lips and teeth of unconscious clients. In addition to toothbrushing, the nurse moistens and
Toothbrushing is the preferred technique for providing refreshes the client’s mouth with oral swabs. He or she uses
oral hygiene to unconscious clients (Skill 17-4). Clients who various substances for oral hygiene depending on the circum-
are not alert, however, are at risk for aspirating (inhaling) stances and assessment findings for each client (Table 17-4).
LWBK1004-C17_p345-373.indd 353 2/6/12 7:23 PM

TABLE 17-4 Optional Substances for Oral Care out for long periods permits the gum lines to change, affect-
SUBSTANCE USE
ing the fit. If a nurse removes a client’s bridge or dentures
during the night, he or she stores them in a covered cup.
Antiseptic mouthwash Reduces bacterial growth in the
Plain water is used most often to cover dentures when they
diluted with water mouth and freshens breath
Equal parts of baking soda Removes accumulated
are not in the mouth, but some add mouthwash or denture
and table salt in warm secretions cleanser to the water.
water, or baking soda
mixed with normal saline ➧ Stop, Think, and Respond Box 17-4
One part of hydrogen Releases oxygen and loos- Compare independent oral hygiene performed by a
peroxide to 10 parts of ens dry, sticky particles;
client and that administered by a nurse. How are they
water prolonged use may damage
tooth enamel
similar; how are they different?
Milk of magnesia Reduces oral acidity; dissolves
plaque, increases flow of
saliva, and soothes oral Hair Care
lesions Sometimes, clients need assistance with grooming or sham-
Lemon and glycerin swabs Increases salivation and pooing their hair.
refreshes the mouth;
glycerin may absorb water
from the lips and cause them Hair Grooming
to become dry and cracked The following are recommendations for grooming a client’s
if used for more than several hair:
days
Petroleum jelly Lubricates lips • Try to use a hairstyle the client prefers.
• Brush the hair slowly and carefully to avoid damaging the
hair.
• Brush the hair to increase circulation and distribution of
Denture Care sebum.
Dentures (artificial teeth) substitute for a person’s lower or • Use a wide-toothed comb, starting at the ends of the hair
upper set of teeth, or both. A bridge—a dental appliance that rather than from the crown downward if the hair is matted
replaces one or several teeth—is fixed permanently to other or tangled.
natural teeth so that it cannot be removed, or it is fastened • Apply a conditioner or alcohol to loosen tangles.
with a clasp that allows it to be detached from the mouth. • Use oil on the hair if it is dry. Many preparations are available,
For clients who cannot remove their own dentures, the but pure castor oil, olive oil, and mineral oil are satisfactory.
nurse dons gloves and uses a dry gauze square or clean face • Braid the hair to help prevent tangles.
cloth to grasp and free the denture from the mouth (Fig. 17-6). • If hair loss occurs from cancer therapy or some other dis-
He or she cleans dentures and removable bridges with a ease or medical treatment, provide the client with a turban
toothbrush, denture cleanser or toothpaste, and cold or tepid or baseball cap.
water. The nurse takes care to hold dentures over a plastic • Avoid using hairpins or clips that may injure the scalp.
basin or towel so that they will not break if dropped. • Obtain the client’s or family’s permission before cutting
Dentists recommend that dentures and bridges remain in the hair if it is hopelessly tangled and cutting seems to be
place except during cleaning. Keeping dentures and bridges the only solution to provide adequate grooming.
A B
FIGURE 17-6 A. Removing an upper denture. B. Cleaning dentures.
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Shampooing to infection, the nurse immediately reports any abnormal

Hair should be washed as often as necessary to keep it clean. assessment findings. To avoid injuring the feet, clients should
A weekly shampoo is sufficient for most people, but sham- wear sturdy slippers or clean socks and supportive shoes.
pooing more or less often will not damage the hair.
Long-term health care facilities often employ beauti-
cians and barbers, but if professional services are unavail- Gerontologic Considerations
able, the nurse or delegated nursing staff member sham-
poos the client’s hair (Skill 17-5). Dry shampoos, which are ■ Older adults should be encouraged to purchase sturdy
applied to the hair as a powder, aerosol spray, or foam, are shoes and to replace or repair them as they become worn
to prevent skin and nail impairment in the lower extremities.
available for occasional use. The nurse applies the cleaning
agent to the hair, massages it thoroughly to distribute, and
brushes or towels it from the hair afterward. VISUAL AND HEARING DEVICES
Nail Care
Nail care involves keeping the fingernails and toenails clean Eyeglasses and hearing aids improve communication and
and trimmed. Clients who have diabetes, impaired circu- socialization. Both represent a considerable financial invest-
lation, or thick nails are at risk for vascular complications ment. If they become damaged or broken, the temporary loss
secondary to trauma. The services of a podiatrist (a person deprives clients of full sensory perception. Therefore, they
with special training in caring for feet) are often indicated. should be well maintained and safely stored when not in use.
It is best to check with the client’s physician before cutting Although eyeglasses and hearing aids are not body
fingernails or toenails. structures, they are worn in close contact with the body for
If there are no contraindications, the nurse cares for the long periods. Consequently, they tend to collect secretions,
client’s nails as follows: dirt, and debris that may interfere with their function and
use. Therefore, the nurse cares for these devices at the same
• Soak the hands or feet in warm water to soften the keratin time that he or she provides other hygiene measures.
and loosen trapped debris. (Fig. 17-7).
• Clean under the nails with a wooden orange stick or other Eyeglasses
sturdy but blunt instrument. Prescription lenses are made of glass or plastic. Plastic
• Push cuticles (thin edge of skin at the base of the nail) lenses weigh much less but are more easily scratched. Glass
downward with a soft towel. lenses are more likely to break if dropped. When not in use,
• Use a handheld electric rotary file made by Dremel or eyeglasses are stored in a soft case or rested on the frame.
some other company or an emery board to reduce the The nurse cleans glass and plastic lenses as follows:
length of long fingernails or toenails.
• Hold the eyeglasses by the nose or ear braces.
• Avoid sharp or jagged points that may injure the adjacent
• Run tepid water over both sides of the lenses (hot water
skin.
damages plastic lenses).
To keep the skin and nails soft and supple, the nurse • Wash the lenses with soap or detergent.
applies lotion or an emollient cream after bathing and nail • Rinse with running tap water.
care. If foot perspiration is a problem, he or she uses a pre- • Dry with a clean, soft cloth such as a handkerchief. Do not
scribed antifungal, deodorant powder. Because impaired skin, use paper tissues because some contain wood fibers, and
especially on the feet, is often slow to heal and is susceptible pulp can scratch the lenses.
Some prefer to use a commercial glass cleaner, but this
is not necessary.
Contact Lenses
A contact lens is a small plastic disk placed directly on the
cornea. Clients usually wear contact lenses in both eyes, but
some clients who have had cataract surgery on one eye wear
a single contact lens or a single contact lens and eyeglasses.
The nurse should not assume that someone who wears eye-
glasses does not use a contact lens, and vice versa.
Several types of contact lenses are available: hard,
soft, or gas permeable (Fig. 17-8). All contact lenses, even
disposable types, need removal for cleaning, eye rest, and
disinfection. People who are not conscientious about follow-
ing a routine for contact lens care risk infection, eye abra-
FIGURE 17-7 Soaking a hand before proceeding with nail care. sion, and permanent damage to the cornea.
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A B FIGURE 17-8 The location and size of hard

and soft contact lenses. A. Side view.
B. Front view.
When caring for a client who wears contact lenses, the When repositioning the lens, he or she compresses the lid
nurse asks the client to remove and insert the lenses and to margins together toward the lens. Compression bends the
care for them according to his or her established routine. pliable lens, allowing air to enter beneath it. The air releases
For clients who cannot do so, the nurse may assist with the the lens from the surface of the eye. The nurse then gently
removal of the lenses or should consult the client’s oph- grasps the loosened lens between thumb and forefinger for
thalmologist (a medical doctor who treats eye disorders) removal. Soft lenses dry and crystallize if exposed to air, so
or optometrist (a person who prescribes corrective lenses) the nurse immediately places them in a soaking solution in
about alternatives to promote adequate vision and safety. the storage container (Fig. 17-10).
Some people, when ill, resume wearing eyeglasses tempo- To remove a hard contact lens, the blink method is
rarily, use a magnifying glass, or do without any visual aid. the most common technique. The nurse positions and
Contact Lens Removal

Before removing contact lenses, the nurse obtains an appro-
priate storage container. Commercial containers are avail-
able. Because the lens prescriptions may differ for each eye,
the nurse labels the container “left” and “right.” The nurse
elevates the client’s head and places a towel over the chest to
prevent loss or damage to the contact lenses. The technique
for removing soft contact lenses is different than for hard
contact lenses.
To remove a soft contact lens, the nurse moves the lens
from the cornea to the sclera by sliding it into position with
a clean, gloved finger as the client looks upward (Fig. 17-9).
B
FIGURE 17-10 Contact lenses are stored in a solution-filled
FIGURE 17-9 The nurse removes a soft contact lens from the container labeled R and L for right versus left lens, respec-
client’s eye. tively.
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Artificial Eyes
An artificial eye is a plastic shell that acts as a cosmetic
replacement for the natural eye. There is no way to restore
vision once the natural eye is removed. The artificial eye
and the socket into which it is placed need occasional clean-
ing. If the client cannot care for the artificial eye, the nurse
removes it by depressing the lower eyelid until the lid mar-
gin is wide enough to allow the artificial eye to slide free.
The nurse irrigates the eye socket with water or saline before
FIGURE 17-11 Moving the eyelids toward one another loosens
reinserting the artificial eye.
the hard contact lens from the cornea surface when the client
blinks.
Hearing Aids
There are four types of hearing aids:
• In-the-ear devices are small, self-contained aids that fit in
prepares the client similarly as for removing soft con- the outer ear.
tact lenses, leaving the lens in place on the cornea. He • Canal aids fit deep within the ear canal and are largely
or she places the thumb and a finger on the center of the concealed. Because of their small size, they may be diffi-
upper and lower lids (Fig. 17-11). The nurse applies slight cult to remove and adjust.
opposing pressure to the lids while instructing the client • Behind-the-ear devices consist of a microphone and an
to blink, which separates the hard lens from the cornea. amplifier worn behind the ear that delivers sound to an
If the blink method is unsuccessful, the nurse places an internal receiver.
ophthalmic suction cup on the lens and, with gentle suc- • Body-aid devices use electrical components enclosed in
tion, lifts the lens from the eye. After removal, the nurse a case carried somewhere on the body to deliver sound
soaks the lenses in the storage container. through a wire connected to an ear mold receiver (Fig. 17-12).
FIGURE 17-12 Examples of hearing aids: in-the-ear (A), behind-

the-ear (B), and one whose volume, pitch, and noise reduction
C
can be controlled by a handheld remote control (C).
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In-the-ear and behind-the-ear models are most com- Client and Family Teaching 17-2
mon. Hearing aids for the right ear will be marked with an Maintaining a Hearing Aid
R or will have a red dot; hearing aids for the left ear will be
marked with an L or will have a blue dot. The nurse teaches the client and family as follows:
Behind-the-ear models can be attached to an eyeglass ● Keep a supply of extra batteries on hand.
frame. Use of body aids is most common for those with severe ● Avoid exposing the electrical components to extreme
hearing loss or those who cannot care for a small device. heat, water, cleaning chemicals, or hair spray.
Hearing aids are powered by small mercury or zinc batteries ● Wipe the outer surface of a body aid or behind-the-ear
that need to be replaced after 100 to 200 hours of use. case occasionally.
● Clean cerumen that has become embedded in the
Most clients insert and remove their own hearing aids,
earpiece with a special instrument that comes with the
but the nurse may need to assess and troubleshoot problems
hearing aid. If this is not available, use a thin needle as a
that develop (Table 17-5). Clients and their families need to substitute (Ellis & Bentz, 2007).
know how to maintain the hearing aid (Client and Family ● Turn the hearing aid off when not in use to prolong the
Teaching 17-2). life of the battery.
● Check the battery before inserting a hearing aid by slowly
turning the volume to high, placing a hand over the
Gerontologic Considerations hearing aid, and listening for feedback (Lippincott’s Visual
Encyclopedia of Clinical Skills, 2009).
■ Older adults are more susceptible to impacted cerumen ● Store the hearing aid in a safe place where it will not fall
(ear wax)—a common cause of hearing loss. Over-the- or become lost.
counter eardrops such as Debrox are used to prevent and
treat this condition. Irrigation of the ear with body-
temperature tap water followed by instillation of a drying
agent such as 70% alcohol may be necessary to remove
impacted cerumen.
TABLE 17-5 Troubleshooting Hearing Aid Problems

PROBLEM POSSIBLE CAUSES ACTION
Reduced or absent sound Weak or dead battery Test and replace battery
Incorrect battery position Match the positive pole of the battery to the positive
symbol in the case
Cracked tubing leading to the receiver Repair tubing
Broken wire between body aid and receiver Repair wire
Accumulation of cerumen in the ear Clean the ear
Cerumen plugging the receiver Remove cerumen with an instrument called a wax
loop, or by using the tip of a pin, or the needle on
a syringe
Ear congestion from an upper respiratory Consult the physician about administering a decon-
infection gestant
Damaged electrical components Have the device inspected by a person who services
hearing aids
Shrill noise, called feedback, Malposition or failure to insert the receiver Remove and reinsert
caused by conditions that fully in the ear
return sound to the micro- Kinked receiver tubing Remove and untwist
phone Excessive volume Reduce volume control
Hearing aid left on while removed from the Turn hearing aid off or replace it in the ear
ear
Garbled sound Poor battery contact Check battery for correct size; make sure the battery
compartment is closed; clean metal contact points
with an emery board
Dirty components Clean with a soft cloth
Debris in the on/off switch Move the switch back and forth several times
Corroded battery Remove and replace
Cracked case Repair or replace
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Infrared Listening Devices brightly lit because infrared light jams the signal, causing
Infrared listening devices (IRLDs) resemble earphones audio interference.
attached to a handheld receiver. They are an alternative
to conventional hearing aids. An IRLD converts sound NURSING IMPLICATIONS
into infrared light and sends it through a wall- or ceil-
ing-mounted receiver to the person wearing the listening Clients who require assistance with personal hygiene may
device. The light is converted back into an auditory stimu- have a variety of nursing diagnoses:
lus. People who need help hearing lectures, television, or
• Bathing Self-Care Deficit
live performances may use an IRLD. Some geriatric cent-
• Dressing Self-Care Deficit
ers are installing IRLDs in rooms used for social and rec-
• Activity Intolerance
reational activities.
One advantage of an IRLD over a conventional hear-
ing aid is that an IRLD reduces background noise, which is Nursing Care Plan 17-1 is for a client with a nurs-
a common reason people give for not wearing their hearing ing diagnosis of Bathing Self-Care Deficit, defined in the
aids. A disadvantage is that IRLDs cannot be used outdoors, NANDA-I taxonomy (2012, p. 250) as “impaired ability to
in rooms that contain many windows, or in rooms that are perform or complete bathing activities for self.”
N U R S I N G C A R E P L A N 1 7 - 1 Bathing Self-Care Deficit

Assessment • Assess client’s level of endurance to accomplish hygiene
• Observe client’s motor skills, strength, and coordination to deter- activities such as changes in respiratory and heart rate,
mine the extent to which he or she can perform hygiene skills. increased blood pressure, pain, or fatigue when performing
• Determine if the client’s mental status is sufficient to follow direc- self-care.
tions, complete tasks required for hygiene, and ensure safety.
Nursing Diagnosis. Bathing Self-Care Deficit related to an inability to use hands secondary to bilateral arm fractures sustained
from a fall as manifested by inability to use two hands for self-care due to short arm cast on dominant arm and traction with suspen-
sion applied to nondominant arm.
Expected Outcome. The client will receive assistance with bathing and oral hygiene on a daily and prn (as needed) basis.
Administer a daily bed bath at a convenient time for the client. Scheduling hygiene according to the client’s preference and
avoiding conflicts with other components of care and treat-
ment meets the client’s individualized needs and avoids
unnecessary interruptions.
Use castile soap that the client prefers, soft-bristled tooth- Demonstrates organization and respect for the client’s per-
brush, and fluoride toothpaste. sonal choices.
Let the client use the arm in the cast to dry areas of the skin Facilitates participation in care and maintains self-esteem.
that can be reached after the nurse has washed them.
Turn the client toward the arm in traction when bathing the Avoids disturbing the alignment of the arm in traction.
client’s back and buttocks.
Apply the client’s deodorant and body lotion located in the Demonstrates respect for the client’s choices in hygiene
bedside cabinet after bathing is completed. products; ensures a feeling of well-being and confidence in
social interactions.
Assist the client to don a hospital gown that has sleeves that Facilitates covering the arm suspended in traction.
fasten with snaps.
Help the client to perform oral hygiene by wrapping and tap- Promotes self-care with modifications for using the tooth-
ing a washcloth around the handle of the toothbrush. brush.

• The client’s hygiene needs for bathing and oral care are com- • The client states, “I feel so much better about seeing my doctor
pleted. and visitors after I’ve gotten cleaned up in the morning.”
• The client assists with hygiene needs to the extent possible.
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CRITICAL THINKING EXERCISES 2. When examining the skin of a client with psoriasis,
the nurse is most likely to observe:
1. You have been assigned to two clients: a 75-year- 1. Weeping skin lesions on the trunk of the body
old woman who is unconscious after a stroke and a 2. Red skin patches covered with silvery scales
38-year-old male mechanic being treated for an ulcer. 3. Fluid-filled blisters surrounded by crusts
How do their hygiene needs differ? 4. A red rash containing pus-filled lesions
2. You are responsible for inspecting long-term care 3. When a client develops pruritus (itching skin), which
facilities such as nursing homes. What criteria should nursing measure is best for relieving the client’s
health care agencies meet in relation to bathing discomfort?
facilities and hygiene policies to receive a positive 1. Use a medicated bath with oatmeal or cornstarch.
evaluation? 2. Apply extra wool blankets to the bed for warmth.
3. Explain why attending to shaving, oral hygiene, and 3. Give frequent showers or tub baths.
nail care are important to families of those being 4. Rub the skin dry after bathing.
cared for in a long-term care facility. 4. A client experiences a shrill noise, known as feed-
4. What strategies might a nurse use for meeting the back, from a hearing aid. What are some possible
hygiene needs of a client who refuses to bathe and causes for the nurse to check? Select all that apply.
perform oral care? 1. Incorrect battery position
2. Malposition within the ear
3. Accumulation of cerumen
NCLEX-STYLE REVIEW QUESTIONS 4. Kinked receiver tubing
1. When a health nurse visits the home of a family 5. Excessive volume
being treated for pediculosis (head lice), which of the 5. When shaving a male client with a safety razor,
following items should the nurse discourage? which of the following nursing actions is correct?
1. Pediculicide shampoo 1. Start at the neck working upward.
2. Fine-toothed comb 2. Pull the razor in the direction of hair growth.
3. Hair conditioner 3. Use long strokes with the razor.
4. Warm tap water 4. Replace the razor after each use.
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SKILL 17-1 Providing a Tub Bath or Shower
ASSESSMENT
Check the Kardex or nursing care plan for hygiene directives. Ensures continuity of care.
Assess the client’s level of consciousness, orientation, strength, Provides data for evaluating the client’s ability to carry out hygiene
and mobility. practices independently.
Check for gauze dressings, plaster cast, or electrical or battery- Maintains the client’s safety and ensures integrity of treatment
operated equipment; determine whether they can be protected devices.
with waterproof material or are safe if they become wet.
Determine if and when any laboratory or diagnostic procedures Aids in time management.
are scheduled.
Check the occupancy, cleanliness, and safety of the tub or Helps organize the plan for care.
shower (Fig. A).
Tub and shower equipped for client safety. (Photo by B. Proud.)
PLANNING
Clean the tub or shower if necessary. Reduces potential for spreading microorganisms.
Consult with the client about a convenient time for tending to Promotes client cooperation and participation in decision making.
hygiene needs.
Assemble supplies: floor mat, towels, face cloth, soap, clean Demonstrates organization and efficient time management.
pajamas, or gown.
IMPLEMENTATION
Escort the client to the shower or bathing room. Shows concern for the client’s safety.
Demonstrate how to operate the faucet and drain. Ensures the client’s safety and comfort.
Fill the tub approximately halfway with water 105°–110°F (40°– Demonstrates concern for the client’s safety and comfort.
43°C) or adjust the shower to a similar temperature if the client
cannot operate the faucet.
Place a “Do Not Disturb” or “In Use” sign on the outer door. Ensures privacy.
Help the client into the tub or shower if he or she needs assist- Reduces the risk of falling.
ance by:
• Placing a chair next to the tub
• Having the client swing his or her feet over the edge of the
tub
• Asking the client to lean forward, grab a support bar, and raise
the buttocks and body until he or she can fully enter the tub
(continued)
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Providing a Tub Bath or Shower (continued)
Have the client sit on a stool or seat in the tub or shower if the Ensures safety.
client will have difficulty exiting the tub or may become weak
while bathing (Fig. B).
Shower chair. (Photo by B. Proud.)
Show the client how to summon help. Promotes safety.

Stay close at hand. Ensures proximity in case the client needs assistance.
Check on the client frequently by knocking on the door and Shows respect for privacy yet concern for safety.
waiting for a response.
Escort the client to his or her room after the bath or shower. Demonstrates concern for safety and welfare.
Clean the tub or shower with an antibacterial agent; dispose of Reduces the spread of microorganisms and demonstrates concern
soiled linen in its designated location. for the next person to use the tub or shower.
Remove the “In Use” sign from the door. Indicates that the bathing room is unoccupied.
Evaluation
• Client is clean.
• Client remains uninjured.
Document
• Date and time
• Tub bath or shower
Date and Time Tub bath taken independently. SIGNATURE/TITLE
a
Generally, nurses document routine hygiene measures on a checklist, but for teaching purposes an example of narrative charting has been
provided.
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SKILL 17-2 Administering Perineal Care
ASSESSMENT
Inspect the client’s genital and rectal areas. Provides data for determining if perineal care is necessary.
PLANNING
Chap. 10).
Gather gloves, soap, water, and clean clothes or antiseptic wipes, Provides a means of removing debris and microorganisms.
or a container of cleansing solution in a squeeze bottle, and
several towels or absorptive pads.
Explain the procedure to the client. Reduces anxiety and promotes cooperation.
Pull the privacy curtain. Demonstrates respect for modesty.
Place the client in a dorsal recumbent position and cover with a Provides access to the perineum.
bath blanket (Fig. A).
Positioning and draping the client. (Photo by B. Proud.)
Pull and fan-fold the top linen to the foot of the bed while the Maintains client modesty and keeps upper linen clean and dry.
client holds the top of the blanket.
For a female client, place a disposable pad beneath the buttocks Helps to absorb liquid that may drip during cleansing.
or place the client on a bedpan; for a male client, place a dis-
posable pad under the penis and beneath the buttocks.
IMPLEMENTATION
Bend the female client’s knees and spread her legs. Exposes area for cleansing.
Put on gloves. Prevents contact with blood, secretions, or excretions.
Wash the outer folds of the labia and then separate the folds of Cleanses in a direction from less soiled to more soiled; prevents
the labia and wash from the pubic area toward the anus (Figs. reintroducing microorganisms into previously cleaned areas.
B and C).
Cleansing the outer labia.
B
(continued)
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Administering Perineal Care (continued)
Cleansing the inner labia toward the anus.
Never go back over an area that you already have cleaned. Avoids resoiling already clean areas.
Use a clean area of the cloth or a separate antiseptic wipe for
each stroke.
Wash debris on the outside of a urinary catheter, if one exists, Reduces the number and growth of microorganisms that may
especially where it is in contact with mucous membrane and ascend to the bladder.
genital tissue.
Squeeze the antiseptic solution container, if one is used, starting Ensures that the solution will drain toward more soiled body
at the upper areas of the labia down toward the anus (Fig. D). areas; prevents reintroducing microorganisms into previously
cleaned areas.
Rinsing the perineum.
For males, grasp the penis; if the client is uncircumcised, retract Facilitates removing debris and secretions that may be trapped
the foreskin. beneath the fold of skin.
Clean the tip of the penis using circular motions (Fig. E). Never go Keeps the urethral opening clean.
back over an area that you already have cleaned.
Replace the foreskin. Prevents trauma.
(continued)
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Cleansing the glans penis.
Wipe the shaft of the penis toward the scrotum (Fig. F). Keeps microorganisms and debris from the urethral opening.
Cleansing the shaft of the penis.
Spread the legs and wash the scrotum. Removes debris where it may be trapped and harbor microorgan-
isms.
Pat the skin dry with a towel. Removes excess moisture.
Turn the client to the side and wash from the perineum toward Cleans in a direction toward more soiled body areas.
the anus.
Rinse and pat the skin dry. Prevents skin irritation from soap residue and retained moisture;
a warm, dark, moist environment contributes to fungal skin
infections.
Apply a clean absorbent perineal pad to clients who are menstru- Promotes cleanliness and reduces contact between the skin and
ating or have other types of vaginal or rectal drainage. moist drainage.
Remove damp towels, place an absorbent disposable pad Restores comfort; protects linen from soiling.
beneath the client if drainage is excessive, and cover the client
with bed linen.
Deposit wet cloths, soiled wipes, and towels in an appropriate Controls the spread of microorganisms.
container.
Empty and rinse the bedpan. Controls the spread of microorganisms.
Remove gloves and wash hands or perform hand antisepsis with Reduces the spread of microorganisms.
an alcohol rub (see Chap. 10).
Attend to the client’s comfort and safety. Demonstrates concern for the client’s welfare.
(continued)
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Evaluation
• Genital, perineal, and rectal areas are clean and dry.
• Cleansing has been from less to more soiled areas of the body.
• There has been no direct contact with drainage, secretions, or excretions.
• Soiled articles have been properly disposed.
Document
• Date and time
• Care provided
• Description of drainage and tissue
Date and Time Peri-care provided to remove moderate bloody drainage coming from vagina. Perineal tissue is intact.
SIGNATURE/TITLE
SKILL 17-3 Giving a Bed Batha
ASSESSMENT
Check the Kardex or nursing care plan for hygiene directives. Ensures continuity of care.
Inspect the skin for signs of dryness, drainage, or secretions. Provides data for determining whether a complete or partial bath
is appropriate.
PLANNING
Consult with the client to determine a convenient time for tend- Promotes client cooperation; allows client participation in decision
ing to hygiene needs. making.
Assemble supplies: bath blanket, towels, face cloths, soap, wash Demonstrates organization and efficient time management.
basin, clean pajamas or gown, clean bed linen, other hygiene
articles such as deodorant or antiperspirant, and a razor for
males.
IMPLEMENTATION
Chap. 10).
Pull the privacy curtain. Demonstrates respect for modesty.
Raise the bed to an appropriate height. Reduces muscle strain on the back when providing care.
Remove extra pillows or positioning devices and place the client Prepares the client for washing the anterior body surface.
on his or her back.
Cover the client with a bath blanket. Shows respect for the client’s modesty and provides warmth.
Remove the client’s gown. Facilitates washing the client.
While the client holds the top of the bath blanket, pull and fan-fold Keeps linen, which may be reused, clean.
the top linen to the bottom of the bed, or remove the linen, fold
it, and lay it on a chair.
If linen is too soiled for reuse, place it in a laundry hamper. Reduces the spread of microorganisms.
Hold dirty linen away from contact with your uniform. Reduces the spread of microorganisms.
Fill a basin with 105°–110°F (40°–43°C) water; place the basin on Provides comfortably warm water for bathing within easy access.
the overbed table.
(continued)
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Giving a Bed Batha (continued)
Wet the washcloth and fold it to fashion a mitt (Fig. A). Keeps water from dripping from the margins of the cloth.
Straightening washcloth before folding into mitt.
Wipe each eye with a separate corner of the mitt from the nose Prevents getting soap in the eyes.
toward the ear (Fig. B).
Wiping the eyes.
Lather the wet washcloth with soap and finish washing the face. Removes oil, sweat, and microorganisms.
Rinse the washcloth and remove soapy residue from the face, Prevents drying the skin.
then dry well.
(continued)
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Bathe each of the client’s arms separately; the axillae may be Cleanses soiled material and keeps the client from becoming too
included now or when the chest is washed (Fig. C). chilled.
Washing the arm.
Offer to apply deodorant or antiperspirant after washing the Demonstrates respect for the client’s usual hygiene practices;
axillae. reduces perspiration and body odor.
Place each hand in the basin of water as you wash it (Fig. D). Facilitates more thorough washing than just using the washcloth.
Soaking the hand in a basin.
Discard and replace the water in the basin; rinse the washcloth Eliminates debris, microorganisms, and soap residue and
well or replace it with a clean one. increases the warmth of the water in preparation for washing
cleaner areas of the body.
Wash the chest, abdomen, each leg, and then the feet following Follows the principle of washing from cleaner to more soiled
the steps described for the upper body (Fig. E). areas.
Washing a leg.
E
(continued)
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Help the client onto his or her side. Repositions the client so you can bathe the posterior of the body.
Change the water and bathe the client’s back. Allows washing to begin at a cleaner area on the posterior aspect
(Fig. F) of the body.
Washing the back.
Offer to apply lotion and provide a back rub. Improves circulation and relaxes the client.
Don gloves and wash the buttocks, genitals, and anus last. Dry Reduces the potential for contact with lesions or drainage that
thoroughly. may contain infectious microorganisms. Prevents moisture
accumulation.
Discard the water and wipe the basin dry. Controls growth and spread of microorganisms.
Remove gloves and help the client to don a fresh gown. Restores comfort and modesty.
Evaluation
• Client is completely bathed.
• Client experiences no discomfort or intolerance of activity.
Document
• Date and time
• Type and extent of hygiene
• Client response
• Assessment findings observed during bath
SAMPLE DOCUMENTATIONb
Date and Time Complete bed bath given. Client could wash face and genitals independently. Skin is intact. No dyspnea
noted during bath. SIGNATURE/TITLE
a
The nurses depicted here are wearing gloves; however, gloves are not necessary when giving a bath, unless there is a risk of infectious contact.
b
Generally, nurses document routine hygiene measures on a checklist, but for teaching purposes an example of narrative charting has been used.
LWBK1004-C17_p345-373.indd 369 2/6/12 7:23 PM

SKILL 17-4 Giving Oral Care to Unconscious Clients
ASSESSMENT
Check the nursing care plan about the frequency of oral hygiene. Maintains continuity of care.
Inspect the client’s mouth. Helps to determine equipment and supplies needed.
Look for oral hygiene supplies that may be at the client’s bedside Controls costs.
already.
PLANNING
Arrange to brush the client’s teeth once per shift and to provide Promotes a schedule for removing plaque and microorganisms
additional oral care at least every 2 hours if necessary. and moistening and refreshing the mouth.
Assemble the following equipment: toothbrush, toothpaste, Promotes organization and efficient time management.
suction catheter, water, bulb syringe, padded tongue blade,
emesis basin, towel or absorbent pad, and gloves. Some agen-
cies may stock a toothbrushing device connected directly to a
suction catheter (Fig. A).
Toothbrushing device with suction catheter.
Suction
vent
IMPLEMENTATION
Explain to the client what you are about to do. Reduces anxiety if the client has the cognitive capacity to
understand.
Position the client on the side with the head slightly lowered. Prevents liquids from draining into the airway.
Place a towel beneath the head. Absorbs liquids.
Connect a Yankeur suction tip or catheter to a portable or wall- Promotes safety.
mounted suction source.
Spread toothpaste over a moistened toothbrush. Prepares the toothbrush for use.
Don gloves. Prevents direct contact with blood or microorganisms in the mouth.
Use a tongue blade or lower the client’s chin to open the mouth Serves as a safe substitute for the nurse’s fingers.
and separate the teeth
Brush all tooth surfaces with the toothbrush (Fig. B). Removes plaque and microorganisms.
With the head lowered, the teeth are brushed.
B
(continued)
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Giving Oral Care to Unconscious Clients (continued)
Instill water and suction the mouth with a bulb syringe (Fig. C). Removes loosened debris.
Reduces the potential for aspiration.
Rinsing the mouth while keeping the head lowered.
Suction the rinsing solution with a Yankeur suction device (Fig. D)
Suctioning fluid from the mouth.
Clean and store oral hygiene supplies. Restores cleanliness and order to the client’s environment.
Remove wet towel and gloves; restore client to a position of Demonstrates concern for the client’s dignity and welfare.
comfort and safety.
Evaluation
• The teeth are clean.
• The oral mucosa is smooth, pink, moist, and intact.
• Safety is maintained.
Document
• Date and time
• Assessment findings if significant
• Type of oral care
• Unusual events such as choking and nursing action that was taken
• Outcome of any nursing action
Date and Time Teeth brushed and mouth rinsed. Liquid suctioned from the mouth using a Yankeur suction catheter. No
choking during oral care. Lung sounds are clear bilaterally. SIGNATURE/TITLE
a
Generally, the nurse documents routine hygiene measures on a checklist, but for teaching purposes an example of narrative charting has been
used.
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SKILL 17-5 Shampooing Hair
ASSESSMENT
Inspect the client for oily and limp hair or signs of accumulating Provides data to determine the need for shampooing and what
secretions or lesions on the scalp. supplies may be appropriate to use.
Assess for respiratory symptoms, pain, or other conditions that Aids in establishing priorities for care.
increase or contribute to activity intolerance.
Determine if and when medical treatments or tests are sched- Ensures that hygiene measures will not interrupt therapeutic or
uled. diagnostic procedures.
Discuss the types of products available for shampooing. Facilitates individualized care.
PLANNING
Collaborate with the client on the time of day that is best for Involves the client in decision making.
shampooing.
Assemble equipment, which may include shampoo, conditioner, Promotes organization and efficient time management.
hair oil treatment, towels, a water pitcher, and a shampoo basin
or trough.
IMPLEMENTATION
Close the door to the room and pull the privacy curtain. Reduces the potential for chilling and promotes respect for
privacy.
Remove the pillow and protect the upper area of the bed with Absorbs moisture.
towels; cover the client’s chest and shoulders with a towel.
Don gloves if any open lesions are on or near the head. Prevents direct contact with blood or secretions.
Wet the hair thoroughly and apply shampoo. Dilutes and distributes the shampoo.
(Fig. A).
Shampooing the hair using a shampoo trough.
Work the shampoo into a lather. Facilitates cleansing throughout the hair.
Rinse the hair with water. Removes oil and shampoo from the hair.
Apply conditioner if requested and available. Relaxes the hair and reduces tangles.
Wrap the head with a dry towel and fluff the hair. Absorbs water and shortens the drying time.
Remove and discard gloves when there is no threat for direct Facilitates hair care.
contact with blood or secretions.
Comb, braid, or style the hair according to the client’s preference. Promotes self-esteem.
Clean and store shampooing supplies. Restores cleanliness and order to the client’s environment.
(continued)
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Shampooing Hair (continued)
Evaluation
The hair is clean and dry.
Document
• Date and time
• Type of care
• Response of the client
Date and Time Scalp and hair appear oily. Skin is intact. Bed shampoo provided. Hair dried, combed, and styled in braids.
Scalp is clean and intact. No evidence of chilling, fatigue, or discomfort during shampoo. States, “I feel so
much better.” SIGNATURE/TITLE
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18 Comfort, Rest, and
Sleep
apnea
bruxism
cataplexy 1. Differentiate between comfort, rest, and sleep.
circadian rhythm 2. Describe four ways to modify the client environment to
climate control promote comfort, rest, and sleep.
comfort 3. List four standard furnishings in each client room.
drug tolerance 4. State at least five functions of sleep.
environmental psychologist 5. Describe the two phases of sleep and their differences.
humidity 6. Describe the general trend in sleep requirements as a person
hypersomnia ages.
hypersomnolence 7. Name 10 factors that affect sleep.
hypnogogic hallucinations 8. List four categories of drugs that affect sleep.
hypnotic 9. Name four techniques for assessing sleep patterns.
hypopnea 10. Describe four categories of sleep disorders.
hypoxia 11. Discuss at least five techniques for promoting sleep.
insomnia 12. Name two nursing measures that promote relaxation.
jet lag 13. Discuss unique characteristics of sleep among older adults.
massage
mattress overlay
melatonin
omfort (a state in which a person is relieved of distress) facilitates
C
microsleep
multiple sleep latency test rest (a waking state characterized by reduced activity and mental
narcolepsy stimulation) andsleep (a state of arousable unconsciousness). One
nocturnal enuresis factor that contributes to comfort is a safe, clean, and attractive
nocturnal polysomnography environment.
occupied bed This chapter addresses measures for ensuring that the setting for
parasomnia client care promotes a sense of well-being. It includes measures for
photoperiod
maintaining the order and cleanliness of the client’s bed and room and
phototherapy
progressive relaxation describes nursing interventions that facilitate rest and sleep.
relative humidity
rest
restless legs syndrome CLIENT ENVIRONMENT
sedative
sleep The term environment, as used here, refers to the room where the client
sleep apnea/hypopnea syndrome receives nursing care and its furnishings. In a broader sense, however, the
sleep diary health care facility’s location and design involve many other subtle ele-
sleep paralysis ments that influence the consumer’s overall impression of the institution.
sleep rituals Most clients are unaware of the thoughts and considerations that
sleep–wake cycle disturbance go into their surroundings. Accessible parking, lighting inside and
somnambulism
outside of the physical plant, landscaping, barriers that reducec traffi
stimulants
noise, and signage that helps clientsnd fi their way around the building
sundown syndrome
sunrise syndrome create a positive appeal among those in need of health care.
thermoregulation
tranquilizer Client Rooms
unoccupied bed Client rooms resemble bedrooms but are no longer the bare, white,
ventilation sterile environments of a few decades ago. Thanks to environmental
374
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CHAPTER 18 Comfort, Rest, and Sleep 375
psychologists (specialists who study how the environment fans and dehumidifiers are not always an adequate substi-
affects behavior and well-being), client rooms are now tute but may be used if air conditioners are not available.
brighter, more colorful, and tastefully decorated. The wall In buildings where the air is dry, a humidifier or a cool mist
and floor treatments, lighting, and mechanisms for maintain- machine can add moisture to the environment. Clients who
ing climate control are practical and conducive to comfort. have ineffective thermoregulation (the ability to maintain
stable body temperature) may feel hot or cold even when the
Walls temperature and humidity are optimal.
Blue and colors with blue tints, such as mauve and light green,
promote relaxation, so these color schemes are preferred
within health care settings and client rooms. If these colors Gerontologic Considerations
are not used exclusively, they are integrated into wallpaper
trim and decorative accessories such as framed pictures. The ■ Older adults tend to prefer warmer room temperatures
art often depicts country scenes and peaceful images. because of decreased subcutaneous fat deposits. Those
with cognitive impairment, however, may feel that environ-
Floors mental temperatures are uncomfortably warm or cool, even
Because noise interferes with comfort, the hallways and when the temperature is comfortable for others.
work stations are carpeted in most agencies. The floors in
client rooms have tile or linoleum surfaces to facilitate the
cleaning of spills. Ventilation
At home, methods of ventilation (the movement of air) include
Lighting opening windows or using ceiling fans. In hospitals and nurs-
Adequate lighting, both natural and artificial, is important ing homes, however, open windows are a fire and safety haz-
to the comfort of clients and nursing personnel. Newer ard, and ceiling fans spread infectious microorganisms. Con-
buildings have large window areas, atriums, skylights, and sequently, ventilation usually occurs through a system of air
enclosed courtyards to facilitate exposure to sunlight as a ducts that circulate air in and out of each client room.
technique for reducing stress. Poorly ventilated rooms and buildings tend to smell
Bright artificial light facilitates nursing care but is not badly. Removing soiled articles, emptying bedpans and
conducive to client comfort. Therefore, most client rooms urinals, and opening privacy curtains and room doors help
have multiple lights in various locations with adjustable reduce odors. An alternative is to use an air freshener or deo-
intensity. Dim light and darkness promote sleep; however, dorizer; generally, however, scented sprays substitute one
injuries are more likely in dark and unfamiliar environments. odor for another, and ill clients usually find any strong smell
Therefore, client rooms have adjustable window blinds and disagreeable. Nurses should be conscientious about their
night lights near the floor. own body and oral hygiene, refrain from wearing overpow-
ering perfume, and avoid smelling of cigarette smoke.
Climate Control
Climate control refers to mechanisms for maintaining tem-
Room Furnishings
perature, humidity, and ventilation. It is a method of promot-
Manufacturers of hospital furnishings attempt to design
ing physical comfort.
equipment that is both attractive and practical (Fig. 18-1).
Temperature and Humidity
Most clients are comfortable when the room temperature is
68° to 74°F (20° to 23°C). Newer buildings provide thermo-
stats in each room so that the temperature can be adjusted to
suit the client.
Humidity (the amount of moisture in the air) and relative
humidity (the ratio between the amount of moisture in the air
and the greatest amount of water vapor the air can hold at a
given temperature) affect comfort. At a relative humidity of
60%, the air contains 60% of its potential water capacity. A rel-
ative humidity of 30% to 60% is comfortable for most clients.
If the environmental temperature becomes greater than
the skin temperature, evaporation is the only mechanism for
regulating body temperature. Evaporation is reduced when
humidity levels rise because air that is almost or fully satu-
rated with water cannot absorb additional moisture. There-
fore, instead of evaporating, sweat accumulates and drips FIGURE 18-1 Typical hospital room furnishings. (Photo by B.
from the skin. Many agencies are air-conditioned. Electric Proud.)
LWBK1004-C18_p374-398.indd 375 31/01/12 1:36 AM

The bed and its components—the mattress and pillows, allows more effective cardiac compression than is possible
chairs, overbed table, and bedside stand—must be safe, on a mattress.
durable, and comfortable.
Mattress. Many people equate the comfort of a bed with
the quality of the mattress. A good mattress adjusts to the
Gerontologic Considerations shape of the body while supporting it. A mattress that is too
soft alters the alignment of the spine, causing some people to
■ Older adults who move to institutional settings, such as awaken feeling sore from muscle and joint strain.
nursing homes or assisted living facilities, are usually more Hospital mattresses generally consist of tough materi-
comfortable with their own bed furnishings and personal als that will withstand long-term use. Because mattresses
mementos and belongings. are washed but not sterilized between uses, they are covered
with a waterproof coating that withstands cleaning with
strong antimicrobial solutions.
Bed Occasionally, mattress overlays (layers of foam or
Hospital beds are adjustable; that is, the height and position other devices placed on top of the mattress; Fig. 18-3) are
of the head and knees can be changed either electronically or used to promote comfort or to keep the skin intact (see Chap.
manually. Adjusting the bed promotes comfort, enables self- 23). Box 18-1 lists clients for whom a mattress overlay or
care, and facilitates a therapeutic position (see Chap. 23). therapeutic mattress of foam, gel, air, or water is appropriate.
Hospital beds usually remain in their lowest position except
when clients are receiving nursing care or during a change of Pillows. Pillows are primarily used for comfort, but they
bed linens. Skill 18-1 describes how to make an unoccupied are also used to elevate a part of the body, relieve swelling,
bed (changing the linens when the bed is empty). promote breathing, or help maintain a therapeutic position
Full or half side rails are attached to the bed frame. (see Chap. 23). Pillows are stuffed with foam, kapok (a mass
There is controversy as to whether raised side rails are a risk of silky fibers), or feathers.
or benefit because some clients climb over them rather than
Bed Linen
seek nursing assistance. Side rails are considered a form of
The linens used for most hospital beds includes the following:
physical restraint in long-term care facilities, and their use
must be justified (Omnibus Budget Reconciliation Act of • Mattress pad
1987; see Chap. 19). • Bottom sheet that is sometimes fitted
Some beds have removable headboards (Fig. 18-2). • Optional draw sheet that is placed beneath the client’s hips
This facilitates resuscitation efforts if the client experiences • Top sheet
respiratory or cardiac arrest. Removing the headboard gives • Blanket, depending on the client’s preference
the code team responders better access for airway intuba- • Spread
tion. Placing the headboard under the client’s upper body • Pillowcase
A B
FIGURE 18-2 A. The nurse removes the headboard from a standard hospital bed. B. The nurse
places the headboard beneath a client before resuscitation. (Photo by B. Proud.)
LWBK1004-C18_p374-398.indd 376 31/01/12 1:36 AM

esty whenever it is necessary to examine or expose him or

her for care. It is also used to shield a client from observation
while using a urinal or bedpan.
Overbed Table
An overbed table is a portable, flat platform positioned over
the client’s lap. The height of the table is adjustable depend-
ing on whether the bed is in a high or low position. The
overbed table makes it convenient for the client to eat while
in bed and to perform personal hygiene or other activities
requiring a flat surface. Nurses also use the overbed table
to hold equipment when providing client care. Most over-
bed tables have a concealed compartment that may contain
a mounted mirror and a place for personal items (hairbrush,
comb, cosmetic bag, razor, or book).
Bedside Stand
A bedside stand is actually a small cupboard. It usually con-
FIGURE 18-3 A waterproof mattress cover protects the mat- tains a drawer for personal items and two shelves. The upper
tress overlay. (Photo by B. Proud.) shelf is used to store the client’s bath basin, soap dish, soap,
and a kidney-shaped basin called an “emesis basin.” The
lower shelf is used to store a bedpan, urinal, and toilet paper.
The elimination utensils are kept separate from the hygiene
Some hospitals use printed sheets to provide a more
supplies to reduce the transmission of microorganisms. A
homelike atmosphere.
carafe of water and a drinking container are placed atop the
To control expenses, bed linen may not be changed every
bedside stand.
day, but any wet or soiled linen is changed as frequently as
necessary. Sometimes, folded sheets or disposable, absorb-
ent pads are placed between the client and the bottom sheet to Chairs
avoid the need to change the entire bed when linen becomes Generally, there is at least one chair per client in each room.
soiled. Skill 18-2 explains how to make an occupied bed Hospital chairs usually are straight-backed to facilitate good
(changing the linens while the client remains in bed). postural support. The best sitting position is when the hips,
knees, and ankles are all at 90-degree angles. There may be
➧ Stop, Think, and Respond Box 18-1 one upholstered chair in each client room. Although uphol-
stered chairs are more comfortable, some clients find it dif-
List situations when it would be appropriate to
ficult to rise from them.
change some linens when providing client care and
other situations in which it is more appropriate to
change all linens.
Privacy Curtain
SLEEP AND REST
A privacy curtain is a long fabric partition mounted from the
No matter how comfortable the physical environment or
ceiling. It can be drawn completely around each client’s bed.
how attractive and homelike the furnishings, failure to pro-
The privacy curtain preserves the client’s dignity and mod-
mote rest and sleep may sabotage or prolong recuperation.
Although sleep requirements vary, alterations in sleep pat-
terns can have serious physical and emotional consequences.
B OX 1 8 - 1 Client Criteria for a Mattress Family members, especially spouses, may experience sleep
Overlay or a Therapeutic Mattress disturbances if someone snores, wakes up during the night,
• Complete immobility
or wanders.
• Limited mobility
• Impaired skin integrity
Functions of Sleep
• Inadequate nutritional status
In addition to promoting emotional well-being, sleep
• Incontinence of stool, urine, or both
• Altered tactile perception enhances various physiologic processes. Although the exact
• Compromised circulatory status mechanisms are not totally understood, the restorative
functions of sleep can be inferred from the effects of sleep
LWBK1004-C18_p374-398.indd 377 31/01/12 1:36 AM

Awake:
B OX 1 8 - 2 Effects of Chronic Sleep Deprivation
low-voltage, fast
• Reduced physical stamina
• Altered comfort, such as headaches and nausea
• Impaired coordination, especially of fine motor skills
• Loss of muscle mass and weight
• Increased susceptibility to infection Awake eyes closed:
• Slower wound healing alpha-waves, 8–12 cps
• Decreased pain tolerance
• Poor concentration
• Impaired judgment
• Unstable moods
• Suspiciousness
NREM:
Stage 1:
theta-waves, 3–7 cps
deprivation (Box 18-2). Sleep is believed to play a role in

the following:
• Reducing fatigue Stage 2:
sleep spindles, 12–14 cps;
• Stabilizing mood
K-complex
• Improving blood flow to the brain
• Increasing protein synthesis
• Maintaining the disease-fighting mechanisms of the
sleep spindle
immune system K-complex
• Promoting cellular growth and repair
Stages 3 and 4:
• Improving the capacity for learning and memory storage
delta-waves, 0.5–2 cps
Sleep Phases
Sleep is divided into two phases: nonrapid eye movement
(NREM) sleep and rapid eye movement (REM) sleep. These
names derive from the periods during sleep when eye move-
ments are either subdued or energetic.
NREM sleep, which progresses through four stages, REM:
is also called “slow wave sleep” because during this phase low-voltage mixed frequency
electroencephalographic waves appear as progressively sawtoothed waves
slower oscillations. The REM phase of sleep is referred to
as paradoxical sleep because the electroencephalographic sawtooth
waves appear similar to those produced during periods of FIGURE 18-4 Characteristic electroencephalogram waveforms
wakefulness (Fig. 18-4), but it is the deepest stage of sleep. by sleep stage. cps, cycles per second. (From Craven, R.F., &
Thus, NREM sleep is characterized as quiet sleep and REM Hirnle, C.J. [2008]. Fundamentals of nursing: Human health
sleep as active sleep. and function [6th ed.]. Philadelphia, PA: Lippincott Williams &
Wilkins.)
Sleep Cycles
During sleep, people alternate between NREM and REM
phases (Table 18-1). NREM sleep normally precedes REM 9 hours of sleep is a requirement from adolescence through
sleep, the phase during which most dreaming occurs. Although old age, 20% of Americans report sleeping less than 6 hours
the time spent in any one phase or stage varies according to a night, an increase from the 13% reporting the same a dec-
age and other variables, most people cycle between stages 2, ade ago (National Sleep Foundation, 2009a).
3, and 4 of NREM to REM phases four to six times during With age, the time spent in stages 3 and 4 of NREM
the night. decreases, whereas periods of REM sleep increase (Fig.
18-5). According to the National Sleep Foundation (2009b),
Sleep Requirements older adults sleep more on weeknights, but younger adults
Sleep requirements vary among different age groups. The sleep more on weekends. Older adults nap more than younger
need for sleep decreases from birth to adulthood, although adults, a fact that may be attributed to daytime inactivity or
individuals vary (Table 18-2). Although an average of 7 to reduced mental stimulation.
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TABLE 18-1 Characteristics of Sleep Phases

SLEEP PHASE LENGTH FEATURES
NREM 50–90 min Deep, restful, dreamless sleep
Stage 1 A few minutes Light sleep, easily aroused
Gradual reduction in vital signs
Stage 2 10–20 min Deeper relaxation
Can be awakened with effort
Stage 3 15–30 min Early phase of deep sleep
Snoring
Relaxed muscle tone
Little or no physical movement
Difficult to arouse
Stage 4 15–30 min; shortens toward morning Deep sleep
Sleepwalking, sleep talking, and bedwetting may occur
REM 20-min average; lengthens toward Darting eye movements
morning Very difficult to awaken
Vivid, colorful, emotional dreams
Loss of muscle tone; jaw relaxes; tongue may fall to the back of the throat
Vital signs fluctuate
Irregular respirations
Pauses in breathing for 15–20 sec
Absence of snoring
Muscle twitching
Gastric secretions increase
Men may have erections
Factors Affecting Sleep

Gerontologic Considerations Both the quantity and the quality of sleep decreases with
age. According to the Division of Sleep Medicine at Harvard
■ Older adults often report feeling tired, complain of sleep Medical School (2007), older adults suffer disproportion-
problems, and spend more time in bed without actually ately from chronic sleep deprivation. The latter finding is
sleeping. not surprising because older adults awaken more frequently
■ Short daytime naps and rest periods, usually less than
during the night for several reasons: pain; smaller blad-
2 hours in duration, can restore energy for an older adult
der capacity, which results in an increased need to urinate;
without interfering with nighttime sleep. However, 7 to 9
hours of sleep within a 24-hour period is the usual total dementia-related sleep problems; side effects from medica-
amount of sleep required by older adults. Therefore, expec- tions such as diuretics; and diminished production of neu-
tations for the number of sleep hours during the night must rochemicals, such as melatonin, that promote sleep. Other
be adjusted according to the amount of daytime sleep. factors not related to age also affect the amount and quality
■ Boredom may be a cause of daytime napping. Working of a person’s sleep (Table 18-3).
with older adults to determine meaningful diversions may
actually help with nighttime sleep, when naps are diminished.
TABLE 18-3 Factors Affecting Sleep
SLEEP-PROMOTING FACTORS SLEEP-SUPPRESSING FACTORS
TABLE 18-2 Sleep Requirements Darkness, dim light Sunlight, bright light
Consistent sleep schedule Inconsistent sleep schedule
PERCENTAGE Secretion of melatonin Suppression of melatonin
AGE TOTAL SLEEP TIME IN REM Familiar sleep environment Strange sleep environment
Newborn 16–20 hr/day 50 Optimal warmth and ventilation Cold, hot, stuffy room
3 months–1 year 14–15 hr/day 35 Performance of sleep rituals Disturbance of sleep rituals
Toddler 12 hr/night No data Sedative, hypnotic drugs Stimulant drugs
plus 1 or 2 naps Depression Depression, anxiety, worry
Preschool 9–12 hr/night No data Relaxation Activity
5–6 years 11 hr/night 20 Satiation Hunger, thirst
6–11 years 10–11 hr/night No data Proteins containing L-tryptophan Protein-deficient diets
11 years 9 hr/night No data Excessive alcohol consumption Metabolism of alcohol
Adolescent 7–9 hr/night 25 Comfort Pain, nausea, full bladder
Adult 7–9 hr/night 20–25 Quiet Noise
Elderly 7–9 hr/night 13–15 Effortless breathing Difficulty breathing
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Younger Older
Awake
REM sleep
FIGURE 18-5 The time spent in

Deep sleep
REM and NREM sleep is different
in younger adults than in older
11 PM to 6 AM 11 PM to 6 AM adults.
Gerontologic Considerations sleep, especially the deep sleep of NREM stage 4. When
physical activity occurs just before bedtime, however, it has
a stimulating rather than a relaxing effect.
■ Using night lights rather than bright room lights is pre-
ferred if an older adult arises during the night. Bright lights
stimulate the brain and interfere with efforts to resume
sleep. Gerontologic Considerations
■ Older adults with limited mobility may sleep better if

Light they participate in chair or water exercises during the day.
Daylight and darkness influence the sleep–wake cycle. Cir-
cadian rhythm (phenomena that cycle on a 24-hour basis)
is a term derived from two Latin words: circa (about) and Environment
dies (day). Thus, drowsiness and sleep correlate with the Most people sleep best in their usual environment; they
circadian rhythm of the setting sun and night. Wakefulness develop a preference for a particular pillow, mattress, and
corresponds with sunrise and daylight. blankets. They also tend to adapt to the unique sounds where
Researchers (Rosenthal et al., 1984) have suggested that they live, such as traffic, trains, and the hum of appliance
the cycles of wakefulness followed by sleep are linked to a motors or furnaces.
photosensitive system involving the eyes and the pineal gland
in the brain (Fig. 18-6). Without bright light, the pineal gland
secretes melatonin (a hormone that induces drowsiness and
sleep); light triggers the suppression of melatonin secretion.
■ The older adult’s established pattern and circadian

rhythms may not correspond to schedules of institutional
settings. Modifications in established institutional routines
may be needed to accommodate individual differences.
Activity
Activity, especially exercise, increases fatigue and the need FIGURE 18-6 A photosensitive light system influences the
for sleep. Activity appears to increase both REM and NREM sleep–wake cycle.
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In addition, sleep rituals (habitual activities performed Alcohol is a depressive drug that promotes sleep, but
before retiring) induce sleep. Examples include eating a it tends to reduce normal REM and deep-sleep stages of
light snack, watching television, reading, and performing NREM sleep. As alcohol is metabolized, stimulating chemi-
hygiene. Therefore, alterations in the environment or the cals that were blocked by the sedative effects of the alcohol
activities performed before bedtime—such as occur during surge forth from neurons, causing early awakening. Bever-
vacation or in the hospital—negatively affect a person’s abil- ages containing caffeine, a central nervous system stimulant,
ity to fall and remain asleep. cause wakefulness. Caffeine is present in coffee, tea, choco-
late, and most cola drinks.
Motivation
When a person has no particular reason to stay awake, sleep Illness
generally occurs easily. But if the desire to remain awake Stress, anxiety, and discomfort accompany almost any illness,
is strong, such as when a person wishes to participate in which can alter normal sleep patterns. In the hospital, other
something interesting or important, the desire to sleep can factors that contribute to sleep loss or fragmentation include
be overcome. being aroused by noise from equipment, awakened for nurs-
Emotions and Moods ing activities, and disturbed by unfamiliar sounds such as loud
Depressive disorders are classically associated with an ina- talking, elevators, dietary carts, and housekeeping equipment.
bility to sleep or the tendency to sleep more than usual. Also, Several medical disorders involve symptoms that are
emotions such as anger, fear, anxiety, and dread interfere aggravated at night or can disturb sleep. For example, ulcers
with sleep. All are more than likely the result of changes in tend to be more painful during the night because hydrochlo-
the types and amounts of neurotransmitters that affect the ric acid increases during REM sleep. In fact, pain of any
sleep–wake center in the brain. kind is more distressing when there are few distractions.
Sometimes sleeplessness is conditioned—that is, antici- Conditions worsened by lying flat in bed, such as some car-
pating sleeplessness, a characteristic pattern of some chronic diac, respiratory, and musculoskeletal disorders, contribute
insomniacs, actually reinforces it (a self-fulfilling proph- to sleeplessness.
ecy). The expectation that the onset of sleep will be difficult
increases the person’s anxiety. The anxiety then floods the Drugs
brain with stimulating chemicals that interfere with relaxa- Caffeine and alcohol, which have already been discussed,
tion, a prerequisite for natural sleep. are nonprescription drugs that affect sleep. Some prescribed
drugs also can promote or interfere with sleep. Sedatives
Food and Beverages and tranquilizers (drugs that produce a relaxing and calm-
Hunger or thirst interferes with sleep. The consumption of ing effect) promote rest, a precursor to sleep. Hypnotics are
particular foods and beverages also may promote or inhibit drugs that induce sleep. Stimulants (drugs that excite struc-
the ability to sleep. tures in the brain) cause wakefulness (Table 18-4).
Sleep is facilitated by a chemical known as L-tryptophan, Some sedatives and hypnotics have a paradoxical effect
found in protein foods such as milk and dairy products. The when administered to older adults: they tend to produce rest-
recommendation to drink warm milk to induce sleep may lessness and wakefulness instead of sleep. Also, people who
have originally been an anecdotal observation of its hyp- chronically take sedative and hypnotic drugs tend to develop
notic (sleep-producing) effect. L-tryptophan is also present drug tolerance (a diminished effect from the drug at its
in poultry, fish, eggs, and, to some extent, plant sources of usual dosage range). Without realizing the danger, these peo-
protein such as legumes. ple may increase the dose of the drug or the frequency of its
TABLE 18-4 Drugs That Affect Sleep

DRUG CATEGORY DRUG FAMILY EXAMPLE ADVERSE REACTIONS
Sedatives Barbiturates phenobarbital (Luminal) Sleepiness, lethargy, slowed respiratory rate,
agitation, confusion
Antihistamines diphenhydramine (Benadryl) Sleepiness, dizziness, slowed reaction time, impaired
coordination
Antipsychotics haloperidol (Haldol) Sleepiness, postural hypotension, abnormal facial and
mouth movements, stiff gait, dry mouth
Tranquilizers Benzodiazepines alprazolam (Xanax) Sleepiness, dry mouth, constipation, slowed heart
rate, hypotension, liver damage
Hypnotics Barbiturates pentobarbital (Nembutal) Same as phenobarbital, daytime drowsiness
Nonbarbiturates temazepam (Restoril) Dizziness, lethargy during the day
Stimulants Amphetamines dextroamphetamine (Dexedrine) Insomnia, restlessness, anorexia, rapid heart rate
Amphetamine-like methylphenidate (Ritalin) Nervousness, insomnia, rash, anorexia, nausea
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administration to achieve the same effect first experienced Although sleep diaries and questionnaires such as the
at a lower dose. Increasing the dose or frequency has poten- Pittsburgh Sleep Quality Index and the Epworth Sleepiness
tially life-threatening consequences. Scale are inexpensive and simple to compile, they can vary
The abrupt discontinuation of sedatives, tranquilizers, in accuracy and reliability (Smyth, 2008, 2009). Therefore,
and hypnotics produces a period of intense stimulation that sleep assessments include other objective diagnostic tech-
interferes with sleep. niques for gathering data to ensure the accurate identifica-
Some drugs that increase the formation of urine, such tion of sleep disorders and their etiologies.
as diuretics, may awaken those who take them with a need
to empty the bladder. For this reason, diuretics generally are Nocturnal Polysomnography
administered early in the morning so that the peak effect has Nocturnal polysomnography is a diagnostic assessment
diminished by bedtime. technique in which a client is monitored for an entire night’s
sleep to obtain physiologic data. It generally takes place in
a sleep disorder clinic, but it is now possible to conduct the
SLEEP ASSESSMENT study at the client’s home; a technician monitors a computer-
ized recording system up to 60 ft. away.
Many people blame inadequate sleep for daytime fatigue, Dime-sized sensors attached to the head and body
or they underestimate the actual time they sleep. Nurses can (Fig. 18-7) record the following:
obtain a more accurate sleep pattern assessment through • Brain waves
sleep questionnaires, sleep diaries, polysomnographic evalu- • Eye movements
ation, and a multiple latency sleep test. • Muscle tone
• Limb movement
Questionnaires • Body position
Several questionnaires have been developed to help identify • Nasal and oral airflow
sleep patterns. They are either designed to obtain specific • Chest and abdominal respiratory effort
information or are unstructured to give the person more free- • Snoring sounds
dom to respond. Nurses can gather data during interviews, or • Oxygen level in the blood
clients can answer the questions independently in the form
of a self-reporting assessment.
Examples of questions for the client include the fol-
lowing:
• When you think about your sleep, what kinds of impres-
sions come to mind?
• Does anything about your sleep bother you?
• Do you fall asleep at inappropriate times?
• Do you wake feeling rested?
• How long does it take you to fall asleep?
• Do you feel stiff and sore in the morning?
• Have you been told that you stop breathing while asleep?
• Do you fall asleep during physical activities?
• What do you do to help yourself sleep well?
Examples of questions for members of the client’s
household include the following:
• Does the client snore or gasp for air when sleeping?
• Does the client kick or thrash around while sleeping?
• Does the client sleepwalk?
Sleep Diary
A sleep diary is a daily account of sleeping and waking
activities. The client or personnel compile the information in
a sleep disorder clinic. The client notes the times he or she
sleeps, describes daily activities during each 15-minute wak-
ing period, completes a 24-hour log of consumed food and
beverages, and notes when he or she takes any medications. FIGURE 18-7 Providers evaluate normal sleep patterns and
These self-kept diaries generally cover a 2-week period. sleep disorders by collecting physiologic data.
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The diagnostic data are compared with the patterns and

characteristics of normal sleep cycles to help diagnose sleep Promoting Sleep
disorders.
The nurse teaches the client or the family as follows:
Multiple Sleep Latency Test ● Resist napping during the day.
● Use the bed and bedroom just for sleeping.
A multiple sleep latency test (an assessment of daytime
● Perform sleep rituals.
sleepiness) is another helpful study. The person undergoing
● Go to bed and get up at approximately the same time,
this test is asked to take a daytime nap at 2-hour intervals
even on weekends or days off.
while attached to sensors similar to those used in polysom- ● If you cannot get to sleep for more than 20 to 30 minutes,
nography. The client is allowed to nap for about 20 minutes. get out of bed and do something else such as reading.
The nap periods are repeated four or five times throughout ● Try a bedtime relaxation tape that plays soothing music,
the day. sounds of nature, or a constant background sound (white
Clients who have certain sleep disorders causing day- noise).
time sleepiness have a short latency period—that is, they fall ● Exercise regularly during the day but not late in the
asleep in less than 5 minutes. Most well-rested persons take evening.
an average of 15 minutes before they experience the onset of ● Avoid alcohol, nicotine, and caffeine.
● Eat dairy products and other proteins daily.
daytime sleep.
● Modify the temperature and ventilation in the bedroom
Experiencing early REM sleep is also a pathologic find-
according to personal preferences.
ing that can be detected during a multiple sleep latency test. A ● Use earplugs or eyeshades to reduce environmental
REM period normally does not occur for at least 1 hour and noise or light.
after cycling through the first four stages of NREM. There- ● Avoid using nonprescription or prescription sleeping pills
fore, REM should not occur during a 20-minute test nap. unless they have been recommended by a physician.
Hypnotics should be used only on a short-term basis.
● Try drinking chamomile tea, which some claim improves
sleep.
SLEEP DISORDERS ● Follow label directions on any medications.
● If a diuretic drug is prescribed, take it early in the morning.
About 40 million Americans have some type of sleep dis-
order, the most common being insomnia, followed by sleep
apnea. An additional 20 to 30 million have intermittent
sleep-related problems (National Institute of Neurological Pharmacologic Considerations
Disorders and Stroke, 2007). Many of those affected do not
seek treatment. Most problems are short-lived, but some ■ The National Institute of Neurological Disorders and
sleep disorders are both chronic and serious. Stroke (2006) recommends that sleep disorders in older
adults be managed without hypnotic medications, which
There are four categories of sleep disorders: insom-
tend to have paradoxical effects in older adults (ie, a stimu-
nia, hypersomnia, sleep–wake cycle disturbance, and par-
lating effect or mental changes).
asomnia. ■ Although hypnotic medications may be effective initially,
tolerance usually develops sometimes within a few days;
therefore, their use is not recommended for longer than 2
Gerontologic Considerations weeks. Hypnotic medications reduce REM sleep and may
cause older adults to have nightmares and other sleep cycle
■ Insomnia and hypersomnia are often manifestations of disturbances for several weeks after discontinuation.
depression among older adults. ■ Many hypnotic medications, particularly those with a very
long half-life such as flurazepam (Dalmane), tend to cause
daytime drowsiness and increase the risk for falls. Exam-
ples of hypnotics with shorter half-lives that are better toler-
Insomnia ated by older adults include triazolam (Halcion), temazepam
Insomnia means difficulty in falling asleep, awakening (Restoril), zolpidem (Ambien), or zaleplon (Sonata).
frequently during the night, or awakening early. It results
in feeling unrested the next day. Almost everyone has had
insomnia, and most cases resolve in less than 3 weeks. Hypersomnia
According to the American Psychiatric Association (2000), Hypersomnia is a sleep disorder characterized by feeling
insomnia is considered a sleep disturbance if it occurs over sleepy despite getting normal sleep. Two conditions of hyper-
at least 1 month. Although chronic insomnia can be treated somnia are sleep apnea/hypopnea syndrome and narcolepsy.
with hypnotic drugs, it is helpful to start treatment with Sleep Apnea/Hypopnea Syndrome
nonpharmacologic interventions (see Client and Family Apnea (the cessation of breathing) and hypopnea (hypo-
Teaching 18-1). ventilation) are concomitant forms of hypersomnia: sleep
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apnea/hypopnea syndrome. In this disorder, the sleeper Institute of Neurologic Disorders and Stroke, 2006). If
stops breathing or breathing slows for 10 seconds or longer untreated, the client may become involved in a motor vehi-
five or more times per hour (Rowley, 2009). This is dis- cle crash or occupational accident. Prescribed stimulant
cussed further in Chapter 21. drugs, such as methylphenidate (Ritalin) or amphetamine
During the apneic or hypopneic periods, ventilation (Adderall), help improve alertness. Antidepressants reduce
decreases and blood oxygenation drops. The accumulation the symptoms associated with atypical REM sleep.
of carbon dioxide and the fall in oxygen cause brief periods
of awakening throughout the night. This disturbs the normal Sleep–Wake Cycle Disturbances
transitions and periods of NREM and REM sleep. Conse- A sleep–wake cycle disturbance results from a sleep
quently, clients with sleep apnea/hypopnea syndrome feel schedule that involves daytime sleeping and interferes with
tired after having slept, or worse, their symptoms may cause a biologic rhythms. Changes in the intensity of light trigger
heart attack, stroke, or sudden death from hypoxia (decreased sleeping. When exposure to light comes at an atypical time,
cellular oxygenation) of the heart, brain, and other organs. the sleep–wake cycle is desynchronized. Sleep–wake cycle
The incidence of sleep apnea is highest among older disorders occur among shift workers, jet travelers, and those
adults, especially obese men who snore. Methods to reduce diagnosed with seasonal affective disorder, a cyclical mood
apneic episodes include sleeping in other than the supine disorder believed to be linked to diminished exposure to
position, losing weight, and avoiding substances that sunlight.
depress respirations such as alcohol or sleeping medications.
In severe cases, clients wear a continuous positive airway
pressure (CPAP) mask (see Chap. 21) that keeps the alveoli Gerontologic Considerations
inflated during sleep. Surgery on the tonsils, uvula, pharynx,
tongue, or epiglottis is another treatment option when con- ■ Some older adults with cognitive impairment develop
servative measures are ineffective. sundown syndrome (the onset of disorientation as the
sun sets) (Box 18-3). Others develop sunrise syndrome
(early-morning confusion) associated with inadequate sleep
Gerontologic Considerations or the effects of sedative and hypnotic medications.
■ Older adults may need an evaluation for sleep apnea if

morning headaches or frequent nighttime awakenings Shift Work
occur. Those who work evening or night shifts or who switch from
one shift to another are especially prone to unsynchronized
sleep–wake cycles. The indoor lighting to which most
Narcolepsy
shift workers are exposed is not bright enough to suppress
Narcolepsy is characterized by the sudden onset of daytime
melatonin; consequently, many shift workers fight to stay
sleep, a short NREM period before the first REM phase,
awake. Some experience microsleep, which is uninten-
and pathologic manifestations of REM sleep. This disabling
tional sleep lasting 20 to 30 seconds. Statistics show that
condition should not be confused with hypersomnolence,
shift workers are more prone to errors and accidents from
which is excessive sleeping for long periods, as in Washing-
sleepiness (Harrington, 2001; National Institute for Occu-
ton Irving’s 1819 American folk story, Rip Van Winkle.
pational Safety and Health [NIOSH], 2004). Most people
Although the diagnosis of narcolepsy generally requires
who work night shifts never completely adapt to the reversal
a multiple sleep latency test and polysomnography, its symp-
of day and night activities, no matter how long the pattern
toms help distinguish it from other conditions that cause
is established.
sleepiness. For example, the sleepiness of narcolepsy is
accompanied by the following:
• Sleep paralysis—the person cannot move for a few min-
utes just before falling asleep or awakening B OX 1 8 - 3 Characteristics of Sundown
• Cataplexy—a sudden loss of muscle tone triggered by an Syndrome
emotional change such as laughing or anger • Alert and oriented during the day
• Hypnogogic hallucinations—a dream-like auditory or • Onset of disorientation as the sun sets
visual experiences while dozing or falling asleep • Disorganized thinking
• Automatic behavior—the performance of routine tasks • Restlessness
without full awareness or later memory of having done them • Agitation
• Perseveration (ruminating over the same repetitive thought)
Many older adults experience a decrease in the sever- • Wandering
ity of narcoleptic symptoms after 60 years of age (National
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Jet Travel they disturb others in the household—most significantly,

Jet travel causes a sudden change in the currently established the bed partner. Some examples of parasomnias include the
photoperiod (the number of daylight hours) to which a person following:
is accustomed. Consequently, travelers often describe having
• Somnambulism (sleepwalking)
jet lag, or emotional and physical changes experienced
• Nocturnal enuresis (bedwetting)
when arriving in a different time zone. Many travelers have
• Sleep talking
difficulty falling or staying asleep, but jet lag is more tran-
• Nightmares and night terrors
sient than shift work. Some travelers re-establish normal
• Bruxism (grinding of the teeth)
sleep–wake cycles, but it takes at least 1 day for each time
• Restless legs syndrome (movement typically in the legs
zone that is crossed when traveling east, slightly less when
[but occasionally in the arms or other body parts] to relieve
traveling west.
disturbing skin sensations)
Seasonal Affective Disorder Restless legs syndrome, also known as nocturnal myo-
Seasonal affective disorder is characterized by depression, clonus, may be the most disabling parasomnia. The symp-
hypersomnolence, a lack of energy when awake, increased toms keep the person awake or prevent continuous sleep.
appetite accompanied by cravings for sweets, and weight Eventually, sleep deprivation affects the person’s life, dam-
gain. The symptoms begin during darker winter months and aging work productivity and personal relationships. Medi-
disappear as daylight hours increase in the spring. In some cal etiologies, such as iron deficiency, kidney failure, and
ways, the disorder resembles the hibernation patterns in peripheral nerve pathology, can mimic the manifestations of
bears and other animals. restless legs syndrome. Once these conditions are diagnosti-
Some suggest that seasonal affective disorder results cally eliminated, the condition is confirmed with polysom-
from excessive melatonin. To counteract the symptoms, nography.
phototherapy (a technique for suppressing melatonin by Conservative treatments for parasomnias include safety
stimulating light receptors in the eye) is prescribed. The arti- measures for sleepwalkers (stair gates, security locks on
ficial light used in phototherapy is at least 2,000 to 2,500 lux, doors and windows), mouth devices for bruxism, lifestyle
the equivalent of the bright light measured on a sunny spring changes, nutritional support, and good sleep hygiene. In
day. Clients use the lights for 2 to 6 hours each day to sim- severe cases, drug therapy is used.
ulate the number of daylight hours during sunnier months
(Box 18-4). Phototherapy usually relieves symptoms within
3 to 5 days, but symptoms tend to recur in the same amount
of time if a client abruptly discontinues phototherapy. NURSING IMPLICATIONS
Parasomnia After assessing client comfort and sleep patterns and the
Parasomnias are conditions associated with activities that accompanying symptoms, nurses identify one or more nurs-
cause arousal or partial arousal, usually during transitions in ing diagnoses that require interventions:
NREM periods of sleep. They are not life-threatening, but
• Fatigue
• Impaired bed mobility
• Disturbed sleep pattern
B OX 1 8 - 4 Components of Phototherapy • Sleep deprivation
• Relocation stress syndrome
To relieve the symptoms of seasonal affective disorder, the • Risk for injury
client: • Impaired gas exchange
• Initiates a schedule of full-spectruma light exposure begin-
ning in October and November Nursing Care Plan 18-1 is an example of how the nurs-
• Removes eyeglasses or contact lenses that have ultraviolet ing process has been used to develop a plan of care for a
filters client with Insomnia, defined in the NANDA-I taxonomy
• Sits within 3 ft. of the artificial light for approximately (2012, p. 217) as a “disruption in amount and quality of
2 hours soon after awakening from sleep sleep that impairs functioning.”
• Glances at the light periodically but may engage in other Several sleep-promoting nursing measures, such as
activities such as reading or handiwork
maintaining sleep rituals, reducing the intake of stimulating
• Repeats the exposure to light after sundown (to simulate
chemicals, promoting daytime exercise, and adhering to a
extending the daylight hours) up to a cumulative time of
3 to 6 hours a day regular schedule for retiring and awakening, have already
• Continues the pattern of light exposure until spring been discussed. Two additional beneficial methods are
assisting the client with progressive relaxation exercises and
a
Full-spectrum light simulates the energy of bright natural sunlight. providing a back massage.
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N U R S I N G C A R E P L A N 1 8 - 1 Insomnia
Assessment • Number of times awakened during sleep and reason for
• Ask the client to rate his or her quality of sleep using a awakening
numeric scale of 10 indicating severe disturbance to 0 indicat- • Time of awakening in the morning
ing satisfactory. • Number and length of daytime naps
• Identify sleep aids including medications, alcohol, and sleep • Compare collected data with age-related norms.
rituals and lifestyle practices, such as excessive consumption • Seek information from his or her sleep partner regarding
of caffeine, that may interfere with sleep. symptoms of disorders manifested during sleep, such as snor-
• Inquire about the client’s usual time for retiring and awakening ing interrupted by a period of apnea, unusual movement, or
without an alarm clock. sleepwalking.
• Have the client keep a diary for several days of: • Consult with the family regarding the client’s level of stress,
• Bedtime emotional stability, attention, work endurance, and incidence
• Approximate time for onset of sleep of work-related or driving accidents.
Nursing Diagnosis. Insomnia related to excessive neurostimulation secondary to anxiety over slow recovery from illness as
evidenced by statement, “I’d rate the quality of my sleep at 5. It seems that it takes forever to fall asleep. It’s been 2 weeks since
I’ve gotten more than 4 hours of sleep. I worry constantly that I’ll never go home again,” and need for barbiturate hypnotic that is
repeated each night.
Expected Outcome. The client will sleep within 30 minutes of going to bed and remain asleep for a minimum of 7 hours within
5 days (by 3/15).
Have the client retire at 2100 each evening and arise at 0730 Retiring and arising at a consistent time helps to develop a
each morning regardless of the duration or quality of sleep. sleep–wake pattern.
Allow naps only in early morning. More REM sleep occurs during early morning than afternoon
naps. Increasing REM will improve a feeling of rest and
well-being.
Limit naps to less than 90 minutes. Short naps promote longer sleep cycles during the night, which
in turn contributes to additional REM periods of sleep.
Avoid disturbing the client at night within 100-minute blocks The duration of a complete cycle of NREM and REM sleep is
of sleep. approximately 70–100 minutes four or five times a night.
Reduce or eliminate the client’s intake of caffeine. Caffeine is a central nervous system stimulant that interferes
with relaxation and sleep.
Encourage moderate exercise for at least 20 minutes three Regular exercise promotes sleep but may overstimulate a
times a day but no later than 1930. person if performed close to bedtime.
Provide milk, yogurt, vanilla pudding, custard, or some other Dairy products are a good source of L-tryptophan, which pro-
dairy product at approximately 2030. motes sleep.
Delay administering sleeping medication and give a back Massage promotes relaxation, which is a precursor to sleep.
massage at bedtime. Sleep medications can interfere with REM sleep and may
cause daytime drowsiness.

• The client was observed to fall asleep in 30–45 minutes.
• The client experienced uninterrupted sleep for 3 hours.
• The client’s total duration of sleep was 6–7 hours.
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Rationales
Facilitating Progressive Relaxation
• Select a room that is quiet, private, and dimly lit. Such a setting • Tell the client to tighten the muscles in an area of the body,
reduces stimulation of the arousal center in the brain, which such as the foot, and hold the position for at least 5 seconds.
responds to noise, bright lights, and activity. Tightening a muscle depletes the level of stimulating neuro-
• Encourage the client to assume a comfortable position; this transmitters.
usually involves lying down or sitting. Sitting or lying down • Direct the client to relax the tensed muscles and focus on the
provides external support for the body, which facilitates muscle pleasant feeling. Focusing on the pleasant feeling directs the
relaxation. cortex’s attention to the desired outcome and raises the client’s
• Advise the client to avoid talking and instead listen to the sug- awareness.
gestions that will follow. Advising the client to take a passive • Proceed with sequence after sequence of muscle contraction
role reduces performance anxiety (a worry about appearing followed by relaxation until all muscle groups in the body
incompetent or foolish). have been exercised. Continued tensing and relaxation leads to
• Instruct the client to close the eyes and consciously focus on higher planes of relaxation.
breathing. Closing the eyes blocks visual stimuli; focusing • Continue suggesting throughout that the client focus on how
on breathing helps to turn the client’s attention away from relaxed or weightless he or she feels. These verbal cues rein-
distracting thoughts and feelings. force relaxation.
• Tell the client to inhale deeply through the nose and exhale • Tell the client that as you reach zero after counting backward
slowly out the mouth. Repeat the activity several times. This from 10, he or she can begin to move. This provides a gradual
breathing oxygenates the blood and brain and reduces the end to the relaxation period.
heart rate.
Progressive Relaxation techniques (Table 18-5). Stimulating strokes are omitted if

Progressive relaxation is a therapeutic exercise in which the purpose is to relax the client.
a person actively contracts then relaxes muscle groups to
break the worry–tension cycle that interferes with relaxation ➧ Stop, Think, and Respond Box 18-2
(see Nursing Guidelines 18-1). Describe techniques for maximizing the positive
Clients can learn to perform progressive relaxation effects of a back massage.
exercises independently using self-suggestion. Some clients
eventually omit the muscle contraction phase and go directly
to progressive relaxation of muscle groups. Gerontologic Considerations
■ Sleep may be promoted among older adults with any of

Back Massage the following relaxation techniques before bedtime: imag-
Massage (stroking the skin) promotes two desired out- ery, meditation, deep breathing, soothing music, body or
comes: it relaxes tense muscles and improves circulation foot massage, chair rocking, reading nonstimulating materi-
(Skill 18-3). Nurses perform massage using various stroking als, or watching nonstimulating television programs.
TABLE 18-5 Massage Techniques

TECHNIQUE DESCRIPTION METHOD
Effleurage To skim the surface The hands are used to make a circular pattern using long strokes over the massaged area.
Pétrissage To knead The skin is lifted and compressed or pulled in opposing directions.
Frôlement To brush The skin is lightly touched with the fingertips.
Tapotement To tap The skin is lightly struck with the sides of the hands.
Vibration To set in motion The skin is moved rhythmically with open or cupped palms, causing the tissue to quiver.
Friction To rub The skin is pulled from opposite directions using the thumbs and fingers.
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CRITICAL THINKING EXERCISES 3. To help a client suffering from insomnia, which plan
for nursing care is best?
1. What items in the health care environment would you 1. Administer a prescribed hypnotic drug each
find important in supporting your comfort, rest, and night.
sleep? 2. Try to duplicate the client’s pattern of sleep
2. What actions could a nurse take to promote sleep rituals.
among clients in a hospital or other types of health 3. Have the client exercise for 30 minutes at bedtime.
care facility such as a nursing home? 4. Suggest the client go to bed earlier than the usual
3. Discuss possible effects of suffering from or living time.
with a person who has a sleep disorder. 4. Which of the following are aseptic practices that are
4. Explain why nursing interventions that promote sleep appropriate when making an unoccupied bed? Select
may be preferable to administering a medication that all that apply.
promotes sleep. 1. Raise the bed to a high position.
2. Loosen the bed linen from the mattress.
3. Place clean linen on a chair.
NCLEX-STYLE REVIEW QUESTIONS 4. Hold soiled linen away from the uniform.
5. Place soiled linen directly into a hamper.
1. When observing an unlicensed nursing assistant make
5. When observing a sleeping client, which of the fol-
an occupied bed, which of the following actions indi-
lowing suggests that the client is in REM sleep?
cates a need for further learning?
Select all that apply.
1. The assistant loosens all the linen under the client.
1. Muscle twitching
2. The assistant wears gloves to remove soiled linen.
2. Snoring
3. The assistant keeps the bed in a low position.
3. Little physical movement
4. The assistant rolls the client to the far side of the
4. Darting movement beneath the eyelids
bed.
5. Talking while asleep
2. When making an unoccupied bed of a client who has
been incontinent of stool, which action is essential?
1. The nurse discards all linen.
2. The nurse dons clean disposable gloves.
3. The nurse uses a fitted bottom sheet.
4. The nurse puts a blanket over the top sheet.
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SKILL 18-1 Making an Unoccupied Bed
ASSESSMENT
Check the Kardex or nursing care plan to determine the client’s Determines if the client can be out of bed during bedmaking.
activity level.
Inspect the linen for moisture or evidence of soiling. Indicates what and how much linen must be changed and if
gloves are appropriate when removing soiled linen.
PLANNING
Plan to change the linen after the client’s hygiene needs have Reduces the potential for wetting or soiling the clean linen.
been met.
Chap. 10). Use gloves if there is a potential for direct contact
with blood, stool, or other body fluids.
Bring necessary bed linen to the room. Demonstrates organization and efficient time management.
Place the clean linen on a clean, dry surface such as the seat or Reduces transmission of microorganisms to clean supplies.
back of a chair (Fig. A).
Arranging clean bed linen. (Photo by B. Proud.)
Assist the client from the bed. Facilitates bedmaking.
IMPLEMENTATION
Raise the bed to a high position and lower the side rails. Prevents postural and muscular strain.
Remove equipment attached to the bed linens, such as the Avoids breakage, spills, or loss of personal items.
signal cord and drainage tubes, and check for personal
items.
Loosen the bed linen from where it has been tucked under the Facilitates removal or retightening.
mattress.
Fold any linen that may be reused and place it on a clean Promotes efficiency and orderliness.
surface.
(continued)
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Making an Unoccupied Bed (continued)
Don gloves, if necessary, and roll linen that will be replaced so Gloves are a standard precaution to provide a barrier between
that the soiled surface is enclosed (Fig. B). the nurse and blood or body fluids; gloves are unnecessary
if linen does not contain blood or body fluid. Rolling linen
with the soiled side inward reduces contact with sources
of microorganisms.
Enclosing soiled side of linen. (Photo by B. Proud.)
Remove the soiled linen while holding it away from your uniform Prevents transferring microorganisms to your uniform and then to
(Fig. C). other clients.
Avoiding contact with uniform. (Photo by B. Proud.)
C
(continued)
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Place the soiled linen directly into a pillowcase, laundry hamper, Keeps the soiled linen from being further contaminated.
or self-made pouch from one of the removed sheets (Fig. D).
Do not place the soiled linen on the floor.
Placing soiled linen in hamper. (Photo by B. Proud.)
Remove gloves and wash hands or perform hand antisepsis Facilitates use of the hands.
with an alcohol rub (see Chap. 10) once contact with body
secretions is no longer likely.
Reposition the mattress so it is flush with the headboard. Provides maximum foot room.
Tighten any linen that will be reused. Removes wrinkles, which promotes client comfort.
If the bottom sheet needs changing, center the longitudinal fold Reduces postural strain.
and open the layers of folded linen to one side of the bed.
If using a flat sheet, make sure the flat edge of the hem is flush Prevents skin pressure and irritation.
with the edge of the mattress at the foot end.
If using a flat sheet, tuck the upper portion under the mattress. Anchors the bottom sheet.
Make a mitered or square corner at the top of the bed.
If using a fitted sheet, position the upper and lower corners
of the mattress within the contoured corners of the sheet
(Fig. E).
Stretching the fitted sheet taut. (Photo by B. Proud.)
E
(continued)
LWBK1004-C18_p374-398.indd 391 31/01/12 1:36 AM

If the client is apt to soil the linen with urine or stool, fold a flat Reduces the need to change all the bottom linen.
sheet horizontally with the smooth edge of the hem toward
the foot of the bed and tuck it in place approximately where
the buttocks will be. Do the same if a draw sheet is available
(Fig. F).
Smoothing the draw sheet before securing it snugly under the mattress.
Position the top linen on one half of the bed at this time. Move Saves time by reducing the number of moves around the bed.
to the other side of the bed, pull the linen taut, and tuck the
free edges beneath the mattress.
Alternatively, wait until you have secured all the bottom linen to Secures and smooths the bottom linens.
position the top sheet.
Center the top sheet and unfold it to one side, leaving sufficient Provides a smooth edge next to the client’s neck.
length at the top to make a fold over the spread.
Add blankets if the client wishes. Demonstrates concern for the client’s comfort.
Cover the top sheet with the spread if desired. Tuck the excess Secures the top linen.
linen at the foot of the bed under the bottom of the mattress
and finish the sides with a mitered or square corner (Fig. G).
1 2 3
G
(1) Folding the edge of the top sheet back onto itself. (2) Tucking the edge hanging from the bed under the mattress. (3) Pulling
the top sheet taut. (Photo by B. Proud.)
(continued)
LWBK1004-C18_p374-398.indd 392 31/01/12 1:36 AM

Smooth the top sheet (Fig. H).
Smoothing the top sheet. (Photo by B. Proud.)
Gather the pillowcase as you would hosiery and slip the case Prevents contact between the pillow and your uniform.
over the pillow (Fig. I).
Covering the pillow. (Photo by B. Proud.)
Place the pillow at the head of the bed with the open end away Presents a tidy view of the room from the hallway; prevents pres-
from the door and the seam of the pillowcase toward the sure on the skin around the head and neck.
headboard. (continued)
LWBK1004-C18_p374-398.indd 393 31/01/12 1:37 AM

Fan-fold or pie-fold the top linen toward the foot of the bed Facilitates returning to bed.
(Fig. J).
Prefolding the linen. (Photo by B. Proud.
Secure the signal device on or to the bed. Ensures that the client can receive nursing assistance.
Adjust the bed to a low position. Enables the client to return to bed.
Chap. 10).
Evaluation
• The bed is clean and dry.
• The linen is free of wrinkles.
• The environment is orderly.
• The client feels comfortable.
Document
• Date and time
• Characteristics of drainage, if present
• Any unique measures taken to ensure client comfort
Date and Time Menses established. Bed linen changed while shower taken. Given a supply of sanitary napkins. Absorb-
ent pad placed over bottom sheet. SIGNATURE/TITLE
LWBK1004-C18_p374-398.indd 394 31/01/12 1:37 AM

SKILL 18-2 Making an Occupied Bed
ASSESSMENT
Check the Kardex or nursing care plan to confirm that the client Demonstrates compliance with the care plan.
must remain in bed.
Assess the client’s level of consciousness, physical strength, Indicates a need for bedrest if abnormal findings are noted,
breathing pattern, heart rate, and blood pressure. whether it has been prescribed or not.
Inspect the linen for moisture or evidence of soiling. Indicates what and how much linen must be changed and if
gloves are appropriate when removing soiled linen.
Determine who might be available to assist if the client is too Avoids postural or muscular injury and ensures the client’s
weak or unable to cooperate. comfort and safety.
PLANNING
Plan to change the linen after the client’s hygiene needs have Reduces the potential for wetting or soiling the clean linen.
been met.
Chap. 10). Use gloves if there is a potential for direct contact
with blood, stool, or other body fluids.
Bring necessary bed linen to the room. Demonstrates organization and efficient time management.
Place the clean linen on a clean, dry surface such as the back of Reduces the transmission of microorganisms to clean supplies.
a chair.
IMPLEMENTATION
Explain what you plan to do. Informs the client and promotes cooperation.
Raise the bed to a high position. Prevents postural and muscular strain.
Cover the client with a bath blanket or leave the top sheet Maintains warmth and demonstrates respect for modesty.
loosened but in place.
Fold the top sheet or spread if it will be reused and place it on a Promotes efficiency and orderliness.
clean surface.
Unfasten equipment attached to the bottom linen and check for Avoids breakage, spills, or loss of personal items.
personal items.
Loosen the bed linen from where it has been tucked under the Facilitates removal or retightening.
mattress.
Lower the rail on the side of the bed where you are standing Provides room for making the bed while ensuring the client’s
and roll the client toward the opposite side rail. safety.
Roll the soiled bottom sheets as close to the client as possible. Facilitates removal.
Proceed to unfold and tuck the bottom sheet and drawsheet on Remakes half of the bed with clean linen.
the vacant side of the bed, as described in Skill 18-1 (Fig A).
Changing linen on half of the bed. (Photo by B. Proud.)
Fold the free edges of the sheet under the folded portion of the Keeps the clean sheet from becoming soiled; facilitates pulling
soiled sheets. the sheets from under the client.
Raise the side rail and move to the opposite side of the bed. Prevents postural and muscular strain.
(continued)
LWBK1004-C18_p374-398.indd 395 31/01/12 1:37 AM

Making an Occupied Bed (continued)
Lower the side rail in your new position and help the client to Helps reposition the client on the clean side of the bed.
roll over the mound of sheets.
Pull the soiled laundry close to the edge of the bed and the Reduces the mound of linen in the center of the bed.
clean linen close beside it.
Remove the soiled linen and place it into a pillowcase or pouch Keeps the soiled linen from becoming further contaminated.
that is off the floor.
Pull the clean bottom sheet until it is unfolded from beneath the Promotes client comfort.
client (Fig. B).
Pulling the clean linen through. (Photo by B. Proud.)
Miter or square the upper corner of the sheet; pull and tuck the Secures the clean sheets.
free edges under the mattress.
Assist the client to the middle of the bed. Ensures comfort and safety.
Straighten or replace the top sheet, blankets, and spread; Restores comfort and orderliness to the environment.
remove and replace the pillowcase if necessary.
Reposition the client according to the therapeutic regimen or Demonstrates compliance with the care plan; shows concern for
comfort. client comfort.
Lower the height of the bed and raise the remaining side rail if Reduces the potential for injury.
appropriate.
Dispose of the soiled linens in a laundry hamper outside of the Restores order to the room and ensures that the linens will be
room. collected for laundering.
Wash hands or perform hand antisepsis with an alcohol rub Reduces the transmission of microorganisms.
(see Chap. 10).
Evaluation
• The bed is clean and dry.
• The linen is free of wrinkles.
• The environment is orderly.
• The client feels comfortable.
Document
• Date and time
• Characteristics of drainage, if present
• Measures taken to ensure client comfort.
Date and Time Unresponsive even to painful stimuli. Complete bed bath given followed by linen change. Repositioned on
L side with head at a 45-degree elevation. Full side rails raised. Bed in low position. ___ SIGNATURE/TITLE
LWBK1004-C18_p374-398.indd 396 31/01/12 1:37 AM

SKILL 18-3 Giving a Back Massage
ASSESSMENT
Observe if the client is still awake 30 minutes after retiring for Indicates a delay in the usual onset of sleep.
sleep.
Determine if the client is experiencing pain, has a need for blad- Eliminates all but psychophysiologic etiologies as the cause for
der or bowel elimination, is hungry, is too warm or cold, or sleeplessness.
has any other physical or environmental problem that may be
easily overcome.
Check the medical record to determine if the client has any con- Demonstrates concern for the client’s safety and comfort.
dition that would contraindicate a backrub, such as fractured
ribs or a back injury.
Ask the client if he or she would like a back massage. Allows the client an opportunity to participate in decision making.
PLANNING
Obtain lotion or an alternative substance such as alcohol or Demonstrates organization and efficient time management.
powder if the client’s skin is oily.
Use gloves if there are any open, draining lesions on the skin. Provides a barrier against blood-borne microorganisms.
Reduce environmental stimuli such as bright lights and loud noise. Decreases stimulation of the wake center in the brain.
IMPLEMENTATION
Pull the privacy curtain around the client’s bed. Demonstrates respect for modesty.
Raise the bed to an appropriate height to avoid bending at the Reduces back strain.
waist.
Chap. 10); don gloves if appropriate.
Help the client to lie on the abdomen or side, and untie the Provides access to the back.
hospital gown or remove it completely.
Instruct the client to breathe slowly and deeply in and out Promotes ventilation and relaxation.
through an open mouth.
Squirt a generous amount of lotion into your hands and rub Warms the lotion.
them together.
Place the entire surface of the hands on either side of the lower Uses effleurage to promote relaxation.
spine and move them upward over the shoulders and back
again using long, continuous strokes. Repeat the stroke pat-
tern several times (Fig. A).
Effleurage Effleurage
(example 1). (example 2).
Apply firmer pressure with the upstroke and lighter pressure Enhances relaxation by alternating pressure and rhythm.
during the downstroke.
Make smaller circular strokes up and down the length of the Improves blood flow and removes chemicals that accumulate in
back with the thumbs. contracted muscles.
(continued)
LWBK1004-C18_p374-398.indd 397 31/01/12 1:37 AM

Giving a Back Massage (continued)
Lift and gently compress tissue with the fingers, starting at the Uses pétrissage to increase blood circulation.
base of the spine and ending at the neck and shoulder areas
(Fig. B).
Pétrissage Pétrissage
(example 1). (example 2).
Frôlement.
Pull the skin in opposite directions in a kneading fashion to lift Uses another pétrissage technique to reduce tension in muscles
and stretch it from the base of the spine to the shoulder and improve circulation.
areas.
End the backrub by lightly stroking the length of the back, Uses frôlement to prolong the sensation of relaxation.
gradually lightening the pressure as you move the fingers
downward (Fig. C).
Lightly cover the client and lower the bed. Extends the period of relaxation by reducing activity and may
induce NREM sleep.
Evaluation
• Client feels relaxed.
• Sleep is promoted.
Document
• Date and time of back massage
• Response of client
Date and Time Unable to sleep. Assisted to bathroom to void. Light snack of graham crackers and milk provided. Back
massaged for 10 minutes. Observed to be sleeping 20 minutes later. SIGNATURE/TITLE
LWBK1004-C18_p374-398.indd 398 31/01/12 1:37 AM

Photo to
Come
FPO
19# Safety
asphyxiation
chemical restraints
drowning 1. Discuss the purpose of the National Patient Safety goals and
electrical shock methods for implementing them.
environmental hazards 2. Give an example of one common injury that predominates dur-
fire plan ing each developmental stage (infancy through older adulthood).
latex-safe environment 3. Name six injuries that result from environmental hazards.
latex sensitivity 4. Identify at least two methods for reducing latex sensitization.
macroshock 5. List four areas of responsibility incorporated into most fire plans.
microshock 6. Describe the indications for using each class of fire
National Patient Safety Goals extinguishers.
physical restraints 7. Discuss five measures for preventing burns.
poisoning 8. Name three common causes of asphyxiation.
restraint alternatives 9. Discuss two methods for preventing drowning.
safety 10. Explain why humans are susceptible to electrical shock.
thermal burn 11. Discuss three methods for preventing electrical shock.
12. Name at least six common substances associated with
poisonings.
13. Discuss four methods for preventing poisonings.
14. Discuss the benefits and risks of using physical restraints.
15. Explain the basis for enacting restraint legislation and the Joint
Commission’s accreditation standards.
16. Differentiate between a restraint and a restraint alternative.
17. Give at least four criteria for applying a physical restraint.
18. Describe two areas of concern during an accident.
19. Explain why older adults are prone to falling.
S
afety (measures that prevent accidents or unintentional injuries)
is a major nursing responsibility. The Joint Commission considers
safety a priority when caring for clients and began establishing Na-
tional Patient Safety Goals in 2003. The purpose of these goals is
to help health care organizations obtain and retain their accreditation by
demonstrating safe and effective care of the highest quality by reducing
the risk of adverse client outcomes. The goals are revised yearly based
on the recommendations of the Patient Safety Advisory Group to reduce
the incidences of deaths and injuries among those being cared for in
health agencies (Table 19-1). Methods of implementing the goals are
integrated within skills that appear in this text.
Most hospital deaths and injuries are attributed to medication errors
and adverse medication effects, infections, and surgical errors (Starfield,
2000). If identified and ranked by the National Center for Health Sta-
tistics, deaths from hospital errors, excluding preventable deaths due to
medical treatments outside of hospitals, would be between the fifth and
eighth leading cause of death (Woo et al., 2008). Such findings validate
399
LWBK1004-C19_p399-416.indd 399 2/6/12 7:25 PM

TABLE 19-1 Summary of National Patient Safety Goals 2009–2010

GOAL IMPLEMENTATION
Prevent infection Follow handwashing and hand antisepsis guidelines recommended by the Centers for
Disease Control and Prevention or the World Health Organization.
Use evidence-based practices to prevent and treat infections.
Promote influenza and pneumococcal immunizations among institutionalized older adults.
Identify patients/clients correctly Use at least two methods for identification (for example, the client’s name and date of
birth) prior to administering medications or performing a treatment such as a blood
transfusion.
Improve staff communication Use only approved abbreviations and symbols.
Contact appropriate health care providers promptly when a client’s health status changes.
Inform the appropriate person quickly about important test results.
Repeat or read back verbal and phone orders.
Discuss a client’s care with a subsequent caregiver prior to a transfer.
Use medicines safely Label all medications that are not already labeled in syringes, cups, and basins; be espe-
cially cautious with clients who take medications that thin the blood.
Confirm that any new medication or medication prescribed in small amounts or for a short
time is appropriate to take with current medications.
Provide a list of the client’s current medications to the physician, client, family, and next
caregiver prior to the client’s discharge.
Identify clients with safety risks Assess clients who are at risk for falls, suicide, and fires from oxygen administration, and
institute precautionary measures.
Prevent pressure ulcers Determine which clients are at risk for pressure ulcers, develop a plan for their prevention,
and reassess periodically.
Prevent surgical errors Mark the body part intended for surgery; include the client’s participation.
Perform a “time out” to check the client and required documents immediately before a
surgical procedure begins.
Involve clients in their care Inform clients how to report safety issues.
Adapted from The 2009 National Patient Safety Goals. http://www.jointcommission.org/NR/rdonlyres/40A7233C-

C4F7-4680-80CDFD5F62CF/09_NPSG_HAP_gp.pdf; 2010 National Patient Safety Goals. http://www.jointcommis-
sion.org/GeneralPublic/NPSG/10_npsgs.htm.
the conclusion that receiving health care is an extreme risk School-Aged Children and Adolescents
to a person’s safety. This chapter examines factors that place School-aged children are physically active, which makes
people at risk for injuries, environmental hazards in homes them prone to play-related injuries. Many adolescents suf-
and health care facilities, and nursing measures that keep fer sports-related injuries because they participate in physi-
clients safe. cally challenging activities—sometimes without adequate
protective equipment—before their musculoskeletal sys-
tems can withstand the stress. Adolescents also tend to be
AGE-RELATED SAFETY FACTORS impulsive and take risks as a result of poor judgment and
peer pressure.
No age group is immune to accidental injury. Distinct dif-
ferences among age groups exist, however, because of vary- Adults
ing levels of cognitive function and judgment, activity and Adults are at risk for injuries from ignoring safety issues,
mobility, and degree of supervision, as well as the design of fatigue, sensory changes, and effects of disease. The types
and safety devices within physical surroundings. of injuries that young, middle-aged, and older adults incur
depend on their social, developmental, and physical differ-
Infants and Toddlers ences (Table 19-2).
Infants rely on the safety consciousness of their adult care-
takers. They are especially vulnerable to injuries resulting
from falling off changing tables or being unrestrained in ENVIRONMENTAL HAZARDS
automobiles. Toddlers are naturally inquisitive and more
mobile than infants and fail to understand the dangers that Environmental hazards are potentially dangerous condi-
accompany climbing. Consequently, they are often the vic- tions in the physical surroundings. Examples in the home
tims of accidental poisoning, falls down stairs or from high and health care environment include latex sensitization,
chairs, burns, electrocution from exploring outlets or manip- thermal burns, asphyxiation, electrical shock, poisoning,
ulating electric cords, and drowning. and falls.
LWBK1004-C19_p399-416.indd 400 2/6/12 7:25 PM

CHAPTER 19 Safety 401
TABLE 19-2 Age-Related Factors Affecting Adult Safety

ADULT GROUP CONTRIBUTING FACTORS COMMON TYPES OF INJURIES
Young adults Alcohol and drug abuse Motor vehicle collisions
Emancipation from parental supervision Boating accidents
Naiveté about workplace hazards Head and spinal cord injuries
Eye injuries, chemical burns, traumatic ampu-
tations, and soft tissue and back injuries
Middle-aged adults Failure to use safety devices Physical trauma (see previous)
Overexertion and fatigue Burns and asphyxiation related to nonfunc-
Disregard for use of seat belts and car safety harnesses tioning smoke, heat, and carbon monoxide
Lack of expertise in performing home maintenance or repairs detectors
Older adults Visual impairment Falls
Urinary urgency Poisoning/medication errors
Postural hypotension Hypothermia and hyperthermia
Reduced coordination Scalds and burns
Impaired mobility
Inadequate home maintenance
Mental confusion
Impaired temperature regulation
Latex Sensitization Sensitized people also can develop a cross-reaction to

Increasing numbers of people are developing latex sensitivity fruits and vegetables such as avocados, bananas, almonds,
(allergic response to the proteins in latex). Latex, a natural peaches, kiwi, tomatoes, and others because the molecular
rubber sap whose origin is a species of tree indigenous to structure of latex and other plant substances is similar.
Brazil, is a component of many household items, such as
Safeguarding Clients and Personnel
balloons, envelope glue, erasers, and carpet backing, as well
One of the best techniques for preventing latex sensiti-
as health care products. Health-related sensitization is partly
zation and allergic reactions is to minimize or eliminate
the result of repeated exposure to latex in medical gloves
latex exposure. Health care agencies now provide person-
and other equipment (Box 19-1). Clients predisposed to
nel with more than one type of glove (Table 19-3). If they
latex sensitivity include those with a history of asthma and
use latex gloves, nurses should avoid using oil-based hand
allergies to other substances, multiple surgeries, and recur-
creams or lotions and should wash their hands thoroughly
ring medical procedures.
after removing gloves to reduce the transfer of latex pro-
Types of Latex Reactions teins to others and to other objects in the environment.
Sensitization follows latex exposure through the skin, Other measures to protect clients and personnel include
mucous membranes, inhalation, ingestion, injection, or the following:
wound management. The two forms of allergic reactions to • Obtaining an allergy history, and a sensitivity to latex in
latex or the chemicals used in its manufacture are as follows: particular
• Contact dermatitis, a delayed localized skin reaction that • Flagging the chart and room door and attaching an allergy-
occurs within 6 to 48 hours and lasts for several days alert identification bracelet on latex-sensitive clients
• Immediate hypersensitivity, an instantaneous or fairly • Assigning clients with a latex allergy to a private room or
prompt systemic reaction manifested by swelling, itching, latex-safe environment (room stocked with latex-free
respiratory distress, hypotension, and death in severe cases equipment and wiped clean of glove powder)
• Stocking a latex-safe cart containing synthetic gloves and
latex-free client care and resuscitation equipment in the
room of a client sensitive to latex
B OX 1 9 - 1 Common Items Containing Latex • Communicating with personnel in other departments so
that they use nonlatex equipment and supplies during diag-
Medical gloves Intravenous injection ports
nostic or treatment procedures
Band-Aids Nondisposable sheet protectors
Bulb syringes Stethoscope tubing • Reporting allergic events and their possible cause promptly
Medication vial stoppers Tourniquets to the agency’s administration; administrators are required
Urinary catheters Elastic (Jobst) stockings to report injuries, serious illnesses, or deaths from unsafe
Condoms Mattress covers equipment to the U.S. Food and Drug Administration
Wound drains Dental bands • Referring sensitized clients to latex allergy support groups
Endoscopes Blood pressure cuffs and tubing • Recommending that latex-sensitive clients wear a Medic-
Alert bracelet at all times
LWBK1004-C19_p399-416.indd 401 2/6/12 7:25 PM

TABLE 19-3 Types of Medical Gloves

Latex
Powdered latex Inexpensive Releases latex protein allergen into the air via
Elastic powder
Adequate barrier against blood-borne pathogens
Low-powder latex Less potential for airborne distribution of latex and Unproven ability to prevent sensitization
chemical proteins
Powder-free latex Reduced sensitization of nonallergic individuals Deposits latex protein on surface environment,
from lack of airborne distribution of latex allergen causing symptoms in sensitized individuals
Slightly more expensive than powdered latex
gloves
Low-protein latex Less latex protein No significant evidence that use eliminates
sensitization
Nonlatex
Vinyl—powder and powder-free Similar strength of latex gloves Less durable and more likely to leak than latex
Cost approximately the same as powdered latex Recommend changing after 30 minutes to
gloves maintain barrier protection
Nitrile Better resistance to tears, punctures, and chemical Possible contact dermatitis from chemicals
disintegration than latex or vinyl gloves contained in nitrile
More expensive than latex or vinyl
Neoprene Fit, strength, and barrier protection similar to latex Contains potentially allergic chemicals
More expensive than nitrile gloves
Thermoplastic elastomer Strength and protection similar or superior to latex Free of latex or chemical allergens
Most expensive of all gloves
• Advising latex-sensitive clients to notify their employer’s • Use of the fire alarm system
health officer about the allergy in case of a future claim for • Roles in preparing for building evacuation
worker’s compensation or a legal case concerning discrim- • Location and proper use of equipment for evacuation or
ination in the workplace transporting clients to areas of refuge
• Building compartmentalization procedures for containing
Burns smoke and fire (National Fire Protection Agency, 2006)
A thermal burn is a skin injury caused by flames, hot liq-
To obtain the Joint Commission’s accreditation, staff
uids, or steam and is the most common form of burn. Burns
members on each shift also must participate in fire drills,
also result from contact with caustic chemicals such as lye,
the frequency of which must be identified in the agency’s
electric wires, or lightning.
fire plan.
Burn Prevention
Because many adults become complacent about safety haz- Fire Management
ards, the nurse reviews burn-prevention measures with cli- The National Fire Protection Association, whose Life Safety
ents being treated for thermal-related accidents (see Client Code is the basis for the Joint Commission’s management
and Family Teaching 19-1). standards, recommends using the acronym RACE to identify
Exits must be identified, lighted, and unlocked. Most fire the basic steps to take when managing a fire:
codes require that public buildings, including hospitals and R—Rescue
nursing homes, have a functioning sprinkler system. Sprin- A—Alarm
kler systems help control fires and limit structural damage. C—Confine (the fire)
E—Extinguish
Fire Plans
To prevent or limit burn injuries in a health care setting, all Most health care agencies incorporate these concepts by
employees must know and follow the agency’s fire plan including the following actions in their fire plans:
(procedure followed for a possible or actual fire). Compli-
• Evacuate clients from the room with the fire.
ance with the fire plan is a major component of the Joint
• Inform the switchboard operator of the fire’s location. He
Commission’s inspection. Every accredited health care
or she will alert personnel over the public address system
agency must demonstrate and document that staff members
and notify the fire department.
have been trained in the following five areas:
• Return to the nursing unit when an alarm sounds; do not
• Specific roles and responsibilities at and away from the use the elevator.
fire’s point of origin • Clear the halls of visitors and equipment.
LWBK1004-C19_p399-416.indd 402 2/6/12 7:25 PM


Burn Prevention
The nurse teaches the client or the family the following: ● Never run if clothing is on fire; instead stop, drop, and roll.
● Do not overload electrical outlets or circuits.
● Change the batteries in smoke, heat, and carbon monox-
● Set thermostats on hot water heaters to less than 120°F
ide detectors at least every year.
● Equip the home with at least one fire extinguisher. (48.8°C).
● Keep cords to coffee pots, electric frying pans, or other
● Develop an evacuation plan (and an alternate escape
route) and a place for family members to meet after exit- small cooking appliances above the reach of young
ing a burning home. children.
● Follow label directions about the use of gloves when
● Practice the evacuation plan periodically.
● Keep all windows and doors barrier free. using chemicals.
● Flush chemicals with copious amounts of water if they
● Identify the location of exits when staying in a hotel.
● Dispose of rags that have been saturated with solvents. come in contact with skin.
● Go inside if the weather is threatening or you see lightning.
● Keep items away from the pilot lights on the furnace,
● If you are inside a burning building:
water heater, or clothes dryer.
● Feel if the surface of a door is hot before opening it.
● Avoid storing gasoline, kerosene, turpentine, or other solvents.
● Close doors behind you.
● Go to public fireworks displays rather than igniting them
● Crawl on the floor if the room is smoke-filled.
at home.
● Use stairs rather than elevators.
● Never smoke when sleepy or around oxygen equipment.
● Never go back inside, regardless of whom or what has
● Use safety matches rather than a lighter; children are less
capable of using matches. been left there.
● Go to a neighbor’s home to call the fire department or
● Buy clothing, especially sleepwear, made from natural or
flame-resistant fabrics. 911 operator.
• Close the doors to client rooms and stairwells as well as Rescue and Evacuation
fire doors between adjacent units. Wait for further direc- The first priority is to rescue clients in the immediate vicin-
tions. ity of the fire. Nurses lead those who can walk to a safe area
• Place moist towels or bath blankets at the threshold of and close the room and fire doors after exiting. Nursing
doors if smoke is escaping. personnel evacuate those who cannot walk using a variety of
• Use an appropriate fire extinguisher if necessary. techniques (Fig. 19-1).
FIGURE 19-1 Evacuation of clients.

A. Human crutches—rescuers secure a
weak but ambulatory client’s arm and
waist. B. Seat carry—rescuers inter-
lock arms and carry a nonambulatory
client. C. Body drag—rescuer drags an C
unconscious victim or one who can-
not assist on a blanket or sheet.
LWBK1004-C19_p399-416.indd 403 2/6/12 7:25 PM

TABLE 19-4 Types of Fire Extinguishers

TYPE SYMBOL CONTENTS USE
Class A Water under pressure Burning paper, wood, and cloth
A
Class B Carbon dioxide Fires caused by gasoline, oil, paint,
B grease, and other flammable
liquids
Class C Dry chemicals Electrical fires
C
Class ABC (combination Graphite Fires of any kind
extinguisher)
A B C
Fire Extinguishers detector, however, when it begins to emit an audible alarm

There are four types of fire extinguishers (Table 19-4). Each signaling low battery power, and they fail to replace the
type is labeled. Nurses must know the type of extinguisher batteries.
that is appropriate for the burning substance and how to use
it (see Nursing Guidelines 19-1). Carbon Monoxide
CO, an odorless gas, is released during the incomplete com-
Asphyxiation bustion of carbon products such as fossil fuels (eg, kerosene,
Asphyxiation (an inability to breathe) can result from air- natural gas, wood, and coal; substances commonly used to
way obstruction (see Chap. 37), drowning, or inhalation of heat homes). When inhaled, CO binds with hemoglobin and
noxious gases such as smoke or carbon monoxide (CO). interferes with the oxygenation of cells. Without adequate
ventilation, the consequences can be lethal.
Smoke Inhalation Because CO can be present even without smoke, CO
Smoke can be more deadly than fire. Almost all health care detectors should be installed in all homes, and fire depart-
facilities have banned cigarette smoking; consequently, ment personnel should investigate alarms. Without detec-
smoke inhalation now accounts for far fewer deaths. How- tors, victims may be unaware of the presence of CO and
ever, when a fire occurs, regardless of its location or cause, may attribute their symptoms to the flu (Box 19-2). As their
smoke inhalation results in 50% to 80% of the deaths rather condition deteriorates, they become confused and lapse into
than burns (Holstege, 2007; Fig. 19-2). a coma, followed by death.
Despite efforts to ban smoking, there continues to be a If a person is suspected of being poisoned by CO, ini-
risk for fires from smoking in health care facilities and other tial treatment requires getting the victim out of the present
nonresidential locations. Some attribute this to the fact that environment. If moving the person out of doors is impos-
secretive smokers tend to discard smoldering cigarette butts sible, rescuers should open windows and doors to reduce the
quickly in order to avoid being discovered. Home fires, on the level of toxic gas and promote adequate ventilation. Once
other hand, often occur when smokers fall asleep with a burn- emergency personnel arrive, they administer oxygen. In
ing cigarette or when children play with matches or lighters. the case of extremely high blood levels of CO, the victim
Many homes and apartment buildings are equipped may be treated with hyperbaric (high-pressure) oxygen (see
with smoke detectors. Some people dismantle their smoke Chap. 21).

Rationales
Using a Fire Extinguisher
• Know the location of each type of fire extinguisher. Doing so • Move the nozzle from side to side. Doing so increases the
minimizes response time. effectiveness of fire control.
• Free the extinguisher from its enclosure. The extinguisher must • Avoid skin contact with the contents of the fire extinguisher.
be removed for use. The chemicals in the extinguisher can cause injury.
• Remove the pin that locks the handle. The pin must be removed • Return the extinguisher to the maintenance department. The
for use. extinguisher will be replaced or refilled for future use.
• Aim the nozzle near the edge, not the center, of the fire. The
chemical will contain the fire.
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Other known fore, nurses should never leave any helpless or cognitively
confined fire impaired client, young or old, alone in a tub of water regard-
Confined heating 1% Smoking
equipment 1% less of its depth.
3% Victims of cold-water drownings are more likely to be
Contained
trash or
resuscitated because the cold lowers their metabolism, thus
rubbish fire conserving oxygen (see Chap. 12). Prevention, however, is
9% far better:
• Learn to swim.
• Never swim alone.
• Wear an approved flotation device.
• Do not drink alcohol when participating in water-related
sports.
Confined cooking • Notify a law enforcement officer if boaters appear unsafe.
equipment
49% Resuscitation
Nonconfined Cardiopulmonary resuscitation (CPR), if begun imme-
37% diately, may be lifesaving for a victim of asphyxiation or
drowning. Current CPR certification is generally an employ-
ment requirement for nurses. Many hospitals teach new par-
ents how to administer CPR (Fig. 19-3).
Electrical Shock
Electrical shock (the discharge of electricity through the
body) is a potential hazard wherever there are machines and
FIGURE 19-2 Fire statistics as collected by the National Fire electrical equipment. The body is susceptible to electrical
Protection Association. (From Flynn, J. [2009]. Structure fires shock because it is composed of water and electrolytes, both
in medical, mental health, and substance abuse facilities.
National Fire Protection Association. Accessed March 15, 2010,
of which are good conductors of electricity. A conductor is
from http://www.nfpa.org/assets/files/PDF/ a substance that facilitates the flow of electrical current; an
MentalHealthExecSum.pdf) insulator is a substance that contains electrical currents so
they do not scatter. Electric cords are covered with rubber or
some other insulating substance.
Drowning Macroshock is a harmless distribution of low-amperage
Drowning is a condition in which fluid occupies the air- electricity over a large area of the body. It feels like a slight
way and interferes with ventilation. It can occur in swim- tingling. Microshock is low-voltage but high-amperage dis-
mers and nonswimmers alike. Accidental drownings occur tribution of electricity. A person with intact skin usually does
during water activities such as fishing, boating, swimming, not feel microshock because intact skin offers resistance or
and water skiing. Some incidents are linked to alcohol abuse, acts as a barrier between the electrical current and the water
which tends to interfere with judgment and promotes risk
taking. Other victims overestimate their stamina.
Drownings also can occur at home or in health care
environments. Young children can drown if left momentar-
ily in a bathtub or if they have access to a swimming pool.
Swimming pools should be fenced and locked, and children
should never be left unattended in a bathtub or pool.
Although the potential for drowning in a health care
institution is statistically remote, it can happen. There-
B OX 1 9 - 2 Symptoms of Carbon Monoxide

Poisoning
Nausea Confusion
Vomiting Shortness of breath
Headache Cherry-red skin color
Dizziness Loss of consciousness
Muscle weakness FIGURE 19-3 Parents being taught cardiopulmonary resuscita-
tion as part of discharge planning. (Photo by B. Proud.)
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and electrolytes within. If the skin is wet or its integrity is Gerontologic Considerations
impaired, however, the electrical current can be fatal, espe-
cially if delivered directly to the heart. ■ Older adults with cognitive impairments need protection
Use of grounded equipment reduces the potential for from accidental ingestion of toxic substances, such as
electrical shock. A ground diverts leaking electrical energy medications and cleaning agents, in households and institu-
to the earth. Grounded equipment can be identified by the tional settings. These items should be kept in secure,
presence of a three-pronged plug. locked locations at all times.
In addition to using grounded equipment, other safety
measures to prevent electrical shock include the following:
Health care facilities have fewer poisonings because
• Never use an adaptor to bypass a grounded outlet. they keep medications locked. By law, they must keep chem-
• Make sure all outlets and switches have cover plates. icals such as liquid antiseptics, which are intended for exter-
• Plug all machines used for client care into outlets within nal use, separate from other drugs. Nevertheless, medication
12 ft. of one another or within the same cluster of wall errors (see Chap. 32), in which the wrong medication or dose
outlets. is administered or given to the wrong client, persist.
• Unplug machines if they are no longer necessary.
• Discourage clients from resting electric hair dryers, curling Prevention
irons, or razors on or near a sink that contains water. Children should be educated about the hazards of poisons.
• Do not use a machine that has a frayed or cracked cord or The American Association of Poison Control Centers pro-
a plug with exposed wires. motes awareness for assistance with accidental poisoning
• Grasp the plug, not the cord, to remove it from an outlet. with a “poison help” logo (Fig. 19-4). The logo provides
• Do not use extension cords. a nationwide toll-free number that, when dialed, automati-
• Report macroshocks to the engineering department. cally connects the caller to the closest poison control center.
• Clean liquid spills as soon as possible. Nurses and pharmacists who are certified specialists in
• Stand clear of the client and bed during cardiac defibrilla- poison information answer emergency calls around the
tion. clock. All nurses can teach parents and others how to reduce
the risk of poisoning in the home (see Client and Family
Poisoning Teaching 19-2). Adults who have trouble remembering or
Poisoning is injury caused by the ingestion, inhalation, or who cannot administer their own medications safely can use
absorption of a toxic substance. These are more common containers prefilled by a responsible person (Fig. 19-5).
in homes than in health care institutions, although medica-
tion errors could be considered a form of poisoning (see Treatment
Chap. 32). Preventing medication errors is addressed in Initial treatment for a victim of suspected poisoning involves
the National Patient Safety Goals for keeping people safe maintaining breathing and cardiac function. After that, res-
in health care agencies. Medication safety is discussed in cuers attempt to identify what was ingested, how much, and
more depth in Unit 9, Medication Administration. Acci- when. Definitive treatment depends on the substance, the cli-
dental poisonings usually occur among toddlers and com- ent’s condition, and if the substance is still in the stomach.
monly involve substances located in bathrooms or kitchens For ingestions of commercial products containing multiple
(Box 19-3). Many children treated for accidental poisoning ingredients, the poison control center is consulted. Other-
have a repeat episode. wise, treatment follows the decision tree in Figure 19-6.
Falls
Falls, more than any other injury discussed thus far, are the
B OX 1 9 - 3 Common Substances Associated most common accident experienced by older adults and
With Childhood Poisonings
Drugs: Aspirin, acetaminophen, vitamins with iron, antide-
pressants, sedatives, tranquilizers, antacid tablets, diet pills,
and laxatives
Cleaning agents: Bleach, toilet bowl or tank disks, detergents,
and drain cleaners
Paint solvents: Turpentine, kerosene, and gasoline
Heavy metals: Lead paint chips
Chemical products: Glue, shoe polish, antifreeze, and insecti-
cides
Cosmetics: Hair dye, shampoo, and nail polish remover
Plants: Mistletoe berries, rhubarb leaves, foxglove, and castor FIGURE 19-4 The toll-free number provides immediate access
beans to an expert at a poison center with answers to questions
about poisons and poisonings.
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POISON
Client and Family Teaching 19-2 ↓
Preventing Childhood Poisoning Petroleum
Caustic
The nurse teaches the parents or the caretakers the Corrosive
following:
● Install child-resistant latches on cupboard doors. ↓ ↓
● Request childproof caps on all prescription medications. Yes No
● Buy chemicals and nonprescription drugs with tamper- ↓ ↓
Dilute with water or milk. Alert
proof lids.
↓
● Never transfer a toxic substance to a container usually ↓ ↓
Prevent vomiting.
used for storing food. ↓
Yes No
● Do not refer to medications as “candy,” and do not tell ↓ ↓
Hydrate.
children they taste “yummy.” Induce vomiting. Give antidote.
↓
● Do not keep drugs in your purse. or or
Treat symptoms.
Lavage. Lavage.
● Remind grandparents or babysitters to “childproof” their
↓ ↓
homes.
↓
● Remove toxic houseplants from the home. ↓
● Keep the home well ventilated when using an aerosol or Give activated charcoal.
another substance that leaves lingering fumes in the air. ↓
Administer laxative.
FIGURE 19-6 Decision tree for treating ingested poisons.
have the most serious consequences for this age group.

More than one third of adults aged 65 years and older fall
each year in the United States; falls are the most com- Gerontologic Considerations
mon cause of nonfatal injuries and hospital admissions for
trauma. According to statistics from 2009, of those people ■ Osteoporosis (loss of bone mass) increases the risk of
who fell, more than 433,000 required hospitalization, and fractures, especially in older women. Osteoporotic fractures
nearly 16,000 died (National Center for Injury Prevention may occur with little or no trauma and even without a fall.
■ Older adults who have had a previous fall or have a his-
and Control, 2009). Most falls among older adults occur at
tory of falling are more likely to fall again and often exhibit a
home. Common injuries include those to the head, wrist, characteristic gait attributed more to being overly cautious
spine, and hip. Half of all clients hospitalized after falling than a result of a prior injury. Fear of falling can significantly
are transferred to a nursing care facility (Tideiksaar, 2010). limit mobility, which may actually increase the risk for falls.
Many who survive a fall suffer years of disability, impaired ■ Practical methods such as assessing risk factors for falls
mobility, and pain. and teaching fall management should be initiated. Placing
beds at low heights may diminish risks from falls.
Contributing Factors
Older adults are more prone to falls for several reasons.
Many have age-related changes such as visual impairments
and disorders affecting gait, balance, and coordination. Some
take medications that lower blood pressure, causing them to
feel dizzy on rising. Others have urinary urgency and rush to
reach the toilet. Other social and environmental factors also
contribute to the risk of falling. For example, older adults
often wear slippers to accommodate swollen feet. Although
slippers are more comfortable, less expensive, and less tiring
to put on than shoes, they do not offer much support or trac-
tion. Clutter may accumulate around the house if the older
adult lacks the energy to clean or does not want to discard
old items.
For hospitalized older adults, the risk for falls rises.
They are in an unfamiliar environment. They must rely on
nursing assistance for mobility, and such assistance may not
FIGURE 19-5 A pill organizer may help reduce the incidence of be prompt. Medications and altered health status may cause
medication overdoses. (Photo by B. Proud.) temporary confusion and poor judgment.
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Risk Factors Risk Points Score
Confusion/disorientation +4
Depression +2
Altered elimination (incontinence, +1
nocturia, frequency)
Dizziness/vertigo +1
Sex = male +1
Antiepileptics (any prescribed) +2
Benzodiazepines (any prescribed) +1 FIGURE 19-7 The Hendrich Fall
Get-up-and-go (rising from chair) test: Risk Tool. (Original research in
Able to rise in a single movement 0 Hendrich, A., Nyhuis, A.,
Pushes up, successful in one attempt +1 Kippenbrock, T., & Soja, M. E.
Multiple attempts, but successful +3 [1995]. Hospital falls:
Unable to rise without assistance +4 Development of a predictive
model for clinical practice.
Applied Nursing Research, 8[3],
FINAL RISK SCORE = * 129–139. Used with permission
of Ann Hendrich, MSN, RN,
* KEY: >5, High risk for falling Methodist Hospital, Indianapolis,
IN.)
Assessment
Determining which clients are at higher risk can prevent
some falls. Identifying at risk clients and preventing falls
also is a National Patient Safety Goal (see Table 19-1).
Preventing Falls
Accredited hospitals and long-term care agencies use assess-
ment tools to determine which clients need fall-prevention The nurse teaches the client or the family as follows:
protocols (Fig. 19-7). ● Keep the environment well lit.
● Install and use handrails on stairs inside and outside the
Prevention home.
Different fall-prevention approaches are used in the home ● Place a strip of light-colored adhesive tape on the edge of
and in health care facilities. Measures for preventing falls are each stair for visibility.
modified based on the client’s circumstances (see Client and ● Remove scatter rugs.
Family Teaching 19-3). ● Keep extension cords next to the wall.
Older adults should keep a list of emergency numbers ● Do not wax floors.
posted by the phone. Those who live alone may want to ● Wear well fitting shoes that enclose the heel and toe of
become part of a daily phone tree in which someone inves- the foot and have nonskid soles.
tigates if an older adult does not call in or answer a call. ● Keep pathways clutter free.
● Wear short robes without cloth belts that may loosen and
Personal response services are also available in which the
trip the client.
subscriber wears a wireless, waterproof pendant with a but-
● Use a cane or walker if prescribed.
ton that he or she can use to summon help in an emergency. ● Replace the tip on a cane as it wears down.
Activating the button places a call to the manufacturer’s ● Stay indoors when the weather is icy or snowy.
emergency response center; once connected, the user can ● Sit down when using public transportation, even if it
carry on a two-way hands-free conversation. The center means asking someone for his or her seat.
directs calls for assistance to predetermined people such as ● Install and use grab bars in the shower and near the
family, neighbors, the physician, or emergency personnel. If toilet.
the user cannot communicate, the center dispatches emer- ● Place a nonskid mat or decals on the floor of the tub or
gency personnel to the user’s location. shower.
● Use soap-on-a-rope or a suspended container of liquid
soap to prevent slipping on a loose soap bar.
● Use a flashlight or nightlight when it is dark.
RESTRAINTS ● Make sure that pets are not underfoot.
● Mop up spills immediately.
In health care agencies, fall prevention measures are nec- ● Use long-handled tongs rather than climbing on a chair to
essary for identified clients. The use of restraints, however, reach high objects.
is closely regulated. Physical restraints are methods that
LWBK1004-C19_p399-416.indd 408 2/6/12 7:25 PM

immobilize or reduce the ability of a client to freely move B OX 1 9 - 4 OBRA Legislation Addressing
his or her arms, legs, body, or head. Chemical restraints Restraints
are medications that are not a standard treatment or dosage
for the client’s condition but rather are used to manage a cli- The Omnibus Reconciliation Act (OBRA) of 1987 specifies that:
The resident (patient) has the right to be free from any
ent’s behavior or freedom of movement. These are generally
physical restraints imposed or psychoactive drug admin-
warranted to manage violent or self-destructive behavior that istered for purposes of discipline or convenience, and not
jeopardizes the immediate physical safety of the client, staff, required to treat the resident’s (patient’s) medical symptoms.
or others. Physical restraint devices that may be used for cli- . . . Restraints may only be imposed to ensure the physical
ent safety include those that protect a client from falling out safety of the resident or other residents and only upon the
of bed or permit the client to participate in activities without written order of a physician that specifies the duration and
the risk of physical harm (The Joint Commission, 2009). the circumstances under which the restraints are to be used
(except in emergency situations which must be addressed in
the facility’s restraint policy).
■ Wandering is not a justification for restraining clients.

Older adults who are confused or otherwise cognitively Restraints must be the last intervention used after trying all
impaired, without an awareness or appreciation for per- other measures to solve the problem. Nurses must take meas-
sonal safety, may need alternative precautions to prevent ures to protect the restrained client’s health, safety, dignity,
wandering. Helpful devices include placing a specially rights, and well-being.
designed net with a stop sign across the exit doorway with
Velcro, using bells over doors to alert caregivers, or disguis- Legislation
ing an exit door by covering it with a curtain or wallpaper After research studies revealed the widespread use of physi-
that blends in with the surrounding environment. Several
cal restraints in long-term care facilities, federal legislation
different types of monitors, identification bracelets (that
include a phone number), and alerting/alarm devices are
known as the Nursing Home Reform Law was incorporated
available for use with older adults at risk for wandering. in the Omnibus Budget Reconciliation Act (OBRA) in 1987
■ Special environments may be designed so that the hall- (Box 19-4). Compliance with the law has been mandatory
ways form a circle around the nursing stations, allowing the since 1990.
older adult to walk, yet remain in view of the nursing staff,
rather than having exit doors placed at the ends of hallways. Accreditation Standards
■ Caregivers should be aware that early identification is The Joint Commission followed the lead of OBRA legisla-
necessary so that proper precautions can be initiated. Daily tion by developing restraint and seclusion standards in 1991.
documentation of what a person is wearing is helpful They continue to revise these standards, which differ for
should the client wander and need to be identified. nonpsychiatric and psychiatric institutions; the most recent
■ The Alzheimer’s Association (1-800-272-3900) sponsors a
revision occurred in 2009. The standards address three areas:
program called “Safe Return,” which facilitates the reporting
and return of people with cognitive impairments who
agency restraint protocol, medical orders, and client moni-
become lost. Local police departments may provide a ser- toring and documentation of nursing care.
vice of digital photography of the older adult and coded
Restraint Protocol
identification bracelets. The photos and identification codes
are stored in the computers maintained by the police depart-
A protocol is a plan or set of steps to follow when imple-
ment for identification of an adult found wandering. Clients menting an intervention. During a Joint Commission inspec-
with dementia may also be fitted with a global positioning tion, the accrediting team examines an agency’s protocol for
satellite (GPS) device to facilitate locating a missing person. restraint use that the medical staff has approved. The pro-
tocol must identify the criteria that justify the application
and discontinuation of restraints. Nonphysical interventions,
Although the use of restraints may be intended to such as reorienting a person to place and circumstances, or
prevent falls and other injuries, in many cases, their risks “time-out,” which involves removing the client from the
outweigh their benefits. Restrained clients become increas- immediate environment to a quiet room, is preferred. In the
ingly confused; suffer chronic constipation, incontinence, case of a client attempting to remove an endotracheal tube
and infections such as pneumonia and pressure ulcers; and that facilitates mechanical ventilation, personnel must first
experience a progressive decline in their ability to perform attempt less restrictive measures, such as having someone
activities of daily living. Restrained clients are more likely sit with the client.
to die during their hospital stay than those who are not
restrained. Medical Orders
It is unethical and a violation of the Joint Commis- A physician must write a restraint order, or a nurse must
sion’s standards to use physical or chemical restraints for obtain one from a physician by telephone. If a physician
disciplinary reasons or to compensate for limited personnel. is unavailable, a registered nurse who has knowledge,
LWBK1004-C19_p399-416.indd 409 2/6/12 7:25 PM

training, and experience in the techniques that necessitate

the use of restraints may initiate restraint use based on
appropriate assessment of the client.
If need for a restraint used to protect the physical safety
of a nonviolent or nondestructive client is ongoing, the
physician must renew the medical order according to the
agency’s protocol.
Monitoring and Documentation

FIGURE 19-8 Examples of restraint alternatives.
The client’s chart must contain documented evidence of
frequent and regular nursing assessments of the restrained
client’s vital signs; circulation; skin condition or signs of
injury; psychological status and comfort; and readiness for or harnesses with front-releasing Velcro or buckle closures,
discontinuing restraint. In addition, the nurse must record and commercial or homemade tilt wedges (Fig. 19-8). If
nursing care concerning toileting, nutrition, hydration, and the client is unaware of or cannot release the restraint alter-
range of motion while the client is restrained. The docu- native, it is considered a restraint.
mented care must reflect the agency’s established protocol. Other supplementary measures also may reduce the
The nurse also promptly communicates with the client’s need for restraints. Personnel are encouraged to improve gait
family regarding the need for restraints and notes the time in training, provide physical exercise, reorient clients, encour-
the documentation. When the assessment findings indicate age assistive ambulatory devices such as walkers and hall
that the client has improved, the nurse must legally and ethi- rails, and use electronic seat and bed monitors that sound an
cally remove the restraint. alarm when clients get up without assistance. Before consid-
ering the use of physical restraints, the nurse observes and
Restraint Alternatives documents the client’s response to other alternatives. When
Agencies are being challenged to implement interventions clients are in a wheelchair, nurses must position them cor-
that protect clients from injury while ensuring their free- rectly (Table 19-5).
dom, mobility, and dignity. The intent of both the OBRA
legislation and the Joint Commission standards is to promote
restraint alternatives (protective or adaptive devices that Use of Restraints
promote client safety and postural support but that the cli- When the use of restraints is justified, nurses and the person-
ent can release independently) and, eventually, restraint-free nel they supervise must demonstrate continued competency
client care. in their safe application. Skill 19-1 explains how to apply
Restraint alternatives are generally appropriate for cli- restraints and use them appropriately.
ents who tend to need repositioning to maintain their body
alignment or improve their independence and functional
status. Some examples include seat inserts or gripping List some methods for avoiding a lawsuit when re-
straints are necessary.
materials that prevent sliding, support pillows, seat belts
TABLE 19-5 Basic Wheelchair Positioning Principles

STRUCTURE FRONT VIEW SIDE VIEW
Head Head/neck centered over trunk midline Head/ear centered over hip
Shoulders Level in horizontal line Top of shoulder over hip
Trunk Sternum perpendicular to center of pelvis Spine perpendicular to hip
Pelvis Top of hip level in horizontal line Lumbar curve preserved
Thighs Knee level in horizontal line Hip and knee level in horizontal line
Knees Knees not touching; legs perpendicular to floor Knees bent 90 degrees; edge of seat 3 in. from knee
crease
Feet Great toes and fifth toes level in horizontal line Heel and forefoot positioned on footplate; ankle in
neutral position
Available from Posey Co. J.T., & Arcadia, CA. Positioning in wheelchairs, http://www.posey.com/Products/
Positioning-In-Wheelchairs_8509.aspx.
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NURSING IMPLICATIONS a person is “at risk for injury as a result of environmental

conditions interacting with the individual’s adaptive and
Nurses must recognize safety hazards and identify clients at defensive resources.”
the greatest risk for injury. Once they gather and analyze the Despite appropriate assessments and plans for prevent-
data, they may identify several nursing diagnoses: ing injuries, accidents still occur. When they do, the nurse’s
first concerns are the safety of the client and the potential for
• Risk for Latex Allergy Response allegations of malpractice. Therefore, if an accident occurs,
• Risk for Injury the nurse takes the following actions:
• Risk for Trauma
• Impaired Walking • Checks the client’s condition immediately
• Disturbed Sensory Perception • Calls for help if the client is in danger
• Acute Confusion • Begins resuscitation measures if necessary
• Chronic Confusion • Comforts and reassures the client
• Impaired Environmental Interpretation Syndrome • Avoids moving the client until safe to do so
• Impaired Home Maintenance • Reports the accident and assessment findings to the physi-
cian
Nursing Care Plan 19-1 gives sample interventions for a • Completes an incident report as soon as the client is stabi-
client with a nursing diagnosis of Risk for Injury, defined in lized (see Chap. 3)
the NANDA-I taxonomy (2012, p. 430) as a state in which
N U R S I N G C A R E P L A N 1 9 - 1 Risk for Injury

Assessment • Check the client’s use of an ambulatory aid such as crutches,
• Note evidence of altered mental status. canes, or a walker.
• Determine signs of impaired mobility, balance, and coordination. • Communicate with the client regarding self-assessment of
• Take vital signs and document postural changes in blood pres- functional status.
sure.
• Consult drug references for medications that cause sensory or
motor effects or deficits.
Nursing Diagnosis. Risk for Injury related to impaired mobility and postural hypotension as evidenced by a difference of
20 mm Hg in systolic pressure when lying and standing (135/85 lying; 115/80 standing), previous fall that resulted in a fractured hip,
inconsistent use of walker, and client’s statement, “I’ve had some near-falls at home since my surgery. I get dizzy when I hurry and
my feet get all tangled up.”
Expected Outcome. The client will remain free of injury throughout the duration of care.
Assess blood pressure (BP) lying and standing daily at 0800. Determines effects of postural changes on BP regulation.
Keep the bed in a low position. Facilitates safety when relocating from the bed to a chair or to
ambulate.
Reinforce the need to use the call signal. Obtaining assistance with ambulation reduces the potential
for falling.
Assist the client to a sitting position until dizziness passes Given time, baroreceptors for regulating BP can adjust to
before standing. accommodate for venous pooling.
Keep the walker within reach at all times. Enhances the possibility that the client will use the ambula-
tory aid.
Help to put on nonskid shoes or slippers and glasses for Footwear with traction and support and maximizing vision
ambulation. help reduce the risk for falling.

• Ambulation is delayed briefly until dizziness has passed. • Client ambulates with assistance and the use of a walker.
• Client is assisted with nonskid slippers and glasses before • No falls occur.
ambulating.
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CRITICAL THINKING EXERCISES 3. When providing health teaching to caregivers of older

adults, the nurse is most correct in identifying which
1. What rationale would you give as the reason the Joint of the following as the greatest safety issue?
Commission identified National Patient Safety Goals 1. Chemical poisoning
as a criterion for compliance with accreditation? 2. Thermal burns
2. If someone you know is contemplating a career in 3. Electrical shock
nursing, but is hesitant because of a latex allergy, 4. Accidental falls
what information would you offer? 4. Which of the following nursing actions is best to
3. When discharging an older adult to the care of a fam- implement initially when discovering an alert person
ily member, what safety measures are appropriate to who has ingested too much prescribed medication?
include in the discharge instructions? 1. Induce vomiting
4. Without resorting to the use of restraints, how can 2. Administer an antacid
you prevent falls in a client with an unsteady gait? 3. Transport the person to the emergency department
4. Call the person’s personal physician immediately
5. If a nurse determines that a physical restraint is
NCLEX-STYLE REVIEW QUESTIONS necessary to maintain a client’s safety, which of the
1. When examining an unconscious client, which following is essential?
assessment finding is most indicative of carbon mon- 1. Obtaining a medical order for its use
oxide poisoning? 2. Notifying the nursing supervisor
1. Bilaterally dilated pupils 3. Administering a mild sedative
2. Cherry-red skin color 4. Charging the client for the equipment
3. Smoky odor to clothing
4. Rapid, irregular pulse rate
2. During the orientation of an unlicensed nursing
assistant, which of the nurse’s descriptions of a
restraint alternative is most accurate?
1. It fastens behind the client.
2. It is made of cloth or nylon.
3. The client must be able to release the device.
4. The client must give consent for its application.
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SKILL 19-1 Using Physical Restraints
ASSESSMENT
Assess the client’s physical and mental status for signs suggest- Provides data for determining the need for physical protective
ing the need for safety. restraints.
Consult with staff and the family on options other than restraints. Supports the principle of using less restrictive approaches initially.
Observe the client’s response to alternative measures. Determines the need to revise the current plan for care.
Contact the physician for an order for the use of restraints. Complies with the Joint Commission requirements.
Review the agency’s restraint policy or procedure if unable to Follows the standards for care.
contact the physician.
Assess the client’s skin and circulation. Provides a baseline of information for future comparisons.
Inspect the restraint that will be used and avoid any that are in Ensures safety.
poor condition.
PLANNING
Choose a restraint compatible with the client’s size. Prevents injury.
Approach the client slowly and calmly. Speak in a soft, controlled Reduces agitation.
voice.
Use the client’s name and make eye contact. Helps secure the client’s attention.
Explain why a restraint is necessary. Promotes understanding and cooperation.
Reassure the client that the restraints will be discontinued when Indicates the criteria for releasing restraints.
the possibility for injury no longer exists.
Plan to remove or loosen the restraints at times established by Demonstrates attention to basic physiologic and safety needs;
agency policy to assess circulation, provide joint mobility, give supports the principle that restraints are not applied longer
skin care, assist with elimination, offer food and fluids, and than necessary.
evaluate whether restraints are still needed.
IMPLEMENTATION
Place the client in a position of comfort with proper body align- Maintains functional position and reduces discomfort.
ment.
Protect any bony prominences or fragile skin that a restraint may Reduces or prevents injury.
injure.
Upper Extremity Restraints
Apply mitts rather than wrist restraints, if possible (Fig. A). Maintains freedom to move elbows and shoulders.
A netted hand mitt. (Photo by B. Proud.)
A
(continued)
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Using Physical Restraints (continued)
Use soft cloth restraints instead of stiff leather (Fig. B). Promotes skin integrity.
Soft wrist restraints are applied over padded bony prominences. Ensure that two
fingers can be inserted between the restraint and the wrist. (Photo by B. Proud.)
Provide as much length as possible without allowing the client to Facilitates movement.
pull at tubes or other treatment devices.
Wheelchair Restraints
Avoid back cushions if possible. Creates the potential for slack if they become dislodged.
Make sure the client’s hips are flush with the back of the chair. Promotes good posture and skeletal alignment.
Apply belts snugly over the thighs with at least a 45-degree angle Minimizes sliding up toward the ribs and compromising breathing.
between the belt and knees (Fig. C).
With the lap strap at a 45-degree angle to the knees, the hips are held toward the back of the chair.
C
Apply vests with Velcro or zipper closures at the back; use criss- Keeps fasteners out of reach; prevents strangulation.
crossing vests with front closures only on docile clients.
Support the feet on footrests. Reduces pressure behind the knees and promotes blood circulation.
(continued)
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Tie restraints under the chair, not behind the back (Fig. D). Prevents suffocation if the client should slide downward.
Restraint ties are secured beneath the chair. (Photo by B. Proud.)
Use a quick-release knot when tying any type of restraint (Fig. E). Facilitates removal should the client’s safety become compro-
mised.
Follow the sequence in steps A, B, and C to tie a quick-release knot.
E C
Keep the client in sight whenever restraints are used. Aids in monitoring the client’s safety.
Never restrain a client to a toilet. Prevents drowning or falls.
Bed Restraints
Position the client in the center of the mattress. Allows maximum movement and proper body alignment.
Use full side rails and maintain them in an “up” position while the Prevents injury from slipping between or below half rails.
client is restrained.
Apply side rail covers or pad the rails with soft bath blankets if the Reduces the potential for becoming caught or injured within the
client is extremely restless. open spaces of the rails.
Apply jacket restraints snugly enough to prevent harm but not so Ensures ventilation.
tight as to constrict the chest and interfere with breathing.
(continued)
LWBK1004-C19_p399-416.indd 415 2/6/12 7:25 PM

Secure the straps to the moveable part of the bed frame, not the Prevents sliding and chest compression.
side rails or stationary frame (Fig. F)
The restraint ties are secured to the moveable portion of the bed frame. (Photo by B. Proud.)
Monitor aggressive, agitated, or restless clients frequently. Promotes client safety.

Evaluation
• Restraints are applied correctly.
• Client remains free of injury.
• Restraints are released according to policy.
• Basic needs are met.
• Restraints are discontinued when no longer needed.
Document
• Assessment findings that indicate a need for restraint
• Types of restraint alternatives and the client’s response
• Condition of skin, circulation, sensation, and joint mobility before restraint application
• Type of restraint applied
• Communication with physician and responsible family member
• Frequency of release and assessment findings
• Nursing measures used to promote skin integrity and joint flexibility, and to meet nutritional and elimination needs
• Assessments indicating an ongoing need for restraints
Date and Time Pulling on urinary catheter. Reminded to leave catheter alone. Placed close to nursing station to allow
quick intervention. Given a skein of yarn to wrap as a ball to distract client from catheter. Continues to tug
at catheter. Catheter is patent, but urine now appears bloody. Order obtained for soft cloth wrist restraints.
Skin over wrists is intact, no edema, full mobility, fingers are warm and pink, can differentiate sharp from
dull sensation. Restraints secured to arms of wheelchair. Daughter notified of need to use restraints at this
time and concurs with treatment plan. SIGNATURE/TITLE
LWBK1004-C19_p399-416.indd 416 2/6/12 7:25 PM

Photo to
Come
FPO
20# Pain Management
acupressure
acupuncture
acute pain 1. Give a general definition of pain.
adjuvants 2. List four phases in the pain process.
alternative medical therapy 3. Explain the difference between pain perception, pain threshold,
analgesic and pain tolerance.
biofeedback 4. Discuss how endogenous opioids reduce pain transmission.
bolus 5. Name at least five types of pain.
chronic pain 6. Give at least three characteristics that differentiate acute pain
controlled substances from chronic pain.
cordotomy 7. List five components of a basic pain assessment.
cutaneous pain 8. Name four common pain-intensity assessment tools used by
distraction nurses.
endogenous opioids 9. Identify at least three occasions when it is essential to perform
equianalgesic dose a pain assessment and document assessment findings.
fifth vital sign 10. Name four physiologic mechanisms for managing pain.
hypnosis 11. Give three categories of drugs used alone or in combination to
imagery manage pain.
intractable pain 12. Identify two surgical procedures used when other methods of
intraspinal analgesia pain management are ineffective.
loading dose 13. List at least five nondrug, nonsurgical methods for managing
malingerer pain.
meditation 14. Discuss the most common reason why clients request frequent
modulation administrations of pain-relieving drugs.
neuropathic pain 15. Define addiction.
nociceptors 16. Discuss how fear of addiction affects pain management.
nonopioids 17. Define placebo and explain the basis for its positive effect.
opioids
pain
pain management
pain threshold ain is probably the major cause of physical distress among clients.
pain tolerance
patient-controlled analgesia (PCA)
perception
percutaneous electrical nerve
stimulation (PENS)
placebo
P According to the American Pain Society (2004), clients “should have
access to the best pain relief that can safely be provided.” This chap-
ter provides information about pain and techniques for pain relief.
referred pain PAIN

relaxation
rhizotomy Pain is an unpleasant sensation usually associated with disease or injury.
somatic pain It causes physical discomfort and also is accompanied by suffering,
suffering which is the emotional component of pain. Because there is no effective
transcutaneous electrical nerve
method for validating or invalidating pain, Margo McCaffery (1968), a
stimulation (TENS)
nursing expert on pain, defines pain as being “whatever the person says
transduction
transmission it is, and existing whenever the person says it does.” Understanding how
visceral pain pain is produced and perceived is essentialnding
to fi mechanisms for
417
LWBK1004-C20_p417-437.indd 417 31/01/12 1:26 AM

Perception
3
Transduction
1 4 Modulation
Transmission 2
FIGURE 20-1 The phases of pain.
pain relief. Extensive research is being conducted to dis-

cover more about pain transmission, types of pain, and the
management of pain.
The Process of Pain

The process by which people experience pain occurs in four
phases: transduction, transmission, perception, and modula-
tion (Fig. 20-1).
Transduction
Transduction refers to the conversion of chemical informa-
tion at the cellular level into electrical impulses that move
toward the spinal cord. Transduction begins when injured
cells release chemicals such as substance P, prostagland-
ins, bradykinin, histamine, and glutamate. These chemicals
excite nociceptors (a type of sensory nerve receptors acti-
vated by noxious stimuli) located in the skin, bones, joints,
muscles, and internal organs (Fig. 20-2).
Transmission
Transmission is the phase during which stimuli move from
the peripheral nervous system toward the brain. Transmis-
sion occurs when peripheral nociceptors form synapses with
neurons within the spinal cord that carry pain impulses and
other sensory information such as pressure and temperature
changes via fast and slow nerve fibers. A-delta fibers, which
are large myelinated fibers, carry impulses rapidly at a rate
of approximately 5 to 30 meters per second (m/sec) (Porth &
Matfin, 2008). Impulses through the fast pain pathway result
in sharp, acute initial sensations like those felt when touching FIGURE 20-2 Pain transmission pathway.
LWBK1004-C20_p417-437.indd 418 31/01/12 1:26 AM

CHAPTER 20 Pain Management 419
a hot iron. The result is that the person almost immediately Modulation
withdraws from the pain-provoking stimulus. Following the Modulation is the last phase of pain impulse transmission
fast transmission, impulses from small unmyelinated fibers during which the brain interacts with the spinal nerves in a
known as C-fibers carry impulses at a slower rate of 0.5 to downward fashion to subsequently alter the pain experience.
2 m/sec. They are responsible for the throbbing, aching, or At this point, the release of pain-inhibiting neurochemicals
burning sensation that persists after the initial discomfort. reduces the painful sensation. Examples of such neurochem-
With the help of substance P, pain impulses move to icals include endogenous opioids (discussed later in this
sequentially higher levels in the brain, such as the reticular chapter), gamma-aminobutyric acid (GABA), and others.
activating system, thalamus, cerebral cortex, and limbic sys- Research is being conducted to develop new types of
tem. Prostaglandin, a chemical released from injured cells, pain-modulating drugs. Current efforts are being directed at
speeds up the transmission. As the pain impulses are trans- medications that (1) occupy cell receptors for neurotrans-
mitted, pain receptors become increasingly sensitized. This mitters like acetylcholine and serotonin, (2) block glutamate
finding helps explain the clinical observation that established receptors and peptides (protein compounds) like tachykinin-
pain is more difficult to suppress. neurokinin and substance P, and (3) reduce cytokines (a type
When pain impulses reach the thalamus within the brain, of immune system protein) that trigger pain by promoting
two responses occur. First, the thalamus transmits the mes- inflammation; and other scientific endeavors to discover new
sage to the cortex, where the location and severity of the methods for relieving pain without the unwanted side effects
injury are identified. Second, it notifies the nociceptors that of current analgesics (Pain—Hope Through Research,
the message has been received and that continued transmis- 2009).
sion is no longer necessary. A malfunction in this secondary
process may be one reason why chronic pain lingers. Pain Theories
Several theories attempt to explain how pain is transmitted
Perception and reduced. No one theory is all-encompassing.
Perception (the conscious experience of discomfort) occurs A hypothesis for how the perception of pain is dimin-
when the pain threshold (the point at which sufficient pain- ished involves endogenous opioids (naturally produced
transmitting stimuli reach the brain) is reached. Once pain is morphine-like chemicals). The endogenous opioids–
perceived, structures within the brain determine its intensity, endorphins, dynorphins, and enkephalins–reduce pain.
attach meaningfulness to the event, and provoke emotional Two neurotransmitters, serotonin and norepinephrine,
responses. stimulate their release (see Chap. 5). When endogenous
Pain thresholds tend to be the same among healthy peo- opioids are released, they are thought to bind to sites on
ple, but each person tolerates or bears the sensation of pain the nerve cell’s membrane that block the transmission of
differently. Pain tolerance (the amount of pain a person pain-conducting neurotransmitters such as substance P and
endures) is influenced by genetics; learned behaviors spe- prostaglandins (Fig. 20-3).
cific to gender, age, and culture (see Chap. 6); and other bio-
psychosocially unique factors such as current anxiety level, Types of Pain
past pain experiences, and overall emotional disposition Not all pain is exactly the same. Five types of pain have been
(Mayo Clinic, 2009). described according to the source (cutaneous, visceral, and
neuropathic) or duration (acute and chronic).
■ Data related to age-associated changes in pain percep-

tion, sensitivity, and tolerance are conflicting. Therefore, it
is a dangerous assumption to believe that older adults are
less sensitive to pain stimuli. Older adults may experience
needless suffering or undertreatment as a result of this
assumption.
■ Older adults with depression, chronic conditions, or high
levels of stress usually have diminished pain tolerance
because they have less energy to cope with pain.
■ Older adults may endure pain for several reasons. They
may not want to be perceived as a nuisance or a com-
plainer, may believe that pain is expected with aging or indi-
cates weakness, may fear tests or becoming addicted to
pain medication, or may believe that they are suffering from
a serious illness.
FIGURE 20-3 Mechanism of pain transmission and interference.
LWBK1004-C20_p417-437.indd 419 31/01/12 1:26 AM

Cutaneous Pain symptoms such as nausea, vomiting, pallor, hypotension,

Cutaneous pain, discomfort that originates at the skin level, and sweating may accompany visceral pain.
is a commonly experienced sensation resulting from some
form of trauma. The depth of the trauma determines the type Neuropathic Pain
of sensation felt. Damage confined to the epidermis pro- Neuropathic pain (pain with atypical characteristics) is also
duces a burning sensation. At the dermis level, pain is local- called functional pain. This type of pain often is experienced
ized and superficial. Subcutaneous tissue injuries produce days, weeks, or even months after the source of the pain has
an aching, throbbing pain. Somatic pain (discomfort gener- been treated and resolved (Copstead-Kirkhorn & Banasik,
ated from deeper connective tissue) develops from injury to 2010). This has led some to speculate that the transduction
structures such as muscles, tendons, and joints. circuitry is dysfunctional, allowing pain stimuli to continue
in the absence of injury or disease.
Visceral Pain One example of neuropathic pain is phantom limb pain
Visceral pain (discomfort arising from internal organs) is or phantom limb sensation, in which a person with an ampu-
associated with disease or injury. It is sometimes referred or tated limb perceives that the limb still exists and feels burn-
poorly localized. Referred pain (discomfort perceived in a ing, itching, and deep pain in tissues that have been surgically
general area of the body, usually away from the site of stimu- removed. Some researchers believe that the pain associated
lation) is not experienced in the exact site where an organ with fibromyalgia is a pain processing disorder caused by the
is located (Fig. 20-4). Other autonomic nervous system disruption in the way the body perceives and communicates
pain (Roan, 2005).
Acute Pain
Acute pain (discomfort that has a short duration) lasts for a
few seconds to less than 6 months. It is associated with tis-
sue trauma, including surgery or some other recent identifi-
able etiology. Although severe initially, acute pain eases with
healing and eventually disappears. The gradual reduction in
pain promotes coping with the discomfort because there
is a reinforcing belief that the pain will disappear in time.
Both acute and chronic pain result in physical and emotional
distress and can be intermittent (incorporating periods of
relief), but that is where the similarities end.
Chronic Pain
The characteristics of chronic pain (discomfort that lasts
longer than 6 months) are almost totally opposite from those
of acute pain (Table 20-1). The longer the pain exists, the
more far-reaching its effects on the sufferer (Box 20-1).
Other people begin to show negative reactions to the chronic
pain sufferer, such as the following:
• Saying they are tired of hearing about the pain
• Ignoring the sufferer’s concerns and complaints
B OX 2 0 - 1 Quality-of-Life Activities Affected by

Chronic Pain
• Exercising
• Working around the house
• Sleeping
• Enjoying hobbies and leisure time
• Socializing
• Walking
• Concentrating
• Having sex
• Maintaining relationships with family and friends
• Working a full day
• Caring for children
FIGURE 20-4 Areas of referred pain.
LWBK1004-C20_p417-437.indd 420 31/01/12 1:26 AM

TABLE 20-1 Characteristics of Acute and Chronic Pain

ACUTE PAIN CHRONIC PAIN
Recent onset Remote onset
Symptomatic of primary injury or disease Uncharacteristic of primary injury or disease
Specific and localized Nonspecific and generalized
Severity associated with the acuity of the injury or disease process Severity out of proportion to the stage of the injury or disease
Favorable response to drug therapy Poor response to drug therapy
Requires less and less drug therapy Requires more and more drug therapy
Diminishes with healing Persists beyond the healing stage
Suffering is decreased Suffering is intensified
Associated with sympathetic nervous system responses such as Absence of autonomic nervous system responses; manifests
hypertension, tachycardia, restlessness, and anxiety depression and irritability
• Getting angry managed care organization has the right to an assessment

• Suggesting that the pain has a psychological basis and management of pain.
• Telling the person he or she is using the pain to manipulate • Pain is assessed using a tool appropriate for the person’s
others for selfish purposes age, developmental level, health condition, and cultural
• Criticizing the person for using drugs “as a crutch” identity. Refer to Table 20-2 for pain-related information
• Suggesting that the person is addicted to pain medication that is included in an initial comprehensive pain assessment.
(American Chronic Pain Association, 2004) • Pain is assessed regularly throughout the health care delivery.
• Pain is treated in the health care agency, or the client is
referred elsewhere.
• Health care workers are educated regarding pain assess-
PAIN ASSESSMENT STANDARDS ment and management.
• Clients and their families are educated about effective pain
The American Pain Society has proposed that pain assess-
management as an important part of care.
ment is the fifth vital sign. In other words, the nurse checks
• The client’s choices regarding pain management are
and documents the client’s pain every time he or she assesses
respected.
the client’s temperature, pulse, respirations, and blood pres-
sure. In August 1999, The Joint Commission established To comply with the established standards of care, the
Pain Assessment and Management Standards with which all nurse assesses pain whenever he or she considers it appropri-
accredited health care organizations must comply. Aspects ate and routinely in the following circumstances:
incorporated in the Joint Commission standards include the
• When the client is admitted
following:
• Whenever the nurse takes vital signs
• Everyone cared for in an accredited hospital, long-term • At least once per shift when pain is an actual or potential
care facility, home health care agency, outpatient clinic, or problem
TABLE 20-2 Components of a Comprehensive Pain Assessmenta

COMPONENT FOCUS OF ASSESSMENT
Intensity Rating for present pain, worst pain, and least pain using a consistent scale
Location Site of pain or identifying mark on a diagram
Quality Description in client’s own words
Onset Time the pain began
Duration Period that pain has existed
Variations Pain characteristics that change
Patterns Repetitiveness or lack thereof
Alleviating factors Techniques or circumstances that reduce or relieve the pain
Aggravating factors Techniques or circumstances that cause the pain to return or escalate in intensity
Present pain management regimen Approaches used to control the pain and results and effectiveness
Pain management history Past medications or interventions and response; manner of expressing pain; personal,
cultural, spiritual, or ethnic beliefs that affect pain management
Effects of pain Alterations in self-care, sleep, dietary intake, thought processes, lifestyle, and relationships
Person’s goal for pain control Expectations for level of pain relief, tolerance, or restoration of functional abilities
Physical examination of pain Assessment of structures that relate to the site of pain
a
If clients have pain in more than one area, assessment data are collected for each.
LWBK1004-C20_p417-437.indd 421 31/01/12 1:26 AM

• When the client is at rest and when involved in a nursing B OX 2 0 - 2 Underassessed and Undertreated
activity Pain Populations
• After each potentially painful procedure or treatment
• Before implementing a pain-management intervention, • Infants
• Children younger than 7 years of age
such as administering an analgesic (a pain-relieving drug)
• Culturally diverse clients
and again 30 minutes later • Clients who are mentally challenged
• Clients with dementia (diminished brain function)
• Clients who are hearing or speech impaired
PAIN ASSESSMENT DATA • Clients who are psychologically disturbed
A basic or brief pain assessment includes the client’s descrip-

tion of the onset, quality, intensity, location, and duration of
the pain (Table 20-3). Nurses also ask about symptoms that increased vital signs, reduced social interactions, irritability,
accompany the pain and what, if anything, makes it better or difficulty concentrating, and changes in eating and sleeping.
worse. During an admission assessment, the nurse also asks Autonomic nervous system responses such as tachycardia,
questions such as: hypertension, dilated pupils, perspiration, pallor, rapid and
shallow breathing, urinary retention, reduced bowel motility,
• What activities are you unable to do because of pain? and elevated blood glucose levels may be apparent. Clients
• Do you ever take pain medication? If so, when? with chronic pain are not as likely to manifest autonomic
• What are the names and dosages of pain medicine you nervous system responses.
take?
• What nondrug methods, such as rest, do you use to relieve
your pain? Gerontologic Considerations
• How does your pain change with self-treatment?
• What are your preferences for managing your pain? ■ Regardless of its source, pain is one of the most com-
• What pain level is an acceptable goal for you if total pain mon complaints of older people, who are more likely to
relief is not possible? have atypical presentations of pain.
■ Older adults with cognitive impairment may not be able
to complain of pain or discomfort. Changes in mental sta-
Gerontologic Considerations tus or behavior are primary manifestations of pain in people
with dementia. When assessing pain in older adults, atten-
■ Chronic illnesses and disease increase the risk for pain tion should be focused on how the pain or discomfort inter-
for older people. Multiple chronic conditions (eg, peripheral feres with activities of daily living and quality of life.
vascular disease, diabetic neuropathies, orthopedic prob- ■ Astute assessment of behavior changes such as
lems, cancer) can contribute to the pain. Pain often goes increased pulse, respiration, restlessness, agitation, and
underreported among older adults because of many factors. wandering may provide the only clues to pain in older
For example, the older person may believe that pain is a adults with cognitive or expressive changes.
normal part of aging, may be a punishment for past actions,
may result in a loss of independence, or may indicate that
death is near, or that nothing can be done about it.
PAIN INTENSITY
ASSESSMENT TOOLS
When caring for clients, especially those who are often
underassessed and undertreated (Box 20-2), the nurse observes There is no perfect way for determining whether pain exists
for behavioral signs that are common nonverbal indicators of and how severe it is. Because no machines or laboratory
pain, such as moaning, crying, grimacing, guarded position, tests can measure pain, nurses are limited to the subjective
TABLE 20-3 Basic Components of Pain Assessment

CHARACTERISTIC DESCRIPTION EXAMPLES
Onset Time or circumstances under which the pain After eating, while shoveling snow, during the night
became apparent
Quality Sensory experiences and degree of suffering Throbbing, crushing, agonizing, annoying
Intensity Magnitude of pain None, slight, mild, moderate, severe; or numeric
scale from 0–10
Location Anatomic site Chest, abdomen, jaw
Duration Time span of pain Continuous, intermittent, hours, weeks, months
LWBK1004-C20_p417-437.indd 422 31/01/12 1:26 AM

Pain intensity scales
Simple Descriptive Pain Intensity Scale*

FIGURE 20-6 The Wong-Baker FACES Pain Rating Scale.
Instructions: Explain to the person that each face is for a per-
son who feels happy because he or she has no pain (hurt) or
for a person who feels sad because he or she has some or a
No Mild Moderate Severe Very Worst
lot of pain. Face 0 is very happy because he or she does not
pain pain pain pain severe possible
hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little
pain pain
more. Face 3 hurts even more. Face 4 hurts a whole lot. Face
5 hurts as much as you can imagine, although you do not have
0 – 10 Numeric Pain Intensity Scale* to be crying to hurt this bad. Ask the person to choose the face
that best describes how he or she is feeling. Rating scale is
recommended for persons aged 3 years and older. (From
Wong, D. L., Hockenberry-Eaton, M., Wilson D., Winkelstein,
0 1 2 3 4 5 6 7 8 9 10 M. L., Ahmann, E., & DiVito-Thomas, P. A. [1999]. Whaley &
No Moderate Worst Wong’s nursing care of infants and children [6th ed., p. 1153].
pain pain possible St. Louis: Mosby. Copyrighted by Mosby-Year Book, Inc.
pain Reprinted by permission.)
Visual Analog Scale (VAS)**
Treatment Biases
No Pain as bad According to McCaffery and Ferrell (1999), nurses some-
pain as it could times delay pain-relieving measures because “[they] expect
possibly be someone in severe pain to look as if he hurts.” Neither
behaviors nor physiologic data, however, are irrefutable
* If used as a graphic rating scale, a 10-cm baseline indicators of pain. Responses to pain and coping techniques
is recommended.
are learned, and clients may express them in a variety of
** A 10-cm baseline is recommended for VAS scales.
ways. If a client’s expressions of pain are incongruent with
FIGURE 20-5 Pain assessment tools: word scale (top), numeric
scale (middle), and linear scale (bottom). the nurse’s expectations, pain management may not be read-
ily forthcoming. Consequently, the client’s pain may be
undertreated.
information that only clients can provide. Individual charac- Pain Management Techniques
teristics, family, culture, and ethnicity influence tolerance and Pain management (techniques for preventing, reducing,
expression of pain. or relieving pain) is a major focus for quality improve-
Nurses generally use one of the four simple assessment ment programs in health care agencies. The American Pain
tools to quantify a client’s pain intensity: a numeric scale, Society, working with the Agency for Health Care Policy
a word scale, a linear scale (Fig. 20-5), and a picture scale and Research (a division of the Department of Health and
(Fig. 20-6). Clients identify how their pain compares with Human Services), has developed Standards for the Relief of
the choices on the scale. Acute Pain and Cancer Pain (Box 20-3). The objective of
One scale is not better than another. A numeric scale is this collaborative effort is to improve how pain is assessed
the most commonly used tool when assessing adults. The and controlled. The original effort has been expanded to
Wong-Baker FACES scale is best for children or clients who include the assessment and treatment of pain in all client
are culturally diverse or mentally challenged. Children as populations.
young as 3 years can use the FACES scale. Regardless of the Most techniques for managing pain fall into one of the
assessment tool used, many clients underrate or minimize four general physiologic categories (Table 20-4).
their pain intensity.
Drug Therapy
Drug therapy, either alone or in combination with other ther-
PAIN MANAGEMENT apeutic measures, is the cornerstone of pain management.
The World Health Organization (WHO, 2010) recommends
Because of the wide variety of types of pain and effects on following a three-tiered drug approach based on the pain
lifestyle and personal relationships, management of the cli- intensity and the client’s response to therapy (Fig. 20-7). The
ent’s pain is a priority. Despite the fact that the client is the original target of the WHO’s analgesic ladder in 1996 was to
only reliable source for quantifying pain, nurses are not con- address methods for relieving pain from cancer. Neverthe-
sistent in responding to clients’ reports of pain because of less, the principles continue to be applicable for managing
personal biases. pain from cancer as well as other causes of pain (American
LWBK1004-C20_p417-437.indd 423 31/01/12 1:26 AM

Freedom from pain

B OX 2 0 - 3 Standards for the Relief of Acute
Pain and Cancer Pain
Standard I
Acute and cancer pain are recognized and effectively treated. Opioid for mod
Pain persisting erate-to-
severe pain
Standard II
Information about analgesics is readily available.
or increasing
+/- Nonopioid
+/- Adjuvant
3
Standard III Opioid for
mild-to-mo
de
Patients are informed on admission, both orally and in writing,
that effective pain relief is an important part of their treatment,
+/- Nonop rate pain
+/- Adjuva
ioid
nt
2
that their communication of unrelieved pain is essential, and that
health professionals will respond quickly to their reports of pain.
Nonopio
Standard IV
Explicit policies for use of advanced analgesic technologies
id
+/- Adjuv
ant 1
are defined.
Standard V FIGURE 20-7 The World Health Organization (WHO) pain relief
Adherence to standards is monitored by an interdisciplinary ladder.
committee.
Nonopioid Drugs
Reprinted with permission from American Pain Society. (2008). Principles Nonopioid drugs are nonnarcotics including aspirin, aceta-
of analgesic use in the treatment of acute pain and chronic cancer pain
(6th ed.) Skokie, IL: Author. minophen (Tylenol), and nonsteroidal anti-inflammatory
drugs (NSAIDs) such as ibuprofen (Motrin, Advil, Nuprin),
ketoprofen (Orudis KT), and naproxen sodium (Naprosyn,
Pain Society, 2005). It is the WHO’s belief that if the recom- Aleve). These drugs relieve pain by altering neurotransmis-
mendations for pain management are followed, 80% to 90% sion peripherally at the site of injury.
of clients will be free of pain (WHO, 2009). Another category of nonopioid drugs is the cyclooxy-
Using a tiered approach, physicians prescribe one or genase-2 (COX-2) inhibitors. COX is an enzyme: COX-1
more of the following classes of drugs: nonopioids (non- protects the gastrointestinal tract and urinary system, and
narcotic drugs), opioids (narcotic drugs), and adjuvants COX-2 promotes the production of pain-transmitting and
(drugs that assist in accomplishing the desired effect of a inflammatory chemicals such as prostaglandins. The inhibi-
primary drug). The choice of drug, its dose, and the timing of tion of COX-2 results in pain relief. COX-2 inhibitors are
medication administration are critical in achieving optimal believed to be superior to older NSAIDs, which suppress both
pain relief. COX-1 and COX-2 enzymes. Inhibiting COX-2 to a greater
extent than COX-1 causes fewer undesirable gastric side
effects. However, all COX-2 inhibitors with the exception of
celecoxib (Celebrex) have been withdrawn from prescription
use either voluntarily by the manufacturing drug company
■ Adverse effects of analgesics, even over-the-counter
or by the U.S. Food and Drug Administration because there
products, often are more pronounced in older adults.
Common adverse effects include confusion, disorientation,
have been cardiac-related deaths among some users.
gastritis, constipation, urinary retention, blurred vision, and Most nonopioids are very effective at relieving pain
gastrointestinal bleeding. caused by inflammation. The exception is acetaminophen,
which has limited anti-inflammatory activity; however, it is
TABLE 20-4 Approaches to Pain Management

APPROACH INTERVENTION EXAMPLES
Interrupting pain-transmitting chemicals Local anesthetics, anti-inflammatory Procaine, lidocaine, aspirin, ibuprofen, acetami-
at the site of injury drugs nophen, naproxen, indomethacin
Altering transmission at the spinal cord Intraspinal anesthesia and analgesia, Epidural, caudal, rhizotomy, cordotomy, sym-
neurosurgery pathectomy
Substituting sensory stimuli for pain- Cutaneous stimuli Massage, acupuncture, acupressure, heat, cold,
producing stimuli therapeutic touch, electrical stimulation
Blocking brain perception Narcotics, nondrug techniques Morphine, codeine, hypnosis, imagery, distraction
LWBK1004-C20_p417-437.indd 424 31/01/12 1:26 AM

still an effective analgesic. Almost all of the NSAIDs cause ■ Older adults have increased sensitivity to narcotics. Initial
gastrointestinal irritation and bleeding, so they should be dosing should be at lower levels (begin with half of the
given with food. recommended dose) and titrated to the most effective
dose. “Start low, go slow” is a rule of thumb for analgesic
Opioid Drugs administration.
When pain is no longer controlled with a nonopioid, the non-
opioid is combined with an opioid; for example, aspirin with Because of an exaggerated fear of causing addiction,
codeine or acetaminophen with codeine or an adjuvant drug, narcotics tend to be underprescribed even if clients can ben-
which is discussed later. Opioids (synthetic narcotics) and efit from their use. When they are used, treatment biases lead
opiate analgesics, narcotics containing opium or its deriva- some nurses to administer the lowest dosage of a prescribed
tives, are controlled substances (drugs whose prescription range or to delay administration until the maximum time
and dispensing are regulated by federal law because they between dosages has elapsed. Consequently, many clients
have the potential for being abused). Examples include the experience inadequate pain management, which contributes
following: to long-term suffering and disability. In addition, unrelieved
pain can lead to pneumonia due to shallow breathing, sup-
• Morphine sulfate
pressed coughing, and reduced movement. Psychological
• Codeine sulfate
effects of unrelieved pain include anxiety, depression, and
• Meperidine (Demerol)
despair, even to the point of suicide.
• Fentanyl (Duragesic, Sublimaze)
Narcotics interfere with central pain perception (at the Patient-Controlled Analgesia
brain) and generally are reserved for treating moderate and Patient-controlled analgesia (PCA) is an intervention that
severe pain. They are administered primarily by the oral, rec- allows clients to self-administer narcotic pain medication
tal, transdermal, or parenteral (injected) route. Opioids and through use of an infusion device (Fig. 20-8). PCA is used
opiates cause sedation, nausea, constipation, and respiratory primarily to relieve acute pain after surgery, but this tech-
depression. nology is finding its way into the home health arena where
nonhospitalized clients with cancer are using it.
PCA has several advantages to both clients and nurses:
Pharmacologic Considerations • Pain relief is rapid because the drug is delivered intrave-
■ Normeperidine, a metabolite of meperidine, is a potent nously.
convulsant, especially in persons who are not able to break • Pain is kept within a constant tolerable level (Fig. 20-9).
down or excrete the drug properly. Therefore, some physi- • Less drug is actually used because small doses continu-
cians are less apt to prescribe it. ously control the pain.
■ Fentanyl is 100 times as potent as morphine. It is cur- • Clients are spared the discomfort of repeated injections.
rently one of the most widely prescribed synthetic opioids • Anxiety is reduced because the client does not wait for the
because of the various choices in methods of administra- nurse to prepare and administer an injection.
tion. One of the most popular methods of administration is • Side effects are reduced with smaller individual dosages
a transdermal patch, which is especially useful for control- and lower total dosages.
ling chronic pain. Another form of fentanyl that is available
• Clients tend to ambulate and move more, reducing the
is a buccal soluble film that dissolves almost immediately
when it makes contact with the mucosa of the cheek.
potential for complications from immobility.
Some clients prefer a fentanyl lozenge in a berry-flavored
lollipop that dissolves slowly for transmucosal absorption.
■ Physiologic changes in older adults such as decreased

gastric acid production, decreased gastrointestinal motility,
changes in body fat ratio, and changes in organ function
(eg, decreased liver blood flow and decreased glomerular
filtration rate) affect drug absorption, metabolism, and
excretion. Medication may be absorbed more slowly from
the intramuscular route in older adults, resulting in delayed
onset of action, prolonged duration, and altered absorption
with potential for toxicity. Dermal, oral, and sublingual
routes may be more effective. FIGURE 20-8 Patient-controlled analgesia.
LWBK1004-C20_p417-437.indd 425 31/01/12 1:26 AM

Respiratory Respiratory
depression depression
Sedation Sedation
Analgesia Analgesia
Pain Pain
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
A 4 hr. IM analgesia administration B PCA use

FIGURE 20-9 Pain is less effectively controlled and produces more side effects with intra-
muscular (IM) analgesia (A) than with patient-controlled analgesia (PCA) (B). (Adapted from
Harmer, M., Rosen, M., Vickers, M. D. Eds. [1985]. Patient-controlled analgesia. St. Louis:
CV Mosby.)
• Clients take an active role in their pain management. • Anticonvulsants: carbamazepine (Tegretol), gabapentin
• The nurse is free to carry out other nursing responsibili- (Neurontin)
ties. • N-methyl-D-aspartate (NMDA) receptor antagonists: dex-
tromethorphan, ketamine (Ketalar)
The nurse programs the infusion device so that the client
• Nutritional supplements such as glucosamine
can receive a bolus or loading dose (a larger dose of drug
administered initially or when pain is exceptionally intense) Each category of adjuvant drugs acts by different mech-
and additional lower doses at frequent intervals depending anisms. The antidepressants may produce their analgesic-
on the client’s level of discomfort (Skill 20-1). Once a dose enhancing effect by increasing norepinephrine and serotonin
is delivered, the client cannot administer another dose for a levels, augmenting the release of endorphins. Anticonvul-
specified amount of time; this period, known as a lockout, sants are believed to inhibit the transmission of pain by
prevents overdoses. regulating and potentiating the inhibitory neurotransmit-
ter GABA (see Chap. 5). NMDA drugs interfere with the
➧ Stop, Think, and Respond Box 20-1 function of nociceptive nerve fibers, perhaps blocking the
Discuss appropriate nursing actions when a client release of substance P, its nerve-sensitizing properties, and
uses the maximum doses of drug with a PCA infuser. other inflammatory chemicals. Those who favor alterna-
tive medical therapy (treatment outside the mainstream of
Intraspinal Analgesia traditional medicine) contend that glucosamine slows the
Intraspinal analgesia is a method of relieving pain by instill- breakdown of joint cartilage and promotes its regeneration,
ing a narcotic or local anesthetic through a catheter into the relieving pain associated with joint diseases.
subarachnoid or epidural space of the spinal cord. It is another Adjuvant drugs are never used as a first-line treat-
technique for managing pain. The intraspinal analgesic is ment for pain. When they are used as combination drug
administered several times per day or as a continuous low-dose therapy, however, the dose of the primary drug can often
infusion. Intraspinal analgesia relieves pain while producing be decreased. With a lowered opioid dosage, for instance,
minimal systemic drug effects. In clients who need long-term the client will have less sedation and fewer undesirable side
analgesia, the use of intraspinal analgesia diminishes the risk effects.
for injuring the subcutaneous tissue with repeated injections
that may eventually lessen drug absorption.
Adjuvant Drugs
■ Although the administration of low doses of antidepres-
Analgesic drugs are combined with a wide range of adjuvant sants, anticonvulsants, or stimulants may enhance the effec-
drugs to improve pain control. The categories of adjuvant tiveness of analgesics for older adults, these agents also
drugs and examples of each are as follows: increase the risk for adverse effects and drug interactions.
• Antidepressants: tricyclic antidepressants such as amitrip-
tyline (Elavil); selective serotonin reuptake inhibitors such
as fluoxetine (Prozac) and paroxetine (Paxil), and selective Botulinum Toxin Therapy
serotonin and norepinephrine reuptake inhibitors such as Botulinum toxin (Botox) is an agent made from the bac-
duloxetine (Cymbalta). terium Clostridium botulinum, which is found in soil and
LWBK1004-C20_p417-437.indd 426 31/01/12 1:26 AM

water. Of the seven types of neurotoxins it produces, botu- Client and Family Teaching 20-1
linum type A (BTX-A) has been approved to treat painful Pain and Its Management
musculoskeletal conditions and various types of headaches.
When injected directly into a muscle, the toxin blocks The nurse teaches the client and the family as follows:
the action of acetylcholine. Under normal conditions, ace- ● Ask the doctor what to expect from the disorder or its
tylcholine, a neurotransmitter, causes skeletal muscle con- treatment.
traction when it is released at the synapses of motor nerves. ● Discuss pain-control methods that have worked well or
Blocking acetylcholine results in temporary paralysis of not so well before.
the injected muscle. When muscles are paralyzed, spasms ● Talk with the doctor and nurses about any concerns you
and nociceptive transduction are inhibited, resulting in pain have about pain medicine.
● Identify any drug allergies you have.
relief. The effect is local and specific rather than systemic
● Inform the doctor and nurses about other medicines you
and lasts 2 to 6 months or more (Childers, 2009; M.D. take, in case they may interact with pain medications.
Anderson Cancer Center, 2009). Injections must be repeated ● Help the doctor and nurses measure your pain on a pain
to continue the therapeutic effect. The duration of each scale by stating the number or word that best describes
injection’s effect tends to become shorter over time. Clinical the pain.
resistance may result from the development of neutralizing ● Ask for or take pain-relieving drugs when pain begins or
BTX-A antibodies. before an activity that causes pain.
Those who are candidates for botulinum toxin therapy ● Set a pain-control goal such as having no pain worse than
may experience local pain, bruising, or infection at the injec- 4 on a scale of 0 to 10.
tion site. The muscle weakness may be somewhat disturb- ● Inform the doctor and nurses if the pain medication is not
ing to some; a few develop new patterns of pain. Because working.
● Perform simple techniques such as abdominal breathing
this type of therapy has been approved only since 1989 and
and jaw relaxation to increase comfort.
increasingly used since 1997, the long-term risks and ben- ● Consult with the doctor or nurses about using cold or
efits are still being compiled. hot packs or other nondrug techniques to enhance pain
control.
Surgical Approaches
Intractable pain (pain unresponsive to other methods of
pain management) can be relieved with surgery. Rhizotomy
and cordotomy are neurosurgical procedures that provide Education
pain relief. Educating clients about pain and methods of pain manage-
Rhizotomy refers to the surgical sectioning of a nerve ment supports the principle that clients who assume an active
root close to the spinal cord. It prevents sensory impulses role in their treatment achieve positive outcomes sooner
from entering the spinal cord and traveling to the brain. Gen- than others (see Client and Family Teaching 20-1). It may
erally, more than one nerve needs to be sectioned to achieve be unrealistic for clients to expect to be totally pain-free, but
the desired result. Chemical rhizotomy, which uses alcohol they should not have to endure severe pain.
or phenol, and percutaneous rhizotomy, which uses radio-
frequency waves, are nonsurgical alternatives for destroying Imagery
nerve fibers. Cordotomy refers to surgical interruption of pain Imagery means using the mind to visualize an experience
pathways in the spinal cord. It is accomplished by cutting bun- and sometimes is referred to as intentional daydreaming.
dles of nerves. Although both procedures interrupt the sensa- The person chooses images based on pleasant memories.
tion of pain, they also inhibit the perception of pressure and In guided imagery, the nurse or another person suggests the
temperature in the area supplied by the nerves. Consequently, image to use, such as a walk in the woods, and describes
there is a greater risk for undesirable secondary effects. the sensory experiences in great detail. Tape recordings for
guided imagery and relaxation (discussed later) are also
Nondrug and Nonsurgical Interventions available, but the subject matter and descriptions can become
Several additional interventions can be used to help manage boring when played repeatedly. Some prefer to use taped
pain. Some independent nursing measures include educa- sounds of nature, making it easy to conjure different images
tion, imagery, distraction, relaxation techniques, and appli- each time.
cations of heat or cold. Other interventions, such as trans- Physiologically, the process of imagery produces an
cutaneous electrical nerve stimulation (TENS), acupuncture alteration in consciousness that allows the client to for-
and acupressure, percutaneous electrical nerve stimulation get uncomfortable sensory experiences such as pain. Some
(PENS), biofeedback, and hypnosis, require collaboration believe that imagery stimulates the visual portion of the
with people who have specialized training and expertise. brain’s cortex, located in the right hemisphere, where abstract
The latter interventions are more likely to be used for clients concepts and creative activities occur (Fig. 20-10). While the
with chronic pain or those for whom acute pain management person is imaging, neurotransmitters are released that calm
techniques have been unsuccessful or are contraindicated. the body physically and promote emotional well-being.
LWBK1004-C20_p417-437.indd 427 31/01/12 1:26 AM


Right brain Left brain Relaxation
The nurse teaches the client and family as follows:
Logical ● Assume a comfortable position, either sitting or lying
Intuitive
Abstract Concrete down.
Subjective Objective ● Close your eyes and clear your mind.
Spontaneous Cautious ● Let the chair or bed effortlessly support your body.
Fantasy-oriented Reality-based ● Become aware of how your body feels.
Imaginative Rational ● Take deep abdominal breaths.
Visual Mathematical ● Focus on the rhythm of your breathing.
Fanciful Sensible ● Relax with each breath in and out.
● Tighten and then release muscles in sequential parts of
FIGURE 20-10 Right hemispheric functions are used during your body such as the toes, feet, lower legs, thighs, and
imagery and meditation.
buttocks. Progress toward the face and scalp.
● Visualize healing energy flowing from your feet through
your head. Release your worries and discomfort as it
Meditation passes through.
Meditation involves concentrating on a word or idea that ● Let yourself sleep, if possible.
promotes tranquility and is similar to imagery except the sub- ● At the end of the session, wake up or begin to move
ject matter tends to be more spiritual. Sometimes meditation gradually.
involves silent repetition of a word such as “love” or “peace,”
a prayer, or a statement that reflects a strong personal or reli-
gious belief. Those who use this technique successfully tend microwave], or moist packs) are placed over a painful area
to experience a relaxed state with lowered blood pressure and 24 to 48 hours after the injury.
pulse rates. Thermal applications, whether hot or cold, are never
used longer than 20 minutes at any one time (see Chap. 28).
Distraction The skin is always protected with an insulating layer such as
Distraction is the intentional diversion of attention to switch a cloth or a towel. The client should never go to sleep while
the person’s focus from an unpleasant sensory experience to a hot or cold pack is in place, and hot and cold applications
one that is neutral or more pleasant. The distraction occurs in are contraindicated in areas of the body where circulation or
the “here and now”: it is not imagined. Examples include talk- sensation is impaired.
ing with someone, watching television, participating in a hobby, Menthol (Icy Hot, Heet, BenGay) and capsaicin (Zos-
and listening to music. The mind can attend to only one stimu- trix), compounds found in red pepper, are chemicals some-
lus at a time; while the person is occupied with the diversional times applied topically. Both increase blood flow in the area
activity, the brain is blocked from perceiving painful stimuli. of application, creating a warm or cool feeling that lasts for
several hours.
Relaxation
Relaxation is a technique for releasing muscle tension and
quieting the mind, which helps reduce pain, relieve anxiety, Gerontologic Considerations
and promote a sense of well-being. Consciously relaxing
breaks the circuit among neurons that are overloading the ■ To ensure safety, it is important to assess the condition
brain with distressing thoughts and painful stimuli (see Cli- of the skin and cognitive level of older adults prior to using
ent and Family Teaching 20-2 for a procedure clients can topical application of heat or cold.
learn for relaxation).
Heat and Cold Transcutaneous Electrical Nerve Stimulation

Applications of heat or cold (thermal therapy) are well Transcutaneous electrical nerve stimulation (TENS), a
established techniques for relieving pain. In some locations medically prescribed pain management technique that deliv-
of practice, nurses must obtain permission from the physi- ers bursts of electricity to the skin and underlying nerves, is
cian before applying heat or cold. an intervention implemented by nurses (Skill 20-2). The cli-
Pain caused by an injury is best treated initially with cold ent perceives the electrical stimulus, generated by a battery-
applications (ice bag or chemical pack). The cold reduces powered stimulator, as a pleasant tapping, tingling, vibrating,
localized swelling and promotes vasoconstriction decreasing or buzzing sensation. TENS is used intermittently for 15 to
the circulation of pain-producing chemicals. Many believe 30 minutes or longer whenever the client feels a need for it.
that cold applications relieve pain faster and sustain pain For some time, clients with chronic pain have used
relief longer. Heat applications (hot water bottle, rice bag TENS, but currently, surgical clients also are using it. Reports
[cloth bag containing uncooked rice that is heated in the of its effectiveness range from “useless” to “fantastic.”
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No one is sure exactly how TENS works. Supposedly,

the transmission of electrical stimuli over larger myelinated
nerves takes precedence over the transmission of pain-
producing stimuli to the brain. Others believe that TENS
stimulates the body to release endogenous opioids, and still
others suggest that its effectiveness is based on the power
of suggestion.
TENS is a nonnarcotic, noninvasive method with-
out harmful side effects. It is contraindicated in pregnant
women because its effect on the unborn fetus has not been
determined. Clients with cardiac pacemakers (especially the
demand type), clients prone to an irregular heartbeat, and cli-
ents with previous heart attacks are not candidates for TENS. T12
+ L1 –
– L2 +
➧ Stop, Think, and Respond Box 20-2 +
L3
L4 –
Give some reasons that a person may object to using L5
– S1 +
a TENS unit for pain management. S2
S3
+ –
Acupuncture and Acupressure
Acupuncture is a pain management technique in which
long, thin needles are inserted into the skin; acupressure is
a technique that involves tissue compression rather than nee-
dles to reduce pain. Both are based on ancient traditions of
Chinese medicine and have been demonstrated to prevent or
relieve pain. Their exact analgesic mechanisms, however, are
not completely understood. Some speculate that these tech- FIGURE 20-11 With percutaneous electrical nerve stimulation
niques stimulate the body’s production of endogenous opio- (PENS) therapy, five pairs of electrical stimulating leads (alter-
ids or that the twisting and vibration of the needles and the nating positive and negative current) are connected to needles
inserted into the lumbar and sacral regions of the spine.
pressure applied are forms of cutaneous stimuli that interfere
with pain-transmitting neurochemicals. Others believe that
the pain relief is a result of a placebo effect (see later discus-
on clients with low back pain, pain caused by the spread of
sion); however, combining acupuncture with conventional
cancer to bones, shingles (acute herpes zoster viral infec-
treatment has shown better results than with conventional
tion), diabetic neuropathy, and migraine headaches.
treatment alone. Acupuncture and acupressure are becom-
ing more accepted as legitimate forms of pain therapy in Biofeedback
the United States (National Center for Complementary and With biofeedback, a client learns to control or alter a physio-
Alternative Medicine, 2009). logic phenomenon (eg, pain, blood pressure, headache, heart
rate and rhythm, seizures) as an adjunct to traditional pain
Percutaneous Electrical Nerve Stimulation management. Initially, the client is connected to a physio-
One of the newer innovations in acute and chronic pain logic sensing instrument such as a pulse oximeter or an elec-
management is percutaneous electrical nerve stimulation tromyography machine. The instrument produces a visual or
(PENS), a pain management technique involving a combi- audible signal that correlates with the person’s heart rate,
nation of acupuncture needles and TENS. Acupuncture-like skin temperature, or muscle tension. The client is encouraged
needles are inserted into the soft tissue at the site of pain, to reduce or extinguish the signal using whatever mechanism
and an electrical stimulus is conducted through the needles he or she can—generally by physically relaxing. The feed-
(Fig. 20-11). Percutaneous neuromodulation therapy is an back from the machine demonstrates to the client how well
investigational variation of PENS, the difference being that he or she is accomplishing the goal. Eventually, clients can
the needle-like filaments are of different lengths and are learn to control their symptoms without the assistance of the
placed in anatomic landmarks rather than at the site of pain. equipment, using self-suggestion alone.
PENS is considered superior to TENS in providing pain
relief because the needles are located closer to nerve end- Hypnosis
ings. PENS therapy is administered three times a week for Hypnosis is a therapeutic technique in which a person enters
30 minutes for 4 or more weeks. Sustained analgesia for a a trance-like state resulting in an alteration in perception and
period of time can be obtained by performing PENS for at memory. During hypnosis, the suggestion is made that the
least 8 weeks (Yokoyama et al., 2004; Johnson & Martinson, person’s pain will be eliminated or that the client will experi-
2007). The technique has been successful in research trials ence the sensation in a more pleasant way.
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Although self-hypnosis is possible, more often, hyp- of a client with Acute Pain, a nursing diagnosis defined in the
nosis is induced with the help of a hypnotherapist. Hypno- NANDA-I taxonomy (2012, p. 478) as “an unpleasant sen-
therapists receive special clinical training; their professional sory and emotional experience arising from actual or potential
organizations include the American Society of Clinical Hyp- tissue damage or described in terms of such damage (Inter-
nosis and the International Society for Medical and Psycho- national Association for the Study of Pain); sudden or slow
logical Hypnosis. onset of any intensity from mild to severe with an anticipated
or predictable end and a duration of less than 6 months.”
NURSING IMPLICATIONS Addiction

One of the leading factors interfering with adequate pain
Nurses must increase their knowledge about pain, take every management is the fear of addiction. The American Pain
client’s pain seriously, and implement measures for treat- Society (2008) defines addiction as “a pattern of compulsive
ing pain effectively. Whenever a client’s pain is not con- drug use characterized by a continued craving for an opioid
trolled to his or her satisfaction, the nurse pursues better and the need to use the opioid for effects other than pain
goal achievement by collaborating with pain experts (see relief.” Statistics indicate that the fear of addiction is greater
Nursing Guidelines 20-1). than the reality.
Clients with pain are likely to have various nursing Nurses often assume that a client’s desire to experi-
diagnoses, including the following: ence the drug’s pleasant effects motivates his or her desire
for frequent doses of narcotics. What may be happening is
• Acute Pain
that the prescribed dose or frequency of administration is
• Chronic Pain
not controlling the pain, a phenomenon that occurs as clients
• Anxiety
develop drug tolerance. Nurses may undertreat the pain or
• Fear
may convince the physician to prescribe a placebo.
• Ineffective Coping
Placebos
Nursing Care Plan 20-1 is an example of how a nurse can A placebo is an inactive substance or treatment used as a
follow the steps in the nursing process when planning the care substitute for an analgesic drug or conventional therapeutic

Rationales
Managing Pain
• Never doubt the client’s description of pain or need for relief. • When the client’s pain is continuous, administer analgesic
Bias on the nurse’s part may lead to withholding prescribed drugs on a scheduled basis rather than irregularly. Giving the
medication or undertreating the symptoms. drugs regularly controls pain when it is at a lower intensity.
• Follow the written medical orders for administering pain medi- • Monitor for drug side effects such as respiratory depression,
cations. This practice demonstrates compliance with nurse decreased levels of consciousness, nausea, vomiting, and
practice acts. constipation. Careful monitoring demonstrates concern for the
• Administer pain-relieving drugs as soon as the need becomes client’s safety and comfort.
evident. Prompt administration of drugs reduces the client’s • Consult the professional literature or experts on the equi-
suffering. analgesic dose (an oral dose that provides the same level of
• Consult the physician if the current drug therapy is not control- pain relief as a parenteral dose). This prevents undertreat-
ling the client’s pain. Consulting with the physician demon- ment of pain because of changes in drug absorption or drug
strates client advocacy. metabolism.
• Collaborate with the physician to develop several pain- • Change the client’s position, elevate a swollen limb to reduce
management options involving combinations of drugs, alterna- swelling, loosen a tight dressing, and assist the client with
tive routes of administration, and different dosing schedules. bowel or bladder elimination. These measures reduce factors
Developing options individualizes pain management. that intensify the pain experience.
• Support the formation of an interdisciplinary pain management • Implement independent and prescribed nondrug interventions,
team (physicians, surgeons, nurses, pharmacists, anesthesiolo- such as client teaching, imagery, meditation, distraction, and
gists, physical therapists, massage therapists, and so forth) who TENS, as additional techniques for pain management. These
can be consulted on hard-to-manage pain problems. Such a techniques reduce mild-to-moderate pain when used alone
group makes available the expertise of a variety of practitioners. or potentiate pain management when combined with drug
• Administer pain medication before an activity that produces therapy.
or intensifies pain. This timing prevents pain, which is much • Allow rest periods between activities. Exhaustion reduces the
easier than treating it. client’s ability to cope with pain.
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N U R S I N G C A R E P L A N 2 0 - 1 Acute Pain
Assessment • Measure the client’s vital signs.
• Determine the source of the client’s pain; when it began; its • Note pain-related behaviors such as grimacing, crying, moan-
intensity, location, characteristics; and related factors such as ing, and assuming a guarded position.
what makes the pain better or worse. • Perform a physical assessment, taking care to gently support
• Ask how the client’s pain interferes with life such as dimin- and assist the client to turn as various structures are examined.
ishing the person’s ability to meet his or her own needs for Use light palpation in areas that are tender. Show concern
hygiene, eating, sleeping, activity, social interactions, emo- when assessment techniques increase the client’s pain. Post-
tional stability, concentration, and so on. pone nonpriority assessments until the client’s pain is reduced.
• Identify at what level the client can tolerate pain.
Nursing Diagnosis. Acute pain related to cellular injury or disease as manifested by the statement, “I’m in severe pain,” rating
pain at a 10 using a numeric scale, pointing to the lower left abdominal quadrant, describing the pain as being “continuous and
throbbing that started this morning” without any known cause.
Expected Outcome. The client will rate the pain intensity at his tolerable level of “5” within 30 minutes of implementing a
pain management technique.
Assess the client’s pain and its characteristics at least every Prompt interventions prevent or minimize pain.
2 hours while awake and 30 minutes after implementing a
pain management technique.
Modify or eliminate factors that contribute to pain such as a Multiple stressors decrease tolerance of pain.
full bladder, uncomfortable position, pain-aggravating activ-
ity, excessively warm or cool environment, noise, and social
isolation.
Determine the client’s choice for pain relief techniques from Doing so encourages and respects the client’s participation
among those available. in decision making.
Administer prescribed analgesics or alternative pain manage- Suffering contributes to the pain experience; eliminating
ment techniques promptly. delays in nursing responses can reduce suffering.
Advocate on the client’s behalf for doses of prescribed anal- The Joint Commission standards mandate nurses and other
gesics or the addition of adjuvant drug therapy if pain is not health care workers to facilitate pain relief for all clients.
satisfactorily relieved.
Administer a prescribed analgesic before a procedure or activ- Prophylactic interventions facilitate keeping pain within a
ity that is likely to result in pain or intensify pain that already manageable level.
exists.
Plan for periods of rest between activities. Fatigue and exhaustion interfere with pain tolerance.
Reassure the client that there are many ways to moderate the Suggesting that there are additional untried options reduces
pain experience. frustration or despair that there is no hope for pain relief.
Assist the client to visualize a pleasant experience. Imaging interrupts pain perception.
Help the client to focus on deep breathing, relaxing muscles, Diverting attention to something other than pain reduces
watching television, putting a puzzle together, or talking to pain perception.
someone on the telephone.
Apply warm or cool compresses to a painful site. Flooding the brain with alternative sensory stimuli interrupts
impulses that transmit pain.
Gently massage a painful area or the same area on the oppo- Massage promotes the release of endorphins and enkepha-
site side of the body (contralateral massage). lins that moderate the sensation of pain.
Promote laughter by suggesting that the client relate a Laughter releases endorphins and enkephalins that promote
humorous story or watch a video or comedy program of his a feeling of well-being.
or her choice.

• The client reports that pain is gone or at a tolerable level. • The client can participate in self-care activities without undue
• The client perceives the pain experience realistically and copes pain.
effectively.
LWBK1004-C20_p417-437.indd 431 31/01/12 1:26 AM

measure. Placebos can relieve pain, especially when clients 2. What type of pain is a client with an amputated arm
have confidence in their health care providers. The trust a experiencing who states, “I know my arm is not there,
client has in the nurse or physician probably has more to but I feel it throbbing?”
do with the efficacy of placebos than any other factor. Con- 1. Referred pain
sequently, it is wrong to assume that a client whose pain is 2. Phantom pain
relieved with placebos is addicted or is a malingerer (some- 3. Visceral pain
one who pretends to be sick or in pain). Using deception 4. Cutaneous pain
and withholding pain medication are considered unethical 3. A nurse can expect that acute pain may have which
(American Pain Society, 2005). of the following effects on the client’s vital signs?
1. The temperature may be elevated.
2. The pulse rate may be rapid.
CRITICAL THINKING EXERCISES 3. The respiratory rate may be slow.
4. The blood pressure may fall.
1. Describe factors that can intensify pain.
4. Which of the following is the best action for a hos-
2. How would you respond to a coworker who feels that
pice nurse to take to provide maximum pain relief
a client is “faking” pain to receive medication?
when caring for a client with terminal cancer?
1. Give analgesic medication whenever the client
requests it.
NCLEX-STYLE REVIEW QUESTIONS 2. Administer pain medication every 3 hours as
prescribed.
1. When a nurse observes that a client with upper
3. Ask the physician to prescribe a high dose of pain
abdominal pain is curled in a fetal position and rock-
medication.
ing back and forth, which action would help most to
4. Give pain medication when the client’s pain is
further assess the client’s pain?
severe.
1. Determine whether the client can stop moving.
5. Which of the following categories of medications
2. Ask the client to rate the pain from 0 to 10.
would be considered adjuvants? Select all that apply.
3. Observe whether the client is perspiring
1. Nonsteroidal anti-inflammatory drugs (NSAIDS)
heavily.
2. Botulinum toxin
4. Give the client a prescribed pain-relieving
3. Antidepressants
drug.
4. Anticonvulsants
5. Opioids (narcotics)
LWBK1004-C20_p417-437.indd 432 31/01/12 1:26 AM

SKILL 20-1 Preparing a Patient-Controlled Analgesia (PCA) Infuser
ASSESSMENT
Check the written medical order for the use of a PCA infusion Provides data for programming the infusion device.
device, the prescribed drug, the initial loading dose, the dose
per self-administration, and the lockout interval.
Check the client’s wristband. Prevents medication errors.
Obtain two forms of identification such as asking the client’s Supports the Joint Commission’s National Patient Safety Goal for
name and date of birth. identifying clients correctly.
Assess what the client understands about PCA. Indicates the type and amount of teaching that must be provided.
Check that the currently infusing intravenous (IV) solution is com- Avoids incompatibility reactions.
patible with the prescribed analgesic.
PLANNING
Obtain the following equipment: the infuser, the PCA tubing, and Promotes organization and efficient time management.
the prefilled medication container.
Plug the power cord into the electrical wall outlet. Prolongs the life of the battery.
Explain the equipment and how it functions. Reduces anxiety and promotes independence.
IMPLEMENTATION
Chap. 10).
Attach the PCA tubing to the assembled syringe (Fig. A). Provides a pathway for delivering the medication.
Connecting the tubing. (Photo by B. Proud.)
Open the cover or door of the infuser and load the syringe into its Stabilizes the syringe within the infuser.
cradle (Fig. B).
Loading the syringe within the PCA machine. (Photo by B. Proud.)
Fill the PCA tubing with fluid. Displaces air from the tubing.
Connect the PCA tubing to the IV tubing. Facilitates intermittent administration of medication.
Assess the client’s pain. Provides data from which to evaluate the drug’s effectiveness.
(continued)
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Preparing a Patient-Controlled Analgesia (PCA) Infuser (continued)
Set the volume for the prescribed loading dose (Fig. C). Administers a slightly larger dose of the drug to establish a
reduced level of pain rather quickly.
Setting the loading dose. (Photo by B. Proud.)
Program the infuser according to the individual dose and lockout Prevents overdosing.
period.
Close the security door and lock it with a key (Fig. D). Prevents tampering.
Locking the infuser within the PCA machine. (Photo by B. Proud.)
Instruct the client to press and release the control button each Educates the client on how to operate the equipment.
time pain relief is needed (Fig. E).
Explaining the use of the PCA infuser. (Photo by B. Proud.)
Explain that a bell will sound when the infuser delivers medication. Provides sensory reinforcement that the machine is working.
Assess the client’s pain at least every 2 hours. Complies with standards of care.
Replace the medication syringe when it becomes empty. Maintains continuous pain management.
Change the primary IV solution container every 24 hours. Complies with infection control policies.
(continued)
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Preparing a Patient-Controlled Analgesia (PCA) Infuser (continued)
Evaluation
• The client self-administers pain medication.
• The client’s pain is controlled within a tolerable level.
Document
• Date and time
• Volume and type of analgesic solution
• Name of analgesic drug
• Initial pain assessment
• Loading dose
• Individual dose and time schedule
• Reassessments of pain
• Total volume self-administered per shift
Date and Time A 30 mL syringe of saline with 30 mg of morphine sulfate inserted into a PCA pump. Describes pain
around abdominal incision as continuous and stabbing. Rates the pain at a level of 7 on a scale of 0–10.
Loading dose of 2 mg administered. Infuser programmed to deliver 0.1 mL—the equivalent of 0.1 mg—at
no more than 10-minute intervals. Rates pain at a level of 5 within 10 minutes after loading dose. Instruct-
ed and observed to self-administer a subsequent dose. __________________________ SIGNATURE/TITLE
SKILL 20-2 Operating a Transcutaneous Electrical Nerve Stimulation (TENS) Unit

ASSESSMENT
Check the written medical order for providing the client with a Demonstrates collaboration with the medical management of
TENS unit. client care.
Ask the physician or physical therapist about the best location for Optimizes pain management by individualizing electrode
electrode placement. Some possible variations are as follows: placement.
• On or near the painful site
• On either side of an incision
• Over cutaneous nerves
• Over a joint
Read the client’s history to determine whether there are any con- Demonstrates concern for client safety.
ditions for which the use of a TENS unit is contraindicated.
Check the client’s wristband, ask the client to identify himself or Prevents errors and ensures proper client identification.
herself, and state his or her date of birth.
Assess what the client understands about TENS. Indicates the type and amount of teaching that the nurse must
provide.
PLANNING
Obtain the TENS unit and two to four self-adhesive electrodes Promotes organization and efficient time management.
(Fig. A).
TENS unit.
A
(continued)
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Operating a Transcutaneous Electrical Nerve Stimulation (TENS) Unit (continued)
Explain the equipment and how it functions. Reduces anxiety and promotes independence.
Establish a goal with the client for the level of pain management Aids in evaluating the effectiveness of the intervention.
desired.
IMPLEMENTATION
Chap. 10).
Peel the backing from the adhesive side of the electrodes. Facilitates skin contact.
Position each electrode flat against the skin (Fig. B). Enhances contact with the skin for maximum effectiveness.
Applying electrodes.
Space the electrodes at least the width of one from the other. Prevents the potential for burning caused by close proximity of
the electrodes.
Make sure the settings on the TENS unit are off. Prevents premature stimulation to the skin.
Attach the cord(s) from the electrodes to the outlet jack(s) on the Completes the circuitry from the electrodes to the battery-
TENS unit, much like a headset connects with a radio. operated power unit.
Turn the amplitude (intensity) knob on to the lowest setting and Helps acquaint the client with the sensation that the TENS unit
assess whether the client can feel a tingling, buzzing, or vibrat- produces.
ing sensation.
Gradually increase the intensity to the point at which the client Adjusts intensity according to the client’s response—a high inten-
experiences a mild or moderately pleasant sensation (Fig. C). sity does not always provide the most pain relief; in fact, it may
cause discomfort, muscle contractions, or itching.
Adjusting the TENS settings.
Set the rate (pulses per second) at a low rate and increase Adjusts the frequency of stimuli according to the client’s comfort
upward; a rate of 80–125 pulses per second is a conventional and tolerance.
setting.
Set the pulse width (the duration of each pulsation); a pulse width Provides wider and deeper stimulation as the pulse width
of 60–100 microseconds usually is used for acute pain, but increases.
220–250 microseconds at higher amplitudes may be necessary
for chronic or intense pain.
(continued)
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Operating a Transcutaneous Electrical Nerve Stimulation (TENS) Unit (continued)
Turn the unit off when a sufficient level of pain relief occurs and Tests whether or not the TENS unit may be sufficient for intermit-
turn it back on when pain reappears. tent rather than continuous use.
Turn the unit off and remove the cord from the outlet jacks before Reduces hazards from potential contact of electrical equipment
bathing the client. with water.
Remove the electrode patches periodically to inspect the skin; Aids in skin assessment.
reapply electrodes if they become loose.
Slightly change the position of the electrodes if skin irritation Promotes skin integrity.
develops.
Replace or recharge the batteries as needed. Maintains function of the unit.
Evaluation
• Pain is managed at the goal set by the client.
• Activity is increased.
• Less pain medication is required.
• Emotional outlook is improved.
Document
• Date and time
• Initial pain assessments
• Location of electrodes
• Power settings
• Length of time TENS unit is in use
• Reassessments of pain 30 minutes after application of unit and at least once per shift
• Time when TENS is stopped or discontinued
Date and Time Rates pain intensity as “10” on a scale from 0 to 10. Pain is described as “piercing” and continuous. Points
to lower spine when asked to identify location of pain. Electrodes placed to the immediate R. and L. of
the lumbosacral vertebrae. TENS unit initially set at a rate of 80 pulses per second and a pulse width of 60
microseconds. Used for 30 minutes, at which time rated pain at “moderate.” Rate increased to 100 pulses
per second with a pulse width of 150. SIGNATURE/TITLE
LWBK1004-C20_p417-437.indd 437 31/01/12 1:26 AM

21 Oxygenation
apnea
arterial blood gas
CPAP mask 1. Explain the difference between ventilation and respiration.
diaphragmatic breathing 2. Differentiate between external and internal respiration.
expiration 3. Name two methods for assessing the oxygenation status of
face tent clients at the bedside.
flowmeter 4. List at least five signs of inadequate oxygenation.
Fowler’s position 5. Name two nursing interventions that can be used to improve
fraction of inspired oxygen ventilation and oxygenation.
humidifier 6. Identify four items that may be needed when providing
hyperbaric oxygen therapy oxygen therapy.
hypercarbia 7. Name four sources for supplemental oxygen.
hypoxemia 8. List five common oxygen delivery devices.
hypoxia 9. Discuss two hazards related to the administration of oxygen.
incentive spirometry 10. Describe two additional therapeutic techniques that relate to
inspiration oxygenation.
liquid oxygen unit 11. Discuss at least two facts concerning oxygenation that affect
nasal cannula the care of older adults.
nasal catheter
nonrebreather mask
orthopneic position
xygen, which measures approximately 21% in the Earth’s
O
oxygen analyzer
oxygen concentrator atmosphere, is essential for sustaining life. Each cell of the
oxygen tent human body uses oxygen to metabolize nutrients and produce
oxygen therapy energy. Without oxygen, cell death occurs rapidly.
oxygen toxicity This chapter describes the anatomic and physiologic aspects
partial rebreather mask of breathing, techniques for assessing and monitoring oxygenation,
pulse oximetry types of equipment used in oxygen therapy, and skills needed to main-
pursed-lip breathing tain respiratory function. Techniques for airway management, such
respiration as suctioning and other methods for maintaining a patent airway, are
simple mask
presented in Chapter 36.
stent
surfactant
tension pneumothorax
tidaling
ANATOMY AND PHYSIOLOGY OF
T-piece BREATHING
tracheostomy collar
transtracheal catheter The elasticity of lung tissue allows the lungs to stretch andll with
fi
ventilation air during inspiration (breathing in) and return to a resting position
Venturi mask after expiration (breathing out). Ventilation (the movement of air in
water-seal chest tube drainage and out of the lungs) facilitates respiration (the exchange of oxy-
gen and carbon dioxide). External respiration takes place at the most
distal point in the airway between the alveolar–capillary membranes
(Fig. 21-1). Internal respiration occurs at the cellular level by means
of hemoglobin and body cells. For people without respiratory disease,
increased blood levels of carbon dioxide and hydrogen ions trigger the
stimulus to breathe, both chemically and neurologically.
438
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CHAPTER 21 Oxygenation 439
Nose - mouth oxygen, additional muscles known as accessory muscles of

Airways of respiration (the pectoralis minor and sternocleidomastoid)
respiratory
contract to assist with even greater chest expansion.
tree (ventilation)
During expiration, the respiratory muscles relax, the tho-
Air blown out Air pulled in racic cavity decreases, the stretched elastic lung tissue recoils,
intrathoracic pressure increases as a result of the compressed
pulmonary space, and air moves out of the respiratory tract.
Alveoli
A person can forcibly exhale additional air by contracting
abdominal muscles such as the rectus abdominis, transverse
abdominis, and external and internal obliques.
External respiration (gas exchange
O2 between air in alveoli and blood in
O2 pulmonary capillaries) Gerontologic Considerations
Internal
Tissue cells
respiration
CO2 (gas exchange ■ Reduced gas exchange and efficiency in ventilation are
O2
Blood in between tissue the major age-related changes in the respiratory system.
pulmonary capillaries Blood flow cells and blood
O2
■ Age-related structural changes affecting the respiratory
in systemic
CO2 capillaries) system in older adults include the following: respiratory
Blood in muscles become weaker and the chest wall becomes
systemic capillaries stiffer as a result of calcification of the intercostal cartilage,
kyphoscoliosis, and arthritic changes to costovertebral
FIGURE 21-1 External and internal respiration. joints; the ribs and vertebrae lose calcium; the lungs
become smaller and less elastic; alveoli enlarge; and alveo-
lar walls become thinner.
Ventilation results from pressure changes within the ■ Functional changes to the respiratory system include
thoracic cavity produced by the contraction and relaxation diminished coughing and gag reflexes, increased use of
of respiratory muscles (Fig. 21-2). During inspiration, the accessory muscles for breathing, diminished efficiency of
dome-shaped diaphragm contracts and moves downward in gas exchange in the lungs, and increased mouth breathing
the thorax. The intercostal muscles move the chest outward and snoring.
by elevating the ribs and sternum. This combination expands ■ Some changes in lung volumes occur, resulting in a slight
the thoracic cavity. Expansion creates more chest space, decrease in overall efficiency and increased energy expen-
causing the pressure within the lungs to fall below that in diture by older adults. Older adults experience no change in
the atmosphere. Because air flows from an area of higher the volume of air in the lungs after maximal inhalation
(known as total lung capacity) as a result of using acces-
pressure to one of lower pressure, air is pulled in through
sory muscles to breathe.
the nose, filling the lungs. When there is an acute need for
Air
Air
Sternocleidomastoid
Intercostals Intercostals
Pectoralis
minor
Diaphragm Diaphragm
Abdominal
muscles
A B
FIGURE 21-2 Ventilation and thoracic pressure changes. A. Inspiration. B. Expiration.
LWBK1004-C21_p438-466.indd 439 2/6/12 7:26 PM

ASSESSING OXYGENATION B OX 2 1- 1 Common Signs of Inadequate

Oxygenation
The nurse can determine the quality of a client’s oxygena-
• Decreased energy
tion by collecting physical assessment data, monitoring arte-
• Restlessness
rial blood gases, and using pulse oximetry. A combination
• Rapid, shallow breathing
of these helps to identify signs of hypoxemia (insufficient • Rapid heart rate
oxygen within arterial blood) and hypoxia (inadequate oxy- • Sitting up to breathe
gen at the cellular level). • Nasal flaring
• Use of accessory muscles
Physical Assessment • Hypertension
The nurse physically assesses oxygenation by monitoring • Sleepiness, confusion, stupor, coma
the client’s respiratory rate, observing the breathing pat- • Cyanosis of the skin (mucous membranes in dark-skinned
tern and effort, checking chest symmetry, and auscultat- clients), lips, and nail beds
ing lung sounds (see Chap. 13). Additional assessments
include recording the heart rate and blood pressure, deter-
mining the client’s level of consciousness, and observing responsible for carrying oxygen to all cells. Initial and
the color of the skin, mucous membranes, lips, and nail subsequent ABGs are ordered to assess the client in acute
beds (Box 21-1). respiratory distress or to evaluate the progress of a client
receiving medical treatment.
In most situations, a laboratory technician and the
Gerontologic Considerations nurse collaboratively collect arterial blood. The nurse noti-
fies the laboratory of the need for the blood test, records
■ Careful assessment of older adults who demonstrate pertinent assessments on the laboratory request form and
restlessness or confusion is imperative to differentiate in the client’s chart, prepares the client, assists the labora-
signs of inadequate oxygenation accurately from signs of tory technician who obtains the specimen, and implements
early delirium or dementia. measures for preventing complications after the arterial
puncture. In emergencies, a nurse who is trained in per-
forming arterial punctures may obtain the specimen (see
Arterial Blood Gases Nursing Guidelines 21-1).
An arterial blood gas (ABG) assessment is a laboratory
test using arterial blood to assess oxygenation, ventila- Pulse Oximetry
tion, and acid–base balance. It measures the partial pres- Pulse oximetry is a noninvasive, transcutaneous technique
sure of oxygen dissolved in plasma (PaO2), the percentage for periodically or continuously monitoring the oxygen satu-
of hemoglobin saturated with oxygen (SaO2), the partial ration of blood (Skill 21-1). A pulse oximeter is composed of
pressure of carbon dioxide in plasma (PaCO2), the pH of a photodetector sensor, a red and infrared light emitter, and a
blood, and the level of bicarbonate (HCO3) ions (Table microprocessor. The device is attached to a finger, toe, earlobe,
21-1). Arterial blood is preferred for sampling because or the bridge of the nose using spring-tension or adhesive. The
arteries have greater oxygen content than veins and are sensor detects the amount of light absorbed by hemoglobin.
TABLE 21-1 Values for Arterial Blood Gases

COMPONENT NORMAL RANGE ABNORMAL FINDINGS INDICATION OF ABNORMAL FINDINGS
pH 7.35–7.45 <7.35 Acidosis
>7.45 Alkalosis
PaO2 80–100 mmHg 60–80 mmHg Mild hypoxemia
40–60 mmHg Moderate hypoxemia
<40 mmHg Severe hypoxemia
>100 mmHg Hyperoxygenation
PaCO2 35–45 mmHg <35 mmHg Hyperventilation
>45 mmHg Hypoventilation
SaO2 95%–100% <95% Hypoventilation
Anemia
HCO3 22–26 mEq <22 or >26 mEq Compensation for acid–base imbalance
LWBK1004-C21_p438-466.indd 440 2/6/12 7:26 PM

Rationales
Assisting With an ABG
• Perform the Allen test before the arterial puncture by doing the oxygen therapy is necessary or aids in evaluating its current
following: effectiveness.
• Flex the client’s elbow and elevate the forearm where the • Hyperextend the wrist over a rolled towel. Hyperextension
arterial puncture will be made. brings the radial artery nearer the skin surface to facilitate
• Compress the radial and ulnar arteries simultaneously (see penetration.
Fig. 21-3A). • Comfort the client during the puncture. An arterial puncture
• Instruct the client to open and close the fist until the palm of tends to be painful unless a local anesthetic is used.
the hand appears blanched. • After obtaining the specimen, expel all air bubbles from it.
• Release pressure from the ulnar artery while maintaining Doing so ensures that the only gas in the specimen is that
pressure on the radial artery (see Fig. 21-3B). contained in the blood.
• Observe whether the skin flushes or remains blanched. • Rotate the collected specimen. Rotation mixes the blood with
• Release pressure on the radial artery. the anticoagulant in the specimen tube, ensuring that the blood
sample will not clot before it can be examined.
The Allen test determines if the hand has an adequate ulnar • Place the specimen on ice immediately. Blood cells deteriorate
arterial blood supply should the radial artery become damaged outside the body, causing changes in the oxygen content of the
or occluded. The radial artery should not be punctured if the sample. Cooling the sample slows cellular metabolism and
Allen test shows absent or poor collateral arterial blood flow as ensures more accurate test results.
evidenced by continued blanching after pressure on the ulnar • Apply direct manual pressure to the arterial puncture site for
artery has been released. Alternative sites include the brachial, 5–10 minutes. Arterial blood flows under higher pressure than
femoral, or dorsalis pedis arteries. venous blood. Therefore, prolonged manual pressure is neces-
• Keep the client at rest for at least 30 minutes before obtaining sary to control bleeding.
the specimen unless the procedure is an emergency. Because • Cover the puncture site with a pressure dressing composed
an ABG reflects the client’s status at the moment of blood sam- of several 4 × 4 in. gauze squares and tape. Tight mechanical
pling, activity can transiently lower oxygen levels in the blood compression provides continued pressure to reduce the poten-
and lead to an incorrect interpretation of the test results. tial for arterial bleeding.
• Record the client’s current temperature, respiratory rate, and • Assess the puncture site periodically for bleeding or formation of
level of activity if other than resting. Increased metabolism and a hematoma (collection of trapped blood) beneath the skin. Peri-
activity affect cellular oxygen demands. Therefore, the data odic inspection aids in the early identification of arterial bleeding,
help in interpreting the results of laboratory findings. which can lead to substantial blood loss and discomfort.
• Record the amount of oxygen the client is receiving at the • Report the laboratory findings to the prescribing physician as
time of the test (either room air or prescribed amount) and soon as they are available. Collaboration with the physician
ventilator settings. This information helps to determine if assists in making changes in the treatment plan to improve the
client’s condition.
Radial artery Radial artery
Blanched palm Flushed palm
Ulnar artery
Ulnar artery
A B
FIGURE 21-3 A. Simultaneous compression of radial and ulnar arteries. B. Pressure on the
ulnar artery is released.
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100 TABLE 21-2 Factors That Interfere With Accurate

Pulse Oximetry
90
FACTOR CAUSE REMEDY
80
Movement of Tremor Relocate sensor
70 the sensor Restlessness to another site
SpO2 - Percent saturation
Loss of adhesion Replace sensor or

60 tape in place
Poor circulation Peripheral vascular Change the sensor
50
at the sensor disease location or type
40 site Edema of sensor
Tourniquet effect from Loosen or change
30 taped sensor sensor location
Vasoconstrictive drug
20 effects
Barrier to light Nail polish Discontinue use
10
Thick toenails temporarily
0 Acrylic nails Remove polish
0 10 20 30 40 50 60 70 80 90 100 110120 130 140 Relocate sensor
PaO2 - Pressure of oxygen (mm Hg) Remove acrylic nails
Extraneous Direct sunlight Cover sensor with
FIGURE 21-4 Draw a line from the SpO2 in the left column
light Treatment lights a towel
across the graph to the point at which it intersects the curve.
Hemoglobin Carbon monoxide Discontinue use
Use the numeric scale at the bottom to calculate the PaO2. In
saturation poisoning temporarily
this example, with an SpO2 of 95%, the PaO2 is approximately
with other
98 mmHg.
substances
The microprocessor then computes the information and

Positioning
displays it on a monitor at the bedside. The measurement
Unless contraindicated by their condition, clients with
of oxygen saturation when obtained by pulse oximetry is
hypoxia are placed in high Fowler’s position (an upright
abbreviated and recorded as SpO2 to distinguish it from the
seated position; see Chap. 23). This position eases breathing
SaO2 measurement obtained from arterial blood.
by allowing the abdominal organs to descend away from the
Based on the oxygen–hemoglobin dissociation curve
diaphragm. As a result, the lungs have the potential to fill
(Fig. 21-4), it is possible to infer the PaO2 from the pulse
with a greater volume of air.
oximetry measurement. The normal SpO2 is 95% to 100%.
As an alternative, clients who find breathing difficult
A sustained level of less than 90% is cause for concern. If the
may benefit from a variation of Fowler’s position called the
SpO2 remains low, the client needs oxygen therapy. Various
orthopneic position. This is a seated position with the arms
factors, however, affect the accuracy of the displayed infor-
supported on pillows or the arm rests of a chair, and the cli-
mation (Table 21-2). Troubleshooting the equipment, per-
ent leans forward over the bedside table or a chair back (Fig.
forming current physical assessments, and obtaining an ABG
21-5). The orthopneic position allows room for maximum
help to confirm the significance of the displayed findings.
vertical and lateral chest expansion and provides comfort
while resting or sleeping.
What actions are appropriate if a client appears to Breathing Techniques
be hypoxemic, but the pulse oximeter indicates a Breathing techniques such as deep breathing with or without
normal SpO2? What action(s) are appropriate if the
an incentive spirometer, pursed-lip breathing, and diaphrag-
opposite occurs—that is, the client appears normal
but the pulse oximeter reading gives you cause for
matic breathing help clients to breathe more efficiently.
concern? Deep Breathing
Deep breathing is a technique for maximizing ventilation.
Taking in a large volume of air fills alveoli to a greater
PROMOTING OXYGENATION capacity, thus improving gas exchange.
Deep breathing is therapeutic for clients who tend to
Many factors affect ventilation and, subsequently, respira- breathe shallowly, such as those who are inactive or in pain.
tion (Table 21-3). Positioning and teaching breathing tech- To encourage deep breathing, the client learns to take in
niques are two nursing interventions frequently used to as much air as possible, hold the breath briefly, and exhale
promote oxygenation. Adhesive nasal strips can be used to slowly. In some cases, it is helpful to use an incentive spirom-
improve oxygenation by reducing nasal airway resistance eter; however, deep breathing alone, if performed effectively,
and improving ventilation. is sufficiently beneficial.
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TABLE 21-3 Factors Affecting Oxygenation

FACT NURSING IMPLICATION
Adequate respiration depends on a minimum of 21% oxygen in Clients with cardiopulmonary disorders require more than 21% oxy-
the environment and normal function of the cardiopulmonary gen to maintain adequate oxygenation of blood and cells.
system.
Breathing can be voluntarily controlled. Assist clients who are hyperventilating to slow the rate of breath-
ing; teach clients to perform pursed-lip breathing to exhale more
completely.
Clients with chronic lung diseases are stimulated to breathe Giving high percentages of oxygen can depress breathing in clients
by low blood levels of oxygen, called “the hypoxic drive to with chronic lung disease. No more than 2–3 L oxygen is safe
breathe.” unless the client is mechanically ventilated.
Smoking causes increased amounts of inhaled carbon monox- Clients who smoke have a greater potential for compromised gas
ide that compete and bond more easily than oxygen to the exchange and acquiring chronic pulmonary and cardiac diseases.
hemoglobin.
Nicotine increases the heart rate and constricts arteries. Teach people who do not smoke never to start.
Identify products that are available, such as nicotine skin patches and
gum, which can help smokers.
Pregnant women who smoke have a risk for low-birth-weight Promote smoking cessation for pregnant women who are addicted
infants because low blood oxygenation affects fetal metabo- to nicotine.
lism and growth.
Pulmonary secretions within the airway and fluid within the Encourage coughing, deep breathing, turning, and ambulating to
interstitial space between the alveoli and capillaries interfere keep alveoli inflated and the airway clear.
with gas exchange. Antibiotics, diuretics, and drugs that improve heart contraction
reduce fluid within the lungs.
Gas exchange is increased by maximum lung expansion and Assist clients to sit up to lower abdominal organs away from the
compromised by any condition that compresses the dia- diaphragm.
phragm, such as obesity, intestinal gas, pregnancy, and an Encourage weight loss, expulsion of gas via ambulation and bowel
enlarged liver. elimination, and assist with removing abdominal fluid by paracen-
tesis (see Chap. 14) to improve breathing.
Activity and emotional stress increase the metabolic need for Provide rest periods and teach stress reduction techniques such as
greater amounts of oxygen. muscle relaxation to promote maintenance of blood oxygen levels.
Pain associated with muscle movement around abdominal and Teach and supervise deep breathing before surgery. Support the
flank surgical incisions decreases the incentive to breathe incision with a pillow and administer drugs that relieve pain to
deeply and cough forcefully. facilitate ventilation.
Incentive Spirometry Pursed-Lip Breathing

Incentive spirometry, a technique for deep breathing using Pursed-lip breathing is a form of controlled ventilation in
a calibrated device, encourages clients to reach a goal- which the client consciously prolongs the expiration phase
directed volume of inspired air. Although spirometers are of breathing. This is another technique for improving gas
constructed in different ways, all are marked in at least 100 mL exchange, which, if done correctly, helps clients eliminate
increments and include some visual cue, such as elevation more than the usual amount of carbon dioxide from the
of lightweight balls, to show how much air the client has lungs. Pursed-lip breathing and diaphragmatic breathing
inhaled (Fig. 21-6). The calibrated measurement also helps are especially helpful for clients who have chronic lung
the nurse to evaluate the effectiveness of the client’s breath- diseases, such as emphysema, which are characterized by
ing efforts (see Client and Family Teaching 21-1). chronic hypoxemia and hypercarbia (excessive levels of
A B
FIGURE 21-5 A. The orthopneic position. B. An alternative orthopneic position.
LWBK1004-C21_p438-466.indd 443 2/6/12 7:26 PM


Diaphragmatic Breathing
The nurse teaches the client and the family as follows:
● Lie down with knees slightly bent.
● Place one hand on the abdomen and the other on the
chest.
● Inhale slowly and deeply through the nose while letting
the abdomen rise more than the chest.
● Purse the lips.
● Contract the abdominal muscles and begin to exhale.
● Press inward and upward with the hand on the abdomen
while continuing to exhale.
● Repeat the exercise for 1 full minute; rest for at least
2 minutes.
● Practice the breathing exercises at least twice a day for a
period of 5–10 minutes.
● Progress to doing diaphragmatic breathing while upright
and active.
is used to increase the volume of air exchanged during inspi-

FIGURE 21-6 During deep inhalation, a ball rises in an incen- ration and expiration. With practice, diaphragmatic breath-
tive spirometer. (Courtesy of Swedish Hospital Medical Center.) ing reduces respiratory effort and relieves rapid, ineffective
breathing (see Client and Family Teaching 21-2).
carbon dioxide in the blood). The client performs pursed-lip Nasal Strips
breathing as follows: Adhesive nasal strips, available commercially in drug stores,
are used to reduce airflow resistance by widening the breath-
• Inhale slowly through the nose while counting to three
ing passageways of the nose. Increasing the nasal diameter
• Purse the lips as though to whistle
promotes easier breathing. Common users of nasal strips are
• Contract the abdominal muscles
people with ineffective breathing as well as athletes, whose
• Exhale through pursed lips for a count of six or more
oxygen requirements increase during sustained exercise.
Expiration should be two to three times longer than Another use for nasal strips is to reduce or eliminate snoring.
inspiration. Not all clients can achieve this goal initially, but
with practice the length of expiration can increase.
OXYGEN THERAPY
Diaphragmatic Breathing
Diaphragmatic breathing is breathing that promotes the When positioning and breathing techniques are inadequate
use of the diaphragm rather than the upper chest muscles. It for keeping the blood adequately saturated with oxygen,
oxygen therapy is necessary. Oxygen therapy is an inter-
vention for administering more oxygen than is present in the
Client and Family Teaching 21-1 atmosphere to prevent or relieve hypoxemia. It requires an
Using an Incentive Spirometer oxygen source, a flowmeter, in some cases an oxygen ana-
The nurse teaches the client and the family as follows: lyzer or humidifier, and an oxygen delivery device.
● Sit upright unless contraindicated.
● Identify the mark indicating the goal for inhalation.
Oxygen Sources
● Exhale normally. Oxygen is supplied from any one of four sources: wall outlet,
● Insert the mouthpiece, sealing it between the lips. portable tank, liquid oxygen unit, or oxygen concentrator.
● Inhale slowly and deeply until the predetermined volume
has been reached.
Wall Outlet
● Hold the breath for 3–6 seconds. Most modern health care facilities supply oxygen through a
● Remove the mouthpiece and exhale normally. wall outlet in the client’s room. The outlet is connected to a
● Relax and breathe normally before the next breath with large central reservoir filled with oxygen on a routine basis.
the spirometer.
● Repeat the exercise 10–20 times per hour while awake or Portable Tanks
as prescribed by the physician. When oxygen is not piped into individual rooms or if the cli-
ent needs to leave the room temporarily, oxygen is provided
LWBK1004-C21_p438-466.indd 444 2/6/12 7:26 PM

FIGURE 21-7 A portable oxygen tank.
FIGURE 21-8 A liquid oxygen unit.

in portable tanks resembling steel cylinders (Fig. 21-7) that
hold various volumes under extreme pressure. A large tank Oxygen Concentrator
of oxygen contains 2,000 lb of pressure per square inch. An oxygen concentrator is a machine that collects and con-
Therefore, tanks are delivered with a protective cap to pre- centrates oxygen from room air and stores it for client use.
vent accidental force against the tank outlet. Any accidental To do so, the concentrator uses a substance called “zeolite”
force applied to a partially opened outlet could cause the tank within two absorbing chambers. The machine compresses
to take off like a rocket, with disastrous results. Therefore, atmospheric air and diverts it into a chamber containing zeo-
oxygen tanks are transported and stored while strapped to a lite. The zeolite absorbs nitrogen from the air, leaving nearly
wheeled carrier. pure oxygen, which is stored in the second chamber. When
Before oxygen is administered from a portable tank, the nitrogen-absorbing chamber becomes saturated, the
the tank is “cracked,” a technique for clearing the outlet of machine releases nitrogen back into the atmosphere, and the
dust and debris. Cracking is done by turning the tank valve process repeats itself, providing a constant supply of oxygen
slightly to allow a brief release of pressurized oxygen. The (Fig. 21-9).
force causes a loud hissing noise, which may be frightening. An oxygen concentrator eliminates the need for a cen-
Therefore, it is best to crack the tank away from the client’s tral reservoir of piped oxygen or the use of bulky tanks that
bedside. must be constantly replaced. This type of oxygen source is
used in home health care and long-term care facilities prima-
Liquid Oxygen Unit
rily because of its convenience and economy.
A liquid oxygen unit is a device that converts cooled liquid
Although it is more economical than oxygen supplied in
oxygen to a gas by passing it through heated coils (Fig. 21-8).
portable tanks, the device increases the client’s electric bill.
Ambulatory clients at home primarily use these small, light-
Other disadvantages are that it generates heat from its motor
weight, portable units because they allow greater mobility
and that it produces an unpleasant odor or taste if the filter
inside and outside the house. Each unit holds approximately
is not cleaned weekly. Also, it is best that clients have a sec-
4 to 8 hours’ worth of oxygen. Potential problems include
ondary source of oxygen available in case of a power failure.
that liquid oxygen is more expensive, the unit may leak dur-
ing warm weather, and frozen moisture may occlude the
Equipment Used in Oxygen
outlet.
Administration
In addition to an oxygen source, other pieces of equipment
Gerontologic Considerations used during the administration of oxygen are a flowmeter,
oxygen analyzer, and humidifier.
■ Older adults who require home oxygen need encourage-
ment to continue socializing with others outside the home Flowmeter
to prevent feelings of isolation and depression. The flow of oxygen is measured in liters per minute (L/min).
A flowmeter is a gauge used to regulate the amount of
LWBK1004-C21_p438-466.indd 445 2/6/12 7:26 PM

Compressor
20
Filter psi
Zeolite
cannisters
Air O2
entry
Oxygen
Concentrator N2
FIGURE 21-9 A portable oxygen

concentrator extracts nitrogen and
concentrates oxygen to enable cli-
ents who require oxygen therapy
to travel about or maintain their
lifestyle without the need for multi-
ple tanks of oxygen.
oxygen delivered to the client and is attached to the oxygen nurse or respiratory therapist first checks the percentage of
source (Fig. 21-10). To adjust the rate of flow, the nurse turns the oxygen in the room air with the analyzer. If there is a normal
dial until the indicator is directly beside the prescribed amount. mixture of oxygen and other gases in the environment, the
The physician prescribes the concentration of oxygen, analyzer indicates 0.21 (21%). When the analyzer is posi-
also called the fraction of inspired oxygen (FIO2; the portion tioned near or within the device used to deliver oxygen, the
of oxygen in relation to total inspired gas), as a percentage reading should register at the prescribed amount (⬎0.21).
or as a decimal (eg, 40% or 0.40). The prescription is based If there is a discrepancy, the nurse adjusts the flowmeter to
on the client’s condition. The Joint Commission recommends reach the desired amount. Oxygen analyzers are used most
that oxygen be prescribed as a percentage rather than in liters often when caring for newborns in isolettes, children in croup
per minute (L/min) because, depending on the oxygen deliv- tents, and clients who are mechanically ventilated.
ery device, liters per minute may provide different percent-
ages of oxygen. Humidifier
A humidifier is a device that produces small water drop-
Oxygen Analyzer lets and may be used during oxygen administration because
An oxygen analyzer is a device that measures the percentage
of delivered oxygen to determine whether the client is receiv-
ing the amount prescribed by the physician (Fig. 21-11). The
Flow meter
Flow indicator
bead
Wall
outlet
Control
dial
FIGURE 21-10 A flowmeter attached to a wall outlet for oxygen

administration. FIGURE 21-11 An oxygen analyzer. (Photo by B. Proud.)
LWBK1004-C21_p438-466.indd 446 2/6/12 7:26 PM

Masks
Oxygen can be delivered using a simple mask, a partial
rebreather mask, a nonrebreather mask, or a Venturi mask.
Simple Mask
A simple mask fits over the nose and mouth and allows
atmospheric air to enter and exit through side ports. An elas-
tic strap holds it in place. The simple mask, like other types
of masks, allows for the administration of higher levels of
oxygen than are possible with a cannula. A simple mask is
sometimes substituted for a cannula when a client has nasal
trauma or breathes through the mouth. When a simple mask
is used, oxygen is delivered at no less than 5 L/min.
The efficiency of any mask is affected by how well it
FIGURE 21-12 An oxygen humidifier attached to a flowmeter. fits the face. Without a good seal, the oxygen leaks from the
mask, thus diminishing its concentration. Other problems
are associated with masks as well. All oxygen masks inter-
oxygen is drying to the mucous membranes. In most cases, fere with eating and make verbal communication difficult to
oxygen is humidified only when more than 4 L/min is understand. Also, some clients become anxious when their
administered for an extended period. When humidification is nose and mouth are covered because it creates a feeling of
desired, a bottle is filled with distilled water and attached to being suffocated. Skin care also becomes a priority because
the flowmeter (Fig. 21-12). A respiratory therapist or nurse masks create pressure and trap moisture.
checks the water level daily and refills the bottle as needed.
Partial Rebreather Mask
➧ Stop, Think, and Respond Box 21-2 A partial rebreather mask is an oxygen delivery device
through which a client inhales a mixture of atmospheric air,
Explain the difference between a flowmeter and an
oxygen from its source, and oxygen contained within a reser-
oxygen analyzer.
voir bag. It provides a means for recycling oxygen and venting
all the carbon dioxide during expiration from the mask. Dur-
Common Delivery Devices ing expiration, the first third of exhaled air enters the reservoir
Common oxygen delivery devices include a nasal cannula, bag. The portion of exhaled air in the reservoir bag contains
masks, a face tent, a tracheostomy collar, or a T-piece (Table a high proportion of oxygen because it comes directly from
21-4). The device prescribed depends on the client’s oxy- the upper airways; the gas in this area has not been involved
genation status, physical condition, and amount of oxygen in gas exchange at the alveolar level. Once the reservoir bag
needed. Skill 21-2 describes how to administer oxygen by is filled, the remainder of exhaled air is forced from the mask
common delivery methods. through small ports. With a simple mask, some carbon diox-
ide always remains within the mask and is reinhaled.
Nasal Cannula
A nasal cannula is a hollow tube with 1/2-in. prongs placed
into the client’s nostrils. It is held in place by wrapping the Gerontologic Considerations
tubing around the ears and adjusting the fit beneath the chin.
It provides a means of administering low concentrations of ■ Older adults who have lost weight and subcutaneous fat
oxygen. Therefore, it is ideal for clients who are not extremely in their cheeks or who are not wearing their dentures may
hypoxic or who have chronic lung diseases. High percentages not receive the prescribed amounts of oxygen by mask
because of an inadequate facial seal.
of oxygen are contraindicated for clients with chronic lung dis-
ease because they have adapted to excessive levels of retained
carbon dioxide and low blood oxygen levels stimulate their Non-rebreather Mask
drive to breathe. Consequently, if clients with chronic lung A nonrebreather mask is an oxygen delivery device in which
disease receive more than 2 to 3 L of oxygen over a sustained all the exhaled air leaves the mask rather than partially entering
period, their respiratory rate slows or even stops. the reservoir bag. It is designed to deliver an FIO2 of 90% to
100%. This type of mask contains one-way valves that allow
only oxygen from its source, as well as the oxygen in the reser-
Gerontologic Considerations voir bag, to be inhaled. No air from the atmosphere is inhaled.
■ The skin behind the ears of older adults as well as others
All the air that is exhaled is vented from the mask. None enters
should be assessed for breakdown if oxygen administration the reservoir bag. Obviously, clients for whom nonrebreather
equipment is secured by tubing or elastic. masks are used are those who require high concentrations of
(continued on page 451)
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TABLE 21-4 Comparison of Oxygen Delivery Devices

COMMON RANGE OF
DEVICE ADMINISTRATION ADVANTAGES DISADVANTAGES
Nasal cannula 2–6 L/min Is easy to apply; promotes Dries nasal mucosa at higher flows
FIO2 24%–40%a comfort May irritate the skin at cheeks and behind ears
Does not interfere with eating Is less effective in some patients who tend to
or talking mouth breathe
Is less likely to create a feeling Does not facilitate administering high FIO2 to
of suffocation hypoxic clients
Nasal
prongs
Adjustable
bead
Masks
Simple 5–8 L/min Provides higher concentrations Requires humidification
FIO2 35%–50%a than possible with a cannula Interferes with eating and talking
Is effective for mouth breath- Can cause anxiety among those who are
ers or clients with nasal claustrophobic
disorders Creates a risk for rebreathing CO2 retained
within mask
Adjustable
strap
Adjustable
nose conformer
Air vent
Oxygen
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COMMON RANGE OF
Partial rebreather 6–10 L/min Increases the amount of Requires a minimum of 6 L/min
FIO2 35%–60%a oxygen with lower liter flows Creates a risk for suffocation
Requires monitoring to verify that reservoir
bag remains inflated at all times
2/3 exhaled air
Oxygen
1/3 exhaled air
Reservoir
bag
Nonrebreather 6–10 L/min Delivers highest FIO2 possible See partial rebreather mask
FIO2 60%–90%a with a mask Creates a risk for oxygen toxicity
All exhaled air
One-way
flap
Oxygen
Reservoir
bag
(Table continues on page 450)
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TABLE 21-4 Comparison of Oxygen Delivery Devices (continued)

COMMON RANGE OF
Venturi 4–8 L/min Delivers FIO2 precisely Permits condensation to form in tubing, which
FIO2 24%–40%a diminishes the flow of oxygen
Elastic head strap
Vent hole
Oxygen
Oxygen
regulator
Face tent 8–12 L/min Provides a comfortable fit Interferes with eating
FIO2 30%–55%a Is useful for clients with facial May result in inconsistent FIO2, depending on
trauma and burns environmental loss
Facilitates humidification
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COMMON RANGE OF
Tracheostomy collar 4–10 L/min Facilitates humidifying and Allows water vapor to collect in tubing, which
FIO2 24%–100%a warming oxygen may drain into airway
Tracheostomy
collar
Vent
Oxygen
T-piece 4–10 L/min Delivers any desired FIO2 with May pull on tracheostomy tube
FIO2 24%–100%a high humidity Allows humidity to collect and moisten gauze
dressing
T-piece
Tracheostomy
tube
Oxygen
a
Source: American Association for Respiratory Care (AARC).
oxygen. They are usually critically ill and may eventually need permit only specific amounts of room air to mix with the
mechanical ventilation. oxygen. This feature ensures that the Venturi mask delivers
Humidification is not used when a mask with a reservoir the exact amount of prescribed oxygen. Unlike masks with
bag is used, despite the high concentrations of oxygen. Also, reservoir bags, humidification can be added when a Venturi
clients with partial and nonrebreather masks are monitored mask is used.
closely to ensure that the reservoir bag remains partially
inflated at all times. Face Tent
A face tent provides oxygen to the nose and mouth without
Venturi Mask the discomfort of a mask. Because the face tent is open and
A Venturi mask mixes a precise amount of oxygen and loose around the face, clients are less likely to feel claus-
atmospheric air. Sometimes called a Venti mask, this mask trophobic. An added advantage is that a face mask can be
has a large ringed tube extending from it. Adapters within the used for clients with facial trauma or burns. A disadvantage
tube, which are color-coded or regulated by a dial system, is that the amount of oxygen clients actually receive may be
LWBK1004-C21_p438-466.indd 451 2/6/12 7:27 PM

inconsistent with what is prescribed because of environmen- regularly cleans the nostril with a cotton applicator to remove
tal losses. dried mucus.
Tracheostomy Collar Oxygen Tent
A tracheostomy collar delivers oxygen near an artificial An oxygen tent is a clear plastic enclosure that provides
opening in the neck. It is applied over a tracheostomy–an cooled, humidified oxygen. It is most likely to be used in the
opening into the trachea through which a client breathes (see care of active toddlers. Children this age are less likely to
Chap. 36). Because it bypasses the warming and moistur- keep a mask or cannula in place but may require oxygena-
izing functions of the nose, a tracheostomy collar provides a tion and humidification for respiratory conditions such as
means for both oxygenation and humidification. The mois- croup or bronchitis. A face hood may be used for less-active
ture that collects, however, tends to saturate the gauze dress- infants.
ing around the tracheostomy, making it necessary to change Oxygen concentrations are difficult to control when an
it frequently. oxygen tent is used. Therefore, when caring for a child in an
oxygen tent, the edges of the tent must be tucked securely
T-Piece beneath the mattress; limit opening the zippered access ports
A T-piece fits securely onto a tracheostomy tube or endotra- so that oxygen does not escape too freely. Oxygen levels
cheal tube. It is similar to a tracheostomy collar but is must be monitored with an analyzer.
attached directly to the artificial airway. Although the gauze
around the tracheostomy usually remains dry, the moisture CPAP Mask
that collects within the tubing tends to condense and may A CPAP mask maintains positive pressure within the air-
enter the airway during position changes if it is not drained way throughout the respiratory cycle (Fig. 21-14). It keeps
periodically. Another disadvantage is that the weight of the the alveoli partially inflated even during expiration. The face
T-piece, or its manipulation, may pull on the tracheostomy mask is attached to a portable ventilator.
tube, causing the client to cough or experience discomfort. Clients generally wear this type of mask at night to
maintain oxygenation when they experience sleep apnea
Additional Delivery Devices (periods during which they stop breathing). The residual
Other methods for delivering oxygen are used less com- oxygen within the alveoli continues to diffuse into the blood
monly. Occasionally, oxygen is delivered by means of a during apneic episodes that may last 10 or more seconds and
nasal catheter, oxygen tent, transtracheal catheter, or con- be as frequent as 10 to 15 times an hour. Sleep apnea is dan-
tinuous positive airway pressure (CPAP) mask. gerous because falling oxygen saturation levels may precipi-
tate cardiac arrest and death.
Nasal Catheter
A nasal catheter is a tube for delivering oxygen that is inserted Transtracheal Oxygen
through the nose into the posterior nasal pharynx (Fig. 21-13). Some clients who require long-term oxygen therapy may
It is used for clients who tend to breathe through the mouth prefer its administration through a transtracheal catheter
or experience claustrophobia when a mask covers their face. (a hollow tube inserted within the trachea to deliver oxygen;
The catheter tends to irritate the nasopharynx; therefore, Fig. 21-15). This device is less noticeable than a nasal can-
some clients find it uncomfortable. If a catheter is prescribed, nula. The client is adequately oxygenated with lower flows,
the nurse secures it to the nose to avoid displacement and decreasing the costs of replenishing the oxygen source.
Inlet valve
Head strap
Catheter
Uvula in place Oxygen tubing
Positive-
pressure
valve Adjustable
inflation valve
FIGURE 21-13 Nasal catheter placement. FIGURE 21-14 A CPAP mask.
LWBK1004-C21_p438-466.indd 452 2/6/12 7:27 PM

Administering Oxygen Safely

• Post “Oxygen in Use” signs wherever oxygen is stored or in
use. The sign warns others of a potential fire hazard.
• Prohibit the burning of candles during religious rites. Doing
so eliminates a source of open flames.
• Check that electrical devices have a three-pronged plug (see
Chap. 19). This type of plug provides a ground for leaking
electricity.
• Inspect electrical equipment for frayed wires or loose con-
nections. Inspection helps to prevent sparks or an uncon-
trolled pathway for electricity.
• Avoid using petroleum products, aerosol products (such as
hair spray), and products containing acetone (such as nail
polish remover) where oxygen is used. This measure prevents
ignition of flammable substances.
• Secure portable oxygen cylinders to rigid stands. Doing so
prevents the tank from rupturing.
FIGURE 21-15 Transtracheal oxygen administration. lipoprotein produced by cells in the alveoli that promotes
elasticity of the lungs and enhances gas diffusion.
Once oxygen toxicity develops, it is difficult to reverse.
Before transtracheal oxygen is used, a stent (tube that
Unfortunately, early symptoms are quite subtle (Box 21-2).
keeps a channel open) is inserted into a surgically created
The best prevention is to administer the lowest FIO2 possible
opening and remains there until the wound heals. Thereafter,
for the shortest amount of time.
the stent is removed, and the catheter is inserted and held in
place with a necklace-type chain. Clients learn how to clean
the tracheal opening and catheter, a procedure performed
RELATED OXYGENATION
several times a day. During cleaning, clients administer oxy-
gen with a nasal cannula.
TECHNIQUES
Two additional techniques relate to oxygenation: a water-

➧ Stop, Think, and Respond Box 21-3 seal chest tube drainage system and hyperbaric oxygen ther-
What evidence indicates that a client is well apy (HBOT).
oxygenated?
Water-Seal Chest Tube Drainage
Oxygen Hazards Water-seal chest tube drainage is a technique for evacu-
Regardless of which device is used, oxygen administra- ating air or blood from the pleural cavity, which helps to
tion involves potential hazards: first and foremost, oxygen’s restore negative intrapleural pressure and reinflate the lung.
capacity to support fires, and second, the potential for oxy- Clients who require water-seal drainage have one or two
gen toxicity. chest tubes connected to the drainage system.
Fire Potential
Oxygen itself does not burn, but it does support combus-
tion; in other words, it contributes to the burning process. B OX 2 1- 2 Signs and Symptoms of Oxygen
Therefore, it is necessary to control all possible sources of Toxicity
open flames or ungrounded electricity (see Nursing Guide- • Nonproductive cough
lines 21-2). • Substernal chest pain
• Nasal stuffiness
Oxygen Toxicity • Nausea and vomiting
Oxygen toxicity means lung damage that develops when • Fatigue
oxygen concentrations of more than 50% are administered • Headache
for longer than 48 to 72 hours. The exact mechanism by • Sore throat
which hyperoxygenation damages the lungs is not definitely • Hypoventilation
known. One theory is that it reduces surfactant, which is a
LWBK1004-C21_p438-466.indd 453 2/6/12 7:27 PM

Parietal pleura
Visceral To suction source

pleura (or air)
From patient
Lung Vent to
room air
Pleural cavity
20 mm
250 mm
FIGURE 21-16 The three-

chambered water-seal drainage
system: (1) drainage collection
2 mm chamber from the client, (2) the
water-seal chamber, and (3) the
1 2 3 suction control chamber attached
to a source of suction and vented
Water seal to room air.
Several companies provide equipment for water-seal insufficiency, decompression sickness experienced by deep-
drainage. All of these products consist of a three-chamber sea divers, anaerobic infections (especially in burn clients),
system (Fig. 21-16): and several other medical conditions.
• One chamber collects blood or acts as an exit route for
pleural air.
• A second compartment holds water that prevents atmo-
spheric air from reentering the pleural space (hence the
Nurses assess the oxygenation status of clients on a day-by-
term “water seal”).
day and a shift-by-shift basis. Therefore, it is not unusual to
• A third chamber, if used, facilitates the use of suction,
identify any one or several of the following nursing diag-
which may speed the evacuation of blood or air.
noses among clients experiencing hypoxemia or hypoxia:
One of the most important principles when caring for
• Ineffective Breathing Pattern
clients with water-seal drainage is that the chest tube must
• Impaired Gas Exchange
never be separated from the drainage system unless it is
• Anxiety
clamped. Even then, the tube is clamped for only a brief time.
• Risk for Injury (Related to Oxygen Hazards)
Additional nursing responsibilities are included in Skill 21-3.

Discuss how a collapsed lung affects oxygenation.
Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) consists of the deliv-
ery of 100% oxygen at three times the normal atmospheric
pressure within an airtight chamber (Fig. 21-17). Treatments,
which last approximately 90 minutes, are repeated over days,
weeks, or months of therapy. Providing pressurized oxygen
can deliver 15 times as much oxygen to tissues as can be
obtained by breathing room air (Mayo Clinic, 2009). Provid-
ing clients with brief periods of breathing room air helps to
prevent oxygen toxicity.
HBOT helps to regenerate new tissue at a faster rate;
thus, its most popular use is for promoting wound healing.
It also is used to treat carbon monoxide poisoning, gangrene FIGURE 21-17 A hyperbaric oxygen chamber. (Photo courtesy
associated with diabetes or other conditions of vascular of Moose Jaw Union Hospital, Saskatchewan, Canada.)
LWBK1004-C21_p438-466.indd 454 2/6/12 7:27 PM

Abnormal assessment findings often lead to collabo- nosis of Ineffective Breathing Pattern. This diagnostic cat-
ration with the physician and the prescription for oxygen egory is defined in the NANDA-I taxonomy (2012, p. 233)
therapy. Nursing Care Plan 21-1 is one example of how the as “inspiration and/or expiration that does not provide ade-
nursing process applies to a client with the nursing diag- quate ventilation.”
N U R S I N G C A R E P L A N 2 1 - 1 Ineffective Breathing Pattern

Assessment • Note the client’s body position, which may or may not facili-
• Determine the client’s respiratory rate and effort. tate breathing.
• Check the radial or apical pulse rate. • Measure the client’s SpO2 with a pulse oximeter.
• Measure the client’s blood pressure. • Review the results of arterial blood gas measurements.
• Note the client’s level of consciousness and mental status. • Auscultate anterior, posterior, and lateral lung sounds.
• Assess for the evidence of a cough and its characteristics. • Ask the client to describe his or her current status of
• Observe the use of accessory thoracic and abdominal muscles oxygenation.
for breathing. • Perform a pain assessment.
• Observe the client’s chest contour. • Inquire as to the client’s medical history of respiratory disor-
• Inspect the skin, oral mucous membranes, and nail beds for ders or other conditions that can affect ventilation.
signs of cyanosis. • Identify the client’s smoking history.
• Palpate the client’s abdomen for evidence of distention that • Review the client’s current medication history for drugs that
could crowd the diaphragm. can impair oxygenation.
Nursing Diagnosis. Ineffective Breathing Pattern related to the retention of carbon dioxide secondary to chronic pulmonary
damage from long-term cigarette smoking as manifested by rapid, shallow breathing at 40 breaths per minute accompanied by the
use of accessory muscles to breathe; frequent productive cough; history of smoking one to two packs of cigarettes daily for 30 years;
barrel chest; diminished lung sounds bilaterally; and client’s statements, “It seems so hard for me to get my breath. I can’t work in
my flower garden because I get winded when I try to do any gardening. I can’t sleep lying down because I can’t breathe except
sleeping in a chair.”
Expected Outcome. The client will demonstrate an effective breathing pattern by 5/10 as evidenced by a respiratory rate no
greater than 32 while performing mild activity such as bathing face, arms, and chest.
Provide periods of rest between activities. Rest decreases oxygen demand and facilitates maintenance
or restoration of oxygen within blood.
Elevate the head of the bed up to 90 degrees. Head elevation lowers abdominal organs by gravity and
provides an increased area for chest expansion when the
diaphragm contracts.
Teach how to perform diaphragmatic and pursed-lip breathing Pursed-lip breathing decreases respiratory rate, increases tidal
and practice same at least b.i.d. volume, decreases arterial CO2, increases arterial oxygen,
and improves exercise performance.
Provide a minimum of 2,000 mL of oral fluid per 24 hr. Adequate hydration liquefies respiratory secretions and
facilitates expectoration. Expectoration of sputum clears the
airway and promotes ventilation.
Ensure a daily dietary intake of approximately 2,000–2,500 cal. The act of breathing creates additional caloric demands for
energy.
Administer oxygen per nasal cannula at 2 L/min as prescribed Supplemental oxygen relieves hypoxemia. Administering
by the physician if SpO2 falls below 90% and is sustained 2–3 L/min prevents suppressing the hypoxic drive to breathe,
there. experienced by clients with chronic respiratory diseases.
Explore nicotine cessation therapy with transdermal skin Transdermal nicotine skin patches reduce symptoms associ-
patches. ated with nicotine withdrawal. The dose of nicotine can be
reduced gradually to promote nicotine cessation.

• Respiratory rate decreases from 34 to 26 when placed in high • The client consumes three cans of supplemental liquid nourish-
Fowler’s position. ment, each of which has 350 cal, three times a day, to facilitate
• SpO2 increases from 86% to 90% with 2 L of oxygen per reaching a minimum caloric goal of 2,000 cal.
minute. • Fluid intake for 24 hours is between 1,800 and 2,200 mL.
• The client demonstrates and performs pursed-lip breathing. • Client expectorates copious volume of sputum.
LWBK1004-C21_p438-466.indd 455 2/6/12 7:27 PM

Gerontologic Considerations 2. If a client is adequately oxygenated, in what range

should a pulse oximeter identify as the SpO2 meas-
■ Advise older adults to receive annual influenza immuniza- urement?
tions and a pneumonia immunization after 65 years of age 1. 80 to 100 mmHg
or earlier if there is a history of chronic illness. Current 2. 95 to 100 mmHg
guidelines recommend a booster dose for older adults who 3. 80% to 100%
received their initial pneumonia immunization 5 or more 4. 95% to 100%
years ago. 3. When administering oxygen with a partial rebreather
mask, which of the following observations is most
important to report to the respiratory therapy
department?
CRITICAL THINKING EXERCISES 1. Moisture accumulates inside the mask.
1. What levels of oxygen saturation and pulse rates are 2. The reservoir bag collapses during inspiration.
a cause for nursing concern and indicate a need for 3. The mask covers the mouth and nose.
further assessment? 4. The strap around the head is snug.
2. Discuss some differences between oxygen therapy in 4. Which of the following oxygen flow rates is most
a health care setting and that in a home environment. appropriate for a client with emphysema, a chronic
3. What health teaching would you provide to reduce lung disease?
potential problems with oxygenation? 1. 2 L/min
4. What nursing actions may be appropriate if the alarm 2. 5 L/min
on a pulse oximeter sounds frequently because the 3. 8 L/min
sensor does not stay on a client’s finger? 4. 10 L/min
5. When the nurse monitors the water-seal chamber of a
commercial chest tube drainage system that is drain-
NCLEX-STYLE REVIEW QUESTIONS ing by gravity, which finding suggests that the system
is functioning appropriately?
1. When a client returns from surgery, which sign is an 1. The fluid rises and falls with respirations.
early indication that the client’s oxygenation status is 2. The fluid level is lower than when first filled.
compromised? 3. The fluid bubbles continuously.
1. The client’s dressing is bloody. 4. The fluid looks frothy white.
2. The client becomes restless.
3. The client’s heart rate is irregular.
4. The client reports being thirsty.
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SKILL 21-1 Using a Pulse Oximeter
ASSESSMENT
Assess potential sensor sites for quality of circulation, edema, Determines where sensor is best applied. The finger is the
tremor, restlessness, nail polish, or artificial nails (Fig. A) preferred site, followed by the toe, earlobe, and bridge of the
nose. Aids in controlling possible factors that might invalidate
monitored findings.
Assessing a sensor site.
Review the medical history for data indicating vascular or other Suggests the potential for unreliable data. There must be ade-
pathology, such as anemia or carbon monoxide inhalation. quate circulation, red blood cells, and oxygenated hemoglobin
for reliable results.
Check prescribed medications for vasoconstrictive effects. Impaired blood flow interferes with the accuracy of pulse
oximetry.
Determine how much the client understands about pulse Indicates the need for and type of teaching; the best learning
oximetry. takes place when it is individualized.
PLANNING
Explain the procedure to the client. Reduces anxiety and promotes cooperation and a sense of secu-
rity for coping with unfamiliar situations.
Obtain equipment. Promotes organization and efficient time management, prevent-
ing wasted motion and repeating actions.
IMPLEMENTATION
Chap. 10).
Position the probe so that the photodetector sensor is directly Ensures accurate monitoring; proper light and sensor alignment
opposite the source of light emission (Fig. B). ensure accurate measurement of red and infrared light absorp-
tion by hemoglobin.
Positioning the sensor.
B
(continued)
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Using a Pulse Oximeter (continued)
Attach the sensor cable to the machine (Fig. C). Connects the sensor with the microprocessor to ensure proper
function.
Connecting the sensing equipment.
Observe the numeric display, audible sound, and waveform on Indicates that the equipment is functioning.
the machine (Fig. D).
Checking the displayed data.
Set the alarms for saturation level and pulse rate according to Programs the machine to alert the nurse to check the client.
the manufacturer’s directions. Spot checks of SpO2 are appropriate for clients who are stable
and receiving oxygen therapy; continuous pulse oximetry is
recommended for clients who are unstable and may abruptly
experience desaturation.
Move an adhesive finger sensor if the finger becomes pale, Prevents vascular impairment and skin breakdown because
swollen, or cold; remove and reapply a spring-tension sensor pressure greater than 32 mm Hg leads to tissue hypoxia and
every 2 hours. cellular necrosis.
Evaluation
• SpO2 measurements remain within 95%–100%.
• Client exhibits no evidence of hypoxemia or hypoxia.
• SpO2 measurements correlate with SaO2 measurements.
Document
• Normal SpO2 measurements once a shift unless ordered otherwise
• Abnormal SpO2 measurements when they are sustained
• Nursing measures to improve oxygenation if SpO2 levels fall below 90% and are prolonged
• Person to whom abnormal measurements have been reported and outcome of communication
• Removal and relocation of sensor
• Condition of skin at sensor site
(continued)
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Using a Pulse Oximeter (continued)
Date and Time SpO2 remains constant at 95% to 98% with pulse rate that ranges between 80 and 92 bpm while receiv-
ing oxygen by nasal cannula at 4 L/min. Respirations unlabored. Skin under sensor is intact and warm.
Nailbed beneath sensor is pink with capillary refill <2 seconds. Spring-tension sensor changed from L.
index finger to R. index finger. SIGNATURE/TITLE
SKILL 21-2 Administering Oxygen
ASSESSMENT
Perform physical assessment techniques that focus on Provides a baseline for future comparisons.
oxygenation.
Monitor the SpO2 level with a pulse oximeter. Provides a baseline for future comparisons.
Check the medical order for the type of oxygen delivery device, Ensures compliance with the plan for medical treatment, because
liter flow or prescribed percentage, and whether the oxygen oxygen therapy is medically prescribed (except in emergencies).
is to be administered continuously or only as needed.
Note whether a wall outlet is available or if another type of Promotes organization and efficient time management.
oxygen source must be obtained.
Determine how much the client understands about oxygen Indicates the need for and the type of teaching that must be
therapy. done.
PLANNING
Obtain equipment, which usually includes a flowmeter, delivery Promotes organization and efficient time management.
device, and in some cases, a humidifier.
Contact the respiratory therapy department for equipment, if Follows interdepartmental guidelines; ensures nursing collabora-
that is agency policy. tion with various paraprofessionals to provide client care.
“Crack” the portable oxygen tank if that is the type of oxygen Prevents alarming the client.
source being used.
Explain the procedure to the client. Decreases anxiety and promotes cooperation.
Eliminate safety hazards that may support a fire or explosion. Demonstrates concern for safety because open flames, electrical
sparks, smoking, and petroleum products are contraindicated
when oxygen is in use.
IMPLEMENTATION
Chap. 10).
Assist the client to a Fowler’s or alternate position. Promotes optimal ventilation.
Attach the flowmeter to the oxygen source (Fig. A). Provides a means for regulating the prescribed amount of oxygen.
Attaching the flowmeter. (Photo by B. Proud.)
A
(continued)
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Administering Oxygen (continued)
Fill a humidifier bottle with distilled water to the appropriate Provides moisture because oxygen dries mucous membranes. The
level if administering 4 L/min or more. potential increases with the percentage being administered.
Connect the humidifier bottle to the flowmeter (Fig. B). Provides a pathway through which moisture is added to the oxygen.
Connecting the humidification bottle. (Photo by B. Proud.)
Insert the appropriate color-coded valve or dial the prescribed Regulates the FIO2.
percentage if a Venturi mask is being used.
Attach the distal end of the tubing from the oxygen delivery Provides a pathway for oxygen from its source to the client.
device to the flowmeter or humidifier bottle (Fig. C).
Attaching tubing from the delivery device. (Photo by B. Proud.)
Turn on the oxygen by adjusting the flowmeter to the prescribed Fills the delivery device with oxygen-rich air.
volume.
Note that bubbles appear in the humidifier bottle, if one is used, Indicates that oxygen is being released.
or that air is felt at the proximal end of the delivery device.
Make sure that if a reservoir bag is used, it is partially filled and Prevents asphyxiation and promotes high oxygenation. A reservoir
remains that way throughout oxygen therapy. bag must never become totally deflated during inhalation.
Attach the delivery device to the client. Provides oxygen therapy.
Drain any tubing that collects condensation. Maintains a clear pathway for oxygen and prevents accidental
aspiration when turning a client.
Remove the oxygen delivery device and provide skin, oral, and Maintains intact skin and mucous membranes; reduces the
nasal hygiene at least every 4–8 hours. growth of microorganisms.
Reassess the client’s oxygenation status every 2–4 hours. Indicates how well the client is responding to oxygen therapy.
Notify the physician if the client manifests signs of hypoxemia Demonstrates concern for the client’s safety and well-being.
or hypoxia despite oxygen therapy.
(continued)
LWBK1004-C21_p438-466.indd 460 2/6/12 7:27 PM

Administering Oxygen (continued)
Evaluation
• Respiratory rate is 12–24 breaths per min at rest.
• Breathing is effortless.
• Heart rate is less than 100 bpm.
• Client is alert and oriented.
• Skin and mucous membranes are normal in color.
• SpO2 is greater than or equal to 90%.
• FIO2 and delivery device correspond to medical order.
Document
• Assessment data
• Percentage or liter flow of oxygen administration
• Type of delivery device
• Length of time in use
• Client’s response to oxygen therapy
Date and Time Restless, pulse rate 120, resp. rate 32 with nasal flaring. Placed in high Fowler’s position. SpO2 at 85%–
88%. Simple mask applied with administration of oxygen at 6 L/min. After 15 minutes of oxygen therapy
is less agitated, pulse rate 100, respiratory rate 28, no nasal flaring noted. SpO2 at 90%–92%. Oxygen
continues to be administered. SIGNATURE/TITLE
SKILL 21-3 Maintaining a Water-Seal Chest Tube Drainage System
ASSESSMENT
Review the client’s medical record to determine the condition Indicates whether to expect air, bloody drainage, or both; any
that necessitated inserting a chest tube. condition that causes an opening between the atmosphere and
pleural space results in a loss of intrapleural negative pressure
and subsequent lung deflation.
Determine if the physician has inserted one or two chest tubes Helps direct assessment; the usual sites for chest tubes are at
(Fig. A). the 2nd intercostal space in the midclavicular line and in the
5th to 8th intercostal spaces in the midaxillary line.
Determining whether the physician has inserted one or two chest tubes.
Air
Bloody
drainage
Note the date of chest tube(s) insertion. Provides a point of reference for analyzing assessment data.
Check the medical orders to determine whether the drainage is Provides guidelines for carrying out medical treatment; mechani-
being collected by gravity or with the addition of suction. cal suction is used when there is a large air leak or potential for
a large accumulation of drainage.
(continued)
LWBK1004-C21_p438-466.indd 461 2/6/12 7:27 PM

Maintaining a Water-Seal Chest Tube Drainage System (continued)
PLANNING
Arrange to perform a physical assessment of the client and Establishes a baseline and early opportunity for troubleshooting
equipment as soon as possible after receiving the report. abnormal findings.
Locate a roll of tape and a container of sterile distilled water. Facilitates efficient time management for general maintenance of
the drainage system.
IMPLEMENTATION
Introduce yourself to the client and explain the purpose for the Reduces anxiety and promotes cooperation.
interaction.
Wash hands or perform hand antisepsis with an alcohol rub (see Reduces the transmission of microorganisms; conscientious
Chap. 10). handwashing is one of the most effective methods for prevent-
ing infection.
Check to see that a pair of hemostats (instruments for clamp- Facilitates checking for air leaks in the tubing or clamping the
ing) is at the bedside. chest tube in the event the drainage system must be replaced
to prevent the reentry of atmospheric air within the pleural
space, thus maintaining lung expansion.
Turn off the suction regulator, if one is used, before assessing Eliminates noise that may interfere with chest auscultation.
the client.
Assess the client’s lung sounds. Provides a baseline for future comparison; because lung sounds
cannot be heard in uninflated areas, lung sounds in previously
silent areas indicates reexpansion.
Inspect the dressing for signs that it has become loose or satu- Indicates a need for changing the dressing.
rated with drainage.
Palpate the skin around the chest tube insertion site to feel and Indicates a subcutaneous air leak and an internal displacement of
listen for air crackling in the tissues (Fig. B). the drainage tube.
Palpating the skin around the chest tube inser-

tion site to feel and listen for air crackling in the
tissue. (Photo by B. Proud.)
Inspect all connections to determine that they are taped and Indicates appropriate care has been taken and ensures that the
secure. drainage system will not become accidentally separated.
Reinforce connections where the tape may be loose. Prevents accidental separation.
(continued)
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Check that all tubing is unkinked and hangs freely into the drain- Ensures the evacuation of air and bloody drainage because fluid
age system (Fig. C). cannot drain upward against gravity; neither air nor fluid can
pass through a physical obstruction.
Keeping chest tubes unobstructed from the client to the drainage chamber.
Observe the fluid level in the water-seal chamber to see if it is at Maintains the water seal, preventing the passage of atmospheric
the 2-cm level and that the water in the suction chamber is at air into the pleural space and provides the usual water level for
the 20-cm mark or the pressure prescribed by the physician suction.
(Fig. D).
20 cm 20 cm
(suction
control)
Noting water levels.
2 cm
(water
seal)
Chest
drainage
D
(continued)
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Add sterile distilled water to the 2-cm mark in the water-seal Two cm of water maintains the water seal; the 20-cm depth of
chamber or 20-cm mark to the suction control chamber if the water in the suction chamber determines the amount of negative
fluid is below standard (Fig. E). pressure, not the pressure setting on the suction source.
Adding water to the suction control chamber.
Note if the water is tidaling (the rise and fall of water in the Indicates that the tubing is unobstructed and the lung has not
water-seal chamber that coincides with respiration) (Fig. F). completely inflated; intrathoracic pressure changes during
breathing cause the fluid to rise and fall.
Watching for tidaling—movement of water up and down in the water-seal chamber.
Observe for continuous bubbling in the water-seal chamber. Indicates an air leak in the tubing or at a connection; constant
bubbling is normal and expected in the suction control chamber
as long as it is used.
If constant bubbling is observed, clamp hemostats at the chest Provides a means for determining the location of an air leak
and within a few inches away; observe if the bubbling stops; within the tubing because gas escapes through the path of
continue releasing and reapplying the hemostats toward the least resistance.
drainage system until the bubbling stops.
Apply tape around the tube above where the last clamp was Seals the origin of the air leak.
applied when the bubbling stopped.
Regulate the wall suction so that it produces gentle bubbling. Prevents rapid evaporation and unnecessary noise.
(continued)
LWBK1004-C21_p438-466.indd 464 2/6/12 7:27 PM

Observe the nature and amount of drainage in the collection Provides comparative data; more than 100 mL/hr or bright-red
chamber (Fig. G). drainage is reported immediately.
Observing drainage characteristics.
Keep the drainage system below chest level. Maintains gravity flow of drainage.
Position the client to avoid compressing the tubing. Facilitates drainage.
Curl and secure excess tubing on the bed. Avoids dependent loops to facilitate drainage.
Milk the tubing, a process of compressing and stripping the tub- Creates extremely high negative intrapleural pressure; milking is
ing to move stationary clots, but only if necessary. never done routinely.
Encourage coughing and deep breathing at least every 2 hours Promotes lung reexpansion because the mechanics of breathing
while awake. and forceful coughing help evacuate air and fluid.
Instruct the client to move about in bed, ambulate while carry- Prevents hazards of immobility and maintains joint flexibility with
ing the drainage system, and exercise the shoulder on the no danger to the client while the tube to the suction source is
side of the drainage tube(s). disconnected as long as the water seal remains intact.
Never clamp the chest tube for an extended period. Predisposes to developing a tension pneumothorax (extreme
air pressure within the lung when there is no avenue for its
escape); clamping a chest tube briefly is safe, for example,
when changing the entire drainage system.
If the tube and drainage system become separated, insert a Provides a temporary water seal to prevent the entrance of
separated chest tube within sterile water until it can be reat- atmospheric air, which can recollapse the lung.
tached and secured to the drainage system.
Prevent air from entering the tube insertion site by covering it Reduces the amount of lung collapse.
with a gloved hand or woven fabric if the tube is accidentally
pulled out.
Mark the drainage level on the collection chamber at the end of Provides data about fluid loss without the risk of recollapsing the
each shift (Fig. H). lung; never empty the drainage container.
Marking the drainage level.
(continued)
LWBK1004-C21_p438-466.indd 465 2/6/12 7:27 PM

Evaluation
• Client exhibits no evidence of respiratory distress.
• Dressing is dry and intact.
• Equipment is functioning appropriately.
• Water is at recommended levels.
Document
• Care provided
• Amount of drainage during period of care
Date and Time Upper and lower chest tubes connected to water-seal drainage system. Normal lung sounds heard
throughout chest except in apex and base of left lung, where chest tubes are inserted. Tidaling still
observed in water-seal chamber. 20 cm of suction maintained. Dark-red chest tube drainage measures a
scant 50 mL. Ambulated in hall while disconnected from suction. Performed full range of motion with left
shoulder. SIGNATURE/TITLE
LWBK1004-C21_p438-466.indd 466 2/6/12 7:27 PM

Photo to
Come
FPO
22# Infection Control
airborne precautions
colonization
contact precautions 1. Explain the meaning of infectious diseases.
double bagging 2. Differentiate between infection and colonization.
droplet precautions 3. List five stages in the course of an infectious disease.
hyperendemic infections 4. Define infection control measures.
infection 5. Name two major techniques for infection control.
infection control precautions 6. Identify three new elements of standard precautions.
infectious diseases 7. Discuss situations in which nurses use standard precautions and
N95 respirator transmission-based precautions.
personal protective equipment 8. Describe the rationale for using airborne, droplet, and contact
Powered Air Purifying Respirator precautions.
respiratory hygiene/cough etiquette 9. Explain the purpose of personal protective equipment (PPE).
safe injection practices 10. Discuss the rationale for removing PPE in a specific sequence
standard precautions after caring for a client with an infection.
transmission-based precautions 11. Explain how nurses perform double bagging.
12. List two psychological problems common among clients with
infectious diseases.
13. Provide at least three teaching suggestions for preventing
infections.
14. Discuss one unique characteristic of older adults in relation to
infectious diseases.
nfectious diseases (diseases that spread from one person to another)
I are also called contagious or communicable diseases and community-

acquired infections. They were once the leading cause of death, but
that is no longer true because of vaccines, aggressive public health
measures, and advances in drug therapy. Nevertheless, infectious diseases
have not disappeared. In fact, the microorganisms that cause tuberculosis
(TB), gonorrhea, and some forms of wound and respiratory infections
have developed drug-resistant strains (see Chap. 10). Add to that the cur-
rent public health problem with AIDS, an infectious disease spread by
HIV in blood and some body fluids (Box 22-1), severe acute respiratory
syndrome (SARS), and the potential for bird flu, and it is clear that hu-
mans have not won the war against pathogens.
This chapter discusses precautions that confine the reservoir of
infectious agents and block their transmission from one host to another.
To understand the concepts of infection control, it is important to under-
stand the chain of infection (see Chap. 10) and the course of an infection.
INFECTION
Infection is a condition that results when microorganisms cause injury

to a host. Infection differs from colonization, a condition in which
467
LWBK1004-C22_p467-492.indd 467 31/01/12 1:38 AM

B OX 2 2 - 1 Facts and Myths About the TABLE 22-1 Course of Infectious Diseases
Transmission of HIV STAGE CHARACTERISTIC
Facts Incubation period Infectious agent reproduces, but there are

HIV is transmitted by: no recognizable symptoms. The infec-
• Having unprotected vaginal, anal, or oral sexual contact tious agent may, however, exit the host
at this time and infect others.
with an infected person
Prodromal stage Initial symptoms appear, which may
• Sharing needles or syringes with an infected person
be vague and nonspecific. They may
• Acquiring a needle-stick injury with the blood of an include mild fever, headache, and loss
infected person (see Chap. 34) of usual energy.
• Receiving transfusions of infected blood or blood products Acute stage Symptoms become severe and specific to
• Being born to or breast-fed by an HIV-infected mother the tissue or organ that is affected. For
• Having contact with the blood of an infected person through example, TB is manifested by respira-
unsterilized equipment for ear piercing, tattooing, acu- tory symptoms.
puncture, dental procedures, safety razors, or toothbrushes Convalescent The symptoms subside as the host over-
• Contacting blood of an infected person through an open stage comes the infectious agent.
cut or splashes into the mucous membranes such as the Resolution The pathogen is destroyed. Health
eyes or inside of the nose improves or is restored.
• Artificial insemination with infected semen
TB, tuberculosis.
• Organ transplant taken from an HIV-infected donor
Myths
HIV is not transmitted by:
• Donating blood Gerontologic Considerations
• Being bitten by insects
• Sharing cups and eating utensils ■ Older clients are more susceptible to infections caused
• Inhaling droplets from sneezes or coughs by diminished immune system functioning and inadequate
• Hugging, touching, or closed-mouth kissing an infected nutrition and fluid intake.
person ■ Symptoms of infections tend to be subtle among older
• Sharing telephones or computer keyboards adults. Because older adults tend to have a lower “normal”
• Going to any public place with people infected with HIV or baseline temperature, a temperature in the normal range
• Using public drinking fountains or toilet seats may actually be elevated for an older adult.
• Swimming in pools ■ Infections are more likely to have a rapid course and life-
threatening consequences once they become established.
From Centers for Disease Control and Prevention. HIV and its transmis- Common manifestations of infections in older adults
sion. Accessed April, 2010, from, http://www.cdc.gov/hiv/resources/
factsheets/transmission.htm, last updated July 2007, accessed 4/10; Ten include changes in behavior and mental status.
things everyone should know about HIV; Symptom checker. Accessed
April 2010, from, http://symptomchecker.about.com/od/Diagnoses.hivaids.
htm, last modified February 2005.
INFECTION CONTROL PRECAUTIONS
microorganisms are present, but the host does not manifest
any signs or symptoms of infection. Regardless of whether Infection control precautions are physical measures
the host is infected or colonized, the host can transmit patho- designed to curtail the spread of infectious diseases. They
gens and infectious diseases to others. are essential when caring for clients. Infection control pre-
cautions require knowledge of the mechanisms by which an
infectious disease is transmitted and the methods that will
Gerontologic Considerations interfere with the chain of infection.
■ Many long-term care residents, older hospitalized clients,

and health care personnel are colonized with antibiotic-
resistant bacteria, possibly with few or no symptoms. Gerontologic Considerations
■ Thinning, drying, and decreases in vascular supply to

Infections progress through distinct stages (Table 22-1). the skin predispose the older person to skin infections.
The characteristics and length of each stage may differ Maintaining intact skin is an excellent first-line defense
depending on the infectious agent. For example, the incu- against acquiring infections.
bation period for the common cold is approximately 2 to ■ Infections are often transmitted to vulnerable older
4 days before symptoms appear, but it may take months adults through equipment reservoirs such as indwelling
or years before a person infected with HIV demonstrates urinary catheters, humidifiers, and oxygen equipment
symptoms of AIDS. or through incisional sites such as those for intravenous
LWBK1004-C22_p467-492.indd 468 31/01/12 1:39 AM

CHAPTER 22 Infection Control 469
tubing, parenteral nutrition, or tube feedings. Use of the potential for transmitting infectious agents in blood, body
proper aseptic techniques is essential for preventing the fluids, secretions, and excretions (except sweat), nonintact
introduction of microorganisms. A daily assessment for skin, mucous membranes, and equipment or items in the cli-
any signs of infection is imperative. ent’s environment that may contain transmissible infectious
■ Older adults, family caregivers/members in close contact
agents whether or not they contain visible blood. Health care
with older people, and all personnel in health care settings
personnel follow standard precautions when caring for all
should obtain annual immunizations against influenza.
Those who are 65 years and older and younger people with clients in all settings in which health care is delivered. Stand-
chronic diseases should receive an initial dose of the pneu- ard precautions include hand hygiene, use of gloves, a gown,
mococcal vaccine. a mask, eye protection or a face shield, and safe injection
■ Visitors with respiratory infections need to wear a mask practices (see Chap. 34). The type of personal protective
or avoid contact with older adults in their home or long- equipment (PPE) used is determined by the nature of the
term care settings until their symptoms have subsided. In client interaction and the extent of anticipated blood, body
addition to a mask, frequent and thorough hand hygiene fluid, or pathogen exposure.
can help prevent the transfer of organisms. A sign that alerts health care workers may be posted in
■ Health care workers who are ill should take sick leave various areas of the health care agency (Fig. 22-1).
rather than exposing susceptible clients to infectious
organisms.
New Standard Precaution
Recommendations
Under the auspices of the Centers for Disease Control
The CDC has identified three new standard precautions for
and Prevention (CDC), the Healthcare Infection Control
infection control. They include respiratory hygiene/cough
Practices Advisory Committee (2007) has continued to rec-
etiquette, safe injection practices, and practices for special
ommend guidelines for two major categories of infection
lumbar puncture procedures.
control precautions: standard precautions and transmission-
based precautions. Respiratory Hygiene/Cough Etiquette
Respiratory hygiene/cough etiquette (Fig. 22-2) refers
Standard Precautions
to infection control measures used at the first point of an
Standard precautions are measures for reducing the risk
encounter with clients, family, or friends of persons with
of microorganism transmission from both recognized and
signs of illness suggesting an undiagnosed transmissible res-
unrecognized sources of infection. Health care personnel
piratory infection. It includes:
follow standard precautions when caring for all clients,
regardless of the suspected or confirmed infection status • Covering the mouth/nose with a tissue when coughing;
(Box 22-2). This precautionary system combines methods coughing or sneezing into an upper sleeve or elbow is
previously known as universal precautions and body sub- another alternative when a tissue is unavailable.
stance isolation. The use of standard precautions reduces • Disposing of used tissues promptly.
FIGURE 22-1 A Sign that identi-

fies standard precautions.
LWBK1004-C22_p467-492.indd 469 31/01/12 1:39 AM

B OX 2 2 - 2 Standard Precautions
Hand Hygiene Client-Care Equipment
• Use an alcohol-based product or plain (nonantimicrobial) soap • Locate containers for used disposable or reusable PPE at a site
for routine hand hygiene. that is convenient for the removal and disposal of contaminated
• Perform hand hygiene after touching blood, body fluids, materials.
secretions, excretions, and contaminated items, whether or not • Handle equipment soiled with blood, body fluids, secretions,
gloves are worn. and excretions so as to prevent the transfer of microorganisms
• Perform hand hygiene immediately after gloves are removed, to oneself, others, or the environment.
between client contacts, and when otherwise indicated; per- • Ensure that soiled reusable equipment is cleaned and disin-
form hand hygiene between tasks and procedures on the same fected or sterilized before another subsequent use.
client to prevent cross-contamination of different body sites. • Discard soiled single-use equipment properly.
• Use an antimicrobial agent or a waterless antiseptic agent to
control outbreaks or hyperendemic infections (infections that Environmental Control
are highly infectious in all age groups). • Ensure that procedures for the routine cleaning and disinfec-
tion of environmental surfaces, beds, bed rails, bedside equip-
Gloves ment, and other frequently touched surfaces are carried out.
• Wear clean, nonsterile gloves that fit snugly around the wrist
when touching blood, body fluids, secretions, excretions, and Linen
contaminated items; latex or nitrile gloves are preferred for • Handle, transport, and process soiled linen in such a way as to
clinical procedures that require manual dexterity or involve prevent exposure to oneself, others, and the environment.
more than brief client contact.
• Change gloves between tasks on the same client after contact Occupational Health and Blood-Borne Pathogens
with material that may contain a high concentration of micro- • Prevent injuries when using needles, scalpels, and other sharp
organisms and before touching portable computer keyboards or devices.
other mobile equipment that is transported from room to room. • Never recap used needles.
• Remove gloves and perform hand hygiene immediately before • Use either a one-handed “scoop” method or a mechanical
caring for another client. device for covering a needle.
• Place all disposable sharp items in a puncture-resistant
Mask, Eye Protection, Face Shield container as close to the location of use as possible; transport
• Wear a mask and eye protection (goggles), or face shield to reusable syringes and needles in a puncture-resistant container
protect the eyes, nose, and mouth when there is a likelihood for reprocessing.
that splashes or sprays of blood, body fluids, secretions, or • Use mouthpieces, resuscitation bags, or other ventilation
excretions will occur; eyeglasses and contact lenses are not devices as an alternative to mouth-to-mouth resuscitation
adequate for eye protection. methods in areas where the need for resuscitation is
• Obtain a user-seal check (also called a “fit check”) to minimize predictable.
air leakage around the facepiece of a respirator; reuse of a
particulate respirator by the same person is acceptable as long Client Placement
as the respirator is not damaged or soiled, the fit is not com- • Place potentially infectious clients in a private room whenever
promised by change in shape, and the respirator has not been possible.
contaminated with blood or body fluids. • Consult with an infection control professional concerning
alternatives if a private room is not available.
Gown • Place a client who contaminates the environment, who does
• Wear a clean, nonsterile gown that covers the arms and body not—or cannot be expected to—assist in maintaining appropri-
from neck to mid thigh or below when there is a likelihood that ate hygiene or environmental control in a private room.
splashes or sprays of blood, body fluids, secretions, or excre-
tions will occur.
• Remove a soiled gown promptly and perform hand hygiene.
Adapted from Centers for Disease Control and Prevention. (2007). 2007 Guidelines for isolation precautions:
Preventing transmission of infectious agents in healthcare settings. Accessed April 12, 2010, from http://www.
cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf.
• Performing hand hygiene after contact with respiratory Safe Injection Practices
secretions. Safe injection practices are infection control measures
• Using a surgical mask on a coughing client who can toler- that prevent the transmission of viral hepatitis B (HBV) and
ate this measure. hepatitis C (HCV) through the use of aseptic techniques
• Distancing the person with respiratory symptoms at least involving the preparation and administration of parenteral
3 ft. from others in common waiting areas. medications (see Chap. 34). Health care workers are advised
LWBK1004-C22_p467-492.indd 470 31/01/12 1:39 AM

FIGURE 22-2 Techniques for prevent-

ing or reducing the spread of respira-
tory pathogens.
to (1) use a sterile, single-use, disposable syringe for each precautions, and contact precautions (Table 22-2). These
injection, (2) prevent the contamination of injection equip- three types replace the earlier categories of strict isolation,
ment and medication, and (3) use single-dose vials rather contact isolation, respiratory isolation, tuberculosis (AFB)
than multiple-dose vials when administering medications to isolation, enteric precautions, and drainage/secretion pre-
multiple clients. Measures to handle needles and other sharp cautions. Health care personnel base the decision to use one
devices in a manner that avoids injury to the user and others or a combination of precautions on the mechanism of trans-
who may encounter the device during or after a procedure mission of the pathogen. They use one or more categories of
continue to be a standard practice (see Chaps. 34 and 35). transmission-based precautions concurrently when diseases
have multiple routes of transmission.
Infection Control Practices for Special Lumbar
Puncture Procedures
Lumbar puncture procedures are performed for a number of
reasons such as performing a myeleogram, administering spi-
■ Older adults with cognitive impairment need more assis-
nal and epidural anesthesia, placement of spinal catheters, and
tance with complying with infection control measures.
injecting medications within the spinal canal. Because there
has been an increase in the incidence of bacterial meningitis
Transmission-based precautions are required for vari-
most likely from respiratory droplet transmission at the time
ous lengths of time, depending on how long the risk of
these procedures were performed, it is now recommended that
transmission of the infectious agent persists or for the dura-
the person performing the procedure wears a mask in addition
tion of the illness. Personnel discontinue some precautions,
to the usual protective equipment that is used.
with the exception of standard precautions, when culture or
other laboratory findings document that the disease has been
Transmission-Based Precautions resolved, when a wound or lesion stops draining, after the
Transmission-based precautions are measures for control- initiation of effective therapy, or when state laws and regu-
ling the spread of highly transmissible or epidemiologically lations have dictated discontinuation. Sometimes personnel
important infectious agents from clients when the known or employ them throughout a client’s treatment.
suspected route(s) of transmission is (are) not completely
interrupted using standard precautions alone. They are also Airborne Precautions
called isolation precautions. The three types of transmis- Airborne precautions are measures that reduce the risk
sion-based precautions are airborne precautions, droplet for transmitting pathogens that remain infectious over long
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TABLE 22-2 Transmission-Based Precautions

TYPE OF PRECAUTION CLIENT PLACEMENT PROTECTION EXAMPLES OF DISEASES
Airborne Private room or in a room Follow standard precautions. Pulmonary TB
with a similarly infected Keep door closed; confine client to room. Measles (rubeola)
client Wear a mask for trapping airborne pathogens, Chickenpox (varicella)
Negative air pressurea such as N95 respirator or Powered Air Purify- Severe acute respiratory
Six to 12 air changes ing Respirator in the case of tuberculosis syndrome (SARS)
per hour (TB).
Discharge of room air to Place a mask on the client if transport is
environment or filtered required.
before being circulated
Droplet Private room or in a room Follow standard precautions. Influenza
with a similarly infected Leave door open or closed. Rubella
client or one in which Wear a mask when entering the room depend- Streptococcal pneumonia
there are at least 3 ft. ing on agency policy but always when within Meningococcal meningitis
between other clients 3 ft. of the client. Whooping cough
and visitors. Place a mask on the client if transport is
required.
Contact Private room or in a room Follow standard precautions. Gastrointestinal, respiratory,
with similarly infected Don gloves before entering the room. skin, or wound infections
client or consult with an Change gloves during client care after contact that are drug resistant
infection control profes- with infective material that contains high Gas gangrene
sional if the previous concentrations of microorganisms. Acute diarrhea
options are not available Remove gloves before leaving the room. Acute viral conjunctivitis
Perform handwashing or perform an alcohol- Draining abscess
based handrub with an antimicrobial agent
immediately after removing gloves.
Do not touch potentially contaminated surfaces
or items in the immediate environment after
glove removal and handwashing.
Wear a gown when entering the room if there
is the possibility that your clothing will touch
the client, environmental surfaces, or items
in the room, or if the client is incontinent or
has diarrhea, an ileostomy, a colostomy, or
wound drainage not contained by a dressing.
Remove the gown before leaving the
environment.
Avoid transporting the client but, if transport
is required, use precautions that minimize
transmission.
Clean bedside equipment and client care items
daily.
Use items such as a stethoscope, sphyg-
momanometer, and other assessment tools
exclusively for the infected client; clean and
disinfect them before use for another client.
a
Negative air pressure pulls air from the hall into the room when the door is opened, as opposed to positive air pres-
sure, which pulls room air into the hall.
From Centers for Disease Control and Prevention. (2007). 2007 Guidelines for isolation precautions: Preventing
transmission of infectious agents in healthcare settings. Accessed April 12, 2010, from http://www.cdc.gov/ncidod/
dhqp/pdf/isolation2007.pdf
distances when suspended in the air (see Table 22-2). They more, provided the device fits the face snugly (Fig. 22-3A).
block pathogens, 0.3 microns or smaller, that are present in A Powered Air Purifying Respirator (PAPR) is an alterna-
the residue of evaporated droplets that remain suspended in tive if a caregiver has not been fitted with an N95 respirator
the air, as well as those attached to dust particles. or has facial hair or a facial deformity that prevents a tight
TB is an example of a disease transmitted through the seal with an N95 respirator (Fig. 22-3B). A PAPR blows
air. Caregivers must wear a specific type of mask when car- atmospheric air through belt-mounted air-purifying canisters
ing for clients with TB. An N95 respirator, which is indi- to the facepiece through a flexible tube. A PAPR can also be
vidually fitted for each caregiver, can filter particles 1 micron used when rescuing victims exposed to hazardous chemicals
(smaller than a millimeter) with an efficiency of 95% or or bioterrorist substances.
LWBK1004-C22_p467-492.indd 472 31/01/12 1:39 AM

FIGURE 22-3 A. An N95 respirator must fit

tightly around the mouth and nose with straps
that attach it to the head. A secure seal is evi-
denced by a slight bulging on exhalation and
slight collapse upon inhalation. B. A Powered
Air Purifying Respirator uses a blower to
remove contaminated air through a filter and
supplies purified air to a facepiece. A B

Which type of transmission precautions do health
care personnel follow when caring for clients with
■ The incidence of TB in community-living older adults is
the following medical diagnoses: (1) pulmonary
twice that of the general population (Miller, 2008). All long-
TB, (2) streptococcal pneumonia, (3) an infected
term care facilities are required to test each resident on
wound, (4) acute diarrhea, and (5) meningococcal
admission and each new employee for TB.
meningitis?
Droplet Precautions INFECTION CONTROL MEASURES

Droplet precautions are measures that block infectious
pathogens within moist droplets larger than 5 microns. They Infection control measures involve the use of PPE (garments
are used to reduce pathogen transmission from close con- that block the transfer of pathogens from one person, place,
tact (usually 3 ft. or less) with respiratory secretions or or object to oneself or others) and techniques that serve as
mucous membranes between infected persons or a person barriers to transmission (Fig. 22-4). Depending on the type
who is a carrier of a droplet-spread microorganism and oth- of precautions used, nurses implement all or some of the fol-
ers. Microorganisms carried on droplets commonly exit the lowing measures:
body during coughing, sneezing, talking, and procedures
such as airway suctioning (see Chap. 36) and bronchoscopy. • Locating a client and equipping a room so as to confine
Airborne precautions are not used because droplets do not pathogens to one area
remain suspended in the air. • Using PPE such as cover gowns, face shields or goggles,
cloth or paper masks or respirators (see Chap. 10), and
Contact Precautions gloves to prevent spreading microorganisms through direct
Contact precautions are measures used to block the trans- and indirect contact
mission of pathogens by direct or indirect contact. This is • Disposing of contaminated linen, equipment, and supplies
the final category of transmission-based precautions. Direct in such a way that nurses do not transfer pathogens to others
contact involves skin-to-skin contact with an infected or • Using infection control measures to prevent pathogens from
colonized person. Indirect contact occurs by touching a con- spreading when transporting laboratory specimens or clients
taminated intermediate object in the client’s environment.
Additional precautions are necessary if the microorganism is Client Environment
resistant to antibiotics. The client environment includes the room designated for the
Some infectious diseases like chickenpox (varicella), care of a client with an infectious disease and the equip-
smallpox (variola), and SARS require both airborne and ment and supplies essential for controlling transmission of
contact precautions. the pathogens.
LWBK1004-C22_p467-492.indd 473 31/01/12 1:39 AM

avoid transferring organisms on the wet mop to other client

areas. They deposit the mop head, if not disposable, with the
soiled linen and wipe the mop handle with a disinfectant.
Infectious client
T They flush solutions used for cleaning down the toilet.
R
A Equipment and Supplies
N The infection control room contains the same equipment
S Blood
M and supplies as any other hospital room, with a few modi-
I fications. A dedicated stethoscope and sphygmomanometer
S remain in the client’s room whenever possible. This prevents
Noninfected S
clients Body substances the need to clean and disinfect these items each time they
I
and O would need to be removed.
personnel N For the same reason, disposable thermometers are pre-
ferred. Personnel disinfect electronic or tympanic thermo-
B Air meters to make them safe for the next client. Items such as a
A
R container for soiled laundry (Fig. 22-6), lined waste contain-
R ers, and liquid soap dispensers are also placed in the room.
I
E Droplets
R Personal Protective Equipment
S Infection control measures involve the use of one or more items
for personal protection. PPE, also called “barrier garments”
Linen, equipment, supplies (Fig. 22-7), includes gowns, masks, respirators, goggles or face
FIGURE 22-4 Blocking sources of infectious disease transmis- shields, and gloves (see Chap. 10). These items are located just
sion. outside the client’s room or in an anteroom (Fig. 22-8).
Cover Gowns
Infection Control Room Cover gowns are worn for two reasons: they prevent con-
Except when using standard precautions, most health care tamination of clothing and protect the skin from contact with
agencies assign infectious or potentially infectious clients to blood and body fluids. When they are removed after direct
private rooms. Infection control personnel can offer alterna- care of the infectious client, they reduce the possibility of
tives if a private room is not available (see Table 22-2). They transmitting pathogens from the client, the client’s environ-
keep the door to the room closed to control air currents and ment, or contaminated objects. Many types of cover gowns
the circulation of dust particles. exist, but all have the following common characteristics:
The room has a private bathroom so that personnel can
• They open in the back to reduce inadvertent contact with
flush contaminated liquids and biodegradable solids. A sink
the client and objects.
is also located in the room for handwashing.
• They have close-fitting wristbands to help avoid contami-
Staff members post an instruction card on the door or
nating the forearms.
nearby at eye level stating that isolation precautions are
• They fasten at the neck and waist to keep the gown securely
required (Fig. 22-5). Nurses are responsible for teaching
closed, thus covering all the wearer’s clothing.
visitors how to comply with the infection control measures.
In accord with the principles of medical asepsis, house- Nurses wear a cover gown only once and then discard
keeping personnel clean the infectious client’s room last to it. They place discarded cloth gowns in the client’s laundry
FIGURE 22-5 A Door instruc-

tional card.
LWBK1004-C22_p467-492.indd 474 31/01/12 1:39 AM

FIGURE 22-8 An anteroom outside the infection control room.

FIGURE 22-6 Containing soiled laundry. (Photo by B. Proud.) (Photo by B. Proud.)
hamper, and remove them with the soiled linen. Cloth cover Gloves are not a total and complete barrier to microor-
gowns are laundered before being used again. Disposable ganisms. They are easily punctured and can leak; the poten-
paper gowns are placed in a waste container and incinerated. tial for leakage increases with the stress of use.
Wearing gloves does not replace the need for hand anti-
Face-Protection Devices sepsis (see Chap. 10) after removal. Hands can be contami-
Depending on the mode of transmission of the pathogen, nated during glove removal, and microorganisms that were
health care personnel wear a mask or respirator (see Chap. present on the hands before gloving grow and multiply rap-
10), goggles, or a face shield. They always apply these items idly in the warm, moist environment beneath the gloves.
before entering the client’s room.
Gloves ➧ Stop, Think, and Respond Box 22-2

Gloves are required when an infectious disease is transmit- What personal protective items would you expect
ted by direct contact or contact with blood and body fluid to wear when managing the care of a client with a
substances. Health care personnel always don gloves before draining wound abscess?
or immediately on entering the client’s room. After one use,
they are discarded. Removing Personal Protective Equipment
Regardless of which garments they wear, nurses follow an
orderly sequence for removing them (Skill 22-1). The goal
is to leave the client’s room without contaminating oneself
or one’s uniform. The procedure involves making contact
between two contaminated surfaces or two clean surfaces.
Nurses remove the garments that are most contaminated
first, preserving the clean uniform underneath (Fig. 22-9).
Nurses can modify the technique to accommodate the
removal of any combination of equipment. The most impor-
tant nursing action is to perform thorough handwashing before
leaving the client’s room and before touching any other client,
personnel, environmental surface, or client care items.
Disposing of Contaminated Linen,

Equipment, and Supplies
Receptacles in the client’s room are used to collect con-
taminated items. Soiled waste containers are emptied at the
end of each shift or more often if their contents accumulate
(Fig. 22-10). To avoid spreading pathogens, some items are
double bagged.
FIGURE 22-7 Donning personal protective equipment (PPE)
helps prevent the transmission of infectious microorganisms. Double bagging is an infection control measure in which
(Photo by B. Proud.) one bag of contaminated items, such as trash or laundry, is
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FIGURE 22-11 Double bagging technique.
Following the termination of transmission-based pre-

FIGURE 22-9 Removing and disposing the most contaminated
cautions, equipment that will be used again for other client
garments first. (Photo by B. Proud.) care must first be thoroughly cleaned and disinfected.
Discarding Biodegradable Trash

placed within another. This measure requires two people. Biodegradable trash is refuse that will decompose natu-
One person bags the items and deposits the bag in a second rally into less complex compounds. It includes items such
bag held by another person outside of the client’s room. The as unconsumed beverages, paper tissues, the contents of
person holding the second bag prevents contamination by drainage collectors, urine, and stool. All these items can be
manipulating the bag underneath a folded cuff (Fig. 22-11). flushed down the toilet in the client’s room. Chemicals and
The Centers for Disease Control and Prevention (2007) filtration methods in sewage treatment centers are sufficient
have relaxed their recommendation concerning double bag- for destroying pathogens in human wastes.
ging. Their revised position is that one bag is adequate if Nurses place bulkier items in a lined trash container
the bag is sturdy and the articles are placed in the bag with- and remove them from the room by single or double bag-
out contaminating the outside of the bag. Otherwise, double ging. They wrap moist items such as soiled dressings so that
bagging is used. during their containment, flying or crawling insects cannot
transfer pathogens. Eventually, the bag and its contents are
destroyed by incineration, or they are autoclaved. Auto-
claved items can be safely disposed of in landfills.
Removing Reusable Items

To reduce the need for disinfection of reusable items, dispos-
able equipment and supplies such as plastic bedpans, basins,
eating utensils, and paper plates and cups are used as much
as possible. Following the termination of transmission-based
precautions, equipment that will be used again for other cli-
ent care must first be thoroughly cleaned, disinfected, and
sterilized (see Chap. 10).
Delivering Laboratory Specimens

Specimens are delivered to the laboratory in sealed contain-
ers in a plastic biohazard bag. When the testing is complete,
most specimens are flushed, incinerated, or sterilized.
Transporting Clients
Clients with infectious diseases may need to be transported
to other areas such as the X-ray department. During trans-
FIGURE 22-10 A waste container used for infectious waste. port, nurses use methods to prevent the spread of pathogens
(Photo by B. Proud.) either directly or indirectly from the client. For example,
LWBK1004-C22_p467-492.indd 476 31/01/12 1:39 AM

to prevent the exit of pathogens from the client onto trans- encourage visitors to come as often as the agency’s policies
port equipment, nurses line the surface of the wheelchair or and the client’s condition permit. They use every opportu-
stretcher with a clean sheet or bath blanket to protect the nity to emphasize that as long as visitors follow the infection
surface from direct client contact. They use a second sheet control precautions, they are not likely to acquire the disease.
or blanket to cover as much of the client’s body as possible
during transport. The client wears a mask or particulate air Combating Sensory Deprivation
filter respirator if the pathogen is transmitted by the airborne Sensory deprivation results when a person experiences
or droplet route. Any hospital personnel having direct con- insufficient sensory stimulation or is exposed to sensory
tact with the client use PPE similar to that used in client care. stimulation that is continuous and monotonous. The goal is
Interdepartmental coordination is important. The to provide a variety of sensory experiences at intervals (see
department to which the client is transported is made aware Nursing Guidelines 22-1).
that the client has an infectious disease. This facilitates the
expeditious care of the client and avoids unnecessary wait-
ing in areas with other clients. NURSING IMPLICATIONS
When the client returns, the nurse deposits the soiled
linen in the linen hamper in the client’s room, touching only Caring for clients with infectious diseases involves meeting
the outside surface of the protective covers. Some agencies their physical and emotional needs. Some frequently identi-
also spray or wash the transport vehicle with a disinfectant fied nursing diagnoses include the following:
before reuse.
• Risk for Infection
• Risk for Infection Transmission (not currently on the
PYSCHOLOGICAL IMPLICATIONS NANDA list)
• Impaired Social Interaction
Although infection control measures are necessary, they
• Social Isolation
often leave clients feeling shunned or abandoned. Clients
• Risk for Loneliness
with infectious diseases continue to need human contact
• Deficient Diversional Activity
and interaction, both of which are often minimal because
• Powerlessness
of the elaborate precautions taken on entering and leaving
• Fear
the room. Fearful family and friends may avoid visiting, and
clients are restricted from leaving their rooms. Measures are Nursing Care Plan 22-1 demonstrates how nurses apply
needed to relieve the client’s feelings of isolation by provid- the nursing process when caring for a client with the nurs-
ing social interaction and sensory stimulation. ing diagnosis of Risk for Infection Transmission. The North
American Nursing Diagnosis Association has not currently
Promoting Social Interaction approved this diagnostic category, but Carpenito-Moyet
When transmission-based precautions are in effect, it is (2010, p. 331) defines it as “a person at high risk for trans-
important to plan frequent contact with the client. Nurses ferring an infectious agent to others.”

Rationales
Providing Sensory Stimulation
• Move the bed to various places in the room or periodically • Change the location of equipment that produces monotonous
rearrange the furnishings in the room. Such a change provides sounds. Changing the location will vary the volume or pitch of
a new perspective for the client. the noise.
• Position the client so that he or she can look out the window. • Encourage the client to be active, within the confines of the
Having something different to look at reduces boredom. room. Activity provides a means of stimulation.
• Encourage the client to use the telephone. Telephone calls • Encourage activities that the client can do independently
allow social interaction. such as reading, working crossword puzzles, playing soli-
• Communicate using the intercom system if entering the room taire, and putting picture puzzles together. Such activities
is inconvenient. This shows that the nurse is paying attention are diverting.
to the client. • Offer a wide choice of foods with different flavors, tempera-
• Converse with the client about current world events. Conversa- tures, and textures. Eating a variety of foods stimulates oral
tion stimulates the client’s thought processes. and olfactory sensations.
• Help the client to select television or radio programs. Watching • Use touch appropriately by giving a backrub or changing the
television or listening to the radio engages the client’s attention. client’s position. Touch produces tactile stimulation.
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N U R S I N G C A R E P L A N 2 2 - 1 Risk for Infection Transmission

Assessment • Inspect the area around invasive devices such as an intravenous
• Monitor laboratory test findings for evidence of infection such catheter, wound drain, abdominal feeding tube, and so on.
as an elevated white blood cell count or the results of a culture • Ask whether the client has a decreased appetite, has lost
indicating the growth of a pathogen. weight, or feels weak and tired.
• Check the client’s temperature regularly and note if there is a • Inquire about recent travel in a country or area where there has
persistent elevation. been an incidence of infectious disease or contact with others
• Inspect the skin, mucous membranes, wounds, sputum, urine, who have been ill lately.
and stool for signs of purulent or unusual drainage. • Ask about the client’s immunization history.
• Listen for abnormal lung sounds, especially if the client has a • Read the results of a current skin test for tuberculosis or refer
cough. to a person who is certified to do so.
Nursing Diagnosis. Risk for infection transmission related to the airborne spread of the pathogen causing TB (positive TB test
and suspicious chest X-ray).
Expected Outcome. The client will comply with infection control measures and accurately describe postdischarge drug therapy
and medical follow-up by time of discharge.
Follow airborne transmission precautions until sputum culture Airborne transmission precautions are the specified infection
is negative; follow standard precautions throughout the control measures for preventing the spread of TB to suscep-
length of stay. tible individuals. Nurses implement standard precautions
during the care of all clients.
Once sputum specimens are free of infectious microorgan-
isms, the client will no longer require airborne transmission
precautions.
Post infection control measures on the room door, but do not Posting instructions on the client’s door informs personnel,
identify the name of the disease. family, and friends how to protect themselves from contact
with organisms that can cause the infectious disease. Pri-
vacy regulations require that the client’s health problem be
kept confidential.
Wear a particulate air filter respirator during client care. A particulate air filter respirator is more efficient than a cloth
or paper mask because it can filter particles 0.3 micron in
size with a minimum efficiency of 95%.
Teach the client to cover his or her nose and mouth with a A paper tissue collects moist respiratory secretions and
paper tissue when coughing, sneezing, or laughing, and decreases airborne transmission. Paper is disposable and is
dispose of tissue in a paper bag. incinerated to destroy microorganisms present in secretions.
Directly observe the client taking prescribed drug therapy. A combination of various medications can eliminate the infec-
tious organism that causes TB when a client is compliant
with drug therapy.
Explain the purpose of combination drug therapy and the need An informed and knowledgeable client promotes compliance.
to continue its uninterrupted administration to avoid treat-
ment failure and the development of a drug-resistant strain.
Direct the client to provide a sputum specimen at the public Continued monitoring of the client’s sputum provides a means
health department within 2 to 3 weeks following discharge. for evaluating whether the client is noninfectious and
responding to treatment.
Recommend TB skin testing for close family members or TB is usually spread among those who have close contact
friends. with the infected person. Any person who previously had
a negative skin test and now tests positive is placed on
prophylactic drug therapy.

• The client remained in a private infection control room. • The client’s wife and children have received TB skin tests with
• The client used a paper tissue when coughing, sneezing, and negative results.
talking. • The client verbalized how to self-administer his medications
• The client took all prescribed medications. and the importance for remaining compliant.
• The client’s family and friends followed posted infection • The client identified the date for a follow-up appointment with
control instructions. the Public Health Department for a repeat of sputum analysis.
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Client and Family Teaching 22-1 3. What action(s) is/are appropriate to take if there are
Preventing Infections several residents in a long-term care facility who
acquire an infection with a transmittable pathogen
The nurse teaches the client and the family as follows: and there are not enough private rooms to relocate
● Bathe daily and perform other forms of personal hygiene them?
such as oral care. 4. If there is an outbreak in the community of H1N1
● Keep the home environment clean and uncluttered. viral influenza A (swine flu), what measures might a
● Use diluted household bleach (1:10 or 1:100) as a long-term health care facility take to protect clients?
disinfectant.
● Obtain appropriate adult immunizations (tetanus vaccine
at 10-year intervals, influenza vaccine yearly). A pneumo-
coccal pneumonia immunization lasts a lifetime or revac-
cination is required every 5 years for extremely high-risk 1. When a nurse empties the secretions from a wound
people. suction container, which of the following infection
● Investigate necessary vaccines, water purification tech- control measures is most important?
niques, and foods to avoid when traveling outside the 1. Wear a mask
United States.
2. Wear a gown
● Practice a healthy lifestyle such as eating the recom-
mended number of servings from the MyPlate nutrition
3. Wear goggles
guidelines (see Chap. 15). 4. Wear gloves
● Perform frequent handwashing, especially before eating, 2. When a person comes to the emergency department with
after contact with nasal secretions, and after using the respiratory symptoms, which of the following infection
toilet. control measures is appropriate to use initially?
● Use disposable tissues rather than a cloth handkerchief 1. Contact precautions
for nasal and oral secretions. 2. Airborne precautions
● Avoid sharing personal care items such as washcloths 3. Respiratory hygiene/cough etiquette
and towels, razors, and cups. 4. Droplet precautions
● Stay home from work or school when ill rather than
3. When exiting the room of a client being cared for
exposing others to infectious pathogens.
with contact precautions, what is the first step in
● Assume the task of cooking if the family member who
usually cooks is ill.
removing personal protection items?
● Keep food refrigerated until use. 1. Take off the mask or particulate air respirator
● Cook food thoroughly. 2. Unfasten the waist tie at the back of the gown
● Avoid crowds and public places during outbreaks of 3. Unfasten the tie at the neck closure of the gown
influenza. 4. Remove gloves one at a time
● Follow infection control instructions when visiting hospi- 4. What is the best advice the nurse can give to some-
talized family members and friends. one who is allergic to latex, yet must wear gloves for
● Comply with drug therapy when prescribed. standard precautions?
1. Rinse the latex gloves with running tap water
before donning them
2. Apply a petroleum ointment to both hands before
donning latex gloves
Nurses also play a pivotal role by teaching measures to
3. Eliminate wearing gloves, but wash both hands
prevent infection (see Client and Family Teaching 22-1).
vigorously with alcohol afterward
4. Wear two pairs of vinyl gloves when there is a
potential for contact with blood or body fluid
CRITICAL THINKING EXERCISES 5. Other than obtaining an immunization against influ-
1. Give some reasons why controlling the spread of enza, what is the best advice the nurse can give to
infectious diseases is difficult among children cared high-risk people to avoid acquiring this infection?
for in day-care centers. 1. Consume adequate vitamin C
2. Discuss some reasons why new cases of AIDS occur 2. Avoid going to crowded places
despite the fact that its mode of transmission is 3. Dress warmly in cold weather
known. 4. Reduce daily stress and anxiety
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SKILL 22-1 Removing Personal Protective Equipment
ASSESSMENT
Determine which type of infection control precautions is being Indicates whether garments must be removed and discarded
used. within the room.
Note whether there are sufficient hand hygiene supplies, paper Provides a means for hand antisepsis and confining soiled gar-
towels, a laundry hamper, and a lined waste receptacle within ments and materials.
the room.
PLANNING
Make sure that all direct care of the client has been completed. Avoids having to don barrier garments a second time.
IMPLEMENTATION
Untie the waist closure if it is fastened at the front of the cover The front of the cover gown is considered grossly contaminated.
gown; if it is secured on the backside, proceed with removing
gloves.
Remove one glove by grasping at the wrist and pulling the glove Contains the contaminated surface inside the glove.
inside out with a gloved hand (Fig. A).
Removing the first glove.
Insert the fingers of the ungloved hand under the wrist of the Reduces contact with the most contaminated surface of the
remaining glove. gloves.
Pull the remaining glove inside out while holding the first Enfolds the contaminated surface inside the glove.
removed glove (Fig. B)
Removing the second glove.
B
(continued)
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Removing Personal Protective Equipment (continued)
Wash hands or perform an alcohol-based hand rub (see Chap. 10). Removes microorganisms from the surface of previously gloved
hands.
Remove mask (see Chap. 10) or other disposable face-protection The ties or other materials used to attach the mask or other face
items by touching only the ties or elastic bands and discard protection items are considered “clean” and can be touched
them in the waste container (Fig. C). with the bare hands; the surface covering the eyes and face
are considered contaminated.
Unfastening ties.
Untie or unfasten the neck and then the back closure of the The back of the gown is considered less contaminated than the
cover gown. front and can be touched with the bare hands.
Remove the gown by inserting your fingers at the shoulder and Prevents gross contamination of the hands with contaminated
pulling the gown forward to turn the gown inside out (Fig. D). areas of the gown.
Removing a cover gown. (Photo by B. Proud.)
Fold the soiled side of the gown to the inside while holding it Prevents contamination of the hands and uniform.
away from your uniform.
(continued)
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Removing Personal Protective Equipment (continued)
Roll up the gown with the inner surface exposed and discard it Confines contaminated garments.
in the waste container if it is made of paper. If the gown is
made of cloth, discard it in the laundry hamper in the room
(Fig. E).
Discarding the cover gown.
Wash hands or perform an alcohol-based hand rub. Removes microorganisms that may have been inadvertently
transferred during face protection items and gown removal.
Use a clean paper towel to open the room door. Protects clean hands from recontamination.
Discard the paper towel in the waste container in the client’s Confines contaminated material.
room.
Leave the room, taking care not to touch anything. Prevents recontamination.
Go directly to the utility room and perform hand antisepsis one Removes microorganisms; it is always safer to overdo than
final time. underdo any practice that controls the spread of pathogens.
Evaluation
• Appropriate PPE was worn.
• Garments were removed with the least contamination possible.
• Hand washing was performed appropriately.
Document
• Type of transmission-based precautions being followed
• Care provided
Date and Time Contact precautions followed. Assisted with bath while wearing gloves and gown. States, “I wish the door
to my room could be left opened. It gets rather boring in here.” Reinforced the purpose for keeping the
door closed. ______________________________________________________________________ SIGNATURE/TITLE
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UNIT 5
End of Unit Exercises for Chapters 15, 16, 17, 18, 19, 20, 21, and 22
1. __________________ can result from a combination of sugar, plaque, and bacteria eroding the tooth enamel. (Caries,
Gingivitis, Tartar)
2. A/an __________________ treats eye disorders medically and surgically. (ophthalmologist, optometrist, podiatrist)
3. __________________ is a waking state characterized by reduced activity and decreased mental stimulation. (Comfort,
Rest, Sleep)
4. __________________ refers to disturbances in the sleep–wake cycle in which there is arousal or partial arousal, usually
during transitions in NREM periods of sleep. (Hypersomnia, Insomnia, Parasomnia)
5. __________________ can result from airway obstruction, drowning, or inhalation of noxious gases such as smoke or
carbon monoxide. (Asphyxiation, Macroshock, Poisoning)
6. A(n) __________________ is a substance that confines electrical currents so that they do not scatter. (conductor,
ground, insulator)
7. __________________ is the conversion of chemical information at the cellular level into electrical impulses that move
toward the spinal cord. (Perception, Transduction, Transmission)
8. __________________ pain is discomfort arising from diseased or injured internal organs. (Cutaneous, Neuropathic,
Visceral)
9. __________________ is a loss of appetite associated with illness, altered taste and smell, oral problems, or tension and
depression. (Anorexia, Cachexia, Nausea)
10. __________________, which commonly accompanies nausea, is the loss of stomach contents through the mouth.
(Emesis, Regurgitation, Retching)
11. Electrolytes with a positive charge are called __________________. (anions, cations, ions)
12. __________________ is a fluid imbalance with an increased volume of water in the intravascular fluid compartment.
(Hypervolemia, Hypoalbuminemia, Hypovolemia)
13. Insufficient oxygen in the arterial blood is called __________________. (hypocarbia, hypoxemia, hypoxia)
14. A caregiver should use __________________ to avoid infectious diseases transmitted by direct contact with a client’s
body, blood, or body substances. (gloves, hand lotion, towels)
15. __________________ is the intentional diversion of attention from an unpleasant sensory experience to one that is neu-
tral or more pleasant. (Distraction, Imagery, Meditation)
1. T____F____ The cells in the epidermis are shed continuously and replaced from the dermis.
2. T____F____ The contraction of small arrector pili muscles around hair follicles is commonly described as goose bumps.
3. T____F____ Sedatives produce a relaxing and calming effect in older clients, thus promoting rest.
4. T____F____ The EEG waves produced during REM sleep appear similar to those produced during wakefulness.
483
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5. T____F____ Carbon dioxide is an odorless gas released during the incomplete combustion of fossil fuels commonly
used to heat homes.
6. T____F____ A person with intact skin usually does not feel microshock.
7. T____F____ The Wong-Baker FACES scale can be used to assess pain in clients with language barriers.
8. T____F____ Adjuvant drugs are used as a first-line treatment for pain.
9. T____F____ Flatus is a discharge of gas from the stomach through the mouth.
10. T____F____ Dehydration is a fluid deficit in both the extracellular and intracellular compartments of the human body.
11. T____F____ Passive diffusion is an identical balance of cations with anions in any given fluid compartment.
12. T____F____ Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the
expiration phase.
13. T____F____ Oxygen toxicity is lung damage that develops when oxygen concentrations of more than 20% are
administered for longer than 24 hours.
14. T____F____ Infection control precautions are physical measures designed to curtail the spread of contagious diseases.
15. T____F____ When preparing to assist with a surgical or obstetric procedure, the nurse should perform a surgical scrub
before applying a mask and hair cover.

1. Practices that promote health through personal cleanliness __________________
2. Dried crusts containing mucus, microorganisms, and epithelial cells shed from the mucous membrane
__________________
3. Sudden loss of muscle tone triggered by an emotional change, such as laughing or anger __________________
4. Hormone secreted by the pineal gland in the absence of bright light __________________
5. A condition in which fluid occupies the airway and interferes with ventilation __________________
6. An inactive substance that resembles medication and can relieve symptoms, like pain, despite the absence of any active
chemicals __________________
7. Sensory nerve receptor activated by noxious stimuli __________________
8. Anthropometric measurement that helps to determine a client’s skeletal muscle mass __________________
9. Fluid in the tissue space between and around cells __________________
10. Naturally produced morphine-like chemicals that reduce pain __________________
Activity D: 1. Match the terms related to nutrition in Column A with their descriptions in Column B.
Column A Column B
1. __________________ Proteins A. Noncaloric substances in food that are essential to all
cells
2. __________________ Carbohydrates B. Nutrients that contain glyceride molecules and are
collectively known as lipids
3. __________________ Minerals C. Nutrients composed of amino acids (chemical
compounds containing nitrogen, carbon, hydrogen,
and oxygen)
4. __________________ Fats D. Nutrients that include sugars and starches
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2. Match the types of fire extinguishers in Column A with their uses in Column B.
Column A Column B
1. __________________ Class A A. Fires caused by gasoline, oil, paint, grease, and other
flammable liquids
2. __________________ Class B B. Fires caused by electricity
3. __________________ Class C C. Fires of any kind
4. __________________ Class ABC D. Fires caused by burning paper, wood, or cloth
3. Match the terms related to body fluids and chemical balance in Column A with their descriptions in Column B.
Column A Column B
1. __________________ Venipuncture A. Process by which body fluid is distributed from one
location to another
2. __________________ Emulsion B. Method of accessing the venous system by piercing a
vein with a needle
3. __________________ Edema C. Mixture of two liquids, one of which is insoluble in the
other
4. __________________ Osmosis D. Condition that develops when excess fluid is distributed
to the interstitial space
Activity E: 1. Differentiate between crystalloid and colloid solutions.

Crystalloid Solution Colloid Solution
Definition
Effects
Examples
2. Differentiate between acute and chronic pain.

Acute Pain Chronic Pain
Duration
Cause
Site of pain
Relief of pain
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3. Differentiate between inspiration and expiration.

Inspiration Expiration
Definition
Process
Additional muscles involved
1. Identify and label the figure.
Activity G:
1. Pain is an unpleasant sensation usually associated with disease or injury. People experience pain in four phases. Write
down in the boxes below the correct sequence of the phases in the pain process.
a. Perception
b. Transmission
c. Modulation
d. Transduction
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2. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed
volume of inspired air. Write down in the boxes below the correct sequence for using an incentive spirometer.
a. Hold the breath for 3 to 6 seconds.
b. Sit upright unless contraindicated.
c. Insert the mouthpiece, sealing it between the lips.
d. Exhale normally.
e. Relax and breathe normally before the next breath with the spirometer.
f. Identify the mark indicating the goal for inhalation.
g. Remove the mouthpiece and exhale normally.
h. Inhale slowly and deeply until the predetermined volume has been reached.

1. What is an infrared listening device?
2. How should the nurse care for a client’s dentures?
3. What are the benefits of sleep?
4. What are the four categories of drugs that promote or interfere with sleep?
5. What is a thermal burn?
6. What are environmental hazards? Give examples.
7. What are the six nutritional components in food?
8. What are the seven common hospital diets?
9. What is parenteral nutrition?
10. What are the reasons for administering intravenous solutions?
11. Which two surgical procedures may be used when other methods of pain management are ineffective?
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12. What is addiction?
13. Why are adhesive nasal strips used?
14. What are the uses and common characteristics of medical cover gowns?

1. Why is it important for the nurse to consult the client regarding a convenient time for a bath?
2. Why are diuretics administered early in the morning?
3. Why should the nurse suggest that the client with a disturbed sleep pattern reduce or eliminate caffeine intake?
4. Why are victims of cold-water drowning more likely to be resuscitated?
5. Why is high-density lipoprotein (HDL) referred to as good cholesterol?
6. Why do the plastic bags of intravenous solutions not need vented tubing?
7. When is it preferable to administer analgesic drugs on a scheduled basis?
8. Why is it important to use a humidifier when administering 4 L or more oxygen?
9. What is the purpose for implementing contact precautions during client care?
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1. A nurse is providing oral care for a client in a coma.
a. What risks are involved in giving oral care to this client?
b. What precautions should the nurse take when providing oral care for the client?
2. A nurse is caring for a client with a disturbed sleep pattern who cannot sleep for more than 4 hours most nights.
a. What measures could the nurse take to promote the client’s sleep?
b. What methods could the nurse use to promote relaxation of the sleep-disturbed client’s muscles and improve blood
circulation?
3. A nurse is caring for a client who keeps tugging at the line being used for intravenous therapy.
a. What should the nurse do before considering the use of any restraint?
b. What are the nurse’s responsibilities if a restraint is applied to the client?
4. A nurse is preparing to provide perineal care to a client who has given birth vaginally.
a. What precautions should the nurse take when providing perineal care to the client?
b. For what reasons would a sitz bath be beneficial to this client?
5. A client has been instructed to perform diaphragmatic breathing to reduce respiratory effort and relieve rapid, ineffective
breathing. How should the nurse instruct this client to perform diaphragmatic breathing?
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6. A nurse at an extended-care facility is using transmission-based precautions while caring for a client with acute diarrhea
caused by an infectious microorganism.
a. What transmission-based precautions should the nurse take when caring for this client?
b. What actions should the nurse perform when discarding biodegradable trash from this client and his or her room?
7. A nurse at an extended-care facility is caring for a client having difficulty chewing and swallowing food.
a. What kind of a diet is best for this client?
b. What interventions should the nurse perform when feeding the client?
8. A nurse is caring for a client who has been ordered intravenous therapy.
a. What actions should the nurse perform before preparing the intravenous solution?
b. What technique will the nurse follow to remove air bubbles from the tubing?
1. A nurse is caring for an elderly client with Alzheimer’s disease at an extended-care facility. Sometimes the client is alert
and oriented; at other times, she is agitated or unaware of her surroundings. During periods of confusion and disorienta-
tion, the client needs assistance with activities of daily living and hygiene.
a. How should the nurse assist the client with activities of daily living?
b. What actions should the nurse take with respect to the client’s hygiene?
2. A nurse is caring for a client who is to undergo surgery the following day. The client is anxious and cannot sleep.
a. What interventions should the nurse perform to help the client relax?
b. How can the nurse ensure that the client gets adequate sleep?
3. A fire erupts in the storeroom of the health care facility following an electrical short circuit. The storage area contains
papers, books, and gauze dressing supplies. The fire spreads quickly toward the clients’ rooms.
a. How can the nurse ensure the safety of clients in this situation?
b. What are the nurse’s responsibilities during a fire?
4. A nurse is caring for a client who has undergone an amputation of the left leg and is experiencing pain at the
severed site.
a. What methods should the nurse use to divert the client’s attention from the pain?
b. What actions should the nurse perform when administering ordered drugs for pain relief?
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5. During assessment of an adolescent in her first trimester of pregnancy, the nurse learns that the client smokes regularly.
The client plans to care for the baby herself.
a. What are the possible implications for the client’s respiratory health and the health of the baby?
b. What client teaching should the nurse provide?
6. A physician has ordered a transfusion to compensate for blood loss in a client following a severe accident.
a. What procedures should the nurse perform before the blood transfusion?
b. What actions should the nurse perform during the transfusion?
7. A nurse is required to clean and dress pressure ulcers on the feet of a client with restricted mobility.
a. What actions should the nurse take to promote healing of the pressure ulcers?
b. What precautions should the nurse take when changing this client’s bed linens that contain serous drainage?

1. Which of the following measures is most appropriate when cleaning plastic eyeglasses?
a. Use paper tissue to clean the lenses.
b. Rinse the lenses with running tap water.
c. Immerse the lenses in hot soapy water.
d. Allow the lenses to air dry.
2. A client with hypersomnolence related to seasonal affective disorder has been prescribed phototherapy. Which of the
following points should the nurse include in the client teaching?
a. Wear eyeglasses or contact lenses with ultraviolet filters.
b. Sit 5 feet from the artificial light during phototherapy.
c. Look at the artificial light continuously.
d. Repeat exposure to artificial light up to 3 to 6 hours a day.
3. During a routine well child visit, the nurse needs to teach parents safety measures to prevent childhood poisoning. Which
of the following should the nurse tell the parents?
a. Discard old medications in the wastebasket.
b. Tell the child that medication is sweet to help him or her take it.
c. Keep the home ventilated when using aerosol sprays.
d. Carry regular medications in purses.
4. A client with cancer is receiving patient-controlled analgesia (PCA). During the client teaching about the equipment,
which of the following should the nurse tell the client?
a. Pain relief is slow and long lasting.
b. PCA requires less of the drug overall to control pain.
c. Ambulation may be difficult.
d. Complications from immobility may arise.
5. A nurse is caring for a client with hypoxia. What position should the nurse assist the client to assume to best facilitate
improved breathing?
a. Lie flat on the back.
b. Sit with the bed inclined 15 degrees.
c. Lie on the left side.
d. Lean forward over the bedside table.
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6. A nurse is caring for a client recovering from tuberculosis. What infection control interventions should the nurse follow?
a. Ask family members and friends to obtain a tuberculosis skin test.
b. Ask the client to use paper tissues when coughing and then dispose of them.
c. Keep the client’s wheelchair or stretcher covered with a clean sheet.
d. Read and analyze the client’s latest skin test report for tuberculosis.
e. Wear a particulate air filter respirator during client care.
7. A client who has been hospitalized and is recuperating from pneumonia is complaining of stomach gas. Which of the
following interventions should the nurse perform? Select all that apply.
a. Encourage walking if possible.
b. Suggest drinking carbonated beverages.
c. Provide a straw for drinking.
d. Ask the client to avoid chewing gum.
e. Remind the client to chew with the mouth closed.
8. Which of the following nursing interventions are appropriate for a client who is on fluid restrictions? Select all that apply.
a. Suggest rinsing the mouth without swallowing water.
b. Provide fluids in a plastic squeeze bottle or spray atomizer.
c. Explain the need to restrict fluids in the diet.
d. Encourage the intake of food with a moderately high salt content.
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UNIT 6
Assisting the Inactive Client
23 Body Mechanics, Positioning, and Moving 494
24 Therapeutic Exercise 519
25 Mechanical Immobilization 537
26 Ambulatory Aids 560
493
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23 Body Mechanics,
Positioning, and
Moving
alignment
anatomic position
balance 1. Identify characteristics of good posture in a standing, sitting,
bariatric client or lying position.
base of support 2. Describe three principles of correct body mechanics.
bed board 3. Explain the purpose of ergonomics.
body mechanics 4. Give at least two examples of ergonomic recommendations
center of gravity in the workplace.
contractures 5. Describe at least 10 signs or symptoms associated with the
disuse syndrome disuse syndrome.
energy 6. Describe six common client positions.
ergonomics 7. Explain the purpose of five different positioning devices used
foot drop for safety and comfort.
Fowler’s position 8. Name one advantage for each of three different pressure-
functional mobility relieving devices.
functional position 9. Discuss four types of transfer devices.
gravity 10. Give at least five general guidelines that apply to transferring
lateral oblique position clients.
lateral position
line of gravity
muscle spasms
I
nactivity leads to deterioration of health. Multiple complications
neutral position
can occur among people with limited activity and movement
posture
(Table 23-1).
prone position
repetitive strain injuries
shearing
Sims’ position
supine position
transfer Gerontologic Considerations
■ By the 7th or 8th decade of life, muscle strength, endurance, and

coordination decline. Older adults need to maintain as much mobility
as possible to prevent disability.
■ The risk for social isolation among older adults increases as
mobility is limited.
The consequences of inactivity are collectively referred to as

disuse syndrome (signs and symptoms that result from inactivity).
Nursing care activities such as positioning and moving clients reduce
the potential for disuse syndrome. Nurses can become injured, how-
ever, if they fail to use good posture and body mechanics while per-
forming these activities.
This chapter describes how to position and move clients to pre-
vent complications associated with inactivity. It also discusses meth-
ods for protecting nurses from work-related injuries. Basic terms are
defined in Table 23-2.
494
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CHAPTER 23 Body Mechanics, Positioning, and Moving 495
TABLE 23-1 Dangers of Inactivity Line of gravity
SYSTEMS EFFECTS
Muscular Weakness
Decreased tone/strength
Decreased size (atrophy)
Skeletal Poor posture
Contractures
Foot drop Center of
Cardiovascular Impaired circulation gravity
Thrombus (clot) formation
Dependent edema
Respiratory Pooling of secretions
Shallow respirations
Atelectasis (collapsed alveoli)
Urinary Oliguria (scanty urine)
Urinary tract infections
Calculi (stone) formation
Incontinence (inability to control elimination)
Gastrointestinal Anorexia (loss of appetite)
Wide base
Constipation
of support
Fecal impaction
Integumentary Pressure sores FIGURE 23-1 Good posture helps to align gravity through the
Endocrine Decreased metabolic rate center of the body. A wide stance provides a stable base for
Decreased hormonal secretions support.
Central nervous Sleep pattern disturbances
Psychosocial changes
When a person performs work while using poor pos-
ture, muscle spasms (sudden, forceful, and involuntary
muscle contractions) often result. They occur more often
when muscles are strained and forced to work beyond their
MAINTAINING GOOD POSTURE capacity.
Posture (the position of the body, or the way in which it is
Standing
held) affects a person’s appearance, stamina, and ability to
To maintain good posture in a standing position (Fig. 23-2):
use the musculoskeletal system efficiently. Good posture,
whether in a standing, sitting, or lying position, distributes • Keep the feet parallel, at right angles to the lower legs, and
gravity through the center of the body over a wide base of about 4 to 8 in. (10 to 20 cm) apart.
support (Fig. 23-1). Good posture is important for both cli- • Distribute weight equally on both feet to provide a broad
ents and nurses. base of support.
TABLE 23-2 Basic Terminology

TERM DEFINITION AND EXAMPLE
Gravity Force that pulls objects toward the center of the earth. The pull of gravity causes objects, such as an item
dropped from the hand, to fall to the ground. It causes water to drain to its lowest level.
Energy Capacity to do work. Energy is used to move the body from place to place. Energy is required to overcome the
force of gravity.
Balance Steady position with weight. A person falls when off balance.
Center of gravity Point at which the mass of an object is centered. The center of gravity for a standing position is the center of the
pelvis and about halfway between the umbilicus and the pubic bone.
Line of gravity Imaginary vertical line that passes through the center of gravity. The line of gravity in a standing person is a
straight line from the head to the feet through the center of the body.
Base of support Area on which an object rests. The feet are the base of support when a person is in a standing position.
Alignment Parts of an object being in proper relationship to one another. The body is in good alignment in a position of good
posture.
Neutral position The position of a limb that is turned neither toward nor away from the body’s midline.
Anatomic position Frontal and back views with arms at the sides and palms forward.
Functional position Position in which an activity is performed properly and normally. In the hand, the wrists are slightly dorsiflexed
between 20 and 35 degrees and the proximal finger joints are flexed between 45 and 60 degrees, with the
thumb in opposition and in alignment with the pads of the fingers.
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496 UNIT 6 Assisting the Inactive Client
A B
FIGURE 23-3 A. A correct sitting posture. B. An incorrect sitting
A B posture. (Courtesy of Lowren West, New York, NY.)
FIGURE 23-2 A. A good standing posture results when abdom-

inal and gluteal muscles are contracted. B. A poor standing
posture results when abdominal muscles are relaxed, causing
altered body alignment. Gerontologic Considerations
■ Skeletal changes such as kyphosis, lordosis, or scoliosis

change the older person’s center of gravity. Also, pressure
on cervical vertebrae from kyphotic changes while lying
• Bend the knees slightly to avoid straining the joints.
supine may be minimized by using a small towel roll or
• Maintain the hips at an even level. neck roll pillow.
• Pull in the buttocks and hold the abdomen up and in to
keep the spine properly aligned. This position supports the
abdominal organs and reduces strain on both back and
abdominal muscles. BODY MECHANICS
• Hold the chest up and slightly forward and extend or
stretch the waist to give internal organs more space and The use of proper body mechanics (the efficient use of the mus-
maintain good alignment of the spine. culoskeletal system) increases muscle effectiveness, reduces
• Keep the shoulders even and centered above the hips. fatigue, and helps to avoid repetitive strain injuries (disor-
• Hold the head erect with the face forward and the chin ders that result from cumulative trauma to musculoskeletal
slightly tucked.
Sitting
In a good sitting position (Fig. 23-3), the buttocks and upper
thighs become the base of support. Both feet rest on the floor.
The knees are bent, with the posterior of the knee free from the
edge of the chair to avoid interfering with distal circulation.
A
Lying Down
Good posture in a lying position looks the same as in a stand-
ing position, except the person is horizontal (Fig. 23-4). The
head and neck muscles are in a neutral position, centered
between the shoulders. The shoulders are level, whereas the
arms, hips, and knees are slightly flexed with no compres-
sion of the arms or legs under the body. The trunk is straight B
and the hips are level. The legs are parallel to each other with FIGURE 23-4 A. A correct lying posture. B. An incorrect lying
the feet at right angles to the leg. posture. (Courtesy of Lowren West, New York, NY.)
LWBK1004-C23_p493-518.indd 496 04/02/12 3:08 PM


Rationales
Using Good Body Mechanics
• Use the longest and strongest muscles of the arms and legs. • Keep feet apart for a broad base of support. This stance lowers
Use of these muscles provides the greatest strength and poten-the center of gravity, which promotes stability.
tial for performing work. • Bend the knees and keep the back straight when lifting an
• When lifting a heavy load, center it over the feet. Such posi- object, rather than bending over from the waist with straight
tioning creates a base of support. knees. This stance makes best use of the longest and strongest
• Hold objects close to the body. Doing so increases balance. body muscles and improves balance by keeping the weight of
• Bend the knees. Bending the knees prepares the spine to accept the object close to the center of gravity.
the weight of the load. • Avoid twisting and stretching muscles during work. Twisting
• Contract the abdominal muscles and make a long midriff. can strain muscles because the line of gravity is outside the
Doing so protects the muscles of the abdomen and pelvis and body’s base of support.
prevents strain and injury to the abdominal wall. • Rest between periods of exertion. Resting promotes work
• Push, pull, or roll objects whenever possible rather than lifting endurance.
them. Lifting requires more effort.
• Use body weight as a lever to assist with pushing or pulling an
object. This reduces muscle strain.
structures). Basic principles of body mechanics are important • Using a chair with good back support. A chair should be
regardless of a person’s occupation or daily activities, but high enough so the user can place his or her feet firmly on
body mechanics alone will not necessarily reduce muscu- the floor. There should be room for two fingers between the
loskeletal injuries (see Nursing Guidelines 23-1). edge of the seat and the back of the knees. Arm rests should
allow a relaxed shoulder position.
• Keeping the elbows flexed no more than 100 to 110 degrees,
Gerontologic Considerations or use wrist rests to keep the wrists in a neutral position
when working at a computer.
■ An older person may be taught to use appropriate body • Working under nonglare lighting.
mechanics, such as sitting in a chair to lift an object directly
in front of it. Emphasize that the lifting of objects should be Despite being taught principles of good body mechan-
done only from directly in front to prevent pulling of lateral ics, health care workers, particularly nurses, are vulnerable
back muscles or vertebral disk compression. to ergonomic hazards in the workplace as a direct conse-
quence of (1) lifting heavy loads (ie, clients), (2) reaching
and lifting with loads far from the body, (3) twisting while
ERGONOMICS lifting, (4) unexpected changes in load demand during the
lift, (5) reaching low or high to begin a lift, and (6) mov-
Using proper body mechanics is one component of preserv-
ing or carrying a load a significant distance (Fragala et al.,
ing the integrity of the body, but body mechanics alone will
2005). Nursing personnel are among the occupational work-
not necessarily reduce musculoskeletal injuries. The other
ers at the highest risk for musculoskeletal injuries (deCastro,
component is applying and implementing ergonomics
2004), a fact supported by the Department of Health and
(a specialty field of engineering science devoted to promot-
Human Services, which found that nurses experience 12.6
ing comfort, performance, and health in the workplace).
injuries per 100 full-time workers compared to 4.0 work-
Ergonomics is used to improve the design of the work envi-
related injuries per 100 workers in mining, 7.9 in construc-
ronment and equipment. The National Institute for Occupa-
tion, and 8.1 in manufacturing (Pascale, 2007).
tional Safety and Health (NIOSH), a division of the Centers
Because of the pervasiveness of the problem and its
for Disease Control and Prevention, requires employers to
direct link to a shortage of employed nurses, the American
comply with many ergonomic recommendations. Examples
Nurses Association (ANA) has taken an initiative to reduce
injuries to nurses (and their clients) by recommending a “no
• Using assistive devices to lift or transport heavy items or lift policy,” known as the Handle With CareCampaign, in
clients. the workplace. The campaign is an effort to reduce injuries
• Using alternative equipment for tasks that require repeti- through the use of assistive equipment and devices. Using
tive motions—for instance, telephone headsets or auto- assistive devices has many advantages (Box 23-1).
matic staplers. Health care agencies have already begun to implement
• Positioning equipment no more than 20 to 30 degrees the ANA guidelines. In 2009, two federal bills, H.R. 2381
away—about an arm’s length—to avoid reaching or twist- and S. 1788, entitled Nurses and Healthcare Worker Protec-
ing the trunk or neck. tion Act of 2009 were introduced. The proposed legislation
LWBK1004-C23_p493-518.indd 497 04/02/12 3:08 PM

B OX 2 3 - 1 Advantages of Assistive Devices

Nurses
• Lessens physical exertion during positioning, moving, and
transferring clients
• Reduces musculoskeletal injuries
• Decreases sick or absentee time
• Lowers medical costs, pain, and suffering
• Decreases workman’s compensation claims
• Maintains workforce of employed nurses
Clients
• Provides more security during repositioning and transfers
from bed, chairs, toilets, stretchers
• Results in fewer handling mishaps and secondary injuries
• Relieves anxiety concerning safety
• Promotes comfort by reducing awkward or forceful manual
handling
• Maintains dignity and self-esteem
• Promotes faster recovery
(Adapted from American Nurses Association. (2003). Handle with care FIGURE 23-5 These nurses are using the Phil-e-slide Patient
campaign. Available at http://www.nursingworld.org/handlewithcare.) Handling System to transfer a client. (Photo courtesy of
ErgoSafe Products, LLC. St. Louis, MO).
mandates safe patient/client movement for direct-care • Turn the client as a complete unit to avoid twisting the spine.
licensed nurses and other health care providers as a critical • Place the client in good alignment with joints slightly flexed.
component in protecting health care workers and increas- • Replace pillows and positioning devices.
ing patient/client safety (http://www.asphp.org/pdfs/SPH_ • Support limbs in a functional position.
Legislation_Update_March_2011.pdf). The congressional • Use elevation to relieve swelling or promote comfort.
bills support methods to reduce risks associated with moving • Provide skin care after repositioning.
clients and evaluating alternatives or restricting manual lifting
to emergency, life-threatening, or exceptional circumstances
(Anderson, 2006). Voluntary changes in nursing practice, Gerontologic Considerations
however, should not, and have not been delayed while wait-
ing for federal legislative action; as of 2011, nine states have ■ Older adults with cognitive impairment may have diffi-
enacted safe client handling legislation. culty following directions regarding positioning and transfer-
ring. Instructions should be given using clear, simple words
to make one request at a time. Demonstrations are very
helpful in conveying the message if word recall is dimin-
POSITIONING CLIENTS ished. Photographs of the desired action may also be used.
Good posture and body mechanics and ergonomically

designed assistive devices are necessary when inactive clients Common Positions
require positioning and moving. An inactive client’s position is Nurses commonly use six body positions when caring for
changed to relieve pressure on bony areas of the body, promote bedridden clients: supine, lateral, lateral oblique, prone,
functional mobility (an alignment that maintains the potential Sims’, and Fowler’s (Fig. 23-6).
for movement and ambulation), and provide for therapeutic
Supine Position
needs. General principles for positioning are as follows:
In the supine position, the person lies on his or her back.
• Change the inactive client’s position at least every 2 hours. There are two primary concerns associated with the supine
• Enlist the assistance of at least one other caregiver. position: prolonged pressure, especially at the end of the
• Raise the bed to the height of the caregiver’s elbow. spine, leads to skin breakdown; and gravity, combined with
• Remove pillows and positioning devices. pressure on the toes from bed linen, creates a potential for
• Unfasten drainage tubes from the bed linen. foot drop (a permanent dysfunctional position caused by
• Use a low-friction fabric or gel-filled plastic sheet, roller a shortening of the calf muscles and a lengthening of the
sheet with handles, or a repositioning sling to slide, rather opposing muscles on the anterior leg; Fig. 23-7). Foot drop
than to drag or lift, the client while turning or transferring hinders ambulation because it interferes with a person’s
from bed to a stretcher (Fig. 23-5). ability to place the heel on the floor. The supine position,
LWBK1004-C23_p493-518.indd 498 04/02/12 3:08 PM

A B
C D
FIGURE 23-6 Body positions for bedridden clients.

(A) The supine position. (B) The lateral position. (C) The
lateral oblique position. (D) The prone position. (E) The
G Sims’ position. (F) The low Fowler’s position. (G) The
high Fowler’s position.
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variations are common. In a low Fowler’s position, the head

and torso are elevated to 30 degrees. A mid-Fowler’s or semi-
Fowler’s position refers to an elevation of up to 45 degrees.
A high Fowler’s position is an elevation of 60 to 90 degrees.
The knees may not be elevated, but doing so relieves strain
on the lower spine.
The Fowler’s position is especially helpful for clients
with dyspnea because it causes the abdominal organs to drop
FIGURE 23-7 Foot drop is a consequence of weaked muscles away from the diaphragm. Relieving pressure on the dia-
for dorsiflexion resulting in permanent plantarflexion. phragm allows the exchange of a greater volume of air. Sit-
ting for a prolonged period, however, decreases blood flow
however, is recommended as a way to reduce the incidence to tissues in the coccyx area and increases the risk for pres-
of sudden infant death syndrome among newborns (National sure ulcers in that area.
Institute of Child Health and Human Development, 2006).
Lateral Position ➧ Stop, Think, and Respond Box 23-1

With the lateral position (a side-lying position), foot drop is Give one advantage and one disadvantage for the
of less concern because gravity does not pull down the feet supine, lateral and lateral oblique, prone, Sims’, and
as happens when clients are supine. Nevertheless, unless the Fowler’s positions.
upper shoulder and arm are supported, they may rotate for-
ward and interfere with breathing. Positioning Devices
Many devices are available to help maintain good body
Lateral Oblique Position alignment in bed and to prevent discomfort or pressure. Any
In the lateral oblique position (a variation of the side- position, no matter how comfortable or anatomically correct,
lying position), the client lies on the side with the top leg must be changed frequently.
placed in 30 degrees of hip flexion and 35 degrees of knee
flexion. The calf of the top leg is placed behind the midline Adjustable Bed
of the body on a support such as a pillow. The back is sup- The adjustable bed (see Chap. 18) can be raised or lowered and
ported, and the bottom leg is in neutral position. This posi- allows the position of the head and knees to be changed. The
tion produces less pressure on the hip than a strictly lateral high position facilitates the performance of nursing care. Rais-
position and reduces the potential for skin breakdown. ing the head of the bed helps the client to look around without
twisting and bending. It also promotes drainage of the upper
Prone Position lobes of the lungs and prepares the client for eventually stand-
The prone position (one in which the client lies on the abdo- ing and walking. The low position enables an independent
men) is an alternative position for the person with skin break- client to get in and out of the bed safely (Fig. 23-8). Placing a
down from pressure ulcers (see Chap. 28). The prone posi- bed in a slight Trendelenburg position may help keep the client
tion also provides good drainage from bronchioles, stretches from sliding down toward the foot of the bed (Fig. 23-9).
the trunk and extremities, and keeps the hips in an extended
position. The prone position has been found to improve arte- Mattress
rial oxygenation in critically ill clients with adult respiratory A comfortable, supportive mattress is firm but flexible
distress syndrome who are mechanically ventilated, but does enough to permit good body alignment. An unsupportive
not necessarily result in higher rates of survival (Taccone mattress promotes an unnatural curvature of the spine.
et al., 2009). The prone position poses a nursing challenge
for assessing and communicating with clients, however, and
it is uncomfortable for clients with recent abdominal surgery
or back pain, and interferes with eating.
Sims’ Position
In Sims’ position (a semi-prone position), the client lies on
the left side with the right knee drawn up toward the chest.
An arm is positioned along the client’s back, and the chest
and abdomen are allowed to lean forward. The Sims’ posi-
tion is also used for the examination of and procedures
involving the rectum and vagina (see Chap. 14).
Fowler’s Position FIGURE 23-8 Grasping the mattress and pushing down with
The Fowler’s position (a semi-sitting position) makes the other hand is an independent technique for sitting on the
it easier for the client to eat, talk, and look around. Three edge of the bed in preparation for ambulating.
LWBK1004-C23_p493-518.indd 500 04/02/12 3:08 PM

FIGURE 23-9 In the Trendelenburg position, the head is lower

than the feet.
Bed Board
A bed board (a rigid structure placed under a mattress)
provides additional skeletal support. Bed boards usually are
made of plywood or some other firm material. The size var-
ies with the situation. If sections of the bed (the head and FIGURE 23-10 A roller sheet is used for turning, moving, and
repositioning.
foot) can be raised, the board must be divided into hinged
sections. For home use, full bed boards can be purchased or
made from sheets of plywood.
depends on factors such as size, weight, mental status, and
Pillows strength.
Pillows are used to support and elevate a body part. Small
pillows, such as contour pillows, triangular wedges, and
bolsters, are ideal for supporting and elevating the head,
extremities, and shoulders. For home use, oversized pil-
■ Elevated toilet seats with handrails may be helpful to
lows are useful for elevating the upper part of the body if an
allow older people to use arm muscles, rather than leg
adjustable bed is not available.
muscles, to assist with sitting and rising.
Roller Sheet ■ Older adults require extra time and assistance during
A roller sheet (also known as a slider sheet) that extends positioning, transferring, and ambulating. They may need
modifications to positions because of limitations from pain
from the upper back to midthighs is a helpful position-
or joint degeneration. Allow a few minutes for an older per-
ing device. Some are designed with handles on either side. son’s position changes, such as from supine to sitting or
When made of substances that reduce friction, the roller standing, to allow for compensatory changes in blood pres-
sheets diminish the work of turning a client and avoid the sure, thus preventing orthostatic hypotension. Teach the cli-
potential for skin injuries. They are used to slide and roll, ent to wait until any dizziness has resolved before moving,
rather than to lift, the client. They help to move up clients thus decreasing the risk for falls.
in bed from a supine position in the center of the bed to the ■ Older adults may fear falling and thus may limit their
side of the bed, to turn clients to a lateral position, or to mobility. Handrails may be strategically placed to promote
transfer clients from bed to a stretcher. A mechanical lift, confidence in ambulation. In addition, placement of chairs
which is discussed later, or a repositioning sling is recom- near a frequent pathway in the home or institution allow for
mended when major repositioning is required. The roller a “rest stop,” thus increasing confidence in ambulation.
sheet is placed close to the sides of the client’s body dur-
ing repositioning (Fig. 23-10). Working as a team, nurses If all criteria suggest that the nurse and client can accom-
use the roller sheet to change the client to an alternate plish the task at hand, the nurse enlists the client’s coop-
position while avoiding any stooping, reaching, or twist- eration by explaining the plan and how the client can help.
ing. The sheet is removed after being used or kept dry and Assistive devices and additional caregivers are needed when
free of wrinkles to prevent skin breakdown. turning or moving a client who cannot change from one
position to another independently or who needs help doing
Turning and Moving Clients so. Good turning and moving skills are important to prevent
In some cases the client may be fully capable of assisting injury to the nurse and the client. Skill 23-1 describes the
with turning or moving. The amount of client assistance process of repositioning and moving clients.
LWBK1004-C23_p493-518.indd 501 04/02/12 3:08 PM


Rationales
Using a Trochanter Roll
• Fold a sheet lengthwise in half or in thirds and place it under
the client’s hips. The sheet will anchor the body in the correct
position.
• Place a rolled-up bath blanket or two bath towels under each
end of the sheet that extends on either side of the client. This
provides support to the trochanters.
• Roll the sheet around the blanket so that the end of the roll is
underneath. This action prevents unrolling.
• Secure the rolls next to each hip and thigh. The rolls prevent
an external rotation of the hip.
• Permit the leg to rest against the trochanter roll. This position
FIGURE 23-11 Placement of trochanter rolls. allows for normal alignment of the hips, preventing internal or
external rotation.
Trochanter Rolls Some commercial foot boards have supports that prevent the
Trochanter rolls (Fig. 23-11) prevent the legs from turning outward rotation of the foot and lower leg.
outward. The trochanters are the bony protrusions at the If the client is short and cannot reach a foot board, a foot
head of the femur near the hip. Placing a positioning device splint is used. A foot splint allows for more variety in body
at the trochanters helps to prevent the leg from rotating out- positioning while maintaining the foot in a functional posi-
ward (see Nursing Guidelines 23-2). tion. Some nurses have clients wear ankle-high tennis shoes
while in bed to prevent foot drop. They remove the shoes
Hand Rolls regularly and give proper foot care.
Hand rolls (Fig. 23-12) are devices that preserve the client’s If a foot splint or foot board is not available, the nurse
functional ability to grasp and pick up objects. Hand rolls can use a pillow and large sheet. He or she rolls the pillow
prevent contractures (permanently shortened muscles that in the sheet and twists the ends of the sheet before tucking it
resist stretching) of the fingers. They keep the thumb posi- under the foot of the mattress. A pillow support does not pro-
tioned slightly away from the hand and at a moderate angle to vide the firmness of a board or splint, and the nurse replaces
the fingers. The fingers are kept in a slightly neutral position it as soon as possible with a sturdier device.
rather than a tight fist. A rolled-up washcloth or a ball can be
used as an alternative to commercial hand rolls. Hand rolls
are removed regularly to facilitate movement and exercise.
In addition to the usual hospital bed, what else will
Foot Boards, Boots, and Foot Splints you obtain to facilitate moving and repositioning a
Foot boards, boots, and splints are devices that prevent foot client who is weak and cannot assist with positioning
drop by keeping the feet in a functional position (Fig. 23-13). and turning?
FIGURE 23-13 Protective boots to avoid foot drop. (Photo by

FIGURE 23-12 A hand roll. (Photo by B. Proud.) B. Proud.)
LWBK1004-C23_p493-518.indd 502 04/02/12 3:08 PM

FIGURE 23-15 Using side rails to prepare for ambulation and

to change position.
tissue because it conforms to the client’s body and acts like

a cushion. Consequently, it redistributes pressure over a
greater area, reducing the compressive effect on skin and tis-
sue. Foam also contains channels and cells filled with air that
allow for the evaporation of moisture and the escape of heat.
Some foam mattresses are convoluted or made with a
series of elevations and depressions, resembling an egg crate
FIGURE 23-14 Using a trapeze to facilitate movement.
(see Chap. 18) or waffle. The density of the foam and the
manner in which the foam is formed determine the degree of
pressure reduction.
Trapeze Egg-crate foam mattresses provide minimal pressure
A trapeze is a triangular piece of metal hung by a chain reduction and are recommended for comfort only. Thicker,
over the head of the bed (Fig. 23-14). The client grasps the waffle-shaped foam mattresses offer greater pressure reduc-
trapeze to lift the body and move about in bed. Unless arm tion; nurses can use them to prevent skin breakdown.
movement or lifting is undesirable, a trapeze is an excellent Gel is an alternative substance used to fill cushions and
device for helping a bedridden client to increase his or her mattresses. It differs from foam in that it suspends and sup-
activity. ports the body part. Nurses place gel and foam cushions in
wheelchairs to prevent the “hammock effect”—the posterior
and lateral compression that occurs when sitting in a sling-
PROTECTIVE DEVICES like seat.
Items such as side rails, mattress overlays, cradles, and specialty Static Air Mattress
beds protect inactive clients from harm or complications. A static air pressure mattress is filled with a fixed volume of
air. It is similar in appearance to those used for recreational
Side Rails purposes. It suspends the client on a buoyant surface, distrib-
Side rails (Fig. 23-15) are a valuable device to aid clients in uting the pressure on the underlying tissue. If the mattress
changing their position and moving about while in bed. With becomes underinflated, however, it loses its effectiveness as
side rails in place, the client can safely turn from side to side a pressure-relieving device. Because plastic is nonabsorbent,
and sit up in bed. These activities help clients to maintain or air mattresses permit less evaporation of moisture than foam.
regain muscle strength and joint flexibility. Also, sharp objects can damage the integrity of the mattress.
Mattress Overlays Alternating Air Mattress

Mattress overlays are accessory items made of foam or con- An alternating air mattress (Fig. 23-16) is similar to a static
taining gel, air, or water that nurses place over a standard one with one exception: every other channel inflates as the
hospital mattress. Nurses use mattress overlays to reduce next one deflates. The process is then reversed. The wave-
pressure and restore skin integrity (see Chap. 28). like redistribution of air cyclically relieves pressure over
bony prominences. This repetitive process promotes blood
Foam and Gel Mattresses flow and keeps the tissues supplied with oxygen. The tubing
Several types of foam mattresses, made of latex or polyeth- connecting the mattress to its motor-driven compressor must
ylene, are available. Foam acts like a layer of subcutaneous not become kinked. The noise may disturb some clients.
LWBK1004-C23_p493-518.indd 503 04/02/12 3:08 PM

FIGURE 23-17 A bed cradle beneath the top sheet.
Puncturing leads to damage. Filling and emptying, although

done infrequently, are time-consuming.
Cradle
FIGURE 23-16 An alternating air mattress. (First Step Plus;
A cradle is a metal frame secured to or placed on top of the
Courtesy of KCI Therapeutic Services, San Antonio, TX.) mattress. It forms a shell over the client’s lower legs to keep
bed linen off the feet or legs (Fig. 23-17). A cradle is often
used for clients with burns, painful joint disease, and frac-
Water Mattress tures of the leg.
A water mattress supports the body and equalizes the pres-
sure per square inch over its surface. The pressure-relieving Specialty Beds
effect is maintained regardless of any shift in the client’s Specialty beds such as low–air-loss beds, air-fluidized beds,
position. Many claim that sleeping on a waterbed produces oscillating support beds, and circular beds offer more func-
a feeling of tranquility, which may provide beneficial emotions than standard hospital beds. Like mattress overlays,
tional effects. Water mattresses are heavy; therefore, the they are used to relieve pressure and to prevent other prob-
floor and the bed frame must be able to support the weight. lems associated with inactivity and immobility (Table 23-3).
TABLE 23-3 Pressure-Relieving Devices

DEVICE EXAMPLES INDICATIONS FOR USE
Foam mattress or gel cushion Egg crate Intact skin and minimal risk for breakdown
Geo-Matt Changes in position occur spontaneously or require minimal assistance
Static air, alternating air, or TENDER Cloud At some risk for skin breakdown
water mattress Sof-Care A superficial or single deep break in skin but pressure easily relieved
Pulsair Need for prolonged bed rest with immobilization
Lotus
Oscillating support bed Roto Rest At high risk for systemic effects of immobility, such as pneumonia and skin
Tilt and Turn breakdown
Paragon 9000
Low–air-loss bed KinAir Combination of the following:
FLEXICAIR Impaired skin
Mediscus Continued existence of risk factors for further skin breakdown
Alternative positions limited, less than adequate, or impossible
Assistance required for frequent transfers from bed
Air-fluidized bed Clinitron Combination of the following:
FluidAir Impaired skin
Continued existence of risk factors for further skin breakdown
Alternative positions limited, less than adequate, or impossible
Seldom transferred from bed
Circular bed CircOlectric Current or high risk for skin breakdown because of multiple trauma, especially if it
involves the head, neck, or spine
Burns that require frequent dressing changes or topical applications
LWBK1004-C23_p493-518.indd 504 04/02/12 3:08 PM

FIGURE 23-18 A low–air-loss bed. (Courtesy of Hill-Rom

Company, Inc., Batesville, Indiana.)
Low–Air-Loss Bed
A low–air-loss bed (Fig. 23-18) contains inflated air sacs within
the mattress. It maintains capillary pressure well below that
which can interfere with blood flow. Regardless of changes in
FIGURE 23-20 An oscillating bed. (Courtesy of Kinetic
body position, the mattress selectively responds by redistrib-
Concepts, Inc., San Antonio, TX.)
uting the air to maintain low pressure to all skin areas.
Air-Fluidized Bed Oscillating Support Bed
An air-fluidized bed (Fig. 23-19) contains a collection of An oscillating bed (Fig. 23-20) slowly and continuously
tiny beads within a mattress cover. The beads are blown rocks the client from side to side in a 124-degree arc. Oscil-
upward on warm air. When suspended, the dry beads take on lation relieves skin pressure and helps to mobilize respira-
the characteristics of fluid, allowing the client to float on the tory secretions. Foam-covered supports applied to the head,
lifted beads. Excretions and secretions drain away from the arms, and legs prevent sliding and skin shearing (the force
body and through the beads, thereby preventing skin irrita- exerted against the surface and layers of the skin as tissues
tion and maceration from moisture. The pressure-relieving slide in opposite but parallel directions). Compartments
effects of this type of bed have been shown to speed the heal- within the bed are removed temporarily to facilitate assess-
ing of severely impaired tissue. ment and care of the posterior body.
An air-fluidized bed is better used for a client who is
likely to remain in bed for long periods. Fluid balance may Circular Bed
become a problem because of the accelerated evaporation A circular bed supports the client on a 6 or 7-ft anterior
caused by the warm, blowing air. Puncturing or tearing the or posterior platform suspended across the diameter of the
mattress is also a potential problem. frame (Fig. 23-21). This type of bed allows the client to
FIGURE 23-19 An air-fluidized bed.
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FIGURE 23-22 A transfer handle.
like side rails because the client is free to move around. It

promotes activity and mobility for many who are physically
challenged.
FIGURE 23-21 A circular bed.
Transfer Belt
remain passively immobilized during a position change. The A transfer belt is a padded device secured around the client’s
bed has the capacity to rotate the client, who is sandwiched waist. Its handles provide a means of gripping and support-
between the anterior and posterior frames, in a 180-degree ing the client (Fig. 23-23). This device is designed for cli-
arc. Turning permits access to the client for nursing care. ents who can bear weight and help with the transfer but are
Clients learn how to operate the bed to make minor adjust- unsteady. It also may be used as a walking belt to provide
ments in their position. This promotes a sense of control safety and security while assisting a client with ambulation
among otherwise dependent clients. (see Chap. 26).
Transfer Boards
TRANSFERRING CLIENTS A transfer board serves as a supportive bridge between two
surfaces such as the bed and a wheelchair, the bed and a
Transfer (moving a client from place to place) refers to
moving a client from the bed to a chair, toilet, or stretcher
and back to bed again. The client assists in an active transfer.
A transfer done with the help of one or more nursing person-
nel with an assistive device is a passive transfer. Transfer
aids are assistive devices that help clients move laterally.
Several devices are available to help transfer clients. Some
examples of transfer aids are transfer handles, transfer belts,
transfer boards, and mechanical or electrical lifts. Transfer
devices are especially helpful for decreasing the potential for
injury to caregivers and clients or for times when caring for
clients who fear falling or lack confidence in the ability of
personnel to transfer them safely and comfortably.
Transfer Handle
Some clients with disabilities find that a transfer handle helps
them to remain active and independent (Fig. 23-22). A trans-
fer handle fits between the mattress and the bed frame or box
spring and serves as a combination grab bar and handrail
to support the client’s weight while exiting and returning to FIGURE 23-23 A belt is used to assist with transferring a client
bed. A transfer handle is not considered a restrictive device from the bed to a wheelchair and back to bed.
LWBK1004-C23_p493-518.indd 506 04/02/12 3:09 PM

FIGURE 23-24 A transfer board is used to move a client from

the bed to a stretcher.
stretcher, the wheelchair and a car seat, or the wheelchair and

the toilet. Transfer boards come in a variety of widths and
lengths. Some are curved to facilitate transferring around fixed
armrests; others may have wheels on their underneath side.
FIGURE 23-26 A standing lift supports a client who can bear
Transfer boards are positioned in such a way that the client’s some body weight. It also facilitates lowering the client to a
buttocks or body can slide across what would otherwise be sitting position on a chair or toilet.
an open space or a gap in height between two surfaces (Fig.
23-24). Some clients with strong arm and upper body muscles
can use a transfer board independently. For clients who need and lower clients secured in a canvas sling and move them
assistance, the nurse uses a transfer belt in conjunction with around on a wheeled frame. The wheels are locked when a
a transfer board. Full-body transfer boards also are available stationary position is desired such as when lowering a cli-
for moving supine clients to a stretcher or an X-ray table. A ent into place. Standing assist lifts are an alternative for use
low-friction roller sheet may be used in conjunction with a when clients have some ability to bear weight (Fig. 23-26).
transfer board. It is best to use assistive devices when they are needed,
observe the guidelines in Nursing Guidelines 23-3, and use
Mechanical Lift the recommendations in Skill 23-2 when transferring clients.
A mechanical lift (Fig. 23-25) helps to move heavy clients
or those with limited ability to assist from the bed to a chair,
toilet, or tub, and back again. Both electric and hydrau-
lic models are available with a lifting capacity of 350 to NURSING GUIDELINES 23-3
600 lb. Using a mechanical lift enables a caregiver to raise
Assisting with Client Transfer
• Be realistic about how much you can safely lift. Not exceed-
ing one’s capabilities demonstrates good judgment.
• Always practice good body mechanics. They reduce the
potential for injury.
• Put on braces and other supportive devices before getting a
client out of bed. Doing so maximizes time management.
• Have the client wear shoes or nonskid slippers. Appropriate
footwear provides support and prevents foot injuries.
• Plan to transfer clients across the shortest distance. A short
transfer reduces the potential for injury.
• Make sure that the client’s stronger leg, if there is one, is
nearest the chair to which the client is transferring. This
action ensures safety.
• Stand on the side of the bed to which the client will be mov-
ing. This position helps the nurse assist the client.
• Explain to the client what will be done, step by step, and sol-
FIGURE 23-25 A hydraulic mechanical lift is used to raise and icit the client’s help as much as possible. These actions inform
transfer an obese or helpless client to some other location and the client, encourage self-help, and reduce the workload.
return the client to bed.
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B OX 2 3 - 2 Levels of Functional Status Client and Family Teaching 23-1

0 ⫽ Completely independent Promoting Activity and Mobility
1 ⫽ Requires the use of an assistive device The nurse teaches the client and the family as follows:
2 ⫽ Needs minimal help
● Balance periods of activity with periods of rest.
3 ⫽ Needs assistance and/or some supervision
● Become aware of the dangers of inactivity.
4 ⫽ Needs total supervision
● Allow adequate time for performing activities.
5 ⫽ Needs total assistance or unable to assist
● Join a club that involves social activities.
(Carpenito-Moyet, 2005) ● Develop hobbies or recreational interests.
● Become a volunteer at the hospital, your church, or a
➧ Stop, Think, and Respond Box 23-3 municipal group.
● Join a local group—a coffee club, a needlework group,
List the various devices for transferring clients in a se- football friends, or bingo or card players.
quence from the one that requires the least work on the ● Remove objects that might pose safety hazards, such as
part of the nurse to the one that may require the most. throw rugs or electrical cords. Make sure chair legs are not
in the way. Promptly mop up any water spilled on the floor.
● Rent or purchase hospital equipment from a medical sup-
NURSING IMPLICATIONS ply company.
● Investigate the loan of equipment for homebound
During the initial and subsequent client assessments, the terminal clients from national organizations such as the
nurse determines the client’s level of dependence on nurs- American Cancer Society.
ing assistance. One scale for quantifying the client’s status ● Ask about community services that encourage independent
is shown in Box 23-2. The nurse selects positioning, trans- living, such as homemaker services, trained dogs, Meals on
fer, and protective devices according to whether the client is Wheels, social services, and church organizations.
independent or requires partial or total assistance.
Various nursing diagnoses may apply to inactive clients:
• Impaired Physical Mobility the nursing diagnosis of Risk for Disuse Syndrome. The
• Risk for Injury NANDA-I taxonomy (2012, p. 222) describes this diagnostic
• Risk for Disuse Syndrome category as a state in which a person is “at risk for deterioration
• Risk for Perioperative Positioning Injury of body systems as the result of prescribed or unavoidable
• Impaired Transfer Ability musculoskeletal inactivity.”
• Impaired Bed Mobility While providing nursing care, there may be opportuni-
• Risk for Impaired Skin Integrity ties to teach clients and their caregivers about techniques
Nursing Care Plan 23-1 illustrates how nurses apply the that promote activity or reduce the potential for complica-
steps in the nursing process when caring for a client with tions from inactivity. See Client and Family Teaching 23-1.
N U R S I N G C A R E P L A N 2 3 - 1 Risk for Disuse Syndrome

Assessment • Check the Homans’ sign.
• Assess the client’s independent movement and activity status. • Determine if there is a potential for infection of any type such
• Inspect the integrity of the skin. as an indwelling urinary or venous catheter, artificial airway,
• Inquire as to the client’s bowel elimination pattern and charac- wound, etc.
teristics of stool. • Observe if the client has sufficient muscle strength and coordi-
• Observe the client’s depth of respirations and the ability to nation to protect himself or herself from a potential injury.
raise pulmonary secretions. • Assess if there is any impairment of vision, hearing, and tactile
• Check skin color, capillary refill of nail beds, and urinary sensation.
output for evidence of circulatory perfusion. • Note the client’s mental status for signs of dementia, depres-
• Palpate distal peripheral pulses for rate and quality. sion, or apathy.
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NURSING CARE PLAN 23-1 Risk for Disuse Syndrome ( c o n ti n u e d )
Nursing Diagnosis. Risk for disuse syndrome (A syndrome diagnosis contains its etiology in the diagnosis; consequently, when
a syndrome diagnosis is made, it is identified in a one-part statement [Carpenito-Moyet, 2010, p. 20]).
Expected Outcome. The client will have no evidence of complications associated with disuse as evidenced by intact skin/tis-
sue integrity; full range of joint motion; clear lung sounds; capillary refill in less than 3 seconds; strong peripheral pulses; negative
Homans’ sign; regular bowel movements of soft stool; urinary output greater than 1,500 mL/day throughout length of care.
Reposition the client every 2 hours around the clock. Position changes relieve pressure and maintain sufficient capil-
lary circulation to ensure cellular and tissue integrity.
Provide clean, dry, and wrinkle-free bedding at all times. Clean dry linen prevents the maceration of skin from prolonged
contact with moisture. Keeping the linen wrinkle-free pre-
vents compromised circulation from increased pressure per
square inch (psi) of skin.
Use and check incontinence pads on bed every 2 hr; change Incontinence pads wick moisture away from the client and
immediately when soiled. keep the bed linen dry. Changing soiled incontinence pads
prevents skin maceration from contact with moisture and
waste products of elimination.
Assist the client to the bedside commode every 4 hr when Transferring from bed to a commode promotes use of the
awake. musculoskeletal system, increases circulation and breathing,
and relieves pressure on skin from lying positions in bed. Use
of the commode promotes continence and dignity.
Use a foam mattress on the bed. Foam acts like a layer of subcutaneous tissue and redistributes
pressure over a greater area, reducing the potential for skin
breakdown.
Use trochanter rolls for supine positioning. Trochanter rolls prevent external rotation of the hips and legs.
Maintaining a neutral position facilitates the potential for
ambulation and independence.
Apply a footboard to the bed or foot splints to both legs. These devices prevent foot drop and help to ensure the poten-
tial for normal ambulation.
Encourage active exercise with a bed trapeze and participa- Activity reduces the potential for complications associated with
tion in activities of daily living such as assisting with bathing, disuse.
grooming, oral hygiene, and eating.
Vary the daily routine when possible. Variety in the routine stimulates the mind and cognitive processes.
Include the client in planning the daily routine. Giving the client a locus of control maintains dignity and self-
esteem.
Teach the family how to turn and position the client. Involving the client’s family provides a sense of personal satis-
faction for being involved in the care of a loved one. Teaching
helps to prepare them to assist the client when eventually
discharged or transferred to another level of care.

• The client’s skin is pink, dry, and intact in all areas. • The capillary refill in nail beds of great toes is 2 to 3 seconds.
• The client has full range of motion in all joints. • The client has a daily bowel movement without straining.
• The client’s lungs are clear to auscultation anteriorly, posteri- • The client’s urine is clear yellow with a daily volume between
orly, and laterally. 2,000 and 2,200 mL.
• The pedal pulses are present and strong bilaterally. • No foot drop or external rotation of hips and legs is noted when
• The Homans’ sign is negative bilaterally when the feet are footboard and trochanter rolls are in use.
dorsiflexed.
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CRITICAL THINKING EXERCISES 2. Which of the following body positions is best for the
nurse to use to promote drainage from an abdominal
1. You observe a coworker using incorrect body mechanics
wound?
while giving care to a client. How would you approach
1. Lithotomy position
this coworker? What suggestions would you give?
2. Fowler’s position
2. List nursing activities that predispose one to work-
3. Supine position
related injuries. How can the nurse reduce the risk for
4. Trendelenburg position
injury during each?
3. Before turning a postoperative client from a supine to
3. What precautions would you advocate for reposition-
a lateral position, which nursing instruction is most
ing or moving a bariatric client, one who is defined
appropriate?
by the American Obesity Association (2005) as
1. “Hold your breath as you are turning.”
severely overweight with a body mass index (BMI) of
2. “Bend your knee as far as possible over the other.”
30 to 39.9 or morbidly obese with a BMI over 40?
3. “Curl up in a ball before I help you turn.”
4. What factors pose unique challenges in positioning
4. “Let me roll you as if you were a log.”
and moving geriatric clients?
4. What is the purpose for using a trochanter roll when
positioning a client?
1. Preventing hip adduction
NCLEX-STYLE REVIEW QUESTIONS 2. Preventing hip abduction
1. Which client position is most correct when a nurse 3. Preventing hip flexion
assists with a diagnostic examination involving the 4. Preventing hip rotation
lower gastrointestinal tract, such as a sigmoidoscopy? 5. Which of the following is most helpful for facilitating
1. Lithotomy position a client’s independent movement?
2. Sims’ position 1. A bed cradle
3. Supine position 2. A bed board
4. Fowler’s position 3. An overbed trapeze
4. Lower side rails
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SKILL 23-1 Turning and Moving a Client
ASSESSMENT
Assess for risk factors that may contribute to inactivity. Indicates a need to reposition more frequently.
Determine the time of the last position change. Ensures following the plan for care.
Assess the physical, mental, and emotional ability to assist in Determines if additional help or assistive devices are needed.
turning, positioning, or moving.
Inspect for drainage tubes and equipment. Ensures that they will not be displaced or cause discomfort to the
client.
PLANNING
Explain the procedure to the client. Increases cooperation and decreases anxiety.
Remove all pillows and current positioning devices, such as Reduces interference during repositioning.
trochanter rolls.
Raise the bed to elbow height, which is a suitable working height. Prevents back strain by maintaining the center of gravity.
Secure two or three additional caregivers, positioning and moving Ensures safety.
devices (eg, roller sheets, repositioning sling, mechanical lift), or
both as needed.
Close the door or draw the bedside curtain. Demonstrates respect for privacy.
IMPLEMENTATION
Turning the Client from Supine to Lateral or Prone Position
Wash hands or perform an alcohol-based hand rub when Reduces the transmission of microorganisms.
appropriate (see Chap. 10).
Help or have the client slide to one side of the bed. Provides room when repositioning.
Raise the side rail. Ensures safety.
Flex the client’s knee over the other with the arms across the Aids in turning and protects the client’s arms.
chest.
Spread your feet, flex your knees, and place one foot behind the Provides a broad base of support.
other.
Place one hand on the client’s shoulder and one on the hip. Facilitates turning.
Roll the client toward the side rail (Fig. A). Reduces effort.
Directing the client to turn.
(continued)
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Turning and Moving a Client (continued)
Replace pillows behind the back, between the legs, and under the Aids in maintaining position and provides comfort.
upper arm (Fig. B).
Supporting arms and legs with pillows.
Raise the side rails and lower the height of the bed. Ensures safety.
For a Prone Position
Begin as described earlier for the lateral position. Follows the same principles.
Have the client turn his or her head opposite to the direction for Prevents pressure on the face and arms during and after
rolling and leave the arms extended at each side (Fig. C). repositioning.
Preparing for prone positioning.
(continued)
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Shift your hands from the posterior of the shoulder and hip to the Controls the speed with which the client is repositioned.
anterior as the client rolls independently onto his or her abdo-
men (Fig. D).
Bracing the client during turning.
Center the client in bed. Prevents pressure on arms.

Arrange pillows. Provides for comfort and support.
Raise the side rails and lower the height of the bed. Ensures safety.
Moving the Mobile Client up in Bed (One-Nurse and Client Technique)
Remove the pillow from under the client’s head. Prevents strain on the neck and head during moving.
Place the pillow against the headboard. Cushions the head from contact with the headboard.
Raise the bed to elbow height. Reduces back strain.
Place a roller/slider sheet beneath the buttocks to facilitate move- Promotes gliding and reduces friction.
ment if needed if the client is weak or unable to fully assist.
Instruct the client to bend both knees and grasp a trapeze if one Aids in assisting by using the stronger muscles of the arms and
is available. legs.
Ask the client to push down with his or her feet, causing the legs Creates momentum to facilitate moving.
to straighten (Fig. E). Repeat again if necessary.
Moving up in bed.
(continued)
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Rearrange pillows and remove the roller sheet unless it will be Restores comfort.
needed again in the near future.
Place the client in a slight Trendelenburg position if sliding Gravity keeps the client from sliding downward.
downward is a persistent problem.
Two-Nurse and Roller Sheet Technique
Protect the headboard with a pillow. Ensures client safety.
Raise the bed to elbow height. Reduces back strain.
Place a roller/slider sheet beneath the client’s shoulders and Facilitates gliding the client rather than lifting.
buttocks.
Stand facing each other on opposite sides of the bed between Aids in coordinating movement between nurses.
the client’s hips and shoulders.
Roll the slider sheet to the sides of the client. A palms-up grip provides more strength by keeping the elbows
close to the body, thus reducing the workload.
Grasp the rolled sheet with the palms up and the knuckles in A palms-up grip provides more strength by keeping the elbows
contact with the bed sheet. close to the body, thus reducing the workload. Keeping the
knuckles in contact with the bed sheet ensures a sliding, rather
than a lifting, motion.
Bend hips and knees; spread feet. Follows principles of good body mechanics and provides momen-
tum to facilitate sliding.
Slide the client up on reaching a previously agreed signal (Fig. F), Promotes coordination of effort.
such as the count of three.
Moving the client up in bed with a rolled sheet and the assistance of two people.
Avoid shrugging the shoulders while moving the client. Shrugging the shoulders indicates that the client is being lifted.
Rearrange pillows; remove the roller sheet unless it will be Restores comfort.
needed again in the near future.
Place the client in a slight Trendelenburg position if sliding Gravity keeps the client from sliding downward.
downward is a persistent problem.
Wash hands or use an alcohol-based hand rub when appropriate Reduces the transmission of microorganisms.
(see Chap. 10).
Evaluation
• Movement is achieved.
• Client is comfortable.
• Pressure is relieved.
• Joints and limbs are supported. (continued)
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Document
• Frequency of turning and moving
• Positions used
• Use of positioning devices
• Assistance required
• Client’s response
Date and Time Position changed q 2 h from supine to R and L lateral positions with assistance of client. Pillows used to
support limbs and maintain positions. Foot board in place. No shortness of breath noted. No evidence of
discomfort during repositioning. __________________________________________________ SIGNATURE/TITLE
SKILL 23-2 Transferring Clients
ASSESSMENT
Check the Kardex, nursing care plan, and medical orders for activ- Complies with the plan for care.
ity level.
Assess the client’s strength and mobility, as well as his or her Determines the need for additional personnel or a mechanical
mental and emotional status. lifting device.
PLANNING
Consult with the client on the preferred time for getting out of bed. Helps client participate in decision making.
Locate a straight-backed chair, wheelchair, or stretcher to which Facilitates efficient time management.
the client will be transferred.
Arrange the chair or stretcher next to or close to the bed on the Ensures safety.
client’s stronger side, if there is one.
Lock the wheels of the bed, wheelchair, or stretcher. Prevents rolling and ensures safety.
Explain how the transfer will be accomplished. Reduces anxiety and promotes cooperation.
From Bed to Chair
Wash hands or perform an alcohol-based hand rub when appropri- Reduces the transmission of microorganisms.
ate (see Chap. 10).
Assist the client to a sitting position on the side of the bed. Reduces dizziness; enables the client to stand.
Help the client don a bathrobe and nonskid slippers. Ensures warmth, modesty, and safety.
Place the chair parallel to the bed on the client’s stronger side; Provides for easy access.
raise the footrests if using a wheelchair.
Apply a transfer belt or other assistive device, if needed (Fig. A). Reduces the risk for falling.
Applying a transfer belt.
A
(continued)
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Transferring Clients (continued)
Grasp the transfer belt or reach under the client’s arms. Helps support the upper body.
Instruct the client to grasp your shoulders. Gives the client leverage for rising.
Bend the hips and knees; brace the client’s knees (Fig. B). Stabilizes the client and follows principles of good body mechanics.
Bracing the client’s knees.
Rock the client to a standing position at an agreed signal while Provides momentum and reduces the need to lift the client.
encouraging the client to straighten his or her knees and hips.
Pivot the client with his or her back toward the chair. Positions the client for sitting.
Tell the client to step back until he or she feels the chair at the Places the client in close proximity with the chair.
back of the legs.
Instruct the client to grasp the arms of the chair while you stabilize Promotes safety.
his or her knees and lower the client into the chair (Fig. C).
Backing into a wheelchair.
Support the feet on the footrests. Facilitates good posture.

Using a Transfer Board
Remove an arm from the wheelchair. Reduces interference with transfer.
Lock the brakes on the bed and wheelchair. Prevents rolling and ensures safety.
Slide the client to the edge of the bed. Maintains shortest distance for transfer.
(continued)
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Angle the transfer board from the client’s buttocks and hips down Places the board where there is maximum weight.
toward the seat of the chair.
Position the transfer board beneath the client. Supports upper body.
Support and brace the client’s knee with your knees while main- Prevents injury.
taining proper body mechanics.
Slide the client down the transfer board into the seat of the chair Reduces the need to lift the client.
at an agreed-on signal (Fig. D).
Using a transfer board. (Photo by B. Proud.)
Wash hands or perform an alcohol-based hand rub if appropriate Reduces the transmission of microorganisms.
(see Chap. 10).
Using a Mechanical Lift
(see Chap. 10).
Raise the bed to a height that places the client near the nurse’s Reduces the risk for back injury.
center of gravity.
Lock the brakes on the bed. Prevents the bed from moving and causing injury.
Place the canvas sling under the client from the shoulders to mid- Positions the sling where it will support the greatest mass of the
thigh (Fig. E). client.
Applying the lift’s sling.
Move the lift device on the same side of the bed as the chair or Facilitates safety when the client and equipment are within close
stretcher to which the client will be transferred. proximity.
Position the boom on the lift over the client’s torso. Enables the attachment of lifting chains to the canvas sling.
Lock the wheels on the lift. Stabilizes the lift in place.
(continued)
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Attach the hooks on the lifting chain or straps to the holes in the Connects the lift to the client.
canvas sling (Fig. F).
Positioning the lift and the client.
Position the client’s arms across his or her chest. Protects the client’s arms and hands from being injured.
Pump the jack handle to elevate the client to about 6 inches above Aids in assessing whether the client is properly and safely within
the mattress (Fig. G). the sling.
Raising the client.
Unlock the wheels on the lift and move the lifted client directly Relocates the client to the desired location.
over the chair or stretcher.
Relock the wheels of the lift. Ensures the client’s safety.
Release the jack handle slowly. Lowers the client from the suspended position.
Remove the lifting chains, but leave the canvas sling in place Facilitates returning the client to bed.
beneath the client.
(see Chap. 10).
Evaluation
• Client is relocated.
• No injury occurs to client or personnel.
Document
• Method of transfer
Date and Time Transferred from bed to wheelchair by standing and pivoting with weight bearing on right leg. Transient
pain rated at 1 on a scale of 0 to 10 experienced in left hip during transfer. Declined offer for pain medica-
tion. Up in chair approximately 1 hour _____________________________________________ SIGNATURE/TITLE
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24 Therapeutic Exercise
active exercise
aerobic exercise On completion of this chapter, the reader should be able to:
ambulatory electrocardiogram 1. List at least five benefits of regular exercise.
ankylosis 2. Define fitness.
body composition 3. Identify seven factors that interfere with fitness.
cardiac ischemia 4. Name at least two methods of fitness testing.
continuous passive motion machine 5. Describe how to calculate a person’s target heart rate.
exercise 6. Define metabolic energy equivalent.
fitness 7. Differentiate fitness exercise from therapeutic exercise.
fitness exercise 8. Differentiate isotonic exercise from isometric exercise.
isometric exercise 9. Give at least one example of isotonic and isometric exercises.
isotonic exercise 10. Differentiate between active exercise and passive exercise.
maximum heart rate 11. Discuss how and why range-of-motion exercises are performed.
metabolic energy equivalent 12. Provide at least two suggestions for helping older adults
passive exercise become or stay physically active.
range-of-motion exercises
recovery index
step test
E
xercise (purposeful physical activity) is beneficial to people of all
stress electrocardiogram
age groups (Box 24-1), and the health risks of a sedentary lifestyle
submaximal fitness test
target heart rate are well documented. This chapter addresses techniques for improv-
therapeutic exercise ing health and maintaining or restoring muscle and joint function by
walk-a-mile test promoting exercise. Because exercise must be individualized, nurses are
responsible for assessing each person’s fitness level before initiating an
exercise program with a client.
FITNESS ASSESSMENT
Fitness means the capacity to exercise. Factors such as a sedentary life-

style, health problems, compromised muscle and skeletal function, obes-
ity, advanced age, smoking, and high blood pressure can impair a client’s
fitness and stamina. They could even result in injury during exercise.
Therefore, before a client begins an exercise program, assessment of his
or her fitness level is necessary. Some assessment techniques include
measuring body composition, evaluating trends in vital signs, and per-
forming fitness tests.
Body Composition
Body composition is the amount of body tissue that is lean versus the
amount that is fat. Determining factors include anthropometric meas-
urements such as height, weight, body-mass index, skin-fold thickness,
and mid-arm muscle circumference (see Chap. 13). Inactivity without
reduced food intake tends to promote obesity. Overweight or obese peo-
ple are less fit than their leaner counterparts and need to proceed gradu-
ally when initiating an exercise program.
519
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B OX 2 4 - 1 Benefits of Physical Exercise

• Improved cardiopulmonary function
• Reduced blood pressure
• Increased muscle tone and strength
• Greater physical endurance
• Increased lean mass and weight loss
• Reduced blood glucose level
• Decreased low-density blood lipids
• Improved physical appearance
• Increased bone density
• Regularity of bowel elimination
• Promotion of sleep
• Reduced tension and depression
Vital Signs
Vital signs—temperature, pulse rate, respiratory rate, and
blood pressure—reflect a person’s physical status (see
Chap. 12). Elevated pulse rate, respiratory rate, and blood
pressure while resting are signs that the person may have
life-threatening cardiovascular symptoms during exercise.
After a period of modified exercise, vital signs may decrease,
thus reducing the potential for heart-related complications.
Fitness Tests
Fitness tests provide an objective measure of a person’s cur-
rent fitness level and his or her potential for safe exercise.
They also help to establish safe parameters for the level and
duration of exercise. Two methods of fitness testing are a
stress electrocardiogram (ECG) and an ambulatory ECG. FIGURE 24-1 A stress electrocardiogram. (Image© Texas Heart
Institute, www.texasheart.org.)
Another is a submaximal fitness test, which is an exercise
test that does not stress a person to exhaustion. Examples
of submaximal fitness tests include a step test and a walk-a- Ambulatory electrocardiography helps to assess the
mile test. Because submaximal tests are less demanding, the heart’s response to normal activity rather than activity
validity of their results is less reliable than results obtained imposed during a stress ECG. It also helps to evaluate how
through ECG testing. a person is responding to cardiac rehabilitation and medical
Stress Electrocardiogram therapy.
A stress electrocadiogram tests electrical conduction through The Holter monitor, which is connected to chest leads,
the heart during maximal activity and is performed in an acute is attached to a belt or shoulder strap or carried in a pocket
care facility or an outpatient clinic (Fig. 24-1). The client first (Fig. 24-2). During ambulatory electrocardiography, the cli-
walks slowly on a flat treadmill. As the test progresses, the ent should not shower or swim; a sponge bath is permitted as
speed and incline of the treadmill are increased. The exam- long as the monitor does not get wet. The client also should
iner notes the client’s heart rate and rhythm, blood pressure, avoid magnets, metal detectors, electric blankets, and high-
breathing, and symptoms such as dizziness and chest pain. A voltage areas that may cause artifacts on the recordings that
pulse oximeter (see Chap. 21) is used to measure peripheral interfere with an accurate interpretation of the test results.
oxygenation. The examiner stops the test if the client develops The client keeps a diary of the time and type of activities
an abnormal heart rhythm, cardiac ischemia (impaired blood performed, when he or she took medications, and when he
flow to the heart), elevated blood pressure, or exhaustion. or she experienced symptoms, if any. After the test period,
the client returns the monitor, and then a computer and
Ambulatory Electrocardiogram the physician check the electrically recorded information.
An ambulatory electrocardiogram is a continuous recording The physician compares the client’s diary with the ECG. The
of heart rate and rhythm during normal activity. It requires the assessment results help to determine whether oxygenation to
client to wear a device called a Holter monitor for 24 hours. the heart muscle was temporarily impaired during an activ-
This less taxing version of a stress ECG is used when the per- ity or if an abnormal heart rhythm developed. Either finding
son has had prior cardiac-related symptoms, such as chest pain, indicates that exercise should begin at a very low intensity
or has major health risks that contraindicate a stress ECG. and for a short duration.
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CHAPTER 24 Therapeutic Exercise 521
TABLE 24-1 Cardiovascular Endurance Fitness

Levels
SCORE FITNESS CLASSIFICATION
≥90 Excellent
89–80 Good
79–65 Average
64–56 Below average
≤55 Poor
From Fitness testing; Harvard step test. Accessed April 27, 2010, from http://
www.topendsports.com/testing/tests/step-harvard.htm.
Walk-a-Mile Test
The walk-a-mile test, devised by the American College of
Sports Medicine (2009), measures the time it takes a person
to walk 1 mile. The person is instructed to walk 1 mile on
a flat surface as fast as possible. The examiner calculates
the time from start to finish and interprets results using the
guidelines in Table 24-2.
EXERCISE PRESCRIPTIONS
The prescription for an exercise program involves determin-
ing the person’s target heart rate and the metabolic energy
equivalents (METs) of particular activities based on the per-
FIGURE 24-2 Ambulatory electrocardiography.
son’s fitness level.
Target Heart Rate

Step Test Target heart rate means the goal for heart rate during
A step test is a submaximal fitness test involving a timed step- exercise. It is determined by first calculating the person’s
ping activity. Several variations include the Harvard Step Test, maximum heart rate (the highest limit for heart rate during
the Queens College Step Test, and the Chester Step Test. A exercise). Maximum heart rate is calculated by subtracting
person undergoing this type of fitness analysis will step up and a person’s age from 220. Thus, a 20-year-old has a maxi-
down on a platform of a prescribed height (20 in. for men, 16 mum heart rate of 200 beats per minute (bpm), whereas a 50
in. for women) for 3 to 5 minutes at a rate of at least 76 steps year old has a maximum heart rate of 170 bpm. The target
per minute. A step up or down is considered one step. The heart rate for moderate intensity is 50% to 70% of the maxi-
time is shortened when the client can no longer sustain the pre- mum heart rate (Centers for Disease Control and Prevention,
scribed rate or develops discomfort. The examiner uses a met- 2010). Beginners should not exceed 50%, intermediates can
ronome and a stopwatch to keep track of the rate and the time. exercise up to 70%, and competitive athletes may tolerate
Examiners calculate the client’s recovery index (a 70% to 85% of their maximum heart rate during vigorous
guide for determining a person’s fitness level) by taking a 30- intensive physical activity.
second pulse rate at 1, 2, and 3 minutes after the test and
using the following formula: ➧ Stop, Think, and Respond Box 24-1
(100 × test duration in seconds) What is the maximum heart rate and minimum tar-
Recovery index =
2 × total of the 30-second get heart rate for a person who is 25 years old and a
pulse assessments competitive athlete who is 32 years old?
The examiner compares results with standardized fit-

ness levels (Table 24-1). A fit person has a smaller decline TABLE 24-2 Evaluation Criteria for the
in heart rate at each assessment. Another fitness indicator Walk-a-Mile Test
is how close the pulse rate at the end of recovery compares PERFORMANCE TIME PERFORMANCE TIME
with the pretest pulse rate. The more similar the pretest and FOR MEN (MIN) FOR WOMEN (min) FITNESS LEVEL*
posttest pulse rates, the more fit is the person. ≥15:3 ≥17:3 Poor
The step test must be used with caution. Personnel cer- 14:01–14:42 15:07–16:06 Average
tified in cardiopulmonary resuscitation and use of an auto- 12:54–14:00 14:12–15:06 Good
<12:54 <14:12 Excellent
matic cardiac defibrillator (see Chap. 37) should be available
to assist if there is an adverse cardiac event. *Based on adults age 40–49.
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TABLE 24-3 Levels of Physical Activity

METABOLIC ENERGY
EQUIVALENT (MET) EXAMPLES OF ACTIVITIES
1 Sewing
Watching television
Dressing
1–2 Walking 1 mph on level ground
Bowling
2–3 Golfing with a cart
Mowing lawn with a power mower
3–4 Playing badminton (doubles)
Raking leaves
4–5 Slow swimming
Lifting 50 lb
5–6 Square dancing
FIGURE 24-3 Stationary cycling.
Shoveling snow
6–7 Water skiing
Moving heavy furniture tory conditioning and increase lean muscle mass, a person
7–8 Playing basketball should perform isotonic exercise at his or her target heart rate.
Playing noncompetitive handball
8–9 Cross-country skiing
Playing contact football Gerontologic Considerations
≥10 Running 6 mph or faster
■ Older adults need to eliminate their intake of caffeinated
and alcoholic beverages before and during physical activity
Exercising at the target rate for 15 minutes (excluding to avoid depleting fluid volume. Water is the preferred drink
the warm-up and cool-down periods) three or more times for fluid replacement.
per week strengthens the heart muscle and promotes the use ■ Encourage families and caregivers of older adults with
of fat reserves for energy. Exercising beyond the target heart cognitive impairment to help older persons participate in
rate reduces endurance by increasing fatigue. physical activities such as walking and ball throwing. If
the older person has difficulty with balance, exercises may
Metabolic Energy Equivalent be done while sitting or lying down. Active range-of-motion
Because fitness levels vary, exercises also are prescribed (ROM) exercises should be scheduled daily and may be
divided into short sessions. If the older adult cannot partici-
according to their metabolic energy equivalent (MET; the
pate actively in an exercise program, the caregivers can
measure of energy and oxygen consumption during exercise). perform passive ROM exercises, at least daily, to prevent
This is the prescribed amount that a person’s cardiovascular muscle atrophy and disuse syndrome.
system can safely support. Low-to-vigorous physical activi- ■ Many shopping malls permit, and even encourage, people
ties and their approximate METs are listed in Table 24-3. to walk through the mall before stores open for business.
■ Swimming or exercising in water puts less stress on
joints and is beneficial for older adults.
TYPES OF EXERCISE ■ Many physically challenging sports, such as bowling,
golfing, walking in marathons, and weight lifting, have com-
Exercise is performed to promote fitness or to achieve thera- petition categories for older adults.
■ Precautions, such as wearing safe shoes with nonskid
peutic outcomes. The two major types of exercise are fitness
soles, are necessary to prevent falls when older adults
exercise and therapeutic exercise.
exercise. Complications from falls contribute to morbidity
and mortality among older people.
Fitness Exercise
Fitness exercise means physical activity performed by
healthy adults. Fitness exercise develops and maintains car- Isometric exercise consists of stationary exercises gen-
diorespiratory function, muscular strength, and endurance erally performed against a resistive force. Examples include
(Fig. 24-3). The two categories of fitness exercise are isot- body building, weight lifting, and less intense activities such
onic and isometric. as simply contracting and relaxing muscle groups while sit-
Isotonic exercise is activity that involves movement ting or standing. Isometric exercises increase muscle mass
and work. The prime example is aerobic exercise, which and strength, and tone and define muscle groups. Although
involves rhythmically moving all parts of the body at a mod- they improve blood circulation, they do not promote cardi-
erate to slow speed without hindering the ability to breathe. orespiratory function. In fact, strenuous isometric exercises
In other words, the person can talk comfortably if the exercise elevate blood pressure temporarily (see Client and Family
is within his or her level of fitness. To promote cardiorespira- Teaching 24-1).
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Client and Family Teaching 24-1 Active therapeutic exercise often is limited to a particu-
A Safe Exercise Program lar part of the body that is in a weakened condition. It is
assumed that clients will use their unaffected muscle groups
The nurse teaches the client and the family as follows: while performing activities of daily living such as bathing
● Seek a pre-exercise fitness evaluation from a health care and dressing.
provider or a certified sports trainer.
● Determine the target heart rate according to fitness level. Passive Exercise
● Determine the appropriate level of METs. Passive exercise is therapeutic activity that the client per-
● Choose a form of exercise that seems pleasurable and forms with assistance and is provided when a client cannot
involves as many muscle groups as possible. move one or more parts of the body. For example, for cli-
● Plan at least 20-minute exercise periods at a convenient ents who are comatose or paralyzed from a stroke or spinal
time 3–5 days each week (American College of Sports injury, nurses perform exercises that maintain muscle tone
Medicine, 2009). and flexible joints. One form of frequently provided passive
● Build up to 30 minutes or more of moderate-intensity
therapeutic exercise is ROM exercise. Another form is deliv-
physical activity on most (preferably all) days of the week
ered with a continuous passive motion (CPM) machine.
(Thompson et al., 2003).
● Exercise with a partner for safety and motivation.
Range-of-Motion Exercises
● Avoid exercising in extreme weather conditions (high
humidity, smog).
Range-of-motion exercises are therapeutic activities that
● Dress in layers according to the temperature and weather move the joints. They are performed for the following reasons:
conditions. • To assess joint flexibility before initiating an exercise pro-
● Wear supportive shoes.
gram
● Wear reflective clothing after dark.
• To maintain joint mobility and flexibility in inactive clients
● Walk or jog against traffic; cycle in the same direction as
traffic.
• To prevent ankylosis (the permanent loss of joint move-
● Eat complex carbohydrates (pasta, rice, cooked cereal) ment)
rather than fasting or eating simple sugars (cookies, • To stretch joints before performing more strenuous activities
chocolate, sweetened drinks) before exercising. • To evaluate the client’s response to a therapeutic exercise
● Avoid drinking alcohol, which dilates the blood vessels, program
promotes heat loss, and interferes with good judgment.
● Warm up for 5 minutes by stretching muscle groups or
During ROM exercises, the client moves or is assisted
doing light calisthenics. to move joints in the positions that the joint normally per-
● Measure the heart rate two or three times while exercising. mits (Table 24-4). Whenever possible, the client actively
● Slow down if the heart rate exceeds the pre-established
target. TABLE 24-4 Joint Positions
● Try to sustain the target heart rate for at least 12 to
15 minutes. POSITION DESCRIPTION
● Never stop exercising abruptly. Flexion Bending so as to decrease the angle
● Cool down for at least 5 minutes in a manner similar to between two adjoining bones
the warm-up. Extension Straightening so as to increase the angle
between two adjoining bones up to 180
degrees
Hyperextension Increasing the angle between two adjoining
Therapeutic Exercise bones more than 180 degrees
Therapeutic exercise is activity performed by people with Abduction Moving away from the midline
health risks or those being treated for an existing health Adduction Moving toward the midline
problem. Clients perform therapeutic exercise to prevent Rotation Turning from side to side as in an arc
health-related complications or to restore lost functions (see External rotation Turning outward, away from the midline of
the body
Performing Leg Exercises in Chap. 27 and Strengthening
Internal rotation Turning inward, toward the midline of the
Pelvic Floor Muscles in Chap. 30). Therapeutic exercise body
may be isotonic or isometric; isotonic exercises are per- Circumduction Forming a circle
formed actively or passively. Pronation Turning downward
Supination Turning upward
Active Exercise Plantar flexion Bending toward the sole of the foot
Active exercise is therapeutic activity that the client per- Dorsiflexion Bending the foot toward the dorsum or
forms independently after proper instruction. For example, anterior side
clients who have undergone a mastectomy learn to exercise Inversion Turning the sole of the foot toward the
midline
the arm on the surgical side by combing their hair, squeezing Eversion Turning the sole of the foot away from the
a soft ball, finger-climbing the vertical surface of a wall, and midline
swinging a rope attached to a doorknob.
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Rationales
Performing Range-of-Motion Exercises
• Use good body mechanics (see Chap. 23). Doing so conserves • Watch for nonverbal communication. Nonverbal signs may
energy and avoids muscle strain and injury. indicate the client’s response.
• Remove pillows and other positioning devices. Such items can • Avoid exercising a painful joint. Doing so can contribute to
interfere with the exercises. injury.
• Position the client to facilitate movement of the joint through • Stop if spasticity develops, as manifested by a sudden, continu-
all its usual positions. This positioning makes it easier to ous muscle contraction. Taking a break gives muscles time to
perform a comprehensive exercise program. relax and recover.
• Follow a systematic, repetitive pattern—such as beginning at • Apply gentle pressure to the muscle or move the spastic limb
the head and moving down. A routine prevents overlooking a more slowly. These actions relieve spasticity.
joint. • Expect the client’s respiratory and heart rates to increase
• Perform similar movements with each extremity. Doing so during exercise but to return to a resting rate later. This is a
exercises the joints bilaterally. normal cardiopulmonary response to activity.
• Support the joint being exercised. Support reduces discomfort. • Teach the family to perform ROM exercises. A regular exercise
• Move each joint until there is resistance but not pain. This program improves the potential for regaining function.
method exercises each joint to its point of limitation.
exercises as many joints as possible while the nurse assists with

those that are compromised (see Nursing Guidelines 24-1).
Nurses perform ROM exercises whenever they care for
inactive clients (Skill 24-1).

Why would a nurse promote active ROM exercises
in the upper body for a client who is paralyzed below
the waist after a motor vehicle collision?
Continuous Passive Motion Machine

A continuous passive motion machine is an electrical FIGURE 24-4 A continuous passive motion machine.
device used as a supplement or substitute for manual ROM
exercise (Fig. 24-4). A machine-assisted ROM sometimes
TABLE 24-5 Physical Activity Guidelines for Americans

GOAL RECOMMENDATION STRATEGIES EXAMPLES
Increase aerobic Do at least 2 1/2 hours of Build up time slowly Moderate (can talk, but not sing during per-
physical activities moderate level activities Do at least 10 minutes at a time formance):
or 1 1/4 hours of vigor- Combine moderate and vigorous Walking briskly
ous activities per week activities Ballroom and line dancing
Biking on level ground or with few hills
Increase muscle Do at least 2 days/week Include all the major muscle General gardening (raking, trimming shrubs)
strengthening groups (legs, hips, back, chest, Sports where you catch and throw (base-
activities stomach, shoulders, and arms) ball, softball, volleyball)
Repeat 8–12 times for each mus- Water aerobics
cle group per session Vigorous (can say a few words without stop-
ping for a breath)
Jogging
Fast or aerobic dancing
Biking faster than 10 mph
Heavy gardening (digging, hoeing)
Jumping rope
Swimming fast or swimming laps
Sports with a lot of running (basket-ball,
soccer, hockey)
From US Department of Health and Human Services. (2008). Be active your way: A fact sheet for adults. Accessed
April 28, 2010, from http://www.health.gov/paguidelines/factSheetAdults.aspx.
LWBK1004-C24_p519-536.indd 524 04/02/12 3:10 PM

is preferred during the rehabilitation of clients who have client’s extremity in the machine and programs the speed
experienced burns or have had knee or hip replacement and the degree of desired joint flexion according to the phy-
surgery because the machine precisely controls the degree sician’s exercise prescription (Skill 24-2).
of joint movement and can increase it in specific increments
throughout recovery. ➧ Stop, Think, and Respond Box 24-3
In addition to restoring and increasing joint ROM, the List the assessment findings that indicate a positive
movement created by the machine prevents the pooling of response to the use of a CPM machine.
venous blood, thus decreasing the risk of blood clots. Also,
it accelerates wound healing because the synovial fluid cir-
culates around the joint. NURSING IMPLICATIONS
Most machines produce 0 to 110 degrees of motion 2 to
10 times per minute. Initially, the nurse sets the machine at Few people exercise sufficiently to promote optimal
very low speeds and degrees of movement—it is common to health. With this in mind, the Department of Health and
begin with 5 or 10 degrees of flexion cycling twice a minute Human Services has established Physical Activity Guide-
for at least six times a day. The nurse increases the settings lines for Americans for improving the health of US citi-
as the client’s tolerance builds. The nurse positions the zens (Table 24-5). Nurses can set an example for others
N U R S I N G C A R E P L A N 2 4 - 1 Unilateral Neglect
Assessment • Determine whether the client omits, ignores, or favors activi-
• Observe the client’s bilateral movement or unilateral lack of ties or objects consistently on one side.
movement. • Check the client’s vision and sensation bilaterally.
• Note whether the client uses both sides of the body in an inte-
grated and coordinated manner.
Nursing Diagnosis. Unilateral Neglect related to a lack of awareness of objects in the left visual field secondary to stroke as mani-
fested by a lack of attention to food on the left side of the plate and tray, an inability to see objects placed on the left side, combing only
the right side of hair, no response to touch or pain stimuli on the left side, and an inability to differentiate between warm and cold on
the left.
Expected Outcome. The client will identify his or her own body parts on the left side, attend to his or her care, and incorporate
objects within his or her extrapersonal environment located to the client’s left side by 4/21.
Approach the client always from the right side. The client’s perception and attention are limited to the unaf-
fected side.
Place items for safety, such as the signal cord, and those for The neurologic deficit predisposes the client to ignore objects
self-care, such as a glass of water, on the client’s right side. on the affected side.
Suggest that the client turn his or her head from side to side Directing the client to scan the environment uses the visual
for a panoramic view of the environment. areas in the unaffected structures of the brain.
Show the client three objects on the right side of the visual Repetition in scanning both sides helps the client to develop
field each shift; then relocate objects to the left side and awareness skills.
encourage the client to turn his or her head and identify
where they are located.
Have the client locate and touch the left arm and other body Attending to the affected side helps to retrain the client’s brain
structures on the left side. to recognize and integrate parts of the self.
Add one self-care task at a time such as bathing the affected Practice and repetition facilitate progress in reaching goals.
arm, inserting the arm into a gown or shirt, and grasping
and exercising the affected hand with the unaffected hand
as the client’s awareness and competence develop.

• The nurse transfers the client to a room with a door on the • The client touches and moves the affected left arm with the
right side of the client to facilitate awareness. right arm.
• The client locates and identifies one of three objects such as • The client performs ROM exercises with assistance from the
pen, watch, and banana after looking at them in the right visual nurse for affected extremities.
field and then in the left. • The client continues to practice bathing and exercise.
• The client states “That’s my arm and leg” when instructed to
look to the left side of his or her body.
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in the community by improving their own physical fitness NCLEX-STYLE REVIEW QUESTIONS
and encouraging others to do so.
1. What will the nurse observe if a client performs iso-
metric exercises of the quadriceps muscles correctly?
Gerontologic Considerations 1. The client moves the toes toward and away from
the head.
■ Older adults, especially those who are disabled, need to 2. The client contracts and relaxes the muscles of the
balance periods of physical activity with periods of rest. thigh.
Shortness of breath or an increased heart rate indicates 3. The client lifts the lower leg up and down from the
that the level of activity is beyond the client’s tolerance. bed.
4. The client bends the knee and pulls the lower leg
For people with medical disorders, nurses may iden- upward.
tify one or more of the following nursing diagnoses that are 2. When the nursing team develops a plan of care for
treated with activity or an exercise regimen: a client with a stroke, which area of nursing man-
agement is most important to the client’s rehabilita-
• Impaired Physical Mobility tion?
• Risk for Disuse Syndrome 1. Regulating bowel and bladder elimination
• Unilateral Neglect 2. Dealing with problems of disturbed body image
• Risk for Delayed Surgical Recovery 3. Preventing contractures and joint deformities
• Activity Intolerance 4. Facilitating positive outcomes from grieving
Nursing Care Plan 24-1 illustrates how a nurse can 3. What nursing explanation best describes the primary
incorporate exercise into the care of a client with a stroke purpose of a CPM machine?
using the nursing diagnosis of Unilateral Neglect. The 1. A CPM machine is used to strengthen leg muscles.
NANDA-I taxonomy (2012, p. 259) defines this diagnosis 2. A CPM machine is used to relieve foot swelling.
as “inattention to one side (of the body) and overattention to 3. A CPM machine is used to reduce surgical pain.
the opposite side.” 4. A CPM machine is used to restore joint function.
4. What information is essential to document in relation
to a client’s progress in using a CPM machine? Select
CRITICAL THINKING EXERCISES all that apply.
1. Condition of the sutures around the incision
1. List at least five excuses people give for not exercis- 2. Degree of joint flexion
ing and offer counterarguments for each. 3. Amount of time the client used the machine
2. A client with paralysis of the lower extremities is 4. Characteristics of drainage from the wound
depressed and questions the purpose for performing 5. Number of cycles per minute
passive ROM exercises on the lower body. Assuming 6. Presence and quality of arterial pulses
paralysis is permanent and the client will never walk 5. When a client asks of what use a stress ECG will be,
again, how would you respond? what is the most accurate answer the nurse can give?
3. What advantages would you offer to a friend 1. A stress ECG shows how the heart performs during
who is physically inactive and could benefit from exercise.
exercise? 2. A stress ECG helps determine the client’s potential
4. What are some reasons the federal government sets target heart rate.
goals and objectives for physical activity and fitness 3. A stress ECG verifies how much exercise is needed
in its Healthy People campaigns? to improve fitness.
4. A stress ECG can predict whether the client will
have a heart attack soon.
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SKILL 24-1 Performing Range-of-Motion Exercises
ASSESSMENT
Review the medical record and nursing plan for care. Determines whether activity problems have been
identified.
Assess the client’s level of activity and joint mobility. Indicates whether, and the extent to which, joints should be
passively exercised.
Assess the client’s understanding of the hazards of inactivity Determines the type and amount of health teaching needed.
and purposes for exercise.
PLANNING
Explain the procedure for performing ROM exercises. Reduces anxiety and promotes cooperation.
Consult with the client on when ROM exercises may be best Shows respect for independent decision making.
performed.
Suggest performing ROM exercises during a time that requires Demonstrates efficient time management.
general activity, such as bathing.
Perform ROM exercises at least twice a day. Promotes recovery or maintains functional use.
Exercise each joint at least two to five times during each exer- Increases exercise benefits.
cise period.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub (see Reduces the potential for transferring microorganisms.
Chap. 10).
Help the client to a sitting or lying position. Promotes relaxation and access to the body.
Pull the privacy curtains. Demonstrates respect for modesty.
Drape the client loosely or suggest loose-fitting underwear or Avoids exposing the client.
shorts.
Begin at the head. Facilitates organization.
Support the client’s neck and bring the chin toward the chest Flexes and hyperextends the neck (Fig. A).
and then as far back in the opposite position as possible.
Neck hyperextension. Neck flexion.
Place a hand on either side of the head and move the neck from Rotates the neck (Fig. B).
side to side.
B
Neck rotation. (continued)
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Performing Range-of-Motion Exercises (continued)
Turn the head in a circular fashion. Puts the head and neck through circumduction (Fig. C).
Circumduction of the neck.
C
Support the elbow and wrist while moving the straightened arm Flexes, extends, then hyperextends the shoulder (Fig. D).
above the head and behind the body.
Flexion and extension of the shoulder.
Move the straightened arm away from the body and then Abducts and adducts the shoulder (Fig. E).
toward the midline.
E
Abduction and adduction of the shoulder. (continued)
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Bend the elbow and move the arm so that the palm is upward Produces internal and external rotation of the shoulder (Fig. F).
and then downward.
Internal and external rotation of the shoulder.
Move the arm in a full circle. Circumducts the shoulder (Fig. G).
Circumduction of the shoulder.
Place the arm at the client’s side and bend the forearm toward Flexes and extends the elbow (Fig. H).
the shoulder, and then straighten it again.
Flexion and extension of the elbow.
H
(continued)
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Bend the wrist forward and then backward. Moves the wrist from flexion to extension and then hyperexten-
sion (Fig. I).
Flexion and extension of the wrist.
Twist the wrist to the right and then left. Rotates the wrist joint (Fig. J).
Rotation of the wrist.
Bend the thumb side of the hand way from the wrist and then in Provides adduction and then abduction of the wrist (Fig. K).
the opposite direction.
Abduction and adduction of the wrist.
(continued)
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Turn the palm downward and then upward. Pronates and supinates the wrist (Fig. L).
Pronation and supination of the wrist.
Open and close the fingers as though making a fist. Extends and flexes the fingers (Fig. M).
Flexion and extension of the fingers.
Bend the thumb toward the center of the palm and then back to Flexes and extends the thumb (Fig. N).
its original position.
Flexion and extension of the thumb.
N (continued)
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Spread the fingers and thumb as widely as possible and then Abducts and adducts the fingers and thumb (Fig. O).
bring them back together again.
Abduction and adduction of the fingers and thumb.
Bring the straightened leg forward of and backward from the Flexes, extends, and hyperextends the hip (Fig. P).
body in a standing position.
Flexion and extension of the hip in a lying position.
Move the straightened leg away from the body and back beyond Abducts and then adducts the hip (Fig. Q).
the midline.
Abduction and adduction of the hip.
Turn the leg away from the other leg and then toward it. Rotates the hip externally and then internally (Fig. R).
Internal and external rotation of the hip.
R
(continued)
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Turn the leg in a circle. Circumducts the hip (Fig. S).
Circumduction of the hip.
Bend the knee and then straighten it again. Flexes and extends the knee (Fig. T).
Flexion and extension of the knee.
Bend the foot toward the ankle and then away from the ankle. Causes dorsiflexion and plantar flexion (Fig. U).
Dorsiflexion and plantar flexion of the foot.
(continued)
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Bend the sole of the foot toward the midline and then away Inverts and everts the ankle (Fig. V).
from midline.
Inversion and eversion of the ankle.
Bend and then straighten the toes. Flexes and extends the toes (Fig. W).
Flexion and extension of the toes.
Evaluation
All joints are exercised to the extent possible.
Document
• Performance of exercise regimen
Date and Time Assisted to perform ROM exercises during bath. Actively moves all joints on the right side of
the body. Joints on the left side passively exercised through full ranges. No resistance or pain
experienced. __________________________________________________________SIGNATURE/TITLE
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SKILL 24-2 Using a Continuous Passive Motion Machine
ASSESSMENT
Review the medical record and nursing care plan for the amount Determines the exercise prescription for the client.
of joint flexion, cycles per minute, frequency, and duration of
exercise.
Explore how much the client understands about CPM, Determines the level and type of health teaching to provide.
especially if this is the first time it is being used.
Assess the quality of peripheral pulses, capillary refill, edema, Provides a baseline of data for future comparisons.
temperature, sensation, and mobility of the affected
extremity.
Compare assessment findings with the unaffected extremity. Provides comparative data.
Determine the client’s need for pain-relieving medication before Controls pain before it intensifies with exercise.
use of the CPM machine.
PLANNING
Develop a schedule with the client for using the machine. Involves the client in decision making.
Instruct the client on techniques for muscle relaxation and pain Empowers the client with techniques for controlling pain.
control such as deep breathing, listening to tapes, watching
television, or applying an ice bag.
Obtain the CPM machine and secure a length of sheepskin or Prepares the machine for supporting the leg.
soft flannel cloth to the horizontal bars to form a cradle (sling)
for the calf.
Wash hands or perform an alcohol-based hand rub (see Reduces the transmission of microorganisms.
Chap. 10).
Don gloves and empty any wound drainage containers; change Prevents leakage during exercise, when drainage is likely to
or reinforce the dressing (see Chap. 28). increase.
IMPLEMENTATION
Explain the purpose, application, and use of the CPM machine. Reduces anxiety and promotes cooperation.
Position the client flat or slightly elevate the head of the bed. Promotes comfort during exercise.
Place the CPM machine on the bed and position the client’s foot Prepares the client for exercise.
so that it rests against the foot cradle (Fig. A).
Range of motion of the knee with a continuous passive motion machine.

Check that the knee joint corresponds to the foot actuator knob Positions the knee correctly.
and goniometer, a device for measuring ROM.
Use Velcro or canvas straps to secure the leg within the fabric Supports and stabilizes the leg.
cradle of the machine.
Adjust the machine to a lower than prescribed rate and degree Provides gradual progression to prescribed parameters.
of flexion.
Turn on the machine and observe the client’s response. Indicates the client’s level of tolerance.
Readjust the alignment of the leg or position of the machine for Demonstrates concern for the client’s well-being.
optimal comfort.
Increase the degree of flexion and cycles per minute gradually Facilitates adaptation.
until the prescribed levels are reached.
Turn off the machine with the leg in an extended position at the Facilitates lifting the leg from the machine.
end of the prescribed period of exercise.
Release the straps and support the joints beneath the knee and Reduces discomfort.
ankle while lifting the leg.
Remove the machine from the bed; encourage active ROM Potentiates effects from CPM.
exercises and isometric exercises.
(continued)
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Using a Continuous Passive Motion Machine (continued)
Evaluation
CPM applied and used according to exercise prescription.
Document
• Assessment data
• Use of machine
• Current amount of flexion, cycles per minute, and duration
• Tolerance of exercise
Date and Time Knee incision is dry and intact. Toes on both feet are warm with capillary refill <3 seconds. Pedal pulses
present and strong bilaterally. CPM machine used for 15 minutes with ROM at 30-degree knee flexion
for 5 cycles per minute. Discomfort increased from a level 4 before exercise to level 7 during exercise.
Pain at a level of 5 after 15 minutes of rest following exercise. _____________________ SIGNATURE/TITLE
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25 Mechanical
Immobilization
adaptation
bivalved cast
alarmcaststage On completion of this chapter, the reader should be able to:
body
catastrophize
braces 1. List at least three purposes of mechanical immobilization.
coping mechanisms
cast 2. Name four types of splints.
coping strategies
cervical collar 3. Discuss why slings and braces are used.
endorphins syndrome
compartment 4. Explain the purpose of a cast.
feedbackcast
cylinder loop 5. Name three types of casts.
fight or flfiight
external response
xator 6. Describe at least five nursing actions that are appropriate
general adaptation
functional braces syndrome when caring for clients with casts.
homeostasis
immobilizers 7. Discuss how casts are removed.
hypothalamus-pituitary-adrenal
inflatable splints (HPA) axis 8. Explain what traction implies.
neurotransmitters
manual traction 9. List three types of traction.
primary splints
molded prevention 10. Name seven principles that apply to maintaining effective
secondary prevention
orthoses traction.
sensory manipulation
petals 11. Describe the purpose of an external fixator.
stage
pin siteof exhaustion 12. Identify the rationale for performing pin site care.
stage of resistance
prophylactic braces
stress
rehabilitative braces
stress management
skeletal traction techniques
stressors
S
skin traction ome clients are inactive and physically immobile as a result of
stress-reduction techniques
sling an overall debilitating condition. For others, impaired mobility
stress-related
spica cast disorders results from trauma or its treatment. Such is the case for clients
tertiary prevention
splint with orthoses, which are orthopedic devices that support or align
traction a body part and prevent or correct deformities. Examples of orthoses
traction splints include splints, immobilizers, and braces. Other clients have limited
window
mobility when the use of slings, casts, traction, and external fixators is
necessary. Caring for clients who are mechanically immobilized with
orthopedic devices requires specialized nursing skills described in this
chapter.
PURPOSES OF MECHANICAL
IMMOBILIZATION
Most clients who require mechanical immobilization have suffered

trauma to the musculoskeletal system. Such injuries are painful and
heal less rapidly than injuries to the skin or soft tissue. They require a
period of inactivity to allow new cells to restore integrity to the dam-
aged structures.
Mechanical immobilization of a body part accomplishes the
following:
• Relieves pain and muscle spasm
• Supports and aligns skeletal injuries
• Restricts movement while injuries heal
• Maintains a functional position until healing is complete
537
LWBK1004-C25_p537-559.indd 537 04/02/12 4:00 PM

• Allows activity while restricting movement of an injured

area
• Prevents further structural damage and deformity
MECHANICAL IMMOBILIZING
DEVICES
FIGURE 25-1 Emergency first-aid splinting immobilizes the
The use of various immobilizing devices can achieve thera- injured leg to the uninjured leg with a make shift splint, such
peutic benefits. Examples of such devices include splints, as a board, broom handle, or golf club. Neckties, belts, or
slings, braces, casts, and traction. scarves keep the splint in place.
Splints
Gerontologic Considerations Some conditions are treated with a splint, which is a device
that immobilizes and protects an injured body part. Splints
■ As adults live longer, many are dealing with the pain and are used before or instead of casts or traction.
loss of function associated with arthritis. Treatment options
involve rehabilitation with various types of mechanical Emergency Splints
devices in the home or rehabilitation setting. Splints often are applied as a first-aid measure for suspected
■ Some fractures in older adults, particularly of the upper sprains or fractures (Fig. 25-1) (see Nursing Guidelines 25-1).
extremities, are treated nonsurgically with immobilization.
Occupational and physical therapists are helpful in assisting Commercial Splints
older adults to regain function and range of motion Commercial splints are more effective than improvised
following any period of immobilization to prevent a splints. They are available in various designs depending
decrease or a permanent loss of function. on the injury. Examples include inflatable splints, traction
■ Because of diminished tactile sensation, older adults splints, immobilizers, molded splints, and cervical collars.
may be unaware of skin pressure from a splint, cast,
Inflatable and traction splints are intended for short-term use;
traction, or other mechanical device. Assess the skin
they usually are applied just after the injury and are removed
of an older person daily for redness or other signs of
pressure (a reddened area that does not resolve in 30 shortly after a more thorough assessment of the injury.
minutes of pressure relief). If the older person cannot Immobilizers and molded splints are used for longer periods.
change positions, the caregiver is responsible for
ensuring that pressure is relieved at least every Inflatable Splints
2 hours. Inflatable splints, also called “pneumatic splints,” are
immobilizing devices that become rigid when filled with

Rationales
Applying an Emergency Splint
• Avoid changing the position of the injured part even if it • Use an uninjured area of the body adjacent to the injured
appears grossly deformed. Keeping the injured part in place part as a splint, if no other sturdy material is available. The
prevents additional injuries. uninjured part can serve as a substitute for an external
• Leave a high-top shoe or a ski boot in place if the injury splint.
involves an ankle. The shoe or boot limits movement and • Use wide tape or wide strips of fabric to confine the injured
reduces pain and swelling. part to the splint. Securing the body part prevents displacement
• Cover any open wounds with clean material. Such a covering and reduces the risk for compromising circulation.
absorbs blood and prevents dirt and additional pathogens from • Loosen the splint or the material used to attach it if the fingers
entering. or toes are pale, blue, or cold. Loosening the splint facilitates
• Select a rigid splinting material such as a flat board, broom circulation.
handle, or rolled-up newspaper. Rigid material provides sup- • Elevate the immobilized part, if possible, so that the lowest
port while restricting movement. point is higher than the heart. Elevation reduces swelling and
• Pad bony prominences with soft material. Padding reduces enhances venous return to the heart.
pressure and prevents friction on the skin. • Keep the client warm and safe. Shock is a risk.
• Apply the splinting device so that it spans the injured area • Seek assistance in transporting the client to a health care
from the joint above to the joint below the injury. Such place- agency. The client requires more sophisticated treatment.
ment immobilizes the injured tissue.
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CHAPTER 25 Mechanical Immobilization 539
FIGURE 25-2 An inflatable splint.
FIGURE 25-4 A leg immobilizer.

air (Fig. 25-2). In addition to limiting motion, they control
bleeding and swelling. The injured body part is inserted into
the deflated splint. When air is infused, the splint molds to immobilizers limit motion in the area of a painful but heal-
the contour of the injured part, preventing movement. The ing injury such as the neck and the knee. They are removed
splint is filled with air to the point at which it can be indented for brief periods during hygiene and dressing.
0.5 in. (1.3 cm) with the fingertips. The injury should be
examined and treated within 30 to 45 minutes after applica- Molded Splints
tion of the splint; otherwise, circulation may be affected. Molded splints are orthotic devices made of rigid materi-
als and are used for chronic injuries or diseases. They may
Traction Splints be appropriate for clients with repetitive motion disorders
Traction splints are metal devices that immobilize and such as carpal tunnel syndrome. They provide prolonged
pull on contracted muscles. They are not as easy to apply support and limit movement to prevent further injury and
as inflatable splints. One example is a Thomas splint, which pain (Fig. 25-5). They maintain the body part in a functional
requires special training for its application to prevent addi- position to prevent contractures and muscle atrophy during
tional injuries (Fig. 25-3). immobility.
Immobilizers Cervical Collars

Immobilizers are commercial splints made from cloth and A cervical collar is a foam or rigid splint placed around the
foam and held in place by adjustable hook and loop tape neck. It is used to treat athletic neck injuries and other trauma
(such as Velcro) straps (Fig. 25-4). As the name implies, that results in a neck sprain or strain (Fig. 25-6). Neck strain
is sometimes referred to as whiplash or a whiplash injury.
The incidence of whiplash injuries has decreased primarily
for two reasons: improved athletic protective equipment and
A use of shoulder harnesses and neck supports in automobiles.
When a neck injury—which is generally more painful
the day after trauma—is mild or moderate, a foam collar,
FIGURE 25-3 A. A Thomas splint. B. A Thomas splint applied to

the lower extremity. FIGURE 25-5 A molded splint.
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Neck
circumference
Chin to shoulder
FIGURE 25-7 Vertical and circumferential measurements for

cervical collar size.
Clients wear cervical collars almost continuously, even

while sleeping, for 10 days to 2 weeks. They remove them
to do gentle range-of-motion neck exercises (see Chap. 24).
The sooner a client performs exercise (within his or her pain
tolerance), the faster revascularization and recovery occur.
B Prolonged dependence on the collar for comfort can lead to
permanent stiffness in the neck.
During recovery, the nurse assesses the client’s neu-
romuscular status by having the client perform movements
that correlate with muscular functions controlled by cervical
FIGURE 25-6 A. A foam cervical collar. B. A rigid cervical collar.
spine and peripheral nerve roots. If neuromuscular function
is intact, the client can do the following:
• Elevate both shoulders
covered with stockinette (a stretchable cotton fabric), is
• Flex and extend the elbows and the wrists
used. When the client wears it, it reminds him or her to
• Generate a strong hand grip
limit neck and head movements. For more serious injuries, a
• Spread the fingers
rigid splint made from polyurethane is used to control neck
• Touch the thumb to the little finger on each hand
motion and support the head, reducing its load-bearing force
on the cervical spine. The nurse documents and communicates to the physi-
To determine the proper collar size, the nurse measures cian any difference in strength or movement on one side or
the neck circumference and the distance between the shoul- the other.
der and the chin (Fig. 25-7). He or she compares measure-
ments with the size guide suggested by the collar manufac- Slings
turer. For example, a person with a neck size of 15 to 20 in. A sling is a cloth device used to elevate, cradle, and support
and a shoulder-to-chin height of 3 in. probably would require parts of the body. Slings are applied commonly to the arm
a regular adult size. Adult sizes also come in short, tall, and (Fig. 25-8), leg, or pelvis after immobilization and exami-
extra tall. Pediatric collars are also available. nation of the injury. Many ambulatory clients use the com-
When applying a cervical collar, the head is placed in mercial type of arm sling; a triangular piece of muslin cloth
a neutral position (see Chap. 23). The front of the collar is occasionally may be used to fashion a sling. To be effective,
positioned well beneath the chin and slid upward until the slings require proper application (Skill 25-1).
chin is well supported. The opening of the collar is centered
at the back of the neck. Straps made of Velcro or other mate- ➧ Stop, Think, and Respond Box 25-1
rials are used to secure the collar in the desired position. List the advantages and disadvantages of using a
When applied appropriately, the client can breathe and swal- commercially made canvas sling and a triangular
low effortlessly while wearing the collar. cloth sling.
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FIGURE 25-8 A commercial sling used for arm suspension. FIGURE 25-9 A rehabilitative brace that ensures appropriate
(Photo by B. Proud.) control of knee motion following an operative procedure.
Braces The purpose of the cast is to immobilize the injured struc-

Braces are custom-made or custom-fitted devices designed ture. Casts usually are applied to fractured (broken) bones.
to support weakened structures. The three categories of They are formed using either wetted rolls of plaster of Paris
braces are (1) prophylactic braces (those used to prevent or premoistened rolls of fiberglass (Table 25-1).
or reduce the severity of a joint injury), (2) rehabilitative
braces (those that allow protected motion of an injured joint
that has been treated operatively; Fig. 25-9), and (3) func-
tional braces (those that provide stability for an unstable
joint).
■ Hip fractures are common in older adults, especially
Because clients generally wear braces during active
postmenopausal women not treated for osteoporosis. The
periods, braces are made of sturdy materials such as metal or fracture may result from weakness of the bone and lead to
leather. Leg braces may be incorporated into a shoe. Some a fall, or a fall may cause the fracture of a weakened bone.
back braces are made of cloth with metal staves, or strips, ■ With aging, bones become brittle and weak, resulting in
sewn within the fabric of the brace. An improperly applied longer healing time for fractures.
or ill-fitting brace can cause discomfort, deformity, and skin
ulcerations from friction or prolonged pressure.
Casts Types of Casts

A cast is a rigid mold placed around an injured body part There are basically three types of casts: cylinder, body, and
after it has been restored to correct the anatomic alignment. spica. Cylinder and body casts may be bivalved.
TABLE 25-1 Cast Materials

SUBSTANCE ADVANTAGES DISADVANTAGES
Plaster of Paris Inexpensive Takes 24–48 hours to dry; large casts may take up to 72 hours to dry
Easy to apply Weight bearing must be delayed until thoroughly dried
Low incidence of allergic reactions Heavy
Prone to cracking or crumbling, especially at the edges
Softens when wet
Fiberglass Lightweight Expensive
Porous Not recommended for severe injuries or those accompanied by
Dries in 5–15 minutes excessive swelling
Allows immediate weight bearing Macerates skin if padding becomes wet
Durable Cast edges may be sharp and may cause skin abrasions
Unaffected by water
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Cylinder Cast remains in place. The process is repeated when caring for
A cylinder cast encircles an arm or leg and leaves the toes or the opposite body area. Once care has been completed, the
fingers exposed. The cast extends from the joints above and removed piece is replaced and the two halves are held in
below the affected bone. This prevents movement in the injured place by wrapping them together with an elastic bandage.
area, thereby maintaining correct alignment during healing. As
healing progresses, the cast may be trimmed or shortened. Spica Cast
A spica cast encircles one or both the arms or legs and the chest
Body Cast or trunk. It may have an abduction bar to help maintain the
A body cast is a larger form of a cylinder cast and encircles position of the repaired injury. When applied to the upper body,
the trunk of the body instead of an extremity. It generally the cast is referred to as a shoulder spica; one applied to the
extends from the nipple line to the hips. For some clients lower extremities is called a hip spica (Fig. 25-11). Spica casts,
with spinal problems, the body cast extends from the back especially those on the lower extremities, are heavy, hot, and
of the head and chin areas to the hips, with modifications for frustrating because they severely restrict movement and activity.
exposing the arms. When applied to a lower extremity, the cast is trimmed
in the anal and genital areas to allow for the elimination
Bivalved Cast of urine and stool. Clients with a hip spica cannot sit dur-
The physician may create a bivalved cast (one that is cut ing elimination, so the nurse protects the cast from soiling
into two pieces lengthwise) from either a body or a cylinder using plastic wrap and positions the client on a small bedpan
cast. Creating a front and a back for a body cast facilitates known as a fracture pan (see Chap 30).
bathing and skin care. A bivalved cast on an extremity Cast Application
(Fig. 25-10) is created when: Cast application generally requires more than one person.
• Swelling compresses tissue and interferes with circulation The nurse prepares the client, assembles the cast supplies,
• The client is being weaned from the cast and helps the physician during the cast application (Skill
• A sharper X-ray image is needed 25-2). A light-cured fiberglass cast requires exposure to
• Painful joints need to be immobilized temporarily for a ultraviolet light to harden.
client with arthritis
Basic Cast Care
Creating a front and a back for a body cast facilitates Some clients need extended care after surgery that has
bathing and skin care. If the physician approves, half of the included the application of a cast. The nurse is responsible
shell is removed temporarily for hygiene while the other half for caring for the cast and making appropriate assessments
B
FIGURE 25-11 Hip spica cast. (Timby, B.K., & Smith, N. [2010].
FIGURE 25-10 A. A bivalved cast. B. The two halves are Introductory medical-surgical nursing [10th ed., p. 970].
rejoined. Philadelphia: Lippincott Williams & Wilkins.)
LWBK1004-C25_p537-559.indd 542 04/02/12 4:00 PM


Rationales
Making and Applying Petals
• Cut multiple strips of adhesive tape approximately 2 in. wide • Tuck one end of the tape or moleskin inside the cast edge, tak-
by 2 to 3 in. in length or use precut ovals from moleskin. The ing care to avoid wrinkles. Wrinkles can cause friction on the
width of the tape is optional depending on the circumference skin and may lead to abrasions.
of the cast that needs to be covered. Each petal must be of suf- • Overlap the strips of tape or moleskin around the rough cast
ficient length for placement of an end both inside and outside edge (see Fig. 25-12). Overlapping ensures that there are no
the cast edges. gaps that expose a rough area that will continue to irritate the
• Round the end of each adhesive strip like a flower petal or trim skin.
to create chevrons that resemble arrows; moleskin may already • Continue to monitor the skin for signs of impairment. If petals
be shaped in an oval. Modifying the ends of the tape reduces do not relieve skin irritation, the physician may need to smooth
the potential for wrinkles. the edge with additional strips of plaster.
to prevent complications (Skill 25-3). See Nursing Guide- and may contain scales or patches of dead skin. The skin
lines 25-2 and Figure 25-12 for instructions on making and is washed as usual with soapy warm water, but the semi-
applying petals, strips of adhesive tape or moleskin for the attached areas of skin are left in place; they are not forcibly
purpose of reducing skin irritation from the rough edges of removed. Applying lotion to the skin adds moisture and tends
a cast. to prevent the rough skin edges from catching on clothing.
Eventually, the dead skin fragments will slough free.
➧ Stop, Think, and Respond Box 25-2 Traction

Discuss the discharge teaching for a client who has Traction is a pulling effect exerted on a part of the skeletal
had a cast applied. system. It is a treatment measure for musculoskeletal trauma
and disorders. Traction is used to accomplish the following:
Cast Removal
In most cases, casts are removed when they need to be • Reduce muscle spasms
changed and reapplied, or when the injury has healed suffi- • Realign bones
ciently that the cast is no longer necessary. A cast is removed • Relieve pain
prematurely if complications develop. • Prevent deformities
Most casts are removed with an electric cast cutter, an The pull of the traction generally is offset by the
instrument that looks like a circular saw (Fig. 25-13). The counterpull from the client’s own body weight. Except for
cast cutter is noisy and may frighten clients. There is a traction exerted with the hands, application of traction
natural expectation that an instrument sharp enough to cut a involves the use of weights connected to the client through
cast is sharp enough to cut skin and tissue. Proper use of an a system of ropes, pulleys, slings, and other equipment.
electric cast cutter, however, leaves the skin intact.
When the cast is removed, the unexercised muscle is Types of Traction
usually smaller and weaker. The joints may have a limited The three basic types of traction are manual, skin, and skeletal.
range of motion. The skin usually appears pale and waxy The categories reflect the manner in which traction is applied.
FIGURE 25-12 Petals are overlapped and

applied around the edge circumference of a
cast.
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A B
FIGURE 25-13 A cast removal. A. The cast is bivalved with an electric cast cutter. B. The cast is
split. C. The padding is manually cut.
Manual Traction Skeletal Traction

Manual traction means pulling on the body using a person’s Skeletal traction means pull exerted directly on the skeletal
hands and muscular strength (Fig. 25-14). It most often is system by attaching wires, pins, or tongs into or through a
used briefly to realign a broken bone. It is also used to replace bone (Fig. 25-17). Skeletal traction is applied continuously
a dislocated bone into its original position within a joint. for an extended period.
Skin Traction Traction Care
Skin traction means a pulling effect on the skeletal system Regardless of the type of traction used, its effectiveness
by applying devices to the skin, such as a pelvic belt and depends on the application of certain principles during the
a cervical halter (Fig. 25-15). Other names for commonly client’s care (see Box 25-1 and Skill 23-4).
applied forms of skin traction are Buck’s traction and
Russell’s traction (Fig. 25-16). External Fixators
An external fixator is a metal device inserted into and through
one or more broken bones to stabilize fragments during
B OX 2 5 - 1 Principles for Maintaining

Effective Traction
• Traction must produce a pulling effect on the body.
• Countertraction (counterpull) must be maintained.
• The pull of traction and the counterpull must be in exactly
opposite directions.
• Splints and slings must be suspended without interference.
• Ropes must move freely through each pulley.
• The prescribed amount of weight must be applied.
• The weights must hang free.
FIGURE 25-14 Manual traction.
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A B
FIGURE 25-15 A. A pelvic belt. B. A cervical halter.
A B
FIGURE 25-16 A. Buck’s traction. B. Russell’s traction.
A B FIGURE 25-17 The application of skele-

tal traction. A. A pin transects the bone.
B. Traction is applied.
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healing (Fig. 25-18). Although the external fixator immobi-

lizes the area of injury, the client is encouraged to be active and
mobile (see Chap. 26 for information about ambulatory aids).
During recovery, the nurse provides care for the pin
site (the location where pins, wires, or tongs enter or exit
the skin). In conjunction with an external fixator and skeletal
traction, pin site care is essential to prevent infection. Inser-
tion of pins impairs skin integrity and provides a port of entry
for pathogens. Caring for a pin site is described in Skill 25-5.

A culture from a specimen taken at a pin site reveals
that the pin site is infected with Staphylococcus
aureus. What nursing actions are required for contact
precautions to control transmission of the pathogen?
(Use information in Chap. 22 as a resource or to
review.)
Clients with immobilizing devices such as casts and traction

may have one or more of the following nursing diagnoses:
• Acute Pain
• Impaired Physical Mobility
• Risk for Disuse Syndrome
• Risk for Peripheral Neurovascular Dysfunction
• Impaired Bed Mobility
• Risk for Ineffective Tissue Perfusion
• Bathing Self-Care Deficit
Nursing Care Plan 25-1 describes the nursing process as it
applies to a client with a nursing diagnosis of Risk for Periph-
eral Neurovascular Dysfunction, defined in the NANDA-I tax-
FIGURE 25-18 An external fixator. Metal rods exert traction onomy (2012, p. 434) as a state in which a client is “at risk for
between two sets of skeletal pins. disruption in circulation, sensation, or motion of an extremity.”
N U R S I N G C A R E P L A N 2 5 - 1 Risk for Peripheral Neurovascular Dysfunction

Assessment • Look at the skin color and compare differences in the
• Monitor peripheral circulation: extremities.
• Check for the presence and quality of peripheral pulses in • Assess the client’s neurologic status in both extremities:
affected and unaffected extremities. • Ask the client to move the toes or fingers in the extremities.
• Feel the temperature of exposed toes or fingers and compare • Touch the client’s extremities with objects that are sharp, dull,
findings with the opposite extremity. warm, or cold to determine whether the client can differentiate
• Compress the nailbeds and determine the time for the color the stimuli without actually seeing the source of stimulation.
to return following blanching. • Quantify the client’s level of pain, its location, characteris-
• Observe for swelling in the affected extremity in comparison tics, and whether it decreases or increases with usual
to the unaffected extremity. pain-relieving measures.
Nursing Diagnosis. Risk for Peripheral Neurovascular Dysfunction related to tissue swelling and compression of blood ves-
sels and nerves secondary to injury and recent cast application to the left leg.
Expected Outcome. The client’s neurovascular status will be normal as evidenced by a report of pain relief from present rate
of 9 to ≤7. Pedal pulses will be equally strong. Movement and sensation will be equal in both extremities. Capillary refill will be
≤3 seconds bilaterally within 3 hours today (8/20).
(continued)
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NURSING CARE PLAN 25-1 Risk for Peripheral Neurovascular Dysfunction ( c o n t inue d)
Elevate the casted left leg so that toes are higher than the Use of gravity facilitates the venous return of blood from distal
client’s heart. areas to the heart.
Have client exercise toes of left foot in cast every 15 minutes Contraction of skeletal muscles compresses capillaries and
while awake. veins, which propels venous blood toward the heart.
Apply an ice bag on the cast over the area of injury; empty Application of cold causes blood vessels to constrict and
and refill ice bag every 20 minutes. reduces tissue swelling.
Monitor circulatory status, sensation including tactile and pain, Lack of improvement or escalation of signs suggesting neurov-
and mobility of toes in affected extremity every 30 minutes. ascular impairment indicate a medical emergency.
Report worsening of symptoms to the charge nurse and Failure to report and implement additional interventions can
physician immediately. cause the client to permanently lose function in the limb or
require surgical amputation.

• The pedal pulse is diminished in extremity in cast; pulse is strong • Capillary refill is 2 seconds in toes on both feet. Pedal pulses
and regular in unaffected foot despite the elevation of casted leg are palpable and equal bilaterally. The client moves and detects
on three pillows. The client performs active exercises with toes sensation equally bilaterally and rates pain at 5 after cast is
every 15 minutes. Ice bag is applied to cast over lateral ankle. bivalved.
• Client rates pain at 10 after receiving Demerol 75 mg intra- • Affected leg remains elevated with ice bag applied. Client does
muscularly. exercises as directed.
• The nurse notifies the doctor, who gives orders to obtain a cast
cutter for bivalving cast.
CRITICAL THINKING EXERCISES 2. Which one of the following is accurate when a nurse
describes the advantage of fiberglass casts?
1. Although slings are applied most often to support 1. Fiberglass casts are generally less expensive.
injured extremities, discuss possible reasons for 2. Fiberglass casts are generally more lightweight.
applying a sling on an arm paralyzed by a stroke. 3. Fiberglass casts are generally more flexible.
2. Discuss the differences and similarities between car- 4. Fiberglass casts are generally less restrictive.
ing for clients with casts and caring for clients in 3. Which of the following techniques is best for assess-
traction. ing circulation in the casted extremity of a client with
3. Discuss ways to provide diversions for clients with a a long leg plaster cast?
cast or in traction who are confined to bed while their 1. Ask the client whether the cast feels exceptionally
injuries heal. heavy.
4. A nursing assistant reports that a client with a cast 2. Feel the cast to determine whether it is unusually
is experiencing pain that is being rated at higher cold.
and higher levels since the cast was applied this 3. Depress the nail bed and time the return of color.
morning. What actions should the nurse take? What 4. See whether there is room to insert a finger within
complication could be the cause of the client’s the cast.
discomfort? 4. Which finding is most suggestive that a client
in skeletal traction has an infection at the pin
site?
1. There is serous drainage at the pin site.
1. As the physician wraps the arm of a client with rolls 2. There is bloody drainage at the pin site.
of wet plaster, what is the most appropriate method 3. There is mucoid drainage at the pin site.
the nurse should use for supporting the wet cast? 4. There is purulent drainage at the pin site.
1. Support the wet cast on a soft mattress. 5. While providing nursing care for a client in Buck’s
2. Support the wet cast on a firm surface. skin traction, which of the following indicates a need
3. Support the wet cast with the tips of the fingers. for immediate action?
4. Support the wet cast with the palms of the hands. 1. The traction weights are hanging above the floor.
2. The leg is in line with the pull of the traction.
3. The client’s foot is touching the end of the bed.
4. The rope is in the groove of the traction pulley.
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SKILL 25-1 Applying an Arm Sling
ASSESSMENT
Check the medical orders. Integrates nursing activities with medical treatment.
Assess the skin color and temperature, capillary refill time, and Provides baseline objective data for future comparisons.
amount of edema; verify the presence of peripheral pulses in
the injured arm (don gloves if there is a potential for contact
with blood or nonintact skin).
Ask the client to describe how the fingers and arm feel and to Provides baseline subjective data for future comparisons.
rate any pain on a scale of 0–10.
Determine whether the client had required an arm sling in the past. Indicates the level and type of health teaching needed.
PLANNING
Explain the purpose for the sling. Adds to the client’s understanding.
Obtain a canvas or triangular sling, depending on what is Complies with medical practice.
available or prescribed for use.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub Reduces the potential for transferring microorganisms.
(see Chap. 10).
Position forearm across the client’s chest with the thumb Flexes the elbow.
pointing upward.
Avoid more than 90 degrees of flexion, especially if the elbow Facilitates circulation.
has been injured.
Canvas Sling
Slip the flexed arm into the canvas sling so that the elbow fits Encloses the forearm and wrist.
flush with the corner of the sling (Fig. A).
Positioning a commercial arm sling.
Bring the strap around the opposing shoulder and fasten it to Provides the means for support.
the sling (Fig. B).
Placing the strap around the neck.
(continued)
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Applying an Arm Sling (continued)
Pad and tighten the strap sufficiently (Fig. C). Reduces friction and pressure to preserve skin integrity.
Placing padding between the strap and neck.
Keep the elbow flexed and the wrist elevated (Fig. D). Promotes circulation.
The sling in place.
Triangular Sling
Place the longer side of the sling from the shoulder opposite Positions the sling where length is needed.
the injured arm to the waist.
(continued)
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Position the apex or point of the triangle under the elbow (Fig. E). Facilitates making a hammock for the arm.
Positioning a triangular sling.
Bring the point at the waist up to join the point at the neck and Encloses the injured arm.
tie them.
Position the knot to the side of the neck. Avoids pressure on the vertebrae.
Fold in and secure excess fabric at the elbow; a safety pin may Keeps the elbow enclosed.
be necessary (Fig. F).
A completed sling.
Inspect the condition of the skin at the neck and the circulation, Provides comparative data.
mobility, and sensation of the fingers at least once per shift.
Pad the skin at the neck with soft gauze or towel material if the Reduces pressure and friction.
skin becomes irritated.
Tell the client to report any changes in sensation, especially pain Indicates developing complications.
with limited movement or pressure.
(continued)
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Evaluation
• Forearm is supported.
• Wrist is elevated.
• Pain and swelling are reduced.
• Circulation, mobility, and sensation are maintained.
Document
• Baseline and comparative assessment data
• Type of sling applied or used
• To whom significant abnormal assessments were reported
• Outcomes of the verbal report
Date and Time Fingers on R. hand are pale, cool, and swollen. Capillary refill is sluggish, taking 4 seconds for color to
return. Can move all fingers. Can discriminate sharp and dull stimuli. No tingling identified. Pain rated at 8
on a scale of 0–10. All above data reported to Dr. Stuckey. Orders received for pain medication and canvas
sling. Demerol 75 mg given IM in vastus lateralis. Sling applied. _____________________ SIGNATURE/TITLE
SKILL 25-2 Assisting with a Cast Application
ASSESSMENT
Check the medical orders. Integrates nursing activities with the medical treatment.
Assess the appearance of the skin that the cast will cover; also Provides a baseline of data for future comparisons.
check circulation, mobility, and sensation.
Ask the client to describe the location, type, and intensity of any Determines whether the client needs analgesic medication.
pain.
Determine what the client understands about the application of Indicates the type of health teaching needed.
a cast.
Check with the physician as to whether a plaster of Paris or Facilitates assembling appropriate supplies.
fiberglass cast will be applied.
PLANNING
Obtain a signature on a treatment consent form, if required. Ensures legal protection.
Administer pain medication, if prescribed. Relieves discomfort.
Remove the client’s clothing that may not stretch over the cast Avoids having to cut and destroy clothing.
once it is applied.
Provide a gown or drape. Preserves dignity and protects clothing.
Assemble materials, which may include a stockinette, felt pad- Facilitates organization and efficient time management.
ding, cotton batting, rolls of cast material, gloves, and apron.
Anticipate that if the cast is being applied to a lower extremity, Shows awareness of discharge planning.
the client will need crutches and instructions on their use
(see Chap. 26).
Have an arm sling available if applying the cast to an upper Shows awareness of discharge planning.
extremity.
IMPLEMENTATION
Explain how the cast will be applied. If using plaster of Paris, be Reduces anxiety and promotes cooperation.
sure to tell the client that it will feel warm as it dries.
Wash your hands or perform an alcohol-based hand rub (see Reduces the potential for transferring microorganisms.
Chap. 10).
Wash the client’s skin with soap and water and dry well. Removes dirt, body oil, and some microorganisms.
(continued)
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Assisting With a Cast Application (continued)
Cover the skin with a stockinette and protective padding as Protects the skin from direct contact with the cast material and
directed (Fig. A). provides a fabric cushion that protects the skin.
A stockinette in place.
If applying a plaster cast, open rolls and strips of plaster gauze Prepares the cast material for application.
material. Dip them, one at a time, briefly in water and wring
out the excess moisture.
If using fiberglass material, open the foil packets one at a time. Reduces the risk of rapidly drying and becoming unfit for use.
Support the extremity while the physician wraps the cast mate- Facilitates going around the injured area; ensures proper align-
rial around the arm or leg (Fig. B). ment because fiberglass is harder to mold.
Casting material being applied.
For a fiberglass cast, hold the extremity in this position until the
cast is dry (approximately 15 minutes).
(continued)
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Assisting With a Cast Application (continued)
Help to fold back the edges of the stockinette at each end of the Forms a smooth, soft edge at the margins of the cast, which may
cast just before the final layer of cast material is applied (Fig. C). protect the skin from becoming irritated.
The folded stockinette beneath the cast protects the skin from the sharp edges of the cast.
Elevate the cast on pillows or other support. Helps to reduce swelling and pain.
If a plaster cast was applied, use a special sink with a plaster trap Prevents clogging of plumbing.
to dispose of the water in which plaster rolls were soaked.
Provide verbal and written instructions on cast care. Facilitates independence and safe self-care.
Evaluation
• Skin has been cleaned and protected.
• Cast has been applied and is drying or dried.
• Circulation and sensation are within acceptable parameters.
• Client can repeat discharge instructions.
Document
• Assessment data
• Type of cast
• Cast material
• Name of physician who applied the cast
• Discharge instructions
Date and Time Wrist appears swollen but skin is warm, dry, and intact. Capillary refill <3 seconds. X-ray department
reports a fracture of the wrist. Dr. Roberts notified. Dr. Roberts applied cylinder fiberglass cast from middle
of hand to above elbow. Assessment findings remain unchanged after cast application. Casted arm sup-
ported in a canvas sling. Standard instructions for cast care provided (see copy attached). Instructed to
call Dr. Roberts if pain or swelling increases and make an office appointment in 2 weeks.
________________________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C25_p537-559.indd 553 04/02/12 4:00 PM

SKILL 25-3 Providing Basic Care of a Client With a Cast
ASSESSMENT
Determine the type of cast, the body location, and when the Plaster casts do not completely dry for 24–72 hours or longer
cast was initially applied. depending on the size and type of cast; fiberglass casts dry
within 30 minutes.
Check whether there is a trapeze on the client’s bed. A trapeze helps a client change position or move up or down in
bed.
PLANNING
Plan to check the condition of the cast, the neurovascular sta- A plaster cast is vulnerable to changing shape until it has dried;
tus, and the condition of the skin on the limb enclosed by the neurovascular complications are more likely to occur in the
cast every 30 minutes initially and twice per shift once it has early hours after the initial cast application; and the risk for
dried. impaired skin integrity and infection is ongoing.
Explain the purpose and methods for assessment to the client. Adds to the client’s understanding.
IMPLEMENTATION
Place the bed at a comfortable height. Prevents back strain.
Wash your hands or perform an alcohol-based hand rub (see Removes transient microorganisms and reduces the transmission
Chap. 10). of pathogens.
Observe and feel the condition of the cast on the anterior as A dry cast is white, shiny, and odorless; a damp cast is gray, dull,
well as posterior surfaces. Position a fresh plaster cast on and musty-smelling. The buoyancy of the pillow reduces the
pillows without plastic covers. direct force of the hard mattress against the cast that may alter
its shape. Plastic covered pillows trap heat and moisture, which
retards drying.
Use the palms of the hands, not the fingers, to move or reposi- Use of the fingers can cause indentations, which can cause pres-
tion the cast before it is thoroughly dry. sure sores to develop under the cast.
Leave a freshly applied plaster cast uncovered until it is dry; turn Aids in the evaporation of water from the plaster which is neces-
the client periodically to expose all the surfaces of the cast sary for drying the cast.
to air.
Avoid using the abduction bar in a hip spica cast when turning Pulling on the abduction bar is likely to break it free from its
a client. attachment to the cast.
Observe the color, temperature, and size of the fingers or toes Digits that are pink, warm, and of a similar size bilaterally suggest
on the extremity with the cast; compare with those on the that there is an adequate distal blood supply.
opposite extremity.
Assess capillary refill in exposed fingers or toes (Fig. A); Color should reappear in 2–3 seconds as the capillaries refill
compare with the uncasted digits. following blanching; checking the opposite nailbeds provides
comparative data.
Assessing capillary refill. (Photo by B. Proud.)
Elevate an extremity that appears swollen. Elevation promotes the return of venous blood to the heart that
may be trapped distally by a swelling extremity.
Circle areas where blood has seeped through the cast; note the Identification helps in evaluating the significance of blood loss.
time on the cast. Recircle any expanding blood seepage and
identify the time.
(continued)
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Providing Basic Care of a Client With a Cast (continued)
Apply ice packs to the cast at the level of injury or where sur- Cold is conducted through the skin causing vasoconstriction,
gery has been performed if swelling is evident (Fig. B). which helps to control swelling and bleeding.
Applying an ice pack. (Photo by B. Proud.)
Monitor the mobility of the fingers or toes (Fig. C). The ability to move the fingers or toes upon request reflects
intact neuromuscular status.
Checking mobility. (Photo by B. Proud.)
Assess sensation in exposed fingers or toes (Fig. D). The ability to feel sensation indicates intact neurologic status.
Assessing sensation in exposed fingers. (Photo by B. Proud.)
Assess the presence and quality of pain in the area covered by Unrelieved pain of increasing intensity suggests a complication
the cast, especially if it is unrelieved by elevation, cold appli- known as compartment syndrome, which is caused by pressure
cations, and analgesic medication. due to swelling within the inelastic fascia that surrounds muscles.
Report pain that escalates and does not respond to pain The pressure from compartment syndrome, if unrelieved, disrupts
relieving measures. circulation and damages nerves, which may cause permanent
disability.
(continued)
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Providing Basic Care of a Client With a Cast (continued)
Be aware of any foul odor or purulent drainage coming from A foul odor and purulent drainage suggests a possible infection.
within the cast.
Encourage the client to exercise fingers or toes frequently. Exercise helps to increase circulation, decrease swelling, and
prevent stiffness.
Swab remnants of plaster from the skin with a damp cloth; Water moistens plaster, allowing it to be removed; alcohol and
remove fiberglass resin from the skin with alcohol or acetone. acetone are chemical solvents.
Avoid getting a cast wet. If it becomes wet, dry the area using a Water softens plaster and may saturate the padding next to the
blow dryer on a cool setting. skin of both plaster and fiberglass casts. Prolonged dampness
weakens plaster; damp padding can macerate the skin integrity.
Ensure that the edges of the cast are smooth and padded (Fig. E). Padding reduces the risk for skin irritation and breakdown.
Soft cast edges minimizes the risk for skin impairment. (Photo by B. Proud.)
Rough edges can be reinforced with petals made of tape or

moleskin (Nursing Guidelines 25-2).
Caution clients not to insert objects (eg, straws, combs, Foreign objects can impair the skin by causing abrasions or pro-
utensils) within the cast. longed pressure if retained within the cast.
Report itching, which may be treated with oral medication or by Antipruritic medications relieve itching, but may cause drowsiness.
blowing cool air from a hair dryer down the cast. Cool blown air is not harmful nor does it cause side effects.
Advise clients not to paint a fiberglass cast, but friends may Painting fiberglass interferes with its porosity.
write or draw on either type of cast.
Replace a window, a small square cut from a cast for the Replacing a window prevents the skin from bulging into the open
purpose of inspecting the skin or incision beneath a cast, by space, causing impaired skin and circulation in the area.
taping it back in place.
Ambulate clients as soon as possible or have them exercise in bed. Movement prevents complications from immobility.
Evaluation
• The cast is dry without any evidence of dents or cracks.
• The skin is warm and pink without evidence of swelling.
• Pain is absent or reduced using pain-relieving measures.
• The client is able to move fingers or toes and has normal sensory perception.
• The exposed skin at the cast edges is intact.
• There is no evidence of purulent drainage.
Document
• Date, time, and results of assessments
• Measures used to relieve swelling or itching, if any occurred
• Level of pain, pain relieving techniques, and outcome following their use
• Skin care that is provided
• To whom abnormal findings were communicated, the content of the reported information, and the response of the caregiver receiving
the information
Date and Time Long leg cast on left leg is dry and shiny, and elevated on two pillows. No evidence of dents or cracks
in cast. Toes are pink, warm, and similar in size to those on the right. Capillary refill of toes on left is
2 seconds. Can move all toes and perceives being touched. Rates pain at a level 3 and refuses any pain
relieving measures. ___________________________________________________________ SIGNATURE/TITLE
LWBK1004-C25_p537-559.indd 556 04/02/12 4:00 PM

SKILL 25-4 Caring for Clients in Traction
ASSESSMENT
Check the medical orders to determine the type of traction and Integrates nursing activities with medical treatment.
amount of weight that has been prescribed.
Note whether there is a trapeze attached to the overbed frame. Facilitates mobility and self-care.
Inspect the mechanical equipment used to apply traction. Inspection determines the status of the equipment.
Check whether traction ropes move freely through the pulleys. Fraying or knots in the traction ropes may interfere with the pull
of traction.
Determine whether the weights are hanging free of the bed or Unobstructed and unsupported weights ensure the effectiveness
floor. of traction.
Observe the client’s body position. Effective traction occurs when the body part is positioned in an
opposite line with the pull of the traction equipment.
Inspect the skin and pin sites. Pressure from traction equipment, immobility, and tissue com-
promised by skeletal pins predispose a client to impaired skin
integrity and the risk of infection.
Assess the client’s circulation and sensation in the area to which Neurovascular complications can occur when a part of the body is
traction has been applied. immobilized.
Determine the client’s last date of bowel elimination. Immobility and having to use a bedpan predisposes the client to
constipation and fecal impaction.
Note the frequency, volume, and color of urine. Certain traction positions interfere with the complete emptying
of the bladder; urinary stasis predisposes the client to stone
formation and bladder infection.
Auscultate the client’s lungs. Immobilized clients tend to breathe shallowly, creating a risk for
pneumonia.
Review the trend in the client’s temperature. An elevation in body temperature is suggestive of infection.
Assess the client’s level of pain or discomfort. Pain is the fifth vital sign.
Observe the client’s emotional state. Prolonged confinement, immobilization, and decreased sensory
stimulation place the client at risk for boredom, depression,
and loneliness.
PLANNING
Explain the purpose of the traction and the care that will follow. Adds to the client’s understanding.
IMPLEMENTATION
Keep the traction applied continuously unless there are medical Continuous traction fosters the achievement of desired out-
orders to the contrary. comes.
Raise the height of the bed to ensure that the weights hang Weights provide the musculoskeletal pull in traction.
above the floor.
Limit the client’s positions to those indicated in the medical Positions that alter the pull and counterpull of traction interfere
orders or standards for care. with therapy.
Provide for the client’s hygiene and oral needs. Clients are encouraged to perform as much self-care as possible.
Bathe the back of clients who must remain in a supine or other Facilitates skin care and hygiene.
back-lying position by depressing the mattress enough to
insert a hand.
Remove and apply bottom bed linen from the foot of the bed Maintains body alignment.
rather than turning the client from side to side.
Avoid tucking top sheets, blankets, or bedspread beneath the Bedding tucked under the mattress interferes with the pull of
mattress. traction equipment.
Do not use a pillow if the client’s head or neck is in traction Using a pillow could disturb the line of pull and counterpull.
unless medical orders indicate otherwise.
Use pressure-relieving devices (see Chaps. 23 and 28) and a Prevents impaired skin integrity.
regimen of frequent conscientious skin care if the client is
confined to bed for a prolonged time.
Insert padding within slings if they tend to wrinkle. Helps to cushion and distribute pressure, prevents interference
with circulation, and reduces the risk for skin breakdown.
Cleanse the skin around a skeletal pin insertion using an antimi- Reduces the risk of infection.
crobial agent (See Skill 25-5).
Cover the tips of protruding metal pins or other sharp traction Prevents accidental injury.
devices with corks or other protective material.
Use a small bedpan, called a “fracture pan,” if elevating the hips Ensures alignment and maintains the effectiveness of traction.
alters the line of pull.
(continued)
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Caring for Clients in Traction (continued)
Encourage isometric, isotonic, and active range-of-motion Maintains the tone, strength, and flexibility of the musculoskel-
exercises. etal system.
Provide diversional activities as often as possible. Relieves boredom and sensory deprivation.
Evaluation
• The type of traction and amount of traction weight correlates with the medical orders.
• The weights hang freely above the floor.
• There are no knots in the traction rope close to the pulleys.
• The traction ropes are unfrayed and move freely through the pulleys.
• The client lies in the center of the bed in proper alignment with the pull of the traction.
• There is a trapeze within reach of the client.
• Physical assessment data are normal.
• Hygiene is accomplished on a regular basis.
Document
• Date and time of care
• Type of traction and location of application
• Amount of weight currently applied
• Results of physical assessment
• To whom abnormal findings were reported and changes recommended as a result of the report
Date and Time Buck’s skin traction applied to left leg with 5 lbs. of weight attached. Ropes move freely through pulleys and
weights are hanging freely off the floor. Client in supine position with left leg aligned with pull of traction.
Peripheral pulses are present and strong in both extremities; capillary refill is less than 2–3 seconds in
toes on the left, the toes on the left are warm and move when instructed to do so, sensation in left foot
is normal. Skin remains intact and free of redness. Eliminating stool and urine regularly. Lung sounds
are clear upon auscultation. Pain rated at 2 which is within a tolerable range. Mood is appropriate for
situation. _________________________________________________________________________ SIGNATURE/TITLE
SKILL 25-5 Providing Pin Site Care
ASSESSMENT
Check the medical orders or standards for care regarding the Demonstrates collaboration with the medical treatment.
frequency of pin site care and the preferred cleansing agent.
Review the medical record for trends in the client’s tempera- Uses data that reflect indications of infection.
ture, white blood cell count, reports of pain, and frequency
for treating pain.
Inspect the area around the pin insertion site for redness, swell- Provides data for current and future comparisons.
ing, increased tenderness, and drainage.
Examine the pin for signs of bending or shifting. Identifies potential problems with maintaining traction and
desired position.
PLANNING
Explain the purpose and technique for pin site care to the client. Adds to the client’s understanding.
Assemble gloves, the prescribed cleansing agent (usually hydro- Contributes to organization and efficient time management.
gen peroxide or povidone iodine), and sterile cotton-tipped
applicators. Sometimes presaturated swabs are used.
Place the bed at a comfortable height. Prevents back strain.
IMPLEMENTATION
Don gloves; clean gloves can be used to hold the stick end of Prevents skin contact with blood or body fluid.
the applicator.
(continued)
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Providing Pin Site Care (continued)
Open the package containing cotton-tipped applicators without Avoids contaminating the point of contact between the applicator
touching the applicator tips. tip and the client’s skin.
Pour enough cleansing agent to saturate the dry applicators Prepares applicators for use while maintaining the sterility of the
while holding them over a basin or wastebasket. applicator tip.
Cleanse the skin at the pin site moving outward in a circular Prevents moving microorganisms toward the area of open skin.
manner (Fig. A).
Providing pin site care.
Gently remove crusted secretions. Removes debris that supports the growth of microorganisms.
Use a separate applicator for each pin site or if the site needs Prevents reintroducing microorganisms into cleaned areas.
more than one circular swipe for additional cleansing.
Avoid applying ointment to pin sites unless prescribed. Reduces retained moisture at the site and occludes drainage,
both of which increase the risk for microbial growth.
Check with the physician or infection-control policy about obtain- Aids in determining the identity of pathogenic microorganisms
ing a wound culture if purulent drainage (that which contains and the need to institute infection-control measures, such as
pus) is present. contact precautions (see Chap. 22).
Teach the client to not touch the pin sites. Prevents introducing transient and resident microorganisms into
the wound.
Discard soiled supplies in an enclosed, lined container; remove Demonstrates the principles of medical asepsis (see Chap. 10).
gloves; and wash hands or perform an alcohol-based hand rub.
Evaluation
• The skin and tissue around the pin site are free of redness, swelling, or pain.
• There is no evidence of purulent drainage.
• The client’s temperature and white blood cell count are within normal ranges.
Document
• Date, time, and location of pin site care
• Type of cleansing agent
• Appearance of the pin site and the client’s subjective remarks regarding the presence of tenderness or pain
• Collection of a wound specimen for a culture test, if ordered, and time of its delivery to the laboratory
• To whom abnormal findings were communicated, the content of the reported information, and the response of the caregiver receiving
the information
Date and Time Pin sites on medial and lateral sides of left thigh cleansed with povidone–iodine. Sites appear dry and
without evidence of inflammation. No complaints of pain or discomfort. __________ SIGNATURE/TITLE
LWBK1004-C25_p537-559.indd 559 04/02/12 4:00 PM

26 Ambulatory Aids
axillary crutches
cane On completion of this chapter, the reader should be able to:
crutches 1. Name four activities that prepare clients for ambulation.
crutch palsy 2. Give two examples of isometric exercises that tone and
dangling strengthen lower extremities.
forearm crutches 3. Identify one technique for building upper arm strength.
gluteal setting 4. Explain the reason for dangling clients or using a tilt table.
parallel bars 5. Name two devices used to assist clients with ambulation.
platform crutches 6. Give three examples of ambulatory aids.
prosthetic limb 7. Identify the most stable type of ambulatory aid.
prosthetist 8. Describe three characteristics of appropriately fitted crutches.
quadriceps setting 9. Name four types of crutch-walking gaits.
strength 10. Explain the purpose of a temporary prosthetic limb.
tilt table 11. Discuss two criteria that must be met before constructing
tone a permanent prosthetic limb.
walker 12. Name four components of above-the-knee and below-the-
walking belt knee prosthetic limbs.
13. Describe how a prosthetic limb is applied.
14. Discuss age-related changes that affect the gait and ambula-
tion of older adults.
C
lients with disorders of or injuries to the musculoskeletal system
and those who are weak or unsteady because of age-related or
neurologic problems may have difficulty walking. This chapter
provides information on nursing activities and devices used to
promote or enhance mobility.
■ Maintaining independence is important to the older person.

Mobility facilitates staying active and independent.
■ An older adult’s self-perception is often linked to their functional
ability. Functional ability involves both mobility and making adaptations
to compensate for changes occurring with aging or disease processes.
Older people may need encouragement and support to integrate adap-
tations for mobility to maintain their activities of daily living.
■ An elevated toilet seat and grab bars may be needed to improve
an older adult’s ability to transfer and to maintain independence.
560
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CHAPTER 26 Ambulatory Aids 561
PREPARING FOR AMBULATION
Debilitated clients (those who are frail or weak from pro-

longed inactivity) require physical conditioning before they
can ambulate again. Some techniques for increasing muscu-
lar strength and the ability to bear weight include performing
isometric exercises with the lower limbs, performing isot-
onic exercises with the upper arms, dangling at the bedside,
and using a device called a tilt table.
Isometric Exercises
FIGURE 26-1 Modified hand push-ups are performed by
Isometric exercises (see Chap. 24) are used to promote mus-
extending the elbows and flexing the wrists to lift the buttocks
cle tone and strength. Tone means the ability of muscles slightly off the mattress.
to respond when stimulated; strength means the power to
perform. Both tone and strength are inherent in maintain-
ing mobility. Frequent contraction of muscle fibers retains or Gluteal Setting
improves muscle tone and strength. Active people maintain Gluteal setting is the contraction and relaxation of the glu-
these two qualities through everyday activities, but inactive teal muscles (gluteus maximus, gluteus medius, and gluteus
people and those who have been immobilized in casts or minimus) to improve their strength and tone. As a group,
traction may require focused periods of exercise to reestab- the muscles in the buttocks aid in extending, abducting, and
lish their previous ability to walk. rotating the leg—functions that are essential to walking.
Quadriceps setting and gluteal setting exercises are two
types of isometric exercises that promote tone and strength Upper Arm Strengthening
in weight-bearing muscles. Both types are easily performed Clients who will use a walker, cane, or crutches need upper
in bed or in a chair. They are initiated long before the antici- arm strength. An exercise regimen to strengthen the upper
pated time when ambulation will start. Most clients can arms typically includes flexion and extension of the arms
perform these exercises independently once they have been and wrists, raising and lowering weights with the hands,
instructed (see Client and Family Teaching 26-1). squeezing a ball or spring grip, and performing modified
hand push-ups in bed (Fig. 26-1).
Quadriceps Setting
Clients perform modified push-ups (exercises in which
Quadriceps setting is an isometric exercise in which the
clients support their upper body on the arms) several ways,
client alternately tenses and relaxes the quadriceps muscles.
depending on age and condition. While sitting in bed, a cli-
This type of exercise is sometimes referred to as quad setting.
ent may lift the hips off the bed by pushing down on the mat-
The quadriceps muscles (rectus femoris, vastus intermedius,
tress with the hands. If the mattress is soft, the nurse places
vastus medialis, and vastus lateralis) cover the front and side
a block or books on the bed under the client’s hands. If a
of the thigh. Together they aid in extending the leg. Exercising
sturdy armchair is available, the client can raise his or her
the quadriceps muscles, therefore, enables clients to stand and
body from the seat while pushing on the armrests.
support their body weight.
If the client can lie on the abdomen, he or she performs
push-ups in the following sequence:
Client and Family Teaching 26-1 1. Flex the elbows.
Quadriceps and Gluteal Setting Exercises 2. Place the hands, palms down, at approximately shoulder
level.
3. Straighten the elbows to lift the head and chest off the bed.
● Tighten (contract) the quadriceps muscles by flattening
the backs of the knees into the mattress. If that is not For effectiveness, clients must perform push-ups three
possible, place a rolled towel under the knee or heel or four times a day.
before attempting to tighten the quadriceps muscles.
● Check to see that the kneecaps move upward. This is an Dangling
indication that the client is performing the exercise cor- Dangling (sitting on the edge of the bed; Fig. 26-2) helps to
rectly. normalize blood pressure, which may drop when the client
● Hold the contracted position for a count of five. rises from a reclining position (see the section on postural
● Relax and repeat two or three times each hour.
hypotension in Chap. 12; see Nursing Guidelines 26-1).
● Tighten (contract) the gluteal muscles by pinching the
cheeks of the buttocks together.
● Hold the contracted position for a count of five. Using a Tilt Table
● Relax and repeat two or three times each hour. A tilt table is a device that raises the client from a supine to a
standing position (Fig. 26-3). It helps clients adjust to being
LWBK1004-C26_p560-586.indd 561 2/6/12 9:55 PM

FIGURE 26-2 Dangling. (Copyright B. Proud.)

FIGURE 26-3 A tilt table.
upright and bearing weight on their feet. Although the tilt Just before using a tilt table, the nurse applies elastic
table is usually located in the physical therapy department, stockings (see the section on antiembolism stockings in
nurses often prepare the client for this type of preambulation Chap. 27). These stockings help to compress vein walls, thus
therapy and communicate with the therapists about the cli- preventing the pooling of blood in the extremities, which
ent’s response. may trigger fainting.
After being transferred from the bed or stretcher to the
horizontal tilt table, the client is strapped securely to prevent
a fall. The feet are positioned against the foot rest. The entire
NURSING GUIDELINES 26-1 table is then tilted in increments of 15 to 30 degrees until the
client is in a vertical position. If symptoms such as dizziness
Assisting Clients to Dangle and hypotension develop, the table is lowered or returned to
• Perform dangling before ambulating whenever a client has the horizontal position.
been inactive for an extended period. Performing dangling
before ambulating demonstrates concern for the client’s
safety.
• Place the client in a Fowler’s position for a few minutes. This
ASSISTIVE DEVICES
position maintains safety should the client become dizzy or
faint. Some clients still need assistance to ambulate independently
• Lower the height of the bed. With a lowered bed, the client even after performing strengthening exercises. Two devices
can use the floor for support. used to provide support and assistance with walking are par-
• Provide a footstool if the client’s feet do not reach the floor. allel bars and a walking belt, which is also known as a gait
A footstool is an alternative for supporting the feet. belt.
• Fold back the top linen. Linen can interfere with movement. Clients use parallel bars (a double row of stationary
• Provide the client with a robe and slippers. Doing so main- bars) as handrails to gain practice in ambulating. Sometimes
tains warmth and shows respect for the client’s modesty. a tilt table is positioned just in front of the parallel bars so
• Help the client pivot a quarter of a turn to swing the legs over
that the client can progress from being upright to actually
the side and sit on the edge of the bed. This position helps the
client adjust to the sitting position.
walking again (Fig. 26-4).
• Stay with the client until he or she no longer feels dizzy or A walking belt is applied around the client’s waist. If the
light-headed. The nurse can provide immediate assistance. client loses balance, the nurse can support him or her and pre-
vent injuries. When assisting a client to ambulate, the nurse
LWBK1004-C26_p560-586.indd 562 2/6/12 9:55 PM

FIGURE 26-4 Parallel bars.
walks alongside the client, holding the walking belt or the While ambulating, the nurse observes the client for
client’s own belt and supporting the client’s arm (Fig. 26-5). pallor, weakness, or dizziness. If fainting seems likely, the
nurse supports the client by sliding an arm under the axilla
and placing a foot to the side, forming a wide base of sup-
Gerontologic Considerations port. With the client’s weight braced, the nurse balances the
client on a hip until help arrives or slides the client down the
■ A walking or gait belt can be used to assist an older per- length of the nurse’s leg to the floor (Fig. 26-6).
son with transferring, even if the client is not ambulatory.
The older client balances on the stronger extremity while
being supported with the gait belt. The client should never Gerontologic Considerations
be forced to walk if unable.
■ Limited or unsteady mobility may be a problem for some
older adults as a result of age-related postural changes. It
may lead to the development of a swaying or shuffling gait.
As a person ages, he or she may develop flexion of the
spine, which can alter the center of gravity and may result
in an increase in falls.
■ If a client appears to have an unusual gait, assess the
feet for corns, calluses, bunions, and ingrown or very long
toenails. If any of these conditions are found, a podiatry
referral may be indicated. Vascular changes may lead to
numbness and a decreased sensory ability to perceive con-
tact with the ground, which can also change a person’s gait.
AMBULATORY AIDS
Three aids are used to help with ambulation: canes, walkers,

and crutches.
Canes
A client who has weakness on one side of the body uses a
cane, which is a handheld ambulation device made of wood
or aluminum. Aluminum canes are more common. Canes
FIGURE 26-5 Using a walking belt. have rubber tips to reduce the potential for slipping.
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FIGURE 26-6 A. One nurse guides a

client to the floor. B. A client is lowered
to the floor with two nurses. (From
Taylor, C., Lillis, C., LeMone, P., et al.
[2008]. Fundamentals of nursing [6th ed.
p. 1304]. Philadelphia: Lippincott
Williams & Wilkins.) A B
Clients may use different types of canes depending on metal buttons in the telescoping shaft can shorten or lengthen
their physical deficits. For clients who need minimal support, aluminum canes (see Client and Family Teaching 26-2).
a cane with a half-circle handle is appropriate. A T-handle When clients are beginning to use a cane, the nurse
cane has a handgrip with a slightly bent shaft, offering the assists by applying a walking belt and standing toward the
user more stability. A quad cane has four supports at the back of the client’s stronger side.
base and provides even more stability than the other types.
(Fig. 26-7).
A cane must be the right height for the client. The cane’s Client and Family Teaching 26-2
handle should be parallel with the client’s hip, providing an Using a Cane
elbow flexion of approximately 30 degrees. Removing a por- The nurse teaches the client and the family as follows:
tion of the lower end can shorten wooden canes. Depressing
● Place the cane on the stronger side of the body.
● Stand upright with the cane 4 to 6 in. (10–15 cm) to the
side of the toes.
● Move the cane forward at the same time as the weaker
extremity.
● Take the next step with the stronger extremity.
● When using stairs:
● Use a stair rail rather than the cane when going up or
down stairs, if possible.
● Take each step up with the stronger leg followed by the
weaker one. Reverse the pattern for descending the stairs.
● If there is no stair rail, advance the cane just before ris-
ing or descending with the weaker leg.
● When sitting:
● Back up to the chair until the seat is against the back of
the legs.
● Rest the cane close by.
● Grip the arm rests with both hands.
● Sit down.
● When getting up from a chair:
● Grip the arm rests while holding the cane in the
stronger hand.
● Advance the stronger leg.
● Lean forward.
● Push with both arms against the arm rests.
FIGURE 26-7 A quad cane. Note that the handle is parallel to ● Stand until balanced and any symptoms of dizziness pass.
the client’s hip. (Photo by B. Proud.)
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client releases the grip on the walker while using the free
hand to grasp the opposite arm rest and lowers himself or
herself into the chair. To rise, the client moves to the edge of
the chair and repositions the walker. After pushing up on the
arm rests with both arms until the body weight is centered,
the client uses one hand, then the other to grasp the walker.
■ Older adults sometimes use a “step-stop” pattern when

using an ambulatory aid; that is, they take one step, then
stop, and repeat again. If that is the case, encourage a
smooth, progressive cadence.
■ Some older adults develop the habit of picking up and
carrying a walker rather than having it make contact with
the floor. In these situations, the person may benefit from
another type of walker such as a walker with wheels or a
three-wheeled walker. A physical therapist can assess the
situation and recommend an appropriate walker.
■ Rubber tips and handgrips on ambulatory aids should be
kept clean and replaced when they are worn. Worn or
dirty tips and handgrips contribute to falls and unsafe
mobility.
■ Before discharging an older person who will be
using a mobility device, advise the family to make the
home safer by removing scatter rugs and ensuring that
FIGURE 26-8 Using a walker with wheels. lighting is adequate and that no electric cords are in
passageways. Furniture may have to be rearranged and
railings or grab bars may need to be added to bathrooms
and outside entrances.
Walkers ■ A ramp with a hand rail helps older adults to enter and
Clients who require considerable support and assistance leave their residence more conveniently and safely when
with balance use a walker, the most stable form of ambula- they are using an ambulatory aid.
tory aid. Examples of clients who commonly use walkers
are those beginning to ambulate after prolonged bed rest or
after hip surgery. Crutches
Standard walkers are constructed of curved aluminum Crutches, an ambulatory aid generally used in pairs, are con-
bars that form a three-sided enclosure with four legs for sup- structed of wood or aluminum. Because the use of crutches
port. Some have front wheels (Fig. 26-8) or a seat. Other requires a great deal of upper arm strength and balance, older
adaptations are made for clients who have compromised use adults or weak clients do not commonly use them.
of one or both arms or those who must use stairs. The height The three basic types of crutches are axillary, forearm,
of a walker as well as a cane is adjustable. and platform (Fig. 26-9). The most familiar type is axillary
Nurses instruct clients who use a walker to: crutches (the standard type of crutches) that have a bar that
fits beneath the axilla. Clients who need brief, temporary
• Stand within the walker
assistance with ambulation are likely to use axillary crutches.
• Hold on to the walker at the padded handgrips
Lofstrand and Canadian crutches are examples of forearm
• Pick up the walker and advance it 6 to 8 in. (15 to 20 cm)
crutches; they have an arm cuff but no axillary bar. Fore-
• Take a step forward
arm crutches generally are used by experienced clients who
• Support the body weight on the handgrips when moving
need permanent assistance with walking. Platform crutches
the weaker leg (for clients with partial or non–weight-
(crutches that support the forearm) are used by clients who
bearing on one leg)
cannot bear weight with their hands and wrists. Many clients
When the client with a walker wants to sit down, the with arthritis use them. Sometimes a client uses one axillary
technique is similar to that with a cane, with one exception. crutch and one platform crutch—for example, when one arm
When the legs are at the front of the chair seat, the client is broken.
grips an arm rest with one arm while placing the other hand Once the type of ambulatory aid is medically prescribed,
on the walker and using the stronger leg for support. The the client is measured (Skill 26-1).
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PROSTHETIC LIMBS
Some clients with leg amputations ambulate using a pros-

thetic limb (a substitute for an arm or leg) without the
assistance of crutches or other ambulatory aids. The design
of a prosthetic limb varies depending on whether the lower
extremity is amputated at the foot (Syme’s amputation), is
a below-the-knee (BK) amputation, or is an above-the-knee
(AK) amputation, or whether the entire leg and a portion of
the hip (hemipelvectomy) are removed.
Temporary Prosthetic Limb

In many cases, clients return from surgery with an immediate
postoperative prosthesis (IPOP), which is a temporary artifi-
cial limb. It consists of a walking pylon, a lightweight tube,
attached to a shell made of plaster or plastic on the stump,
and a rigid foot (Fig. 26-10). A belt with garters keeps the
temporary prosthesis in place. The belt is loosened while the
client is in bed and is tightened during ambulation. Some
IPOPs are attached to the residual limb with a pneumatic air
bag or with a clamshell design, which permits removal when
the client is not ambulating. An IPOP facilitates early ambu-
lation and promotes an intact body image immediately after
surgery. It also helps to control stump swelling.
A B C The nurse is responsible for ensuring that the incision
FIGURE 26-9 Three types of crutches: axillary (A), forearm (B), heals and that no complications, such as joint contractures or
and platform (C). infection, develop. Complications delay rehabilitation. Con-
tractures interfere with limb and prosthetic alignment, which
ultimately affects the client’s ability to walk.
Crutch-Walking Gaits
The term gait refers to one’s manner of walking. A crutch- Permanent Prosthetic Components
walking gait is the walking pattern used when ambulating Construction of a permanent prosthesis is delayed for several
with crutches; clients use some of the same gaits with walk- weeks or months until the wound heals and the stump size is
ers or canes.
The four types of crutch-walking gaits are the four-
point gait, the three-point gait (non–weight-bearing or partial
weight-bearing), the two-point gait, and the swing-through
gait (Table 26-1). The word point refers to the sum of the
crutches and legs used when performing the gait. Nurses are
responsible for assisting clients who are learning to walk
with crutches (Skill 26-2).
■ Older adults who have difficulty going up and down

stairs may consider rearranging their homes so all neces-
sary furnishings are on one level. A bedside commode
decreases the number of trips up and down stairs if the
bathroom is not on the same level as the bedroom or living
area.

FIGURE 26-10 Many amputees receive prostheses soon after
What negative consequences can occur when a client
surgery and begin learning to use them with the support of the
uses ambulatory aids?
rehabilitation team.
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TABLE 26-1 Crutch-Walking Gaits

GAIT INDICATIONS FOR USE GAIT PATTERN ILLUSTRATION
Four-point Bilateral weakness or dis- One crutch, opposite foot, other 1 4 2 3

ability such as arthritis crutch, remaining foot
or cerebral palsy
Two-point Same as for four-point, One crutch and opposite foot

but clients have more moved in unison, followed by
strength, coordination, the remaining pair
and balance
Three-point non– One amputated, injured, Both crutches move forward fol-
weight-bearing or disabled extremity lowed by the weight-bearing
(fractured leg or severe leg
ankle sprain)
Three-point partial Amputee learning to use Both crutches are advanced with
weight-bearing prosthesis, minor injury the weaker leg; the stronger
to one leg, or previous leg is placed parallel to the
injury showing signs of weaker leg
healing
Swing-through Injury or disorder affecting Both crutches are moved

one or both legs, such forward; one or both legs are
as a paralyzed client advanced beyond the crutches
with leg braces or an
amputee before being
fitted with a prosthesis
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the heel that permits compression during walking. The cli-

ent wears a sock and shoe on the prosthetic foot. The client
can vary his or her shoes, but all should be of similar height
Socket
to ensure alignment of the prosthesis and a near-normal gait
pattern.
Client Care
Nurses are responsible for managing the care of the stump
Knee and ensuring maintenance of the prosthesis (Skill 26-3).
system
Ambulation With a Lower

Limb Prosthesis
Ambulation with a lower limb prosthesis requires strength
Shank and endurance. The more natural joints that are preserved,
the more natural the gait appears, and the more easily it is
performed. To ensure as normal a gait as possible, clients
learn to stand erect and look ahead when walking. They keep
Foot-ankle the feet close together and take each step without hiking the
system hip unnaturally to swing the artificial limb forward. If using
a cane, the client holds it in the hand opposite the prosthetic
FIGURE 26-11 Components of a permanent prosthetic limb; a
limb. When going up or down stairs, curbs, or hills, the cli-
prosthesis for a BK amputation does not contain a knee system
or a thigh socket. ent moves the unaffected leg first, followed by the one with
the prosthesis.
Amputees who wish to participate in strenuous activities
relatively stable. The permanent prosthesis is custom-made such as snow skiing can use a sturdier modified prosthesis.
to conform to the stump and to meet the client’s needs.
Permanent prostheses for BK amputees include a ➧ Stop, Think, and Respond Box 26-2
socket, a shank, and an ankle/foot system. AK prosthe-
Give some reasons why amputees may abandon
ses also include a knee system to replace the knee joint rehabilitation and the use of a prosthesis; discuss
(Fig. 26-11). how clients can overcome these impediments.
The socket, a molded cone, holds the stump and ena-
bles the amputee to move the prosthesis. It is held in place
by suction or by a leather belt, also referred to as a sling.
Many clients wear one or more socks over the stump as a NURSING IMPLICATIONS
layer between the skin and the socket. Stump socks, made of
wool or cotton, come in a variety of thicknesses to accom- Many nursing diagnoses are possible for clients who need to
modate slight changes in stump size. Tube socks are not use an ambulatory aid. Applicable nursing diagnoses include
an appropriate substitute. Despite the expense, stump socks the following:
must be replaced whenever holes develop or they become
• Impaired Physical Mobility
worn; a darned stump sock can cause skin breakdown as
• Risk for Disuse Syndrome
a result of friction within the socket. Some amputees also
• Unilateral Neglect
wear a nylon sheath beneath the stump sock to wick perspi-
• Risk for Trauma
ration from the skin toward the sock and reduce friction on
• Risk for Peripheral Neurovascular Dysfunction
the skin.
• Risk for Activity Intolerance
For AK amputees, the prosthetic knee system allows
flexion and extension to accommodate sitting and a more Nursing Care Plan 26-1 demonstrates how the nurse
natural gait while walking. The knee system connects the would devise a care plan for a client with the nursing diagno-
socket to the shank of the prosthesis. sis of Impaired Physical Mobility, defined in the NANDA-I
The shank usually is shaped like a natural lower leg. It taxonomy (2012, p. 224) as a “limitation in independent,
transfers the body weight to the walking surface. The shank purposeful physical movement of the body or of one or more
is painted to resemble the client’s skin color. extremities.” This diagnosis can be used for clients who
There are two basic types of ankle/foot systems: those are completely independent; those who require help from
that have one or more moving artificial joints (articulated another person for assistance, supervision, or teaching; those
systems) and those that do not. Although articulated systems who require help from another person for assistance and a
allow more motion, the nonarticulated type has a cushion in device; or those who are totally dependent.
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N U R S I N G C A R E P L A N 2 6 - 1 Impaired Physical Mobility

Assessment • Inspect the client’s lower extremities to determine whether the
• Assess motor strength and range of motion in both lower client wears a lower limb prosthesis or a mechanical brace.
extremities. • Review the client’s health history for disorders that affect or
• Observe the client’s ability to turn himself or herself, rise impair mobility such as a previous stroke, joint disease like
from a lying or sitting position, and move from one location to arthritis, or neurologic deficits that affect balance and coordi-
another. nation such as Parkinson’s disease.
• Watch the client walk, noting whether the client has a stable or • Gather information about the client’s current use of prescrip-
unstable gait. tion and nonprescription medications and research possible
• Ask whether the client uses any type of ambulatory assistive actions or side effects that can cause sedation, dizziness, and
device like crutches, cane, or walker. physical instability.
Nursing Diagnosis. Impaired Physical Mobility related to restricted positioning, limited weight bearing, pain, and fear of am-
bulating as manifested by hip replacement surgery 3 days earlier, joint position of operative hip limited to extension, slight flexion,
and continuous abduction, partial weight bearing on operative leg with three-point gait following physical therapy instruction, and
statement, “My hip hurts and I feel so scared about walking.”
Expected Outcome. The client will ambulate 6 ft with the assistance of a walker following physical therapy on 2/10.
Instruct and supervise the client to dorsiflex, plantar flex, Active exercise and range of motion promote joint flexibility and
and perform quad-setting exercises of both lower extremi- muscle tone.
ties every hour while awake.
Maintain abduction wedge between legs to keep knees Maintaining abduction prevents the hip prosthesis from
apart at all times while in bed. becoming displaced until healing is complete.
Keep flat with slight elevation (30–45 degrees) of head. Preventing hip flexion helps to maintain the placement of the hip
prosthesis until healing is complete.
Encourage the use of a patient-controlled analgesia (PCA) Relieving pain facilitates the client’s comfort and cooperation in
pump at frequent intervals to control pain. performing rehabilitative exercise and mobility.
Transfer from the bed to a standing position at the bedside, Preventing hip flexion helps to maintain the placement of the hip
following these directions: prosthesis until healing is complete.
• Slide affected left leg to edge of bed; remove abduction
wedge.
• Have client use trapeze or elbows and hands to slide
buttocks and legs perpendicular to bed. Remind client to
avoid leaning forward and praise efforts at moving.
• Lower unaffected right foot to floor and help with lower-
ing affected left foot, keeping knees apart.
• Dangle at bedside for approximately 5 minutes.
• Apply walking safety belt around waist.
• Brace feet and pull forward on belt.
• Stand at bedside, putting only partial weight on left leg.
• Reverse actions for returning the client to bed.

• Client maintains postoperative positions as ordered by physician. • Client can transfer from bed and stand at bedside following the
• Abduction wedge is in place while client is in bed. procedure outlined in the written plan of care.
• Client performs active isotonic and isometric (quad-setting) • Client alternates full weight bearing on right leg with partial
exercises. weight bearing on left leg in preparation for ambulation in the
• Use of PCA pump reduces pain to a level that facilitates exer- physical therapy department.
cise.
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CRITICAL THINKING EXERCISES 3. After a client undergoes a total hip replacement,

which position of the operative hip is essential for the
1. Compare the differences in using two types of nurse to maintain?
ambulatory aids, such as crutches and a walker. 1. Adduction
2. Discuss stereotypes of people who use ambulatory 2. Abduction
aids. 3. Flexion
3. What are some advantages of implementing an 4. Rotation
exercise regimen to promote early ambulation? 4. Which activity is best to plan immediately after
4. What rationales could the nurse offer a client for surgery for strengthening the muscles of a client
providing an IPOP on an amputated limb? before ambulating with crutches?
1. Standing at the side of the bed
2. Balancing between parallel bars
NCLEX-STYLE REVIEW QUESTIONS 3. Lifting with the overbed trapeze
1. What is the best evidence that a client using a walker 4. Transferring from bed to a chair
is performing a three-point partial weight-bearing 5. Which of the following observations is most indica-
gait correctly? tive that the crutches a client is using need further
1. The client advances the walker and the operative adjustment?
leg while putting most of the weight on the hand 1. The client stands straight without bending forward.
grips of the walker. 2. The elbows are slightly flexed when standing in
2. The client advances the walker and the operative place.
leg while putting most of the weight on the back 3. The top bars of the crutches fit snugly into the
legs of the walker. axillae.
3. The client advances the walker and the operative 4. The wrists are hyperextended when grasping the
leg while putting most of the weight on the toes of handgrips.
the operative leg.
4. The client advances the walker and the operative
leg while putting most of the weight on the heel of
the unoperative leg.
2. When the nurse observes a client with arthritis using
a cane, which finding indicates that the client needs
more instruction about its use?
1. The client’s cane tip is covered with a rubber cap.
2. The client wears athletic shoes with nonskid soles.
3. The client uses the cane on the painful side.
4. The client holds the head up and looks straight
ahead.
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SKILL 26-1 Measuring for Crutches, Canes, and Walkers
ASSESSMENT
Check the medical orders. Collaborates nursing activities with the medical treatment.
Determine the type of ambulatory aid the client will use. Indicates the type of measurements needed.
Check agency policy about personnel responsible for measuring Complies with agency procedures; clients in health care agencies
and dispensing ambulatory aids. sometimes are referred to personnel in the physical therapy
department.
Determine the strength of the client’s arm and leg muscles. Indicates the client’s potential for weight bearing; weakness
suggests a need to measure the client in bed or for further col-
laboration with the physician concerning muscle strengthening.
PLANNING
Obtain a long tape measure. Facilitates measuring clients with a range of heights.
Wash your hands or perform an alcohol-based hand rub (see Reduces the transmission of microorganisms.
Chap. 10).
Assist the client with donning socks and walking shoes, if the Aids in more accurate measurement that accommodates added
client can stand for the measurement. height of the heel.
IMPLEMENTATION
Axillary Crutches
Assist the client who can support his or her body weight to a Positions the client in a posture for the actual use of crutches.
standing position at the bedside with supportive shoes.
Measure from the anterior skinfold of the axilla to approximately Approximates the length required for appropriate use.
4–8 in. (10–20 cm) diagonally from the foot (Fig A).
Anterior
axillary fold
Measuring for crutches in a standing position.
4-8 inches
(10–20 cm)
A
(continued)
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Measuring for Crutches, Canes, and Walkers (continued)
Place a weak client in a supine position. Simulates the client’s height in a standing position.
Measure the distance from the anterior skinfold of the axilla to Accommodates for the added height of the heel.
heel and add 2 in. (5 cm) or subtract 16 in. (40 cm) from the
client’s height (Fig. B).
+ 2 inches
Measuring for crutches in a supine
position.
Adjust the handgrips so there is 30 degrees of elbow flexion Ensures the potential for extending the elbow and supporting
and 15 degrees of wrist hyperextension when client grasps body weight.
the handgrips standing upright (Fig. C).
30 flexion
15 hyperextension
Appropriate position for handgrips.
C
(continued)
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Lengthen or shorten axillary crutches by removing wing nuts Customizes the length of the crutches according to the client’s
and replacing metal screws in the appropriate hole in the height.
stem of the crutch. Adjust handgrips in the same way (Fig. D).
Adjusting length of an axillary crutch. (Photo by B. Proud.)
Forearm Crutches
Stand the client in shoes with the elbows flexed so the crease Simulates the appropriate posture when using forearm crutches.
of the wrist is at the hip.
Measure the forearm from 3 in. below the elbow, then add the Adjusts total length to accommodate for elbow and wrist flexion.
distance between the wrist and floor (Fig. E).
30° flexion
Hip A
joint
Measuring forearm crutches. Total length C ⫽ sum of A (3 in. below elbow to wrist) ⫹ B (wrist to floor).
Hip
joint
C
Adjust the length of the forearm crutches by telescoping them Customizes the final fit.
up or down.
(continued)
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Canes
Have the client stand erect in shoes that he or she wears most Incorporates the height of the client’s shoes.
often for ambulating.
Instruct the client to avoid leaning forward or elevating the Ensures an accurate measurement.
shoulders.
Measure from the wrist to the floor. Determines the appropriate length of the cane.
Adjust the length of cane to provide 30 degrees of elbow flex- Customizes the final height of the cane.
ion with the hand on the grip.
Walkers
Have the client stand while wearing supportive shoes. Accommodates for the added height of shoes.
Measure from the mid-buttocks to the floor. Facilitates the approximate height of the walker.
Adjust the legs of the walker to provide approximately Customizes the final fit of the walker.
30 degrees of elbow flexion.
Evaluation
• The client stands upright with the shoulders relaxed.
• With axillary crutches, there is space for two fingers between the axilla and axillary bar to prevent crutch palsy (a weakened forearm,
wrist, and hand muscles from nerve impairment secondary to pressure on the brachial plexus of nerves in the axilla) from incorrectly
fitted crutches or poor posture.
• There is 30 degrees of elbow flexion and slight hyperextension of the wrist when standing in place.
Document
• Type of ambulatory aid
• Measurements for ambulatory aid
• Method for measuring client
Date and Time Measured for axillary crutches. Approximate length of crutches is 53 in. (132.5 cm) based on length from
axillary fold to heel (51 in.) while in a supine position and the addition of 2 in. ________ SIGNATURE/TITLE
SKILL 26-2 Assisting with Crutch-Walking
ASSESSMENT
Review the medical orders for the type of activity and crutch- Reflects the implementation of the medical treatment.
walking gait.
Read any previous nursing documentation regarding the client’s Provides evaluative data and indicates the need to simulate or
efforts at crutch-walking. modify nursing interventions.
Wash hands or perform an alcohol-based hand rub (see Reduces the transmission of microorganisms.
Chap. 10).
Observe the condition of the client’s axillae and palms. Provides objective data concerning the weight-bearing effects on
the upper body.
Ask the client whether there is any muscle or joint pain or Provides subjective data concerning the effects of crutch-walking
tingling or numbness in the fingers. and possible nerve irritation.
Inspect the conditions of the axillary pads and rubber crutch tips. Demonstrates concern for safety.
PLANNING
Consult with the client about the preferred time for ambulation. Shows respect for individual decision making.
Assist the client to don clothes or a robe and supportive shoes Demonstrates concern for modesty and safety.
or slippers with nonskid soles.
Apply a walking belt if the client is weak or inexperienced in the Demonstrates concern for safety.
use of crutches.
Clear a pathway where the client will ambulate. Demonstrates concern for safety.
Review the technique for performing the prescribed crutch- Reinforces prior learning.
walking gait. (continued)
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Assisting with Crutch-Walking (continued)
IMPLEMENTATION
Help the client to a standing position. Prepares the client for ambulation.
Offer the crutches and observe that they are placed 4–8 in. Forms a triangle for good balance.
(10–20 cm) to the side of the feet (Fig. A).
A tripod of support.
Remind the client to stand straight with the shoulders relaxed. Reduces muscle strain.
Position yourself to the side and slightly behind the client on the Facilitates assistance without causing interference.
weaker side (Fig. B).
Positioning for assistance. (Photo by B. Proud.)
Take hold of the walking belt. Helps steady or support the client.
Instruct the client to advance the crutches, lean forward, put Promotes walking.
some weight on the handgrips, and move one or both feet,
depending on the prescribed gait.
Remind the client to slow down if there is evidence of fatigue Demonstrates concern for the client’s well-being.
or intolerance to the activity.
(continued)
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For Sitting
Recommend backing up to the seat of the chair. Promotes a position for sitting.
Have the client place both crutches in the hand on the same Frees the opposite hand.
side as the weaker leg (Fig. C).
Sitting down.
While using the handgrips on the crutches for support, have the Reduces the potential for falling.
client grasp one armrest with the free hand.
When balanced, tell the client to lower himself or herself into Facilitates sitting.
the seat of the chair.
To get up, help the client to the edge of the chair. Facilitates using the stronger muscles of the thighs.
Instruct the client to hold the crutches upright on the weaker Positions crutches for support.
side, balancing the crutches with one hand.
Tell the client to position the weaker leg forward of the body Helps to distribute weight over the stronger leg.
and the stronger leg toward the base of the chair.
Tell the client to push on the handgrips and armrest, lean Raises the client from the chair.
forward, and press down with the stronger leg.
To Climb Stairs
Have the client use a handrail on the stronger side of the body, Balances needed support.
if possible.
Have the client transfer both crutches to the hand opposite the Frees one hand for grasping the handrail for support.
handrail.
(continued)
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Tell the client to push down on the handrail and step up with Uses the stronger muscles for bearing weight.
the good leg (Fig. D).
Climbing stairs.
Follow by raising the weaker leg. Brings both legs to the same stair.
Remind the client that when going down the stairs, the weaker Enables a safe descent.
leg is advanced first with the support of the crutches or hand-
rail; then the stronger leg is moved.
Evaluation
• Crutches fit appropriately.
• Client performs crutch-walking gait correctly.
• No fatigue or other symptoms develop.
• Client remains free of injury.
Document
• Distance ambulated
• Gait used
Date and Time Ambulated length of hospital corridor (approximately 100 ft) using crutches and a three-point non–
weight-bearing gait. No breathlessness noted. States upper arms “ache” and attributes discomfort to
“muscle strain” from previous day’s ambulation efforts. Refuses medication for muscle discomfort.
____________________________________________________________________________ SIGNATURE/TITLE
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SKILL 26-3 Applying a Leg Prosthesis
ASSESSMENT
Wash hands or perform an alcohol-based hand rub (see Chap. 10). Reduces the transmission of microorganisms.
Inspect the stump for evidence of bleeding, wound drainage, Detects complications that delay healing and rehabilitation or that
skin abrasions, blisters, and edema. interfere with ambulation.
Weigh the client at regular intervals. Helps to detect fluctuations in weight that alter the size of the
stump and the fit of the prosthesis.
Observe the ease or difficulty of inserting the stump within the Indicates changes in stump size and the need to add or decrease
socket. the numbers or thickness of stump socks.
Examine the joint connections in the prosthetic limb. Determines whether lubrication or prosthetic maintenance is
necessary; concerns about the mechanical features of the
prosthesis or its fit are referred to a prosthetist (a person who
constructs prostheses) immediately.
Inspect the shoe on the prosthetic limb for signs of wear or Establishes whether heels or the entire shoe need to be replaced
moisture. or dried.
PLANNING
Cleanse the skin on the stump each evening, not in the morning. Allows sufficient time for the skin to be moisture-free.
Rinse the soap from the stump and dry it well. Avoids skin impairment and irritation.
Encourage the client to lie supine or prone periodically during Promotes venous circulation, reduces stump edema, and avoids
the day. joint contractures.
Instruct the client to avoid crossing the legs or keeping the Prevents circulatory problems.
natural knee flexed for a prolonged period.
Wash the socket each evening with water and mild soap. Removes soil and perspiration.
Dry the socket well before application. Prevents skin breakdown.
Use a small brush to clean the valve on a prosthesis with a Removes dust and facilitates the formation of a vacuum.
suction socket.
Keep a supply of clean stump socks to facilitate a daily change Promotes cleanliness and comfort.
and a nylon sheath if one is used.
Store clean wool stump socks for several days before use. Allows the restoration of wool fiber resiliency.
Wash a nylon sheath in soapy lukewarm water, rinse well, and Maintains shape and integrity.
stretch it lengthwise before air drying; never remove water
by twisting the sheath.
Advise the client with a new prosthesis to wear it for short peri- Prevents overexertion and impaired skin integrity.
ods initially and then increase the wearing time each day.
IMPLEMENTATION
Cover the prosthetic foot with the stocking and shoe of choice. Coordinates apparel and helps to conceal the appearance of the
prosthetic limb.
Apply the nylon sheath, if used, and the appropriate number or Promotes comfort and the fit of the stump within the prosthesis.
ply of stump socks.
Place a nylon stocking over the stump sock, allowing a long por- Helps to slide the stump within the socket.
tion of the toe to extend from the base of the stump (Fig. A).
A nylon stocking covers the stump sock.
A
(continued)
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Applying a Leg Prosthesis (continued)
Stand and position the prosthetic limb next to the residual limb. Facilitates application.
Pull the toe of the nylon stocking through the valve at the base Locates the stump well within the lower area of the socket.
of the socket (Fig. B).
The nylon is pulled through the valve hole on the socket of the prosthesis.
Pump the stump up and down as the nylon stocking is com- Expels air and creates a vacuum that keeps the prosthesis
pletely removed. attached to the stump.
Replace the plug within the valve opening. Ensures the retention of vacuum suction.
Fasten all slings if other than a suction-socket type of prosthesis Secures the prosthesis to the stump.
is used.
Evaluation
• Stump size is unchanged.
• Skin is intact.
• Circulation is adequate based on similar skin color in the stump and the remaining limb.
• Joints above the amputation have full range of motion.
• Prosthesis is mechanically sound.
• Client ambulates without discomfort or injury.
Document
• Care and condition of the stump
• Care of stump socks
• Care and condition of the prosthesis
• Level of client performance in stump care and application of the prosthesis
• Client’s performance in ambulation
Date and Time Stump washed and dried by client. No evidence of skin breakdown. Soiled stump socks exchanged with
spouse for supply of clean socks. Inside of prosthetic socket cleaned and dried. Client observed while
independently donning prosthesis. Procedure completed accurately and appropriately. Ambulated for
approximately 15 min. without loss of balance or other difficulties. _______________ SIGNATURE/TITLE
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UNIT 6
1. __________________ crutches are used by clients who cannot bear weight on their hands and wrists. (Axillary, Forearm,
Platform)
2. __________________ exercises are stationary movements performed against a resistive force. (Dangling, Isometric,
Isotonic)
3. A(n) __________________ splint is made of rigid materials that maintain a body part in a functional position to prevent
contractures and muscle atrophy during periods of immobility. (inflatable, molded, traction)
4. A __________________ cast encircles one or both arms or legs and the chest or trunk. (bivalved, cylinder, spica)
5. The force of __________________ pulls objects toward the center of the earth. (density, energy, gravity)
6. Permanent shortening of muscles that resist stretching is called a __________________. (contraction, contracture,
fracture)
7. The capacity to which a person can exercise is called __________________. (fitness, power, strength)
8. The range-of-motion exercise that involves spreading the fingers and thumb as widely as possible is called
__________________. (abduction, adduction, flexion)
1. T____F____ The ability of the muscles to respond to stimulation is referred to as strength.
2. T____F____ The gluteal muscles in the buttocks aid in extending, abducting, and rotating the leg.
3. T____F____ Braces are custom-made or custom-fitted devices designed to support weakened structures.
4. T____F____ A bivalved cast is cut in two pieces lengthwise from either a body or a cylinder cast.
5. T____F____ Skin shearing is the force exerted against the surface and layers of the skin as tissues slide in opposite but
parallel directions.
6. T____F____ A trapeze is a rectangular piece of metal hung by a chain over the foot of the bed.
7. T____F____ Target heart rate means the goal for heart rate during exercise.

1. Amputation of the foot __________________
2. Metal device inserted into and through one or more broken bones to stabilize fragments during healing
__________________
3. Large cylinder cast that encircles the trunk, rather than an extremity __________________
4. Pulling effect directly exerted on a bone by attaching wires, pins, or tongs into or through it __________________
5. Field of engineering science devoted to promoting comfort, performance, and health in the workplace
__________________
580
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Activity D: 1. Match the types of mechanical immobilizing devices in Column A with their uses in Column B.
Column A Column B
1. __________________Inflatable splint A. Prevents or reduces the severity of a joint injury
2. __________________Prophylactic brace B. Prevents movement to maintain alignment during healing
3. __________________Manual traction C. Controls bleeding and swelling
4. __________________Cylinder cast D. Realigns a broken bone briefly by pulling on the body using
muscular strength
2. Match the common body positions in Column A with their descriptions in Column B.
Column A Column B
1. __________________Supine position A. Semi-prone with the right knee drawn toward the chest
2. __________________Lateral position B. Semi-sitting
3. __________________Prone position C. Side lying with the hip and knee of the top leg in flexion
4. __________________Sims’ position D. Back lying
5. __________________Fowler’s position E. Abdomen lying
6. __________________Lateral oblique position F. Side-lying
Activity E: 1. Differentiate between casts made from plaster of Paris and from fiberglass in the categories identified
below.
Plaster of Paris Fiberglass
Application
Cost
Durability
Weight
Weight bearing
Effect of water
2. Differentiate between active exercise and passive exercise in the categories listed below.
Active Exercise Passive Exercise
Definition
Uses
Examples
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1.
A B
a. Identify the devices shown in the figure.

b. What are they used for?
Activity G: A trochanter is the bony protrusion at the head of the femur near the hip. Trochanter rolls prevent the legs
from turning outward. Write in the boxes provided below the correct sequence for using trochanter rolls.
1. Roll the sheet around the blanket so that the end of each roll is underneath.
2. Fold a sheet lengthwise in half or in thirds and place it under the client’s hips.
3. Secure the rolls next to each hip and thigh.
4. Permit the leg to rest against the trochanter roll.
5. Place a rolled-up bath blanket under each end of the sheet that extends on either side of the client.

1. What is the purpose of a tilt table?
2. What are the functions of mechanical immobilization of a body part?
3. What is a cast? When is it used?
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4. What are common nursing diagnoses applicable to a client with an immobilizing device?
5. How can one maintain a good standing posture?
6. What methods are used to prevent foot drop?
7. What are seven factors that may compromise a client’s fitness and stamina?

1. Why should the nurse encourage a client who is being fitted with a prosthetic limb to lie supine or prone periodically
during the day?
2. Why are bedridden older adults prone to developing problems from skin pressure?
3. Why is it important for the nurse to provide meticulous care to a pin site?
4. Why is the Fowler’s position helpful for clients with dyspnea?
5. Why is a continuous passive motion machine used for the rehabilitation of clients who have undergone hip replacement
surgery?
1. A nurse is caring for a client recovering from hip surgery who is learning to ambulate with a walker.
a. What instructions should the nurse give to the client regarding the use of the walker?
b. How should the nurse teach this client the techniques of sitting down and rising from a chair?
2. A nurse is caring for a client who has a whiplash injury.

a. How should the nurse determine the size of the cervical collar for this client?
b. How should the nurse assess the client’s neuromuscular function during recovery?
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3. A nurse is preparing to transfer an elderly client from a bed to a chair. What general guidelines should the nurse follow
when assisting with this client transfer?
4. A nurse is caring for an obese client with cardiovascular symptoms. The physician has ordered a balanced diet and an
exercise program aimed at weight reduction for the client.
a. What methods can the nurse use to assess the client’s fitness level?
b. How is the client’s target heart rate calculated, and how does the client’s fitness influence the prescription of a
metabolic energy equivalent?
5. A nurse is caring for elderly clients at an extended care facility who can maintain some regular activity and exercise.
a. How can the nurse help to ensure that fluid intake is appropriate for these clients?
b. How can the nurse help these clients stay physically active?
6. The nurse is caring for a client who will need to use crutches.
a. How can the nurse ensure that the client will be strong enough to use crutches?
b. What kind of push-ups should the nurse teach a client who is still bedfast?
1. A nurse is caring for a 32-year-old client who is to be fitted with a prosthetic limb following a below-the-knee amputation
of his right leg. The client is struggling to accept his condition.
a. What actions can the nurse take to ensure that the prosthetic limb is comfortable for the client?
b. How can the nurse help the client begin accepting the amputation and the need for the prosthetic limb?
2. A nurse is caring for a 64-year-old client with a fractured leg in a cast following a fall. The client is taking prescribed
analgesics for pain. She has not been eating well, and her mobility is restricted.
a. What actions can the nurse take regarding the client’s nutritional intake and use of analgesics?
b. What are major concerns when caring for elderly clients with casts?
3. A nurse is providing care for a client with paraplegia who requires assistance with activities of daily living.
a. How can the nurse help to prevent disuse syndrome?
b. What positioning devices might be considered for this client?
4. A nurse is working with a client who has lost movement on one side of his body following a cerebrovascular accident.
What interventions can the nurse perform to maintain or restore functional use when caring for this client?
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1. A nurse is teaching a client with a fractured right leg how to climb stairs with a pair of crutches. Which of the following
should the nurse tell the client?
a. Step up by raising the right leg.
b. Use the handrail if it is on the right side.
c. Grasp both crutches at the handpiece in the right hand.
d. Follow the right leg with the left leg.
2. A nurse is measuring an elderly client for a cane following an ankle sprain. Which of the following actions by the nurse is
correct?
a. Instruct the client to lean forward.
b. Have the client stand barefoot with a support.
c. Ensure 40 degrees of elbow flexion with the hand on the grip.
d. Measure from the client’s wrist to the floor.
3. What guidelines should the nurse follow when applying an emergency splint to a client? Select all that apply.
a. Cover any open wounds with clean material.
b. Swab the skin using alcohol or acetone.
c. Select rigid material to provide support.
d. Use wide tape to confine the injured part to the splint.
e. Encourage the client to exercise fingers and toes frequently.
4. A nurse is caring for a client with a fractured wrist in a cylinder cast. Which of the following actions should the nurse
perform to obtain information about the client’s neuromuscular function? Select all that apply.
a. Monitor the mobility of the fingers.
b. Assess for sensation in the exposed fingers.
c. Elevate the cast on pillows or another support.
d. Apply an ice pack at the level of injury.
e. Depress nail beds and time the color return.
5. The nurse is caring for a client with impaired mobility who is to be moved to another unit of the health care facility. What
principles of body mechanics should the nurse follow to avoid self-injury when transferring the client to a wheelchair?
a. Stretch the muscles as far as possible.
b. Keep feet apart for a broad base of support.
c. Rest between periods of exertion.
d. Keep the knees bent.
e. Avoid contracting the abdominal muscles.
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LWBK1004-C26_p560-586.indd 586 2/6/12 9:55 PM
UNIT 7
The Surgical Client
27 Perioperative Care 588
28 Wound Care 610
29 Gastrointestinal Intubation 635
587
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27 Perioperative Care
anesthesiologist
anesthetist
antiembolism stockings 1. Define perioperative care.
atelectasis 2. Identify the three phases of perioperative care.
autologous transfusion 3. Differentiate inpatient from outpatient surgery.
conscious sedation 4. List at least four advantages of laser surgery.
depilatory agent 5. Discuss two methods for donating blood before surgery.
directed donors 6. Identify four major activities that nurses perform for all clients
discharge instructions immediately before surgery.
emancipated minor 7. Name three topics to address in preoperative teaching.
emboli 8. Explain the purpose of antiembolism stockings.
forced coughing 9. Name two recommended methods for removing hair when
informed consent preparing the skin for surgery.
inpatient surgery 10. List at least five items that are verified on the preoperative
intraoperative period checklist.
microabrasions 11. Name three areas of the surgical department used during the
outpatient surgery intraoperative period.
perioperative care 12. Describe the focus of nursing care during the immediate post-
plume operative period.
pneumatic compression device 13. Give four examples of common postoperative complications.
pneumonia 14. Discuss the purpose of a pneumatic compression device.
postanesthesia care unit 15. Describe at least two items of information included in dis-
postoperative care charge instructions for postsurgical clients.
postoperative period 16. Discuss at least two ways in which the surgical care of older
preoperative checklist adults differs from that of other age groups.
preoperative period
receiving room
reversal drugs
erioperative care (care that clients receive before, during, and
P
substituted judgment
surgical waiting area after surgery) is unique. The current trend is to facilitate as short
thrombophlebitis a perioperative period as possible. This trend is driven by efforts
thrombus to control health care costs by facilitating the client’s recovery in
the comfort and support of his or her home environment. This chapter
discusses the general responsibilities nurses assume when caring for
clients during the preoperative, intraoperative, and postoperative peri-
ods of perioperative care.
■ Chronic health concerns may be present in older adults and may

increase the complexity of both the preoperative, intraoperative, and
postoperative periods.
588
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CHAPTER 27 Perioperative Care 589
TABLE 27-1 Types of Surgery According to Their Urgency

TYPE DESCRIPTION EXAMPLE
Optional Surgery is performed at the client’s request. Surgery for cosmetic purposes
Elective Surgery is planned at the client’s convenience. Failure to have Surgery for the removal of a superficial cyst
the surgery does not result in catastrophe.
Required Surgery is necessary and should be done relatively promptly. Surgery for the removal of a cataract
Urgent Surgery is required promptly, within 1 or 2 days if at all possible. Surgery for the removal of a malignant tumor
Emergency Surgery is required immediately for survival. Surgery to relieve an intestinal perforation
PREOPERATIVE PERIOD performed on clients who return home the same day. It gener-
ally is reserved for clients in an optimal state of health whose
The preoperative period starts when clients, or their fami- recovery is expected to be uneventful. Advantages and disad-
lies in an emergency, learn that surgery is necessary and ends vantages of outpatient surgery are listed in Table 27-4.
when clients are transported to the operating room. This Outpatient surgical units are located in either a hospi-
period can be short or long; one major factor affecting its tal or a separate building that the hospital owns. Others are
length is the urgency with which the surgery must be per- free-standing, privately owned facilities not affiliated with a
formed (Table 27-1). hospital. The client remains in the outpatient surgical suite
for a brief time and is discharged by midafternoon or early
Inpatient Surgery evening when (1) the client is awake and alert, (2) vital signs
Surgery is performed for various reasons (Table 27-2). Inpa- are stable, (3) pain and nausea are controlled, (4) oral fluids
tient surgery is the term used for procedures performed on are retained, (5) the client voids a sufficient quantity of urine,
a client who is admitted to the hospital, expected to remain and (6) the client has received discharge instructions. If a
at least overnight, and in need of nursing care for more than complication develops, the client is transferred and admitted
1 day after surgery. All except the sickest of clients usually to a hospital unit.
are admitted the morning of the scheduled surgery. Outpatient procedures have increased dramatically as a
Many people who have inpatient surgery undergo result of advances in techniques such as those using endo-
prior laboratory and diagnostic tests. Some have met with scopes, an instrument for performing internal procedures in
an anesthesiologist (a physician who administers chemi- lieu of those requiring an incision (see Chap. 14), and lasers;
cal agents that temporarily eliminate sensation and pain; methods of anesthesia; prospective reimbursement; man-
Table 27-3) or an anesthetist (a nurse specialist who admin- aged care; and changes in Medicare and Medicaid provi-
isters anesthesia under the direction of a physician). Most sions (Smeltzer & Bare, 2009).
clients will have received preoperative instructions from
either the surgeon’s office nurse or a hospital nurse. Laser Surgery
The acronym LASER stands for light amplification by the
Outpatient Surgery stimulated emission of radiation. Lasers convert a solid, gas,
Outpatient surgery, also called ambulatory surgery and or liquid into light. When focused, the energy from the light
same-day surgery, is the term used for operative procedures is converted to heat, causing the vaporization of tissue and
TABLE 27-2 Reasons for Surgery

TYPE OF SURGERY PURPOSE EXAMPLES
Diagnostic Removal and study of tissue to make a diagnosis Breast biopsy
Biopsy of skin lesion
Exploratory More extensive means to diagnose a problem; Exploration of abdomen for unexplained pain
usually involves exploration of a body cavity or Exploratory laparoscopy
use of scopes inserted through small incisions
Curative Removal or replacement of defective tissue to Cholecystectomy
restore function Total hip replacement
Palliative Relief of symptoms or enhancement of function Resection of a tumor to relieve pressure and pain
without cure
Cosmetic Correction of defects, improvement of appearance, Rhinoplasty
or change to a physical feature Cleft lip repair
Mammoplasty
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590 UNIT 7 The Surgical Client
TABLE 27-3 Types of Anesthesia Laser technology requires unique safety precautions
TYPE DESCRIPTION
such as eye, fire, heat, and vapor protection. Depending on
the type of laser used, everyone—including the client—
General Anesthesia Eliminates all sensation and conscious-
wears goggles. In some cases, prescription glasses with side
ness or memory of the event
Inhalants Includes gas or volatile liquids
shields are sufficient, but contact lenses are not allowed.
Injectables Are given intravenously Because lasers produce heat, fire, and electrical dis-
charge, safety is paramount. Volatile substances such as
Regional Anesthesia Blocks sensation in an area, but con-
sciousness is unaffected
alcohol and acetone are not used around lasers because of
Spinal (includes Eliminates sensation in lower extremi- their flammability. Surgical instruments are coated black to
epidural) ties, lower abdomen, and pelvis avoid absorbing scattered light that causes them to heat up.
Local Blocks sensation in a circumscribed Sometimes even the client’s teeth are covered with plastic or
area of skin and subcutaneous tissue a rubber mouth guard to shield metal dental fillings. For the
Topical Inhibits sensation where directly
same reason, no jewelry is allowed.
applied in epithelial tissues such as
skin and mucous membranes When a laser is used, it releases a plume (a substance
composed of vaporized tissue, carbon dioxide, and water)
that may contain intact cells. Plumes are accompanied by
smoke, an offensive odor, and (for some) burning and itch-
coagulation of blood vessels. Examples include the carbon ing eyes. The latter effects are not hazardous and usually can
dioxide laser, the argon laser, the ruby laser, and the yttrium– be reduced with the use of smoke evacuators. The greater
aluminum–garnet (YAG) laser. concern involves the consequences of inhaling plumes. Air-
Laser surgery is used as an alternative to many previ- borne cells in the inhaled plume may contain viruses, pos-
ously conventional surgical techniques such as reattach- sibly including HIV. Although no cases of HIV transmission
ing the retina, removing skin tattoos, and revascularizing through lasers have been documented, high-efficiency respi-
ischemic heart muscle (instead of coronary artery bypass rator masks (see Chap. 22) are better than conventional sur-
graft surgery). Laser surgery offers the following advan- gical masks for reducing the risk for infection transmission.
tages:
Informed Consent
• Cost effectiveness
Regardless of whether surgery is performed conventionally,
• Reduced need for general anesthesia
endoscopically, or with a laser, clients commonly are fearful
• Smaller incisions
and anxious. They often have many questions and precon-
• Minimal blood loss
ceived ideas about what surgery involves. Health care pro-
• Reduced swelling
viders may answer some of these questions. Nevertheless,
• Less pain
the physician is responsible for providing information that
• Decreased incidence of wound infections
meets the criteria for informed consent (permission a client
• Reduced scarring
gives after an explanation of the risks, benefits, and alterna-
• Less time recuperating
tives; see Chap. 14). A signed form, witnessed by a nurse, is
evidence that consent has been obtained (Fig. 27-1).
If an adult client is confused, unconscious, or mentally
TABLE 27-4 Advantages and Disadvantages of incompetent, the client’s spouse, nearest blood relative, or
Outpatient Surgery someone with a durable power of attorney for the client’s
health care must sign the consent form. If an adult client
ADVANTAGES DISADVANTAGES
is under the influence of a mind-altering drug such as a
Lowers the surgical costs Reduces the time for narcotic or is alcohol intoxicated, obtaining consent must
because of the reduced establishing a nurse–client
use of hospital services relationship
be delayed until the drug has been metabolized. In a life-
Reduces the time spent Requires intensive preoperative threatening emergency, a court may waive the need to obtain
away from home, school, teaching in a short amount a written or verbal consent from a client who requires imme-
or place of employment of time diate surgery on the basis of substituted judgment; that is,
Interferes less with the Reduces the opportunity for the court believes that if the client had the capacity to con-
client’s usual daily routine reinforcement of teaching
Provides the potential for and for answering questions
sent, he or she would have done so. Refer to Chapter 14 for
more rest and sleep Allows for fewer delays in the elements that constitute informed consent.
before and after surgery assessing and preparing a If the client is younger than 18 years, a parent or legal
Allows more opportunity client once he or she arrives guardian must sign the consent form. In an emergency, health
for family contact and for surgery care personnel make every effort to obtain consent by tel-
support Requires that care of the client
after discharge be carried out
ephone, telegram, or fax. Adolescents younger than 18 years,
by unskilled people living independently, and supporting themselves are regarded
as emancipated minors and may sign their own consent forms.
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FIGURE 27-1 A surgical consent

form.
Each nurse must be familiar with agency policies and Preoperative Blood Donation
state laws regarding surgical consent forms. Clients must The low risk for acquiring HIV from a blood transfusion
sign the consent form before receiving any preoperative sometimes is discussed during the preoperative period.
sedatives. When the client or designated person has signed Although publicly donated blood is tested for several
the permit, an adult witness also signs it to indicate that the pathogens including HIV and hepatitis B, the potential,
client or designee signed voluntarily. This witness usually although slight, for acquiring a blood-borne disease still
is a member of the health care team or an employee in the exists. Therefore, some clients undergoing surgery donate
admissions department. The nurse is responsible for ensur- their own blood preoperatively. Predonated blood is held on
ing that all necessary parties have signed the consent form reserve in the event that the client needs a blood transfusion
and that it is in the client’s chart before the client goes to the during or after surgery. Receiving one’s own blood is called
operating room. an autologous transfusion (self-donated blood). Autologous
LWBK1004-C27_p587-609.indd 591 2/6/12 7:00 PM

transfusions also are prepared by salvaging blood lost dur- When surgery is not an emergency, the nurse performs
ing or immediately after surgery. The salvaged blood is suc- a thorough history and physical examination. He or she
tioned, cleaned, and filtered from drainage collection devices. assesses the client’s understanding of the surgical proce-
Clients who do not meet the time or health requirements dure, postoperative expectations, and ability to participate
for self-donation may select directed donors (blood donors in recovery. The nurse also considers cultural needs, specifi-
chosen from among the client’s relatives and friends). The cally as they relate to beliefs about surgery, personal privacy,
client’s siblings should not donate blood for the client. Doing and presence of family members during the preoperative
so would rule them out as future organ or tissue donors for and postoperative phases. The nurse may question the cli-
the client because antigens in the transfused blood would ent regarding strong culturally influenced feelings about dis-
sensitize the recipient, increasing the risk for organ or tis- posal of body parts and blood transfusions.
sue rejection. Also, a male sexual partner of a woman in her On admission, the nurse reviews preoperative instruc-
reproductive years should not be a directed donor to avoid tions, such as diet and fluid restrictions, bowel and skin
possible antibody reactions against a fetus in any future preparations, and the withholding or self-administration of
pregnancy. medications, to ensure that the client has followed them. If
Most authorities believe that receiving blood from the client has not carried out a specific portion of the instruc-
directed donors is no safer than receiving blood from pub- tions, the nurse immediately notifies the surgeon.
lic donors. Although predonation of blood is available in the
United States, the criteria for autologous and directed donors
(Table 27-5) vary among regions and hospitals. Because Gerontologic Considerations
directed donors must meet the same requirements as public
donors, if the intended recipient does not use the blood, it is ■ The older person should be educated about taking usual
released into the public pool and can be given to someone else. medications before surgical procedures and about resum-
ing usual or new medications after surgery.
Immediate Preoperative Care
Although some presurgical activities take place weeks in
advance, others cannot be performed until just before sur-
gery. During the immediate preoperative period—the few Pharmacologic Considerations
hours before the procedure—several major tasks must be
■ Many adults are on anticoagulation therapy—including
completed: conducting a nursing assessment, providing pre-
self-therapy with low-dose aspirin—and may need to have
operative teaching, performing methods of physical prepara-
this addressed as a preoperative consideration. Evaluate
tion, administering medications, assisting with psychosocial the person’s use of aspirin and medications containing
preparation, and completing the surgical checklist. salicylates. Ibuprofen (Advil) and naproxen (Aleve) may
also increase the risk for gastrointestinal (GI) side effects
Nursing Assessment
such as bleeding. Assessment of alternative therapies,
Nurses share with physicians the responsibility for assessing such as herbs (eg, ginkgo, ginseng), is necessary because
preoperative clients. The assessment varies depending on the these therapies may increase the risk for bleeding
urgency of the surgery and if the client is admitted the same postoperatively.
day of surgery or earlier. Although assessment of the surgi-
cal client is always necessary, the particular circumstances
dictate the extent of the process. There may not be time to The nurse identifies the client’s potential risks for
perform a detailed assessment. complications during or after the surgery. Certain surgical
TABLE 27-5 Criteria for Autologous and Directed Blood Donation

AUTOLOGOUS DONATION DIRECTED DONATION
To bank one’s own blood, the donor must: To be a directed donor, the person must:
Have a physician’s recommendation Be at least 17 years of age
Have a hematocrit within a safe range Meet all the criteria of a public donor
Be free of infection at the time of donation Have the same blood type as the potential recipient or one that is
Meet the blood collection center’s minimum weight requirement compatible
Donate 40 to 3 days before the anticipated date of use Not have received a blood transfusion within the last 6 months
Donate no more frequently than every 3–5 days; once per week Donate 20 to 3 days before the anticipated use
is preferred Be free from blood-borne pathogens and high-risk behaviors
Assume responsibility for costs above the usual processing fees
even if blood is not used
Be advised that his or her blood will be discarded if unused
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risk factors increase the likelihood of perioperative compli- free from pain or in less pain at this time, which facilitates
cations: their participation. Knowledge of what to expect on the part
of clients and family can enhance recovery from surgery.
• Extremes of age
The following are examples of information to include in
• Dehydration
preoperative teaching:
• Malnutrition
• Obesity • Preoperative medications—when they are given and their
• Smoking effects
• Diabetes • Postoperative pain control
• Cardiopulmonary disease • Explanation and description of the postanesthesia recovery
• Drug and alcohol abuse room or postsurgical protocol
• Bleeding tendencies • Discussion of the frequency of assessing vital signs and the
• Low hemoglobin and red cells use of monitoring equipment
• Pregnancy
The nurse also explains and demonstrates how to per-
Some problems, such as an unexplained elevation in form deep breathing, coughing, and leg exercises.
temperature, abnormal laboratory data, current infectious
disease, or significant deviations in vital signs, are causes for Deep Breathing
postponing or canceling the surgery (Table 27-6). Deep breathing, a form of controlled ventilation that opens
and fills small air passages in the lungs (see Chap. 21), is
Preoperative Teaching especially advantageous for clients who receive general
Preoperative teaching varies with the type of surgery and the anesthesia or who breathe shallowly after surgery because
length of hospitalization. Preoperatively, clients are alert and of pain. Deep breathing reduces the postoperative risk for
TABLE 27-6 Surgical Risk Factors and Potential Complications

VARIABLE POTENTIAL COMPLICATION
Age
Very young—Immaturity of organ systems and regulatory Respiratory obstruction, fluid overload, dehydration, hypothermia, and
mechanisms infection
Elderly—Multiple organ degeneration and slowed regulatory Decreased metabolism and excretion of anesthetics and pain
mechanisms medications, fluid overload, renal failure, formation of blood clots,
delayed wound healing, infection, confusion, and respiratory
complications
Nutritional Status
Malnourished—Low weight and nutrient deficiencies Fluid and electrolyte imbalances, cardiac dysrhythmias, delayed
wound healing, and wound infections
Obese—Stressed cardiovascular system, decreased circulation, Atelectasis, pneumonia, blood clots, delayed wound healing, wound
and decreased pulmonary function infection, delayed metabolism, and excretion of anesthetics and
pain medication
Substance Abuse
Alcohol, tobacco, sedatives—Altered respiratory function, Atelectasis, pneumonia, altered effectiveness of anesthetics and pain
nutritional status, or liver function medications, drug interactions, and drug withdrawal
Medical Problems
Immune—Allergies and immunosuppression secondary to Adverse reactions to medications, blood transfusions, or latex;
corticosteroid therapy, transplants, chemotherapy, or disinfection
eases such as AIDS
Respiratory—Acute and chronic respiratory problems and his- Atelectasis, bronchopneumonia, and respiratory failure
tory of tobacco use
Cardiovascular—Hypertension, coronary artery disease, and Hypotension, hypertension, fluid overload, congestive heart failure,
peripheral vascular disease shock, dysrhythmias, myocardial infarction, stroke, and blood clots
Hepatic—Liver dysfunction Delayed drug metabolism leading to drug toxicity, disrupted clotting
mechanisms leading to excessive bleeding or hemorrhage, confu-
sion, and increased risk for infection
Renal—Kidney disease, chronic renal insufficiency, and renal Fluid and electrolyte imbalances, congestive heart failure, dysrhyth-
failure mias, delayed excretion of drugs leading to drug toxicity
Endocrine—Diabetes Hypoglycemia, hyperglycemia, hypokalemia, infection, and delayed
wound healing
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FIGURE 27-3 Teaching the client to splint the incision and to

cough. (Photo by Ken Kasper.)
FIGURE 27-2 Teaching deep breathing. (Photo by B. Proud.)
30 minutes before coughing or splinting the incision dur-

respiratory complications such as atelectasis (airless, col- ing coughing can reduce discomfort. Methods of splinting
lapsed lung areas) and pneumonia (lung infection), both of include pressing on the incision with both hands, pressing on
which can lead to hypoxemia. a pillow placed over the incision, or wrapping a bath blanket
The nurse practices deep breathing with clients before around the client (Fig. 27-3).
they undergo surgery (Fig. 27-2). Deep breathing involves
inhaling deeply using the abdominal muscles, holding the Leg Exercises
breath for several seconds, and exhaling slowly. Pursing the Leg exercises help to promote circulation and reduce the
lips may extend the period of exhalation. Incentive spirom- risk for forming a thrombus (a stationary blood clot) in the
eters (see Chap. 21) also are used to promote deep breathing. veins. Blood clots form when venous circulation is sluggish
and when the fluid component of blood is reduced. Surgical
Coughing clients are predisposed to both. Surgical clients have reduced
Thickened respiratory secretions often accompany impaired circulatory volume because of the preoperative restriction of
ventilation. Coughing is a natural method for clearing secre- food and fluids and blood loss during surgery. Also, blood
tions from the airways. Deep breathing alone is sometimes tends to pool in the lower extremities because of the station-
sufficient to produce a natural cough. Forced coughing ary position during surgery and the clients’ reluctance to move
(coughing that is purposely produced) may not be necessary afterward. With the use of leg exercises, efforts to reduce cir-
for all postoperative clients. Forced coughing is most appro- culatory complications begin as soon as the client recovers
priate for clients who have diminished or moist lung sounds from anesthesia (see Client and Family Teaching 27-2 and
or who raise thick sputum. Nevertheless, all clients need to Fig. 27-4).
be prepared for the possibility of having to perform this tech-
nique and should receive instructions about it (see Client and
Coughing is painful for clients with abdominal or chest Client and Family Teaching 27-2
incisions. Administering pain medication approximately Performing Leg Exercises
● Sit with the head slightly raised.
Client and Family Teaching 27-1 ● Bend one knee. Raise and hold the leg above the
Performing Forced Coughing mattress for a few seconds (see Fig. 27-4).
● Straighten the raised leg.
The nurse teaches the client and the family as follows: ● Lower the leg back to the bed gradually.
● Sit upright. ● Do the same with the other leg.
● Take a slow, deep breath through the nose. ● Rest both legs on the bed.
● Make the lower abdomen rise as much as possible. ● Point the toes toward the mattress and then toward the
● Lean slightly forward. head.
● Exhale slowly through the mouth. ● Move both feet in clockwise and then counterclockwise
● Pull the abdomen inward. circles.
● Repeat, but this time cough three times in a row while ● Repeat the exercises five times at least every 2 hours
exhaling. while awake.
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Discuss reasons why surgical clients are not as active
and mobile as nonsurgical clients.
Physical Preparation
Depending on the time of admission to the hospital or surgi-
cal facility, the nurse may perform some physical prepara-
tion that includes skin preparation, attention to elimination,
restriction of food and fluids, care of valuables, donning of
surgical attire, and disposition of prostheses.
Skin Preparation
Skin preparation involves cleansing the skin and, in some
cases, hair removal because skin and hair are reservoirs for
microorganisms (Skill 27-2). The goal is to decrease tran-
sient and resident bacteria without compromising skin integ-
rity. Reducing bacteria helps to prevent postoperative wound
infections.
For planned surgery, the client may be asked to bathe
or shower twice at home with chlorhexidine gluconate for a
minimum of 2 minutes contact time; dry with a fresh, clean
dry towel; and don clean clothing afterwards (AORN, 2008).
Hair usually is not removed before surgery unless it is likely
to interfere with the incision. Shaving causes microabra-
sions (tiny cuts that provide an entrance for microorgan-
isms). For this reason, institutions are switching from razors
to electric or battery-operated clippers for hair removal.
A Depilatory agents, chemicals that remove hair, are another
alternative, but their use is associated with skin irritation
and allergic reactions. Some authorities believe that simply
washing the skin and hair is sufficient to prevent infections.
(Joanna Briggs Institute, 2007; Pfiedler Enterprises, 2009).

Correlate the potential for transmitting an infection
using a razor for presurgical skin preparation with the
B
chain of infection discussed in Chapter 10.
FIGURE 27-4 Components of leg exercises. A. Exercising the
lower legs. B. Exercising the feet.
Elimination
The nurse may need to insert an indwelling urinary catheter
Antiembolism stockings are knee-high or thigh-high (see Chap. 30) preoperatively for some surgeries, particu-
elastic stockings. They are sometimes called thromboem- larly of the lower abdomen. A distended bladder increases
bolic disorder (TED) hose. Antiembolism stockings help to the risks for bladder trauma and difficulty in performing
prevent thrombi and emboli (mobile blood clots) by com- the procedure. The catheter keeps the bladder empty during
pressing superficial veins and capillaries, redirecting more surgery. If a catheter is not inserted, the nurse instructs the
blood to larger and deeper veins, where it flows more effec- client to urinate immediately before receiving preoperative
tively toward the heart. Intermittent pneumatic compression medication.
devices (discussed later in this chapter) are used for the same Enemas or a laxative may be ordered to clean the lower
purpose but are applied postoperatively. bowel (see Chap. 31) if the client is having abdominal or pel-
Antiembolism stockings must fit the client properly vic surgery. A clean bowel allows for improved visualization
and must be applied correctly (Skill 27-1). Stockings that of the surgical site and prevents trauma to the intestines or
become dirty are laundered, during which a second pair is accidental contamination of the abdominal cavity with feces.
used. If washed by hand, the stockings are laid flat to dry to A cleansing enema or laxative is prescribed the evening
prevent loss of their elasticity. before surgery and may be repeated the morning of surgery.
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If bowel surgery is scheduled, antibiotics may be prescribed oxygenation. If a client has acrylic nails, one usually is
to destroy intestinal microorganisms. removed to attach a pulse oximeter, which measures oxygen
saturation (see Chap. 21).
Food and Fluids
The physician gives specific instructions about how long to
Dentures and Prostheses
restrict food and fluids preoperatively. Fasting from food
Depending on agency policy and the preference of the
and water from midnight onward before surgery is com-
anesthesiologist or surgeon, the client removes full or par-
mon, but the basis for the practice is now questionable. Fast-
tial dentures. Doing so prevents the dentures from causing
ing is used to reduce the potential for aspirating (inhaling)
airway obstruction during the administration of a general
stomach contents while a client is anesthetized. However,
anesthetic. Some anesthesiologists prefer that well-fitting
aspiration is uncommon today with standard practices used
dentures remain in place to preserve facial contours, but that
by those administering general anesthesia. Consequently,
information must be communicated and well documented.
the American Society of Anesthesiology (1999) recom-
When dentures are removed, they are placed in a denture
mends that healthy preoperative clients can consume clear
container and stored at the client’s bedside or with the cli-
liquids 2 hours before elective surgery, have a light break-
ent’s belongings. Other prostheses, such as artificial limbs,
fast 6 hours before a surgical procedure, and eat a heavier
also are removed unless otherwise ordered.
meal 6 to 8 hours beforehand (deAguilar-Nascimento &
Dock-Nascimento, 2010). Despite these newer recommen-
dations, old practices persist. The nurse, therefore, encour- Gerontologic Considerations
ages clients to maintain good nutrition and hydration before
the restricted time to promote nutrients, such as protein and ■ Older adults also are likely to be self-conscious when
ascorbic acid (vitamin C), which are needed for healing. dentures are removed before surgery. Collaboration with
operating room personnel regarding the removal of den-
tures, eyeglasses, and hearing aids is helpful to ensure
Gerontologic Considerations their use as much or as long as possible.
■ Older adults who rely on eyeglasses or hearing aids may
■ The period of fluid restriction before surgery may be
experience sensory deprivation if these aids are removed
shortened for older adults to reduce their risk for dehydra- before surgery or other procedures. Removal may interfere
tion and hypotension. Vital signs, weight, and sternal skin with communication or contribute to confusion and altered
turgor should be assessed before fluid restriction to serve mental status.
as a baseline for comparison.
Preoperative Medications
Valuables The anesthesiologist or surgeon orders preoperative parenteral
The nurse instructs the client preoperatively to leave valu- medications.
ables at home. If the client forgets or does not follow this
instruction, he or she must entrust valuables to a family
member. Otherwise, health care agency personnel itemize Pharmacologic Considerations
them, place them in an envelope, and lock them in a desig-
nated area. The client signs a receipt, and the nurse notes the Common preoperative medications include one or more of
items’ whereabouts in the client’s medical record. the following:
■ Anticholinergics, such as glycopyrrolate (Robinul), decrease
If the client is reluctant to remove a wedding band, the
respiratory secretions, dry mucous membranes, and prevent
nurse may slip a ribbon of gauze under the ring and then
vagal nerve stimulation during endotracheal intubation.
loop the gauze around the finger and wrist or apply adhesive ■ Antianxiety drugs, such as lorazepam (Ativan), reduce
tape around a plain wedding band. The client also removes preoperative anxiety, cause slight sedation, slow motor
eyeglasses and contact lenses, which the nurse places in a activity, and promote the induction of anesthesia.
safe location or gives to a family member. ■ Histamine-2 receptor antagonists, such as cimetidine
(Tagamet), decrease gastric acidity and volume.
Surgical Attire ■ Narcotics, such as morphine sulfate, sedate the client
Usually, clients wear a hospital gown and surgical cap to and decrease the amount of anesthesia.
the operating room. The physician may order thigh-high or ■ Sedatives, such as midazolam (Versed), promote sleep or
knee-high antiembolism stockings or order the client’s legs conscious sedation and decrease anxiety.
wrapped in elastic roller bandages (see Chap. 28) before sur- ■ Antibiotics, such as kanamycin (Kantrex), destroy enteric
gery to prevent venous stasis. microorganisms.
Hair ornaments are removed to avoid injury with equip-
ment used to administer oxygen and inhalant anesthetics. Before administering preoperative medications, the
Makeup and nail polish are omitted to facilitate assessing nurse uses at least two methods to verify the identity of the
LWBK1004-C27_p587-609.indd 596 2/6/12 7:00 PM

client. An example would be checking the client’s identifica- Preoperative Checklist

tion bracelet and asking the client to state his or her name and A preoperative checklist (Fig. 27-5) is a form that identifies
date of birth (see Chaps. 19, 32, and 34). The nurse asks about the status of essential presurgical activities and is completed
drug allergies, obtains vital signs, asks the client to void, and before surgery. The nurse verifies the following:
ensures that the surgical consent form has been signed.
• The history and physical examination have been docu-
mented.
Psychosocial Preparation • The name of the procedure on the surgical consent form
Preparing the client emotionally and spiritually is as impor- matches that scheduled in the operating room.
tant as doing so physically. Psychosocial preparation should • The surgical consent form has been signed and witnessed.
begin as soon as the client is aware that surgery is necessary. • All laboratory and diagnostic test results, such as a fast-
Anxiety and fear, if extreme, can affect a client’s condition ing blood sugar or electrocardiogram (ECG), have been
during and after surgery. Anxious clients have a poor response returned and reported if abnormal.
to surgery and are prone to complications (Heisler, 2009). • Allergies have been identified.
Many clients are fearful because they know little or noth- • The client is wearing an identification bracelet and allergy
ing about what will happen before, during, and after surgery. bracelet, if any exist.
Careful listening and explaining by the nurse about what will • The client has had nothing by mouth (NPO, nil per os)
happen and what to expect can help to allay some of these since midnight or the number of hours prescribed.
fears and anxieties. The nurse also must assess methods the • Skin preparation has been completed.
client uses for coping. Religious faith is a source of strength • Vital signs have been assessed and recorded.
for many clients; therefore, nurses facilitate contact with a • Nail polish, glasses, contact lenses, and hairpins have been
client’s clergyperson or the hospital chaplain, if requested. removed.
FIGURE 27-5 Preoperative checklist.
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• Jewelry has been removed or the wedding ring has been INTRAOPERATIVE PERIOD
secured.
• Dentures have been removed or left in place if requested The intraoperative period (the time during which the cli-
by the person administering inhalant anesthesia. ent undergoes surgery) takes place in the operating suite.
• The client is wearing only a hospital gown and hair cover. It involves transportation to a receiving room then to the
• The client has urinated. operating room where anesthesia is administered and the
• Location of intravenous (IV) site, type of IV solution, and procedure is performed. The family is directed to a surgical
rate of infusion are identified. waiting area during this time.
• The prescribed preoperative medication has been given.
The nurse is responsible for completing and signing the Receiving Room
checklist. Operating room personnel review it when they The receiving room (Fig. 27-6) is a place in the surgery
arrive to transport the client. Surgery may be delayed if the department where clients are observed until the operating
checklist is incomplete. room and surgical team are ready. In some hospitals, preop-
Emphasis has increased relative to ensuring that the erative medication is administered when clients reach the
right client has the proper procedure on the correct side (if receiving room rather than before leaving the nursing unit.
that applies). See Box 27-1 for the universal protocol devel- This practice coordinates the client’s sedation more closely
oped by The Joint Commission (2010) to prevent errors in with the actual time of surgery.
these categories. Skin preparation may be delayed until this time as well.
There is a direct relationship between the time the skin prep-
aration is performed and the rate of microbial proliferation
(Centers for Disease Control and Prevention, 2008; Odom-
B OX 2 7- 1 Universal Protocol for Preventing
Forren, 2006).
Wrong Site, Wrong Procedure,
Wrong Person Surgery
Operating Room
Preoperative Verification Process
Eventually, clients are taken to the operating room, where
• Purpose: To ensure that all of the relevant documents and
their care and safety are in the hands of a team of experts
studies are available before the start of the procedure; that
they have been reviewed; and that they are consistent with including physicians and nurses. Anesthesia is administered
each other, with the client’s expectations, and with the team’s in the operating room.
understanding of the intended client, procedure, site, and, as Various types of anesthesia cause partial or complete
applicable, any implants. Missing information or discrepan- loss of sensation with or without a loss of consciousness.
cies must be addressed before starting the procedure. They include general, regional, and local anesthesia.
• Process: An ongoing process of information gathering and
verification, beginning with the determination to do the General Anesthesia
procedure, continuing through all settings and interventions
General anesthesia acts on the central nervous system to
involved in the preoperative preparation of the client, up
produce a loss of sensation, reflexes, and consciousness.
to and including the “time out” just before the start of the
procedure. General anesthetics commonly are administered via inhaled
and intravenous routes.
Marking the Operative Site
• Purpose: To identify unambiguously the intended site of inci-
sion or insertion.
• Process: For procedures involving right/left distinction, mul-
tiple structures (such as fingers and toes), or multiple levels
(as in spinal procedures), the intended site must be marked
such that the mark will be visible after the client has been
prepped and draped.
“Time Out” Immediately Before Starting the Procedure

• Purpose: To conduct a final verification of the correct client,
procedure, site and, as applicable, implants.
• Process: Active communication among all members of the
surgical/procedure team, consistently initiated by a desig-
nated member of the team, conducted in a “fail-safe” mode;
that is, the procedure is not started until any questions or
concerns are resolved.
Adapted from The Joint Commission (2010). Accessed May 26, 2010, FIGURE 27-6 A receiving room being prepared for an incom-
from http://www.jointcommission.org/patientsafety/universalprotocol. ing client. (Photo by B. Proud.)
LWBK1004-C27_p587-609.indd 598 2/6/12 7:00 PM

Throughout the duration of and recovery from anesthe- Surgical Waiting Area
sia, the client is monitored closely for effective breathing The surgical waiting area is the room where family and
and oxygenation; effective circulatory status, including friends await information about the client. It is staffed by
blood pressure (BP) and pulse within normal ranges; effec- volunteers who provide comfort, support, and news about
tive temperature regulation; and adequate fluid balance. Dur- how the client’s surgery is progressing. Many agencies pro-
ing weaning from the anesthetic at the end of surgery, the vide food and beverages, public telephones, television, and
client’s consciousness will be elevated sufficiently for him magazines in this area. Often, the surgeon comes to the wait-
or her to follow commands and breathe independently. The ing area immediately after the procedure to contact the fam-
recovery period can be brief or long. Many effects of general ily. The family and surgeon generally go to a private room
anesthesia take some time for the client to eliminate com- where the surgeon discusses the client’s status and the pro-
pletely. Usually, clients do not remember much about the cedure so as to ensure confidentiality.
initial recovery period.
Regional Anesthesia POSTOPERATIVE PERIOD

Regional anesthesia interferes with the conduction of sensory
and motor nerve impulses to a specific area of the body. The The postoperative period begins after the operative proce-
client experiences loss of sensation and decreased mobility dure is completed and the client is transported to an area to
to the specific anesthetized area. He or she does not lose con- recover from the anesthesia and ends when the client is dis-
sciousness. Depending on the surgery, the client may receive charged. The postanesthesia care unit (PACU), also known
a sedative to promote relaxation and comfort during the pro- as the postanesthesia reacting (PAR) room or the recovery
cedure. Types of regional anesthesia include local and spinal room, is the area in the surgical department where clients
anesthesia and epidural and peripheral nerve blocks. are intensively monitored (Fig. 27-7). Nurses in the PACU
The major advantage of regional anesthesia is the ensure the safe recovery of surgical clients from anesthesia.
decreased risk for respiratory, cardiac, and GI complications. Immediate Postoperative Care
Team members must monitor the client for signs of allergic The focus of postoperative care (nursing care after surgery)
reactions, changes in vital signs, and toxic reactions. In addi- is different during the immediate postoperative period than it
tion, they must protect the anesthetized area if sensation is is later, when clients are more stable. The immediate postop-
absent because the client is at risk for injury. erative period refers to the first 24 hours after surgery. Dur-
Conscious Sedation ing this time, nurses monitor the client for complications as
Conscious sedation refers to a state in which clients are he or she recovers from anesthesia and is sufficiently stable
sedated, a state of relaxation and emotional comfort, but to be transferred to a nursing unit for continued assessment.
are not unconscious. They are free of pain, fear, and anxiety Initial Postoperative Assessments
and can tolerate unpleasant diagnostic and short therapeutic The circulating surgical nurse or anesthesiologist reports
surgical procedures, such as endoscopies or bone marrow pertinent information regarding the surgery and the client’s
aspiration, while maintaining independent cardiorespiratory
function. They can respond verbally and physically.
The intravenous route is used to administer medications
that create conscious sedation. If other routes are used, the
client must have venous access for the treatment of possible
adverse effects such as hypoxemia and central nervous system
depression. The responsibility for ensuring client safety and
comfort during sedation rests with the nurse directly involved
in the client’s care. Although numerous types of equipment
for monitoring clients are available, no equipment replaces a
nurse’s careful observations. Clients are discharged shortly
after the procedure in which conscious sedation is used.
■ Reversal drugs, medications that counteract the effects

of those used for conscious sedation, must be readily availa-
ble in case the client becomes overly sedated. Two examples
of reversal drugs are naloxone (Narcan), which is the antago-
nist for opiates like morphine, and flumazenil (Romazicon),
which reverses antianxiety drugs like midazolam (Versed).
FIGURE 27-7 A postanesthesia care unit. (Photo by B. Proud.)
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condition to the nurse in the PACU. Once the care of the client Providing Food and Oral Fluids
is transitioned to the recovery room nurse, the PACU nurse’s After surgery, the client needs to resume eating. Food and
major responsibilities are to ensure a patent airway; help to oral fluids are withheld until surgical clients are awake, are
maintain adequate circulation; prevent or assist with the man- free of nausea and vomiting, and bowel sounds are active.
agement of shock; maintain proper positions and function of Postoperative clients usually progress from a clear liquid
drains, tubes, and intravenous infusions; and detect evidence diet to a surgical soft diet unless complications develop.
of any complications. The nurse systematically checks the Nurses monitor fluid intake and output to ensure that clients
following: are adequately hydrated.
• Level of consciousness
• Vital signs Nutrition Notes
• Effectiveness of respirations
• Presence or need for supplemental oxygen ■ The postsurgical diet order may be “Progress from clear
• Condition of the wound and dressing liquids to a regular diet as tolerated.” A quick progression to
• Location of drains and drainage characteristics self-selected regular food by the second postsurgical meal
• Location, type, and rate of intravenous fluid is safe for most clients, even those who have had major GI
• Level of pain and need for analgesia surgery, and may even hasten recovery.
• Presence of a urinary catheter and urine volume
Continuing Postoperative Care

Once the client is stable, the client is readied for transport to Gerontologic Considerations
the general surgical unit where the client’s room is prepared
and assessments will continue to prevent, detect, or mini- ■ If an indwelling catheter is inserted before surgery,
mize complications. it is best to remove it as soon as possible after surgery
to prevent urinary tract infections. Prompt attention to the
Preparing the Room client’s bladder schedule is indicated to ensure adequate
The next stage of care begins with getting the client’s bed voiding amounts and timing, especially if a bedpan will be
and the environment ready. required during a period of ambulatory restrictions.
The nurses fold the top bed linen toward the foot or side
of the bed. They place the bed in a high position to facilitate
transferring the client from the stretcher. Often, they keep Promoting Venous Circulation
additional blankets ready for use because some clients feel Surgical clients ambulate with assistance as soon as possible
cold after being quiet and inactive. to reduce the potential for pulmonary and vascular compli-
Additionally, nurses assemble bedside supplies and cations. After some surgical procedures, however, antiem-
equipment that facilitate caring for the client. Potentially use- bolism stockings, leg exercises, ambulation, and elevation
ful items include oxygen equipment (see Chap. 21), a pole or of the lower extremities may not be enough to reduce swell-
electronic infusion device for continuing the administration ing of the lower extremities and the potential for thrombus
of intravenous fluids (see Chap. 16), an emesis basin if the formation.
client vomits, paper tissues, and a device for collecting and
measuring urine (see Chap. 30). Suction canisters may be Gerontologic Considerations
necessary for clients who have gastric tubes (see Chap. 29).
Monitoring for Complications ■ Muscle atrophy occurs in older adults who have been on
Postoperative clients are at risk for many complications bed rest even for 1 or 2 days. Range of motion and muscle
(Table 27-7), some of which are more likely to develop soon tone can be maintained through routine active or passive
range-of-motion exercises.
after surgery. Frequently focused assessments of the client
and equipment facilitate a safe postoperative recovery (see
Nursing Guidelines 27-1). For clients who have the potential for impaired circula-
tion in one or both extremities, a pneumatic compression
device a machine that promotes the circulation of venous
Gerontologic Considerations blood and relocation of excess fluid into the lymphatic vessels)
may be medically prescribed. Various companies make pneu-
■ The cardiac status of older adults is monitored carefully matic compression devices, but they all consist of an extrem-
after surgery because they may not be able to tolerate or ity sleeve with tubes that connect to an electrical air pump
eliminate intravenous fluids given at standard rates.
(Fig. 27-8). The device compresses the sleeved extremity
Similarly, rates of intravenous fluids may need to be
adjusted for older adults, especially if their renal or cardiac
either intermittently or sequentially from distal to proximal
status is compromised. areas. Most devices cycle on for a few seconds and then
cycle off for a longer period. Depending on the manufacturer,
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TABLE 27-7 Postoperative Complications

COMPLICATION DESCRIPTION TREATMENT
Airway occlusion Obstruction of throat Tilt the head and lift the chin
Insert an artificial airway
Hemorrhage Severe, rapid blood loss Control bleeding
Administer intravenous fluid
Replace blood
Shock Inadequate blood flow Place the client in a modified Trendelenburg position
A modified Trendelenburg position.
Replace fluids
Administer oxygen
Give emergency drugs
Pulmonary embolus Obstruction of circulation through the lung Give oxygen

as a result of a wedged blood clot that Administer anticoagulant drugs
began as a thrombus
Hypoxemia Inadequate oxygenation of blood Give oxygen
Adynamic ileus Lack of bowel motility Treat the cause
Give nothing by mouth
Insert a nasogastric tube and connect to suction
Administer intravenous fluid
Urinary retention Inability to void Insert a catheter
Wound infection Proliferation of pathogens at or beneath Cleanse with antimicrobial agents
the incision Open and drain incision
Administer antibiotics
Dehiscence Separation of incision Reinforce wound edges
Apply a binder
Evisceration Protrusion of abdominal organs through Cover with wet dressing
separated wound Reapproximate wound
pumps may cycle one to four times per minute. The nurse is
responsible for applying this device (Skill 27-3).
Other measures to prevent thrombi include drinking
plenty of fluids, avoiding long periods of sitting, keeping
the legs uncrossed (especially at the knees), ambulating, and
changing position frequently.

Compare the use of TED hose with a pneumatic com-
pression device; list advantages and disadvantages
for each.
Performing Wound Management

Nurses assess the condition of the wound and the character-
istics of drainage at least once in each shift. Dressings are
FIGURE 27-8 A pneumatic compression device. reinforced or changed if they become loose or saturated.
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Eventually, sutures or staples are removed (see Chap. 28). • How to care for the incision site
Most hospitalized clients are discharged within 3 to 5 days • Signs of complications to report
of surgery or sooner to continue their recuperation at home. • What drugs to use to relieve pain
• How to self-administer prescribed drugs
• When presurgical activity can be resumed
Gerontologic Considerations • If and how much weight can be lifted
• Which foods to consume or avoid
• When and where to return for a medical appointment
■ Wound healing in older adults may occur more slowly
because of age-related skin changes and impaired circula- The nurse gives information verbally and in written form.
tion and oxygenation. Poor hydration and nutrition further
interfere with wound healing. A registered dietitian can rec-
ommend nutritional interventions such as protein, zinc, and
vitamin C to improve wound healing. Gerontologic Considerations
■ If older adults develop postoperative infections, the mani-
festations are likely to be subtle or delayed. Older adults ■ A thorough assessment of an older client’s support sys-
are likely to have a lower “normal” temperature. Therefore, tem must be done well before discharge. It should include
it is imperative to document the client’s usual baseline tem- the ability of the support system to provide assistance
perature so that deviations can be assessed. A change in once the client is discharged. Support people should be
mental status may be an early indicator of infection. included in discharge teaching, with plenty of time to pro-
vide any return demonstration of learning regarding the
needs of the older adult. Additionally, the home’s environ-
Providing Discharge Instructions ment should be assessed before discharge for safety
The nurse provides discharge instructions (directions for issues (eg, use of scatter rugs, lighting, rails, grab bars).
managing self-care and medical follow-up) before the client ■ If the older person cannot manage his or her postopera-
leaves. Common areas to address when discharging clients tive care independently or with the assistance of support-
who have undergone surgery include the following: ive family or friends, options relative to extended or skilled
Rationales
Providing Postoperative Care
• Obtain a summary report from a PACU nurse. This report pro- • Check the incisional area and the dressing for drainage. Find-
vides current assessment data concerning the client’s progress. ings provide data concerning the status of the wound and
• Check the postoperative medical orders on the chart. The medi- blood loss.
cal orders provide instructions for individualized care. • Inspect all tubes, insertion sites, and connections. For optimal
• Assist PACU personnel to transfer the client to bed. The client outcomes, the equipment must function properly.
should be observed continuously at this time. • Check the type of intravenous fluid, rate of administration, and
• Observe the client’s respiratory pattern and auscultate the volume that remains. Findings provide data regarding fluid
lungs. Maintaining breathing is a priority for care. therapy.
• Check oxygen saturation using a pulse oximeter if the client • Monitor urination; report failure to void within 8 hours of
seems hypoxic (see Chap. 21). An oximeter indicates the qual- surgery. Failure to void indicates urinary retention.
ity of internal respiration. • Auscultate bowel sounds. Findings provide data concerning
• Administer oxygen if the oxygen saturation is less than 90% bowel motility.
or if prescribed by the physician. Oxygen administration • Assess the client’s level of pain, its location, and characteris-
increases oxygen available for binding with hemoglobin and tics. Pain indicates the need for analgesia.
for becoming dissolved in the plasma. • Administer analgesic drugs according to prescribed medical
• Note the client’s level of consciousness and response to stimu- orders, if doing so is safe. Analgesic drugs relieve pain.
lation. Findings indicate the client’s neurologic status. • Remind the client to perform leg exercises or apply antiem-
• Orient the client and instruct him or her to take several deep bolism stockings. Leg exercises and antiembolism stockings
breaths, as taught preoperatively. Deep breathing improves promote circulation.
ventilation and gas exchange. • Use a side-lying position if the client is lethargic or unrespon-
• Check vital signs. Findings provide data for assessing the cli- sive. This position prevents airway obstruction by the tongue
ent’s current general condition. and aspiration of emesis if vomiting occurs.
• Repeat vital sign assessments at least every 15 minutes until • Raise the side rails unless providing direct care. Keeping the
they are stable; then follow agency policy and retake them side rails up ensures safety.
every hour to every 4 hours depending on the client’s condition • Fasten the signal device within the client’s reach. The signal
or medical orders. Repeat assessment of vital signs provides device is a way for the client to communicate and obtain
comparative data. assistance.
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nursing care should be explored and discussed. Options for • Risk for Infection
skilled nursing or rehabilitation services may be available for • Risk for Deficient Fluid Volume
home settings. • Ineffective Breathing Pattern
• Ineffective Airway Clearance
• Risk for Impaired Gas Exchange
NURSING IMPLICATIONS • Disturbed Body Image
• Risk for Self-Health Management
Surgical clients offer unique nursing care problems. Appli-
cable nursing diagnoses include the following: Nursing Care Plan 27-1 shows how the nurse can use
the nursing process to identify and resolve a diagnosis of
• Deficient Knowledge disturbed body image, defined in the NANDA-I taxonomy
• Fear (2012, p. 291) as “confusion in (the) mental picture of one’s
• Acute Pain physical self.” This diagnosis is especially pertinent to clients
• Impaired Skin Integrity who have had their appearance altered as a result of surgery.
N U R S I N G C A R E P L A N 2 7 - 1 Disturbed Body Image

Assessment • Observe if the client seeks others to manage care for which he
• Observe the client’s reaction to his or her body changes. or she is capable.
• Note if the client refuses to touch or look at the body part that • Watch the quality and quantity of the client’s social interac-
has been altered. tions or avoidance of others.
• Scrutinize the client’s involvement, or lack of it, in learning • Listen for self-depreciating remarks or hostility toward others.
techniques for self-care or rehabilitation.
Nursing Diagnosis. Disturbed Body Image related to fear of rejection based on altered elimination secondary to a colectomy
with ileostomy as evidenced by asking that room freshener be sprayed frequently, applying perfume heavily, positioning herself more
than 5 from visitors, and stating, “I hate myself for agreeing to this operation. This ‘thing’ fills up, it bulges, and it smells. No one
will ever want to come near me again.”
Expected Outcome. The client will demonstrate acceptance and less self-consciousness about changed body image by interacting
with a visitor within 3 feet by 10/9.
Spend at least 15 minutes with the client midmorning, Social interaction not associated with performing a task commu-
midafternoon, and early evening without performing nicates interest and acceptance of the client as a worthwhile
direct care. person.
During interaction, sit within 3 of the client. Sitting closely provides evidence that closeness is not a problem.
Acknowledge verbally that the ostomy and resulting change Verbalizing what the client is implying nonverbally and actively
in elimination are difficult to accept. demonstrating shows empathy.
Offer to contact another person with an ostomy through Interacting with another person who is coping well with a similar
the United Ostomy Association. change can help the client to share feelings and acquire a dif-
ferent perspective from an objective role model.
Offer a referral to an enterostomal nurse therapist. An enterostomal nurse therapist has knowledge and skills for
managing problems experienced by clients with ostomies,
such as odor control and other wound and skin impairments.
During ostomy teaching sessions and care of the stoma, Nonverbal behavior is more accurate than verbal expressions
avoid facial expressions that may communicate disgust or during communication.
repulsion.
Use terminology such as “your stoma,” and avoid any Using inappropriate terms trivializes the significance of the issue
depersonalized or slang names for the changed body part. with which the client is coping.

• Client moved away to provide more distance during close • Client read booklet provided by the United Ostomy
interaction. Association.
• Client looked at stoma while skin care and changing of appli- • Client agreed to meet with the enterostomal therapist.
ance were demonstrated.
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CRITICAL THINKING EXERCISES 2. From whom is it most appropriate to obtain consent

to perform surgery on an adolescent with a fractured
1. The following data is reviewed by a nurse preparing tibia?
a client for surgery: The client is 60 years old; weighs 1. The client
205 lb; has a history of chronic pulmonary disease; 2. The client’s physician
quit smoking 10 years ago, vital signs are BP 140/88, 3. The client’s minister
temperature is 101.8°F, pulse is 92, and respiratory 4. The client’s parent
rate is 28 breaths per minute. Which finding is most 3. If a client who will undergo surgery is wearing a ring,
important to report to the surgeon? which action is most correct?
2. A client reports having taken only one shower with 1. Put the ring in the bedside stand.
chlorhexidine gluconate rather than two the night 2. Leave the ring on the client’s finger.
before surgery. What actions could the nurse take? 3. Give the ring to the security guard.
3. A nurse assesses a postoperative client and obtains 4. Lock the ring with his valuables.
the following data: BP 102/64, pulse rate 90, respira- 4. What is the most important nursing action after giv-
tions 32 and shallow, responds when shaken, and ing a preoperative medication containing a narcotic?
experiences nausea. What finding is most serious at 1. Raise the side rails.
this time, and what nursing actions are appropriate? 2. Help the client to the toilet.
4. A preoperative client who is Native American wants 3. Provide oral hygiene.
you to attach a dream catcher, a circular object with 4. Teach leg exercises.
a woven web, to the IV pole. What is an appropriate 5. When the nurse assesses a client postoperatively,
way to respond to the client’s request? which assessment is most indicative of shock?
1. Bounding pulse
2. Slow respirations
NCLEX-STYLE REVIEW QUESTIONS 3. Low blood pressure
1. Assuming a client is admitted the evening before 4. High body temperature
surgery, when is it best for the nurse to perform
preoperative skin antisepsis and hair removal, if the
latter is necessary, on a client who is scheduled for a
procedure at 1300?
1. The night before surgery
2. After the morning shower
3. Before transport to the receiving area
4. When in the operating room
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SKILL 27-1 Applying Antiembolism Stockings
ASSESSMENT
Review the medical orders and the nursing plan for care. Directs client care.
Chap. 10).
Check the Homans’ sign by dorsiflexing the foot and noting if the Indicates the possibility of thrombophlebitis (inflammation of a
client experiences pain in the calf. Report a positive finding. vein as a result of a thrombus).
Measure the client’s leg from the flat of the heel to the bend of Determines the length needed for knee-high or thigh-high
the knee or to midthigh. stockings.
Measure the calf or thigh circumference. Determines the size needed.
Assess the client’s understanding of the purpose and use of Determines the type and amount of health teaching needed.
elastic stockings.
Check the fit of stockings that the client is currently wearing. Identifies the potential complications from tight, loose, or wrin-
kled stockings.
PLANNING
Obtain the correct size of stockings before surgery or as soon Facilitates early preventive treatment.
as possible after they are ordered.
Plan to remove the stockings for 20 minutes once in each shift Allows for assessment and hygiene.
or at least twice a day and then reapply them.
Elevate the legs for at least 15 minutes before applying the Promotes venous circulation and avoids trapping venous blood in
stockings if the client has been sitting or standing for some the lower extremities.
time.
IMPLEMENTATION
Wash and dry the feet. Removes dirt, skin oil, and some microorganisms.
Apply corn starch or talcum powder if desired. Reduces friction when applying the stockings.
Avoid massaging the legs. Prevents dislodging a thrombus if one is present.
Turn the stockings inside out (Fig. A). Facilitates threading the stockings over the foot and leg.
Turning the stocking inside out and tucking the heel inside. (Photo by B. Proud.)
(continued)
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Applying Antiembolism Stockings (continued)
Insert the toes and pull the stocking upward a few inches until it Reduces bunching and bulkiness.
covers the foot (Fig. B).
Easing the foot section over the toe and heel. (Photo by B. Proud.)
Gather the remaining length of the stocking and pull it upward a Eases application and avoids forming wrinkles.
few inches at a time (Fig. C).
Pulling the stocking upward over the rest of the leg. (Photo by B. Proud.)
Evaluation
• Skin remains intact and circulation is adequate.
• No calf pain on dorsiflexion of the foot.
• Stockings are removed and reapplied at least b.i.d.
Document
• Removal and reapplication of elastic stockings
• To whom abnormal assessment findings have been reported and the outcome of the communication
Date and Time Toes are warm. Blood returns to nail beds within 3 seconds of compression. Skin over legs is smooth and
intact. Homans’ sign is negative. TED hose applied after bathing. ____________________ SIGNATURE/TITLE
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SKILL 27-2 Performing Presurgical Skin Preparation
ASSESSMENT
Determine that the client has followed instructions regarding Washing and rinsing with an antiseptic removes microorganisms
showering and avoiding shaving the surgical site before com- from the skin; shaving the surgical area hours or the day before
ing to the facility. surgery significantly increases the risk for a surgical site infection.
Consult the preoperative medical orders to determine if it is Studies indicate that surgical site infections are reduced by omit-
necessary to remove hair in the area of the potential surgical ting hair removal or only removing hair without a razor at or
incision. around the incision site if it will interfere with the procedure.
Wash your hands or perform an alcohol-based hand rub Reduces the transmission of microorganisms.
(see Chap. 10).
Assess the condition of the skin, looking especially for skin Indicates areas that may bleed if irritated or provide a reservoir of
lesions. microorganisms.
Explore how much the client understands about the purpose Helps to identify the extent and level of health teaching needed.
and extent of skin preparation.
PLANNING
Arrange to perform the skin preparation before the client is Reduces the time during which microorganisms will recolonize
transported for surgery. the skin.
Explain the procedure. Reduces anxiety and promotes cooperation.
Provide an opportunity for the client to don a hospital gown. Protects personal clothing and provides access for care.
Obtain electric or battery-operated clippers or depilatory agent, Provides essential supplies.
if ordered, a towel, a bath blanket, and gloves.
Braid scalp hair or use a nonflammable gel to keep hair out of Leaving scalp hair in place has not been shown to increase the
the way prior to surgical procedures in which an incision will incidence of surgical site infections and promotes a client’s
be made in the scalp. self-esteem postoperatively.
IMPLEMENTATION
(see Chap. 10) and don clean gloves.
Provide privacy. Shows respect for dignity.
Position the client so the area to be prepared is accessible. Facilitates performing the procedure.
Drape the client with a bath blanket. Maintains dignity as well as warmth.
Protect the bed with towels or a disposable pad. Contains the dispersal of loose hair.
Use a single-use hair clippers or clippers with a reusable head that Prevents transmission of microorganisms to other clients.
can be disinfected to remove hair from the designated area.
Follow the manufacturer’s directions regarding skin testing in a Determines if hypersensitivity or skin irritation develops.
small area if a depilatory is used.
Keep a depilatory away from the client’s eyes and genitalia. Reduces the potential for skin and tissue irritation.
Deposit or dispose of items used for skin antisepsis and hair Confines sources of infectious disease transmission, and restores
removal in appropriate containers. comfort and orderliness.
Remove the reusable head from a non disposable hair clipper Reduces the transmission of microorganisms.
and follow the agency’s policy for disinfection.
Remove gloves and wash hands. Reduces the transmission of microorganisms.
Return reusable clippers to their designated location and Ensures that reusable hair clippers are in working condition for
recharge the battery. future use.
Evaluation
• Skin has been prepared according to policy and medical orders
• Skin remains essentially intact
Document
• Technique for preoperative skin antisepsis (ie, bathing, showers, hair removed with clippers, depilatory, or not removed)
• Area prepared
Date and Time Client reports taking two showers with chlorhexidine gluconate the evening before surgery. No hair
removed from the potential site of the incision. Skin is intact. No evidence of lesions or body
piercings. __________________________________________________________________ SIGNATURE/TITLE
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SKILL 27-3 Applying a Pneumatic Compression Device
ASSESSMENT
Review the medical orders and the nursing plan for care. Directs client care.
Determine whether the device will be applied to one or both Gives direction for gathering assessment data and applying the
extremities. device.
Wash your hands or perform an alcohol-based hand rub Reduces the potential for the transmission of microorganisms.
(see Chap. 10).
Assess the circulation of the toes and integrity of the skin. Provides a baseline of data for future comparison.
Check the Homans’ sign (see Skill 27-1) and report if it is Indicates a possible thrombophlebitis; if positive, it is a contraindi-
positive. cation for use of a pneumatic compression device.
Measure the calf circumference and assess for pitting edema in Provides a baseline of data for future comparisons.
extremities.
Palpate the pedal pulses. Validates arterial blood flow to the foot if present and strong.
Assess the client’s understanding of the purpose and use of a Determines the type and amount of health teaching needed.
pneumatic compression device.
PLANNING
Obtain the extremity sleeves, electric air pump, and accompa- Facilitates expeditious implementation of the medical order.
nying air tubes.
Assist the client with any elimination needs. Avoids having to disconnect the equipment shortly after the
device is applied.
Arrange supplies the client may need within his or her reach, Promotes independence yet ensures that the client can call for
including the signal device. assistance.
Help the client to a position of comfort such as a supine or low Fosters rest and relaxation.
Fowler’s position.
IMPLEMENTATION
Wrap the extremity sleeve snugly around the extremity (Fig. A). Positions the sleeve where compression is desired.
Applying the extremity sleeve. (Photo by B. Proud.)
Secure the sleeve once it encircles the leg; most are secured Ensures that the sleeve will remain in the applied position.
with Velcro.
Secure the air pump to the bottom of the bed or a stable Protects the device from damage and prevents injury to staff or
surface. visitors.
(continued)
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Applying a Pneumatic Compression Device (continued)
Attach the air tubes to the ports that extend from the sleeve Provides a channel through which air is delivered to the extremity
and to the adapter within the air pump (Fig. B). sleeve.
Attaching air tubes so that the arrows align. (Photo by B. Proud.)
Check that the air tubes are unkinked and not compressed Ensures the unobstructed delivery of air.
under the client or the wheels of the bed.
Plug the air pump into an electrical outlet. Delivers power to the air pump motor.
Set the pressure on the air pump to the amount prescribed Provides intermittent compression at an appropriate pressure to
(most medical orders range from 35 to 55 mm Hg, with a promote venous circulation.
common average of 40 mm Hg).
Turn the power switch on and observe that the function lights illu- Indicates that the machine is operational.
minate during compression and turn off between compressions.
Assess the client’s circulatory status and comfort every 2–4 hours Focuses assessment on signs that indicate adverse effects.
throughout the therapeutic treatment, which is continuous
for some clients.
Remove the extremity sleeve before ambulation or other out-of- Allows freedom of movement from the tether of the air tubes and
bed activities. pump.
Discontinue the compressions if serious impairment of circula- Helps to avoid serious complications.
tion and sensation, tingling, numbness, or leg pain occurs.
Remove the extremity sleeve and assess calf size and circula- Provides comparative data with which to evaluate the therapeutic
tion to distal areas of the extremity at least once per day. response.
Apply elastic stockings and reinforce the need to perform leg Promotes venous circulation.
exercises every hour when the machine is not in use.
Place equipment in a safe area where it is available for the next use. Demonstrates regard for safety and efficient time management.
Evaluation
• Calf size is reduced or does not increase in diameter.
• Homans’ sign is negative.
• Skin in lower extremity is intact, warm, and is the appropriate color for ethnicity.
• Capillary refill is less than 2–3 seconds.
• Pedal pulses are present and strong.
Document
• Assessment findings before and after application
• Extremity to which device was applied
• Setting and duration of application
• To whom abnormal assessment findings have been reported and the outcome of the communication
Date and Time Right calf measures 18 in. (45 cm). Left calf is 20 in. (50 cm). Toes are warm. Blood returns to nail beds within
3 seconds of compression. Skin over legs is pink, warm, and intact. Homans’ sign is negative bilaterally.
Pneumatic compression device applied to calves of both legs and set at a pressure of 40 mm Hg.
__________________________________________________________________________________ SIGNATURE/TITLE
Date and Time Pneumatic compression device removed after 2 hours of use to facilitate bathing and reapplied at 40 mm Hg.
__________________________________________________________________________________ SIGNATURE/TITLE
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28 Wound Care
aquathermia pad
bandage
binder 1. Define the term wound.
capillary action 2. Name three phases of wound repair.
closed wound 3. Identify five signs and symptoms classically associated with
collagen the inflammatory response.
compresses 4. Discuss the purpose of phagocytosis, including the two types
debridement of cells involved.
dehiscence 5. Name three ways in which the integrity of a wound is restored.
douche 6. Explain first-, second-, and third-intention healing.
drains 7. Name two types of wounds.
dressing 8. State at least three purposes for using a dressing.
evisceration 9. Explain the rationale for keeping wounds moist.
first-intention healing 10. Describe two types of drains, including the purpose of each.
granulation tissue 11. Name the two major methods for securing surgical wounds
hydrotherapy together until they heal.
inflammation 12. Explain three reasons for using a bandage or binder.
irrigation 13. Discuss the purpose for using one type of binder.
leukocytes 14. Give examples of four methods used to remove nonliving
leukocytosis tissue from a wound.
macrophages 15. List three commonly irrigated structures.
Montgomery straps 16. State two uses each for applying heat and for applying cold.
necrotic tissue 17. Identify at least four methods for applying heat and cold.
open wound 18. List at least five risk factors for developing pressure ulcers.
pack 19. Discuss three techniques for preventing pressure ulcers.
phagocytosis
pressure ulcer
proliferation
B
ody tissues have a remarkable ability to recover when injured.
purulent drainage
This chapter discusses several types of tissue injury, including
regeneration
those caused by surgical incisions and prolonged pressure. It also
remodeling
resolution addresses nursing interventions to support the healing process
scar formation and actions to prevent tissue injury.
second-intention healing
sepsis
serous drainage WOUNDS
shearing force
sitz bath A wound (damaged skin or soft tissue) results from trauma (a gen-
skin tear eral term referring to injury). Examples of tissue trauma include cuts,
slough blows, poor circulation, strong chemicals, and excessive heat or cold.
soak Such trauma produces two basic types of wounds: open and closed
staples (Table 28-1).
sutures
An open wound is one in which the surface of the skin or mucous
therapeutic baths
membrane is no longer intact. It may be caused accidentally or inten-
third-intention healing
trauma tionally, as when a surgeon incises the tissue. In a closed wound, there
undermining is no opening in the skin or mucous membrane. Closed wounds occur
wound more often from blunt trauma or pressure.
610
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CHAPTER 28 Wound Care 611
TABLE 28-1 Types of Wounds Tissue injury
WOUND TYPES DESCRIPTION

Open Wounds Cellular response
Incision A clean separation of skin and tissue
with smooth, even edges
Increased membrane permeability
Laceration A separation of skin and tissue in which
the edges are torn and irregular
Abrasion A wound in which the surface layers of Swelling
skin are scraped away
Avulsion Stripping away of large areas of skin
and underlying tissue, leaving carti- Reduced local circulation
lage and bone exposed
Ulceration A shallow crater in which the skin or
the mucous membrane is missing
Puncture An opening of skin, underlying tissue, Vascular response Chemical response
or mucous membrane caused by a
narrow, sharp, pointed object
Closed Wounds Dilation, redness, Pain
and warmth
Contusion Injury to soft tissue underlying the skin
from the force of contact with a hard
object, sometimes called a bruise
Decreased function
Leukocytosis
WOUND REPAIR
Phagocytosis
Regardless of the type of wound, the body immediately
attempts to repair the injury and heal the wound. The process Wound repair
of wound repair proceeds in three sequential phases: inflam- FIGURE 28-1 The inflammatory response. The words in red are
mation, proliferation, and remodeling. the five classic signs and symptoms of inflammation.
Inflammation
Neutrophils and monocytes, specific kinds of white
Inflammation, the physiologic process immediately after
blood cells, are primarily responsible for phagocytosis,
tissue injury, lasts approximately 2 to 5 days. Its purposes
which is a process by which these cells consume pathogens,
are to (1) limit the local damage, (2) remove injured cells
coagulated blood, and cellular debris. Collectively, neu-
and debris, and (3) prepare the wound for healing. Inflam-
trophils and monocytes clean the injured area and prepare
mation progresses through several stages (Fig. 28-1).
the site for wound healing.
During the first stage, local changes occur. Immediately
following an injury, blood vessels constrict to control blood Proliferation
loss and confine the damage. Shortly thereafter, the blood Proliferation (a period during which new cells fill and seal
vessels dilate to deliver platelets that form a loose clot. The a wound) occurs from 2 days to 3 weeks after the inflamma-
membranes of the damaged cells become more permeable, tory phase. It is characterized by the appearance of granula-
causing the release of plasma and chemical substances that tion tissue (a combination of new blood vessels, fibroblasts,
transmit a sensation of discomfort. The local response pro- and epithelial cells), which is bright pink to red because of
duces the characteristic signs and symptoms of inflammation: the extensive projections of capillaries in the area.
swelling, redness, warmth, pain, and decreased function. Granulation tissue grows from the wound margin toward
A second wave of defense follows the local changes the center. It is fragile and easily disrupted by physical or
when leukocytes and macrophages (types of white blood chemical means. As more and more fibroblasts produce col-
cells) migrate to the site of injury, and the body produces lagen (a tough and inelastic protein substance), the adhesive
more and more white blood cells to take their place. Leu- strength of the wound increases. Toward the end of the pro-
kocytosis (an increased production of white blood cells) is liferative phase, the new blood vessels degenerate, causing
confirmed and monitored by counting the number and type the previously pink color to regress.
of white blood cells in a sample of the client’s blood. The Generally, the integrity of skin and damaged tissue is
laboratory test is called a white blood cell count and dif- restored by (1) resolution (a process by which damaged cells
ferential count. Increased production of white blood cells, recover and reestablish their normal function), (2) regenera-
particularly neutrophils and monocytes, suggests an inflam- tion (cell duplication), or (3) scar formation (replacement
matory and, in some cases, infectious process. of damaged cells with fibrous scar tissue). Fibrous scar tissue
LWBK1004-C28_p610-634.indd 611 04/02/12 3:15 PM

acts as a nonfunctioning patch. The extent of scar tissue that

forms depends on the magnitude of tissue damage and the
manner of wound healing (discussed later in this chapter).
Remodeling
Remodeling (a period during which the wound undergoes
changes and maturation) follows the proliferative phase and
may last 6 months to 2 years (Porth & Matfin, 2008). During
this time, the wound contracts, and the scar shrinks.
A
WOUND HEALING
Several factors affect wound healing:

• Type of wound injury
• Expanse or depth of wound
• Quality of circulation
• Amount of wound debris
• Presence of infection
• Status of the client’s health
The speed of wound repair and the extent of scar tissue
that forms depend on whether the wound heals by first, sec-
B ond, or third intention (Fig. 28-2).
First-intention healing, also called healing by primary
intention, is a reparative process in which the wound edges
are directly next to each other. Because the space between
the wound is so narrow, only a small amount of scar tissue
forms. Most surgical wounds that are closely approximated
heal by first intention (Fig. 28-3).
In second-intention healing, the wound edges are
widely separated, leading to a more time-consuming and
complex reparative process. Because the margins of the
wound are not in direct contact, the granulation tissue needs
additional time to extend across the expanse of the wound.
Generally, a conspicuous scar results. Healing by second
C intention is prolonged when the wound contains body fluid
FIGURE 28-2 A. First-intention healing. B. Second-intention or other wound debris. Wound care must be performed cau-
healing. C. Third-intention healing. tiously to avoid disrupting the granulation tissue and retard-
ing the healing process.
With third-intention healing, the wound edges are
intentionally left widely separated and are later brought
together with some type of closure material. This reparative
process results in a broad, deep scar. Generally, wounds that
heal by third intention are deep and are likely to contain exten-
sive drainage and tissue debris. To speed up healing, they may
contain drainage devices or be packed with absorbent gauze.
■ Wound healing is delayed in older adults. Regeneration

of healthy skin takes twice as long for an 80-year-old client
as it does for a 30-year-old client.
■ Age-related changes that affect wound healing include
diminished collagen and blood supply and decreased
quality of elastin. Long-term exposure to ultraviolet
FIGURE 28-3 Example of a first-intention wound healing. rays from the sun compounds these age-related changes.
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■ Factors such as depression, poor appetite, cognitive

impairments, and physical or economic barriers that inter- Gerontologic Considerations
fere with adequate nutrition in older adults may impair
wound healing. These factors may be addressed by enlist- ■ Diminished immune response from reduced T-lymphocyte
ing the assistance of registered dietitians, who can suggest cells predisposes older adults to wound infections.
appropriate nutritional interventions, and by making refer- ■ Signs of inflammation may be subtle in older adults (see
rals to community resources such as home-delivered meals Chap. 22).
or homemaker/home health aide services. ■ Diabetes or other conditions that may interfere with cir-
culation increase the older adult’s susceptibility to delayed
wound healing and wound infections.
Nutrition Notes The nurse assesses the wound to determine whether it

is intact or shows evidence of unusual swelling, redness,
■ Wounds may require increased amounts of protein
warmth, drainage, and increasing discomfort. When assess-
depending on their severity and the client’s nutritional
ing the wound it is important to look for undermining, ero-
status. For instance, pressure ulcers may increase protein
requirement by 50% to 100% depending on the stage
sion of tissue from underneath intact skin at the wound edge;
and number of ulcers, whereas minor surgery may have slough, which is dead tissue on the wound surface that is
no impact on nutrient needs. Adequate calories must be moist, stringy, yellow, tan, gray, or green; and necrotic tissue,
provided so that protein is not used for energy but for tissue which is dry, brown or black devitalized tissue (Fig. 28-4).
healing. Often, high-protein beverages are given to boost The latter two must be removed to facilitate wound healing
protein intake; they are easy to consume and may be less (see the later discussion on debridement).
filling than solid food. Two potentially serious surgical wound complications
■ Vitamin C and zinc play important roles in tissue repair include dehiscence (the separation of wound edges) and evis-
and may be given as supplements to facilitate healing. ceration (wound separation with the protrusion of organs)
(Fig. 28-5). These complications are most likely within 7 to
10 days after surgery. They may be caused by insufficient
WOUND-HEALING COMPLICATIONS dietary intake of protein and sources of vitamin C; premature
removal of sutures or staples; unusual strain on the incision
The key to wound healing is adequate blood flow to the from severe coughing, sneezing, vomiting, dry heaves, or
injured tissue. Factors that may interfere include compro- hiccupping; weak tissue or muscular support secondary to
mised circulation, infection, and purulent, bloody, or serous obesity; distention of the abdomen from accumulated intesti-
fluid accumulation that prevent skin and tissue approxima- nal gas; or compromised tissue integrity from previous surgi-
tion. In addition, excessive tension or pulling on wound cal procedures in the same area.
edges contributes to wound disruption and delays healing. The client may describe that something has “given way.”
One or several of these factors may be secondary to poor Pinkish drainage may appear suddenly on the dressing. If
nutrition, impaired inflammatory or immune responses wound disruption is suspected, the nurse positions the client to
related to drugs like corticosteroids, and obesity (see discus- put the least strain on the operated area. If evisceration occurs,
sion on surgical risks in Chap. 27). the nurse places sterile dressings moistened with normal
FIGURE 28-4 Components in wound

assessment.
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FIGURE 28-5 A. Wound dehiscence.

A B
B. Wound evisceration.
saline over the protruding organs and tissues. For any wound Gauze Dressings
disruption, the nurse notifies the physician immediately. The Gauze dressings are made of woven cloth fibers. Their
nurse must be alert for signs and symptoms of impaired blood highly absorbent nature makes them ideal for covering fresh
flow such as swelling, localized pallor or mottled appearance, wounds that are likely to bleed or wounds that exude drain-
and coolness of the tissue in the area around the wound. age. Unfortunately, gauze dressings obscure the wound and
interfere with wound assessment. Unless an ointment is used
➧ Stop, Think, and Respond Box 28-1 on the wound or the gauze is lubricated with an ointment
Discuss the signs and symptoms a person would such as petroleum, granulation tissue may adhere to the
exhibit if a wound were infected. gauze fibers and disrupt the wound when removed.
Gauze dressings usually are secured with tape. If gauze
WOUND MANAGEMENT dressings need frequent changing, Montgomery straps
(strips of tape with eyelets) may be used (Fig. 28-6). Another
Wound management involves techniques that promote method may be necessary if the client is allergic to tape (see
wound healing. Surgical wounds result from incising tissue the discussion on bandages and binders later in this chapter).
with a laser (see Chap. 27) or an instrument called a scalpel.
The primary goal of surgical or open wound management is
to reapproximate the tissue to restore its integrity.
A pressure ulcer is a wound caused by prolonged capil-
lary compression that is sufficient to impair circulation to the
skin and underlying tissue. The primary goal in managing
pressure ulcers is prevention. Once a pressure ulcer forms,
however, the nurse implements measures to reduce its size
and to restore skin and tissue integrity.
A
Wound management involves changing dressings, car-
ing for drains, removing sutures or staples when directed by
the surgeon, applying bandages and binders, and performing
wound irrigations.
Dressings
A dressing (the cover over a wound) serves one or more
purposes:
• Keeping the wound clean
• Absorbing drainage
• Controlling bleeding
• Protecting the wound from further injury
B
• Holding medication in place
• Maintaining a moist environment FIGURE 28-6 A. The adhesive outer edge of Montgomery straps
are applied to either side of a wound. B. The inner edges of
Types and sizes of dressings differ depending on their Montgomery straps are tied to hold a dressing over a wound.
purpose. The most common wound coverings are gauze, They prevent skin breakdown and wound disruption from
transparent, and hydrocolloid dressings. repeated tape removal when checking or changing a dressing.
LWBK1004-C28_p610-634.indd 614 04/02/12 3:15 PM

cian may choose to assume total responsibility for changing

the dressing—at least for the initial dressing change. Nurses,
however, commonly reinforce dressings (apply additional
absorbent layers), when dressings become moist. Reinforc-
ing a dressing prevents wicking microorganisms toward the
wound (see Chap. 10).
Because most surgical wounds are covered with gauze
dressings, this example is used when describing the technique
for changing a dressing in Skill 28-1. When using dressings
made of materials other than gauze, nurses can modify the
technique by following the manufacturer’s directions.
Drains
Drains are tubes that provide a means for removing blood
and drainage from a wound. They promote wound healing
by removing fluid and cellular debris. Although some drains
FIGURE 28-7 A transparent dressing. (Photo by B. Proud.) are placed directly within a wound, the current trend is to
insert them so that they exit from a separate location beside
Transparent Dressings the wound. This approach keeps the wound margins approx-
Transparent dressings, such as Op-Site, are clear wound cov- imated and avoids a direct entry site for pathogens. The phy-
erings. One of their chief advantages is that they allow the sician may choose to use an open or closed drain.
nurse to assess a wound without removing the dressing. In Open Drains
addition, they are less bulky than gauze dressings and do not Open drains are flat, flexible tubes that provide a pathway
require tape because they consist of a single sheet of adhe- for drainage toward the dressing. Draining occurs passively
sive material (Fig. 28-7). They commonly are used to cover by gravity and capillary action (the movement of a liquid at
peripheral and central intravenous insertion sites. Transpar- the point of contact with a solid, which in this case is the gauze
ent dressings are not absorbent; therefore, if wound drain- dressing). Sometimes, a safety pin or long clip is attached to
age accumulates, they tend to loosen. Once a dressing is no the drain as it extends from the wound. This prevents the drain
longer intact, many of its original purposes are defeated. from slipping within the tissue. As the drainage decreases,
Hydrocolloid Dressings the physician may instruct the nurse to shorten the drain, ena-
Hydrocolloid dressings, such as DuoDerm, are self-adhesive, bling healing to take place from inside toward the outside
opaque, air- and water-occlusive wound coverings (Fig. 28-8). of the wound. To shorten a drain, the nurse pulls it from the
They keep wounds moist. Moist wounds heal more quickly wound for the specified length. He or she then repositions the
because new cells grow more rapidly in a wet environment. If safety pin or clip near the wound to prevent the drain from
the hydrocolloid dressing remains intact, it can be left in place sliding back internally within the wound (Fig. 28-9).
for up to 1 week. Its occlusive nature also repels other body
substances such as urine or stool. For proper use, a hydro-
colloid dressing must be sized generously, allowing at least a
1-in. margin of healthy skin around the wound.
Dressing Changes
Health care professionals change dressings when a wound
requires assessment or care and when the dressing becomes
loose or saturated with drainage. In some cases, the physi-
FIGURE 28-9 An open drain is pulled from the wound, and the
FIGURE 28-8 A hydrocolloid dressing absorbs drainage into its excess portion is cut. A drain sponge is placed around the
matrix. drain, and the wound is covered with a gauze dressing.
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FIGURE 28-10 A Jackson-Pratt (closed) drain. (Photo by B. Proud.)
Closed Drains
Closed drains are tubes that terminate in a receptacle. Some
examples of closed drainage systems are the Hemovac and
the Jackson-Pratt drain (Fig. 28-10). Closed drains are more
B
efficient than open drains because they pull fluid by creating
a vacuum or negative pressure. This is done by opening the FIGURE 28-12 A. A technique for suture removal. B. A
technique for staple removal.
vent on the receptacle, compressing the drainage collection
chamber, then capping the vent (Fig. 28-11).
When caring for a wound with a drain, the nurse cleans
the insertion site in a circular manner from the center form a bridge that holds the two wound margins together.
outward. After cleansing, he or she places a precut drain Staples are advantageous because they do not compress the
sponge or gauze, which is open to its center, around the tissue if the wound swells.
base of the drain. An open drain may require additional Sutures and staples are left in place until the wound has
layers of gauze because the drainage does not collect in a healed sufficiently to prevent reopening. Depending on the
receptacle. location of the incision, this may be a few days to as long as
2 weeks.
Sutures and Staples The physician may direct the nurse to remove sutures
Sutures, knotted ties that hold an incision together, gener- and staples (Fig. 28-12), sometimes half on one day and the
ally are constructed from silk or synthetic materials such as other half on another day. Adhesive Steri-Strips, also known
nylon. Staples (wide metal clips) perform a similar function. as butterflies because of their winged appearance, can hold a
Staples do not encircle a wound like sutures; instead, they weak incision together temporarily. Sometimes Steri-Strips
are used instead of sutures or staples to close superficial lac-
erations.
Bandages and Binders

A bandage is a strip or roll of cloth wrapped around a body
part. One example is an Ace bandage. A binder is a type
of cloth cover generally applied to a particular body part
such as the abdomen or breast. Bandages and binders are
made from gauze, muslin, elastic rolls, and stockinette (see
Chap. 25).
Bandages and binders serve various purposes:
• Holding dressings in place, especially when tape cannot be
used or if the dressing is extremely large
• Supporting the area around a wound or injury to reduce
FIGURE 28-11 Compressing the bulb on a Jackson-Pratt drain
pain
and capping the vent reestablishes negative pressure that • Limiting movement in the wound area to promote
allows the collection of wound drainage. healing
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Roller Bandage Application briefs are an alternative to a T-binder for stabilizing absorb-
Most bandages are prepared in rolls of varying widths. The ent materials.
nurse holds the end in one hand while passing the roll around
the part being bandaged. Debridement
Nurses follow several principles when applying a roller Most wounds heal rapidly with conventional care. Never-
bandage: theless, some wounds require debridement (the removal of
• Elevate and support the limb. dead tissue) to promote healing. Four methods of debride-
• Wrap from a distal to proximal direction. ment are sharp, enzymatic, autolytic, and mechanical.
• Avoid gaps between each turn of the bandage.
• Exert equal, but not excessive, tension with each turn. Sharp Debridement
• Keep the bandage free of wrinkles. Sharp debridement is the removal of necrotic nonliving tis-
• Secure the end of the roller bandage with metal clips. sue from the healthy areas of a wound with sterile scissors,
• Check the color and sensation of exposed fingers or toes often. forceps, or other instruments (Fig. 28-15). This method
• Remove the bandage for hygiene and replace at least twice is preferred if the wound is infected because it helps the
a day. wound to heal quickly and well. The procedure is done at
the bedside or in the operating room if the wound is exten-
Six basic techniques are used to wrap a roller bandage
sive. Sharp debridement is painful, and the wound may
(Fig. 28-13): circular turn, spiral turn, spiral-reverse turn,
bleed afterward.
figure-of-eight turn, spica turn, and recurrent turn.
A circular turn is used to anchor and secure a band-
age where it starts and ends. It simply involves holding the Enzymatic Debridement
free end of the rolled material in one hand and wrapping it Enzymatic debridement involves the use of topically applied
around the area, bringing it back to the starting point. chemical substances that break down and liquefy wound
A spiral turn partly overlaps a previous turn. The amount debris. A dressing is used to keep the enzyme in contact with
of overlapping varies from one-half to three-fourths of the the wound and to help absorb the drainage. This form of deb-
width of the bandage. Spiral turns are used when wrapping ridement is appropriate for uninfected wounds or for clients
cylindrical parts of the body such as the arms and legs. who cannot tolerate sharp debridement.
A spiral-reverse turn is a modification of a spiral turn.
The roll is reversed or turned downward halfway through the Autolytic Debridement
turn. Autolytic debridement, or self-dissolution, is a painless,
A figure-of-eight turn is best when bandaging a joint natural physiologic process that allows the body’s enzymes
such as the elbow or knee. This pattern is made by making to soften, liquefy, and release devitalized tissue. It is used
oblique turns that alternately ascend and descend, simulating when a wound is small and free of infection. The main disad-
the number eight. vantage in autolysis is the prolonged time it takes to achieve
A spica turn is a variation of the figure-of-eight pattern. desired results. To accelerate autolysis, an occlusive or semi-
It differs in that the wrap includes a portion of the trunk or occlusive dressing keeps the wound moist. Because removal
chest (see spica cast, Chap. 25). of tissue debris is slow, the nurse monitors the client closely
A recurrent turn is made by passing the roll back and for signs of wound infection.
forth over the tip of a body part. Once several recurrent turns
are made, the bandage is anchored by completing the appli- Mechanical Debridement
cation with another basic turn such as the figure-of-eight Mechanical debridement involves the physical removal of
turn. A recurrent turn is especially beneficial when wrapping debris from a deep wound. One technique is the application
the stump of an amputated limb or the head. of wet-to-dry dressings. The wound is packed with moist
gauze, which is removed approximately 4 to 6 hours later
Binder Application when the gauze is dry. Dead tissue adheres to the meshwork
Binders are not used as commonly as bandages; more con- of the gauze and is removed when the dressing is changed.
venient commercial devices have largely replaced bind- Recently, the use of wet-to-dry dressings for debridement
ers. For example, brassieres frequently are used instead of has come under questioning. Some disadvantages include:
breast binders. Sometimes, after rectal or vaginal surgery, (1) impeded healing from local tissue cooling, (2) disruption
nurses apply a T-binder, which, as the name implies, looks of angiogenesis (formation of new blood vessels), and (3)
like the letter T (Fig. 28-14). T-binders are used to secure increased risk for infection from frequent dressing changes
a dressing to the anus or perineum or within the groin. (Moses, 2009). It has also been described as being nonse-
To apply a T-binder, the nurse fastens the crossbar of the lective, traumatic, painful, costly, and time-consuming. An
T around the waist. Then, he or she passes the single or alternative to wet-to-dry dressings is to use a calcium algi-
double tails between the client’s legs and pins the tails to nate dressing such as Algiderm, which consists of absorbent,
the belt. Adhesive sanitary napkins worn inside underwear nonadherent, biodegradable, nonwoven fibers derived from
LWBK1004-C28_p610-634.indd 617 04/02/12 3:16 PM

E
FIGURE 28-13 A. A circular and spiral turn. B. A spiral-reverse turn. C. A figure-of-eight turn.
D. A spica turn. E. A recurrent turn.
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A B
FIGURE 28-14 A. A single T-binder. B. A double T-binder.
seaweed and other chemicals. Its contents form a gel when in

contact with wound drainage, thus facilitating debridement
when it is removed. Calcium alginate dressings are sup-
plied in sheets, pads, and ribbons depending on the wound
requirements.
Another approach to the mechanical removal of wound FIGURE 28-15 A sharp debridement at the bedside.
debris is hydrotherapy (the therapeutic use of water), in which
the body part with the wound is submerged in a whirlpool
Wound Irrigation. Wound irrigation (Skill 28-2) gener-
tank. The agitation of the water, which contains an antiseptic,
ally is carried out just before applying a new dressing. This
softens the dead tissue. Loose debris that remains attached is
technique is best used when granulation tissue has formed.
removed afterward by sharp debridement.
Surface debris should be removed gently without disturbing
A third method for mechanically removing wound
the healthy proliferating cells.
debris is irrigation (a technique for flushing debris). An irri-
gation is used when caring for a wound and also when clean- Eye Irrigation. An eye irrigation flushes a toxic chemical
ing an area of the body such as the eyes, ears, and vagina. from one or both eyes or displaces dried mucus or other
drainage that accumulates from inflamed or infected eye
➧ Stop, Think, and Respond Box 28-2 structures (see Nursing Guidelines 28-1 and Fig. 28-16).
List an advantage and disadvantage of methods used Ear Irrigation. An ear irrigation removes debris from
for wound debridement. the ear. An ear irrigation is contraindicated if the tympanic

Rationales
Eye Irrigation
• Assemble supplies: a bulb syringe, an irrigating solution, gauze • Wipe a moistened gauze square from the nasal corner of the
squares, gloves and other standard precaution apparel, absorb- eye toward the temple; use additional gauze squares, one at a
ent pads, and at least one towel. Assembling equipment ahead time, as needed. This removes gross debris.
of time ensures organization and efficient time management. • Separate the eyelids widely with the fingers of one hand. This
• Warm the solution to approximately body temperature by plac- action widens the exposed surface area.
ing the container in warm water except when administering • Direct the solution onto the conjunctiva, holding the syringe or
emergency first aid. A warm solution is more comfortable for irrigating device about 1 in. (2.5 cm) above the eye (see Fig.
the client. 28-16). Holding the syringe away from the eye prevents injury
• Position the client with the head tilted slightly toward the side. to the cornea.
This position facilitates drainage. • Instruct the client to blink periodically. Blinking distributes
• Place absorbent material in the area of the shoulder. Use of solution under the eyelid and around the eye.
absorbent material prevents saturating the client’s gown and • Continue irrigating until the debris is removed. This accomplishes
bed linen. the desired result.
• Give the client an emesis basin to hold beneath the cheek. The • Dry the client’s face and replace a wet gown or linen. These
basin can be used to collect the irrigating solution. actions promote client comfort.
• Wash hands or use an alcohol-based hand rub and don gloves. • Dispose of soiled materials and gloves; wash hands. These
Hand hygiene and glove use reduce the transmission of micro- measures reduce the transmission of microorganisms.
organisms. • Record assessment data, the specifics of the procedure, and the
• Open and prepare supplies. This enables the nurse to perform outcome. Documentation records performance of the nursing
the irrigation efficiently. intervention and the client’s response.
LWBK1004-C28_p610-634.indd 619 04/02/12 3:16 PM

FIGURE 28-16 Eye irrigation. (Photo by B. Proud.)
membrane (eardrum) is perforated. Performing a gross inspec-

tion of the ear is important if a foreign body is suspected
because a bean, pea, or other dehydrated substance can swell
if the ear is irrigated, causing it to become even more tightly
fixed. Solid objects may require removal with an instrument.
If an ear irrigation is not contraindicated, it is per-
formed much like an eye irrigation except that the nurse
directs the solution toward the roof of the auditory canal
(Fig. 28-17). Also, the nurse takes care to avoid occluding
B
the ear canal with the tip of the syringe because the pressure
of the trapped solution could rupture the eardrum. After the FIGURE 28-17 (A. and B.) Ear irrigation.
irrigation, the nurse places a cotton ball loosely within the
ear to absorb drainage but not to obstruct its flow.
Vaginal Irrigation. A vaginal irrigation, also known as a The terms hot and cold are subject to wide interpreta-
douche (a procedure for cleansing the vaginal canal), is some- tion. Table 28-2 correlates common terms with temperature
times necessary to treat an infection (see Client and Family ranges. Because exposing the skin to extremes of tempera-
Teaching 28-1). ture can result in injuries, the nurse assesses the temperature
of the application and frequently monitors the condition of
Heat and Cold Applications the skin. Direct contact between the skin and the heating or
Heat and cold have various therapeutic uses (Box 28-1), and cooling device is avoided. Hot and cold applications are used
each can be used in several ways. Examples include an ice bag, cautiously in children younger than 2 years, older adults, cli-
collar, chemical pack, compress, and aquathermia pad. Heat ents with diabetes, and clients who are comatose or neuro-
is also applied with soaks, moist packs, and therapeutic baths. logically impaired.
Client and Family Teaching 28-1 ● Clamp the tubing (on reusable equipment) and fill the
Douching reservoir bag.
● Undress and lie down in the bathtub.
The nurse teaches the client or the family as follows:
● Suspend the douche bag (if used) about 18–24 in.
● Do not douche routinely because douching removes (45–60 cm) above the hips.
microbes, called Döderlein bacilli, that help prevent ● Insert the lubricated tip of the nozzle or the prefilled con-
vaginal infections. tainer downward and backward within the vagina about
● Do not douche 24–48 hours before a Pap test (see the distance of a tampon.
Chap. 14). Douching may wash away diagnostic cells. ● Unclamp the tubing and rotate the nozzle as the fluid is
● Consult a physician about symptoms such as itching, instilled.
burning, or drainage rather than attempting self-diagnosis. ● Contract the perineal muscles as though trying to stop
● Find out from the physician if sexual partners also need to urinating and then relax the muscles. Repeat the exercise
be treated with medications to avoid reinfection. four or five times while douching.
● Buy douching equipment from a drugstore; prefilled dis- ● Sit up to facilitate drainage or shower afterward.
posable containers are available. ● Use a sanitary napkin or perineal pad to absorb residual
● Warm the solution to a comfortable temperature (no drainage.
more than 110°F [43.3°C]).
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B OX 2 8 - 1 Common Uses for Heat and Cold

Applications
USES FOR HEAT USES FOR COLD
• Provides warmth • Reduces fevers

• Promotes circulation • Prevents swelling
• Speeds healing • Controls bleeding
• Relieves muscle spasm • Relieves pain
• Reduces pain • Numbs sensation
■ The risk for thermal skin injury is increased in older

adults with impaired tactile sensation or sensory nerve FIGURE 28-18 An ice bag filled with crushed ice.
damage because of circulatory or neurological disorders.
Older adults who have problems with the ability to sense
temperatures need to take special precautions such as the compress, and the area is secured in a towel. As the com-
using a thermometer to ensure that applications involving press material cools or warms outside the range of the intended
heat are less than 100°F (38°C) to avoid burns or injury. temperature, the nurse removes it and reapplies it if necessary.
If the skin is not intact, as in the case of a draining
Ice Bag and Ice Collar wound, nurses wear gloves when applying a compress. They
Ice bags and ice collars are containers for holding crushed use aseptic surgical technique when applying compresses to
ice or small ice cubes (Fig. 28-18). Ice collars usually are an open wound.
applied after tonsil removal. Ice bags are applied to any
Aquathermia Pad
small injury in the process of swelling. Although ice bags
An aquathermia pad (an electrical heating or cooling device)
are available commercially, they can also be improvised. A
is sometimes called a K-pad. It resembles a mat but contains
rubber or plastic glove, a plastic bag with a zipper closure, or
hollow channels through which heated or cooled distilled water
a bag of small frozen vegetables, such as peas, can be used.
circulates (Fig. 28-19). An aquathermia pad is used alone or
Client instruction minimizes the risk for injury (see Client
as a cover over a compress. A thermostat is used to keep the
temperature of the water at a specified setting. As with other
Chemical Packs forms of hot and cold therapeutic devices, the nurse assesses
Commercial cold packs are struck or crushed to activate the the skin frequently and removes the device periodically.
chemicals inside, causing them to become cool. Most first- Before placing the client on the aquathermia pad or wrap-
aid kits generally include this type of cold pack. Commercial ping it around a body part, the nurse covers the pad to help
cold packs can be used only once. Gel packs, designed for prevent thermal skin damage. A roller bandage may help hold
cold or hot application, are reusable. They are stored in the the pad in place. The nurse positions the electrical unit slightly
freezer until needed or heated in a microwave. higher than the client to promote gravity circulation of the fluid.
Compresses
Compresses (moist, warm, or cool cloths) are applied to the
skin. Before applying the compress, the nurse soaks it in tap Using an Ice Bag
water or a medicated solution at the appropriate temperature and
then wrings out excess moisture. To maintain the moisture and The nurse teaches the client or the family as follows:
temperature, a piece of plastic or plastic wrap is used to cover ● Test the ice bag for leaks.
● Fill it one-half to two-thirds full of crushed ice or small
TABLE 28-2 Temperature Ranges for Applications cubes so it can be molded easily to the injured area.
● Eliminate as much air from the bag as possible.
of Heat and Cold
● Pour water over the ice to provide slight melting. This
LEVEL OF HEAT OR COLD TEMPERATURE RANGE tends to smooth the sharp edges from frozen ice crystals.
● Cover the ice bag with a layer of cloth before placing it on
Very hot 40.5°–46.1°C (105°–115°F)
Hot 36.6°–40.5°C (98°–105°F) the body.
Warm and neutral 33.8°–36.6°C (93°–98°F) ● Leave the ice bag in place no more than 20–30 minutes.
Tepid 26.6°–33.8°C (80°–93°F) Allow the skin and tissue to recover for at least 30 min-
Cool 18.3°–26.6°C (65°–80°F) utes before reapplying.
Cold 10°–18.3°C (50°–65°F) ● If the skin becomes mottled or numb, remove the ice
Very cold Below 10°C (below 50°F) bag—it is too cold.
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PRESSURE ULCERS
Pressure ulcers or sores, also referred to as decubitus ulcers,

most often appear over bony prominences of the sacrum,
hips, and heels. They also can develop in other locations such
as the elbows, shoulder blades, the back of the head, and
places where pressure is unrelieved because of infrequent
movement (Fig. 28-20). The tissue in these areas is particu-
larly vulnerable because body fat, which acts as a pressure-
absorbing cushion, is minimal. Consequently, the tissue is
FIGURE 28-19 An aquathermia pad (K-pad). (Photo by B. Proud.) compressed between the bony mass and a rigid surface such
as a chair seat or a bed mattress. If the compression reduces
the pressure in local capillaries to less than 32 mm Hg for 1 to
Larger styles are used to warm clients who are hypo- 2 hours without intermittent relief, the cells die from a lack
thermic or to cool those with heat stroke. Because these cli- of oxygen and nutrients.
ents have dangerously altered body temperatures, the nurse
must monitor vital signs continuously.
Soaks and Moist Packs
A soak is a technique in which a body part is submerged in ■ Age-related changes (ie, a thinning dermal layer of skin,
fluid to provide warmth or to apply a medicated solution. A decreased subcutaneous tissue) result in increased suscep-
pack (a commercial device for applying moist heat) also can tibility to pressure ulcers and shear-type injuries in older
be used. Moist heat is more comforting and therapeutic than adults. Because of the decreased blood supply to the skin,
dry heat. an older adult may need position changes every 60 to
90 minutes, rather than every 120 minutes. Take special
A soak usually lasts 15 to 20 minutes. The nurse keeps
care when moving older adults to avoid friction on the skin.
the temperature of the fluid as constant as possible, which
■ Absorbent undergarments may contribute to skin break-
requires frequent emptying and refilling of the basin. The down because they may not allow for air circulation. Urine
newly added water should not be too hot; overly hot water or feces next to the skin will cause damage and possible
causes discomfort or tissue damage. skin breakdown. Therefore, any incontinent older adult
Packs differ from soaks in two major ways: the duration must be checked every 60 to 90 minutes to prevent skin
of the application is usually longer, and the initial application damage. If urinary incontinence interferes significantly with
of heat is generally more intense. Packs usually are applied wound healing, an indwelling catheter (see Chap. 30) may
at temperatures as warm as the client can tolerate. Because be necessary. It should be removed as soon as feasible,
of the potential for causing burns, a pack never is used on a however, and efforts must be made to restore continence.
client who is unresponsive or paralyzed and cannot perceive ■ Older adults with diminished mobility require aggressive
skin care to prevent pressure ulcers. The elbows, heels,
temperatures. The nurse must make frequent assessments and
coccyx, shoulder blades, and hips are especially vulnerable,
remove the pack if there is any likelihood of a thermal injury.
as are the creases above the ears if oxygen tubing is in
use. Special precautions include heel and elbow protectors,
Therapeutic Baths pressure-relief pads, and mattresses, and a strict routine of
Therapeutic baths (those performed for other than hygiene changing the client’s position at least every 2 hours or
purposes) help reduce a high fever or apply medicated sub- more frequently if the person’s skin becomes reddened in a
stances to the skin to treat skin disorders or discomfort. shorter period. Assessment of at-risk pressure point areas
Examples are baths to which sodium bicarbonate (baking should be done before the 2-hour period.
soda), cornstarch, or oatmeal paste are added.
The most common type of therapeutic bath is a sitz
Stages of Pressure Ulcers
bath (a soak of the perianal area). Sitz baths reduce swell-
Pressure ulcers are grouped into four stages according to the
ing and inflammation and promote healing of wounds after a
extent of tissue injury (Fig. 28-21). Care and healing depend on
hemorrhoidectomy (the surgical removal of engorged veins
the stage of injury. Without aggressive nursing care, early stage
inside and outside the anal sphincter) or an episiotomy (an
pressure ulcers can easily progress to much more serious ones.
incision that facilitates vaginal birth). Some health care
Stage I is characterized by intact but reddened skin. The
agencies have special tubs for administering sitz baths, but
hallmark of cellular damage is skin that remains red and
most provide clients with disposable equipment (Skill 28-3).
fails to resume its normal color when pressure is relieved.
A stage II pressure ulcer is red and accompanied by
➧ Stop, Think, and Respond Box 28-3 blistering or a skin tear (a shallow break in the skin) without
What assessment findings suggest that a sitz bath is slough. Impairment of the skin may lead to colonization and
providing a therapeutic effect? infection of the wound.
LWBK1004-C28_p610-634.indd 622 04/02/12 3:16 PM

Dorsal
thoracic
Occiput Sacrum and coccyx C
area
Shoulder blade
A
Posterior
knee
Sacrum and
coccyx
Ischial
Rim of ear Elbow Heel
tuberosity
Shoulder Perineum Malleus

Side of
head
Foot
B
Ischium Anterior knee

Trochanter
FIGURE 28-20 Locations where pressure ulcers commonly form. A. The supine position.
B. A side-lying position. C. The sitting position.
A stage III pressure ulcer has a shallow skin crater that Stage IV pressure ulcers are life-threatening. The tissue
extends to the subcutaneous tissue. It may be accompanied is deeply ulcerated, exposing muscle and bone (Fig. 28-22).
by serous drainage (leaking plasma), undermining, slough, Slough and necrotic tissue may be evident. The dead or
or purulent drainage (white or greenish fluid) caused by a infected tissue may produce a foul odor. If an infection is
wound infection. The area is relatively painless despite the present, it easily spreads throughout the body, causing sepsis
severity of the ulcer. (a potentially fatal systemic infection).
Reddened area Reddened area
Blister
Epidermis Epidermis
Dermis Dermis
Subcutaneous tissue Subcutaneous tissue
Muscle Muscle
Bone Bone
A B
Epidermis Epidermis
Dermis Dermis
Subcutaneous tissue Subcutaneous tissue
Muscle Muscle
Bone Bone
C D
FIGURE 28-21 Pressure sore stages. A. Stage I. B. Stage II. C. Stage III. D. Stage IV.
LWBK1004-C28_p610-634.indd 623 20/02/12 2:21 PM

Granulation
tissue Epithelial edge
Necrotic
tissue
FIGURE 28-22 Example of stage IV pressure sore. FIGURE 28-23 Heel and ankle protection.
Prevention of Pressure Ulcers B OX 2 8 - 2 Risk Factors for Developing

The first step in prevention is to identify clients with risk Pressure Ulcers
factors for pressure ulcers (Box 28-2). The second step is to
• Inactivity • Incontinence
implement measures that reduce conditions under which pres-
• Immobility • Vascular disease
sure ulcers are likely to form (see Nursing Guidelines 28-2
• Malnutrition • Localized edema
and Fig. 28-23). • Emaciation • Dehydration
• Diaphoresis • Sedation

Rationales
Preventing Pressure Ulcers
• Change the bedridden client’s position frequently. Remind a • Keep the skin clean and dry especially when clients cannot
client who is sitting in a chair to stand and move hourly or at control their bladder or bowel function. Cleansing removes
least to shift his or her weight every 15 minutes while sitting. substances that chemically injure the skin.
Changing positions relieves pressure and restores circulation. • Use a moisturizing skin cleanser rather than soap, if possible.
• Lift rather than drag the client during repositioning. Dragging A nonsoap cleanser maintains skin hydration and avoids alter-
causes friction, which abrades the skin and damages underlying the skin’s natural acidity, which protects it from bacterial
ing blood vessels. colonization.
• Avoid using plastic-covered pillows when positioning clients. • Rinse and dry the skin well. Cleansing then drying removes
Plastic prevents evaporation of perspiration because it is non- chemical residues and surface moisture.
porous. It also raises skin temperature, further contributing to • Use pressure-relieving devices such as special beds or mat-
the growth of microorganisms. tresses (see Chap. 23). These special devices maintain capil-
• Use positioning devices such as pillows to keep two parts of lary blood flow by reducing pressure.
the body from direct contact with each other. Such devices • Pad body areas such as the heels, ankles, and elbows, which are
absorb perspiration, reduce localized heat, and avoid the vulnerable to friction and pressure (see Fig. 28-23). Padding prevents
compression of tissue between two body parts. friction and adds a cushioning layer over the bony prominence.
• Use the lateral oblique position (see Chap. 23) rather than the • Use seat cushions such as a commercial gel-filled pad when
conventional lateral position for side lying. The lateral oblique clients sit for extended periods. These cushions distribute pres-
position more effectively reduces the potential for pressure on sure over a wider area, relieving direct pressure on the coccyx.
vulnerable bony prominences. • Keep the head of the bed elevated no more than 30 degrees.
• Massage bony prominences only if the skin blanches with Sliding down in bed can produce a shearing force (the effect
pressure relief. Massage improves circulation to normal tissue that moves layers of tissue in opposite directions).
but causes further damage to areas where pressure ulcers— • Provide a balanced diet and adequate fluid intake. Adequate
even those that are stage I—are already established. nutrition maintains and restores cells and keeps tissues hydrated.
LWBK1004-C28_p610-634.indd 624 04/02/12 3:16 PM

NURSING IMPLICATIONS • Ineffective Peripheral Tissue Perfusion

• Impaired Tissue Integrity
Clients with a surgical wound, pressure ulcer, or other type • Risk for Infection
of tissue injury are likely to have one or more of the follow- Nursing Care Plan 28-1 shows how nurses use the nurs-
ing nursing diagnoses: ing process to care for a client with Impaired Tissue Integ-
• Acute Pain rity, defined in the 2012 NANDA-I taxonomy (p. 443) as
• Impaired Skin Integrity “damage to mucous membrane, corneal, integumentary, or
subcutaneous tissue.”
N U R S I N G C A R E P L A N 2 8 - 1 Impaired Tissue Integrity

Assessment • Assess the status of the client’s hydration and nutrition.
• Inspect the skin especially over bony prominences. • Determine if the client is incontinent or feverish or has other
• Look for skin redness that does not blanch with relief of pres- contributing factors to skin and tissue breakdown such as
sure, evidence of skin tears, or ulceration. conditions accompanied by edema, those that require the
• Observe the client’s ability to move and reposition himself or application of devices such as a cast or traction, or treatments
herself independently. that increase the potential for impairment of the integument
such as radiation cancer therapy.
Nursing Diagnosis. Impaired Tissue Integrity related to unrelieved pressure secondary to immobility from a spinal cord injury
at the C7 (7th cervical vertebrae) level 2 years ago as manifested by stage III pressure ulcer over the coccyx and a stage I ulcer over
the bilateral heels and elbows.
Expected Outcome. The tissue integrity in the area of the coccygeal pressure sore will be restored as evidenced by the develop-
ment of granulation tissue around the circumference of the wound by 8/30 and closure by 10/1. The elbows and heels will blanch
with pressure relief by 8/18.
Reposition the client every 2 hours until an air-fluidized bed Frequent repositioning maintains capillary pressure above
can be obtained. 32 mm Hg to facilitate the oxygenation of tissue.
Avoid the supine and Fowler’s positions as much as pos- These positions increase the potential for shear forces and
sible. pressure over bony prominences on posterior body areas
such as the coccyx, shoulders, and heels.
After bathing, spray heels and elbows with Bard Barrier Skin products, such as Bard Barrier Film, form a clear, breath-
Film. able film that is impervious to liquids and potential irritants
and protects against skin abrasion and friction.
Until the results of wound culture are obtained, care for the
open coccygeal wound as follows:
• Mix the antimicrobial solution with water and cleanse the wound. An antimicrobial reduces the transient and resident microor-
• Rinse with normal saline. ganisms that can increase the extent and severity of the pres-
• Pack the wound loosely with a continuous strip of gauze sure sore and delay healing. Packing the wound with moist
moistened with normal saline. gauze is a form of mechanical debridement that removes
• Cover with an abdominal pad. devitalized tissue and promotes granulation of the wound.
• Repeat above routine every 4 hours as the packing
becomes dry.
If wound culture is negative for pathogens:
• Eliminate wet-to-dry dressing. A transparent dressing creates a moist environment that accel-
• Clean, dry, and cover wound with transparent dressing erates the healing process. Accumulation of fluid beneath
(Op-Site) and leave in place for 5 days. the dressing increases the potential for loosening the wound
• If drainage collects, pierce Op-Site and aspirate fluid from cover. The aspiration of fluid through the dressing reduces
underneath. Seal the opened area with a small reinforce- fluid volume. Sealing the puncture area restores the occlusive
ment of Op-Site over the punctured area. nature of the dressing without the need to replace it.
Measure the open pressure sore every 3 days (8/18, 8/21, etc.) Regular assessment of the wound helps to determine the need
during the day shift. to continue or revise the plan for wound care.

• Pressure ulcer in area of coccyx measures 2 × 3 × 1/2 in. on
8/18 with 1/16 in. of granulation tissue around the circumfer-
ence of the wound.
• Heels and elbows no longer appear red.
LWBK1004-C28_p610-634.indd 625 04/02/12 3:16 PM

CRITICAL THINKING EXERCISES 3. When a nurse empties the drainage in a Jackson-Pratt

reservoir, which nursing action is essential for rees-
1. What nursing assessments would be evident to sug- tablishing the negative pressure within this drainage
gest that a wound is healing? device?
2. A nurse notes that the gauze dressing that covers a 1. The nurse compresses the bulb reservoir and closes
wound comes loose repeatedly. What measures could the vent.
a nurse take? 2. The nurse opens the vent, allowing the bulb to fill
3. Describe the wound care appropriate for a client with with air.
a stage I pressure ulcer, one with an abdominal inci- 3. The nurse fills the bulb reservoir with sterile nor-
sion, and one with a peripheral intravenous infusion mal saline.
site. 4. The nurse secures the bulb reservoir to the skin
4. A 75-year-old client is admitted from a nursing home near the wound.
to have surgery to repair a fractured hip. Discuss the 4. Which one of the following explanations is best when
factors that may threaten this client’s wound healing. a client asks why the nurse is applying wet-to-dry
dressings over a skin ulcer?
1. “These dressings help to prevent wound infections.”
NCLEX-STYLE REVIEW QUESTIONS 2. “These dressings help to remove dead cells and
1. Which of the following body positions will promote debris.”
wound drainage from an abdominal incision with an 3. “These dressings help to absorb blood and drainage.”
open drain? 4. “These dressings help to protect the skin from
1. Lithotomy injury.”
2. Fowler’s 5. Which of the following is the best evidence that a
3. Recumbent Stage III pressure ulcer is healing?
4. Trendelenburg 1. The size becomes smaller and there is more
2. When the nurse changes a client’s dressing, which drainage.
nursing action is correct? 2. The size becomes smaller and there is less
1. The nurse removes the soiled dressing with sterile discomfort.
gloves. 3. The size becomes smaller and the edges appear
2. The nurse frees the tape by pulling it away from pink.
the incision. 4. The size becomes smaller with a gap under the
3. The nurse encloses the soiled dressing within a wound margin.
latex glove.
4. The nurse cleans the wound in circles toward the
incision.
LWBK1004-C28_p610-634.indd 626 04/02/12 3:16 PM

SKILL 28-1 Changing a Gauze Dressing
ASSESSMENT
Inspect the current dressing for drainage, integrity, and type of Provides assessments indicating a need to change the dressing
dressing supplies used. and supplies that may be needed.
Check the medical orders for a directive to change the dressing. Shows collaboration with the prescribed medical treatment.
Determine if the client has allergies to tape or antimicrobial Helps to determine the dressing supplies to use.
wound agents.
Assess the client’s level of pain and its characteristics. Determines if analgesia will be beneficial before changing the
dressing.
PLANNING
Explain the need and technique for changing the dressing. Relieves anxiety and promotes cooperation.
Consult the client on a preferred time for the dressing change if Empowers the client to participate in decision making.
there is no immediate need for it.
Give pain medication, if needed, 15–30 minutes before the Allows time for medication absorption and effectiveness.
dressing change.
Gather the necessary supplies, which are likely to include a Facilitates organization and efficient time management.
paper bag for the soiled dressing, clean and sterile gloves,
individually packaged gauze dressings, tape, and, in some
cases, an antimicrobial agent such as povidone-iodine swabs
for wound cleansing.
IMPLEMENTATION
Wash your hands or use an alcohol-based hand rub Reduces the transmission of microorganisms.
(see Chap. 10).
Pull the privacy curtain. Shows respect for the client’s dignity.
Position the client to allow access to the dressing. Facilitates comfort and dexterity.
Drape the client to expose the area of the wound. Ensures modesty but facilitates care.
Loosen the tape securing the dressing; pull the tape toward the Facilitates removal without separating the healing wound.
wound (Fig. A).
Loosen the tape. (Photo by B. Proud.)
A
(continued)
LWBK1004-C28_p610-634.indd 627 04/02/12 3:16 PM

Changing a Gauze Dressing (continued)
Don at least one glove and lift the dressing from the wound Provides a barrier against contact with blood and body
(Fig. B). substances.
Remove the dressing.
Moisten the gauze with sterile normal saline if it adheres to the Prevents the disrupting of granulation tissue.
wound.
Discard the soiled dressing in a paper bag or other receptacle Confines the sources of pathogens.
along with the glove(s) (Fig. C).
Dispose of the dressing.
C
Wash your hands again or repeat the alcohol-based hand rub. Removes transient microorganisms.
Tear several long strips of tape and fold the ends over, forming Facilitates handling tape later when wearing gloves and eases
tabs (Fig D). tape removal during the next dressing change.
Prepare the tape.
D
(continued)
LWBK1004-C28_p610-634.indd 628 04/02/12 3:16 PM

Open sterile supplies using the inside wrapper of one of the Ensures an aseptic technique.
gauze dressings as a sterile field, if needed.
Don sterile gloves. Ensures sterility.
Inspect the wound. Provides data for description and comparison.
Cleanse the wound with the antimicrobial agent. Removes drainage and microorganisms.
Use a technique that prevents transferring microorganisms back Supports principles of medical asepsis.
to a cleaned area (Fig. E).
E
Wound cleansing techniques.
Use a single swab or a small gauze square for each stroke. Prevents transferring microorganisms to clean areas.
Allow the antimicrobial agent to dry. Ensures that the tape will stay secured when applied.
Cover the wound with the gauze dressing (Fig. F). Protects the wound.
Apply the dressing.
Secure the dressing with tape in the opposite direction of the Prevents loosening with activity; holds the dressing in place
incision or across a joint. Place a strip of tape at each end of without exposing the wound or incision.
the dressing and in the middle if needed (Fig. G).
Position the tape.
G
(continued)
LWBK1004-C28_p610-634.indd 629 04/02/12 3:16 PM

Remove and discard gloves. Confines the sources of microorganisms.
Rewash hands or repeat the alcohol-based hand rub. Removes transient microorganisms.
Evaluation
• Dressing covers the entire wound.
• Dressing is secure, dry, and intact.
Document
• Type of dressing
• Antimicrobial agent used for cleansing
• Assessment data
Date and Time Gauze dressing changed over abdominal wound. Wound cleansed with povidone iodine. Incision is well
approximated with sutures. No drainage, swelling, or tenderness observed. _________ SIGNATURE/TITLE
SKILL 28-2 Irrigating a Wound
ASSESSMENT
Check the medical orders for a directive to irrigate the wound. Shows collaboration with the prescribed medical treatment.
Determine how much the client understands about the proce- Indicates the level of health teaching needed.
dure.
PLANNING
Plan to irrigate the wound at the same time that the dressing Makes efficient use of time.
requires changing.
Gather the equipment required, which is likely to include a con- Facilitates organization.
tainer of solution, a basin, a bulb or asepto syringe, gloves,
and absorbent material including a towel to dry the skin.
Bring supplies for changing the dressing. Makes efficient use of time.
Consider additional items for standard precautions such as gog- Follows infection control guidelines when there is a potential for
gles or face shield and cover apron or gown. being splashed with blood or body substances.
IMPLEMENTATION
Wash your hands or use an alcohol-based hand rub (see Chap. Reduces the transmission of microorganisms.
10).
Pull the privacy curtain. Shows respect for the client’s dignity.
Drape the client to expose the area of the wound. Ensures modesty but facilitates care.
Follow directions in Skill 28-1 for removing the dressing. Provides access to the wound.
Wash your hands or repeat the alcohol-based hand rub. Reduces the transmission of microorganisms.
Position the client to facilitate filling the wound cavity with solu- Ensures contact between the solution and the inner area of the
tion. wound.
Pad the bed with absorbent material and place an emesis basin Reduces the potential for saturating the bed linens
adjacent to and below the wound.
Open and prepare supplies following the principles of surgical Confines and controls the transmission of microorganisms.
asepsis.
Don gloves and other standard precautions apparel. Reduces the potential for contact with blood and body sub-
stances.
(continued)
LWBK1004-C28_p610-634.indd 630 04/02/12 3:16 PM

Irrigating a Wound (continued)
Fill the syringe with solution and instill it into the wound without Dilutes and loosens debris.
touching the wound directly (Fig. A).
Instill the irrigant.
Hold the emesis basin close to the client’s body to catch the Collects and contains the irrigating solution.
solution as it drains from the wound (Fig. B).
Position the client to drain the irrigant.
Repeat the process until the draining solution seems clear. Indicates the evacuation of debris.
Tilt the client toward the basin. Drains the remaining solution from the wound.
Dry the skin. Facilitates applying a dressing.
Dispose of the drained solution, soiled equipment, and linens. Reduces the potential for transmitting microorganisms.
Remove gloves, wash hands, and prepare to change the Provides for the absorption of residual solution and coverage of
dressing. the wound.
Evaluation
• Irrigation solution shows evidence of debris removal.
• Wound shows evidence of healing.
Document
• Assessment data
• Type and amount of solution
• Outcome of procedure
Date and Time Dressing removed. Moderate purulent drainage on soiled dressing. Wound is separated 3 inches. Approxi-
mately 300 mL of sterile NSS instilled within wound. Drained solution is cloudy with particles of debris.
_________________________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C28_p610-634.indd 631 20/02/12 2:21 PM

SKILL 28-3 Providing a Sitz Bath
ASSESSMENT
Check the medical orders for a directive to administer a sitz Shows collaboration with the prescribed medical treatment.
bath.
Determine how much the client understands about the proce- Indicates the level of health teaching needed.
dure.
Assess the condition of the rectal or perineal wound and the Provides baseline data for future comparisons; indicates if pain
client’s level of pain. medication is needed.
PLANNING
Explain the procedure. Relieves anxiety and promotes cooperation.
Ask if the client prefers the sitz bath before or after routine Involves the client in the decision-making process.
hygiene.
Obtain disposable equipment unless specially installed tubs are Facilitates organization and efficient time management.
available.
Assemble other supplies such as a bath blanket and towels. Prepares for maintaining warmth and provides a means for drying
the skin.
Inspect and clean the bathroom area or the tub room. Supports principles of medical asepsis.
Place the basin inside the rim of the raised toilet seat (Fig. A). Allows for submerging the rectum and the perineum.
Position the sitz bath basin.
IMPLEMENTATION
Wash your hands or use an alcohol-based hand rub Reduces the transmission of microorganisms.
(see Chap. 10).
Help the client don a robe and slippers. Maintains warmth, safety, and comfort.
Help the client to ambulate to the location where the sitz bath Demonstrates concern for safety.
will be administered.
Shut the door to the bathroom or tub room. Provides privacy.
Clamp the tubing attached to the water bag. Prevents a loss of fluid.
(continued)
LWBK1004-C28_p610-634.indd 632 04/02/12 3:16 PM

Providing a Sitz Bath (continued)
Fill the container with warm water, no hotter than 110°F Provides comfort without the danger of burning the skin.
(43.3°C) (Fig. B).
Fill the solution container.
Hang the bag above the toilet seat (Fig. C). Facilitates gravity flow.
Hang the bag and insert the tubing into the basin.
Insert the tubing from the bag into the front of the basin. Provides a means for filling the basin.
Help the client to sit on the basin and unclamp the tubing. Facilitates filling the basin.
Cover the client’s shoulders with a bath blanket if the client Promotes comfort.
feels chilled.
Instruct the client on how to signal for assistance. Ensures safety.
Leave the client alone, but recheck frequently to add more Provides a sustained application of warm water.
warm water to the reservoir bag.
(continued)
LWBK1004-C28_p610-634.indd 633 04/02/12 3:16 PM

Providing a Sitz Bath (continued)
Help the client pat the skin dry after soaking for 20–30 minutes. Restores comfort.
Assist the client back to bed. Ensures safety in case the client feels dizzy from hypotension
caused by peripheral vasodilation.
Don gloves and clean the disposable equipment and bath area. Supports principles of medical asepsis and infection control.
Replace the sitz bath equipment in the client’s bedside cabinet Reduces costs by reusing disposable equipment.
or leave it in the client’s private bathroom.
Evaluation
• A sitz bath is administered according to the agency’s policy or standards of care.
• Safety is maintained.
• The client reports that symptoms are relieved.
Document
• Procedure
• Assessment data
Date and Time Sitz bath provided over 30 minutes. Client states, “I always feel so good after this treatment.” Perineum
is slightly swollen. Margins of episiotomy are approximated. Continues to have moderate bloody vaginal
drainage. _______________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C28_p610-634.indd 634 04/02/12 3:16 PM

Photo to
Come
FPO
29# Gastrointestinal
Intubation
bolus feeding
continuous feeding
cyclic feeding 1. Define intubation and list reasons for gastrointestinal
decompression intubation.
dumping syndrome 2. Identify four general types of gastrointestinal tubes.
enteral nutrition 3. Name at least four assessments that are necessary before
gastric reflux inserting a tube nasally.
gastric residual 4. Explain the purpose of and how to obtain a NEX measurement.
gastrostomy tube (G-tube) 5. Describe three techniques for checking distal placement in the
gavage stomach.
intermittent feeding 6. Discuss three ways that nasointestinal feeding tubes or their
intestinal decompression insertion differ from their gastric counterparts.
intubation 7. Name four schedules for administering tube feedings.
jejunostomy tube (J-tube) 8. Explain the purpose of assessing gastric residual.
lavage 9. Name five nursing activities involved in managing the care of
lumen clients who are being tube-fed.
nasogastric intubation 10. Name two nursing responsibilities for assisting with the inser-
nasogastric tube tion of a tungsten-weighted intestinal decompression tube.
nasointestinal intubation
nasointestinal tubes
NEX measurement
C
orogastric intubation lients, especially those undergoing abdominal or gastrointestinal
orogastric tube (GI) surgery, may require some type of tube placed within their
ostomy stomach or intestine. The use of a gastric or intestinal tube reduces
percutaneous endoscopic gastrostomy or eliminates problems associated with surgery or conditions affect-
(PEG) tube ing the GI tract, such as impaired peristalsis, vomiting, or gas accumu-
percutaneous endoscopic jejunostomy lation. Tubes also can be used to nourish clients who cannot eat. This
(PEJ) tube
chapter discusses the multiple uses for gastric and intestinal tubes and
stylet
the nursing guidelines and skills for managing related client care.
sump tubes
tamponade
transabdominal tubes
INTUBATION
Intubation generally means the placement of a tube into a body struc-

ture; in this chapter, it refers specifically to insertion of a tube into the
stomach or intestine by way of the mouth or nose. Orogastric intu-
bation (the insertion of a tube through the mouth into the stomach),
nasogastric intubation (the insertion of a tube through the nose into
the stomach; Fig. 29-1), and nasointestinal intubation (the insertion of
a tube through the nose to the intestine) are performed to remove gas or
fluids or to administer liquid nourishment.
A tube also may be inserted within an ostomy (a surgically created
opening). A prefix identifies the anatomic site of the ostomy; for instance,
a gastrostomy is an artificial opening into the stomach.
635
LWBK1004-C29_p635-672.indd 635 04/02/12 3:17 PM

according to their use (Table 29-1). The outside diameter of

most tubes is measured using the French scale, indicated by
a number followed by the letter F. Each number on the
French scale equals approximately 0.33 mm. The larger the
number, the larger the diameter of the tube.
Tubes can be identified according to the location of their
insertion (mouth, nose, or abdomen) or the location of their
distal end (stomach [gastric] or intestinal).
Orogastric Tubes
An orogastric tube (a tube inserted through the mouth into
the stomach), such as an Ewald tube, is used in an emer-
gency to remove toxic substances that have been ingested.
The diameter of the tube is large enough to remove pill frag-
ments and stomach debris. Because of its size, the tube is
introduced through the mouth rather than the nose.
Nasogastric Tubes
FIGURE 29-1 The nasogastric intubation pathway. A nasogastric tube (a tube placed through the nose and
advanced to the stomach) is smaller in diameter than an oro-
Gastric or intestinal tubes are used for a variety of rea- gastric tube but larger and shorter than a nasointestinal tube.
sons, including the following: Some nasogastric tubes have more than one lumen (chan-
nel) within the tube.
• Performing a gavage (providing nourishment) A Levin tube is a commonly used, single-lumen gas-
• Administering oral medications that the client cannot tric tube with multiple uses, one of which is decompres-
swallow sion. Gastric sump tubes (double-lumen tubes) are used
• Obtaining a sample of secretions for diagnostic testing almost exclusively to remove fluid and gas from the stomach
• Performing a lavage (removing substances from the stom- (Fig. 29-2). The second lumen serves as a vent. The use of
ach, typically poisons) sump tubes decreases the possibility that the stomach wall
• Promoting decompression (removing gas and liquid con- will adhere to and obstruct the drainage openings when suc-
tents from the stomach or bowel) tion is applied.
• Controlling gastric bleeding, a process called compression Because nasogastric tubes remain in place for several
or tamponade (pressure) days or more, many clients complain of nose and throat dis-
comfort. If the tube’s diameter is too large or pressure from
TYPES OF TUBES the tube is prolonged, tissue irritation or breakdown may
occur. Furthermore, gastric tubes tend to dilate the esopha-
Although all gastric and intestinal tubes have a proximal and geal sphincter also known as the cardiac valve, a circular
distal end, their size, construction, and composition vary muscle between the esophagus and stomach. The stretched
FIGURE 29-2 Vented nasogastric (Salem sump) tube

with a one-way valve. (Photo by B. Proud.)
LWBK1004-C29_p635-672.indd 636 04/02/12 3:17 PM

CHAPTER 29 Gastrointestinal Intubation 637
TABLE 29-1 Types of Gastrointestinal Tubes

TUBE PURPOSE CHARACTERISTICS
Orogastric
Ewald Lavage • Large diameter: 36–40 F
• Single lumen
• Multiple distal openings for drainage
Nasogastric
Levin Lavage • Usual adult size 14–18 F
Gavage • Single lumen
Decompression • 42--50 in. (107–127 cm) long
Diagnostics • Multiple drain openings
Salem sump Decompression • Same diameter as Levin
• Double lumen
• Pigtail vent
• 48 in. (122 cm) long
• Marked at increments to indicate depth of insertion
• Radiopaque
Sengstaken--Blakemore Compression • Usual diameter: 20 F
Drainage • 36 in. (90 cm) long
• Triple lumen; two lead to balloons in the esophagus and
stomach and the third is for removing gastric drainage; a fourth
lumen may be used to remove pharyngeal secretions
Nasointestinal
Keofeed Gavage • Small diameter: 8 F
• 36 in. (90 cm) long
• Polyurethane or silicone
• Weighted tip
• Extremely flexible and may require the use of a stylet during
insertion
• Radiopaque
• Bonded lubricant that becomes activated with moisture
Maxter Intestinal decompression • Usual size: 18 F
• 100 in. (250 cm) long
• Double lumen
• Tungsten-weighted tip
• Graduated marks every 10 in. (25 cm)
Transabdominal
Gastrostomy Gavage; may be used for • Sizes 12–24 F for adults
decompression while • Rubber or silicone
the client is fed through • May have additional side ports for balloon inflation to maintain
a jejunostomy tube placement
• May be capped or plugged between feedings
• Radiopaque
Jejunostomy Gavage • Sizes 5–14 F for adults
• Silicone or polyurethane
• Radiopaque
opening may contribute to gastric reflux (the reverse flow of Feeding Tubes
gastric contents), especially when the tube is used to admin- Nasointestinal tubes used for nutrition, such as a Keofeed
ister liquid formula. If gastric reflux occurs, the liquid could tube, are usually small in diameter and made of a flexible
enter the airway and interfere with respiratory function. substance such as polyurethane or silicone. Their narrow
width and soft composition allow them to remain in the
Nasointestinal Tubes same nostril for 4 weeks or longer. In addition, they reduce
Nasointestinal tubes (tubes inserted through the nose for the potential for gastric reflux because they deliver liquid
distal placement below the stomach) are longer than their nutrition beyond the stomach.
gastric counterparts. The added length permits them to be Narrow tubes are not problem free. They tend to curl
placed in the small bowel. They are used to provide nourish- during insertion because they are so flexible. Therefore,
ment (feeding tubes) or to remove gas and liquid contents some are supplied with a stylet (metal guidewire) that helps
from the small intestine (decompression tubes). straighten and support them during insertion. Almost all
LWBK1004-C29_p635-672.indd 637 04/02/12 3:17 PM

A pression has a double lumen and a weighted tip (Fig. 29-3).

One lumen is used to suction the intestinal contents; the other
acts as a vent to reduce suction-induced trauma to intestinal
tissue. The weighted tip and peristalsis, if present, propel the
B
tube beyond the stomach and into the intestine. The progress of
the radiopaque tip through the GI tract is monitored by X-ray.
At one time, intestinal tubes, such as the Cantor and
Miller-Abbott tubes, were weighted with mercury. Because
of mercury’s hazards to both the client and the environment,
however, mercury-weighted tubes are not used today. Instead,
D C
intestinal tubes, like the Maxter tube (see Table 29-1), are
FIGURE 29-3 An intestinal decompression tube, (A) including
the suction lumen, (B) the vent lumen, (C) openings for suction, now weighted with tungsten.
(D) and the radiopaque tungsten tip.
Transabdominal Tubes
have a weighted tip that helps them descend past the stom- Transabdominal tubes (tubes placed through the abdomi-
ach. Checking the placement of the distal end is more dif- nal wall) provide access to various parts of the GI tract. Two
ficult; these tubes also become obstructed more easily. examples are a gastrostomy tube or G-tube (a transabdomi-
Despite the problems associated with maintenance, nal tube located within the stomach) and a jejunostomy
small-diameter tubes are preferred for their comfort. They tube or J-tube (a transabdominal tube that leads to the jeju-
are ideal for providing a continuous infusion of nourishment. num of the small intestine).
A G-tube is placed surgically or with the use of an
Intestinal Decompression Tubes endoscope. A surgically inserted G-tube resembles a long
Although surgery is often the most common intervention rubber catheter sutured to the abdomen. A percutaneous
when a client has a partial or complete bowel obstruction, endoscopic gastrostomy (PEG) tube (a transabdominal
intestinal decompression (the removal of gas and intestinal tube inserted under endoscopic guidance) is anchored with
contents) also may be used. A tube used for intestinal decom- internal and external crossbars called bumpers (Fig. 29-4A).
Enteral
feeding
bag
Internal
Jejunal
bumper
port
External
bumper
Tube hooked up
to feedings
Abdominal
Distal bolus Gastric Pump
wall
in jejunum port
Stomach
A B
FIGURE 29-4 Transabdominal tubes. A. A percutaneous endoscopic gastrostomy (PEG) tube.
B. A percutaneous endoscopic jejunostomy (PEJ) tube. (Courtesy of IVAC Corporation, San
Diego, CA.)
LWBK1004-C29_p635-672.indd 638 04/02/12 3:17 PM

A percutaneous endoscopic jejunostomy (PEJ) tube (a

tube that is passed through a PEG tube into the jejunum) is
small in diameter so that it can be inserted through the larger
PEG tube (see Fig. 29-4B).
Transabdominal tubes are used instead of nasogastric
or nasointestinal tubes when clients require an alternative to
oral feeding for more than 1 month.
NASOGASTRIC TUBE MANAGEMENT
Usually, nurses insert nasogastric tubes. Additional nursing

responsibilities include keeping the tube patent (or unob-
structed), implementing the prescribed use, and removing
the tube when it has accomplished its therapeutic purpose.
Insertion
Inserting a nasogastric tube involves preparing the client,
conducting preintubation assessments, and placing the FIGURE 29-5 Obtaining the NEX measurement.
tube.
midline of the nose), or a narrow nasal passage excludes a
Client Preparation nostril for tube insertion.
Most clients are anxious about having to swallow a tube.
Suggesting that the diameter of the tube is smaller than most Tube Measurement. Some tubes are already marked to
pieces of food may foster a positive outcome. Explaining indicate the approximate length at which the distal tip will be
the procedure and giving instructions on how the client can located within the stomach. These markings, however, may
assist while the tube is being passed may further reduce anx- not correlate exactly with the client’s anatomy. Therefore,
iety. One of the most important ways to support clients is before inserting a tube, the nurse obtains the client’s NEX
to provide them with some means of control. The nurse can measurement (length from Nose to Earlobe to the Xiphoid
establish with the client a signal, such as the client raising process [tip of the sternum]; Fig. 29-5) and marks the tube
a hand, to indicate the need for a pause during the tube’s appropriately.
passage. The first mark on the tube is made at the measured dis-
tance from the nose to the earlobe. It indicates the distance
Preintubation Assessment to the nasal pharynx–a location that places the tip at the back
Before insertion, the nurse conducts a focused assessment of the throat but above where the gag reflex is stimulated. A
that includes the client’s: second mark is made at the point where the tube reaches the
• Level of consciousness xiphoid process, indicating the depth required to reach the
• Weight stomach.
• Bowel sounds
Tube Placement
• Abdominal distention
When inserting a nasogastric tube, the nurse’s primary con-
• Integrity of nasal and oral mucosa
cerns are to cause as little discomfort as possible, to preserve
• Ability to swallow, cough, and gag
the integrity of the nasal tissue, and to locate the tube within
• Any nausea and vomiting
the stomach, not in the respiratory passages.
Assessment findings serve as a baseline for future com-
parisons and may suggest a need to modify the procedure or
the equipment used. One main goal of the assessment is to Gerontologic Considerations
determine which nostril is best to use when inserting the tube
and the length to which the tube will be inserted. ■ An age-related reduction in the number of laryngeal
nerve endings contributes to diminished efficiency of the
Nasal Inspection gag reflex. Other conditions that depress the gag reflex
After the client clears nasal debris by blowing into a paper include neurologic disorders such as dementia and strokes
tissue, the nurse inspects each nostril for size, shape, and and the repeated insertion and removal of dentures.
patency. The client should exhale while each nostril in turn
is occluded. The presence of nasal polyps (small growths of Once the tube is at its final mark, the nurse must verify
tissue), a deviated septum (nasal cartilage deflected from the the location within the stomach. The physical assessment
LWBK1004-C29_p635-672.indd 639 04/02/12 3:17 PM

FIGURE 29-6 Aspirating gastric fluid. FIGURE 29-7 Checking the pH.
methods that nurses use to determine the distal location of a ➧ Stop, Think, and Respond Box 29-1
nasogastric tube are as follows:
Discuss the consequences of inserting a nasogastric
• Aspirating fluid: If aspirated fluid appears clear, brownish- tube into the respiratory passages.
yellow, or green, the nurse can presume that its source is
the stomach (Fig. 29-6). Use and Maintenance
• Auscultating the abdomen: The nurse instills 10 mL or Nasogastric tubes are connected to suction for gastric
more of air while listening with a stethoscope over the decompression or are used for tube feeding.
abdomen. If a swooshing sound is heard, the nurse can
infer that the cause was air entering the stomach. Gastric Decompression
Belching often indicates that the tip is still in the esoph- Suction is either continuous or intermittent. Continuous suc-
agus. tioning with an unvented tube can cause the tube to adhere
• Testing the pH of aspirated liquid: The first two techniques to the stomach mucosa, resulting in localized irritation and
provide only presumptive signs that the tube is in the stom- interfering with drainage. Using a vented tube or intermittent
ach; testing pH confirms acidic gastric contents. Other than suction prevents or minimizes these effects.
obtaining an abdominal X-ray, the pH test is the most accu- The tube is connected to a wall outlet or portable suc-
rate technique for checking tube placement (see Nursing tion machine (Fig. 29-9). The suction setting is prescribed
Guidelines 29-1 and Fig. 29-7). by the physician or indicated in the agency’s standards for
care. Usually low pressure (40 to 60 mm Hg) is used.
Once the nurse has confirmed stomach placement The tube is clamped or plugged during ambulation or
(using two methods is best), he or she secures the tube to after instilling medications (see Chap. 32).
avoid upward or downward migration (Fig. 29-8). The tube
is then ready to use for its intended purpose. The steps to Promoting Patency
follow when inserting a nasogastric tube are outlined in Even with intermittent suctioning, the tube may become
Skill 29-1. obstructed. Giving ice chips or occasional sips of water to

Rationales
Assessing the pH of Aspirated Fluid
• Wash hands or perform an alcohol-based hand rub (see • Compare the color on the test strip with the color guide on the
Chap. 10). Hand hygiene reduces the transmission of container of reagent strips (see Fig. 29-7). The color of the test
microorganisms. strip changes according to the hydrogen ion concentration of
• Don gloves. They provide a physical barrier between the the liquid. Stomach fluid usually has a pH of 1 to 3—very acid
nurse’s hands and body fluids. on the pH scale. If the pH is 5 or 6, the client may be receiv-
• Aspirate a small volume of fluid from the tube with a clean ing medications to decrease gastric acidity or the fluid may
syringe. Doing so ensures valid test results. be from the duodenum. A pH of 7 or greater indicates that the
• Drop a sample of gastric fluid onto an indicator strip. This step tube is in the respiratory tract.
initiates a chemical reaction on contact and saturation.
LWBK1004-C29_p635-672.indd 640 04/02/12 3:17 PM

FIGURE 29-9 Suction removes liquids and gas from the

stomach.
Restoring Patency
The nurse assesses tube patency frequently by monitoring
the volume and characteristics of drainage and observing
for signs and symptoms suggesting an obstruction (nau-
sea, vomiting, and abdominal distention). Inspection of the
equipment helps to identify possible causes for the assess-
ment findings (Table 29-2). Once the cause is identified, a
variety of simple nursing interventions can resolve it. Some-
times the nasogastric tube must be irrigated to maintain or
B restore patency (Skill 29-2). The nurse must obtain a medi-
cal order before attempting an irrigation.
FIGURE 29-8 A. One end of a piece of tape is split, forming
two narrower strips, and the opposite end is left intact. B. The ➧ Stop, Think, and Respond Box 29-2
wider intact end of the tape is applied to the nose, and the nar- Explain the reason for using an isotonic saline solu-
rower strips are wound around the tube in opposite directions tion, rather than a hypotonic or hypertonic solution,
to secure the nasogastric tube.
to irrigate a nasogastric tube.
a client who is otherwise NPO (receives nothing by mouth) Enteral Nutrition

promotes tube patency. The fluid helps dilute the gastric Enteral nutrition (nourishment provided through the
secretions. Both must be given sparingly, however, because stomach or small intestine rather than by the oral route) is
water is hypotonic and draws electrolytes into the gastric delivered by instilling formula through a tube. Although a
fluid. Because the diluted fluid is ultimately removed, giving nasogastric tube can be used, it is more likely that liquid
the client liberal amounts of water can deplete serum elec- formula will be administered through a nasointestinal or
trolytes (see Chap. 16). transabdominal tube. Both are discussed later in this chapter.
TABLE 29-2 Troubleshooting a Poorly Draining Nasogastric Tube

POSSIBLE CAUSES SOLUTIONS
The drainage holes are adhering to the gastric mucosal wall. Turn the suction off momentarily. Change the client’s position.
The tube is displaced above the esophageal sphincter. If the measured mark is not at the tip of the nose, remove the tape,
advance the tube, check placement, and resecure.
The portable suction machine is disconnected or turned off. Replace the plug into the electrical outlet or turn on power.
The drainage container is filled beyond capacity. Empty and record the amount of drainage in the suction container.
The vent is acting as a siphon. Instill a bolus of air into the vent to restore patency.
The vent is capped or plugged. Remove the cap and restore the port to atmospheric pressure.
The tubing is kinked or disconnected. Straighten tubing or reconnect to the suction machine.
The suction is inadequate. Check that the pressure is 40--60 mm Hg.
The cover on the suction container is loose. Resecure the lid to the container.
A solid particle or thick mucus obstructs the lumen. Increase suction pressure momentarily.
Obtain and implement a medical order for an irrigation.
LWBK1004-C29_p635-672.indd 641 04/02/12 3:18 PM

Removal
Nurses remove a nasogastric tube (Skill 29-3) when the
client’s condition improves, when the tube becomes hope-
lessly obstructed, or according to the agency’s standards for
maintaining the integrity of the nasal mucosa. Unobstructed
larger diameter tubes usually are removed and changed at
least every 2 to 4 weeks for adults. Small-diameter, flexible
tubes are removed and changed every 4 weeks to 3 months,
depending on the agency’s policy. Tubes used for pediatric
clients are changed more frequently because the tissue is
more fragile and there is a greater potential for infection.
Before permanent removal, some physicians prescribe a
trial period during which the tube is clamped and the client
is allowed to consume oral fluids. Remaining asymptomatic FIGURE 29-10 Aspirating to assess the pH. (Photo by B. Proud.)
(ie, no nausea, vomiting, or gastric distention) is a good indi-
cation that the client no longer requires intubation. If symp-
toms develop, the tube is already in place and can be easily for nasogastric tubes. Some modifications are necessary,
reconnected to suction. This practice avoids subjecting the however, because nasointestinal tubes are constructed dif-
client to the discomfort associated with tube replacement. ferently.
To estimate the length of tube required for an intesti-
➧ Stop, Think, and Respond Box 29-3 nal placement, the nurse determines the NEX measurement
If the client who has just had a nasogastric tube re- and adds 9 in. (23 cm). He or she also marks the additional
moved wants something to eat, what nursing actions measurement on the tubing (see Nursing Guidelines 29-2
are appropriate? and Figs. 29-10 and 29-11).
New technologies that promise to promote safety and
efficacy in nasoenteric tube placement are becoming avail-
NASOINTESTINAL TUBE MANAGEMENT able. A computer system that uses electromagnetic tech-
nology to direct and locate a feeding tube has also been
Nurses also insert nasointestinal tubes used for enteral feeding. developed. It consists of an electronically modified feed-
ing tube and a receiver that is placed externally over the
Insertion mid abdomen. A computer then converts the signal into a
The techniques for client preparation, positioning, and graphic display. This helps to identify misplacement imme-
advancement of nasointestinal tubes are similar to those diately, and subsequent use eliminates the need for repeated

Rationales
Inserting a Nasointestinal Feeding Tube
• Wash hands or perform an alcohol-based hand rub (see Chap. 10). • Ambulate or position the client on his or her right side for at least
Hand hygiene reduces the transmission of microorganisms. 1 hour or the time specified in the agency’s policy. This duration
• Don gloves. Gloves provide a physical barrier between the allows the tube to move by gravity through the pyloric valve.
nurse’s hands and body fluids. • Secure the tube at the nose when the third measured mark is
• Follow the manufacturer’s suggestions for activating the lubri- at the nasal tip. This prevents the tube from migrating further
cant bonded to the tube. Two common techniques are to instill than the desired distance.
water through the tube and to immerse the tip in water. Acti- • Verify placement by X-ray, especially in unconscious clients or
vation of the lubricant transforms the dry bond to a gelatinous those with a depressed gag reflex. An X-ray confirms the distal
consistency. location.
• Secure the stylet within the tube. This measure stiffens the tube • Remove the stylet using gentle traction (see Fig. 29-11) or
and facilitates insertion. follow the manufacturer’s suggestions. Opening of the lumen
• Insert the tube to the second mark. Doing so places the tube in allows for the instillation of water and liquid nourishment.
the presumed area of the stomach. • Store the stylet in a clean wrapper at the client’s bedside. This
• Aspirate fluid using a 50-mL syringe (see Fig. 29-10) and test measure avoids charging the client for a new tube should the
the fluid pH. The results provide data for determining gastric current one need to be removed and reintroduced.
placement. • Never reinsert the stylet while the tube is in the client. Reinser-
• Loop the tubing and tape it temporarily to the cheek, if the test tion might cause trauma to the client and damage to the tube.
for placement suggests that the tip is in the stomach. Looping • Measure and record the length of tubing extending from the nose.
provides slack so the tube can descend into the small intestine. Documentation provides data for reassessing distal placement.
LWBK1004-C29_p635-672.indd 642 04/02/12 3:18 PM

B OX 2 9 - 1 Causes of Gastrostomy Leaks

• Disconnection between the feeding delivery tube and G-tube
• Clamped G-tube while tube feeding is infusing
• Mismatch between the size of the G-tube and stoma
• Increased abdominal pressure from formula accumulation,
retching, sneezing, and coughing
• Underinflation of the balloon beneath the skin
• Less than optimal stoma or stomal location
TUBE FEEDINGS
FIGURE 29-11 Removing a stylet. (Photo by B. Proud.)
Providing nutrition by the oral route is always best.
However, if oral feedings are impossible or jeopardize
radiographic verification of its location (Mathus-Vliegen the client’s safety, nourishment is provided enterally or
et al., 2010; Young et al., 2005). parenterally (see section on “Total Parenteral Nutrition,”
Chap. 16). Tube feedings are used when clients have an
Checking Tube Placement intact stomach or intestinal function but are unconscious,
Initial tube placement is traditionally verified with an X-ray have undergone extensive mouth surgery, have difficulty
and eventually may be identified in real time using an elec- swallowing, or have esophageal or gastric disorders.
tromagnetic system once the technology becomes more Skill 29-4 describes the technique for administering tube
widely used. Other techniques for determining placement feedings.
of small-diameter nasogastric feeding tubes are less reliable.
Checking the placement by auscultating air may be incon-
clusive because the air that escapes from the distal tip is less Gerontologic Considerations
pronounced as a result of the small diameter of the tube.
Also, aspiration of stomach contents from small-diameter ■ Long-term use of tube feedings in older adults with
tubes is not always possible because the negative pressure dementia or other chronic declining conditions involves
causes the tube to collapse. Nonetheless, once the feeding many ethical considerations. Refusal to eat (intentional
tube is inserted and secured to avoid slipping, its continued starvation) may be seen as a possible means of suicide in
safe location requires frequent checking. Repeated X-rays the older person or as a symptom of depression.
to reassess tube placement are expensive, impractical, and Caregivers must carefully assess an individual client’s
potentially harmful. Currently, nurses verify the tube’s dis- decision to refuse food or desire to have a feeding tube
removed. Older people who are institutionalized have more
tal placement throughout its use by modifying the aspiration
limited decision-making power in these cases than the per-
technique after the initial X-ray. The modification involves son living at home may have. Nurses should follow the
using a large-volume (50-mL) rather than a small-volume 2001 American Nurses Association position statement
(3- to 5-mL) syringe to obtain a sample of fluid. The larger regarding advance directives related to a client’s wish to
syringe creates less negative pressure during aspiration and, avoid artificial nutrition and hydration. Nurses, especially
therefore, provides enough fluid to test the pH. The place- those working in home care and long-term care settings,
ment of weighted-tip feeding tubes also has been confirmed need up-to-date knowledge about ethical and legal issues
using bedside ultrasonography (Duggan et al., 2008; Vigneau related to the use of tube feedings (see Chap. 3).
et al., 2005). In a small research sample of adults, the tech-
nique proved to be 97% accurate in determining distal tube
location. Benefits and Risks
Tube feedings are delivered through a nasogastric, nasoin-
testinal, or transabdominal tube. Each has its advantages and
TRANSABDOMINAL TUBE disadvantages (Table 29-3).
MANAGEMENT Instilling nutritional formulas into the stomach uses the
body’s natural reservoir for food. It also reduces the potential
The physician inserts transabdominal tubes, such as G- and for enteritis (inflammation of the intestine) because the
J-tubes, but the nurse is responsible for assessing and car- chemicals in the stomach tend to destroy microorganisms.
ing for them and their insertion sites. Conscientious care is Gastric feedings increase the potential for gastric reflux,
necessary because G-tubes may leak (Box 29-1) and cause however, because of their volume and temporary retention
skin breakdown (see Nursing Guidelines 29-3 and Fig. 29-12). within the stomach.
LWBK1004-C29_p635-672.indd 643 04/02/12 3:18 PM


Rationales
Managing a Gastrostomy
• Wash hands or perform an alcohol-based hand rub (see Chap. 10). • Clean the skin with half-strength hydrogen peroxide or 0.9%
Hand hygiene reduces the transmission of microorganisms. saline. After 1 week, using soap and water is sufficient. Dry
• Don gloves. They provide a physical barrier between the the skin well using air or a blow dryer on a cool or low heat
nurse’s hands and body fluids. setting. Appropriate cleaning removes secretions and reduces
• Assess and replace the gauze dressing over a new gastrostomy microorganisms.
if it becomes moist; slight bleeding or a clear serous drainage • Rotate the direction of the external bumper 90 degrees or other
from the wound is normal for a few weeks after the procedure. external retaining device at least once a day. Doing so relieves
These measures reduce the conditions that support the growth pressure and maintains skin integrity.
of microorganisms and maceration of the skin. • Slide the external bumper down so it is flush with the skin.
• Remove and discontinue the dressing after the first 24 hours Sliding restabilizes the tube.
unless the physician orders otherwise. This facilitates • Avoid placing any type of dressing material under the arms of
assessment. the external bumper. This helps to avoid creating pressure on
• Inspect the skin around the tube daily. Regular monitoring pro- the internal bumper and damaging the tissue.
vides assessment data about the status of wound repair. • Replace the water in the balloon weekly using a Luer-tip
• Make sure that the sutures holding a surgically placed tube are (not Luer-lok) syringe. This keeps the balloon fully inflated
intact. Checking prevents tube migration. and prevents tube migration.
• Report any redness or tissue maceration. These findings indi- • Tape the G-tube to the abdomen or secure it with an abdominal
cate early skin impairment. binder or commercial tube stabilizer. Appropriately securing
• Apply a skin barrier ointment such as zinc oxide, karaya gum the tube maintains its position.
wafer, hydrocolloid dressing, or ostomy pouch if the skin • Make sure the tube is not kinked and the skin is not stretched.
appears irritated (see section on “Ostomy Care,” Chap. 31). These assessments ensure tube patency and skin integrity.
Such barriers protect the skin and promote healing. • Insert a Foley catheter (see Chap. 30), if the client is not
• Press down on the skin at the base of the tube (see sensitive to latex, 2–5 in. (5–10 cm) within the opening, and
Fig. 29-12A). If the client has a PEG tube, compress the inflate the balloon if the tube comes out. Doing so maintains
arms of the external bumper together and lift them about 1 in. temporary access to the stomach and, if done within 3 hours of
(2.5 cm) (see Fig. 29-12B). These steps aid in assessing for accidental extubation, prevents the site from closing.
drainage, which normally disappears by the end of the first • Use the G-tube in a manner similar to how a nasogastric tube is
week. used for administering feedings. The tube facilitates nourishment.
Although the placement of tubes within the intestine from the circulating blood to the intestine and a low blood
reduces the risk for gastric reflux, it does not eliminate glucose level related to a surge of insulin. Diarrhea also may
that risk. Additional problems are associated with intesti- result when administering hypertonic formula solutions.
nal tube feedings. For example, an intestinally placed tube
may lead to dumping syndrome (a cluster of symptoms Formula Considerations
from the rapid deposition of calorie-dense nourishment into In addition to the type of tube and the access site, the type
the small intestine). The symptoms, which include weakness, of formula also is individualized based on the client’s nutri-
dizziness, sweating, and nausea, are caused by fluid shifts tional needs (Table 29-4). Factors include the client’s weight,
A B
FIGURE 29-12 Inspection. A. Inspecting for drainage. B. Inspecting the skin.
LWBK1004-C29_p635-672.indd 644 04/02/12 3:18 PM

TABLE 29-3 Comparison of Feeding Tubes

TUBE ADVANTAGES DISADVANTAGES
Nasogastric Low incidence of obstruction Can damage nasal and pharyngeal mucosa from pressure
Accommodates crushed medications or friction
Facilitates bolus or intermittent feedings Dilates esophageal sphincter, potentiating gastric reflux
Easy to check distal placement and gastric residual Potential for aspiration
Requires frequent replacement to ensure the integrity of
nasal tissue
Nasointestinal Easy to insert Requires X-ray to verify placement
Comfortable Becomes obstructed easily
Only slight dilation of esophageal sphincter Best used for continuous feeding
Reduced danger for aspiration
Can remain in place for 4 weeks or longer
Gastrostomy No nasal tube Must wait 24 hours to use after initial placement
Easily concealed May leak and cause skin breakdown
Accommodates long-term use Increased incidence of infection
Infrequent tube replacement Requires skin care at tube site
Client can be taught self-care Can migrate or become dislodged if tube is not secured
Gastric overfill and aspiration possible
Jejunostomy Same as gastrostomy Same as gastrostomy
Reduced potential for reflux and aspiration
nutritional status, concurrent medical conditions, and the pro- Gerontologic Considerations
jected length of therapy. The feeding schedule also affects the
choice of formula: calories may need to be concentrated if ■ Tube-feeding formulas may vary based on the older
the client is being fed several times a day rather than continu- client’s condition (ie, malabsorption syndromes,
ously. Most formulas provide 0.5 to 2.0 kcal/mL. glucose intolerance). Several lactose-free tube-feeding
formulas on the market today may be beneficial to older
clients who experience malabsorption syndromes.
■ Clients with or who are at risk for pressure sores benefit
Nutrition Notes from formulas fortified with additional zinc, protein, and other
nutrients.
■ Specialty formulas are available with altered nutritional ■ In home and long-term care settings, registered dietitians
profiles for specific disease states, such as for clients with may be helpful in the ongoing assessment of tube feedings.
diabetes, renal failure, hepatic failure, respiratory insuf-
ficiency, and wound healing. Pediatric formulas are also avail-
able.
■ Products like Boost, Carnation Breakfast, and Ensure are Tube-Feeding Schedules
primarily intended as oral supplements, not for tube feedings. Tube feedings may be administered on bolus, intermittent,
cyclic, or continuous schedules.
TABLE 29-4 Tube-Feeding Formulas

TYPE EXAMPLES DESCRIPTION
Standard, isotonic Osmolite Routine formulas for clients with normal digestion and absorption; do not
Isocal alter water distribution. Provide approximately 1.0 cal/mL
Nutren 1.0
High calorie Comply Provide up to double the amount of calories of standard formulas for
Nutren 1.5 clients who require a fluid restriction or have high calorie needs.
Nutren 2.0
Deliver 2.0
High protein Promote Provide up to double the amount of protein of standard formulas.
Isocal HN
Ultracal HN plus
Fiber containing Jevity Provide fiber to normalize bowel function in clients with diarrhea or
Compleat constipation.
Ultracal
Partially hydrolyzed Criticare HN Provide nutrients in simple form that require little or no digestion for
Optimental clients with impaired digestion or absorption.
Vivonex T.E.N.
LWBK1004-C29_p635-672.indd 645 18/02/12 11:01 AM

Bolus Feedings 1.5 mL/minute. A feeding pump is used to regulate the instil-
A bolus feeding (the instillation of liquid nourishment in lation. Because only a small amount of fluid is instilled at
less than 30 minutes four to six times a day) usually involves any one time, the formula does not need to be held in the
250 to 400 mL of formula per administration. This schedule reservoir of the stomach; it can be delivered directly into the
is the least desirable because it distends the stomach rapidly, small intestine. Instilling small amounts of fluid beyond the
causing gastric discomfort and an increased risk for reflux. stomach reduces the risk of vomiting and aspiration. Contin-
Bolus feedings may be used because they mimic, to some uous feeding creates some inconvenience, though, because
extent, the natural filling and emptying of the stomach. Some the pump must go wherever the client goes.
clients experience discomfort from the rapid delivery of this
quantity of fluid. Clients who are unconscious or who have
delayed gastric emptying are at greater risk for regurgitation,
vomiting, and aspiration with this method of administration. ■ Older adults tend to tolerate small, continuous feedings.
Intermittent Feedings
An intermittent feeding (the gradual instillation of liquid Client Assessment
nourishment four to six times a day) is administered over 30 The following daily assessments are standard for almost
to 60 minutes, the time most people spend eating a meal. The every client who receives tube feedings: weight, fluid intake
usual volume is 250 to 400 mL per administration. Inter- and output, bowel sounds, lung sounds, temperature, con-
mittent feedings generally are given by gravity drip from a dition of the nasal and oral mucous membranes, breathing
suspended container or with a feeding pump. Gradual fill- pattern, gastric complaints, status of abdominal distention,
ing of the stomach at a slower rate reduces the bloated feel- vomiting, bowel elimination patterns, and skin condition at
ing that can accompany bolus feedings. The container and the site of a transabdominal tube. Once tube feedings have
feeding tube that holds the formula requires thorough flush- been initiated, it is also necessary to routinely assess the cli-
ing after each feeding to reduce the growth of microorgan- ent’s gastric residual (the volume of liquid within the stom-
isms. Tube-feeding administration sets are replaced every ach). The nurse measures the gastric residual to determine
24 hours regardless of the feeding schedule. whether the rate or volume of feeding exceeds the client’s
Cyclic Feedings physiologic capacity. Overfilling the stomach can cause
A cyclic feeding (the continuous instillation of liquid nour- gastric reflux, regurgitation, vomiting, aspiration, and pneu-
ishment for 8 to 12 hours) is followed by a 16- to 12-hour monia. As a rule of thumb, the gastric residual should be
pause. This routine often is used to wean clients from tube no more than 100 mL or no more than 20% of the previous
feedings while continuing to maintain adequate nutrition. hour’s tube-feeding volume. If the gastric residual is high,
The tube feeding is given during the late evening and hours the feeding is stopped and the gastric residual is rechecked
of sleep. During the day, clients eat some food orally. As oral every 30 minutes until it is within a safe volume for resum-
intake increases, the volume and duration of the tube feeding ing the feeding (see Nursing Guidelines 29-4).
gradually decreases.
Continuous Feedings If a client’s nutritional needs are met entirely with
A continuous feeding (the instillation of liquid nutrition tube feedings, what effects might that have on the
without interruption) is administered at a rate of approximately person physically, emotionally, and socially?

Rationales
Checking the Gastric Residual
• Wash hands or perform an alcohol-based hand rub (see Chap. 10). • Reinstill the aspirated fluid. This measure returns partially
Hand hygiene reduces the transmission of microorganisms. digested nutrients and electrolytes to the client.
• Don gloves. Gloves provide a physical barrier between the • Postpone tube feeding and report residual amounts that exceed
nurse’s hands and body fluids. agency guidelines or those established by the physician. Doing
• Stop the infusion of the tube-feeding formula. This measure so reduces the risk of aspiration.
facilitates assessment. • Check gastric residual again in 30 minutes. This duration
• Aspirate fluid from the feeding tube using a 50-mL syringe. allows time for part of the stomach contents to empty into the
Doing so allows for the collection of a large volume of fluid. small intestine.
• Continue aspirating until no more fluid is obtained. This • Provide or resume tube feeding if the gastric residual is within
ensures an accurate assessment. an acceptable range. Doing so prevents overfeeding.
• Measure the aspirated fluid and record the amount. Documen-
tation provides objective data for evaluation.
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Rationales
Clearing an Obstructed Feeding Tube
• Select a syringe with a capacity of at least 50 mL. This capac- • Aspirate as much as possible from the feeding tube. Aspiration
ity reduces negative pressure during aspiration, which could clears the path above the obstructing debris.
lead to the collapse of the tube walls. • Instill 5 mL of the selected solution. Instillation allows for
• Wash hands or perform an alcohol-based hand rub (see Chap. 10). direct contact between the irrigating solution and debris.
Hand hygiene reduces the transmission of micro- • Clamp the tube and wait 15 minutes. This duration gives the sub-
organisms. stance in the solution time to physically affect the obstructing debris.
• Don gloves. They provide a physical barrier between the • Aspirate or flush the tube with water. Repeat if necessary. Use
nurse’s hands and potential contact with body fluids. of negative pressure or positive pressure restores patency.
Nursing Management the fluid volume is excessive, the nurse monitors the client’s
Caring for clients with feeding tubes generally involves urine output and lung sounds to determine whether or not the
maintaining tube patency, clearing any obstructions, pro- client can excrete comparable amounts (see Chap. 16).
viding adequate hydration, dealing with common formula-
related problems, and preparing clients for home care. Gerontologic Considerations
Maintaining Tube Patency ■ Most tube-feeding formulas are highly concentrated;
Feeding tubes, especially those smaller than 12 F, are prone therefore, the hydration status of the older client must be
to obstruction. Common causes are using formulas with closely monitored.
large-molecule nutrients, refeeding partially digested gastric
residual, administering formula at a rate less than 50 mL/
hour, and instilling crushed or hydrophilic (water-absorbing) Dealing With Miscellaneous Problems
medications into the tube. To maintain patency, it is best to Clients who require enteral feeding experience several
flush feeding tubes with 30 to 60 mL of water immediately common or potential problems. Many are associated with
before and after administering a feeding or medications, tube-feeding formulas or the mechanical effects of the tubes
every 4 hours if the client is being continuously fed, and themselves (Table 29-5). Nurses report problems promptly
after refeeding the gastric residual. and make necessary adjustments to the plan of care.
Although tap water is effective as a flush solution, cran-
berry juice and carbonated beverages may be used. Formula Gerontologic Considerations
tends to curdle when it comes in contact with cranberry
juice, which detracts from the efficacy of this approach. ■ Older adults are at increased risk for fluid and electrolyte
disturbances and, as a result, may develop hyperglycemia
Clearing an Obstruction (elevated blood glucose levels) when tube feedings are
If an obstruction occurs, the nurse consults the physician. administered.
Occasionally, it is possible to clear the tube with a solution ■ If an older client is receiving tube feedings with full-
of meat tenderizer or pancreatic enzyme, but both methods strength formula concentrations, it is important to check
require written medical orders (see Nursing Guidelines 29-5). capillary blood glucose levels every 4 hours for a 48-hour
When an obstruction cannot be cleared, the tube is period until the client’s results are within a normal range.
removed and another is inserted rather than compromising ■ Monitor older adults for agitation or confusion, which
nutrition by the delay. may cause them to pull out feeding tubes inadvertently.
Also, a change in mental status is an early indicator of a
Providing Adequate Hydration fluid or electrolyte imbalance.
Although tube feedings are approximately 80% water, cli-
ents usually require additional hydration. Adults require
Preparing for Home Care
30 mL of water per kilogram of body weight, or 1 mL/kcal,
Because of shortened lengths of stay in hospitals, some
on a daily basis (Dudek, 2009).
clients who continue to need tube feedings are discharged
To determine whether or not a client’s hydration needs
to care for themselves at home. Before demonstrating the
are being met, the nurse identifies the amount of water on
procedure, the nurse provides a written instruction sheet that
the label of commercial formula. He or she can then add this
includes the following:
amount to the total volume of flush solution and compare it
with the recommended amount. If there is a significant defi- • Places to obtain equipment and formula
cit, the nurse revises the plan of care to increase either the • The amount and schedule for each feeding and flush, using
volume or, preferably, the frequency of flushing the tube. If household measurements
LWBK1004-C29_p635-672.indd 647 04/02/12 3:18 PM

TABLE 29-5 Common Tube-Feeding Problems

PROBLEM COMMON CAUSES SOLUTIONS
Diarrhea Highly concentrated formula Dilute initial tube feeding to one-quarter to one-half strength.
Rapid administration Start at 25 mL/hr and increase rate by 25 mL q12hr.
Hang no more than 4 hours’ worth of formula.
Bacterial contamination Wash hands.
Change formula bag and tubing q24hr.
Refrigerate unused formula.
Lactose intolerance Consult with the physician on using a milk-free formula.
Inadequate protein content Raise serum albumin levels with total parenteral nutrition
solutions containing supplemental protein, or administer
albumin intravenously.
Medication side effects Consult with the physician about adjusting drug therapy or
administering an antidiarrheal.
Nausea and vomiting Rapid feeding Instill bolus and intermittent feedings by gravity.
Overfeeding Delay feeding until gastric residual is <100 mL or <20% of
hourly volume.
Air in stomach Maintain sitting position for at least 30 minutes after feeding.
Consult with the physician about ordering medication that
facilitates gastric emptying.
Administer continuous feedings.
Instill feedings within the small intestine.
Keep tubing filled with formula or water.
Medication side effects Consult with the physician about adjusting drug therapy or
administering drugs to control symptoms.
Aspiration Incorrect tube placement Check placement before instilling liquids.
Vomiting Keep head elevated at least 30 degrees during feedings and
for 30 minutes afterward.
Keep cuffed tracheostomy and endotracheal tubes inflated.
Refer to measures for controlling vomiting.
Constipation Lack of fiber Change formula.
Dehydration Increase supplemental water.
Consult with the physician on giving a laxative, enema, or
suppository.
Elevated blood glucose level Calorie-concentrated formula Instill diluted formula and gradually increase concentration.
Administer insulin according to medical orders.
Weight loss Inadequate calories Increase calories in formula.
Increase rate or frequency of feedings.
Elevated electrolytes Dehydration Increase supplemental water.
Dry oral and nasal mucous Mouth breathing Provide frequent oral and nasal hygiene.
membranes Dried nasal mucus
Middle ear inflammation Narrowing or obstruction of eustachian Turn from side to side q2hr.
tube from presence of tube in Insert a small-diameter feeding tube.
pharynx
Sore throat Pressure and irritation from tube Use a small-diameter feeding tube.
Plugged feeding tube Instilling crushed or powdered medi- Use liquid medications.
cations through the tube Dilute crushed drugs.
Formula coagulation from drug-food Flush the tubing liberally after drug administration.
interactions Flush tubing with water before and after drug administration.
Follow agency policy for alternative flush solutions such as
carbonated beverages or solutions of meat tenderizer.
Kinked tube Maintain neck in neutral position or change position frequently.
Large molecules in formula Dilute formula.
Flush tubing at least q4hr.
Use a larger diameter feeding tube.
Dumping syndrome Rapid and large instillation of highly con- Administer small, continuous volume.
centrated formula into the intestine Adjust glucose content of formula.
• Guidelines for delaying a feeding • Names and phone numbers of people to call if questions arise
• Special instructions for skin, nose, or stomal care, includ-• Date, time, and place for continued medical follow-up
ing frequency and types of products to use Depending on the client’s self-condence
fi and compe-
• Problems to report such as weight loss, reduced urination, tence in self-administering tube feedings, health care provid-
weakness, diarrhea, nausea and vomiting, and breathing ers often make a referral to a home health agency for post-
diffi culties discharge nursing support.
LWBK1004-C29_p635-672.indd 648 18/02/12 11:01 AM


Rationales
Inserting an Intestinal Decompression Tube
• Assemble all the necessary equipment as for any nasally • Follow agency policy or physician’s instructions for manually
inserted tube. Doing so ensures organization and efficient time advancing the tube several inches each hour. This advancement
management. supplements the natural peristaltic advancement.
• Follow the techniques in Skill 29-1 for inserting a nasogastric • Observe the graduated marks on the tube. They provide a
tube. The same principles are involved during the initial means for monitoring the tube’s progression and approximate
insertion. anatomic location.
• Thread excess tubing through a sling of folded gauze taped to • Request an X-ray confirmation when the tube has reached the
the forehead (see Fig. 29-13) once gastric placement is con- prescribed distance. An X-ray provides objective evidence of
firmed. The sling supports the tube as it advances. the terminal location of the distal tip.
• Ambulate the client, if possible. Ambulation helps the tube to • Secure the tube to the nose once its distal location has been
move through the pyloric valve into the small intestine. confirmed. This measure stabilizes the tube and prevents further
• When the radiograph indicates that the intestinal tube migration.
has advanced beyond the stomach, position the client • Coil the excess tubing and attach it to the client’s pajamas or
on the right side for 2 hours, then on the back in a Fowler’s gown. Coiling and attachment prevent accidental extubation.
position for 2 hours, then on the left side for 2 hours. • Connect the proximal end to a wall or a portable suction
Gravity and positioning promote movement through intestinal source. This measure produces negative pressure to pull sub-
curves. stances from the intestine.
Removal
Gerontologic Considerations Once the intestinal decompression tube has served its
purpose, the nurse begins the process of removing it. An
■ When teaching older adults or older caregivers how to intestinal decompression tube is removed slowly because
manage a G-tube or administer tube feedings at home, removal is in a reverse direction through the curves of the
allow more time for processing information and include
intestine and the valves of the lower and upper ends of the
several practice sessions. A referral for skilled nursing care,
which may be covered by Medicare/Medicaid or private
stomach.
health insurance plans, may be appropriate for ongoing First, the tube is disconnected from the suction source.
teaching and assessments for clients being discharged Next, the tape that secures the tube to the face is removed and
with tube feedings. the tube is withdrawn 6 to 10 in. (15 to 25 cm) at 10-minute
■ For older adults living on a fixed income, dietitians can intervals. When the last 18 in. (45 cm) remains, the tube
suggest ways to prepare less costly, home-blended formu- is pulled gently from the nose. Afterward, nasal and oral
las that meet the client’s nutritional needs. hygiene measures are provided. The tube cannot be removed
nasally if the distal end descends below the ileocecal valve
between the small and large intestine. Instead, the proximal
INTESTINAL DECOMPRESSION end is cut and the tube is gradually removed manually or by
peristalsis when it descends through the anus.
Most nasogastric, nasointestinal, and transabdominal tubes
are used for enteral feeding or gastric decompression. Some-
times, however, clients require intestinal decompression,
which is performed with a tungsten-weighted tube (see
Table 29-1). Intestinal decompression sometimes makes it
possible to avoid surgery.
Tube Insertion
A nasointestinal decompression tube is inserted in the same
manner as a nasogastric tube. The nurse then promotes and
monitors its passage into the intestine. In the presence of
peristalsis, the weight of the tungsten propels the tip of
the tube beyond the stomach. Openings through the distal
end provide channels through which the intestinal contents
are suctioned. An intestinal decompression tube generally
remains in place until the intestinal lumen is patent or until
surgical treatment is instituted (see Nursing Guidelines 29-6). FIGURE 29-13 Fashioning a gauze sling.
LWBK1004-C29_p635-672.indd 649 04/02/12 3:18 PM

NURSING IMPLICATIONS • Impaired Oral Mucous Membrane

• Diarrhea
Depending on data collected during client care, the nurse • Constipation
may identify one or more of the following nursing diagnoses: Nursing Care Plan 29-1 is a model for managing the care
• Imbalanced Nutrition: Less Than Body Requirements of a client with a large gastric residual with a nursing diagnosis
• Feeding Self-Care Decit
fi of Risk for Aspiration, defined by NANDA-I (2012, p. 422) as
• Impaired Swallowing “at risk for entry of gastrointestinal secretions, oropharyngeal
• Risk for Aspiration secretions, solids or fluids into tracheobronchial passages.”
N U R S I N G C A R E P L A N 2 9 - 1 Risk for Aspiration

Assessment • Auscultate bowel sounds.
• Note client’s level of consciousness and prescribed drug • Palpate the abdomen and measure abdominal girth for evi-
therapy that may cause sedation. dence of distention.
• Check for a cough and gag re ex.fl • Ask an alert client about feeling full, nauseous, or vomiting.
• Determine the client’s ability to swallow effectively or review • Check if any medical orders restrict the positioning of a client
the results of a swallow study ordered by the physician. in a Fowler’s position.
• Measure the gastric residual if the client is receiving tube feedings.
Nursing Diagnosis. Risk for Aspiration related to slow gastric emptying as manifested by the measurement of the gastric
residual of 150 mL from a 16 F nasogastric tube 4 hours after previous bolus feeding of 400 mL, unresponsi
veness except for eye
opening and pulling away from painful stimuli following head trauma in a motor vehicle collision, and mechanical ventilation with
an endotracheal tube that has been placed orally.
Expected Outcome. The client’s risk for aspiration will be reduced as evidenced by a gastric residual of less than 100 mL within
1 hour of feeding.
Keep cuff of endotracheal tube inflated at the prescribed An inflated cuff acts as a barrier that prevents stomach con-
pressure. tents from entering the airway.
Maintain head elevation at no less than 30 degrees at all Elevating the upper body promotes the deposition of the tube-
times. feeding formula within the stomach and movement toward
the small intestine.
Monitor bowel sounds; report if absent or fewer than five Active bowel sounds suggest that peristalsis is sufficient to
per minute. facilitate gastric emptying and intestinal absorption and the
elimination of liquid nourishment.
Check the placement of the distal end of the gastric tube Checking the distal placement provides evidence that the end
before administering any liquid substance. of the tube is located within the stomach rather than the
esophagus, airway, or small intestine.
Measure gastric residual before all tube feedings. This standard of care helps to determine the client’s response
to liquid nourishment via a gastric tube.
Refeed gastric residual and follow with a 30 mL tap water Gastric residual contains partially digested nutrients that
flush. should not be discarded; flushing the tube following refeed-
ing helps to prevent obstruction within the tube and provides
additional water intake.
Postpone tube feeding for 30 minutes if the gastric residual Distention of the stomach with additional formula predisposes
measures 100 mL or more or 20% above the hourly rate the client to regurgitation and the potential for aspiration.
for infusion.
Report the gastric residual volume to the physician if it Sharing the assessment findings with the physician facilitates
remains above the maximum volume after delaying feed- collaboration in modifying the plan of care by changing the
ing for 30 minutes. type, volume, or frequency of the tube feeding, or adminis-
tering a medication that promotes gastric emptying.
Maintain the suction machine at the bedside. Having equipment for performing oral–pharyngeal suctioning
ensures a rapid response for clearing the upper gastrointestinal
tract and airway following episodes in which the client vomits.

• Gastric residual measures 50 mL. • Head is elevated 30 degrees.
• Bowel sounds are present and active in all quadrants. • Tube feeding is infusing at 100 mL/hr with the feeding pump
• The endotracheal tube cuff remains ated.
infl rather than with bolus feeding following a change in medical order.
LWBK1004-C29_p635-672.indd 650 18/02/12 11:01 AM

CRITICAL THINKING EXERCISES 3. What is the most appropriate technique for deter-
mining whether the distal end of a tube for gastric
1. What nutritional suggestions could a nurse make for decompression is in the stomach?
a client who has a chronic disease that impairs the 1. Request a portable X-ray of the stomach.
ability to swallow food? 2. Check the pH of aspirated fluid.
2. When a client experiences persistent gagging during 3. Instill 100 mL of tap water into the tube.
attempts to insert a nasogastric tube, what actions 4. Feel for air at the tube’s proximal end.
can the nurse take? 4. Immediately after insertion of a transabdominal
3. Describe the similarities and differences between G-tube, which finding should the nurse consider
inserting a tube for gastric decompression and one for normal when assessing the gastrostomy site?
intestinal decompression. 1. Milky-appearing drainage
4. What questions would be important to ask if a client 2. Serosanguineous drainage
receiving tube feedings at home calls to report the 3. Green-tinged drainage
onset of diarrhea? 4. Bright bloody drainage
5. When a client with a nasogastric tube for gastric
decompression indicates that he or she is very thirsty,
NCLEX-STYLE REVIEW QUESTIONS which nursing intervention is most appropriate to add
1. What is the most correct nursing action to determine to the plan of care?
the length for inserting a nasogastric sump tube? 1. Offer fluids at least every 2 hours.
1. Place the distal tip of the tube at the client’s nose 2. Provide crushed ice in sparse amounts.
and measure the distance from there to the jaw, 3. Increase oral liquids on the dietary tray.
then midway to the sternum. 4. Refill the water carafe twice each shift.
2. Place the distal tip of the tube at the client’s nose
and measure the distance from there to the mouth,
then between the nipples.
and measure the distance from there to the mid-
sternum, then to the umbilicus.
and measure the distance from there to the ear,
then to the xiphoid process.
2. When a practical nurse assists with the insertion of a
single lumen nasogastric tube, which of the following
instructions is correct when the tube is in the client’s
oropharynx?
1. Breathe deeply as the tube is advanced.
2. Hold your head in a sniffing position.
3. Press your chin to your upper chest.
4. Avoid coughing until the tube is down.
LWBK1004-C29_p635-672.indd 651 04/02/12 3:18 PM

SKILL 29-1 Inserting a Nasogastric Tube
ASSESSMENT
Check that a medical order has been written. Ensures that care is within the legal scope of practice.
Determine the reason for the nasogastric tube. Facilitates the evaluation of outcomes.
Identify the client. Ensures that the procedure will be performed on the correct
client.
Assess how much the client understands about the procedure. Indicates the need for and the level of health teaching.
Inspect the nose after the client blows into a paper tissue (Fig. A). Provides data that will determine which naris to use.
Clearing the nose. (Photo by B. Proud.)
Unwrap and uncoil the tube. Straightens the tube and releases bends from product packaging.
Obtain the NEX measurements (Fig. B). Determines length for insertion.
Measuring the tube. (Photo by B. Proud.)
(continued)
LWBK1004-C29_p635-672.indd 652 04/02/12 3:18 PM

Inserting a Nasogastric Tube (continued)
ASSESSMENT (CONTINUED)
Mark the tube at the NE (nose-to-ear) and EX (ear-to-xiphoid) Provides a guide during insertion.
measurements (Fig. C).
Marking the tube. (Photo by B. Proud.)
PLANNING
If a plastic tube feels rigid, place it in or flush it with warm Promotes flexibility.
water.
Assemble the following equipment, in addition to the tube: Contributes to organization and efficient time management.
water, straw, towel, lubricant, tissues, tape, emesis basin,
flashlight, stethoscope, clean gloves, and 50-mL syringe.
Place a suction machine at the bedside if the client is unrespon- Provides a method for clearing the client’s airway of vomitus.
sive or has difficulty swallowing.
Remove dentures. Avoids choking should they become loose or displaced.
Establish a hand signal for pausing. Relieves anxiety by providing the client with some locus for
control.
IMPLEMENTATION
Chap. 10).
Pull the privacy curtain. Demonstrates respect for the client’s dignity.
Assist the client to sit in semi-Fowler’s or high-Fowler’s position Ensures the visualization of the nasal passageway to facilitate
and hyperextend the neck as if in a sniffing position. inserting the tube.
Protect the client, bedclothing, and linen with a towel. Avoids linen changes.
Don gloves. Reduces the transmission of microorganisms.
Lubricate the tube with water-soluble gel over 6--8 in. Reduces friction and tissue trauma.
(15–20 cm) at the distal tip.
(continued)
LWBK1004-C29_p635-672.indd 653 04/02/12 3:18 PM

Insert the tube into the nostril while pointing the tip backward Follows the normal contour of the nasal passage.
and downward (Fig. D).
Preparing to insert the tube. (Photo by B. Proud.)
Do not force the tube. Relubricate or rotate it if there is resist- Prevents trauma.
ance.
Stop when the first mark on the tube is at the tip of the nose. Places the tip above the area where the gag reflex may be
stimulated.
Use a flashlight to inspect the back of the throat. Confirms that the tube has been maneuvered around the nasal
curve.
Instruct the client to lower his or her chin to the chest and swal- Narrows the trachea and opens the esophagus; helps to
low sips of water. advance the tube.
Advance the tube 3–5 in. (7.5–12.5 cm) each time the client Coordinates insertion; reduces the potential for gagging or
swallows. vomiting.
Pause if the client gives the preestablished signal. Demonstrates respect and cooperation.
Discontinue the procedure and raise the tube to the first mark Indicates that the tube is possibly in the airway.
if there are signs of distress such as gasping, coughing, a
bluish skin color, or the inability to speak or hum.
Assess placement, preferably using two different methods Provides data on distal placement.
when the second mark is reached (Fig. E).
Assessing the placement.
E
(continued)
LWBK1004-C29_p635-672.indd 654 04/02/12 3:18 PM

Withdraw the tube to the first mark and reattempt insertion if Ensures safety.
the assessment findings are inconclusive, or consult with the
physician about obtaining an X-ray.
Proceed to secure the tube if the data indicate the tube is in the Prevents tube migration.
stomach (Fig. F).
Securing the tube. (Photo by B. Proud.)
Connect the tube to suction or clamp it while awaiting further Promotes gastric decompression or potential use.
orders.
Remove gloves and wash your hands or use an alcohol-based Reduces the transmission of microorganisms.
hand rub.
Position the client with a minimum head elevation of Prevents gastric reflux.
30 degrees.
Remove equipment from the bedside. Restores orderliness and supports the principles of medical asepsis.
Measure and record the volume of drainage at least every Provides data for evaluating fluid balance.
8 hours.
Evaluation
• Distal placement within the stomach is confirmed.
• Client exhibits no evidence of respiratory distress.
• Client can speak or hum.
• Lung sounds are present and clear bilaterally.
• No bleeding or pain is noted in the area of nasal mucosa.
Document
• Type of tube
• Outcomes of the procedure
• Method for determining placement and outcome of assessment
• Description of drainage
• Type and amount of suction, if the tube is used for decompression
Date and Time A 16 F Salem sump tube inserted without difficulty. Placement verified by noting the sound of air while
auscultating over the stomach and by aspirating gastric secretions, which are yellowish-green and reveal
a pH of 3 when tested. Salem sump tube secured to nose and connected to low, intermittent wall suction.
Positioned with the head of bed elevated 30 degrees. ___________________________________ SIGNATURE/TITLE
LWBK1004-C29_p635-672.indd 655 04/02/12 3:18 PM

SKILL 29-2 Irrigating a Nasogastric Tube
ASSESSMENT
Monitor the client’s symptoms, the volume and rate of drain- Provides data for future comparisons.
age, and evidence of abdominal distention.
Check that a medical order has been written, if that is the Complies with the legal scope of the nursing practice.
agency’s policy.
client.
Assess how much the client understands about the procedure. Provides an opportunity for client teaching.
PLANNING
Assemble the following equipment: Asepto or irrigating syringe, Contributes to organization and efficient time management.
irrigating fluid (isotonic saline solution), container, clean towel
or pad, clean gloves, and cover or plug for end of tube.
Turn off the suction. Facilitates implementation.
IMPLEMENTATION
Chap. 10).
Place a clean pad or towel beneath where the tube will be Avoids changing bed linens and protects the client from soiling.
separated.
Don clean gloves. Complies with standard precautions.
Disconnect the nasogastric tube from the suction tubing and Keeps the connection area clean.
apply cover or insert plug into suction tubing.
Check the distal placement of the tube. Ensures safety.
Fill irrigating syringe with 30–60 mL of normal saline solution. Provides an adequate quantity of isotonic solution to clear tubing.
Insert the tip of the syringe within the proximal end of the tube Dilutes and mobilizes debris.
and allow the solution to flow in by gravity or apply gentle
pressure (Fig. A).
Instilling the irrigation solution. (Photo by B. Proud.)
A
(continued)
LWBK1004-C29_p635-672.indd 656 04/02/12 3:18 PM

Irrigating a Nasogastric Tube (continued)
Aspirate after the fluid has been instilled. Removes substances that may impair future drainage.
Reconnect the tube to the source of suction. Resumes therapeutic management.
Observe the characteristics of the aspirated solution; measure Provides data for evaluating the effectiveness of the procedure.
and discard.
Monitor for the flow of drainage through the suction tubing (Fig. B). Provides evidence that patency is being maintained.
Monitoring drainage. (Photo by B. Proud.)
Remove gloves and perform hand hygiene. Reduces the transmission of microorganisms.
Record the volume of instilled and drained fluid on the bedside Provides accurate data for determining fluid balance.
intake and output sheet.
Evaluation
• Drainage is restored.
• Nausea and vomiting are relieved.
• Abdominal distention is reduced.
Document
• Volume and type of fluid instilled
• Appearance and volume of returned drainage
Date and Time Salem sump tube irrigated with 60 mL of normal saline. Solution instilled with slight pressure. A 100 mL of solu-
tion returned with several large mucus particles. Reconnected to low, intermittent suction. Gastric tube draining
well at the present time. Abdomen is soft. No vomiting. _______________________________ SIGNATURE/TITLE
LWBK1004-C29_p635-672.indd 657 04/02/12 3:18 PM

SKILL 29-3 Removing a Nasogastric Tube
ASSESSMENT
Assess bowel sounds, the condition of the mouth and nasal Provides data for future comparisons and may affect how the
mucosa, the level of consciousness, and gag reflex. procedure is performed.
Check that a medical order has been written. Complies with the legal scope of nursing practice.
client.
Assess how much the client understands the procedure. Provides an opportunity for client teaching.
PLANNING
Assemble the following equipment: towel, emesis basin, Contributes to organization and efficient time management.
cotton-tipped applicator sticks, oral hygiene equipment, and
clean gloves.
IMPLEMENTATION
Pull the privacy curtain. Demonstrates respect for dignity.
Chap. 10).
Place the client in a sitting position, if alert, or in a lateral posi- Prevents aspiration of stomach contents.
tion if not.
Cover the chest with a clean towel and place the emesis basin Prepares for possible vomiting and protects the client from
and tissues within easy reach. soiling.
Remove the tape securing the tube to the client’s nose. Facilitates pulling the tube from the stomach.
Don clean gloves. Complies with standard precautions.
Turn off the suction and separate the tube. Prepares for removal.
Instill a bolus of air into the lumen that drains gastric secretions. Prevents residual fluid from leaking as the tube is withdrawn.
Clamp, plug, or pinch the tube (Fig. A). Prevents fluid from leaking as the tube is withdrawn.
Occluding the tube. (Photo by B. Proud.)
Instruct the client to take a deep breath and hold it just before Reduces the risk for aspirating gastric fluid.
removing the nasogastric tube.
Remove the tube from the client’s nose gently and slowly. Lessens the potential for trauma.
(continued)
LWBK1004-C29_p635-672.indd 658 04/02/12 3:18 PM

Removing a Nasogastric Tube (continued)
Enclose the tube within the towel or glove and discard the tube Provides a transmission barrier against microorganisms.
in a covered container (Fig. B).
Enclosing the tube. (Photo by B. Proud.)
Empty, measure, and record the drainage in the suction con- Provides data for evaluating the client’s fluid status.
tainer.
Remove gloves and perform hand hygiene. Reduces the transmission of microorganisms.
Offer an opportunity for oral hygiene. Removes disagreeable tastes from the client’s mouth.
Encourage the client to clear the nose of mucus and debris with Promotes the integrity of nasal tissue.
paper tissues or cotton-tipped applicators.
Discard disposable equipment; rinse and return portable suction Preserves cleanliness and orderliness in the client’s unit; demon-
equipment. strates accountability for equipment.
Evaluation
• The tube is removed.
• The client resumes eating and taking fluids.
• The client experiences no nausea or vomiting.
• The airway remains clear.
• The nasal mucosa is moist and intact.
Document
• Type of tube removed
• Appearance and volume of drainage
• Appearance of nose and nasopharynx
Date and Time Salem sump tube removed. Brief period of retching during removal. Total of 75 mL clear green drain-
age emptied from suction container. Oral care provided. L. naris swabbed with applicator lubricated with
petroleum jelly. Mucosa is red but intact. ___________________________________________ SIGNATURE/TITLE
LWBK1004-C29_p635-672.indd 659 04/02/12 3:18 PM

SKILL 29-4 Administering Tube Feedings
Bolus Feeding
ASSESSMENT
Check the medical order for the type of nourishment, volume, Complies with the legal scope of nursing practice.
and schedule to follow.
Check the date and identifying information on the container of Ensures accurate administration and avoids using outdated
tube-feeding formula. formula.
Chap. 10).
client.
Distinguish the tubing for gastric or intestinal feeding from Prevents administering nutritional formula into the vascular
the tubing to instill intravenous solutions. system.
Assess bowel sounds. Provides data indicating the safety for instilling liquids through the
tube.
Measure gastric residual if a 12 F or larger tube is in place (Fig. A). Determines if the stomach has the capacity to manage the next
instillation of formula; aspiration of fluid may be impossible
with small-lumen tubes.
Measuring gastric residual. (Photo by B. Proud.)
Measure capillary blood glucose or glucose in the urine. Provides data indicating response to caloric intake.
Assess how much the client understands the procedure. Provides an opportunity for client teaching.
(continued)
LWBK1004-C29_p635-672.indd 660 04/02/12 3:18 PM

Administering Tube Feedings (continued)
PLANNING
Replace any unused formula every 24 hours. Reduces the potential for bacterial growth.
Wait and recheck gastric residual in 30 minutes if it exceeds Avoids overfilling the stomach.
100 mL.
Assemble the following equipment: Asepto syringe, formula, Contributes to organization and efficient time management.
tap water.
Warm refrigerated nourishment to room temperature in a basin Prevents chilling and abdominal cramping.
of warm water.
IMPLEMENTATION
Perform hand hygiene. Reduces the transmission of microorganisms.
Place the client in a 30- to 90-degree sitting position. Prevents regurgitation.
Refeed gastric residual by gravity flow. Returns predigested nutrients without excessive pressure.
Pinch the tube just before all the residual has instilled (Fig. B). Prevents air from entering the tube.
Pinch the tubing before it becomes empty.
Add fresh formula to the syringe and adjust the height to allow Provides nourishment.
a slow but gradual instillation (Fig. C).
Administering a bolus feeding.
Continue filling the syringe before it becomes empty. Prevents air from entering the tube.
(continued)
LWBK1004-C29_p635-672.indd 661 04/02/12 3:18 PM

If a gastrostomy tube is being used, tilt the barrel of the syringe Permits air displacement from the stomach.
during the feeding (Fig. D).
Bolus feeding through a gastrostomy tube (G-tube).
Flush the tubing with at least 30–60 mL of water after each feeding, Ensures that all nourishment has entered the stomach; prevents
or follow the agency’s policy for suggested amounts (Fig. E). fermentation and coagulation of formula in the tube; provides
water for fluid balance.
Instilling water to flush the tubing.
Plug or clamp the tube as the water leaves the syringe. Prevents air from entering the tubing; maintains patency.
Keep the head of the bed elevated for at least 30--60 minutes Prevents gastric reflux.
after a feeding.
Wash and dry the feeding equipment. Return items to the Supports principles of medical asepsis.
bedside.
Record the volume of formula and water administered on the Provides accurate data for assessing fluid balance and caloric
bedside intake and output record. value of nourishment.
Provide oral hygiene at least twice daily. Removes microorganisms and promotes comfort and hygiene of
the client.
(continued)
LWBK1004-C29_p635-672.indd 662 04/02/12 3:18 PM

Intermittent Feeding
ASSESSMENT
Follow the previous sequence for assessment. Principles remain the same.
PLANNING
In addition to those activities listed for bolus feeding, replace Reduces the potential for bacterial growth.
unused formula, feeding containers, and tubing every 24 hours.
IMPLEMENTATION
Fill the feeding container with room-temperature formula. Prevents administration of cold formula, which can cause cramp-
ing; room-temperature formula will be instilled before support-
ing bacterial growth.
Gradually open the clamp on the tubing. Purges air from the tube.
Connect the tubing to the nasogastric or nasoenteral tube. Provides access to formula.
Open the clamp and regulate the drip rate according to the Supports safe administration of liquid nourishment.
physician’s order or the agency’s policy.
Check at 10-minute intervals (Fig. F). Ensures early identification of infusion problems.
Checking the rate of flow.
Flush the tubing with water after the formula has infused (Fig. G). Clears the tubing of formula, prevents obstruction, and provides
water for fluid balance.
Flushing the tubing following feeding.
Pinch the feeding tube just as the last volume of water is Prevents air from entering the tube.
administered.
Clamp or plug the feeding tube. Prevents leaking.
Record the volume of formula and water instilled. Provides accurate data for assessing fluid balance and caloric
value of nourishment.
Follow recommendations for postprocedural care as described Principles for care remain the same.
with a bolus feeding.
(continued)
LWBK1004-C29_p635-672.indd 663 04/02/12 3:18 PM

Continuous Feeding
ASSESSMENT
In addition to previously described assessments, check the Principles remain the same. This method ensures a routine pat-
gastric residual every 4 hours. tern for assessment to accommodate the schedule of continu-
ous feedings and prevents inadvertent overfeeding.
PLANNING
In addition to previously described planning activities, obtain Aids in an accurate administration and sounds an alarm if the infu-
equipment for regulating continuous infusion (eg, tube- sion is interrupted.
feeding pump).
Replace unused formula, feeding containers, and tubing every Reduces the potential for bacterial growth.
24 hours.
Attach a time tape to a feeding container. Facilitates periodic assessment.
IMPLEMENTATION
Flush the new feeding container with water. Reduces surface tension within the tube and enhances the pas-
sage of large protein molecules.
Fill the feeding container with no more than 4 hours’ worth Prevents growth of bacteria; body heat will warm cold formula
of refrigerated formula. Exception: Commercially prepared, when infused at a slow rate.
sterilized containers of formula, or formula that is kept iced
while infusing may hang for longer periods.
Purge the tubing of air. Prevents distention of the stomach or intestine.
Thread the tubing within the feeding pump according to the Ensures the correct mechanical operation of equipment and accu-
manufacturer’s directions (Fig. H). rate administration to the client.
Preparing the pump. (Photo by B. Proud.)
(continued)
LWBK1004-C29_p635-672.indd 664 04/02/12 3:18 PM

Connect the tubing from the feeding pump to the client’s Provides access to formula.
feeding tube (Fig. I).
Connecting the feeding tube to the pump.
Set the prescribed rate on the feeding pump (Fig. J). Complies with the medical order.
Programming the pump. (Photo by B. Proud.)
(continued)
LWBK1004-C29_p635-672.indd 665 04/02/12 3:18 PM

Open the clamp on the feeding tube and start the pump (Fig. K). Initiates infusion.
Releasing the clamp. (Photo by B. Proud.)
Keep the client’s head elevated at all times. Prevents reflux and aspiration.
Flush the tubing with 30–60 mL of water or more every 4 hours Promotes patency and contributes to the client’s fluid balance.
after checking and refeeding gastric residual and after admin-
istering medications.
Record the instilled volume of formula and water. Provides accurate data for assessing fluid balance and caloric
value of nourishment.
Follow recommendations for postprocedural care as described Principles for care remain the same.
with a bolus feeding.
Evaluation
• The client receives a prescribed volume of formula according to an established feeding schedule.
• The client’s weight remains stable or the client reaches the target weight.
• The lungs remain clear.
• Bowel elimination is within normal parameters for client.
• The client has a daily fluid intake between 2,000 and 3,000 mL unless intake is otherwise restricted.
Document
• Volume of gastric residual and actions taken, if excessive
• Type and volume of formula
• Rate of infusion, if continuous
• Volume of water used for flushes
• Response of client; if symptomatic, describe actions taken and results
Date and Time A 50 mL of gastric residual. Residual reinstilled and tube flushed with 60 mL of tap water. A 480 mL of
Enrich with Fiber placed in tube-feeding bag. Formula infusing at 120 mL/hr. No diarrhea or gastric
complaints at this time. _________________________________________________________ SIGNATURE/TITLE
LWBK1004-C29_p635-672.indd 666 04/02/12 3:18 PM

UNIT 7
End of Unit Exercises for Chapters 27, 28, and 29
1. A stationary blood clot in the veins is called a/an __________________. (embolus, thrombophlebitis, thrombus)
2. Surgery that removes or replaces defective tissue to restore function is called __________________. (curative,
exploratory, palliative)
3. __________________ is confirmed and monitored by counting the number and type of white blood cells in a sample of
the client’s blood. (Leukocytosis, Phagocytosis, Pinocytosis)
4. __________________ dressings are self-adhesive, opaque, air- and water-occlusive wound coverings. (Gauze,
Hydrocolloid, Transparent)
5. The use of gastrointestinal tubes to provide nourishment is called __________________ feeding. (bolus, gavage, lavage)
6. __________________ tubes are inserted through the nose for distal placement below the stomach. (Nasogastric,
Nasointestinal, Orogastric)
1. T____F____ The care that clients receive before, during, and after surgery is called perioperative care.
2. T____F____ A wound is damaged skin or soft tissue that results from trauma.
3. T____F____ Inflammation, the immediate physiologic response to tissue injury, lasts about 10 days.
4. T____F____ Gastric reflux is the reverse flow of gastric contents.
5. T____F____ Enteral nutrition is nourishment provided by the oral route.

1. A physician who administers chemical agents that temporarily eliminate sensation and pain __________________
2. Blood donors chosen from among the client’s relatives and friends __________________
3. The period from 2 days to 3 weeks after the inflammatory phase during which new cells fill and seal a wound
__________________
4. A process by which damaged cells recover and reestablish their normal function __________________
5. The procedure of cleansing the vaginal canal to treat an infection __________________
6. Measuring the length from the nose to the earlobe to the xiphoid process __________________
667
LWBK1004-C29_p635-672.indd 667 04/02/12 3:18 PM

Activity D: 1. Match the terms related to wounds and wound care in Column A with their explanations in Column B.
Column A Column B
1. __________________ Collagen A. Removal of dead tissue
2. __________________ Remodeling B. Tough and inelastic protein
3. __________________ Dehiscence C. Movement of a liquid at the point of contact with a
solid
4. __________________ Debridement D. Separation of wound edges
5. __________________ Capillary action E. The period during which the wound undergoes
changes and maturation
2. Match the terms related to tube feeding in Column A with their explanations in Column B.
Column A Column B
1. __________________ Intermittent feeding A. Instillation of liquid nutrition without interruption at a rate of
approximately 1.5 mL/min
2. __________________ Continuous feeding B. Instillation of liquid nourishment for 8 to 12 hours followed
by a pause of 12 to 16 hours
3. __________________ Cyclic feeding C. Instillation of liquid nourishment four to six times a day
Activity E: 1. Differentiate between open drains and closed drains based on the categories given below.
Open Drains Closed Drains

Definition
Method of drainage
Wound care
LWBK1004-C29_p635-672.indd 668 04/02/12 3:18 PM

1. Label and identify what is shown in the figure.

2. What could be the adverse effects of this procedure?
Activity G: Coughing is the natural method of clearing secretions from the airways. Write in the boxes provided below
the correct sequence of performing forced coughing.
1. Take a slow deep breath through the nose.
2. Exhale slowly through the mouth.
3. Sit upright.
4. Lean slightly forward.
5. Pull the abdomen inward.
6. Make the lower abdomen rise to the maximum.

1. What is a pneumatic compression device?
2. What are the three methods for preparing the skin for surgery?
3. What are the three types of wound healing?
LWBK1004-C29_p635-672.indd 669 04/02/12 3:18 PM

4. What are the causes of gastrostomy leaks?
5. What are the uses of gastric or intestinal tubes?

1. Why are volatile substances such as alcohol and acetone avoided around lasers?
2. Why do surgical clients have a reduced circulatory volume?
3. Why are transparent dressings less bulky than gauze dressings?
4. Why it is important to keep wounds moist?
5. Why are mercury-weighted tubes not used anymore?
6. Why should water be given sparingly to clients who are using a tube for gastric decompression?
1. A nurse is caring for a client who is to undergo surgery the following day. What potential risks factors increase the
likelihood of perioperative complications?
LWBK1004-C29_p635-672.indd 670 04/02/12 3:18 PM

2. A nurse in a health care facility is caring for a middle-aged client scheduled for an incisional cholecystectomy.
a. What general preoperative information should the nurse provide for this client?
b. What preoperative physical preparations is the nurse likely to perform for the client?
3. A nurse is to perform an ear irrigation on a client.

a. What process will the nurse follow?
b. What post-irrigation technique should the nurse implement?
4. What six basic techniques should the nurse follow to wrap a roller bandage?
5. A nurse at an extended-care facility is caring for a client receiving tube feedings. The client has asked for self-care at
home even if tube feeding is required.
a. What written instructions should the nurse provide when preparing the client for home care?
b. What are some nursing diagnoses that might be appropriate for this client?
6. What are common nursing guidelines for clients with intestinal decompression tubes?
1. A nurse is caring for a client who has received preoperative spinal anesthesia.
a. What postoperative nursing care will be appropriate for this client?
b. How does client care differ for general anesthesia versus regional anesthesia?
2. An elderly client at an extended care facility is experiencing chronic lower back pain.
a. What measures can the nurse take to provide pain relief?
b. What actions should the nurse perform to help prevent pressure ulcers resulting from restricted mobility in this client?
LWBK1004-C29_p635-672.indd 671 04/02/12 3:18 PM

3. A client has been brought to the health care facility in a semiconscious state following a suicide attempt by drug overdose.
a. What immediate care should the nurse provide for this client?
b. What assistance should the nurse provide during a lavage procedure for this client?

1. The physician has ordered a cold application for a client with a bruised and painful ankle. Which of the following
explanations will the nurse give to the client regarding the benefit of cold applications?
a. Speeds healing
b. Relieves muscle spasm
c. Promotes circulation
d. Numbs sensation
2. How can the nurse clear a small-diameter orogastric feeding tube that is obstructed? Select all that apply.
a. Aspirate as much as possible from the tube.
b. Instill 5 mL of an enzymatic solution.
c. Reinstill the aspirated fluid.
d. Measure the aspirated fluid and record.
e. Clamp the tube and wait for 15 minutes.
3. A physician has ordered tube feedings for a hospitalized client. Which of the following could contribute to the
development of diarrhea in a tube-fed client? Select all that apply.
a. Highly concentrated formula
b. Rapid administration
c. Bacterial contamination
d. Incorrect tube placement
e. Inadequate calories
4. A nurse is providing preoperative information to a client scheduled to undergo surgery. Which of the following
explanations will the nurse give to the client regarding the benefits of deep breathing?
a. Reduces postoperative risk for respiratory complications
b. Helps clear secretions from the airways
c. Eases postoperative pain and discomfort
d. Decreases the risk for circulatory complications
5. An elderly client is scheduled to undergo surgery. Which of the following assessments should a nurse perform before
fluid restriction? Select all that apply.
a. Fluid intake and output
b. Vital signs
c. Level of consciousness
d. Weight
e. Skin turgor
6. A nurse is caring for an elderly client receiving tube feedings. Which of the following signs should the nurse closely
monitor to identify hyperglycemia?
a. Malabsorption syndrome
b. Hydration status
c. Change in skin turgor
d. Elevated body temperature
LWBK1004-C29_p635-672.indd 672 04/02/12 3:18 PM

UNIT 8
Promoting Elimination
30 Urinary Elimination 674
31 Bowel Elimination 705
673
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30 Urinary Elimination
anuria
bedpan
catheter care 1. Identify the collective functions of the urinary system.
catheter irrigation 2. Describe the physical characteristics of urine and factors that
catheterization affect urination.
clean-catch specimen 3. Name four types of urine specimens that nurses commonly
closed drainage system collect.
commode 4. Identify three alternative devices for urinary elimination.
continence training 5. Define continence training.
continuous irrigation 6. Name three types of urinary catheters.
Credé’s maneuver 7. Describe two principles that apply to using a closed drainage
cutaneous triggering system.
dysuria 8. Explain why catheter care is important in the nursing
external catheter management of clients with retention catheters.
fenestrated drape 9. Discuss the purpose for irrigating a catheter and methods for
frequency performing this skill.
incontinence 10. Define urinary diversion.
Kegel exercises 11. Discuss factors that contribute to impaired skin integrity in
nocturia clients with a urostomy.
oliguria
peristomal skin
polyuria
T
residual urine his chapter reviews the process of urinary elimination and de-
retention catheter scribes the nursing skills for assessing and maintaining urinary
stasis elimination.
straight catheter
24-hour specimen
urgency
urinal
urinary diversion
OVERVIEW OF URINARY ELIMINATION
urinary elimination
urinary retention The urinary system (Fig. 30-1) consists of the kidneys, ureters, blad-
urine der, and urethra. These major components, along with some acces-
urostomy sory structures such as the ring-shaped muscles called the internal and
voided specimen external sphincters, work together to produce urine (fluid within the
voiding reflex bladder), collect it, and excrete it from the body.
Urinary elimination (the process of releasing excess fluid and
metabolic wastes), or urination, occurs when urine is excreted. Under
normal conditions, the average person eliminates approximately 1,500
to 3,000 mL of urine each day. The consequences of impaired urinary
elimination can be life-threatening.
Urination takes place several times each day. The need to urinate
becomes apparent when the bladder distends with approximately 150
to 300 mL of urine. The distention with urine causes increased fluid
pressure, stimulating stretch receptors in the bladder wall and creating
a desire to empty it of urine.
674
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CHAPTER 30 Urinary Elimination 675
General measures to promote urination include provid-

ing privacy, assuming a natural position for urination (sitting
for women, standing for men), maintaining an adequate fluid
intake, and using stimuli such as running water from a tap to
Kidney initiate voiding.
Urine Specimen Collection

Ureter
Health care professionals collect urine specimens, or sam-
ples of urine, to identify microscopic or chemical constitu-
ents. Common urine specimens that nurses collect include
voided specimens, clean-catch specimens, catheter speci-
mens, and 24-hour specimens.
Bladder Voided Specimens
Urethra A voided specimen is a sample of fresh urine collected in a
clean container. The first voided specimen of the day is pre-
ferred because it is most likely to contain substantial urinary
components that have accumulated during the night. Nev-
FIGURE 30-1 The major structures of the urinary system. ertheless, the specimen can be voided and collected at any
time it is needed.
The sample of urine is transferred into a specimen con-
CHARACTERISTICS OF URINE tainer and delivered to the laboratory for testing and analy-
sis. If the specimen cannot be examined in less than 1 hour
The physical characteristics of urine include its volume, after collection, it is labeled and refrigerated.
color, clarity, and odor. Variations in what is considered nor-
mal are wide (Table 30-1). Clean-Catch Specimens
A clean-catch specimen is a voided sample of urine consid-
ered sterile and is sometimes called a midstream specimen
FACTORS AFFECTING URINARY because of the way it is collected. To avoid contaminating
ELIMINATION the voided sample with microorganisms or substances other
than those in the urine, the external structures through which
Patterns of urinary elimination depend on physiologic, emo- urine passes (the urinary meatus, which is the opening to the
tional, and social factors. Examples include (1) the degree urethra, and the surrounding tissues) are cleansed. The urine
of neuromuscular development and the integrity of the spinal is collected after the initial stream has been released.
cord; (2) the volume of fluid intake and the amount of fluid Clean-catch specimens are preferred to randomly
losses, including those from other sources; (3) the amount voided specimens. This method of collection is also pref-
and type of food consumed; and (4) the person’s circadian erable when a urine specimen is needed during a woman’s
rhythm, habits, opportunities for urination, and anxiety. menstrual period. As soon as the specimen is collected, it
TABLE 30-1 Characteristics of Urine

CHARACTERISTIC NORMAL ABNORMAL COMMON CAUSES OF VARIATIONS
Volume 500–3,000 mL/day ⬍400 mL/day Low fluid intake
1,200 mL/day average Excess fluid loss
Kidney dysfunction
⬎3,000 mL/day High fluid intake
Diuretic medication
Endocrine diseases
Color Light yellow Dark amber Dehydration
Brown Liver/gallbladder disease
Reddish-brown Blood
Orange, green, blue Water-soluble dyes
Clarity Transparent Cloudy Infection
Stasis
Odor Faintly aromatic Foul Infection
Strong Dehydration
Pungent Certain foods
LWBK1004-C30_p673-704.indd 675 04/02/12 3:21 PM

676 UNIT 8 Promoting Elimination

Collecting a Clean-Catch Specimen
The nurse teaches the female client as follows:
● Wash your hands.
● Remove the lid from the specimen container.
● Rest the lid upside down on its outer surface, taking care
not to touch the inside areas.
● Sit on the toilet and spread your legs.
● Separate your labia with your fingers.
● Cleanse each side of the urinary meatus with a separate
antiseptic swab, wiping from front to back toward the
vagina.
● Use the final clean, moistened swab to wipe directly
down the center of the separated tissue.
● Begin to urinate. FIGURE 30-2 The location for collecting a catheter specimen.
● After releasing a small amount of urine into the toilet, (Photo by B. Proud.)
catch a sample of urine in the specimen container.
● Take care not to touch the mouth of the specimen
container to your skin.
● Place the specimen container nearby on a flat surface. 24-Hour Specimens
● Release your fingers and continue voiding normally. The nurse collects, labels, and delivers a 24-hour specimen
● Wash your hands. (a collection of all urine produced in a full 24-hour period)
● Cover the specimen container with the lid. to the laboratory for analysis. Because the contents in urine
The male client should follow the same steps as above decompose over time, the nurse places the collected urine
but should perform the following cleansing routine: in a container with a chemical preservative or puts the con-
tainer in a basin of ice or in a refrigerator.
● Retract your foreskin, if you are uncircumcised, or
cleanse in a circular direction around the tip of the penis
To establish the 24-hour collection period accurately,
toward its base using a premoistened antiseptic swab. the nurse instructs the client to urinate just before start-
● Repeat with another swab. ing the test and then discards that urine. All urine voided
● Continue retracting the foreskin while initiating the thereafter becomes part of the collected specimen. Exactly
first release of urine and until you have collected the 24 hours later, the nurse asks the client to void one last time
midstream specimen. to complete the test collection. The final urination and all
collected voidings from the preceding 24 hours represent
the total specimen, which the nurse labels and takes to the
laboratory.
is labeled and taken to the laboratory. A clean-catch urine
specimen is refrigerated if the analysis will be delayed more Abnormal Urine Characteristics
Laboratory analysis is a valuable diagnostic tool for iden-
than 1 hour.
tifying abnormal characteristics of urine. Specific terms
Research suggests that collecting a specimen in mid-
describe particular abnormal characteristics of urine and uri-
stream after the use of soap, tap water, and nonsterile gauze
nation. Many terms use the suffix -uria, which refers to urine
for perineal cleansing provides results as reliable as those
or urination. For example:
in which an antiseptic solution is used (Unlu et al., 2007).
Nurses should follow their agency’s policy. • Hematuria: urine containing blood
When a clean-catch specimen is needed, nurses can • Pyuria: urine containing pus
instruct clients who are capable of performing the proce- • Proteinuria: urine containing plasma proteins
dure on the collection technique (see Client and Family • Albuminuria: urine containing albumin, a plasma protein
Teaching 30-1). • Glycosuria: urine containing glucose
• Ketonuria: urine containing ketones
Catheter Specimens
A urine specimen can be collected under sterile conditions
using a catheter, but this is usually done when clients are ABNORMAL URINARY
catheterized for other reasons such as to control inconti- ELIMINATION PATTERNS
nence in an unconscious client. For clients who are already
catheterized, the nurse can aspirate a sample through the Assessment findings may indicate abnormal urinary elimi-
lumen of a latex catheter or from a self-sealing port that has nation patterns. Some common problems include anuria,
been cleansed with an alcohol pad (Fig. 30-2). oliguria, polyuria, nocturia, dysuria, and incontinence.
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Anuria Nocturia
Anuria means the absence of urine or a volume of 100 mL or Nocturia (nighttime urination) is unusual because the rate of
less in 24 hours. It indicates that the kidneys are not forming urine production is normally reduced at night. Consequently,
sufficient urine. In this case, the term “urinary suppression” nocturia suggests an underlying medical problem. In aging
is used. In urinary suppression, the bladder is empty; there- men, an enlarging prostate gland, which encircles the ure-
fore, the client feels no urge to urinate. This distinguishes thra, interferes with complete bladder emptying. As a result,
anuria from urinary retention, in which the client produces there is a need to urinate more frequently, including during
urine but does not release it from the bladder. A sign of uri- the usual hours of sleep.
nary retention is a progressively distending bladder.
Dysuria
Dysuria is the difficult or uncomfortable voiding and a com-
Oliguria
mon symptom of trauma to the urethra or a bladder infec-
Oliguria, urine output less than 400 mL/24 hours, indicates
tion. Frequency (the need to urinate often) and urgency (a
the inadequate elimination of urine. Sometimes oliguria is a
strong feeling that urine must be eliminated quickly) often
sign that the bladder is being only partially emptied during
accompany dysuria.
voidings. Residual urine, or more than 50 mL of urine that
remains in the bladder after voiding, can support the growth
of microorganisms, leading to infection. Also, when there is Gerontologic Considerations
urinary stasis (a lack of movement), dissolved substances
such as calcium can precipitate, leading to urinary stones. ■ Older adults are likely to experience urinary urgency and
frequency because of normal physiologic changes such as
diminished bladder capacity and degenerative changes in the
Gerontologic Considerations cerebral cortex. Subsequently, when they perceive the urge
to void, they need to access a bathroom as soon as possible.
■ Older adults are more likely to have chronic residual urine
(excessive urine in the bladder after urinating), which
increases the risk for urinary tract infections. They may ben- Incontinence
efit from learning double-voiding in which the person voids Incontinence means the inability to control either urinary
then waits a few more minutes to allow any residual urine or bowel elimination and is abnormal after a person is toi-
to be voided. let trained. The term urinary incontinence should not be
used indiscriminately: anyone may be incontinent if his or
her need for assistance goes unnoticed. Once the bladder
becomes extremely distended, spontaneous urination may
Gerontologic Considerations be more of a personnel problem than a client problem. (The
client may not be incontinent if staff members are attentive
■ The prevention of urinary tract infections is best accom- to his or her need to urinate.)
plished by prompt attention to perineal hygiene. Women
should always clean from the urinary area back toward the
rectal area to prevent organisms from the stool entering Gerontologic Considerations
the bladder. In addition, thorough hand washing by the
client and caregiver is necessary. ■ Age-related changes, such as a diminished bladder
capacity and a relaxation of the pelvic floor muscle tone,
increase the risk for incontinence.
■ Fluid restriction may be used in an attempt to control
Polyuria urination, but it may actually contribute to incontinence by
Polyuria means greater than normal urinary elimination causing concentrated urine and eliminating the normal
and may accompany minor dietary variations. For example, perception of a full bladder.
consuming higher than normal amounts of fluids, especially ■ Older adults should be taught that odors may remain in
those with mild diuretic effects (eg, coffee and tea), or taking clothing because of ammonia from urine leakage. Adding
certain medications actually can increase urination. Ordinar- vinegar or using odor-controlling detergents may be useful
ily, urine output is nearly equal to fluid intake. When the when laundering soiled clothing.
cause of polyuria is not apparent, excessive urination may
be the result of a disorder. Common disorders associated
with polyuria include diabetes mellitus, an endocrine disor- Pharmacologic Considerations
der caused by insufficient insulin or insulin resistance, and
diabetes insipidus, an endocrine disease caused by insuf- ■ Diuretic therapy commonly can increase the risk for
ficient antidiuretic hormone. urinary incontinence especially among older adults with
LWBK1004-C30_p673-704.indd 677 18/02/12 11:04 AM

mobility problems. Planning for access to a toilet within 30

to 120 minutes following medication administration should
be included in client education regarding diuretic therapy.
■ A diuretic should be administered in the morning to avoid
disturbing a client’s sleep by the need to urinate.
ASSISTING CLIENTS WITH

URINARY ELIMINATION
Stable clients who can ambulate are assisted to the bathroom

to use the toilet. Clients who are weak or cannot walk to the
bathroom may need a commode. Clients confined to the bed
use a urinal or bedpan.
FIGURE 30-4 Placement of a urinal.
Commode
A commode (a chair with an opening in the seat under which
a receptacle is placed) is located beside or near the bed Using a Bedpan
(Fig. 30-3). It is used for eliminating urine or stool. Imme- A bedpan (a seatlike container for elimination) is used to
diately afterward, the waste container is removed, emptied, collect urine or stool. Most bedpans are made of plastic and
cleaned, and replaced. are several inches deep. A fracture pan, a modified version
of a conventional bedpan, is flat on the sitting end rather than
Urinal rounded (Fig. 30-5). Clients with musculoskeletal disorders
A urinal is a cylindrical container for collecting urine. It is who cannot elevate their hips and sit on a bedpan in the usual
more easily used by males. When given to the client, the uri- manner use a fracture pan. When a client confined to bed
nal should be empty; otherwise, the bed linen may become feels the need to eliminate, the nurse places a bedpan under
wet and soiled. If the client needs help placing the urinal: the buttocks (Skill 30-1).
• Pull the privacy curtain ➧ Stop, Think, and Respond Box 30-1
• Don gloves Describe measures that may reduce a client’s con-
• Ask the client to spread his legs cerns when he or she requires a bedpan.
• Hold the urinal by its handle
• Direct the urinal at an angle between the client’s legs so
that the bottom rests on the bed (Fig. 30-4)
• Lift the penis and place it well within the urinal
MANAGING INCONTINENCE
After use, the nurse promptly empties the urinal. He or Urinary incontinence, depending on its type, may be perma-
she measures and records the volume of urine if the client’s nent or temporary. The six types of urinary incontinence are
intake and output are being monitored (see Chap. 16). The stress, urge, reflex, functional, total, and overflow (Table 30-2).
nurse washes his or her hands and always offers the client an The management of incontinence is complex because
opportunity to wash his hands after voiding. there are so many variations. Treatment is further compli-
cated when clients have more than one type of incontinence;
for example, stress incontinence often accompanies urge
incontinence.
FIGURE 30-5 Two types of bedpans: a fracture pan (left) and a

FIGURE 30-3 A bedside commode. conventional bedpan (right). (Photo by B. Proud.)
LWBK1004-C30_p673-704.indd 678 04/02/12 3:21 PM

TABLE 30-2 Types of Incontinence

TYPE DESCRIPTION EXAMPLE COMMON CAUSES NURSING APPROACH
Stress The loss of small amounts Dribbling is associated with Loss of perineal and sphinc- Pelvic floor muscle
of urine when intra- sneezing, coughing, ter muscle tone second- strengthening
abdominal pressure rises lifting, laughing, or rising ary to childbirth, meno- Weight reduction
from a bed or chair pausal atrophy, prolapsed
uterus, or obesity
Urge Need to void perceived Voiding commences when Bladder irritation second- Restriction of fluid intake
frequently, with short-lived there is a delay in access- ary to infection; loss of of at least 2,000 mL/day
ability to sustain control ing a restroom bladder tone from recent Omit bladder irritants,
of the flow continuous drainage with such as caffeine or
an indwelling catheter alcohol
Administration of diuret-
ics in the morning
Reflex Spontaneous loss of urine The person automatically Damage to motor and sen- Cutaneous triggering
when the bladder is releases urine and cannot sory tracts in the lower Straight intermittent
stretched with urine, but control it spinal cord secondary to catheterization
without prior perception trauma, a tumor, or other
of a need to void neurologic conditions
Functional Control over urination lost Voiding occurs while Impaired mobility, impaired Clothing modification
because of inaccessibility attempting to overcome cognition, physical Access to a toilet, com-
of a toilet or a compro- barriers such as door- restraints, inability to mode, or urinal
mised ability to use one ways, transferring from a communicate Assistance to a toilet
wheelchair, manipulating according to a pre-
clothing, acquiring assist- planned schedule
ance, or making needs
known
Total Loss of urine without any The person passes urine Altered consciousness sec- Absorbent undergar-
identifiable pattern or without any ability or ondary to a head injury, ments
warning effort to control loss of sphincter tone sec- External catheter
ondary to prostatectomy, Indwelling catheter
anatomic leak through a
urethral/vaginal fistula
Overflow Urine leakage because the The person voids small Overstretched bladder or Hydration
bladder is not completely amounts frequently, or weakened muscle tone Adequate bowel elimina-
emptied; bladder dis- urine leaks around a secondary to obstruction
tended with retained urine catheter tion of the urethra by Patency of catheter
debris within a catheter, Credé’s maneuver
an enlarged prostate,
distended bowel, or post-
operative bladder spasms
Some forms of incontinence respond to simple meas- less urine in the bladder and thus diminishes urge inconti-
ures such as modifying clothing to make elimination easier. nence.
Other forms improve only with a more regimented approach ■ Older adults who experience difficulty controlling urine
like continence training. Inserting a retention catheter is the need an evaluation of contributing factors, which may be
treated to reverse the diminished control of urination. Such
least desirable approach to managing incontinence because
causes may include constipation, urinary tract infection, and
it is the leading cause of urinary tract infections in hospitals
medication side effects.
and nursing homes (Centers for Disease Control and Preven- ■ Older adults need encouragement to discuss urinary
tion, 2009; National Institute of Diabetes and Digestive and incontinence with a knowledgeable, nonjudgmental health
Kidney Diseases, 2005). care provider. If they understand that urinary incontinence
is a condition that frequently responds to medication or
behavioral retraining, they are more likely to seek
Gerontologic
G e r o n t o l o g i c C o n s i d e r a t iConsider
ons professional help.
■ Many resources are available to assist older adults in
■ Loss of control over urination often threatens an older evaluating and treating incontinence. For example, some
adult’s independence and self-esteem. It also may cause an health care facilities offer special incontinence clinics and
older adult to restrict activities, possibly contributing to physical therapy departments to teach pelvic muscle exer-
depression. Teaching older adults to structure activities with cises. In addition, biofeedback has been used to strengthen
planned toileting breaks every 60 to 90 minutes results in bladder control. The National Association for Continence
LWBK1004-C30_p673-704.indd 679 18/02/12 11:04 AM

(800-252-3337; http://www.nafc.org) is an excellent source

of information for products, resources, and continence pro-
grams. Nurses can encourage older adults to take advan-
tage of these kinds of resources rather than accepting
incontinence as an inevitable condition that compromises
their quality of life.
■ When efforts to restore continence are unsuccessful,
nurses can encourage older adults to verbalize their
feelings and identify interventions helpful in maintaining
dignity, ultimately enabling older adults to participate in
meaningful activities.
Continence training to restore the control of urination

involves teaching the client to refrain from urinating until
an appropriate time and place. This process sometimes is
referred to as bladder retraining, but this term is inaccurate
because the various techniques used involve mechanisms
other than those unique to the bladder.
Continence training primarily benefits clients with the FIGURE 30-6 Credé’s maneuver.
cognitive ability and desire to participate in a rehabilitation
program. This includes clients with lower body paralysis
who wish to facilitate urination without the use of urinary
• Relieving bladder distention when clients cannot void
drainage devices such as catheters. Clients who are not can-
• Assessing fluid balance accurately
didates for continence training require alternative methods
• Keeping the bladder from becoming distended during
such as absorbent undergarments.
procedures such as surgery
Continence training is often a slow process that requires
• Measuring the residual urine
the combined effort and dedication of the nursing team, cli-
• Obtaining sterile urine specimens
ent, and family (see Nursing Guidelines 30-1 and Fig. 30-6).
• Instilling medication within the bladder
Types of Catheters
Gerontologic Considerations The three common types of catheters are external, straight,
and retention. Most catheters are made of latex. For clients
■ Routine toileting schedules must be offered every 90 to who are sensitive or allergic to latex, latex-free catheters
120 minutes to clients who have problems with inconti- such as those made of silicone are used.
nence.
■ Absorbent products are likely to interfere with the per- External Catheters
son’s independence in toileting and may lead to skin An external catheter (a urine-collecting device applied to
breakdown. Incontinence products are never used primarily the skin) is not inserted within the bladder; instead, it sur-
for staff convenience in institutional settings. In addition, an
rounds the urinary meatus. Examples of external catheters
older person should never be reprimanded for an episode
are a condom catheter (Fig. 30-7) and a urinary bag (U-bag).
of incontinence.
■ When efforts to restore continence are unsuccessful,
External catheters are more effective for male clients.
nurses can encourage older adults to verbalize their feel- Condom catheters are helpful for clients receiving care at
ings and identify interventions helpful in maintaining dig- home because they are easy to apply. A condom catheter has
nity, ultimately enabling older adults to participate in mean- a flexible sheath that is unrolled over the penis. The narrow
ingful activities.
B OX 3 0 - 1 Technique for Performing Kegel

CATHETERIZATION Exercises
• Tighten the internal muscles used to prevent urination or
Catheterization (the act of applying or inserting a hollow interrupt urination once it has begun.
tube), in this case, refers to using a device inside the bladder, • Keep the muscles contracted for at least 10 seconds.
or externally about the urinary meatus. A urinary catheter is • Relax the muscles for the same period.
used for various reasons: • Repeat the pattern of contraction and relaxation 10 to
25 times.
• Keeping incontinent clients dry (catheterization is a last • Perform the exercise regimen three or four times a day for
resort that is used only when all other continence measures 2 weeks to 1 month.
have been exhausted)
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Rationales
Providing Continence Training
• Compile a log of the client’s urinary elimination patterns. • Suggest performing Credé’s maneuver (the act of bending
The data help to reveal the client’s type of incontinence. forward and applying hand pressure over the bladder; see Fig.
• Set realistic, specific, short-term goals with the client. Short- 30-6). Credé’s maneuver increases abdominal pressure to
term goals prevent self-defeating consequences and promote overcome the resistance of the internal sphincter muscle.
client control. • Instruct paralyzed clients to identify any sensation that pre-
• Discourage strict limitation of liquid intake. Intake maintains cedes voiding such as a chill, muscular spasm, restlessness,
fluid balance and ensures adequate urine volume. or spontaneous penile erection. These cues can help the client
• Plan a trial schedule for voiding that correlates with the times anticipate urination.
when the client is usually incontinent or experiences bladder • Suggest that paralyzed clients with reflex incontinence use cuta-
distention. This schedule reduces the potential for accidental neous triggering (lightly massaging or tapping the skin above
voiding or sustained urinary retention. the pubic area). Cutaneous triggering initiates urination in clients
• In the absence of any identifiable pattern, plan to assist the who have retained a voiding reflex (the spontaneous relaxation
client with voiding every 2 hours during the day and every of the urinary sphincter in response to physical stimulation).
4 hours at night. This duration provides time for urine to form. • Teach clients with stress incontinence to perform Kegel exer-
• Communicate the plan to nursing personnel, the client, and the cises (isometric exercises to improve the ability to retain urine
family. Collaboration promotes continuity of care and dedica- within the bladder; see Box 30-1). Kegel exercises strengthen
tion to reaching goals. and tone the pubococcygeal and levator ani muscles used
• Assist the client to a toilet or commode; position the client on a voluntarily to hold back urine and intestinal gas or stool.
bedpan or place a urinal just before the scheduled time for trial • Assist clients with urge incontinence to walk slowly and con-
voiding. These measures prepare the client for releasing urine. centrate on holding their urine when nearing the toilet. These
• Simulate the sound of urination such as by running water from measures reverse previous mental conditioning in which the
the faucet. Doing so simulates relaxation of the sphincter mus- urge to urinate becomes stronger and more overpowering close
cles, allowing the release of urine. to the toilet.
end is connected to tubing that serves as a channel for drain- restricting blood flow to the skin and tissues of the penis.
ing urine. The drainage tube may be attached to a leg bag Second, moisture tends to accumulate beneath the sheath,
(Fig. 30-8) or connected to a larger urine-collection device. leading to skin breakdown. Third, condom catheters fre-
Three potential problems accompany the use of con- quently leak. Applying the catheter correctly and managing
dom catheters. First, the sheath may be applied too tightly, care appropriately can prevent these problems (Skill 30-2).
FIGURE 30-7 A condom catheter is an example of an external FIGURE 30-8 A leg bag collects urine from a catheter but is
urine collection device. (Photo by B. Proud.) concealed under clothing.
LWBK1004-C30_p673-704.indd 681 04/02/12 3:21 PM


Discuss assessments that indicate common prob- Gerontologic Considerations
lems associated with the use of a condom catheter
and nursing measures that can reduce or eliminate ■ Enlargement of the prostate, a common problem among
negative outcomes. older men, can totally obstruct urinary outflow and make
catheterization difficult or impossible. Insertion of a urinary
catheter should never be forced. Sometimes a catheter is
A U-bag is more often used to collect urine speci-
inserted into the bladder through the abdominal wall when
mens from infants. It is attached by adhesive backing to
it cannot be inserted into a narrowed urethra.
the skin surrounding the genitals. Urine collects in the self-
contained bag. Once enough urine is collected, the bag is
removed. ➧ Stop, Think, and Respond Box 30-3
Discuss factors that predispose a female with a Foley
Straight Catheters catheter to develop a urinary tract infection.
A straight catheter is a urine drainage tube inserted but not
left in place. It drains urine temporarily or provides a sterile
urine specimen (Fig. 30-9). Connecting a Closed Drainage System
A closed drainage system (a device used to collect urine
Retention Catheters from a catheter) consists of a calibrated bag, which can be
A retention catheter, also called an indwelling catheter, is opened at the bottom; tubing of sufficient length to accom-
left in place for a period of time (see Fig. 30-9). The most modate for turning and positioning clients; and a hanger
common type is a Foley catheter. from which to suspend the bag from the bed (Fig. 30-10).
Unlike straight catheters, retention catheters are secured The nurse coils excess tubing on the bed but keeps the sec-
with a balloon that is inflated once the distal tip is within the tion from the bed to the collection bag vertical. Dependent
bladder. Both straight and retention catheters are available loops in the tubing interfere with gravity flow. The nurse
in various diameters, sized according to the French (F) scale also takes care to avoid compressing the tubing, which can
(see Chap. 29). For adults, sizes 14, 16, and 18 F are com- obstruct drainage. Placing the tubing over the client’s thigh
monly used. is acceptable.
The nurse always positions the drainage system
lower than the bladder to avoid a backflow of urine. When
Inserting a Catheter
The techniques for inserting straight and retention catheters
are similar, although the steps for inflating the retention bal-
loon do not apply to a straight catheter. When inserting a
straight or a retention catheter in a health agency, the nurse
uses sterile technique. In the home, nurses and clients who
self-catheterize use clean technique because most clients
have adapted to the organisms in their own environment.
Because of anatomic differences, techniques for insertion
differ in men and women and are described in Skills 30-3
and 30-4.
B
A
FIGURE 30-9 Types of urinary catheters. A. A retention (Foley)

catheter with balloon. B. A straight catheter. (Photo by FIGURE 30-10 A closed urine drainage system. (Photo by
B. Proud.) B. Proud.)
LWBK1004-C30_p673-704.indd 682 18/02/12 11:04 AM

A B
FIGURE 30-11 Techniques for suspending a drainage system below the bladder. A. A wheelchair
patient. B. An ambulating patient with and without an IV pole.
transporting the client in a wheelchair, the nurse suspends the Catheter care (hygiene measures used to keep the mea-
drainage bag from the chair below the level of the bladder. tus and adjacent area of the catheter clean) helps to deter the
When the client is ambulating, the nurse secures the drainage growth and spread of colonizing pathogens. Nursing Guide-
bag to the lower part of an IV pole or allows the client to carry lines 30-2 describes the technique for providing catheter
the bag by hand (Fig. 30-11). care. Nurses must follow agency policy for using antiseptic
To reduce the potential for the drainage system becom- and antimicrobial agents because the use of these substances
ing a reservoir of pathogens, the entire drainage system is is not a standard recommendation by the Centers for Disease
replaced whenever the catheter is changed and at least every Control and Prevention (2009).
2 weeks in clients with a urinary tract infection.
Gerontologic Considerations NURSING GUIDELINES 30-2

Providing Catheter Care
■ Indwelling catheters should be avoided if at all possible
because older people have increased susceptibility to urinary • Plan to cleanse the meatus and a nearby section of the cath-
tract infections. Bladder training is much more desirable. If eter at least once a day. Regular cleansing reduces colonizing
indwelling catheters are necessary, meticulous daily care is microorganisms.
required. The tubing should never be placed higher than the • Gather clean gloves, soap, water, washcloth, towel, and a
bladder to prevent any backflow of urine into the bladder. disposable pad. Organization facilitates efficient time manage-
ment.
• Wash your hands or perform an alcohol-based hand rub (see
Chap. 10). Hand hygiene reduces the potential for transmit-
ting microorganisms.
Discuss possible explanations for why urine may not • Place a disposable pad beneath the hips of a female and
flow from a catheter. beneath the penis of a male. The pad protects the bed linen
from becoming wet or soiled.
• Don clean gloves and wash the meatus, the catheter where
Providing Catheter Care
it meets the meatus, the genitalia, and the perineum (in
A retention catheter keeps the meatus slightly dilated, pro-
that order) with warm, soapy water. Rinse and dry. Routine
viding pathogens with a direct pathway to the bladder where hygiene removes gross secretions and transient microorgan-
an infection could develop. Bacteria also tend to adhere to isms while following the principles of asepsis.
the matrix of catheters forming a slimy substance known • Remove soiled materials and gloves, and repeat hand hygiene
as biofilm, which supports bacterial growth and subsequent measures. These steps remove colonizing microorganisms.
antibiotic resistance (Lu, 2008; Falkinham, 2007).
LWBK1004-C30_p673-704.indd 683 04/02/12 3:21 PM

age tubing must have a self-sealing port. After cleansing the

port with an alcohol swab, the nurse pierces the port with
an 18- or 19-gauge, 1.5 in. needle (see Chap. 34). He or she
attaches the needle to a 30- to 60-mL syringe containing a
sterile irrigation solution. The nurse pinches or clamps the
tubing beneath the port and instills the solution. He or she
releases the tubing for drainage. The nurse records the vol-
ume of irrigant as fluid intake or subtracts it from the urine
output to maintain an accurate intake and output record.
Continuous Irrigation
A continuous irrigation (the ongoing instillation of solu-
tion) instills irrigating solution into a catheter by gravity
over a period of days (Fig. 30-12). Continuous irrigations
keep a catheter patent after prostate or other urologic sur-
gery in which blood clots and tissue debris collect within the
bladder and catheter.
A three-way catheter is necessary to provide a continu-
ous irrigation. The catheter has three lumens or channels
within the catheter, each leading to a separate port. One port
connects the catheter to the drainage system; another pro-
FIGURE 30-12 Bladder irrigation using a three-way catheter.
vides a means for inflating the balloon in the catheter; and
the third instills the irrigating solution (Fig. 30-13). The steps
Catheter Irrigation involved in providing a continuous irrigation are as follows:
Catheter irrigation (flushing the lumen of a catheter) is • Hang the sterile irrigating solution from an intravenous
a technique for restoring or maintaining catheter patency. A pole.
catheter that drains well, however, does not need irrigating. • Purge the air from the tubing.
A generous oral fluid intake is usually sufficient to produce • Connect the tubing to the catheter port for irrigation
dilute urine, which thus keeps small shreds of mucus or tis- (Fig. 30-14).
sue debris from obstructing the catheter. Occasionally, how- • Regulate the rate of instillation according to the medical
ever, the catheter may need to be irrigated, such as after a order.
surgical procedure that results in bloody urine. • Monitor the appearance of the urine and volume of urinary
Depending on the type of indwelling catheter, nurses drainage.
irrigate continuously through a three-way catheter or period-
ically using an open system or a closed system (Skill 30-5). ➧ Stop, Think, and Respond Box 30-5
Using an Open System Discuss what actions might be appropriate if irrigat-
An open system is one in which the retention catheter is ing a catheter is unsuccessful in promoting catheter
separated from the drainage tubing to insert the tip of an irri- patency.
gating syringe. Opening the system creates the potential for
infection because it provides an opportunity for pathogens
Indwelling Catheter Removal
to enter the exposed connection. Consequently, it is the least
A catheter is removed when it needs to be replaced or when
desirable of the three methods.
its use is discontinued. The best time to remove a catheter
Using a Closed System is in the morning when there is more opportunity to address
A closed system is irrigated without separating the catheter any urination difficulties without depriving a client of sleep
from the drainage tubing. To do so, the catheter or drain- (see Nursing Guidelines 30-3).
Inflated balloon
Catheter tip
Irrigation
Balloon inflation
Urine drainage
Cross-section
FIGURE 30-13 Components of a three-way catheter.
LWBK1004-C30_p673-704.indd 684 04/02/12 3:21 PM


Removing a Foley Catheter
• Wash your hands or perform an alcohol-based hand rub
(see Chap. 10) and don clean gloves. These measures follow
standard precautions.
• Empty the balloon by aspirating the fluid with a syringe. This
step ensures that all the fluid has been withdrawn.
• Gently pull the catheter near the point where it exits from the
meatus. Doing so facilitates withdrawal.
• Inspect the catheter and discard if it appears to be intact. This
ensures safety.
• Clean the urinary meatus. This promotes comfort and hygiene.
• Monitor the client’s voiding especially for the next 8 to
FIGURE 30-14 Attaching irrigation tubing to a port on a three-
10 hours; measure the volume of each voiding. Findings
way catheter.
determine whether or not elimination is normal as well as
characteristics of the urine.
URINARY DIVERSIONS
It is often difficult to maintain the integrity of the peri-
In a urinary diversion, one or both ureters are surgically stomal skin (the skin around the stoma) because of the fre-
implanted elsewhere. This procedure is done for various life- quent appliance changes and the ammonia in urine. Skin bar-
threatening conditions. The ureters may be brought to and rier products are used, and sometimes an antibiotic or steroid
through the skin of the abdomen (Fig. 30-15) or implanted ointment is applied.
within the bowel (called an ileal conduit). A urostomy (a
urinary diversion that discharges urine from an opening on NURSING IMPLICATIONS
the abdomen) is the focus of this discussion.
Care for an ostomy, a surgically created opening, is dis- Clients with urinary elimination problems may have one or
cussed in more detail in Chapter 31 because those formed more of the following nursing diagnoses:
for bowel elimination are more common. Chapter 31 also
provides a detailed description of an ostomy appliance, the • Toileting Self-Care Deficit
device used for collecting stool or urine, and the manner in • Impaired Urinary Elimination
which it is applied and removed from the skin. • Risk for Infection
Caring for a urostomy and changing a urinary appli- • Stress Urinary Incontinence
ance are more challenging than the care of intestinal stomas. • Urge Urinary Incontinence
Urine drains continuously from a urostomy, increasing the • Reflex Urinary Incontinence
risk for skin breakdown. In addition, because moisture and • Functional Urinary Incontinence
the weight of the collected urine tend to loosen the appliance • Situational Low Self-Esteem
from the skin, a urinary appliance may need to be changed • Risk for Impaired Skin Integrity
more frequently. When changing the appliance, it may help Nursing Care Plan 30-1 is developed for a client with
to place a tampon within the stoma to absorb urine tempo- Urge Urinary Incontinence, defined by NANDA-I (2012,
rarily while the skin is cleansed and prepared for another p. 198) as “the involuntary passage of urine occurring soon
appliance. after a strong sense of urgency to void.”
FIGURE 30-15 Examples of urinary diversions. A. An

ileal conduit. B. A cutaneous ureterostomy. (Smeltzer,
S. C., & Bare, B. G. [2010]. Brunner and Suddarth’s text-
book of medical-surgical nursing [12th ed.].
Philadelphia: Lippincott Williams & Wilkins.) A B
LWBK1004-C30_p673-704.indd 685 18/02/12 11:04 AM

N U R S I N G C A R E P L A N 3 0 - 1 Urge Urinary Incontinence

Assessment • Ask the client if the need to urinate is less easily controlled as
• Inquire about the number of voidings per day; voiding more the person gets nearer to the location of a toilet.
than eight times in 24 hours or waking up two or more times • Determine if the client experiences accidental loss of urine
at night to urinate, or urinating soon after the bladder has been when there is an almost unstoppable need to urinate.
emptied suggests a pattern of urgency or what has also been
referred to as an overactive bladder.
• Identify the interim the client can wait to postpone urination
following the sensation of a need to empty the bladder, com-
monly referred to as warning time (Carpenito-Moyet, 2006).
Nursing Diagnosis. Urge Urinary Incontinence related to uninhibited bladder muscle contractions as manifested by 14 to
18 voidings per day including awakening three times at night to urinate; daily episodes of urinary incontinence with impaired ability
to delay urge to void.
Expected Outcome. The client will report a decrease in the number of daily voidings to <8 per day; absence or limited occasions
of nocturia; ability to delay urination by 15 minutes or more when urination seems imminent; and absence of urinary incontinence
within 6 to 8 weeks of implementing therapeutic interventions, for example, by 9/15.
Keep a record of the frequency of voidings and the length Documenting the client’s unique pattern of urination facilitates
of time between the warning sign for voiding and actual appropriate nursing interventions.
voiding for 3 days beginning 8/1 through 8/3.
Alert all nursing team members to respond as soon as Responding promptly reduces episodes of incontinence
possible to the client’s signal for assistance. and demonstrates a united effort to help the client achieve
control of urination.
Instruct the client to restrain urination as long as possible Efforts to delay urination help to reverse an established habit
after the warning sign is perceived. of over-responding to an urgent need to void.
Suggest that the client uses a technique such as breath- Focusing thoughts on something other than urination may
ing deeply, singing a song, or talking about family to delay provide sufficient distraction to extend the interval between
voiding. the warning sign and actual voiding.
Encourage the client to eliminate the intake of beverages that Caffeine promotes urination; alcohol inhibits the antidiuretic
contain caffeine or alcohol. hormone, which prevents the reabsorption of water in the
nephrons and leads to an increased formation of urine.
Ensure an oral fluid intake of at least 1,500–2,000 mL/day. An adequate fluid intake reduces the potential for urinary
infection or renal stone formation.
Assist the client to the toilet for the purpose of urination Increasing the length of time between voidings reduces
at a frequency that corresponds with the client’s pre- chronic low-volume voiding, improves bladder muscle tone,
conditioning pattern of urination (ie, approximately q1 1/2h), and increases bladder capacity, which potentiates achieving
and extend the time by 15 minutes until there is an interval continence.
of 2 hours between voidings.
Continue to extend the intervals between voiding until the Reconditioning the control of urination is facilitated by repeti-
client is voiding no more frequently than q4h in a 24-hour tion and gradually extending the efforts to control voiding.
period.
Praise the client every time a short-term goal of delaying or Positive reinforcement helps to motivate the client to con-
controlling urination is achieved. tinue efforts to control incontinence.
Share the client’s progress with the physician. Medical interventions such as prescribing a medication that
blocks acetylcholine (anticholinergic agent) may help to
inhibit bladder muscle contractions and promote contraction
of the urinary sphincter.

• The client is able to gradually delay urination.
• Nocturia is reduced to once per night.
• The client has fewer to no episodes of incontinence.
LWBK1004-C30_p673-704.indd 686 04/02/12 3:21 PM

CRITICAL THINKING EXERCISES 2. Encourage the practice because it leads to accom-

plishing the goal.
1. During a nursing assessment, a female client reports 3. Discourage the practice because it contributes to
periodic dribbling of urine. What additional informa- constipation.
tion is important to obtain? 4. Discourage the practice because it predisposes to
2. An older adult client confides that she would like fluid imbalance.
to participate in activities outside her home, but she 3. When applying an external condom catheter, which
is worried that others will notice her problem with nursing action is correct?
urinary incontinence. What response might help this 1. Lubricate the penis before applying the catheter.
client? What suggestions could you offer? 2. Measure the length and circumference of the penis.
3. A resident in a nursing home who has had a reten- 3. Leave space between the penis and bottom of the
tion catheter for the last 6 months says, “I’d do catheter.
anything if I didn’t have to have this catheter.” 4. Retract the foreskin and roll the catheter over the
What suggestions would be appropriate at this penis.
time? 4. After inserting an indwelling retention catheter into
4. The physician orders the removal of a urinary a male client, which of the following describes an
retention catheter. What actions should the nurse appropriate technique for stabilizing the catheter to
take? avoid a penoscrotal fistula?
1. Tape the catheter to the abdomen.
2. Pass the catheter under the client’s leg.
NCLEX-STYLE REVIEW QUESTIONS 3. Fasten the drainage tube to the bed with a safety pin.
1. What is the most important nursing assessment 4. Insert the catheter into the tubing of a collecting
before beginning continence retraining? bag.
1. Recording the times when the client is 5. When the nurse instructs a female client on the tech-
incontinent nique for collecting a clean-catch midstream urine
2. Checking the results of a routine urinalysis specimen for routine urinalysis, which statement is
3. Palpating the extent of bladder distention correct?
4. Observing the characteristics of the client’s 1. Cleanse the urethral area using several circular
urine motions.
2. During continence retraining, what is the best nursing 2. Void into the plastic liner that is under the toilet seat.
response when a client wants to restrict fluid intake 3. After voiding a small amount, collect a sample of
to remain dry for longer periods? urine.
1. Encourage the practice because it shows evidence 4. Mix the antimicrobial solution with the collected
of client cooperation. urine specimen.
LWBK1004-C30_p673-704.indd 687 04/02/12 3:21 PM

SKILL 30-1 Placing and Removing a Bedpan
ASSESSMENT
Ask the client if he or she feels the need to void. Anticipates elimination needs.
Palpate the lower abdomen for signs of bladder distention. Indicates bladder fullness.
Determine if a fracture pan is necessary or if there are any Prevents injury.
restrictions in turning or lifting.
PLANNING
Gather needed supplies such as clean gloves, bedpan, toilet Promotes organization and efficient time management.
tissue, and a disposable pad.
Warm the bedpan by running warm water over it especially if it is Demonstrates concern for the client’s comfort.
made of metal.
IMPLEMENTATION
Chap. 10); don clean gloves.
Place the adjustable bed in high position. Promotes use of good body mechanics.
Close the door and pull the privacy curtains. Demonstrates concern for the client’s right to privacy and dignity.
Raise the top linen enough to determine the location of the client’s Prevents unnecessary exposure.
hips and buttocks.
Instruct the client to bend the knees and press down with the Helps to elevate the hips.
feet.
Place a disposable pad over the bottom sheets, if necessary. Protects bed linen from becoming wet and soiled.
Slip the bedpan beneath the client’s buttocks (Fig. A). Ensures proper placement.
Placing a bedpan.
Or roll the client to the side and position the bedpan (Fig. B). Reduces work effort and the potential for a work-related injury;
aids in placement if client cannot lift buttocks.
Placing a bedpan from a side-lying position.
B
(continued)
LWBK1004-C30_p673-704.indd 688 04/02/12 3:21 PM

Placing and Removing a Bedpan (continued)
Raise the head of the bed (Fig. C). Simulates the natural position for elimination.
The position for elimination.
Ensure that toilet tissue is within the client’s reach. Provides supplies for hygiene.
Identify the location of the signal device and leave the client, if Respects privacy yet provides a mechanism for communicating a
doing so is safe. need for assistance.
Return and remove the bedpan. Prevents discomfort.
Assist with removing residue of urine from the skin, if necessary. Prevents offensive odors and skin irritation.
Wrap the gloved hand with toilet tissue and wipe from the meatus Supports the principles of medical asepsis.
of a female toward the anal area.
Place soiled tissue in the bedpan unless it requires measuring. Contains soiled tissue until the time of disposal.
Help the client to a comfortable position. Ensures the client’s well-being.
Provide supplies for hand hygiene. Removes residue of urine and colonizing microorganisms.
Measure the volume of urine if the client’s intake and output are Ensures accurate data collection.
being monitored.
Save a sample of urine if it appears abnormal in any way. Facilitates laboratory examination or further assessment.
Empty the urine into a toilet and flush. Facilitates disposal.
Clean the bedpan and replace it in a place that is separate from Supports the principles of asepsis.
clean supplies.
Remove gloves and repeat hand hygiene. Removes colonizing microorganisms.
Evaluation
• Bedpan is positioned without injury.
• Urine is eliminated.
• Hygiene measures are performed.
Document
• Volume of urine eliminated (for monitoring intake and output)
• Appearance and other characteristics of the urine
Date and Time Assisted to use the bedpan. Voided 300 mL of clear, amber urine without difficulty. __ SIGNATURE/TITLE
SKILL 30-2 Applying a Condom Catheter
ASSESSMENT
Wash your hands or perform an alcohol-based hand rub Reduces the potential for transmitting microorganisms.
(see Chap. 10).
Assess the penis for swelling or skin breakdown. Provides data for future comparison or a basis for using some
other method for urine collection.
Determine the client’s understanding about the application and Provides an opportunity for health teaching.
use of an external catheter.
(continued)
LWBK1004-C30_p673-704.indd 689 04/02/12 3:21 PM

Applying a Condom Catheter (continued)
Verify the client’s willingness to use a condom catheter. Respects the client’s right to participate in making decisions.
Check the medical record to determine if the client has a latex allergy. Maintains client safety and prevents possible allergic reaction.
PLANNING
Gather supplies such as soap, water, a towel, a condom catheter, Promotes organization and efficient time management.
drainage tubing, a collection device, and clean gloves. Some
devices come packaged with an adhesive strip or Velcro for
securing the catheter.
Place the client in a supine position and cover him with a bath Facilitates the application of the catheter and maintains privacy.
blanket.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub (see Reduces the transmission of microorganisms and follows standard
Chap. 10) and don clean gloves. precautions.
Wash and dry the penis well. Promotes skin integrity.
Wind the adhesive strip in an upward spiral around the penis Reduces the potential for restricting blood flow.
(Fig. A).
Applying the adhesive strip in a spiral.
Ensure that the wider end of the condom catheter is rolled to the Facilitates application to the penis.
narrower tip (Fig. B).
A rolled condom sheath.
B
(continued)
LWBK1004-C30_p673-704.indd 690 04/02/12 3:21 PM

Hold approximately 1–2 in. (2.5–5 cm) of the lower sheath below Leaves space below the urethra to prevent the irritation of the
the tip of the penis and unroll the sheath upward (Fig. C). meatus.
Unrolling the condom catheter sheath over the penis.
Secure the upper end of the unrolled sheath to the skin firmly with Ensures that the catheter will remain in place.
a second strip of adhesive or a Velcro strap but not so tight as to
interfere with circulation (Fig. D).
Securing a condom catheter.
Connect the drainage tip to a drainage collection device (Fig. E). Allows for urine drainage and collection.
Connecting the condom catheter to a drainage collection system.
E
(continued)
LWBK1004-C30_p673-704.indd 691 04/02/12 3:21 PM

Keep the penis in a downward position. Promotes urinary drainage.
Assess the penis at least every 2 hours. Ensures prompt attention to signs of impaired circulation.
Check that the catheter has not become twisted. Maintains catheter patency.
Empty the leg bag, if one is used, as it becomes partially filled Ensures that the catheter will not be pulled from the penis by the
with urine. weight of the collected urine.
Remove and change the catheter daily or more often if it becomes Maintains skin integrity.
loose or tight.
Substitute a waterproof garment during periods of nonuse. Provides a mechanism for absorbing urine.
Wash the catheter and collection bag with mild soap and water Extends the use of the equipment and reduces offensive odors.
and rinse with a 1:7 solution of vinegar and water.
Evaluation
• Catheter remains attached to the penis.
• Penis exhibits no evidence of skin breakdown, swelling, or impaired circulation.
• Linen and clothing remain dry.
Document
• Preapplication assessment data
• Hygiene measures performed
• Time of catheter application
• Content of teaching
• Postapplication assessment data
Date and Time Penis washed with soap and water. Penile skin is intact. No discoloration or lesions noted. Condom cath-
eter applied and connected to a leg bag. Instructed to report any swelling or local discomfort.
________________________________________________________________________________ SIGNATURE/TITLE
SKILL 30-3 Inserting a Foley Catheter in a Female
ASSESSMENT
Check the client’s record to verify that a medical order has been Demonstrates the legal scope of nursing; catheterization is not an
written. independent measure.
Inspect the medical record to determine if the client has a latex Determines if it is safe to use a latex catheter or if a latex-free type
allergy. is needed.
Determine the type of catheter that has been prescribed. Ensures the selection of an appropriate catheter.
Review the client’s record for documentation of genitourinary Provides data by which to modify the procedure or equipment.
problems.
Assess the client’s age, size, and mobility. Influences the size of the catheter and the need for additional
assistance.
Assess the time of the last voiding. Indicates how full the bladder may be.
Determine how much the client understands about catheterization. Provides an opportunity for health teaching.
(continued)
LWBK1004-C30_p673-704.indd 692 04/02/12 3:21 PM

Inserting a Foley Catheter in a Female (continued)
Familiarize yourself with the anatomic landmarks (Fig. A). Facilitates insertion in the appropriate location.
Clitoris
Urinary meatus
Labia minora
Female anatomical landmarks.
Labia majora
Vagina
Anus
PLANNING
Gather supplies, which include a catheterization kit, a bath blanket, Promotes organization and efficient time management.
and additional light, if necessary.
IMPLEMENTATION
Close the door and pull the privacy curtain. Demonstrates concern for the client’s dignity.
Raise the bed to a high position. Prevents back strain.
Wash your hands or perform an alcohol-based hand rub Reduces the potential for transmitting microorganisms.
(see Chap. 10).
Cover the client with a bath blanket and pull the top linen to the Avoids unnecessary exposure.
bottom of the bed.
Position an additional light at the bottom of the bed or ask an Ensures good visualization.
assistant to hold a flashlight.
Use the corners of the bath blanket to cover each leg. Provides warmth and maintains modesty.
Place the client in a dorsal recumbent position with the feet about Provides access to the female urinary system.
2 feet apart (Fig. B).
A client draped and placed in a dorsal recumbent position.
Use a lateral or Sims’ position for clients who have difficulty Provides access to the female urinary system, but neither is the
maintaining a dorsal recumbent position. preferred position.
If the client is soiled, don gloves, wash the client, remove gloves, Supports the principles of asepsis.
and perform hand hygiene measures again.
Remove the wrapper from the catheterization kit and position it Provides a receptacle for collecting soiled supplies.
nearby.
(continued)
LWBK1004-C30_p673-704.indd 693 04/02/12 3:21 PM

Unwrap the sterile cover to maintain the sterility of the supplies Prevents contamination and the potential for infection.
inside (see Chap. 10) (Fig. C).
Opening the sterile catheter tray.
Remove and don the packaged sterile gloves (see Chap. 10). Facilitates handling the remaining equipment without transferring
microorganisms.
Remove the sterile towel from the kit and place it beneath the Provides a sterile field.
client’s hips (Fig. D).
Placing a sterile towel.
Place a fenestrated drape (one with an open circle in its center) Provides a sterile field.
over the perineum (Fig. E).
Placing a fenestrated drape over the perineum.
E
(continued)
LWBK1004-C30_p673-704.indd 694 07/02/12 5:36 PM

Open and pour the packet of antiseptic solution (Betadine) over Prepares the sterile supplies before contaminating one of two
the cotton balls. hands later in the procedure.
Test the balloon on the catheter by instilling fluid from the prefilled Determines if the balloon is intact or defective.
syringe; then aspirate the fluid back within the syringe (Fig. F).
Testing the balloon.
Spread lubricant on the tip of the catheter (Fig. G). Facilitates insertion.
Lubricating the catheter.
Place the catheterization tray on top of the sterile towel between Promotes access to supplies and reduces the potential for
the client’s legs. contamination.
Pick up a moistened cotton ball with the sterile forceps and Cleanses outer skin before cleansing deeper areas of tissue.
wipe one side of the labia majora from an anterior to posterior
direction.
Discard the soiled cotton ball in the outer wrapper of the catheteri- Completes the bilateral cleansing.
zation kit; repeat cleansing the other side of the labia majora.
Separate the labia majora and minora with the thumb and fingers Facilitates the visualization of anatomic landmarks and prevents
of the nondominant hand, exposing the urinary meatus (Fig. H). contaminating the catheter during insertion.
Separating the labia.
H
(continued)
LWBK1004-C30_p673-704.indd 695 07/02/12 5:37 PM

Consider the hand separating the labia to be contaminated. Avoids transferring microorganisms to sterile equipment and
supplies.
Clean each side of the labia minora with a separate cotton ball Removes colonizing microorganisms.
while continuing to retract the tissue with the nondominant
hand.
Use the last cotton ball to wipe centrally, starting above the Completes the cleaning of external structures.
meatus down toward the vagina (Fig. I).
Wiping from above the meatus downward.
Discard the forceps with the last cotton ball into the wrapper for Follows the principles of asepsis.
contaminated supplies.
Keep the clean tissue separated. Prevents recontamination.
Pick up the catheter, holding it approximately 3–4 in. (7.5–10 cm) Facilitates control during insertion.
from its tip (Fig. J).
Preparing to insert the catheter.
Insert the tip of the catheter into the meatus approximately 2–3 in. Locates the tip beyond the length of the female urethra, which is
(5–7.5 cm) or until urine begins to flow. approximately 1.5–2.5 in. (4–6.5 cm).
Recheck anatomic landmarks if there is no evidence of urine; Indicates one of two possibilities: either the bladder is empty or
remove an incorrectly placed catheter and repeat, using another the catheter has been placed within the vagina by mistake;
sterile catheter. ensures sterility of equipment.
Advance the catheter another 0.5–1 in. (1.3–2.5 cm) after urine Ensures that the catheter is well within the bladder, where the
begins to flow. balloon can be safely inflated.
Direct the end of the catheter so that it drains into the equipment Avoids wetting the linens.
tray or specimen container.
Hold the catheter in place with the fingers and thumb that were Stabilizes the catheter externally.
separating the labia.
(continued)
LWBK1004-C30_p673-704.indd 696 07/02/12 5:37 PM

Pick up the prefilled syringe with the sterile, dominant hand, insert Stabilizes the catheter internally.
it into the opening to the balloon, and instill the fluid (Fig. K).
Inflating the balloon.
Withdraw the fluid from the balloon if the client describes feeling Prevents internal injury.
pain or discomfort, advance the catheter a little more, and try
again.
Tug gently on the catheter after the balloon has been filled. Tests whether or not the catheter is well anchored within the
bladder.
Connect the catheter to a urine collection bag. Provides a means of assessing the urine and its volume.
Wipe the meatus and labia of any residual lubricant. Demonstrates concern for the client’s comfort.
Secure the catheter to the leg with tape or other commercial Prevents pulling on the balloon within the catheter.
device (Fig. L).
Securing the catheter to the thigh.
Hang the collection bag below the level of the bladder; coil excess Ensures gravity drainage.
tubing on the mattress.
Discard the catheterization tray and wrapper with soiled supplies. Follows the principles of asepsis.
Remove your gloves and perform hand hygiene. Removes colonizing microorganisms.
Remove the drape, restore the top sheets, make the client Restores comfort and safety.
comfortable, and lower the bed.
Evaluation
• The catheter is inserted under aseptic conditions.
• The urine is draining from the catheter.
• The client exhibits no evidence of discomfort during or after the insertion.
(continued)
LWBK1004-C30_p673-704.indd 697 04/02/12 3:21 PM

Document
• Preassessment data
• Size and type of catheter
• Amount and appearance of urine
Date and Time Unable to void in past 8 hours. Bladder feels distended. Dr. Peter notified. 16 F Foley catheter inserted per
order and connected to gravity drainage. 550 mL of urine drained from bladder at this time. Urine appears
light amber. No discomfort reported. ______________________________________________ SIGNATURE/TITLE
SKILL 30-4 Inserting a Foley Catheter in a Male
ASSESSMENT
Check the client’s record to verify that a medical order has been Demonstrates the legal scope of nursing; catheterization is not an
written. independent measure.
Inspect the medical record to determine if the client has a latex Determines if it is safe to use a latex catheter or if a latex-free type
allergy. is needed.
Determine the type of catheter that has been prescribed. Ensures the selection of the appropriate catheter.
Review the client’s record for documentation of genitourinary Provides data by which to modify the procedure or equipment.
problems.
Assess the client’s age, size, and mobility. Influences the size of the catheter and need for additional
assistance.
Assess the time of the last voiding. Indicates the potential fullness of the bladder.
Determine how much the client understands about catheterization. Provides an opportunity for health teaching.
Familiarize yourself with the anatomic landmarks (Fig. A). Facilitates insertion.
A B
Male anatomical landmarks. A. Circumcised.

B. Uncircumcised.
PLANNING
Gather supplies, which include a catheterization kit, a bath blanket, Promotes organization and efficient time management.
and additional light.
IMPLEMENTATION
Close the door and pull the privacy curtain. Demonstrates concern for the client’s dignity.
Raise the bed to a high position. Prevents back strain.
Perform handwashing or an alcohol-based hand rub (see Chap. 10). Reduces the potential for transmitting microorganisms.
Place the client in a supine position. Provides access to the male urinary system.
(continued)
LWBK1004-C30_p673-704.indd 698 07/02/12 7:07 PM

Inserting a Foley Catheter in a Male (continued)
Cover the client’s upper body with a bath blanket and lower the Provides minimal exposure.
top linen to expose just the penis.
Position an additional light at the bottom of the bed or ask an Ensures good visualization.
assistant to hold a flashlight.
If the client is soiled, don gloves, wash the client, remove gloves, Supports the principles of asepsis.
and repeat hand hygiene measures.
Remove the wrapper from the catheterization kit and position it Provides a receptacle for collecting soiled supplies.
nearby.
Unwrap the sterile inner cover so as to maintain the sterility of the Prevents contamination and the potential for infection.
supplies inside (see Chap. 10).
Remove and don the packaged sterile gloves (see Chap. 10). Facilitates handling the remaining equipment without transferring
microorganisms.
Place the fenestrated drape over the client’s penis without touch- Provides a sterile field.
ing the upper surface of the drape (Fig. B).
Placing a fenestrated drape.
Open and pour the packet of antiseptic solution (Betadine) over Prepares sterile supplies before contaminating one of two hands
the cotton balls. later in the procedure.
Test the balloon on the catheter by instilling fluid from the prefilled Determines whether the balloon is intact or defective.
syringe; then aspirate the fluid back within the syringe.
Place the catheterization tray between the client’s thighs. Promotes ease of access to supplies and reduces the potential for
contamination.
Lift the penis at its base with the nondominant hand; retract the Promotes visualization and support during catheter insertion.
foreskin if the client is uncircumcised.
Consider the gloved hand holding the penis to be contaminated. Avoids transferring microorganisms to sterile equipment and
supplies.
Pick up a moistened cotton ball with the sterile forceps and wipe Moves microorganisms away from the meatus.
the penis in a circular manner from the meatus toward the base;
repeat using a different cotton ball each time (Fig. C).
Cleaning the penis.
(continued)
LWBK1004-C30_p673-704.indd 699 04/02/12 3:21 PM

Discard the forceps with the last cotton ball into the wrapper for Follows the principles of asepsis.
contaminated supplies.
Apply gentle traction to the penis by pulling it straight up with the Straightens the urethra.
nondominant gloved hand.
Instill the contents of a prefilled syringe containing lubricant Avoids trauma to the urethra caused by insufficient lubrication;
directly through the meatus into the urethra (Fig. D). this technique replaces the traditional practice of lubricating the
outer surface of the catheter, which resulted in its accumulation
at the meatus only (Gerard & Sueppel, 1997).
Instilling lubricant.
Insert, but never force the catheter; rather, rotate the catheter, Adjusts for passing the catheter beyond the prostate gland.
apply more traction to the penis, encourage the client to
breathe deeply, or angle the penis toward the toes (Fig. E).
Catheter insertion.
Continue insertion until only the inflation and drainage ports are Locates the tip beyond the length of the male urethra.
exposed and urine flows.
Pick up the prefilled syringe with the sterile, dominant hand, insert Stabilizes the catheter internally.
it into the opening to the balloon, and instill the fluid (Fig. F).
Inflating the balloon.
F
(continued)
LWBK1004-C30_p673-704.indd 700 04/02/12 3:21 PM

Withdraw the fluid from the balloon if the client describes feeling Prevents internal injury.
pain or discomfort, advance the catheter a little more, and try
again.
Tug gently on the catheter after the balloon has been filled. Tests whether or not the catheter is well anchored within the
bladder.
Connect the catheter to a urine collection bag. Provides a means of assessing the urine and its volume.
Wipe the meatus and penis of any residual lubricant. Demonstrates concern for the client’s comfort.
Secure the catheter to the leg or abdomen with tape or other Prevents pulling on the balloon within the catheter.
commercial device (Fig. G).
Securing a catheter.
Hang the collection bag below the level of the bladder; coil excess Ensures gravity drainage.
tubing on the mattress.
Discard the catheterization tray and wrapper with soiled supplies. Follows the principles of asepsis.
Remove your gloves and repeat hand hygiene measures. Removes colonizing microorganisms.
Remove the drape, restore the top sheets, make the client Restores comfort and safety.
comfortable, and lower the bed.
Evaluation
• The catheter is inserted under aseptic conditions.
• The urine is draining from the catheter.
• The client demonstrates no evidence of discomfort during or after insertion.
Document
• Size and type of catheter
• Amount and appearance of urine
Date and Time 16 F Foley catheter inserted before surgery according to preoperative orders. 350 mL of urine
obtained before connecting the catheter to gravity drainage. Urine appears light yellow and
clear. ________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C30_p673-704.indd 701 04/02/12 3:21 PM

SKILL 30-5 Irrigating a Foley Catheter
ASSESSMENT
Check the client’s record to verify that a medical order has been Demonstrates the legal scope of nursing; a catheter irrigation is
written. not an independent measure.
Verify the type of irrigating solution prescribed, or follow the stand- Complies with medical the directives or standards for care.
ard for practice, which usually advises using sterile normal
saline solution.
Assess the urine characteristics. Provides a baseline for assessing the outcome of the procedure.
Determine how much the client understands about a catheter Provides an opportunity for health teaching.
irrigation.
Locate the port on the drainage tube through which fluid can be Ensures a safe procedure and maintains the integrity of the
instilled (Fig. A). catheter.
Identifying the self-sealing irrigation port.
PLANNING
Gather needed equipment and supplies: an irrigation kit, a flask Promotes organization and efficient time management.
of sterile irrigating solution, a 30- to 60-mL syringe, and alcohol
swabs.
IMPLEMENTATION
Wash hands or perform an alcohol-based hand rub (see Chap. 10). Follows the principles of asepsis and standards of practice.
Raise the height of the bed. Reduces back strain.
Pull the privacy curtain. Demonstrates concern for the client’s dignity.
Add 100–200 mL of solution to the irrigating basin. Avoids contaminating and wasting all the solution in the flask.
Don gloves kept at the bedside or within the irrigation kit. Complies with standard precautions.
Attach a needle to the tip of the irrigating syringe found in the Provides a means for penetrating the self-sealing port.
irrigation kit. Fill the syringe with 30–60 mL of solution (Fig. B).
Filling the syringe with solution.
B
(continued)
LWBK1004-C30_p673-704.indd 702 18/02/12 11:04 AM

Irrigating a Foley Catheter (continued)
Clean the port on the catheter with an alcohol swab (Fig. C). Removes gross debris and colonizing microorganisms.
Cleaning the irrigation port.
Clamp or kink the tubing below the port through which the irrigat- Ensures that the solution will move forward into the catheter and
ing solution will be instilled (Fig. D). not into the drainage system.
Clamping the drainage tubing.
While holding the catheter with one hand, insert the syringe into Maintains sterility.
the port (Fig. E).
Instilling the irrigation solution.
Gently instill the solution. Clears the catheter of debris and dilutes particles within the
catheter.
Remove the syringe. Prevents leaking.
(continued)
LWBK1004-C30_p673-704.indd 703 04/02/12 3:21 PM

Irrigating a Foley Catheter (continued)
Release the clamp from the drainage tubing and observe the flow Facilitates gravity drainage.
of urine through the tubing (Fig. F).
Draining the irrigation solution.
Repeat the instillation and drainage if the urine appears to contain Promotes patency.
appreciable debris.
Record the volume of instilled solution as fluid intake. Maintains accurate assessment data.
Discard or protect the sterility of the irrigating equipment, which Complies with the principles of infection control.
may be reused for the next 24 hours as long as it is not
contaminated.
Evaluation
• The prescribed amount and type of solution are instilled.
• The principles of asepsis have been maintained.
• The urine continues to drain well through the catheter.
• The client reports no discomfort.
Document
• Volume and type of solution
• Volume and appearance of drainage
Date and Time Urine appears amber with some evidence of white particles. 60 mL of sterile normal saline solution in-
stilled into catheter. 120 mL drainage returned. Urine appears to have less sediment. Catheter remains
patent. _________________________________________________ _____________________ SIGNATURE/TITLE
LWBK1004-C30_p673-704.indd 704 04/02/12 3:21 PM

Photo to
Come
FPO
31# Bowel Elimination
anal sphincters
appliance
colostomy 1. Describe the process of defecation.
constipation 2. Name two components of a bowel elimination assessment.
continent ostomy 3. List five common alterations in bowel elimination.
defecation 4. Name four types of constipation.
diarrhea 5. Identify measures within the scope of nursing practice for
enema treating constipation.
enterostomal therapist 6. Identify two interventions that promote bowel elimination when
excoriation it does not occur naturally.
fecal impaction 7. Name two categories of enema administration.
fecal incontinence 8. List at least three common solutions used in a cleansing enema.
feces 9. Explain the purpose of an oil retention enema.
flatulence 10. Name four nursing activities involved in ostomy care.
flatus
gastrocolic reflex
ileostomy
T
ostomy his chapter briefly reviews the process of intestinal elimination and
peristalsis discusses measures to help promote it. It also describes nursing skills
retention enema that may assist clients who have alterations in bowel elimination.
stoma
suppository
Valsalva maneuver
DEFECATION
Defecation (bowel elimination) is the act of expelling feces (stool) from

the body. To do so, all structures of the gastrointestinal tract, especially
the components of the large intestine (also referred to as the bowel or
colon), must function in a coordinated manner (Fig. 31-1). In the large
intestine, a remarkable volume of water is removed from the remnants of
digestion, causing the bowel’s contents to become a consolidated mass
of residue before being eliminated.
Peristalsis means the rhythmic contractions of intestinal smooth
muscle that facilitate defecation. Peristalsis moves fiber, water, and
nutritional wastes along the ascending, transverse, descending, and sig-
moid colon toward the rectum. Peristalsis becomes even more active
during eating; this increased peristaltic activity is called the gastrocolic
reflex.
The gastrocolic reflex usually precedes defecation. Its accelerated
wavelike movements, sometimes perceived as slight abdominal cramp-
ing, propel stool forward, packing it within the rectum. As the rec-
tum distends, the person feels the urge to defecate. Stool is eventually
released when the anal sphincters (ring-shaped bands of muscles) relax.
Performing the Valsalva maneuver (closing the glottis and contract-
ing the pelvic and abdominal muscles to increase abdominal pressure)
705
LWBK1004-C31_p705-734.indd 705 07/02/12 7:09 PM

bowel regularity, which can range from 3 times a day to 3

times a week; (2) include daily exercise, (3) eat high-fiber
foods on a regular basis, and (4) drink 8 to 10 glasses of liq-
uid a day (unless contraindicated), and respond to the urge to
defecate as soon as possible.
Nutrition Notes
■ Foods that are high in fiber include apples and pears with
skin, nuts, bran, whole wheat products, oatmeal, brown
rice, beans, lentils, and raw carrots.
■ Adults may be receptive to eating bran cereal or adding
bran to casseroles or muffins as a means to increase fiber
intake.
FIGURE 31-1 The large intestine. Stool Characteristics

Health care providers can obtain objective data about stool
characteristics by inspecting the stool or asking the client
facilitates this process. Several dietary, physical, social, and to describe its appearance. Information that is particularly
emotional factors can influence the bowel’s mechanical diagnostic includes stool color, odor, consistency, shape, and
function (Table 31-1). unusual components (Table 31-2). The incidence of colorec-
tal cancer increases with age. One early sign is a change in
bowel elimination patterns and stool characteristics. There-
ASSESSMENT OF BOWEL fore, advise older adults to have regular endoscopic bowel
ELIMINATION examinations after 50 years of age. Any change in bowel
elimination that does not respond to simple dietary or life-
A comprehensive assessment of bowel elimination involves style changes requires further investigation.
collecting data about the client’s elimination patterns (bowel Whenever stool appears abnormal, a sample is saved in
habits) and the actual characteristics of the feces. a covered container for the physician’s inspection. In some
instances, nurses may independently perform screening tests
Elimination Patterns on stool samples, such as those that determine the presence
Because various elimination patterns can be normal, it is of blood (see Nursing Guidelines 31-1). Nurses then report
essential to determine the client’s usual patterns, including the results, which can be falsely positive, to the physician,
the frequency of elimination, the effort required to expel who may order more specific laboratory or diagnostic tests.
stool, and what elimination aids, if any, he or she uses. Health
education regarding bowel elimination includes the follow-
ing points: (1) adults should identify their own patterns of TABLE 31-2 Characteristics of Stool
CHARACTERISTIC NORMAL ABNORMAL
TABLE 31-1 Common Factors Affecting Bowel Color Brown Black

Elimination Clay colored (tan)
Yellow
FACTOR EFFECT Green
Types of food consumed Influence color, odor, volume, Odor Aromatic Foul
and consistency of stool, and Consistency Soft, formed Soft, bulky
fecal velocity Hard, dry
Fluid intake Influences moisture content of Watery
stool Paste like
Drugs Slow or speed motility Shape Round, full Unformed
Emotions Alter bowel motility Flat
Neuromuscular function Affects the ability to control Pencil-shaped
rectal muscles Stone like
Abdominal muscle tone Affects the ability to increase Components Undigested fiber Worms
intra-abdominal pressure Blood
(Valsalva maneuver) Pus
Opportunity for defecation Inhibits or facilitates elimination Mucus
LWBK1004-C31_p705-734.indd 706 04/02/12 3:22 PM

CHAPTER 31 Bowel Elimination 707
Rationales
Testing Stool for Occult Blood
• Collect stool within a toilet liner or bedpan. Use of such • Cover the entire test space. Doing so ensures more accurate
devices prevents mixing stool with water or urine. findings.
• Don gloves and use an applicator stick to collect the specimen. • Place two drops of the chemical reagent onto the test space.
These measures reduce the transmission of microorganisms. This step promotes a chemical reaction.
• Take a sample from the center area of the stool. A sample from • Wait for 60 seconds. This duration is the time needed for
here provides more diagnostic value because it is not superfi- chemical interaction with the stool.
cially tainted with blood from local tissue. • Observe for a blue color. This finding indicates that blood is
• Apply a thin smear of stool onto the test area supplied with the present.
screening kit. Correct use of the kit ensures thorough contact
with the chemical reagent.
By analyzing assessment findings, nurses may help phy- bowel, resulting in bulkier stool that is more quickly and eas-
sicians to diagnose a medical problem or use the conclusions ily eliminated.
to identify alterations within the scope of nursing manage- Some researchers speculate that a shortened transit
ment. time—the time between when a person eats food and elimi-
nates stool—protects against serious medical disorders. They
argue that the longer the stool is retained, the more contact
COMMON ALTERATIONS IN with and absorption of toxic substances takes place that may
BOWEL ELIMINATION contribute to the development of colorectal cancer (Johnson,
Barret, Gishan, et al., 2006; Talley, Lasch, & Baum, 2008).
Clients often have temporary or chronic problems with Constipation is classified into one of four distinct types
bowel elimination and intestinal function such as constipa- (primary, secondary, iatrogenic, and pseudoconstipation),
tion, fecal impaction, flatulence, diarrhea, and fecal incon- according to the underlying cause.
tinence. If these conditions are a component of a serious
disorder, nurses and physicians collaborate to address them. Primary Constipation
Nurses may treat alterations within the scope of nursing Primary or simple constipation is well within the treatment
practice independently. domain of nurses. It results from lifestyle factors such as
inactivity, inadequate intake of fiber, insufficient fluid intake,
Constipation or ignoring the urge to defecate.
Constipation is an elimination problem characterized by
dry, hard stool that is difficult to pass. Various accompany- Secondary Constipation
ing signs and symptoms include the following: Secondary constipation is a consequence of a pathologic dis-
order such as a partial bowel obstruction. It usually resolves
• Complaints of abdominal fullness or bloating when the primary cause is treated.
• Abdominal distention
• Complaints of rectal fullness or pressure Iatrogenic Constipation
• Pain on defecation Iatrogenic constipation occurs as a consequence of other
• Decreased frequency of bowel movements medical treatments. For example, prolonged use of narcotic
• Inability to pass stool analgesia tends to cause constipation. These and other drugs
• Changes in stool characteristics such as oozing, liquid slow peristalsis, delaying transit time. The longer the stool
stool or hard, small stool remains in the colon, the drier it becomes, making it more
difficult to pass.
The infrequent elimination of stool does not necessarily
indicate that a person is constipated. Some people may be Pseudoconstipation
constipated even though they have a daily bowel movement, Pseudoconstipation, also referred to as Perceived Constipa-
whereas others who defecate irregularly may have normal tion by NANDA International (NANDA-I, 2012), is a term
bowel function. used when clients believe themselves to be constipated even
The incidence of constipation tends to be high among though they are not. Pseudoconstipation may occur in people
those whose dietary habits lack adequate fiber (such as not who are extremely concerned about having a daily bowel
eating sufficient raw fruits and vegetables, whole grains, movement. In their zeal for regularity, they often overuse or
seeds, and nuts). Dietary fiber, which includes undigested abuse laxatives, suppositories, and enemas. Such self-treat-
cellulose, is important because it attracts water within the ment may ultimately cause rather than treat constipation.
LWBK1004-C31_p705-734.indd 707 04/02/12 3:22 PM

Chronic purging eventually weakens bowel tone; conse- result from unsuccessful efforts to evacuate the lower bowel.
quently, bowel elimination is less likely unless it is artifi- Some clients with an impaction pass liquid stool, which may
cially stimulated. be misinterpreted as diarrhea. Forceful muscular contrac-
tions of peristalsis in higher bowel areas, where the stool
is still fluid, cause the liquid stool. These contractions send
Gerontologic Considerations the liquid around the margins of the impacted stool, but this
passage of liquid stool does not relieve the initial condition.
■ Age-related changes, such as a loss of elasticity in the To determine whether or not a fecal impaction is
intestinal walls and slower motility throughout the gastro- present, it may be necessary to insert a lubricated, gloved
intestinal tract, predispose older adults to constipation. finger into the rectum. If the rectum is filled with a mass of
Such changes alone, however, do not cause constipation.
stool, the nurse implements measures for its removal. Some-
Other factors, such as adverse medication effects, dimin-
times nurses administer enemas, first oil retention, and then
ished physical activity, and reliance on commercially pre-
pared meals that are easy to heat and eat, but which are cleansing. These therapeutic measures are discussed later in
low in fiber, fresh fruits, and vegetables, contribute to the this chapter. Another intervention is to remove the stool dig-
development of constipation. itally (see Nursing Guidelines 31-2 and Fig. 31-2).
■ Older adults are likely to implement various home reme-
dies such as drinking prune juice or hot water in the morn-
ing to promote bowel elimination. The consideration of ben- Gerontologic Considerations
efits, potential risks, or lack of effect on an older person’s
usual health practices allows for collaboration regarding the ■ Older adults may have benign lesions such as hemor-
efficacy of continuing the health care behavior with the rhoids or polyps in their lower bowel, which may interfere
older adult. with the passage of stool. If the digital removal of an
■ Older adults may be open to increasing dietary fiber impaction is required, gentle manipulation within the rec-
which is a healthier alternative to using laxatives to tum should be used to prevent bleeding and tissue trauma.
maintain bowel elimination.
■ Older adults may be taught to incorporate a natural laxative
into their diet. The “Power Pudding” recipe consists of 1 cup
wheat bran, 1 cup applesauce, and 1 cup prune juice all Flatulence
mixed thoroughly and refrigerated. The older person can begin Flatulence or flatus (an excessive accumulation of intesti-
with 1 tbsp per day and increase the amount by small incre- nal gas) results from swallowing air while eating or from
ments daily until an ease of bowel movement is achieved and sluggish peristalsis. Another cause is the gas that forms as
no disagreeable symptoms occur (Touhy & Jett, 2010). a by-product of bacterial fermentation in the bowel. Vegeta-
bles such as cabbage, cucumbers, and onions are commonly
known for producing gas. Beans are other gas formers. Eat-
ing beans creates intestinal gas because humans lack an
Pharmacologic Considerations enzyme to completely digest its particular form of complex
carbohydrate.
■ Some adults may become very bowel conscious and
Regardless of its cause, flatus may be expelled rectally,
overuse laxatives or have a sustained laxative abuse. They
thus reducing intestinal accumulation and distention. Some-
can develop healthier bowel elimination habits through use
of bulk-forming products containing psyllium or polycar-
times, however, this is not sufficient to eliminate the cramping
bophil, which are more effective and less irritating than pain or other symptoms. When clients are extremely uncom-
other types of laxatives. Examples of these agents include fortable and ambulating does not eliminate flatus, the nurse
Metamucil (Procter & Gamble, Cincinnati, OH) and FiberCon may insert a rectal tube to help the gas escape (Skill 31-1).
(Lederle Laboratories, Pearl River, NY).
■ Adults who use mineral oil to prevent or relieve constipa-
tion need to be informed that its prolonged use interferes Discuss measures to include in a teaching plan that
with the absorption of fat-soluble vitamins (A, D, E, and K). would help clients reduce or eliminate intestinal
gas.
Fecal Impaction Diarrhea

Fecal impaction occurs when a large, hardened mass of Diarrhea is the urgent passage of watery stool and com-
stool interferes with defecation, making it impossible for the monly is accompanied by abdominal cramping. Simple
client to pass feces voluntarily. Fecal impactions result from diarrhea usually begins suddenly and lasts for a short period.
unrelieved constipation, retained barium from an intestinal Other associated signs and symptoms include nausea and
X-ray, dehydration, and weakness of abdominal muscles. vomiting and blood or mucus in the stools.
Clients with a fecal impaction usually report a frequent Usually, diarrhea is a means of eliminating an irritat-
desire to defecate but an inability to do so. Rectal pain may ing substance such as tainted food or intestinal pathogens.
LWBK1004-C31_p705-734.indd 708 18/02/12 11:05 AM

Rationales
Removing a Fecal Impaction
• Wash your hands or perform an alcohol-based hand rub (see • Insert your lubricated finger within the rectum to the level of
Chap. 10). Hand hygiene reduces the transmission of microor- the hardened mass. Insertion to this level facilitates digital
ganisms. manipulation of the stool.
• Don clean examination gloves. Doing so complies with stand- • Move your finger about slowly and carefully to break up the
ard precautions by providing a barrier between the hands and mass of stool. Movement facilitates removal or voluntary
a substance that contains body fluid. passage.
• Provide privacy. Privacy demonstrates respect for the client’s • Withdraw segments of the stool (see Fig. 31-2) and deposit
dignity. them in the bedpan. Removal reduces the internal mass of
• Place the client in a Sims’ position (see Chap. 14). This posi- stool.
tion facilitates access to the rectum. • Provide periods of rest but continue until the mass has been
• Cover the client with a drape and place a disposable pad under removed or sufficiently reduced. Doing so restores patency to
the client’s hips. Use of these materials prevents soiling. the lower bowel.
• Place a bedpan conveniently on the bed. The bedpan acts as a • Clean the client’s rectal area; dispose of the stool and soiled
container for removed stool. gloves; repeat hand hygiene measures. These measures support
• Lubricate the forefinger of your dominant gloved hand. Lubri- the principles of medical asepsis.
cation eases insertion within the rectum.
Diarrhea may also result from emotional stress, dietary

indiscretions, laxative abuse, or bowel disorders. Nutrition Notes
Resting the bowel temporarily may relieve simple
■ Probiotics are beneficial bacteria present in some com-
diarrhea. This means the person drinks clear liquids but
mercial products like yogurt that contain live cultures. These
avoids solid foods for 12 to 24 hours. Resumed eating begins bacteria survive digestion and colonize within the bowel,
with bland foods and those low in residue such as bananas, making bowel contents more acidic. The lowered intestinal
applesauce, and cottage cheese. If diarrhea is not relieved pH creates a hostile environment for unhealthy bacteria.
within 24 hours, it is best to consult a physician. Eating products containing probiotics is believed to regu-
late and improve elimination, thus reducing symptoms of
diarrhea, constipation, intestinal gas, and bloating.
■ Diarrhea can easily lead to dehydration and electrolyte

imbalances (especially hypokalemia) in older adults, who Fecal Incontinence
tend to have less body fluid reserve than younger people. Fecal incontinence is the inability to control the elimination
of stool. It does not necessarily imply that stool is loose or
watery, although that may be the case. In some instances,
bowel function is normal, but incontinence results from neu-
rologic changes that impair muscle activity, sensation, or
thought processes. Even a fecal impaction may be an under-
lying cause of incontinence. Incontinence also may occur
when a person cannot reach a toilet in time to eliminate, such
as after taking a harsh laxative.
Chronic fecal incontinence can be devastating socially
and emotionally. Clients who cope with chronic fecal incon-
tinence and their families require much support and under-
standing. They may benefit from teaching that the nurse
offers (see Client and Family Teaching 31-1).
MEASURES TO PROMOTE
BOWEL ELIMINATION
Nurses commonly use two interventions—inserting suppos-

itories and administering enemas—to promote elimination
FIGURE 31-2 Removing impacted stool. when it does not occur naturally or when the bowel must
LWBK1004-C31_p705-734.indd 709 04/02/12 3:22 PM

Client and Family Teaching 31-1 Administering an Enema

Managing Fecal Incontinence An enema introduces a solution into the rectum (Skill 31-3).
Nurses give enemas to:
• Cleanse the lower bowel (most common reason)
● Eat regularly and nutritiously.
● Monitor the pattern of incontinence to determine
• Soften feces
whether it occurs at a similar time each day. • Expel flatus
● Sit on the toilet or bedside commode before the time • Soothe irritated mucous membranes
elimination tends to occur. • Outline the colon during diagnostic X-rays
● Consult the physician about inserting a suppository or • Treat worm and parasite infestations
administering an enema every 2 to 3 days to establish a
pattern for bowel elimination. Cleansing Enemas
● Use moisture-proof undergarments and absorbent pads
Cleansing enemas use different types of solution to remove
to protect clothing and bed linen.
feces from the rectum (Table 31-3). Defecation usually
● Teach caregivers to do the following:
● Do not imply, verbally or nonverbally, that the client is
occurs within 5 to 15 minutes after administration.
to blame for the incontinence or that cleaning him or Large-volume cleansing enemas may create discomfort
her is disgusting. because they distend the lower bowel. Nurses must admin-
● Avoid anything that connotes diapering, to preserve the ister them cautiously to clients with intestinal disorders such
client’s dignity and self-esteem. as colitis (inflammation of the colon) because large-volume
enemas may rupture the bowel or cause other secondary com-
plications. In many health agencies and in the home, commer-
cially prepared disposable administration sets have become
the method of choice for cleansing the bowel. Their smaller
be cleansed for other purposes, such as in preparation for
volume makes them less fatiguing and distressing than large-
surgery and endoscopic or X-ray examinations.
volume enemas, and they can be easily self-administered.
Inserting a Rectal Suppository Tap Water and Normal Saline Enemas

A suppository (an oval or cone-shaped mass that melts at Tap water and normal saline solutions are preferred for
body temperature) is inserted into a body cavity such as the their nonirritating effects, especially for clients with rectal
rectum. The most common reason for inserting a suppository diseases or those being prepared for rectal examinations.
is to deliver a drug that will promote the expulsion of feces. Tap water and normal saline appear to have about the same
Other medications, such as drugs to control vomiting and degree of effectiveness for cleansing the bowel.
reduce fever, also are available in suppository form. Because tap water is hypotonic, the fluid can be absorbed
through the bowel. Consequently, if several enemas are
administered in succession, fluid and electrolyte imbalances
Pharmacologic Considerations may occur (see Chap. 16). Therefore, to ensure client safety,
if stool continues to be expelled after the administration of
three enemas, the nurse consults the physician before admin-
■ Medications released from the suppository can have local
or systemic effects. Depending on the drug, local effects istering more.
may include softening and lubricating dry stool, irritating the
wall of the rectum and anal canal to stimulate smooth mus- Soap Solution Enemas
cle contraction, and liberating carbon dioxide, thus increas- A soap solution enema is a mixture of water and soap. Many
ing rectal distention and the urge to defecate. disposable enema kits contain an envelope of soap, which is
Drugs administered in suppository form are chosen TABLE 31-3 Types of Cleansing Enema Solutions
when clients have difficulty retaining or absorbing oral
SOLUTION AMOUNT (ml) MECHANISM OF ACTION
medications because of chronic vomiting or an impaired
ability to swallow, or it is undesirable to delay defecation Tap water 500–1,000 Distends rectum, moistens
stool
while waiting for an oral medication to act. Administer-
Normal saline 500–1,000 Distends rectum, moistens
ing a suppository is a form of medication administration stool
(Skill 31-2). For additional principles, refer to Chapters 32 Soap and water 500–1,000 Distends rectum, moistens
and 33. stool, irritates local tissue
Hypertonic saline 120 Irritates local tissue and draws
➧ Stop, Think, and Respond Box 31-2 water into the bowel
Mineral, olive, or 120–180 Lubricates and softens
Discuss appropriate actions if a mass of stool is felt cottonseed oil stool
when inserting a suppository.
LWBK1004-C31_p705-734.indd 710 04/02/12 3:22 PM

A B
FIGURE 31-3 A. The enema tip is inserted fully within the rectum. B. The chamber that contains
fluid is compressed to instill the solution.
mixed with up to 1 quart (1,000 mL) of water. If these soap 4 oz (120 mL) of solution (Fig. 31-3). The container, which
packets are not available, a comparable mixture is 1 mL of has a lubricated tip, substitutes for enema equipment and
mild liquid soap per 200 mL of solution, or a ratio of 1:200. tubing (see Nursing Guidelines 31-3).
Therefore, 5 mL of soap is added to prepare a volume of
1,000 mL. Retention Enemas
Soap causes chemical irritation of the mucous mem- A retention enema uses a solution held within the large
branes. Adding too much soap or using strong soap can intestine for a specified period, usually at least 30 minutes.
potentiate the irritating effect. Some retention enemas are not expelled at all. One type of
retention enema is called an oil retention enema because the
Hypertonic Saline Enemas fluid instilled is mineral, cottonseed, or olive oil. Oils lubri-
A hypertonic saline (sodium phosphate) enema draws fluid cate and soften the stool, so it can be expelled more easily.
from body tissues into the bowel. This increases the fluid The oil may come in a prefilled container similar to
volume in the intestine beyond what was originally instilled. those that contain hypertonic saline. If disposable equip-
The concentrated solution also acts as a local irritant on the ment is not available, the nurse lubricates and inserts a 14-
mucous membranes. to 22-F tube in the rectum. A small funnel or large syringe
Hypertonic enema solutions are available in commer- is attached to the tube, and the nurse instills approximately
cially prepared, disposable containers holding approximately 100 to 200 mL of warmed oil slowly to avoid stimulating an
Rationales
Administering a Hypertonic Enema Solution
• Warm the container of solution (if it is cold) by placing it in a • Insert the full length of the tip within the rectum. This position-
basin or sink of warm water. Warmth promotes comfort. ing places the tip at a level that promotes effectiveness.
• Assist the client to a Sims’position or use a knee–chest posi- • Apply gentle, steady pressure on the solution container for
tion (see Chap. 14). These positions promote gravity distribu- 1 to 2 minutes or until the solution has been completely admin-
tion of the solution. istered. This method instills a steady stream of solution.
• Wash hands or use an alcohol-based hand rub (see • Compress the container as the solution instills. Compression
Chap. 10) and don gloves. Hand hygiene reduces transmission provides positive pressure rather than gravity to instill fluid.
of microorganisms; gloves provide a barrier from contact with • Encourage the client to retain the solution for 5 to 15 minutes.
a substance that contains body fluid. This duration promotes effectiveness.
• Remove the cover from the lubricated tip. This step facilitates • Clean the client and position for comfort. These measures
administration. demonstrate concern for the client’s well-being.
• Cover the tip with additional lubricant. Lubricant eases • Discard the container, remove gloves, and perform hand
insertion. hygiene measures. Doing so follows the principles of medical
• Invert the container. Inversion causes air in the container to asepsis.
rise toward the upper end.
LWBK1004-C31_p705-734.indd 711 18/02/12 11:05 AM

urge to defecate. Premature defecation defeats the purpose Nutrition Notes

of retaining the oil.
■ Because large amounts of fluid, sodium, and potas-
sium are normally absorbed in the colon, the risk of fluid
List measures for preventing constipation. and electrolyte imbalances increases as the length of the
remaining colon decreases. Clients with ileostomies are
at higher risk of nutritional problems than are clients with
colostomies in which some of the colon is retained.
OSTOMY CARE ■ Clients with ileostomies are encouraged to consume
8 to 10 glasses of fluid daily to maintain a normal urine output
A client with an ostomy (a surgically created opening to and to minimize the risk of renal calculi. Assure clients that
the bowel or other structure; see Chap. 30) requires addi- excess fluid is excreted through the kidneys, not the stoma.
tional care for promoting bowel elimination. Two examples A liberal salt intake may be needed to replenish losses.
of intestinal ostomies are an ileostomy (a surgically created ■ Ileostomies are placed before the terminal ileum where
opening to the ileum) and a colostomy (a surgically created vitamin B12 is absorbed. Nasal sprays or parenteral injec-
opening to a portion of the colon; Fig. 31-4). Materials enter tions of vitamin B12 are necessary to prevent vitamin B12
and exit through a stoma (the entrance to the opening). deficiency anemia.
Most persons with an ostomy, also called ostomates,
wear an appliance (a bag or collection device over the
stoma) to collect stool. Depending on the type and location Providing Peristomal Care
of the ostomy, client care may involve providing peristomal Preventing skin breakdown is a major challenge in ostomy
care, applying an appliance, draining a continent ileostomy, care. Enzymes in the stool can quickly cause excoriation
and, for clients with a colostomy, administering irrigations (chemical injury of the skin). Washing the stoma and the sur-
through the stoma. rounding skin with mild soap and water, and patting it dry
FIGURE 31-4 The locations of intestinal ostomies.
LWBK1004-C31_p705-734.indd 712 04/02/12 3:22 PM

Ileum
Nipple
valve
Reservoir
pouch
FIGURE 31-6 A continent ileostomy.

FIGURE 31-5 An ostomy appliance: a faceplate and pouch.
(Photo by B. Proud.) Irrigating a Colostomy
Clients with a colostomy whose stool is more solid some-
times require the instillation of fluid to promote elimination.
can preserve skin integrity. Another way to protect the skin is Colostomy irrigation involves instilling the solution through
to apply barrier substances such as karaya, a plant substance the stoma into the colon, a process similar to administering
that becomes gelatinous when moistened, and commercial an enema (Skill 31-5).
skin preparations around the stoma. An enterostomal thera- The purpose of the irrigation is to remove formed stool
pist, a nurse certified in caring for ostomies and related skin and, in some cases, to regulate the timing of bowel movements.
problems, may be consulted regarding skin and stomal care.
Applying an Ostomy Appliance Client and Family Teaching 31-2

Draining a Continent Ileostomy
Various appliances are available, but all consist of a pouch
for collecting stool and a faceplate, or disk, that attaches to The nurse teaches the client and the family as follows:
the abdomen. The stoma protrudes through an opening in the ● Assume a sitting position.
center of the appliance (Fig. 31-5). The pouch fastens into ● Insert a lubricated 22- to 28-F catheter into the stoma.
position when pressed over the circular support on the face- ● Expect resistance after inserting the tube approximately
plate. Some clients prefer a type that is also fastened to an 2 in.; this is the location of the valve that controls the
elastic belt worn around the waist. The belt helps to support retention of liquid stool or urine.
the weight of the fecal material and prevents the faceplate ● Gently advance the catheter through the valve at the end
from being pulled away from the abdomen. The client emp- of exhalation, while coughing, or while bearing down as if
ties the pouch by releasing the clamp at the bottom. to pass stool.
● Lower the external end of the catheter at least 12 in.
The faceplate usually remains in place for 3 to 5 days
below the stoma.
unless it becomes loose or causes skin discomfort. Pouches
● Direct the end of the catheter into a container or toilet as
are emptied and rinsed or detached and replaced periodically. stool or urine begins to flow.
The client empties the pouch when it is one-third to one-half ● Allow at least 5 to 10 minutes for complete emptying.
full; otherwise, it may become too heavy and pull the faceplate ● Remove the catheter and clean it with warm soapy water.
from the skin. Although design of the equipment varies, almost ● Place the clean catheter in a sealable plastic bag until its
all types of appliances are changed similarly (Skill 31-4). next use.
● Cover the stoma with a gauze square or a large bandage.
Draining a Continent Ileostomy ● If the catheter becomes plugged with stool or mucus:
A continent ostomy (a surgically created opening that con- ● Bear down as if to have a bowel movement.
trols the drainage of liquid stool or urine by siphoning it from ● Rotate the catheter tip inside the stoma.
● Milk the catheter.
an internal reservoir) also is referred to as a Kock pouch, after
● If these are not successful, remove the catheter, rinse
the surgeon who developed the technique (Fig. 31-6). This
it, and try again.
type of ostomy requires no appliance; however, the client ● Notify the physician if these efforts do not result in
must drain the accumulating liquid stool or urine approxi- drainage.
mately every 4 to 6 hours. The client can use a gravity drain- ● Never wait longer than 6 hours without obtaining drainage.
age system at night (see Client and Family Teaching 31-2).
LWBK1004-C31_p705-734.indd 713 04/02/12 3:22 PM

With regulation, a client with a sigmoid colostomy may not NURSING IMPLICATIONS
need to wear an appliance. The colostomy irrigation helps to
train the bowel to eliminate formed stool following the irriga- While assessing and caring for clients with altered bowel
tion. Once the client has eliminated the stool, he or she will elimination, the nurse may identify one or more of the fol-
expel no more until the next irrigation. This mimics the pat- lowing nursing diagnoses:
tern of natural bowel elimination for most people. Because of
the predictability of bowel elimination, some clients with a • Constipation
sigmoid colostomy feel it is unnecessary to wear an appliance. • Risk for Constipation
• Perceived Constipation
• Diarrhea
Gerontologic Considerations • Bowel Incontinence
• Toileting Self-Care Deficit
■ Musculoskeletal disorders, such as arthritis of the hands, • Situational Low Self-Esteem
may interfere with an older person’s ability to care for an
ostomy appliance or perform colostomy irrigations. An Nursing Care Plan 31-1 reflects the nursing process as
occupational or enterostomal therapist can offer sugges- it applies to a client with constipation. NANDA-I defines
tions for promoting self-care. constipation (2012, p. 203) as “a decrease in normal fre-
quency of defecation accompanied by difficult or incom-
plete passage of stool and/or passage of excessively hard,
➧ Stop, Think, and Respond Box 31-4 dry stool.”
Discuss the various ways an ostomy affects the lives
of clients.
N U R S I N G C A R E P L A N 3 1 - 1 Constipation
Assessment • Ask the client about measures he or she uses to promote bowel
• Note the frequency, amount, and texture of the expelled stool. elimination and their frequency.
• Ask the client about the effort required to eliminate stool. • Ask the client to describe his or her daily intake of fluid and
• Inquire as to whether the client feels that he or she empties the food, including types of beverages and foods commonly eaten.
bowel during stool elimination and if there is any discomfort • Explore lifestyle patterns that may interfere with bowel elimi-
in the rectal area. nation such as a lack of privacy or lengthy travel that interferes
• Auscultate bowel sounds daily. with accessing a toilet when there is a need to eliminate stool.
• Palpate the abdomen to determine if there is any distention. • Note if any physical problems may compromise bowel elimi-
• Determine if any of the client’s medications are constipating. nation such as impaired physical mobility or dementia.
Nursing Diagnosis. Constipation related to inadequate dietary habits as manifested by a distended abdomen; hypoactive bowel
sounds in all four quadrants; and client’s statement: “I’ve got a problem. I haven’t had a bowel movement in 4 days even though I’ve
felt like I need to pass stool. I sit and strain but I only pass a small amount of hard stool. I used to have a problem now and then when
I was a kid; but since I’m living alone it’s getting to be very frequent. Maybe it’s because I don’t eat regularly and when I do, it’s a
lot of convenience food.”
Expected Outcome. The client will have a bowel movement within 24 hours and will list three ways to improve the regularity of
bowel elimination by 10/25.
Give an oil retention enema as ordered for p.r.n. administra- This type of enema lubricates the bowel and softens the stool
tion. for easier expulsion.
Give prescribed laxative at bedtime 10/23 if no bowel move- Laxatives facilitate bowel elimination in various ways; some
ment has occurred. common mechanisms of action include increasing intestinal
peristalsis, irritating the bowel, and attracting water into the
large intestine.
Encourage drinking at least 8–10 glasses of fluid per day; offer Oral fluid promotes hydration and avoids dry stool; prune juice
prune juice or apple juice. has a laxative effect; apple juice contains pectin, which also
adds bulk to the stool.
Instruct about high-fiber foods, and that their intake should Intestinal fiber adds bulk by pulling water into stool; a bulky
be gradually increased as tolerated until the desired effect is soft stool distends the rectum and promotes the urge to
achieved. defecate.
(continued)
LWBK1004-C31_p705-734.indd 714 18/02/12 11:05 AM

NURSING CARE PLAN 31-1 Constipation ( c o n ti n u e d )

• The client eliminated moderate amount of brown-formed stool • The client stated that increasing active exercise for a total of
approximately 6 hours following the administration of the oil 30 minutes each day either all at once or divided and
retention enema. performed several times during the day promotes bowel
• The client identified a minimum goal of consuming eight 8-oz elimination.
glasses of fluid daily.
• The client can name sources of fiber such as wheat bran, whole
wheat bread, whole grain cereal, fresh fruits and vegetables,
dried peas and beans, and nuts.
CRITICAL THINKING EXERCISE 3. Before inserting a rectal tube, which of the follow-
ing nursing measures is most helpful for eliminating
1. When inserting a rectal suppository, the nurse feels intestinal gas?
a hard mass of stool. What actions should be taken 1. Ambulate the client in the hall.
next? 2. Provide a carbonated beverage.
2. What are some possible consequences of chronic 3. Restrict the intake of solid food.
constipation? 4. Administer a narcotic analgesic.
3. Formulate suggestions to promote bowel continence 4. During the administration of a cleansing soapsuds
among older adults with impaired cognition such as enema, a client experiences cramping and has the
those with Alzheimer’s disease. urge to defecate. Which is the best nursing action to
4. What nursing actions are appropriate when peris- take at this time?
tomal skin appears red and excoriated? 1. Quickly finish instilling the remaining solution.
2. Tell the client to hold his or her breath and bear
down.
NCLEX-STYLE REVIEW QUESTIONS 3. Briefly stop the administration of the enema
1. When a client tells the nurse that he or she cannot solution.
have a bowel movement without taking a daily laxa- 4. Withdraw the tip of the enema tubing from the
tive, what information is essential for the nurse to rectum.
explain? 5. When the nurse assesses the stoma of a client with an
1. The chronic use of laxatives impairs natural bowel ostomy, what is the expected normal appearance?
tone. 1. Pale pink
2. Stool softeners are likely to be less harsh. 2. Bright red
3. Daily enemas are more preferable than laxatives. 3. Dark tan
4. Dilating the anal sphincter may aid bowel elimina- 4. Dusky blue
tion.
2. Which of the following assessments is the best indica-
tion that a client has a fecal impaction?
1. The client passes liquid stool frequently.
2. The client has extremely offending bad breath.
3. The client requests medication for a headache.
4. The client has not been eating well lately.
LWBK1004-C31_p705-734.indd 715 04/02/12 3:22 PM

SKILL 31-1 Inserting a Rectal Tube
ASSESSMENT
Check the medical orders. Ensures collaboration between nursing activities and the medical
treatment.
Use two methods to identify the client. Supports the principles of safety recommended by The Joint
Commission.
Inspect the abdomen, auscultate bowel sounds, and gently Provides baseline data for future comparisons.
palpate for distention and fullness.
Determine how much the client understands the procedure. Provides an opportunity for health teaching.
PLANNING
Obtain a 22- to 32-F catheter and lubricant. Ensures proper size and easy insertion.
IMPLEMENTATION
Chap. 10); don gloves.
Place the client in a Sims’ position. Facilitates access to the rectum.
Lubricate the tip of the tube generously (Fig. A). Eases insertion.
Lubricating the rectal tube.
Separate the buttocks well so that the anus is in plain view Helps visualize the insertion location.
(Fig. B).
Separating the buttocks.
B
(continued)
LWBK1004-C31_p705-734.indd 716 18/02/12 11:05 AM

Inserting a Rectal Tube (continued)
Insert the tube 4–6 in. (10–15 cm) in an adult (Fig. C). Places the distal tip above the sphincter muscles, stimulates
peristalsis, and prevents displacement of the tube.
Inserting the rectal tube.
Enclose the free end of the tube within a clean, soft washcloth, Provides a means for absorbing stool should it drain from the tube.
disposable bed pad, or gauze square (Fig. D).
Enclosing the rectal tube.
Tape the tube to the buttocks or inner thigh. Allows the client to ambulate or change positions without tube
displacement.
Leave the rectal tube in place no longer than 20 minutes. Reduces the risk for impairing the sphincter.
Reinsert the tube every 3–4 hours if discomfort returns. Reinstitutes therapeutic management.
Evaluation
• Intestinal gas is eliminated.
• The client states symptoms are relieved.
• The client reports no ill effects.
Document
• Assessment data
• Intervention
• Length of time tube was in place
• Client response
Date and Time Abdomen round, firm, and tympanic. Bowel sounds present in all four quadrants, but difficult to hear
because of distention. States, “I can’t hardly stand the pain anymore.” Ambulated without relief. 26-F
straight catheter inserted into rectum for 20 minutes. Flatus expelled during tube insertion. Abdomen
softer. _______________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C31_p705-734.indd 717 04/02/12 3:22 PM

SKILL 31-2 Inserting a Rectal Suppository
ASSESSMENT
Check the medical orders. Ensures collaboration between nursing activities and the medical
treatment.
Compare the medication administration record (MAR) with the Ensures accuracy.
written medical order.
Read and compare the label on the suppository with the MAR at Prevents errors.
least three times—before, during, and after preparing the drug.
Commission.
Determine how much the client understands the purpose and Provides an opportunity for health teaching.
technique for administering a suppository.
PLANNING
Prepare to administer the suppository according to the time Complies with medical orders.
prescribed by the physician.
Obtain clean gloves and lubricant. Facilitates insertion.
IMPLEMENTATION
(see Chap. 10).
Read the name on the client’s identification band. Prevents errors.
Pull the privacy curtain. Demonstrates respect for the client’s modesty and dignity.
Drape the client to expose only the buttocks. Ensures modesty and dignity.
Don gloves. Reduces the transmission of microorganisms and complies with
Lubricate the suppository and index finger of the dominant hand Reduces friction and tissue trauma and enhances visualization.
and separate the buttocks so that the anus is in plain view
(Fig. A).
The lubricated suppository and insertion finger.
A
(continued)
LWBK1004-C31_p705-734.indd 718 04/02/12 3:22 PM

Inserting a Rectal Suppository (continued)

Instruct the client to take several slow, deep breaths. Introduce Promotes muscle relaxation and places the suppository in the best
the suppository, tapered end first, beyond the internal sphincter, location for achieving a local effect.
about the distance of the finger (Fig. B).
Inserting the suppository.
Avoid placing the suppository within stool. Reduces effectiveness.

Wipe excess lubricant from around the anus with a paper tissue. Promotes comfort.
Tell the client to try to retain the suppository for at least Enhances effectiveness.
15 minutes.
Suggest contracting the gluteal muscles if there is a premature Tightens the anal sphincters.
urge to expel the suppository.
Ask the client to wait to flush the toilet until the stool has been Provides an opportunity for evaluating the drug’s effectiveness.
inspected.
Remove your gloves and wash your hands. Reduces the transmission of microorganisms.
Evaluation
• The client retains the suppository for 15 minutes.
• Bowel elimination occurs.
Document
• Drug, dose, route, and time (see Chap. 32)
• Outcome of drug administration
Date and Time Bisacodyl (Dulcolax) suppository inserted within rectum. Lg. brown-formed stool expelled.
___________________________________________________________________________ SIGNATURE/TITLE
SKILL 31-3 Administering a Cleansing Enema
ASSESSMENT
Check the medical orders for the type of enema and prescribed Ensures collaboration between nursing activities and the medical
solution. treatment.
Check the date of the client’s last bowel movement. Helps to determine the need to check for an impaction or the basis
for realistic expected outcomes.
Commission.
(continued)
LWBK1004-C31_p705-734.indd 719 04/02/12 3:22 PM

Administering a Cleansing Enema (continued)
Wash hands or perform an alcohol-based hand rub (see Chap 10). Reduces the transmission of microorganisms.
Auscultate bowel sounds. Establishes the status of peristalsis.
Determine how much the client understands the procedure. Provides an opportunity for health teaching.
PLANNING
Plan the location where the client will expel the enema solution Determines if a bedpan is necessary.
and stool.
Obtain the appropriate equipment including an enema set, solu- Facilitates organization and efficient time management.
tion, an absorbent pad, lubricant, a bath blanket, and gloves.
Plan to perform the procedure according to the time specified by Demonstrates collaboration and participation of the client in
the physician or when it is most appropriate during client care. decision making.
Prepare the solution and equipment in the utility room. Provides access to supplies.
Warm the solution to approximately 105°–110°F (40°–43°C). Promotes comfort and safety.
Clamp the tubing on the enema set. Prevents the loss of fluid.
Fill the container with the specified solution. Provides the mechanism for cleansing the bowel.
IMPLEMENTATION
Drape the client, exposing the buttocks, and place a waterproof Preserves modesty and protects bed linen.
pad under the hips (Fig. A).
Draping for an enema.
Don gloves. Reduces the transmission of microorganisms and complies with

Place (or hang) the solution container so that it is 12–20 in. Facilitates gravity flow.
(30–50 cm) above the level of the client’s anus.
Open the clamp and fill the tubing with solution (Fig. B). Reclamp. Purges air from the tubing.
Purging air.
B
(continued)
LWBK1004-C31_p705-734.indd 720 04/02/12 3:22 PM

Lubricate the tip of the tube generously (Fig. C). Eases insertion.
Lubricating the tube.
Separate the buttocks well so that the anus is in plain view. Helps to visualize insertion.
Insert the tube 3–4 in. (7–10 cm) in an adult. Places the distal tip above the sphincters.
Direct the tubing at an angle pointing toward the umbilicus Follows the contour of the rectum.
(Fig. D).
The direction for tube insertion.
Hold the tube in place with one hand (Fig. E). Avoids displacement.
Holding the tube in place.
E
(continued)
LWBK1004-C31_p705-734.indd 721 04/02/12 3:22 PM

Release the clamp. Promotes instillation.
Instill the solution gradually over 5–10 minutes (Fig. F). Fills the rectum.
Instilling the enema solution.
Clamp the tube for a brief period while the client takes deep Avoids further stimulation.
breaths and contracts the anal sphincters if cramping occurs.
Resume instillation when the cramping is relieved. Facilitates effectiveness.
Clamp and remove the tubing after sufficient solution has been Completes the procedure.
instilled or the client states that he or she cannot retain more.
Encourage the client to retain the solution for 5–15 minutes. Promotes effectiveness.
Hold the enema tubing in one hand and pull a glove over the Prevents direct contact.
inserting end of the tubing.
Remove and discard the remaining glove and dispose of the Follows the principles of medical asepsis.
enema equipment.
Assist the client to sit while eliminating the solution and stool. Aids in defecation.
Examine the expelled solution. Provides data for evaluating the effectiveness of the procedure.
Clean and dry the client; help him or her to a comfortable position. Demonstrates concern for the client’s well-being.
Evaluation
• A sufficient amount of solution is instilled.
• A comparable amount of solution is expelled.
• The client eliminates stool.
Document
• Type of enema solution
• Volume instilled
Date and Time 1,000 mL tap water enema administered. Lg. amt of brown-formed stool expelled.
__________________________________________________________________________________ SIGNATURE/TITLE
SKILL 31-4 Changing an Ostomy Appliance
ASSESSMENT
Wash hands or perform an alcohol-based hand rub (see Chap. 10). Reduces the transmission of microorganisms and complies with
Use two methods to identify the client. Supports the principles of safety recommended by The Joint Com-
mission.
(continued)
LWBK1004-C31_p705-734.indd 722 18/02/12 11:05 AM

Changing an Ostomy Appliance (continued)
Inspect the faceplate, pouch, and peristomal skin. Determines the necessity for changing the appliance and provides
data about the condition of the stoma and the surrounding skin.
Determine how much the client understands about stomal care Provides an opportunity for health teaching; prepares the client for
and changing an ostomy appliance. assuming self-care.
PLANNING
Obtain replacement equipment, supplies for removing the adhe- Facilitates organization and efficient time management.
sive (eg, the manufacturer’s recommended solvent if appropri-
ate), and products for skin care.
Plan to replace the appliance immediately if the client has localized Prevents complications.
symptoms.
Schedule an appliance change for an asymptomatic client before Coincides with a time when the gastrocolic reflex is less active.
a meal.
Plan to empty the pouch just before the appliance will be changed. Prevents soiling.
IMPLEMENTATION
Place the client in a supine or dorsal recumbent position. Facilitates access to the stoma.
Wash your hands or perform an alcohol-based hand rub; don Reduces the transmission of microorganisms; complies with
gloves. standard precautions.
Unfasten the pouch and discard it in a lined receptacle or Facilitates access to the faceplate.
waterproof container.
Gently peel the faceplate from the skin (Fig. A). Prevents skin trauma.
Removing the faceplate. (Photo by B. Proud.)
Wash the peristomal area with water or mild soapy water using a Cleans mucus and stool from the skin.
soft washcloth or gauze square.
Suggest that the client shower or bathe at this time. Provides an opportunity for daily hygiene and will not affect the
exposed stoma.
After or instead of bathing, pat the peristomal skin dry. Promotes the potential for adhesion when the faceplate is applied.
Measure the stoma using a stomal guide (Fig. B). Determines the size of the stomal opening in the faceplate.
Measuring the stoma. (Photo by B. Proud.)
B
(continued)
LWBK1004-C31_p705-734.indd 723 18/02/12 11:05 AM

Trim the opening in the faceplate to the measured diameter plus Avoids pinching of or pressure on the stoma and causing
approximately 1⁄8 to ¼ inch larger (Fig. C). circulatory impairment.
Trimming the stomal opening. (Photo by B. Proud.)
Attach a new pouch to the ring of the faceplate (Fig. D). Avoids pushing the pouch into place after the faceplate has been
applied.
Attaching the pouch. (Photo by B. Proud.)
Fold and clamp the bottom of the pouch (Fig. E). Seals the pouch so leaking will not occur.
Sealing the pouch. (Photo by B. Proud.)
Peel the backing from the adhesive on the faceplate (Fig. F). Prepares the appliance for application.
Removing the adhesive backing. (Photo by B. Proud.)
F
(continued)
LWBK1004-C31_p705-734.indd 724 04/02/12 3:22 PM

Have the client stand or lie flat. Keeps the skin taut and avoids wrinkles.
Position the opening over the stoma and press into place from the Prevents air gaps and skin wrinkles.
center outward (Fig. G).
Attaching the appliance. (Photo by B. Proud.)
Perform hand hygiene after removing gloves. Removes transient microorganisms.
Evaluation
• The stoma appears pink and moist.
• The skin is clean, dry, and intact with no evidence of redness, irritation, or excoriation.
• The new appliance adheres to the skin without wrinkles or gaps.
Document
• Assessment data
• Peristomal care
• Application of new appliance
Date and Time Ostomy appliance removed. Peristomal skin cleansed with soapy water and patted dry. Stoma is pink and
moist. Peristomal skin is intact and painless. New appliance applied over stoma.
__________________________________________________________________________________ SIGNATURE/TITLE
SKILL 31-5 Irrigating a Colostomy
ASSESSMENT
Check the medical orders to verify the written order and type of Ensures collaboration between nursing activities and the medical
solution to use. treatment.
Use two methods to identify the client. Supports the principles of safety recommended by The Joint Com-
mission.
Determine how much the client understands about colostomy Provides an opportunity for health teaching; prepares the client to
irrigation. assume self-care.
(continued)
LWBK1004-C31_p705-734.indd 725 04/02/12 3:22 PM

Irrigating a Colostomy (continued)
PLANNING
Obtain an irrigating bag and sleeve, lubricant, and a belt (Fig. A). A Promotes organization and efficient time management.
bedpan will be needed if the client is confined to the bed.
Irrigating the sleeve and bag.
Prepare the irrigating bag with solution in the same way as for an Provides the mechanism for cleansing the bowel.
enema set (see Skill 31-3).
Unclamp the tubing and fill it with solution. Purges air from the tubing.
IMPLEMENTATION
Place the client in a sitting position in bed, in a chair in front or Facilitates collecting drainage.
beside the toilet, or on the toilet itself.
Place absorbent pads or towels on the client’s lap. Prevents soiling of linen or clothing.
Hang the container approximately 12 in. (30 cm) above the stoma. Facilitates gravity flow.
Wash your hands or perform an alcohol-based hand rub; don Reduces the transmission of microorganisms; complies with
gloves. standard precautions.
Empty and remove the pouch from the faceplate if the client is Provides access to the stoma.
wearing one.
Secure the sleeve over the stoma and fasten it around the client Provides a pathway for drainage.
with an elastic belt (Fig. B).
Positioning the irrigation sleeve.
B
(continued)
LWBK1004-C31_p705-734.indd 726 04/02/12 3:22 PM

Place the lower end of the sleeve into the toilet, commode, or Collects drainage.
bedpan (Fig. C).
Placing the distal end of the sleeve.
Lubricate the cone at the end of the irrigating bag. Facilitates insertion.
Open the top of the irrigating sleeve. Provides access to the stoma.
Insert the cone into the stoma (Fig. D). Dilates the stoma and provides a means for instilling fluid.
Inserting the irrigation cone.
Hold the cone in place and release the clamp on the tubing. Prevents expulsion of the cone and initiates the instillation.
Clamp the tubing and wait if cramping occurs. Interrupts the instillation while the bowel adjusts.
Release the clamp and continue once the discomfort disappears. Resumes instilling the fluid without discomfort to the client.
(continued)
LWBK1004-C31_p705-734.indd 727 04/02/12 3:22 PM

Clamp the tubing and remove the cone when the irrigating solution Discontinues the administration of solution.
has been instilled.
Close the top of the irrigating sleeve. Keeps drainage in a downward direction.
Give the client reading materials or hygiene supplies. Provides diversion or uses time for other productive activities.
Remove the belt and sleeve when the draining has stopped. Eliminates unnecessary equipment.
Clean the stoma and pat it dry. Maintains tissue integrity.
If client is wearing an appliance, place a clean pouch over the Collects fecal drainage.
stoma or cover the stoma temporarily with a gauze square.
Repeat hand hygiene measures after removing gloves. Removes transient microorganisms.
Evaluation
• A sufficient amount of solution is instilled.
• A comparable amount of solution is expelled.
• Stool is eliminated.
Document
• Type of irrigation solution
• Volume instilled
Date and Time Colostomy irrigated with 500 mL of tap water. Instilled without difficulty. Mod. amt. of semiformed stool
expelled with solution. Stoma cleansed with water and dried. Covered with a gauze square.
________________________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C31_p705-734.indd 728 18/02/12 11:05 AM

UNIT 8
1. __________________ means greater than normal urinary volume. (Anuria, Oliguria, Polyuria)
2. Hypertonic enema solutions are available in commercially prepared disposable containers that hold approximately
__________________ mL of solution. (60, 120, 180)
3. __________________ constipation results from medical treatment. (Iatrogenic, Pseudo, Secondary)
4. A __________________ is a bedside seatlike container used for the elimination of body waste. (bedpan, commode, urinal)
1. T____F____ Catheterization is the insertion of a hollow tube inside the bladder.
2. T____F____ The urinary meatus is the opening to the urethra.
3. T____F____ A straight catheter is an indwelling catheter left in place for a period of time.
4. T____F____ Vegetables such as cabbage and cucumbers are known to prevent intestinal gas.

1. Urine containing blood __________________
2. Skin around the stoma __________________
3. The rhythmic contraction of intestinal smooth muscle that facilitates defecation __________________
4. Chemical injury to the skin resulting from enzymes present in stool __________________
Activity D: 1. Match the terms related to defecation and ostomy in Column A with their explanations in Column B.
Column A Column B
1. __________________ Gastrocolic reflex A. Entrance to a surgically created opening to an organ of
elimination
2. __________________ Anal sphincter B. Closing the glottis and contracting the pelvic and
abdominal muscles to increase abdominal pressure
3. __________________ Stoma C. Accelerated intestinal peristalsis that usually occurs during
or after eating
4. __________________ Valsalva maneuver D. Ring-shaped band of muscles
729
LWBK1004-C31_p705-734.indd 729 18/02/12 11:05 AM

Activity E: 1. Differentiate between fecal impaction and fecal incontinence based on the categories given below.
Fecal Impaction Fecal Incontinence
Definition
Causes
Symptoms
Activity F: Consider the following figures.
A B
1. Identify what is shown in the figures.

2. Explain the techniques in the figures.
LWBK1004-C31_p705-734.indd 730 04/02/12 3:22 PM

Activity G: A catheter is removed when it needs to be replaced or when its use can be discontinued. Write in the boxes
provided below the correct sequence for removing a Foley catheter.
1. Empty the balloon by aspirating the fluid with a syringe.
2. Measure the volume of each voiding for the next 8 to 10 hours.
3. Wash hands and put on clean gloves.
4. Inspect the catheter and discard it, if it appears to be intact.
5. Gently pull the catheter to the point where it exits from the meatus.
6. Clean the urinary meatus.

1. What are the four physical characteristics of urine?
2. What are the uses of a urinary catheter?
3. What are the two components of a bowel elimination assessment?
4. What are the various signs and symptoms of constipation?
5. What are the potential problems of using condom catheters?
LWBK1004-C31_p705-734.indd 731 04/02/12 3:22 PM


1. Why is the first voided specimen of the day preferred as a urine sample?
2. Why is urination during the night considered unusual?
3. Why is it important for the nurse to be cautious when administering large-volume enemas to clients?
4. Why is tap water used when administering an enema?
1. A nurse is caring for a client with urinary incontinence. What nursing diagnoses might be applicable in this situation?
2. A middle-aged client has an indwelling retention catheter. What nursing care is appropriate for this client?
3. A nurse is caring for a client with a colostomy. What are the steps in performing a colostomy irrigation?
4. A nurse is caring for a client with constipation.

a. What are two interventions used to promote bowel elimination for a client with constipation?
b. How should the nurse administer a commercially prepared, disposable container of hypertonic enema solution?
LWBK1004-C31_p705-734.indd 732 04/02/12 3:22 PM

1. A nurse is caring for an elderly client with urinary incontinence who has an indwelling catheter.
a. What possible problems could occur in this client?
b. Describe the appropriate nursing care for this client.
2. A middle-aged client who is scheduled to undergo a colostomy is concerned about how the surgery and its outcomes will
affect his everyday life.
a. How can the nurse prepare the client physically and emotionally for managing the ostomy independently?
b. How can the nurse prepare the family who may need to assist with the care of the client with an ostomy after
discharge?

1. A client who is paralyzed from the waist down is experiencing spontaneous loss of urine. How should the nurse document
this client’s condition?
a. Reflex incontinence
b. Stress incontinence
c. Functional incontinence
d. Urge incontinence
2. A nurse is teaching a client to perform a Credé’s maneuver as part of urinary continence training. Which of the following
instructions should the nurse tell the client regarding this maneuver?
a. Massage or tap the skin lightly above the pubic area.
b. Bend forward and apply hand pressure over the bladder.
c. Relax the urinary sphincter in response to physical stimulation.
d. Contract and relax the muscles alternately for 10 seconds.
3. An elderly client with a musculoskeletal disorder cannot elevate the hips. The nurse is using a fracture pan to collect the
client’s urine and stool. What interventions should the nurse follow when using a nonmetallic fracture pan? Select all that
apply.
a. Warm the bedpan with warm running water.
b. Palpate the client’s lower abdomen.
c. Place soiled tissue in the fracture pan.
d. Slip the fracture pan just beneath the buttocks.
e. Raise the head of the client’s bed.
4. A client at the health care facility reports a frequent desire to defecate but has been passing liquid stool in small quantities
for 2 days. What interventions should the nurse follow when removing a fecal impaction? Select all that apply.
a. Ask the client to contract the gluteal muscles.
b. Instruct the client to breathe slowly and deeply.
c. Place the client in the Sims’ position.
d. Use a lubricated gloved forefinger to break up the mass of stool.
e. Provide periods of rest until the mass is removed.
LWBK1004-C31_p705-734.indd 733 18/02/12 11:05 AM

5. Which of the following statements accurately describes a nursing action involved in draining accumulated urine or stool
from a continent ileostomy?
a. Keep the external end of the catheter at the level of the stoma.
b. Leave the stoma uncovered at all times.
c. Clean the removed catheter with cold soapy water.
d. Expect resistance after inserting the tube approximately 2 inches.
LWBK1004-C31_p705-734.indd 734 04/02/12 3:22 PM

UNIT 9
Medication Administration
32 Oral Medications 736
33 Topical and Inhalant Medications 751
34 Parenteral Medications 762
35 Intravenous Medications 783
735
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32 Oral Medications
barcode medication administration
system
dose 1. Define the term medication.
drug diversion 2. Name seven components of a drug order.
enteric-coated tablet 3. Explain the difference between trade and generic drug
generic name names.
individual supply 4. Name four common routes for administration.
medication administration record 5. Describe the oral route and two general forms of medication
medication order administered this way.
medications 6. Explain the purpose of a medication record.
oral route 7. Name three ways that drugs are supplied.
over-the-counter medication 8. Discuss two nursing responsibilities that apply to the
polypharmacy administration of narcotics.
route of administration 9. Name the five rights of medication administration.
scored tablet 10. Give the formula for calculating a drug dose.
stock supply 11. Discuss at least one guideline that applies to the safe
sustained release administration of medications.
trade name 12. Discuss one point to stress when teaching clients about
unit dose supply taking medications.
xerostomia 13. Explain the circumstances involved in giving oral medica-
tions by an enteral tube and one commonly associated
problem.
14. Describe three appropriate actions in the event of a
medication error.
ne of the nurse’s most important responsibilities is the adminis-
O tration of medications (chemical substances that change body

function). This chapter emphasizes the safe preparation and ad-
ministration of medications, particularly those given by the oral
route. This chapter uses the terms medications and drugs synony-
mously; information on specific drugs can be found in pharmacology
texts or in drug reference manuals.
MEDICATION ORDERS
A medication order lists the drug name and directions for its
administration. Usually, physicians or dentists write a medication
order. Other medical personnel, such as a physician’s assistant or
an advanced practice nurse, also can write medication orders if
legally designated to do so by state statutes. Medication orders
written on the client’s medical record are used here for the pur-
poses of discussion.
736
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CHAPTER 32 Oral Medications 737
Components of a Medication Order involved in prescribing and administering medications

All medication orders must have seven components: should refer to a list that identifies commonly confused drug
names. The list should be updated at least yearly. Knowing
1. The client’s name the purpose for the drug’s administration also may help in
2. The date and time the order is written ensuring that the appropriate drug has been prescribed.
3. The drug name
4. The dose to be administered Drug Dose
5. The route of administration The dose means the amount of drug to administer and is
6. The frequency of administration prescribed using the metric system. Some drugs are also
7. The signature of the person ordering the drug prescribed in units, milliunits, international units, and mil-
If any one of these components is absent, the nurse mustliequivalents (mEq), a unique measurement primarily used
withhold the drug until he or she has obtained the missing for chemical compounds such as potassium chloride.
information. Medication errors are serious. Nurses never For the purposes of safety, The Joint Commission (2010)
implement a questionable medication order until after con- mandates that apothecary measurements, an antiquated sys-
sulting with the person who has written the order. tem of drug dosing, is now subject to exclusion. This safety
measure was brought about because apothecary abbrevia-
Drug Name tions were frequently misread, misinterpreted, and confused
Each drug has a trade name (the name by which a pharma- with metric-system abbreviations. Refer to Table 32-1 for
ceutical company identies fi its drug).A trade name is some- “Do Not Use” abbreviations in prescribed medications that
times called a brand or proprietary name. A drug’s tradeThe Joint Commission has established.
name is generally capitalized and followed by an R within a For home use, drug dosages are converted to house-
circle, as in ®. hold measurements that are more easily interpreted by non-
Drugs also have a generic name (a chemical name not professionals.
protected by a company’s trademark), which is written in
lowercase letters. For example, Demerol® is a trade name Route of Administration
used by Winthrop Pharmaceuticals for the generically named The route of administration means how the drug is given,
drug meperidine hydrochloride. which may be by an oral, topical, inhalant, or parenteral
The Joint Commission (2010) cautions health care pro-route (Table 32-2).Topical and inhalant routes of adminis-
viders such as physicians, nurses, and pharmacists that theretration are discussed in Chapter 33; parenteral administra-
are many look-alike and sound-alike drug names. Everyone tion is described in Chapters 34 and 35.
TABLE 32-1 The Joint Commission’s Official “Do Not Use” List of Abbreviations
DO NOT USE POTENTIAL PROBLEM USE INSTEAD
U (unit) Mistaken for “0” (zero), the number “4” (four), or Write “unit”
“cc” (see below)
IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit”
Q.D., QD, q.d., qd (daily) Mistaken for each other Write “daily”
Q.O.D., QOD, q.o.d, qod (every other day) Period after the Q mistaken for “I” and the “O” Write “every other day”
mistaken for “I”
Trailing zero (X.0 mg) in any medication order Decimal point is missed Write X mg
or medication-related documentation
Lack of leading zero (.X mg) Decimal point is missed Write 0.X mg
MS Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate” or
“magnesium sulfate”
For possible future inclusion in the Official
“Do Not Use” List
> (greater than) Misinterpreted as the number “7” (seven) or the Write “greater than”
letter “L”
< (less than) Confused with “greater than” Write “less than”
Abbreviations for drug names Misinterpreted because of similar abbreviations for Write drug names in full
multiple drugs
Apothecary units Unfamiliar to many practitioners; confused with Use metric units
metric units
@ Mistaken for the number “2” (two) Write “at”
cc (cubic centimeter) Mistaken for U (units) when poorly written Write “mL” or “milliliters”
µg (microgram) Mistaken for mg (milligrams), resulting in 1,000-fold Write “mcg” or “micrograms”
overdose
Adapted from The Official “Do Not Use” List (2010). Available at http://www.jointcommission.org/
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738 UNIT 9 Medication Administration
TABLE 32-2 Routes of Drug Administration Frequency of Administration

ROUTE METHOD OF ADMINISTRATION
The frequency of drug administration refers to how often
and how regularly the medication is to be given. Frequency
Oral Swallowing
of administration is written using standard abbreviations of
Instillation through an enteral tube
Topical Application to skin or mucous membrane
Latin origin. Some common examples include the following:
Inhalant Aerosol • Stat—immediately
Parenteral Injection
• b.i.d.—twice a day
• t.i.d.—three times a day
• q.i.d.—four times a day
• q.h.—hourly
The oral route (the administration of drugs by swallow-
• q4h—every 4 hours
ing or instillation through an enteral tube) facilitates drug
• p.r.n.—as needed
absorption through the gastrointestinal tract. It is the most
common route for medication administration because it is Chapter 9 and Appendix B list other common abbre-
safer, more economical, and more comfortable than others. viations.
Medications administered by the oral route come in both When the medication order is implemented, drug admin-
solid and liquid forms. istration is scheduled according to the prescribed frequency.
Solid medications include tablets and capsules. A scored The health agency sets a predetermined timetable for drug
tablet (a solid drug manufactured with a groove in the center) administrations; hours of administration may vary among
is convenient when only part of a tablet is needed. Enteric- agencies. For example, if a physician orders a q.i.d. (four
coated tablets (a solid drug covered with a substance that times a day) administration of a medication, it may be sched-
dissolves beyond the stomach) are manufactured for drugs uled for administration at 8 a.m., noon, 4 p.m., and 8 p.m.;
that cause irritation of the stomach. Enteric-coated tablets at 10 a.m., 2 p.m., 6 p.m., and 10 p.m.; or at 6 a.m., noon,
are never cut, crushed, or chewed because when the integrity 6 p.m., and midnight.
of the coating is impaired, the drug dissolves prematurely in
gastric secretions. Some capsules also contain beads or pel-
lets of drugs for sustained release (a drug that dissolves Pharmacologic Considerations
at timed intervals). Sustained release capsules are never
crushed: doing so affects the rate of drug absorption. ■ The prescribing health care provider may be able to sim-
Liquid forms of oral drugs include syrups, elixirs, and plify a complex medication regimen by prescribing a longer-
suspensions. Nurses measure and administer liquid medica- acting drug to decrease the frequency of administration or a
tions in calibrated cups, droppers, or syringes, or with a dos- medication combination to decrease the number of pills the
ing spoon (Fig. 32-1). client must take at one time.
Pharmacologic Considerations Verbal and Telephone Orders

Verbal orders are instructions for client care that are given
■ Polypharmacy (the administration of multiple medica- during face-to-face conversations. Telephone orders are
tions to the same person) increases the risk for drug interac- obtained from a physician during a telephone conversation.
tions and adverse medication reactions. Older people taking
more than one medication are more likely to develop mental
changes as an early and common sign of adverse effects. In
fact, medications are the most common physiologic cause
of mental changes in older adults. Therefore, any change in
an older client’s mental status must be reported, with an
evaluation of the potential causative factors.
■ Diminished kidney and liver function increases the con-
centration of many drugs. Increased proportions of body
water and fat and decreased proportion of lean tissue affect
the concentration of some medications. Decreased blood
albumin levels increase the active drug components for
protein-bound medications. Decreased gastric acidity
reduces or delays absorption of some drugs. Urinary
changes influence medications excreted through the kid-
neys. Information regarding the metabolism of each medica-
tion should be considered for anyone with decreased renal,
hepatic, gastrointestinal, or circulatory function. FIGURE 32-1 Measuring liquid medication with a calibrated
cup held at eye level. (Photo by B. Proud.)
LWBK1004-C32_p735-750.indd 738 04/02/12 3:23 PM

paper or a facsimile (fax) transmission request. Drugs are

NURSING GUIDELINES 32-1 supplied, or dispensed, in three major ways. An individual
supply is a container with enough of the prescribed drug
Taking Telephone Orders
for several days or weeks, which is common in long-term
• Have a second nurse listen simultaneously on an extension. A care facilities such as nursing homes (Fig. 32-3). A unit dose
second nurse serves as a witness to the communication. supply (a self-contained packet that holds one tablet or cap-
• Record the drug order directly on the client’s medical record.
sule) is most common in acute care hospitals that stock drugs
A written recording avoids errors in memory.
• Repeat the written information back to the prescriber.
for individual clients several times in 1 day (Fig. 32-4). A
Repetition clarifies understanding. stock supply (stored drugs) remains on the nursing unit for
• Make sure the order includes the essential components. use in an emergency so that a nurse can give a drug without
Doing so complies with standards for care. delay.
• Clarify any drug names that sound similar, such as Celebrex Some facilities use automated medication-dispens-
and Cerebrex, or Nicobid and Nitro-Bid. Checking avoids ing systems (Fig. 32-5). These systems usually contain
medication errors. frequently used medications for that unit, any as-needed
• Spell or repeat numbers that could be misinterpreted, such as (p.r.n.) medications, controlled drugs, and emergency
15 (one, five) and 50 (five, zero). This step avoids medication medications. The nurse accesses the system by using a
errors. personal password and then selects the appropriate choice
• Use the abbreviation “T.O.” at the end of the order. This
from a computerized menu. This type of system automati-
abbreviation indicates the order is a telephone order.
• Write the prescriber’s name and cosign with your name and
cally keeps a record of dispensed medications and records
title. These steps comply with legal standards and demon- the password, user name, and title. To avoid drug diver-
strate accountability for the communication. sion—a term used by the U.S. Drug Enforcement Admin-
istration (DEA) when referring to the theft or possession
of drugs—usually controlled substances, prescribed for
someone else, the user’s password should never be shared
Both types of orders are more likely to result in misinterpre- with anyone.
tation than are written orders. If a prescriber is physically
present, it is appropriate to ask tactfully that the order be Storing Medications
handwritten. When obtaining phone orders, it is important Each health agency has one area for storing drugs. Some
to repeat the dosages of drugs and to spell drug names for agencies keep medications in a mobile cart; others store them
confirmation of accuracy. Some nurses ask a second nurse in a medication room. Each client has a separate drawer or
to listen to a telephone order on an extension (see Nursing cubicle to hold his or her prescribed medications. Regardless
Guidelines 32-1). The person who prescribed the medication of their location, the supply of medications remains locked
must sign the verbal or telephone order within 48 hours or until the drugs are administered.
according to the agency’s policy.
Documentation in the Medication Accounting for Narcotics

Administration Record Narcotics are controlled substances, meaning that federal
Once the nurse has obtained the medication order, he or laws regulate their possession and administration. Health
she transcribes it to the medication administration record agencies keep narcotics in a double-locked drawer, a box, a
(MAR; agency form used to document drug administra- room in the nursing unit, or in an automated medication dis-
tion). Use of the MAR ensures timely and safe medication pensing system. Because narcotics usually are delivered by
administration. Some agencies use a form on which nurses stock supply, nurses are responsible for an accurate account
transcribe the drug order by hand; others use a computer- of their use. They keep a record of each narcotic used from
generated form (Fig. 32-2). Regardless of the type, all MARs the stock supply. Any controlled substance that is wasted in
provide a space for documenting when a drug is given, along whole or in part must be co-signed by a witness.
with a place for the signature, title, and initials of each nurse Nurses count narcotics regularly, usually at each change
who administers a medication. The current MAR is usually of shift. One nurse counts the number in the supply, while
kept separate from the client’s medical record, but it eventu- another checks the record of their administration or amounts
ally becomes a permanent part of it. that have been wasted. Both counts must agree with incon-
sistencies accounted for as soon as possible.
METHODS OF SUPPLYING
MEDICATIONS MEDICATION ADMINISTRATION
After transcribing the medication order to the MAR, the Safety is the main concern in medication administra-
nurse requests the drug from the pharmacy with either a tion. Taking various precautions before, during, and after
LWBK1004-C32_p735-750.indd 739 18/02/12 11:06 AM

FIGURE 32-2 A computer-generated medication administration record (MAR).
each administration reduces the potential for medication Applying the Five Rights
errors. Some precautions include ensuring the five rights of To safeguard against medication errors, nurses follow the
medication administration, calculating drug dosages accu- five rights of medication administration (Fig. 32-6). Some
rately, preparing medications carefully, and recording their nurses have added a sixth right, the right to refuse. Every
administration. rational adult client has the right to refuse medication. If this
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FIGURE 32-3 Medication from an individual supply. (Photo by

B. Proud.)
happens, the nurse identifies the reason why he or she did not
administer the drug, circles the scheduled time on the MAR, FIGURE 32-5 An automated medication dispensing system.
and reports the situation to the prescriber.
In an effort to reduce medication errors, some hospitals supplied amounts are in the same measurements and sys-
are using a barcode medication administration system, a tem of measurement, the quantity for administration can be
point of care software that verifies the name of the medi- easily calculated using a standard formula (Box 32-1) (see
cation, the administration time, the dosage, the drug form, Nursing Guidelines 32-2).
and the client for whom the drug is prescribed; that is, the
five rights to ensure accuracy by scanning a barcode on the Administering Oral Medications
drug’s unopened package and identification band on the cli- Nurses prepare and bring oral medications to the client in
ent. The software also documents the name and title of the a paper or a plastic cup (Skill 32-1). The nurse administers
nurse who administers the medication by scanning a barcode only those medications that he or she has personally pre-
on the nurse’s employee badge. pared; never administer medications prepared by another
nurse. Once at the bedside, it is also important for the nurse
Calculating Dosages to remain with the client while he or she takes medications.
One of the major nursing responsibilities, and one of the five
rights, is preparing the dose accurately. Preparing an accu-
rate dose sometimes requires the nurse to convert doses into
metric and household equivalents. Once the prescribed and
BE SURE YOU
HAVE THE
Drug
DOSE
ROUTE
TIME
CLIENT
FIGURE 32-4 Unit dose medications. (Photo by B. Proud.) FIGURE 32-6 The five rights of medication administration.
LWBK1004-C32_p735-750.indd 741 04/02/12 3:23 PM

B OX 3 2 - 1 Drug Calculation Formula Client and Family Teaching 32-1

Taking Medications
D ×Q = Desired dose
× Quantity
H Dose on hand (supplied dose) The nurse teaches the client and the family as follows:
= Amount to administer ● Inform the prescriber of all other drugs that you are
Example currently taking.
Drug order: Tetracycline 500 mg (desired dose) by mouth q.i.d. ● Have prescriptions filled at the same pharmacy so that
Dose supplied: 250 mg (dose on hand) per 5 mL (quantity) the pharmacist can spot any potential drug interactions.
500 mg ● Consider asking for a new prescription to be partially
Calculation: × 5 mL = 10 mL filled. This provides an opportunity to evaluate the drug’s
250 mg
effect and side effects before purchasing the full amount.
● Read and follow the label directions carefully.
● Take the prescription medication for the full time that it
has been prescribed.
● Check with the prescriber before combining nonprescrip-
Gerontologic Considerations tion and prescription drugs.
● Dispose of old prescription drugs and outdated over-the-
■ Older people who have had cerebrovascular accidents (or counter medications; they tend to disintegrate or change
strokes) or who are experiencing middle-to-late stages of in potency.
dementia may have impaired swallowing. Speech thera- ● Consult with the prescriber if a drug does not relieve
pists are helpful in evaluating swallowing difficulties (dys- symptoms or causes additional discomfort.
phagia) and recommending safe and effective methods of ● Ask the prescriber or pharmacist whether it is appropriate to
administering oral medications. take specific medications with food or on an empty stomach.
■ Some older adults have diminished salivary gland secre- ● Drink a liberal amount of water or other fluids each day to as-
tions and develop xerostomia (dry mouth). Offering a sip sist with the appropriate absorption and elimination of drugs.
of water before administering medications or mixing oral ● Do not take drugs prescribed for someone else, even if
medications with some soft food (such as applesauce) may your symptoms are similar.
prevent medication from adhering to the tongue and, thus, ● Wear a Medic-Alert tag if you are taking prescription
facilitate administration. drugs on a regular and long-term basis.
● Use a pill organizer if you have trouble remembering
If a client is not on the unit at the time of medication whether you took a medication.
administration, the nurse returns the medications to the med-
ication cart or room. Leaving medications unattended may
result in their loss or accidental ingestion by someone else. Many opportunities exist for teaching when administering
medications. Teaching is especially important before discharge
because the client often receives prescriptions for oral medica-
tions. Providing health teaching helps to ensure that clients
administer their own medications safely and remain compli-
ant. Compliance means that the client follows instructions for
Preparing Medications Safely medication administration. Even clients who purchase over-
the-counter medications (nonprescription drugs) may benefit
• Prepare medications under well-lit conditions. Light improves
from instruction (see Client and Family Teaching 32-1).
the ability to read labels accurately.
• Work alone without interruptions and distractions. This
promotes concentration.
• Check the label of the drug container three times: (1) when
reaching for the medication, (2) just before placing the medi-
cation into an administration cup, and (3) when returning the ■ If an older person has difficulty comprehending informa-
medication to the client’s drawer. Checking ensures attention tion about medication routines, include a second responsi-
to important information. ble person in the discharge instructions to ensure client
• Avoid using medications from containers with a missing or safety. A referral for skilled nursing visits is appropriate for
obliterated label. This eliminates speculating on the drug homebound older adults who need additional instructions
name or dose. about medication routines after discharge.
• Return medications with dubious or obscured labels to the ■ Older people should be taught to carry in their wallet or
pharmacy. This step facilitates replacement or new labeling. purse a current list of all their medications, dosages, times of
• Never transfer medications from one container to another. administration, and names of the prescribing provider. Should
Such transfers could lead to mismatching contents. an older client be found wandering or unconscious, an evalua-
• Check the expiration dates on liquid medications. Doing so tion for possible medication adverse effects can happen more
ensures administration at desired potency. quickly if he or she has such information readily available.
• Inspect the medication and reject any that appear to be ■ Older people should use eyeglasses or hearing aids as
decomposing. These steps promote appropriate absorption. needed to optimize their learning conditions. Other important
LWBK1004-C32_p735-750.indd 742 18/02/12 11:06 AM

considerations for the teaching–learning environment are Administering Oral Medications by

adequate nonglare lighting and little, if any, background noise. Enteral Tube
■ An evaluation of comprehension may be best done by hav- When a client cannot swallow oral medications, they can be
ing the older person repeat instructions after they are pro-
instilled by enteral tube (Skill 32-2). Because the lumen of a
vided. Reinforce verbal instructions with written instructions
tube is smaller than the esophagus, special techniques may be
at the older person’s reading level. A copier may be used to
enlarge instructions for clients with visual impairments. required to avoid obstruction (see Nursing Guidelines 32-3).
Written instructions are particularly important for clients with Nurses use slightly different techniques for administering
hearing impairments. They provide a reference for older adults medications through an enteral tube than they do for tubes used
with difficulty recalling or comprehending information. In addi- for decompression or nourishment (see Chap. 29). They may
tion, written instructions serve as a point of reference for give medications through gastric tubes used for decompression
caregivers who may assist with medication administration. (eg, suctioning; see Chap. 29). After administering the drug,
■ Older adults who have problems with manual dexterity the nurse clamps or plugs the tube for at least 30 minutes to
or strength may request that pharmacists use nonchild- prevent removing the drug before it leaves the stomach.
proof caps on their prescription containers. Nurses can give medications while a client is receiving
■ Clients with visual impairments may benefit from meth-
tube feedings, but they instill the medications separately—that
ods of identifying their medication containers other than
is, they do not add the medications to the formula. This is done
reading labels. Suggestions include using rubber bands or
textured materials on certain containers or using bright col- for two reasons. First, some drugs may physically interact with
ors to mark the labels. Many simple-to-use medication the components in the formula, causing it to curdle or other-
management systems, sometimes called pill organizers, wise change its consistency. Also, a slow infusion would alter
are available. Often, a family member is helpful in setting the rate of absorption of the drug.
up weekly medication management systems. For example,
a family member may set out the medications in specially
designed containers weekly. This method enables others to
Documentation
monitor patterns and the adherence to the medication regi- If the nurse is not using a barcode medication system that
men and may be especially helpful when working with documents drug administration immediately and auto-
older people experiencing memory impairments. matically, the nurse should document medication admin-
■ Older adults with insurance coverage for prescription istration manually on the MAR, the client’s chart, or both
payments may find it easier and more economical to have as soon as possible (Fig. 32-7). Timely documentation
prescriptions filled every 3 months. It may also be more prevents medication errors: if the nurse does not record
economical to purchase prescriptions by mail or Internet if the dose, another nurse may assume that the client has not
the insurance provider approves this option. received the medication and may give a second dose.
■ Encourage older adults to question the primary health If a nurse withholds a medication, he or she documents
care provider about prescribing generic forms of medication
its omission according to agency policy. A common method
for cost savings.
of such documentation is to circle the time of administration
and initial the entry. The nurse may document the reason for
➧ Stop, Think, and Respond Box 32-1 the omission in a comment section on the MAR or elsewhere
What actions are appropriate if a client cannot swal- in the client’s medical record.
low medications prescribed by the oral route?

Rationales
Preparing Medications for Enteral Tube Administration
• Use the liquid form of the drug whenever possible. It promotes • Pierce the end of a sealed gelatin capsule and squeeze out the
tube patency. liquid medication, or aspirate it with a needle and syringe.
• Add 15–60 mL of water to thick liquid medications. Water These measures facilitate access to the medication.
dilutes the medication and facilitates instillation. • As an alternative, soak a soft gelatin capsule in 15–30 mL of
• Pulverize tablets except those that are enteric coated. warm water for approximately 1 hour. Soaking dissolves the
Pulverizing creates small granules that may instill more gelatin seal.
readily. • Avoid administering bulk-forming laxatives through an enteral
• Open the shell of a capsule to release the powdered drug. This tube. Such laxatives could obstruct the tube.
step facilitates mixing into a liquid form. • Interrupt a tube feeding for 15–30 minutes before and after
• Avoid crushing sustained-release pellets. Keeping them whole administration of a drug that should be given on an empty
ensures their sequential rate of absorption. stomach. Doing so facilitates the drug’s therapeutic action or
• Mix each drug separately with at least 15–30 mL of water. its absorption.
Water provides a medium and dilute volume for administra- • Clamp a nasogastric tube that is being used to suction gastric
tion. secretions for 30 minutes after administering medication.
• Use warm water when mixing powdered drugs. It promotes Keeping the tubing temporarily clamped allows time for the
dissolving the solid form. medication to move beyond the stomach and be absorbed.
LWBK1004-C32_p735-750.indd 743 04/02/12 3:23 PM

As soon as he or she recognizes an error, the nurse

checks the client’s condition and reports the mistake to the
prescriber and the supervising nurse immediately. Health
care agencies have a form for reporting medication errors
called an incident sheet, or accident sheet (see Chap. 3).
The incident sheet is neither a part of the client’s permanent
record nor does the nurse make any reference in the chart to
the fact that he or she has completed an incident sheet.
Whenever nursing care involves the administration of medi-

cations, one or more of the following nursing diagnoses may
be applicable:
FIGURE 32-7 Documentation of the medication administration
is an important nursing requirement. (Photo by B. Proud.) • Deficient Knowledge; Readiness for Enhanced Knowledge
• Risk for Aspiration
➧ Stop, Think, and Respond Box 32-2 • Ineffective Therapeutic Regimen Management
Give reasons to administer medications through a • Ineffective Self-Help Management
gastric or intestinal tube rather than having the • Noncompliance
client swallow them. Nursing Care Plan 32-1 shows how nurses can follow
the steps in the nursing process to manage the care of a cli-
Medication Errors ent with the nursing diagnosis of Noncompliance, defined
Medication errors happen too often. When errors occur, by NANDA-I (2012, p. 400) as “the person’s or caregiver’s
nurses have an ethical and legal responsibility to report them behavior is fully or partially nonadherent and may lead to
to maintain the client’s safety. clinically ineffective or partially ineffective outcomes.”
N U R S I N G C A R E P L A N 3 2 - 1 Noncompliance
Assessment • Determine by the dates on the containers and the number of
• Check whether the client is returning for scheduled appoint- medications in the container(s) whether the client is using or
ments with the prescribing physician or health care provider. partially using medication.
• Assess the current status of the client’s health problem to • Encourage the client to relate problems encountered with
determine whether the response to the prescribed plan of care self-administration of medications such as intolerance of side
is that which is expected. effects, an inability to pay for refills, a belief that the medica-
• Ask to examine the client’s containers of medications. tion is ineffective, difficulty remembering the dosing schedule,
• Review the labels attached to prescription medications. and trouble opening the containers.
• Have the client identify the number of pills or capsules per dose,
the frequency of self-administration, and time of the last dose.
Nursing Diagnosis. Noncompliance related to an inaccurate belief regarding the use and benefit of prescribed medication thera-
py as manifested by pulse rate of 94 at rest, BP of 178/94 in R arm while sitting, dyspnea following coronary bypass surgery, and the
statement, “I didn’t get my prescriptions filled last week. I wasn’t having any chest pain and I figured the surgery fixed my heart.”
Expected Outcome. The client will (1) explain the purpose of prescribed medications and possible consequences if they are not
taken and (2) resume taking prescribed medications within 24 hours (3/7).
Provide the client with the following information: Health teaching helps clarify the rationale for medication
• The purpose for the prescribed beta-blocker and diuretic therapy and promotes compliance.
medications is to reduce the work of the heart.
• The diuretic helps to lower blood pressure, so the heart
does not have to pump as much circulating blood and can
eject the blood from the heart more easily.
• Easing the work of the heart reduces the potential for recur-
ring chest pain, a subsequent myocardial infarction (heart
attack), or congestive heart failure.
(continued)
LWBK1004-C32_p735-750.indd 744 04/02/12 3:23 PM

NURSING CARE PLAN 32-1 Noncompliance ( c o n ti n u e d )

Have the client rephrase explanations for drug therapy in his Rephrasing provides evidence that the client has understood
own words. the nurse’s explanation.
Note the client’s level of understanding. Doing so indicates whether or not the nurse needs to clarify
misinformation.
Acknowledge when the client’s explanation is accurate or These measures reinforce learning.
re-explain information that continues to be misunderstood.
Go over the schedule of medication administration with the Reviewing the schedule helps the client to plan a routine for
client. self-administration.
Suggest that the client discuss any deviations in medication This offers an alternative if the client feels a need to alter or
schedule or dosage with the physician. discontinue self-administration.

• The client correctly paraphrased information regarding drug • The client indicates that he will take one beta-blocker each
therapy. morning if his heart rate is at least 60 beats per minute and one
• The client states, “I know people take nitroglycerin for heart prob- diuretic tablet every other day, which correlates with the dos-
lems, but I didn’t know how important these other drugs are. I’d ing regimen.
rather take some pills than to have to go back to the hospital again.” • The client is scheduled for another office check-up in 1 month.
• The client plans to have prescriptions filled before returning He states, “I’ll be sure to call if I think there’s a reason I can’t
home following the office visit. take my medications.”
CRITICAL THINKING EXERCISES 2. Consult the physician about the prescribed dose.
3. Give the client half of the 500-mg tablet.
1. The nurse is administering medications to a client. 4. Check whether the drug is manufactured in a
The client says, “I’ve never taken that little yellow pill smaller dose.
before.” What actions are appropriate next? 3. Which action is best when a nurse brings medication
2. A client who lives alone says, “You have to be a to a room for a client named Anna Jones, but the client
genius to keep all these pills straight.” How could you in that room is not wearing an identification bracelet?
help this client organize her medication regimen? 1. The nurse asks the client, “Are you Anna Jones?”
3. What action(s) are appropriate if a barcode medica- 2. The nurse asks the client, “What is your name?”
tion administration system sounds an alert to a prob- 3. The nurse asks a nursing assistant to identify the
lem during the process of administering medication to client.
a client? 4. The nurse asks the client, “What medications do
4. What response would be appropriate if a nurse of you take?”
long-standing asked you to document being a witness 4. When a nurse observes that a client has difficulty
to a wasted controlled substance medication you did swallowing a capsule of medication, which action is
not observe? best?
1. Soak the capsule in water until soft.
2. Tell the client to chew the capsule.
1. When a nurse checks the medication administration 3. Empty the capsule in the client’s mouth.
record (MAR) and reads “diphenoxylate hydrochlo- 4. Offer the client water before giving the capsule.
ride, 5 mg p.o. q.i.d.”, how many times a day will he 5. Which of the following techniques is incorrect when
or she administer the drug? administering oral medication through a nasogastric
1. Once a day tube used to administer a tube feeding?
2. Every other day 1. Crush the medication finely and mix it with 30 mL
3. Three times a day of warm water.
4. Four times a day 2. Flush the nasogastric tube with 30 mL of water
2. If a physician orders 250 mg of a drug, and it is sup- before instilling the drug.
plied in 500-mg scored tablets, which of the follow- 3. Add the liquefied medication to the bag of tube-
ing nursing actions is best? feeding formula.
1. Ask the pharmacist to provide 250-mg tablets 4. Flush the nasogastric tube with 30 mL of water
instead. after instilling the drug.
LWBK1004-C32_p735-750.indd 745 04/02/12 3:23 PM

SKILL 32-1 Administering Oral Medications
ASSESSMENT
Compare the medication administration record (MAR) with the Prevents medication errors.
Review the client’s drug, allergy, and medical history. Avoids potential complications.
Consult a current drug reference concerning the drug’s action, side Ensures appropriate administration based on a thorough
effects, contraindications, and administration information. knowledge base.
PLANNING
Plan to administer medications within 30–60 min of their Demonstrates a timely administration and compliance with the
scheduled time. medical order.
Allow sufficient time to prepare the medications in a location with Promotes safe preparation of drugs.
minimal distractions.
Make sure that there is a sufficient supply of paper and plastic Facilitates organization and efficient time management.
medication cups.
Chill oily medications. Reduces their unpleasant odor and improves palatability.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub (see Removes colonizing microorganisms.
Chap. 10).
Read and compare the label on the drug with the MAR at least Ensures that the right drug is given at the right time by the right
three times—before, during, and after preparing the drug route.
(Fig. A).
Comparing the drug label and the medication administration record

(MAR). (Photo by B. Proud.)
Calculate doses. Complies with the medical order and ensures that the right dose
is given.
Place medications or unit dose packets within a paper or plastic Supports principles of asepsis.
cup without touching the medication itself.
Keep drugs that require special assessments or special administra- Helps identify drugs that require special nursing actions.
tion techniques in a separate cup.
Pour liquids with the drug label toward the palm of the hand. Prevents liquid from running onto the label.
Hold the cup for liquid medications at eye level when pouring. Facilitates accurate measurement.
Prepare a supply of soft-textured food such as applesauce or Facilitates the administration for clients with impaired swallowing.
pudding, according to the client’s individual needs.
Help the client to a sitting position. Facilitates swallowing and prevents aspiration.
(continued)
LWBK1004-C32_p735-750.indd 746 18/02/12 11:06 AM

Administering Oral Medications (continued)
Identify the client using at least two methods, for example, check- Ensures that medications are given to the right client; complies
ing the wristband and asking the client’s name (Fig. B). with the National Patient Safety Goals.
Checking the identification band. (Photo by B. Proud.)
Offer a cup of water with solid forms of oral medications (Fig. C). Water moistens mucous membranes and prevents medication
from sticking.
Offering the patient medication and water. (Photo by B. Proud.)
Advise the client to take medications one at a time or in amounts Prevents choking.
easily swallowed.
Encourage the client to keep his or her head in a neutral position or Protects the airway.
one of slight flexion, rather than hyperextending the neck (Fig. D).
1 2 3
(1) Inappropriate neck position; and (2–3) appropriate neck

positions.
Remain with the client until he or she has swallowed the Ensures the appropriate administration.
medications.
Restore the client to a position of comfort and safety. Shows concern for the client’s well-being.
Record the volume of fluid consumed on the intake and output Demonstrates responsibility for accurate fluid assessment.
record.
Record the administration of the medication. Prevents medication errors.
Assess the client in 30 min for desired and undesired drug Aids in evaluating the client’s response and the effect of drug therapy.
effects.
(continued)
LWBK1004-C32_p735-750.indd 747 04/02/12 3:23 PM

Administering Oral Medications (continued)
Evaluation
• The five rights are upheld.
• The client experiences no choking or aspiration.
• The client exhibits a therapeutic response to the medication.
• The client demonstrates minimal or absent side effects.
Document
• Preassessment data, if indicated
• Date, time, drug, dose, route, signature, title, and initials (usually on the MAR)
• Evidence of client’s response, if it can be determined
Date and Time Temp. 103.8°F. Tylenol tabs ii given by mouth for relief of fever. Fever reduced to 103°F 30 minutes later.
_______________________________________________________________________________ SIGNATURE/TITLE
SKILL 32-2 Administering Medications Through an Enteral Tube
ASSESSMENT
Check the medication administration record (MAR) and compare Prevents medication errors.
the information with the written medical order.
Consult a current drug reference concerning the drug’s action, side Ensures the appropriate administration based on a thorough
Verify the location of the tube by auscultating instilled air or Ensures airway protection and proper tube placement.
aspirating secretions.
Compare the length of the external tube with its measurement Determines whether the tube has migrated.
at the time of insertion.
Inspect the client’s mouth and throat. Determines whether the tube has been displaced and is coiled at
the back of the throat.
PLANNING
Plan to administer medications within 30–60 min of the scheduled Demonstrates timely administration and compliance with the
time. medical order.
Separate and clamp or plug a feeding tube for 15–30 min if the Ensures that the stomach will be relatively empty.
drug will interact with food.
Allow sufficient time to prepare the medications in a location with Promotes the safe preparation of drugs.
Make sure that there is a sufficient supply of plastic medication Facilitates organization and efficient time management.
cups.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub Removes colonizing microorganisms.
(see Chap. 10).
three times—before, during, and after preparing the drug. route.
Prepare each drug separately. Prevents potential physical changes when some drugs are
combined.
Take the cups containing diluted medications to the bedside, along Facilitates instillation.
with water for flushing, a 30–50-mL syringe, a towel or dispos-
able pad, and clean gloves.
Identify the client using at least two methods, for example, check- Ensures that medications are given to the right client; complies
ing the wristband and asking the client’s name. with the National Patient Safety Goals.
(continued)
LWBK1004-C32_p735-750.indd 748 04/02/12 3:23 PM

Administering Medications Through an Enteral Tube (continued)
Help the client into a Fowler’s position. Prevents gastric reflux.
Don clean gloves. Prevents contact with body fluids.
Insert the syringe into the tube and instill 15–30 mL of water by Flushes and reduces the surface tension of the tube.
gravity (Fig. A).
Instilling the medication. (Photo by B. Proud.)
Add the diluted medication to the syringe as it becomes nearly Prevents instilling air.
empty.
Apply gentle pressure with the plunger or bulb of a syringe if the Provides positive pressure.
medication fails to instill easily.
Flush with at least 5 mL of water between each instillation of medi- Prevents drug interactions and obstruction of the tube; fully instills
cation and as much as 30 mL after instilling all the medications. all the prescribed drug.
Pinch the tube as the syringe empties. Prevents distending the stomach with air; maintains patency of
the tube.
Clamp or plug the tube for 30 min before reconnecting a tube to Prevents removing the medication after it has been instilled.
the suction (Fig. B).
Plugging a gastric tube. (Photo by B. Proud.)
Connect a tube used for nourishment immediately if the medica- Facilitates the primary purpose of the enteral tube.
tion and formula will not interact.
Keep the head of the bed elevated for at least 30 min. Reduces the potential for aspiration.
(continued)
LWBK1004-C32_p735-750.indd 749 18/02/12 11:06 AM

Administering Medications Through an Enteral Tube (continued)
Evaluation
• The tube placement is verified.
• The medications instill freely and are flushed afterward.
• The client experiences no abdominal distention, nausea, vomiting, or other undesirable effects.
• The tube remains patent.
Document
• Preadministration assessment data
• Medication administration on the MAR
• Volume of fluid instilled with the medication as well as for flushing the tube on the bedside intake and output record
Date and Time Placement of NG tube verified by auscultation. No evidence of tube migration. Medications administered
(see MAR) per NG tube. Flushed with 30 mL after instilling medications. Tube clamped at this time. No
evidence of nausea or distention. _________________________________________________ SIGNATURE/TITLE
LWBK1004-C32_p735-750.indd 750 04/02/12 3:23 PM

Photo to
Come
FPO
33# Topical and Inhalant
Medications
aerosol
buccal application
cutaneous application 1. Explain how topical medications are administered and
dry powder inhaler commonly applied.
inhalant route 2. Give three examples of an inunction.
inhalers 3. Name two forms of drugs applied by the transdermal route and
inunction principles to follow when applying a skin patch.
metered-dose inhaler 4. Describe where eye medications are applied.
nebulizer 5. Explain how the administration of ear medications differs for
ophthalmic application adults and children.
otic application 6. Explain the rebound effect that accompanies the administration
paste of nasal decongestants.
rebound effect 7. Describe the difference between sublingual and buccal
skin patches administration.
spacer 8. Name a common reason for vaginal applications.
sublingual application 9. Give the form of medication used most often for rectal
topical route administration.
transdermal application 10. Explain why inhalation is a good route for medication
administration.
11. Name two types of inhalers and alternatives for administering
inhaled medications.
rugs are administered by routes other than oral (see Chap. 32). This
D chapter describes the techniques used to administer drugs by the

topical and inhalant routes.
TOPICAL ROUTE
Drugs given by the topical route (the administration of medications to

the skin or mucous membranes) can be applied externally or internally
(Table 33-1). Topically applied drugs have a local or systemic effect.
Many are administered to achieve a direct effect on the tissue to which
they are applied.
Cutaneous Applications
Cutaneous applications are drugs rubbed into or placed in contact with
the skin. They include inunctions and transdermal patches and pastes.
Inunction Application
An inunction is a medication incorporated into an agent (eg, oint-
ment, oil, lotion, cream) that is administered by rubbing it into the skin.
751
LWBK1004-C33_p751-761.indd 751 04/02/12 3:24 PM

TABLE 33-1 Topical Medications

ROUTES LOCATION VEHICLE EXAMPLES
Cutaneous Skin Ointment hydrocortisone (Cortaid)
Skin Cream benzocaine (Lanacane)
Scalp Liquid permethrin (Nix)
Skin Lotion Lubriderma
Skin Patch estrogen (Estraderm)
Skin Paste nitroglycerin (Nitrol)
Oral mucous membrane Gel benzocaine (Anbesol)
Ophthalmic In the eye Drops timolol (Timoptic)
Ointment polymyxin, neomycin, bacitracin
(Neosporin)
Otic In the ear Drops hydrocortisone, neomycin,
polymyxin (Cortisporin Otic)
Irrigation carbamide peroxide (Debrox)
Nasal In the nose Spray oxymetazoline (Afrin)
Drops oxymetazoline (Neo-Synephrine)
Sublingual Under the tongue Tablet nitroglycerin (Nitrostat)
Spray nitroglycerin (Nitrolingual)
Buccal Between the cheek and gum Tablet nitroglycerin (Nitrogard)
Lozenge Cepacola
Vaginal In the vagina Douche povidone iodine (Massengill
medicated douche)
Cream clotrimazole (Gyne-Lotrimin)
Suppository fluconazole (Monistat)
Rectal To or within rectum Irrigation sodium phosphate (Fleet
Enema)
Suppository bisacodyl (Dulcolax)
Ointment hydrocortisone (Anusol)
a
Indicates a nonprescription item that is a combination of ingredients.
Alert clients may self-administer an inunction after receiv-Transdermal Applications

ing proper instruction. In that situation, the nurse teachesDrugs incorporated into patches or pastes are administered
proper application techniques and checks that the client hasastransdermal applications (the method of applying a drug
applied the medication appropriately and as often as pre- on the skin and allowing it to become passiv
ely absorbed).
scribed. For clients who cannot apply their own inunctions,After application, the drug migrates through the skin and
the nurse does so (see Nursing Guidelines 33-1). eventually is absorbed into the bloodstream.

Rationales
Applying an Inunction
• Wash your hands or perform an alcohol-based hand rub (see • Shake the contents of liquid inunctions. Shaking mixes the
Chap. 10). Hand hygiene removes colonizing microorganisms. contents uniformly.
• Check the identity of the client. Doing so prevents administer- • Apply the inunction to the skin with the fingertips, a cotton
ing the medication to the wrong person. ball, or a gauze square.Correct application distributes the
• Don clean gloves if your skin or that of the client is not intact. substance over a wide area.
Gloves provide a barrier to pathogens. • Rub the inunction into the skin. Rubbing promotes absorption.
• Cleanse the area of application with soap and water. Clean skin• Apply local heat to the area if desired (see Chap.Heat 28).
promotes absorption. dilates peripheral blood vessels and speeds absorption.
• Warm the inunction if it will be applied to a sensitive area of
the skin by holding it temporarily in your hands or placing the
sealed container in warm water. Warmth promotes comfort.
LWBK1004-C33_p751-761.indd 752 20/02/12 1:09 PM

CHAPTER 33 Topical and Inhalant Medications 753
Clipping extremely hairy skin areas before an application

may help adhesion.
■ The onset of drug action may be atypical when adminis-

tering topical medications to older adults because of their
diminished subcutaneous fat, which leads to a more rapid
absorption of topical medications.
After application of the patch, it may take approximately

30 minutes for the drug to reach a therapeutic level. There-
after, the patch provides a continuous supply of medication.
In fact, the drug may still be active for up to 30 minutes after
removal of the patch. It is always best to date and initial a
patch so that others can determine when it was applied. The
FIGURE 33-1 The pathway of absorption from a transdermal older patch is removed when a new patch is applied.
skin patch.
Drug Paste
A paste contains a drug within a thick base and is applied
to but not rubbed into the skin. Nitroglycerin can be applied
Skin Patches as a paste. Although sometimes the product is referred to as
Skin patches are drugs bonded to an adhesive bandage and an ointment, the term is a misnomer because the skin is not
applied to the skin (Fig. 33-1). massaged once the drug is applied (see Nursing Guidelines
33-2 and Fig. 33-2).
■ Several drugs are now prepared in patch form, including
nitroglycerin (used to dilate the coronary arteries), scopo- ■ Nitroglycerin paste (an ointment) has a shorter duration
lamine (used to relieve motion sickness), and estrogen of action than that supplied in a transdermal patch. Con-
(a hormone used to treat menopausal symptoms), and sequently, it must be applied more frequently to provide a
potent pain medications (fentanyl). Nicotine withdrawal sustained effect.
therapy and contraceptive drugs also are available as skin ■ When discontinuing transdermal nitroglycerin, the dose
patches. should be decreased gradually rather than stopping it
■ A severe headache, hypotension, and flushing are side
abruptly to prevent the resumption of symptoms such as
effects associated with nitroglycerin. If side effects occur, chest pain.
consult the physician, who may recommend removal of the
transdermal application.
■ Clients who are prescribed nitroglycerin in any form
should not concurrently take a drug for erectile dysfunction Ophthalmic Applications
because the combination may contribute to hypotension An ophthalmic application is a method of applying drugs
due to the combined vasodilation effect. onto the mucous membrane of one or both eyes (described in
■ A transdermal nitroglycerin patch is usually worn for 12
Skill 33-1). The mucous membrane of the eyes is called the
to 14 hours and then removed for 10 hours to facilitate the
conjunctiva. It lines the inner eyelids and the anterior surface
drug’s continued effectiveness.
of the sclera (Fig. 33-3).
Ophthalmic medications are supplied either in liquid
form and instilled as drops, or as ointments applied along
Skin patches are applied to any skin area with adequate the lower lid margin. Blinking, rather than rubbing, distrib-
circulation. Most patches are applied to parts of the upper utes the drug over the surface of the eye. The eye is a delicate
body such as the chest, shoulders, and upper arms. Small structure susceptible to infection and injury, just like any
patches can be applied behind the ear. Each time a new other tissue. Therefore, nurses take care to keep the applica-
patch is applied, it is placed in a slightly different location. tor tip of the medication container sterile.
LWBK1004-C33_p751-761.indd 753 04/02/12 3:24 PM


Rationales
Applying Nitroglycerin Paste
• Wash your hands or perform an alcohol-based hand rub (see • Place the application paper on a clean, nonhairy area of skin.
Chap. 10). Hand hygiene removes colonizing microorganisms. Such a placement facilitates drug absorption.
• Check the identity of the client. Doing so prevents administer- • Cover the paper with a square of plastic kitchen wrap or tape
ing the medication to the wrong person. all the edges of the paper to the skin. This seals the drug
• Squeeze a ribbon of paste from the tube onto an application between the paper and the skin.
paper (see Fig. 33-2). This complies with the medication order, • Remove one application before applying another and remove
which usually specifies the dose in inches. any residue remaining on the skin. Careful application pre-
• Fold the paper or use a wooden applicator to spread the paste vents excessive drug levels.
over approximately a 2.25 ⫻ 3.5 in. (5.6 ⫻ 8.8 cm) area of the • Rotate the sites of medication placement. Site rotation reduces
paper. These techniques facilitate distributing the drug over a the potential for skin irritation.
wide area for quick absorption.
• Do not touch the paste with your bare fingers. Touching the
paste could cause self-absorption of the drug.
Pharmacologic Considerations Gerontologic Considerations
■ Some people have difficulty instilling eye medications ■ Some older adults use two or more types of eye medica-
independently. Devices are available that can diminish tions once or several times daily. If the tops of the eye med-
the frequency of instillation or can facilitate administra- ications are not color-coded, suggest ways to color-code the
tion. For example, one type of medication for glaucoma is containers to help distinguish the different medications.
inserted inside the lower eyelid, requiring administration
only every 7 days. Sight centers, which provide assistive
devices for people with visual impairment, are a good ➧ Stop, Think, and Respond Box 33-1
resource for other devices that facilitate the instillation
of eye drops. What actions should the nurse take if the tip of the
■ Clients who require complex ophthalmic medication
ophthalmic medication becomes contaminated?
regimens that involve the instillation of one or more types
of drops up to four times daily may collaborate with Otic Applications
the prescribing practitioner about longer acting medica- An otic application is a drug instilled in the outer ear. It is
tions that may decrease the frequency of medication usually administered to moisten impacted cerumen or to
routines. instill medications to treat a local bacterial or fungal infection.
■ When more than one eye medication is prescribed, it is When instilling ear medication, the nurse first manipu-
best to wait 5 minutes between instillation of eye drops.
lates the ear to straighten the auditory canal. The technique
■ Eye medications can have adverse systemic effects and
varies depending on whether the client is a young child (the
can interact with other medications, herbal supplements,
or both. nurse pulls the ear down and back) or an adult (the nurse
pulls the ear up and back; see Chap. 13).
Conjunctiva
over sclera
Conjunctiva
FIGURE 33-2 A paste and applicator paper. (Photo by B. Proud.) FIGURE 33-3 Ophthalmic application sites. (Photo by B. Proud.)
LWBK1004-C33_p751-761.indd 754 04/02/12 3:24 PM

Tilting the client’s head away, the nurse instills the pre- Client and Family Teaching 33-1
scribed number of drops of medication within the ear. The Administering Medications Vaginally
client remains in this position briefly as the solution travels
toward the eardrum. The nurse can place a small cotton ball The nurse teaches the client as follows:
loosely in the ear to absorb excess medication. If a bilateral ● Obtain a form of medication based on personal prefer-
administration is prescribed, the nurse waits at least 15 minutes ence; all come with a vaginal applicator.
before instilling medication in the opposite ear. Briefly post- ● Plan to instill the medication before going to bed so that it
poning the application within the second ear avoids displacing can be retained for a prolonged period.
the initially instilled medication when repositioning the client. ● Empty the bladder just before inserting the medication.
● Place the drug in the applicator (see Fig. 33-4A).
● Lubricate the applicator tip with a water-soluble lubricant
Nasal Applications
such as K-Y Jelly.
Topical medications are dropped or sprayed within the nose ● Lie down, bend your knees, and spread your legs.
(Skill 33-2). A proper instillation is important to avoid dis- ● Separate the labia and insert the applicator into the vagina
placing the medication into nearby structures such as the to the length recommended in the package directions,
back of the throat. Adults often self-administer their own usually 2–4 in. (5–10 cm) (see Fig. 33-4B).
nasal medications, but sometimes nurses must assist older ● Depress the plunger once it reaches the proper distance
adults and children. within the vagina to insert the medication.
● Remove the applicator and place it on a clean tissue.
● Apply a sanitary pad if you prefer.
Pharmacologic Considerations ● Remain recumbent for at least 10–30 minutes.
● Discard the applicator if it is disposable. Wash a reus-
■ Nurses warn clients who use over-the-counter decon- able applicator with soap and water when you wash your
gestant nasal sprays that if they use the medication too hands.
frequently or administer more than the recommended ● Consult a physician if symptoms persist.
amount, a rebound effect (swelling of the nasal mucosa
within a short time of drug administration) can occur. Clients
can avoid a rebound effect by following label directions or restores normal tissue integrity. Providing clients with
by using nasal sprays containing only normal saline solution.
instructions about how to administer vaginal medications
■ A prolonged use of topical nasal decongestants can
cause irritation of the nares (American Academy of Family
for the most effective action may be helpful (see Client and
Physicians, 2005). Family Teaching 33-1 and Fig. 33-4).
If the client cannot self-administer a vaginal medica-
tion, the nurse wears gloves to avoid contact with secre-
Sublingual and Buccal Applications tions. After removing the gloves, hand washing or an
A tablet given by sublingual application (a drug placed alcohol-based hand rub is critical. The same advice holds
under the tongue) is left to dissolve slowly and becomes true for rectal applications.
absorbed by the rich blood supply in the area. Some drugs
in spray form also are administered sublingually. A buccal Rectal Applications
application (a drug placed against the mucous membranes Drugs administered rectally are usually in the form of sup-
of the inner cheek) is another method of drug administration. positories (see Chap. 31); however, creams and ointments
When giving sublingual or buccal administrations, also may be prescribed. The technique for using a rectal
nurses instruct clients not to chew or swallow the medica- applicator is similar to that for using a vaginal applicator.
tion. Eating and smoking also are contraindicated during the
brief time needed for a solid medication to dissolve.
Vaginal Applications
■ Some older clients have difficulty reaching areas of the
Topical vaginal applications are used most often to treat body to which topical drugs are applied. For example, arthri-
local infections, which are common and usually result from tis may interfere with applying medication within the vagina
the colonization of vaginal tissue by microorganisms abun- or rectum, or to skin lesions on the lower extremities.
dant in stool (eg, yeasts). The microorganisms usually get
transferred during bowel elimination if the client wipes stool
from the rectal area toward (not away from) the vagina. INHALANT ROUTE
Symptoms of a yeast infection include intense vaginal itch-
ing and a white, cheese-like vaginal discharge. The inhalant route administers drugs to the lower air-
Several nonprescription drugs useful in treating vagi- ways. This method of medication administration is effective
nal yeast infections are available in suppository, dissolvable because the lungs provide an extensive area from which the
tablet, and cream form. Early and appropriate self-treatment circulatory system can quickly absorb the drug.
LWBK1004-C33_p751-761.indd 755 04/02/12 3:24 PM

A B
FIGURE 33-4 Administering drugs vaginally. A. Placing the drug in the applicator. B. Inserting
the applicator with the drug.
A simple method of administering inhaled medica- containing a mouthpiece; when the container is compressed,
tions is through an inhaler. Inhalers are handheld devices a measured volume (the metered dose) of aerosolized drug
for delivering medication into the respiratory passages. They is released. Clients who use metered-dose inhalers do not
consist of a container of medication and a holder with a always do so correctly. As a result, they may swallow, rather
mouthpiece through which the drug is inhaled. than inhale, much of the medication. As a result, their respi-
There are two types of inhalers: (1) a dry powder inhaler ratory symptoms may not be relieved (see Client and Family
holds a reservoir of pulverized drug and a carrier substance, Teaching 33-2 and Fig. 33-6).
and (2) a metered-dose inhaler that delivers aerosolized
medication, which is a liquid drug forced through a narrow
channel via a chemical propellant (Fig. 33-5). Client and Family Teaching 33-2
Using a Metered-Dose Inhaler
Pharmacologic Considerations The nurse teaches the client and the family as follows:
● Insert the canister into the holder.
■ Traditionally, metered-dose inhalers have been propelled
● Shake the canister to distribute the drug in the pressu-
with chloroflurocarbons, which contribute to environmental
rized chamber.
pollution. Current global regulations require them to be
● Remove the cap from the mouthpiece.
reformulated to contain non-ozone-depleting substances.
● Tilt your head back slightly and exhale slowly through
pursed lips.
Dry powder inhalers depend on the client’s inspiratory ● Open your mouth and place the inhaler 1–2 in. away (see
effort to deliver the medication into the lungs. If the inspira- Fig. 33-6). If you have difficulty with this method, place
tory effort is ineffective, the dose of the drug is reduced. the inhaler in your mouth and close your lips around the
A metered-dose inhaler contains medication under pres- mouthpiece.
sure within a canister. The canister is placed into a holder ● Press down on the canister once to release the medication.
● As the medication is released, breathe in slowly through
your mouth for approximately 3–5 seconds.
● Hold your breath for 10 seconds to let the medication
reach your lungs.
● Exhale slowly through pursed lips.
● Wait 1 full minute before doing another inhalation if more
than one is ordered.
Canister ● Clean the inhaler (holder and mouthpiece) daily by rinsing
it in warm water and weekly with mild soap and water.
Holder Allow the inhaler to air dry. Have another inhaler available
Mouthpiece
to use while the first is drying.
● Check the amount of medication in the canister by float-
ing it in a bowl of water; the higher the canister floats,
the less medication it contains.
● Obtain a refill of inhalant medication when the current
canister shows signs of becoming empty.
FIGURE 33-5 The parts of metered-dose inhaler.
LWBK1004-C33_p751-761.indd 756 04/02/12 3:24 PM

FIGURE 33-6 A metered-dose inhaler can be used by holding FIGURE 33-7 Using a metered-dose inhaler with a spacer.
the mouthpiece 1 to 2 in. away prior to depressing the canister
and inhaling, or the mouthpiece can be placed in the mouth
and sealed by the lips prior to administering the drug. to administering an inhalant. A nebulizer, sometimes called a
“breathing machine,” is a device that converts liquid medica-
tion to an aerosol using compressed air. The aerosol is inhaled
Some clients find that the inhaled drug leaves an unpleas-through a mouthpiece or a face mask over 10 to 20 minutes
ant aftertaste. Gargling with salt water may diminish this. Druguntil the mist is no longer visible (Fig. 33-8). The components
residue may accumulate in the mouthpiece; therefore, the of the nebulizer are cleaned after each use with soapy water
client should rinse the mouthpiece in warm water after use. and a small brush. After rinsing the cleaned parts, they are
allowed to air dry before storing them in a closed container.
Pharmacologic Considerations NURSING IMPLICATIONS
■ Sometimes, two inhalers containing different drugs are pre-
scribed. During teaching sessions, it is important to educate
When administering topical or inhalant drugs, nurses often
how and when each drug is used, and the anticipated action. assess and take steps to maintain the integrity of the skin
For example, one drug may act to expand the bronchioles and and mucous membranes. Health teaching may be important
would improve the overall outcome to be administered before to prevent improper self-administration. Applicable nursing
a medication that loosens secretions. Providing simple written diagnoses may include the following:
instructions with each medication is also helpful.
• Defi cient Knowledge; Readiness for Enhanced Knowledge
• Ineffective Self-Help Management
• Impaired Gas Exchange
Gerontologic Considerations • Impaired Skin Integrity
• Impaired Tissue Integrity
■ Monitoring the heart rate and blood pressure of older • Ineffective Breathing Patterns
adults who use inhaled bronchodilators is important
because these medications commonly cause tachycardia
and hypertension. Either or both of these effects increases
the risks for complications, especially in older adults with
an underlying cardiovascular disease.
Clients who have problems coordinating their breathing

with the use of an inhaler may not receive the full dose
aerosol.
of
A spacer (a chamber attached to an inhaler; Fig. 33-7) can be
helpful in this situation. Spacers provide a reservoir for the aer-
osol medication. As the client takes additional breaths, he or she
continues to inhale the medication held in the reservoir. This
tends to maximize drug absorption because it prevents drug
loss. Some clients also find that prolonging inhalation of the
drug reduces side effects such as tachycardia or tremulousness.
Some clients, such as infants, young children, and older FIGURE 33-8 A nebulizer consists of a cup to which liquid
adults, who have difculty
fi coordinating inspiration with the medication is added, a mouthpiece, and tubing that connects
use of a hand held inhaler, may use a nebulizer as an alternativeto an electric or a battery-operated source for compressed air.
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N U R S I N G C A R E P L A N 3 3 - 1 Ineffective Breathing Patterns

Assessment • Establish if the client feels comfortable or anxious with regard
• Count the client’s respiratory rate for a full minute. to breathing.
• Observe the client’s pattern of respirations such as effort, • Measure the client’s hemoglobin saturation with a pulse oximeter.
nasal or mouth breathing, position used to enhance breathing, • Determine techniques the client uses to restore quiet, effortless
and use of accessory muscles. breathing.
Nursing Diagnosis. Ineffective Breathing Patterns related to an improper technique using metered-dose inhaler to manage
shortness of breath and mild hypoxemia associated with underlying lung disease as manifested by the client’s statement, “I struggle
to breathe and my chest gets tight even though I use the inhaler my doctor gave me 2 days ago.”
Expected Outcome. The client’s breathing pattern will be effective as evidenced by quiet, effortless breathing at a respiratory rate
between 16 and 28 breaths per minute with the correct use of the metered-dose inhaler.
Re-demonstrate the correct use of a metered-dose inhaler. Visual and verbal techniques enhance learning.
Observe the client’s technique when using the metered-dose Observation provides a means for evaluating the client’s level
inhaler at least four times after demonstration. of understanding.
Monitor the client’s SpO2 with a pulse oximeter before and Results will help to evaluate the client’s technique using a
after the use of the metered-dose inhaler. metered-dose inhaler and the drug’s effectiveness.

• The client is shown how to use a metered-dose inhaler. • Breathing changes from 32 breaths per minute with effort and
• The client has been observed to perform the technique appro- an SpO2 of 88% to 28 quiet breaths per minute and an SpO2 of
priately with each of the two puffs from the inhaler. 90% within 15 minutes of using the inhaler.
Nursing Care Plan 33-1 shows how nurses use the steps 2. Which instruction is best when teaching a client
of the nursing process when managing the care of a client about inserting vaginal medication?
with the diagnosis of Ineffective Breathing Patterns, defined 1. Place the applicator just inside the vaginal opening.
in the NANDA-I taxonomy (2012, p. 233) as “inspiration 2. Insert the applicator while sitting on the toilet.
and/or expiration that does not provide adequate ventilation.” 3. Instill the medication just before retiring for sleep.
4. Don disposable gloves before applying the drug.
CRITICAL THINKING EXERCISES 3. What is the best technique for the nurse to use when
instilling eye drops?
1. Before discharge from the hospital, a client who has 1. Drop the medication onto the cornea.
had a heart attack says, “You nurses always put my 2. Drop the medication at the inner canthus.
nitroglycerin patches on my back. How can I do that 3. Drop the medication at the outer canthus.
when I have to do it myself?” How would you respond? 4. Drop the medication in the conjunctival sac.
2. How might you help a client who is legally blind and 4. What is the most appropriate nursing action before
lives alone identify two different containers of eye instilling ear drops?
medication? 1. Ensure that the medication is room temperature.
3. How can a nurse prevent eye drops from rolling down 2. Refrigerate the medication for 30 minutes.
a client’s cheek? 3. Clean the outer surface of the dropper.
4. What questions would be important to ask if a client’s 4. Fill the dropper with no more than 1 mL.
symptoms persist after being treated for a vaginal infec- 5. After instilling medication within an ear, what
tion with a regimen of self-administered medication? instruction is most appropriate for the nurse to give
to the client?
NCLEX-STYLE REVIEW QUESTIONS 1. Remain in position for at least 5 minutes.
2. Pack a cotton pledget tightly in the ear.
1. Which body position is best for the nurse to identify 3. Do not blow your nose for at least 1 hour.
when teaching a client how to self-administer nose 4. Avoid drinking very warm or cold beverages.
drops?
1. Bend the head forward
2. Push the nose laterally
3. Tilt the head backward
4. Open the mouth wide
LWBK1004-C33_p751-761.indd 758 04/02/12 3:24 PM

SKILL 33-1 Instilling Eye Medications
ASSESSMENT
PLANNING
Plan to administer medications within 30–60 min of their Demonstrates timely administration and compliance with the
Allow sufficient time to prepare medications in a location with Promotes the safe preparation of drugs.
Warm eye drops and ointments by holding the container between Promotes comfort.
the hands if they have not been stored at room temperature.
IMPLEMENTATION
Wash your hands or perform an alcohol-based hand rub Removes colonizing microorganisms.
(see Chap. 10).
Identify the client using at least two methods, for example, Ensures that medications are given to the right client; complies
checking the wristband and asking the client’s name. with the National Patient Safety Goals.
Position the client supine or sitting with the head tilted back and Prevents the drug from passing into the nasolacrimal duct or
slightly to the side into which the medication will be instilled. being blinked onto the cheek.
Don clean gloves. Acts as a barrier to pathogens in body fluids.
Clean the lids and lashes if they contain debris. Use a cotton ball Promotes comfort and maximizes the potential for absorption.
or tissue moistened with water.
Wipe the eye from the corner by the nose, called the “inner Moves debris away from the nasolacrimal duct.
canthus,” toward the corner near the temple, called the “outer
canthus.”
Instruct the client to look toward the ceiling. Prevents looking directly at the applicator, which usually causes a
blinking reflex as it comes close to the eye.
Make a pouch in the lower lid by pulling the skin downward over Provides a natural reservoir for depositing liquid medication.
the bony orbit.
Move the container of medication from below the client’s line of Prevents a blink reflex.
vision or from the side of the eye.
Steady the container above the location for instillation without Prevents injury.
touching the eye surface.
Instill the prescribed number of drops into the appropriate eye Complies with the medical order by administering the right dose.
within the conjunctival pouch (Fig. A).
Instilling eye drops.
A
(continued)
LWBK1004-C33_p751-761.indd 759 20/02/12 1:09 PM

Instilling Eye Medications (continued)
If using ointment, squeeze a ribbon onto the lower lid margin Applies the ointment to the conjunctiva.
(Fig. B).
Instilling eye ointment.
B
Instruct the client to close the eyelids gently then blink several Distributes the drug.
times.
Wipe the eyes with a clean tissue. Removes excess drug and promotes comfort.
Evaluation
• The tip of the container remains uncontaminated.
• A sufficient amount of the drug is distributed within the eye.
Document
• Assessment data
Date and Time Prescribed eye medication instilled into L. eye before cataract surgery (see MAR). Conjunctiva appears
pink and intact. Lens is opaque. Eyelashes have been clipped. ____________________ SIGNATURE/TITLE
SKILL 33-2 Administering Nasal Medications
ASSESSMENT
effects, contraindications, and administration information. knowledge of the drug.
PLANNING
Plan to administer medications within 30–60 min of their Demonstrates timely administration and compliance with the
Allow sufficient time to prepare the medications in a location with Promotes the safe preparation of drugs.
(continued)
LWBK1004-C33_p751-761.indd 760 04/02/12 3:24 PM

Administering Nasal Medications (continued)
IMPLEMENTATION
Chap. 10).
Identify the client using at least two methods, for example, Ensures that medications are given to the right client; complies
checking the wristband and asking the client’s name with the National Patient Safety Goals.
Help the client to a sitting or lying position with his or her head Facilitates depositing the drug where its effect is desired.
tilted backward or to the side if the drug needs to reach one or
the other sinuses.
Place a rolled towel or pillow beneath the neck if the client cannot Provides support and aids in positioning.
sit.
Remove the cap from the liquid medication to which a dropper Provides a means for administering the drug.
usually is attached.
Aim the tip of the dropper toward the nasal passage and squeeze Deposits the drug within the nose rather than into the throat and
the rubber portion of the cap to administer the number of drops ensures administering the right dose.
prescribed (Fig. A).
Instilling nasal medication.
Instruct the client to breathe through the mouth as the drops are Prevents inhaling large droplets.
instilled.
If the drug is in a spray form, place the tip of the container just Confines the spray within the nasal passage.
inside the nostril.
Occlude the opposite nostril. Administers medication to one and then the other nasal passage.
Instruct the client to inhale as the container is squeezed. Distributes the aerosol.
Repeat in the opposite nostril. Deposits the drug bilaterally for maximum effect.
Advise the client to remain in position for approximately Promotes local absorption.
5 min.
Recap the container and replace it where the medications are Supports the principles of asepsis and demonstrates responsibil-
stored. ity for the client’s property.
Evaluation
• A sufficient amount of the drug is distributed within the nose.
• The client reports decreased nasal congestion.
Document
• Assessment data
Date and Time Indicates nasal passages are congested. Observed to be breathing through the mouth. Nasal medication
administered (see MAR). States symptoms are relieved. ___________________________ SIGNATURE/TITLE
LWBK1004-C33_p751-761.indd 761 04/02/12 3:24 PM

34 Parenteral
Medications
ampule
barrel
deltoid site 1. Name three parts of a syringe.
dorsogluteal site 2. List five factors to consider when selecting a syringe and
gauge needle.
induration 3. Explain the rationale for redesigning conventional syringes
insulin syringe and needles.
intradermal injection 4. Name three ways that pharmaceutical companies prepare
intramuscular injection parenteral drugs.
intravenous injection 5. Discuss an appropriate action before combining two drugs in
lipoatrophy a single syringe.
lipohypertrophy 6. List four injection routes.
parenteral route 7. Identify common sites for intradermal, subcutaneous, and
plunger intramuscular injections.
prefilled cartridge 8. Name a type of syringe commonly used to administer an
reconstitution intradermal, subcutaneous, and intramuscular injection.
rectus femoris site 9. Describe the angles of entry for intradermal, subcutaneous,
scoop method and intramuscular injections.
shaft 10. Discuss why most insulin combinations must be administered
subcutaneous injection within 15 minutes of being mixed.
tip 11. Describe two techniques for preventing bruising when
tuberculin syringe administering heparin subcutaneously.
vastus lateralis site
ventrogluteal site
T
he parenteral route means a route of drug administration other
vial
wheal than oral or through the gastrointestinal tract. This term is com-
Z-track technique monly used when referring to medications given by injection. This
chapter discusses techniques for administering injections. The
preparation and administration of injections follow the principles of
asepsis and infection control.
■ Age-related changes and possible chronic diseases may impair the

older person’s ability to absorb and metabolize medications. A lower
dose of parenteral medications may be indicated to prevent adverse
effects.
■ An assessment of an adverse drug effect should be considered when
any change in mental status or behavior coincides with the administra-
tion of a new medication, regardless of the route of administration.
PARENTERAL ADMINISTRATION
EQUIPMENT
The major equipment used to administer parenteral drugs consists of a

syringe and a needle. Numerous types of syringes and needles are available.
762
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CHAPTER 34 Parenteral Medications 763
FIGURE 34-1 The parts of a syringe.
Syringes
All syringes contain a barrel (the part of the syringe that
holds the medication), a plunger (the part of the syringe
within the barrel that moves back and forth to withdraw
and instill the medication), and a tip or hub (the part of the A B
syringe to which the needle is attached; Fig. 34-1). Syringes FIGURE 34-2 Safety injection devices. A. A syringe with a cir-
are calibrated in milliliters (mL) or cubic centimeters (cc), cular sleeve that covers the needle. B. A syringe with an articu-
lated levered shield that glides over the needle after it is used.
and units (U).
Some syringes may still identify calibrations in minims
(m), a measurement that is no longer used. When drugs are
Modified Safety Injection Equipment
administered parenterally, syringes that hold 1 mL, or its equiv-
Conventional syringes and needles are being redesigned to
alent in units, and up to 3 to 5 mL are used most commonly.
avoid needlestick injuries and, thus, to reduce the risk of
acquiring a blood-borne viral disease such as hepatitis or
Needles
AIDS. Currently, there are three different safety injection
Needles are supplied in various lengths and gauges. The
devices: (1) those with plastic shields that cover the needle
shaft (the length of the needle) depends on the depth to
after its use (Fig. 34-2), (2) those with needles that retract into
which the medication will be instilled. Needle lengths vary
the syringe, and (3) gas-pressured devices that inject medica-
from approximately 1⁄2 to 21⁄2 in. The tip of the shaft is bev-
tions without needles. Most health agencies already are using
eled, or slanted, to pierce the skin more easily (see Skill
one or several types of modified equipment to enclose or cover
16-3, Starting an Intravenous Infusion). Filter needles that
the needle. Some syringes contain blunt substitutes for needles
provide a barrier for glass particles are available when with-
that can pierce laser-cut rubber ports. Twenty-one states now
drawing medication from a glass ampule. Ampules are dis-
require safety needles or needleless devices for administering
cussed later in this chapter.
medications and withdrawing bodily fluids since California
The needle gauge (diameter) refers to its width. For most
enacted legislation for using safer needles in 1998 (National
injections, 18- to 27-gauge needles are used; the smaller the
Institute for Occupational Safety and Health, 2009).
number, the larger the diameter. For example, an 18-gauge
If modified safety injection devices are not available,
needle is wider than a 27-gauge needle. A wider diameter
two techniques are used with standard equipment to prevent
provides a larger lumen, or opening, through which drugs are
needlestick injuries. Before administering an injection, the pro-
administered into the tissue.
tective cap covering a needle is replaced by using the scoop
Several factors are considered when selecting a syringe
method (the technique of threading the needle within the
and needle:
cap without touching the cap itself; Fig. 34-3). After admin-
• The type of medication istering an injection, the needle is left uncapped and depos-
• The depth of tissue ited in the nearest biohazard container, which is usually at
• The volume of prescribed drug the client’s bedside.
• The viscosity of the drug Should an accidental injury occur, health care workers
• The size of the client should follow these recommendations:
Table 34-1 lists common sizes of syringes and needles • Report the injury to a supervisor.
used for various types of injections. • Document the injury in writing.
TABLE 34-1 Common Sizes of Syringes and Needles

TYPE OF INJECTION SIZES OF SYRINGES SIZES OF NEEDLES
Intradermal (tuberculin) 1 mL calibrated in 0.01 mL or in minims 25, 26, or 27 gauge, ½- to 5⁄8-in.
Subcutaneous 1, 2, 2.5, or 3 mL calibrated in 0.1 mL 23, 25, or 26 gauge, ½- or 5⁄8-in.
Insulin, given subcutaneously 1 mL calibrated in units 25, 2, or 27 gauge, ½- or 5⁄8-in.
Intramuscular 3 or 5 mL calibrated in 0.2 mL 20, 21, 22, or 23 gauge, 1½- or 2-in.
LWBK1004-C34_p762-782.indd 763 20/02/12 1:08 PM

FIGURE 34-3 The scoop method for covering a needle. (Photo

by B. Proud.)
FIGURE 34-4 An ampule, a vial, and a prefilled cartridge.
• Identify the client if possible.
• Obtain HIV and hepatitis B virus client status results, if it
is legal to do so. Ampules
• Obtain counseling on the potential for infection. An ampule (a sealed glass drug container) must be broken
• Receive the most appropriate postexposure drug treatment to withdraw the medication (see Nursing Guidelines 34-1
prophylaxis. and Fig. 34-5).
• Be tested for the presence of antibodies at appropriate
intervals. Vials
• Monitor for potential symptoms and obtain a medical A vial (a glass or plastic container of parenteral medication
follow-up. with a self-sealing rubber stopper) must be pierced with a
needle or a needleless adapter to remove medication. The
amount of drug in a vial may be enough for one or multiple
DRUG PREPARATION doses. Any unused drug is dated before it is stored for future
use (see Nursing Guidelines 34-2 and Fig. 34-6).
Drug preparation involves withdrawing medication from an Usually, drugs in vials are in liquid form, but sometimes
ampule or vial or assembling a prefilled syringe cartridge they are supplied as powders that must be dissolved. Recon-
(Fig. 34-4). stitution (the process of adding liquid, known as diluent,

Rationales
Withdrawing Medication from an Ampule
• Select an appropriate syringe and filter needle. Proper • Remove the needle from the ampule when the volume has
equipment ensures appropriate drug administration and been withdrawn. This prepares for drug administration.
prevents aspirating glass particles within the barrel of the • Tap the barrel of the syringe near the hub. Tapping moves air
syringe. toward the needle.
• Tap the top of the ampule. Tapping distributes all the medica- • Push carefully on the plunger. Pushing expels air or excess
tion to the lower portion of the ampule. medication.
• Protect your thumb and fingers with a gauze square or alcohol • Empty the unused portion of medication from the syringe.
swab. These devices reduce the potential for injury. Doing so prevents illegal drug use.
• Snap the neck of the ampule away from your body. Doing so • Discard the glass ampule in a puncture-resistant container.
avoids accidental injury. Proper disposal prevents accidental injury.
• Insert the filter needle into the ampule. Avoid touching the • Remove the filter needle and attach a sterile needle for admin-
outside of the ampule. These methods ensure sterility of the istering the injection. These techniques prevent injecting glass
needle. particles into the client.
• Invert the ampule (see Fig. 34-5). Inversion facilitates with- • Scoop the needle within its protective cap or extend a guard
drawing the medication. that recesses the needle. These measures reduce the risk of a
• Pull back on the plunger. This step fills the syringe. needlestick injury.
LWBK1004-C34_p762-782.indd 764 20/02/12 1:08 PM

FIGURE 34-6 Withdrawing the drug from a vial.
FIGURE 34-5 Withdrawing the drug from an ampule.

several options in diluent volumes, the preparer also writes
the amount on the vial.
to a powdered substance) is done before administering the
drug parenterally. Common diluents for injectable drugs arePrefilled Cartridges
sterile water or sterile normal saline. Reconstituting a drugPharmaceutical companies supply some drugs in alled prefi
just before it is needed ensures maximum potency. When cartridge (a sealed glass cylinder of parenteral medication).
reconstitution is necessary, the drug label lists the following:The cartridge comes with an attached needle. The cylinder is
made so that it fits in a specially designed syringe (Fig. 34-7).
• The typeof diluent to use
• The amount of diluent to add
Combining Medications in One Syringe
• The dosage per volume after reconstitution
Sometimes it is necessary or appropriate to combine more
• Directions for storing the drug
than one drug in a single syringe. Exact amounts must be
If the medication will be used for more than one adminis-withdrawn from each drug container because once the drugs
are in the barrel of the syringe, there is no way to expel one
tration, the preparer writes the date and time on the vial label
and initials it. In some cases, when the directions provide without expelling some of the other (see section on Mixing

Rationales
Withdrawing Medication from a Vial
• Select an appropriate syringe and needle. The correct equip- • Remove the needle or adaptor when the desired volume has
ment ensures appropriate drug administration. entered the barrel of the syringe. Doing so leaves the remain-
• Remove the metal cover from the rubber stopper. This step ing drug for additional administrations.
facilitates inserting the needle or needleless adaptor. • If the medication is a controlled substance such as a narcotic,
• Clean a preopened vial with an alcohol swab. Alcohol swabs aspirate the entire contents from the vial. Full aspiration pre-
remove colonizing microorganisms. vents illegal drug use.
• Fill the syringe with a volume of air equal to the volume that • Discard any excess medication; if the drug is a narcotic, have
will be withdrawn from the vial. This step provides a means someone witness this action. These measures comply with
for increasing pressure within the vial. federal laws to prevent illegal drug use.
• Pierce the rubber stopper with the needle or tip of a needleless• Cover the needle or needleless adaptor and care for the
syringe and instill the air. Doing so facilitates the withdrawal used supplies as described in the guidelines for withdraw-
of the drug. ing from an ampule.Nurses follow aseptic and safety
• Invert the vial, hold, and brace it while pulling on the plunger principles.
(see Fig. 34-6). This step locates medication near the tip of the • Date and initial the vial if the remaining drug will be used in
needle or needleless adaptor to facilitate its withdrawal. the near future. Doing so supports the principles of asepsis.
LWBK1004-C34_p762-782.indd 765 04/02/12 3:27 PM

FIGURE 34-7 Inserting a prefilled cartridge. (Photo by B. Proud.)
Insulins). Before mixing any drugs, however, the nurse con-

sults a drug reference or compatibility chart because some
drugs interact chemically when combined. The chemical
reaction often causes formation of a precipitate.
INJECTION ROUTES
There are four injection routes for parenteral administra-

tion: intradermal injections (injections between the layers
of the skin), subcutaneous injections (injections beneath
the skin but above the muscle), intramuscular injections
(injections in muscle tissue), and intravenous injections
(injections instilled into veins; Fig. 34-8). Each site requires FIGURE 34-9 A tuberculin syringe.
a slightly different injection technique. Intravenous medica-
tion administration is discussed in Chapter 35.
Injection Equipment
Intradermal Injections A tuberculin syringe holds 1 mL of fluid and is calibrated
Intradermal injections are commonly used for diagnostic in 0.01-mL increments (Fig. 34-9). It is used to administer
purposes. Examples include tuberculin tests and allergy test- intradermal injections. A 25- to 27-gauge needle measuring
ing. Small volumes, usually 0.01 to 0.05 mL, are injected a half-inch in length is commonly used when administering
because of the small tissue space. an intradermal injection.
Injection Sites Injection Technique

A common site for an intradermal injection is the inner When giving an intradermal injection, the nurse instills the
aspect of the forearm. Other areas that may be used are the medication shallowly at a 10- to 15-degree angle of entry
back and upper chest. (Skill 34-1).
FIGURE 34-8 Injection routes: intradermal (A), subcutaneous (B), intramuscular and subcuta-
neous in other than thin persons (C), and intravenous (D).
LWBK1004-C34_p762-782.indd 766 04/02/12 3:27 PM

➧ Stop, Think, and Respond Box 34-1 Pharmacologic Considerations

What actions are appropriate if the client shows
signs of an allergic reaction to an agent given ■ Insulin is absorbed at a more consistent rate from one
intradermally? injection to the next when the abdominal site is used.
Exercising an arm or leg after an injection can increase
blood flow and hasten insulin absorption from those areas
Subcutaneous Injections (Diabetes Self-Management, 2006).
A subcutaneous injection is administered more deeply than
an intradermal injection. Medication is instilled between the
skin and muscle and absorbed fairly rapidly: the medication Rotating within one injection site, preferably the abdo-
usually begins acting within 15 to 30 minutes of administra- men, is recommended rather than rotating to a different area
tion. The volume of a subcutaneous injection is usually up to with each injection (American Diabetes Association, 2007).
1 mL. The subcutaneous route is commonly used to admin- Injection sites are rotated a finger’s width apart (about 1 in.)
ister insulin and heparin. from a previous site to avoid repeatedly injecting into the
same area in a short amount of time. Rotating sites avoids
Injection Sites tissue injury. The rate of drug absorption at various subcu-
The preferred site for giving a subcutaneous injection of taneous sites from fastest to slowest is the abdomen, arms,
insulin and heparin is the abdomen. When using the abdo- thighs, and upper buttocks.
men, avoid a 2-in. central area around the umbilicus. Addi-
tional or alternative injection sites for insulin are the outer Injection Equipment
back area of the upper arm, where it is fleshier, and the outer Equipment used for a subcutaneous injection may depend
areas of the thigh and upper buttocks. Subcutaneous injec- on the type of medication prescribed. Insulin is prepared in
tion sites are shown in Figure 34-10. an insulin syringe (see section on Administering Insulin).
FIGURE 34-10 Subcutaneous injec-

tion sites.
LWBK1004-C34_p762-782.indd 767 04/02/12 3:27 PM

0.5'' 0.625''
needle
FIGURE 34-11 Angles and needle lengths for subcutaneous

injections.
Heparin is prepared in a tuberculin syringe, or it may be

supplied in a prefilled cartridge. A 25-gauge needle is used
most often because medications administered subcutane-
ously usually are not viscous. Needle lengths may vary from
½ to 5⁄8 in.
Injection Technique
To reach subcutaneous tissue in a normal-sized or obese per-
son who has a 2-in. tissue fold when it is bunched, the nurse
inserts the needle at a 90-degree angle. For thin clients who FIGURE 34-12 Low-dose and standard insulin syringes.
have a 1-in. fold of tissue, the nurse inserts the needle at a
45-degree angle (Fig. 34-11). Skill 34-2 describes the tech-
nique for administering a subcutaneous injection. cial syringe called an insulin syringe (a syringe calibrated in
units) is used. Various insulin syringes hold volumes of 0.3,
0.5, and 1 mL. The standard dosage strength of insulin is
Pharmacologic Considerations 100 U/mL. Typically, low-dose insulin syringes are used to
deliver insulin dosages of 30 to 50 U or less. A standard insu-
■ If insulin is injected too deeply and reaches the muscle, lin syringe can administer up to 100 U of insulin (Fig. 34-12).
its absorption is accelerated, which increases the risk of Prefilled pen-like devices that facilitate the repeated
lowering blood sugar below the normal range. If insulin is administration of insulin through a special pen needle are
not injected deeply enough, it may leak from the site, thus also available. Depending on the manufacturer, insulin pens
reducing its effectiveness (Becton, Dickinson, & Company, can be adjusted to provide insulin in doses from 0.5 to 80
2008).
U by dialing the prescribed amount on the pen. The pen
generally holds 1 mL (100 U) of insulin. Only the needle is
The tissue usually is bunched between the thumb and changed with each injection. The insulin in prefilled pens is
fingers before administering the injection to avoid instilling stable for up to 30 days.
insulin within the muscle. Bunching is unnecessary when
injecting insulin with an insulin pen because the needle is
only 5-mm long and unlikely to enter a muscle. Gerontologic Considerations
Administering Insulin ■ Older clients with diabetes often have visual problems
Insulin is a hormone required by some clients with diabetes. interfering with their ability to fill their own syringe. They
The most common route of administration is by subcutane- are candidates for using an insulin pen or a loading
ous or intravenous injection. Injectable insulin is supplied gauge that prevents filling a syringe with more than the
and prescribed in a dosage strength called units (U); a spe- prescribed dose. Sight centers are a good resource for
LWBK1004-C34_p762-782.indd 768 20/02/12 3:22 PM

obtaining assistive devices to facilitate self-administration Preparing Insulin

of insulin. Types of insulin vary in their onset, peak effect, and dura-
■ Older adults learning to administer insulin may benefit tion of action. The nurse must read the vial labels carefully
from a referral for skilled nursing or diabetic health educa- because they look similar.
tion following discharge. Health insurance companies Some preparations of insulin contain an additive that
sometimes reimburse such services.
delays its absorption. Insulin and the additive tend to sep-
arate on standing. Therefore, when preparing other than
rapid-acting and short-acting insulin or the long-acting insu-
lin glargine (Lantus), the nurse rotates the vial between the
palms to redistribute the additive and insulin before filling
■ Containers of insulin are refrigerated until they are
the syringe.
opened; thereafter, they are stored at room temperature.
■ Some experts recommend leaving the needle in place fol- Mixing Insulins
lowing the injection of insulin for 5 to 10 seconds to ensure When mixed together, insulins tend to bind and become
that all the insulin is within the injection site and will not be equilibrated. This means that the unique characteristics of
lost due to leakage from the skin (Samuels, 2009; Wolfe, each are offset by those of the other. For this reason, most
2006). types of insulin are combined just before administration.
■ The needle on an insulin pen should be removed imme- When injected within 15 minutes of being combined, they
diately after use. If left in place, air bubbles may enter the act as if they had been injected separately. Rapid-acting insu-
syringe and reduce the next dose. lin and short-acting insulin, which are additive free, are often
combined with an intermediate-acting insulin. The long-act-
Clients who require insulin receive one or more daily ing insulin, glargine, is never mixed with any other type of
injections. Over time, the injection sites tend to undergo insulin (see Nursing Guidelines 34-3 and Fig. 34-13).
changes that interfere with insulin absorption. To avoid Pharmaceutical companies provide some combinations
lipoatrophy (the breakdown of subcutaneous fat at the site of insulin premixed in a single vial. Novolin 70/30 contains
of repeated insulin injections) and lipohypertrophy (the 70% of an intermediate-acting insulin and 30% of a short-
thickening of subcutaneous fat at the site of repeated insu- acting insulin. Humulin 50/50 contains equal amounts of
lin injections), the sites are rotated each time an injection intermediate-acting and short-acting insulin. Commercially
is administered. premixed insulins are stable and can be administered without
concern for time after withdrawal from the vial.
➧ Stop, Think, and Respond Box 34-2 Administering Heparin
In addition to documenting the site of an insulin Heparin is an anticoagulant drug, meaning that it prolongs
injection, discuss additional techniques for ensuring the time it takes for blood to clot. Heparin frequently is
a rotation of sites with each subsequent injection. administered subcutaneously as well as intravenously. Its

Rationales
Mixing Insulins
• Roll the vial of insulin containing an additive between the • Ask another nurse to check the label on the insulin and the
palms. Rolling between the palms mixes the insulin without number of units in the syringe. An additional check helps to
damaging the protein molecules. prevent a medication error.
• Cleanse the rubber stoppers of both vials of insulin. Cleaning • Swab the rubber stopper of the other vial and pierce it with
removes colonizing microorganisms. the needle of the partially filled syringe. This step facilitates
• Instill an amount of air equal to the volume that will be with- withdrawing the other type of insulin.
drawn from the vial containing the insulin with the additive. • Withdraw the specified number of units from the vial contain-
Do not insert the needle into the insulin itself (see Fig. 34-13A, ing the insulin with the additive. Doing so prepares the full
B). These measures avoid coating the needle. prescribed dose.
• Withdraw the needle and use the same syringe to repeat the • Ask another nurse to check the label on the insulin and the
previous step, but this time invert and withdraw the prescribed number of units in the syringe. This step prevents a medication
number of additive-free insulin units (see Fig. 34-13C). Clear error.
insulin is always placed in the syringe before adding the • Administer within 15 minutes of mixing. Prompt administra-
cloudy insulin to avoid altering the additive-free insulin within tion avoids equilibration.
the vial.
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Vial B Vial A
Vial B Vial A
A B
Vial B
FIGURE 34-13 Mixing insulin. A. Instilling air into a vial with

C additive insulin. B. Instilling air into the additive free insulin.
C. Withdrawing from an additive-free insulin vial.
unique characteristics require special techniques when using route of administration. The dose is determined after report-
the subcutaneous route for administration. ing laboratory test results of the client’s partial thrombo-
Heparin is supplied in multiple-dose vials or prefilled plastin time to the physician.
cartridges. The dosages are very small volumes that may ■ Some clients are prescribed one of several low-molecular
weight heparins (LMWH) such as enoxaparin (Lovenox).
require a tuberculin syringe to ensure accuracy. The nurse
LMWH has the advantage of being prescribed in a consistent
removes the needle after withdrawal of the drug from
daily dose with no or fewer required anticoagulation blood
a multidose vial and replaces it with another before tests, less risk for side effects than standard heparin, and it
administration. can be self-administered outside the hospital.
Certain modifications are necessary for the preven-
tion of bruising in the area of the injection. The nurse
changes the needle after filling the syringe with the dose
of heparin, that is, before injecting the client. He or she Intramuscular Injections
rotates the sites with each injection to avoid a previ- An intramuscular injection is the administration of up to
ous area where there has been local bleeding. The nurse 3 mL of medication into one muscle or muscle group. Because
does not aspirate the plunger once the needle is in place. deep muscles have few nerve endings, irritating medications
Massaging the site is contraindicated because this can commonly are given intramuscularly. Except for medica-
increase the tendency for local bleeding. tions injected directly into the bloodstream, absorption from
an intramuscular injection occurs more rapidly than from
the other parenteral routes. Injections should not be admin-
Pharmacologic Considerations istered into limbs that are paralyzed, inactive, or affected by
poor circulation. If an older client has had a mastectomy or
■ The dose of unfractionated (standard) heparin may has a vascular site for hemodialysis, the arm on the affected
change on a daily or even hourly basis depending on the side should be avoided, if possible.
LWBK1004-C34_p762-782.indd 770 04/02/12 3:27 PM

Greater trochanter of the femur

(not illustrated) Superior gluteal artery
Gluteus maximus Gluteus medius
Sciatic nerves
Posterior-superior iliac spine
FIGURE 34-14 The dorsogluteal site.

(Courtesy of Wyeth Laboratories,
Philadelphia, PA.)
Injection Sites can result. To locate the appropriate landmarks, perform the
The five common intramuscular injection sites are named for following (Fig. 34-14):
the muscles into which the medications are injected: the dor-
• Divide the buttock into four imaginary quadrants.
sogluteal, the ventrogluteal, the vastus lateralis, the rectus
• Palpate the posterior iliac spine and the greater trochanter.
femoris, and the deltoid.
• Draw an imaginary diagonal line between the two land-
Dorsogluteal Site marks.
The dorsogluteal site is the upper outer quadrant of the but- • Insert the needle superiorly and laterally to the midpoint of
tocks. The primary muscle in this site is the gluteus max- the diagonal line.
imus, which is large and therefore can hold a fair amount of
injected medication with minimal postinjection discomfort. Ventrogluteal Site
This site is avoided in clients younger than 3 years of age The ventrogluteal site uses the gluteus medius and glu-
because this muscle is not yet sufficiently developed. teus minimus muscles in the hip for injection. This site
If the dorsogluteal site is not identified correctly, dam- has several advantages over the dorsogluteal site: it has no
age to the sciatic nerve with subsequent paralysis of the leg large nerves or blood vessels, and it is usually less fatty and
Ventrogluteal area Anterior-superior Iliac crest

(in triangle) iliac spine (not illustrated)
FIGURE 34-15 The ventrogluteal site. (Courtesy Greater trochanter of Posterior edge iliac crest
of Wyeth Laboratories, Philadelphia, PA.) the femur
LWBK1004-C34_p762-782.indd 771 04/02/12 3:27 PM

A B
FIGURE 34-16 A. Locating the vastus lateralis muscle. B. Spreading the skin at the vastus late-
ralis site and darting the tissue. (Photo by B. Proud.)
cleaner because fecal contamination is rare at this site. This clients who are thin or debilitated with poorly developed glu-
is the favored injection site for adults, but it is also safe for teal muscles.
use in children. Its main disadvantage is that there is only a The nurse locates the vastus lateralis site by placing one
small area for administering the injection (Hunt, 2008). hand above the knee and one hand just below the greater
To locate the ventrogluteal site: trochanter at the top of the thigh. He or she then inserts the
needle into the lateral area of the thigh (Fig. 34-16).
• Place the palm of the hand on the greater trochanter
and the index finger on the anterior-superior iliac spine Rectus Femoris Site
(Fig. 34-15). The rectus femoris site is in the anterior aspect of the thigh.
• Move the middle finger away from the index finger as far This site may be used for infants. The nurse places an injec-
as possible along the iliac crest. tion in this site in the middle third of the thigh, with the client
• Inject into the center of the triangle formed by the index sitting or supine (Fig. 34-17).
finger, the middle finger, and the iliac crest.
Vastus Lateralis Site Deltoid Site

The vastus lateralis site uses the vastus lateralis muscle— The deltoid site, in the lateral aspect of the upper arm
one of the muscles in the quadriceps group of the outer thigh. (Fig. 34-18), is the least used intramuscular injection site
Large nerves and blood vessels usually are absent in this because it is a smaller muscle than the others. It is used
area, which makes it safer. It is a particularly desirable site only for adults because the muscle is not sufficiently devel-
for administering injections to infants and small children and oped in infants and children. Because of its small capacity,
FIGURE 34-17 The location of the rectus femoris injection site.

(Craven, R.F., & Hirnle, C.J. [2009]. Fundamentals of nursing
[6th ed., p 530]. Philadelphia: Lippincott Williams & Wilkins.) FIGURE 34-18 The deltoid site.
LWBK1004-C34_p762-782.indd 772 04/02/12 3:27 PM

intramuscular injections into this site are limited to 1 mL impaired mobility. The dorsogluteal site should be avoided
of solution. because of the risk for damage to the sciatic nerve with
There is a risk of damaging the radial nerve and diminished musculature.
artery if the deltoid site is not well identified. To use this
site safely:
Injection Equipment
• Have the client lie down, sit, or stand with the shoulder Generally, 3- to 5-mL syringes are used to administer medi-
well exposed. cations by the intramuscular route. A 22-gauge needle that is
• Palpate the lower edge of the acromion process. 11⁄2 to 2 in. long is usually adequate for depositing medica-
• Draw an imaginary line at the axilla. tion in most sites.
• Inject in the area between these two landmarks. Injection Technique
When administering intramuscular injections, nurses use a
90-degree angle for piercing the skin (Skill 34-3). Nurses
may administer drugs that may be irritating to the upper
levels of tissue by the Z-track technique (a technique for
manipulating the tissue to seal a medication, especially an
■ Selection and identification of injection site landmarks
irritant, in the muscle). Sometimes called the zigzag tech-
may be difficult when working with older adults experienc-
ing dementia or musculoskeletal deformities such as con- nique, the maneuver resembles the letter Z (see Nursing
tractures. Assistance from a second person to maintain the Guidelines 34-4 and Fig. 34-19).
required position for an injection may be helpful. An expla- Nurses can give any intramuscular injection by the
nation of what will be done is always indicated before the Z-track technique. Clients report slightly less pain during
intervention. The second person may be able to assist with and the next day after a Z-track injection compared with the
providing comfort. usual intramuscular injection technique.
■ If an older person has decreased subcutaneous fat,
pinching the muscular tissue together may be needed to ➧ Stop, Think, and Respond Box 34-3
avoid striking bone when administering an intramuscular
injection. What could occur if parenteral medication intended
■ The deltoid or ventrogluteal muscles may be the pre- for the intramuscular route is instilled into a blood
ferred intramuscular sites for older adults experiencing vessel? How could this be prevented?

Rationales
Giving an Injection by the Z-Track Technique
• Fill the syringe with the prepared drug and then change the needle. • Aspirate for a blood return. Doing so determines whether or
This measure prevents tissue contact with the irritating drug. not the needle is in a blood vessel.
• Attach a needle at least 11⁄2 to 2 in. long. The correct needle • Instill the medication by depressing the plunger with the
length helps to deposit the drug deep within the muscle. thumb. This measure deposits the medication into the
• Add a 0.2-mL bubble of air in the syringe. Air flushes all the muscle.
medication from the syringe during the injection. • Wait 10 seconds with the needle still in place and the skin held
• Select a large muscular injection site such as the ventroglu- taut. This duration provides time to distribute the medication
teal site. A large site provides a location with the capacity for in a larger area.
depositing and absorbing the drug. • Withdraw the needle and immediately release the taut skin.
• Wash your hands and don gloves. These measures reduce the Doing so creates a diagonal path that prevents leaking into
transmission of microorganisms. the subcutaneous and dermal layers of tissue (see
• Use the side of the hand to pull the tissue laterally about 1 in. Fig. 34-19C).
(2.5 cm) until the tissue is taut (see Fig. 34-19A). Taut tissue • Apply pressure, but do not massage the site. This ensures that
creates the mechanism for sealing the drug within the muscle. the medication remains sealed.
• Insert the needle at a 90-degree angle while continuing to hold • Discard the syringe without recapping the needle. Proper
the tissue laterally. Correct placement directs the tip of the disposal reduces the potential for a needlestick injury.
needle well within the muscle. • Remove gloves and wash your hands or perform an alcohol-
• Steady the barrel of the syringe with the fingers and use the based hand rub. These measures reduce the transmission of
thumb to manipulate the plunger (see Fig. 34-19B). These microorganisms.
measures avoid releasing the tissue held taut by the nondomi- • Document the medication administration. Proper recording
nant hand. maintains a current record of client care.
LWBK1004-C34_p762-782.indd 773 20/02/12 1:08 PM

A B C
FIGURE 34-19 A. Stretching the tissue laterally. B. Manipulating the plunger. C. An interrupted
pathway to the sealed medication.
REDUCING INJECTION DISCOMFORT on positioning and relaxation techniques (see Client and
All injections cause discomfort, and some cause more than
others. The nurse can use the following alternative tech-
niques to reduce discomfort associated with injections: Pharmacologic Considerations
• Use the smallest gauge needle that is appropriate. ■ A few products are available that produce anesthesia
• Change the needle before administering a drug that is irri- when applied to the skin or mucous membranes. One
tating to tissue. example is eutectic mixture of local anesthetic (EMLA),
• Select a site that is free of irritation. which reduces or eliminates the local discomfort of inva-
• Rotate injection sites. sive procedures that pierce the skin. It can take 60 to
• Numb the skin with an ice pack before the injection. 120 minutes after application for EMLA cream to take
• Insert and withdraw the needle without hesitation. effect. These time constraints make EMLA impractical
for most situations when time is of the essence in admin-
• Instill the medication slowly and steadily.
istering an injection.
• Use the Z-track technique for intramuscular injections.
• Apply pressure to the site during needle withdrawal.
• Massage the site afterward, if appropriate.
The client also can assist in minimizing the pain
associated with injections. Instructions commonly focus
Nurses who administer parenteral medications may identify
nursing diagnoses as follows:
• Acute Pain
• Anxiety
Client and Family Teaching 34-1 • Fear
Reducing Injection Discomfort
• Risk for Trauma
The nurse teaches the client and the family as follows: • Deficient Knowledge
● Lie prone and point the toes inward when receiving an • Risk for Ineffective Self-Health Management
injection into the dorsogluteal site. Nursing Care Plan 34-1 demonstrates the nursing proc-
● Perform deep breathing and other relaxation techniques
ess for a client with the nursing diagnosis Risk for Ineffective
before receiving an injection.
● Avoid watching when the injection is given.
Self-Health Management, defined in the NANDA-I taxonomy
● Ambulate or move the extremity where the injection was (2012, p. 161) as “a pattern of regulating and integrating into
given as much as possible. daily living a program for treatment of illness and its sequelae
that is unsatisfactory for meeting specific health goals.”
LWBK1004-C34_p762-782.indd 774 04/02/12 3:27 PM

N U R S I N G C A R E P L A N 3 4 - 1 Risk for Ineffective Self-Health Management

Assessment • Explore any health beliefs that may cause conflict in achieving
• Determine the client’s desire to learn about his or her illness. the goals of therapy.
• Assess the client’s ability and interest in managing the disorder. • Inquire about the client’s financial resources for complying
• Review the client’s history for evidence that complications with the health care regimen.
developed from mismanagement of his or her disorder. • Observe the client’s network of significant others and their
• Consider the complexity of self-care skills necessary after the potential for providing physical and emotional support.
client is discharged. • Evaluate the client’s level of understanding of ongoing health
• Identify any problems that may pose a barrier to carrying out teaching throughout the period of nursing care.
a regimen of self-care (eg, dementia, physical weakness, pain,
diminished self-confidence).
Nursing Diagnosis. Risk for Ineffective Self-Health Management related to confusion concerning techniques for balancing
insulin therapy and dietary intake.
Expected Outcome. The client will describe the need to eat food within 30 minutes of an insulin injection and ways to raise
blood glucose levels if symptoms of hypoglycemia develop.
Review onset, peak, and duration of Humulin N insulin each The repetition of information enhances learning.
morning when administering the client’s dose of insulin.
Emphasize that breakfast is required within 30 minutes of Demonstrating a regular pattern between administering insulin
injecting the prescribed dose of insulin. and eating food shortly afterward reinforces learning.
Assist the client with testing his or her own blood glucose Testing capillary blood glucose provides objective evidence of
level before and 2 hours after meals. the relationship between blood glucose levels before and
after eating.
Review the signs and symptoms of low blood glucose level; Providing information and testing the client’s ability to accu-
ask client to recall as many signs and symptoms as possible. rately recall the information measure the client’s learning.
Give the client a list of foods or beverages that can raise Identifying techniques for resolving the problem of low blood
blood glucose levels when signs or symptoms of low blood glucose levels provides the client with options for managing
glucose level occur. self-care.

• Client noted time of insulin administration at 0730 and deliv- • Client named grape juice, orange juice, regular soft drinks, and
ery of breakfast at 0745. LifeSavers as foods or beverages to consume if she experi-
• Client stated, “I will eat a meal within a half hour of giving enced symptoms of low blood glucose levels.
myself my morning insulin.”
• Client observed that blood glucose level was 98 mg/dL before
eating breakfast and increased to 122 mg/dL 2 hours later.
CRITICAL THINKING EXERCISES NCLEX-STYLE REVIEW QUESTIONS

1. How does administration of an intramuscular injection 1. The nurse chooses to inject a prescribed intramuscu-
differ for a 3-year-old client versus a 33-year-old client? lar medication into the dorsogluteal site. If the nurse
2. You are to administer an intramuscular injection to a selects the site correctly, in what location is the injec-
76-year-old client. What factors are important to con- tion administered?
sider before choosing the equipment and injection site? 1. Hip
3. What information would be appropriate for the nurse 2. Arm
to provide to a client who repeatedly administers insulin 3. Thigh
in nearly the exact same location with each injection? 4. Buttock
4. What techniques might a nurse use to avoid injecting
into a muscle when giving a thin client a subcutane-
ous injection?
LWBK1004-C34_p762-782.indd 775 20/02/12 1:08 PM

2. What is a technique that helps reduce discomfort 4. When administering an intradermal tuberculin skin
when giving an intramuscular injection into the dor- test, which angle of needle insertion is correct?
sogluteal site? 1. 180-degree angle
1. Have the client point the toes inward. 2. 90-degree angle
2. Have the client tighten the gluteal muscles. 3. 45-degree angle
3. Have the client cross the legs at the ankles. 4. 10-degree angle
4. Have the client flex the knees. 5. Which of the following actions best indicates that the
3. Just before inserting the needle into the muscle using client needs more practice to combine two insulins,
the Z-track technique, in which direction is the nurse short- and intermediate-acting, before discharge?
correct in pulling the tissue at the injection site? 1. The client rolls the vial of intermediate-acting
1. Laterally insulin to mix it with its additive.
2. Diagonally 2. The client instills air into the short-acting and
3. Downward intermediate-acting insulin vials.
4. Upward 3. The client instills intermediate-acting insulin into
the vial of short-acting insulin.
4. The client inverts each vial before withdrawing the
specified amount of insulin.
LWBK1004-C34_p762-782.indd 776 04/02/12 3:27 PM

SKILL 34-1 Administering Intradermal Injections
ASSESSMENT
Check the medical orders. Collaborates the nursing activities with the medical treatment.
Read and compare the label on the drug with the MAR at least Prevents errors.
three times—before, during, and after preparing the drug.
Check for any documented allergies to food or drugs. Ensures safety.
Determine how much the client understands about the purpose Provides an opportunity for health teaching.
and technique for administering the injection.
PLANNING
Prepare to administer the injection according to the schedule Complies with medical orders.
prescribed.
Obtain clean gloves, a tuberculin syringe, the appropriate Facilitates drug preparation and administration.
needle, and alcohol swabs.
Prepare the syringe with the medication. Fills the syringe with the appropriate volume.
IMPLEMENTATION
Identify the client using at least two methods; for example, Ensures that medications are given to the right client; complies
Select an area on the inner aspect of the forearm, approximately Provides a convenient and easy location for accessing intradermal
a hand’s breadth above the client’s wrist. tissue.
Cleanse the area with an alcohol swab using a circular motion Removes microorganisms following the principles of asepsis.
outward from the site where the needle will pierce the skin.
Allow the skin to dry. Reduces tissue irritation.
Hold the client’s arm and stretch the skin taut. Helps to control the placement of the needle.
Hold the syringe almost parallel to the skin at a 10- to 15-degree Facilitates delivering the drug between the layers of the skin and
angle with the bevel pointing upward.a Then insert the needle advances the needle to the desired depth.
about 1⁄8 in. (Fig. A).
Entering the skin. (Photo by B. Proud.)
A
(continued)
LWBK1004-C34_p762-782.indd 777 04/02/12 3:27 PM

Administering Intradermal Injections (continued)
Push the plunger of the syringe and watch for a small wheal Verifies the correct injection of the drug.
(elevated circle) to appear (Fig. B).
Forming a wheal. (Photo by B. Proud.)
Withdraw the needle at the same angle at which it was Minimizes tissue trauma and discomfort.
inserted.
Do not massage the area after removing the needle. Prevents interfering with test results.
Deposit the uncapped needle and syringe in a puncture- Prevents injury.
resistant container.
Remove gloves and perform hand hygiene. Reduces the risk for the transmission of microorganisms.
Observe the client’s condition for at least the first 30 minutes Ensures that emergency treatment can be quickly administered.
after performing an allergy test.
Observe the area for signs of a local reaction at standard inter- Determines the extent to which the client responds to the
vals such as 24 and 48 hours after the injection. injected substance.
Evaluation
• The injection is administered.
• The client remains free of any untoward effects.
Document
• The date, time, drug, dose, route, and specific site
• Client response
Date and Time Tuberculin skin test administered intradermally in L. forearm with no immediate untoward effects.
Instructed to return in 48 hours for inspection of site. ________________________ SIGNATURE/TITLE
a
One study of a small sample of new learners showed inserting the bevel down decreased bleeding from the site, avoided squirting the
solution into the air, facilitated forming a bleb, and increased the comfort level of clients (Howard et al., 1997).
LWBK1004-C34_p762-782.indd 778 20/02/12 1:08 PM

SKILL 34-2 Administering Subcutaneous Injections
ASSESSMENT
Check for any documented allergies to food or drugs. Ensures safety.
Determine where the last injection was given to ensure site Prevents tissue injury.
rotation.
Inspect the potential injection site for signs of bruising, Indicates injured tissue areas to avoid.
swelling, redness, warmth, or tenderness.
PLANNING
prescribed.
Obtain clean gloves, the appropriate syringe and needle, and Facilitates drug preparation and administration.
alcohol swabs.
Add 0.1–0.2 mL of air to the syringe. Flushes all the medication from the syringe at the time of the
injection.
IMPLEMENTATION
Select and prepare an appropriate site by cleansing it with an Removes colonizing microorganisms.
alcohol swab.
Bunch the skin. Facilitates placement in the subcutaneous level of tissue.
Pierce the skin at a 45-degree (Fig. A) or 90-degree (Fig. B) Facilitates placement in the subcutaneous level of tissue accord-
angle of entry. ing to the length of the needle used and the client’s body
composition.
A B
Entering the tissue at a 45-degree angle. (Photo by B. Proud.) Entering the tissue at a 90-degree angle. (Photo by B. Proud.)
(continued)
LWBK1004-C34_p762-782.indd 779 04/02/12 3:27 PM

Administering Subcutaneous Injections (continued)
Release the tissue once the needle is inserted; use the hand to Steadies the syringe.
support the syringe at its hub.
Do not aspirate. Subcutaneous tissue does not contain major blood vessels, which
negates the need to aspirate, a standard that once was com-
mon practice (Kohn, 2009).
Inject the medication 5 seconds after the needle has been Ensures complete delivery of the insulin.
embedded within the tissue by pushing on the plunger.
Withdraw the needle quickly while applying pressure against Controls bleeding.
the medication site.
Massage the site, unless contraindicated. Promotes absorption and relieves discomfort.
Deposit the uncapped needle and syringe in a puncture-resistant Prevents injury.
container.
Remove gloves; perform hand hygiene. Reduces the transmission of microorganisms.
Assess the client’s condition at least 30 minutes after giving the Aids in evaluating the drug’s effectiveness.
injection.
Evaluation
• The client experiences no untoward effects.
Document
• Site assessment data
Date and Time 10 U of regular insulin administered subcutaneously in 3-o’clock position in abdomen. Site appears
free of redness, swelling, warmth, tenderness, and bruising. Alert and oriented 30 minutes after
injection. ____________________________________________________________________ SIGNATURE/TITLE
a
The administration of drugs usually is documented on the MAR.
SKILL 34-3 Administering Intramuscular Injections
ASSESSMENT
Check for any documented drug allergies. Ensures safety.
Determine where the last injection was given. Prevents tissue injury.
Inspect the potential injection site for signs of bruising, swell- Indicates tissue injury.
ing, redness, warmth, tenderness, or induration (hardness).
PLANNING
prescribed.
Obtain clean gloves, the appropriate syringe and needle, and Facilitates drug preparation and administration.
alcohol swabs.
Add 0.2 mL of air to the syringe. Flushes all the medication from the syringe at the time of the
injection.
(continued)
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Administering Intramuscular Injections (continued)
IMPLEMENTATION
Select and prepare an appropriate site by cleansing it with an Removes colonizing microorganisms.
alcohol swab.
Spread the tissue taut. Facilitates placement in the muscle.
Hold the syringe like a dart and pierce the skin at a 90-degree Reduces discomfort.
angle (Fig. A).
Holding syringe like a dart. (Photo by B. Proud.)
Steady the syringe and aspirate to observe for blood. Determines whether the needle is in a blood vessel; muscular
tissue is more vascular than subcutaneous tissue.
Instill the drug if no blood is apparent. Deposits the drug into the muscle.
Withdraw the needle quickly at the same angle it was inserted Reduces discomfort and controls bleeding.
while applying pressure against the site (Fig. B).
Withdrawing the needle. (Photo by B. Proud.)
(continued)
LWBK1004-C34_p762-782.indd 781 04/02/12 3:27 PM

Administering Intramuscular Injections (continued)
Massage the injection site with the alcohol swab unless con- Distributes the medication and reduces discomfort.
traindicated (Fig. C).
Massaging the site. (Photo by B. Proud.)
Deposit the uncapped needle and syringe in a puncture- Prevents injury.

resistant container.
Remove gloves; perform hand hygiene. Reduces the transmission of microorganisms.
Assess the client’s condition at least 30 minutes after giving the Aids in evaluating the drug’s effectiveness.
injection.
Evaluation
• The client experiences no untoward effects.
Document
• Site assessment data
Date and Time Demerol 50 mg given IM into R. dorsogluteal site for pain rated as No. 8 on a scale of 0–10. No signs of
irritation at the site. Rates pain at No. 5 30 min. after injection. _____________________ SIGNATURE/TITLE
a
The administration of drugs usually is documented on the MAR; p.r.n. drugs may be documented both in the nurse’s notes and in the MAR.
LWBK1004-C34_p762-782.indd 782 20/02/12 1:08 PM

Photo to
Come
FPO
35# Intravenous
Medications
antineoplastic drugs
bolus administration
central venous catheter 1. Name two types of veins into which intravenous medications
continuous infusion are administered.
intermittent infusion 2. Describe at least three appropriate situations for administering
intravenous route intravenous medications.
port 3. Name two ways by which intravenous medications are adminis-
secondary infusion tered.
volume-control set 4. Describe one method for giving bolus administrations of intrave-
nous medications.
5. Describe two methods for administering medicated solutions
intermittently.
6. Explain the technique for administering a piggyback infusion.
7. Discuss two purposes for using a volume-control set.
8. Describe a central venous catheter.
9. Name three types of central venous catheters.
10. Discuss two techniques for protecting oneself when administer-
ing antineoplastic drugs.
A
dministering intravenous (IV) solutions (see Chap. 16) is consid-
ered a form of IV medication administration. The focus of this
chapter, however, is on the methods for administering IV drugs, not
fluid replacement solutions, and the techniques for using various
venous access devices.
The intravenous route (a drug administration through peripheral
and central veins) provides an immediate effect. Consequently, this route
of drug administration is the most dangerous. Drugs given in this man-
ner cannot be retrieved once they have been delivered. Hence, only spe-
cially qualified nurses are permitted to administer IV medications. Those
responsible for IV medication administration must use extreme caution
in preparation and instillation.
■ Older adults are often reluctant to ask questions of health care pro-
fessionals. Therefore, it is imperative that nurses explain the purpose
and potential side effects for each drug administered, especially by the
IV route.
■ A portion of many drugs is bound to protein in the blood. The portion
not bound is called free drug, the physiologically active form. Older
adults tend to have more free drug in proportion to bound drug
because of diminished protein components in their blood and may,
therefore, experience an increased effect from the drug.
783
LWBK1004-C35_p783-808.indd 783 2/6/12 7:16 PM

■ Older adults tend to metabolize and excrete drugs at

a slower rate. This factor may predispose them to toxic
effects from an accumulation of medications. This toxicity
may occur more rapidly when the drug is administered IV.
Adjustments may be needed in the amount or frequency
of dosing. Older adults require frequent and comprehen-
sive assessments during and after IV medication
administration.
INTRAVENOUS MEDICATION
ADMINISTRATION
Despite its risks, IV administration given either continuouslyFIGURE 35-1 An intravenous port. (Photo by B. Proud.)
or intermittently is the route chosen when:

• A quick response is needed during an emergency. administrations,secondary administrations, and those in
• Clients have disorders (eg, serious burns) that affect thewhich a volume-control set is used.
absorption or metabolism of drugs.
• Blood levels of drugs need to be maintained at a consistent
Bolus Administration
therapeutic level such as when treating infections caused The term bolus refers to a substanceen givall at one time.
by drug-resistant pathogens or providing pain relief. A bolus administration (an undiluted or a diluted medica-
• It is in the client’s interest to avoid the discomfort of tion given into a vein in 1 or more minutes) sometimes is
repeated intramuscular injections. described as a drug given by an IV push. Although the term
• A mechanism is needed to administer drug therapy over “push”
a is used, the medication is administered at the rate
prolonged period, as with cancer. specifi ed in a drug reference or at a rate of 1 mL per minute
if no information is available.
Continuous Administration Bolus administrations are given in one of two ways:
A continuous infusion (an instillation of a parenteral drug through a port in an existing IV line or through a medication
over several hours), also called a continuous drip, involveslock (see Chap. 16).
adding medication to a large volume (500 to 1,000 mL) of IV
solution (Skill 35-1). Drugs may be added to a new container Using an IV Port
of IV solution or to an existing infusion if there is a suf
cient
fi A port (a sealed opening) extends from the IV tubing (Fig.
volume to dilute the drug. After the medication is added,35-1).The seal is made of late x or another substance that can
the solution is administered by gravity infusion or, more be pierced with a needle or needleless adapter (see Nursing
commonly, with an electronic infusion device such as a con- Guidelines 35-1 and Fig. 35-2).
troller or pump (see Chap. 16). Because the entire dose is administered quickly, a bolus
administration has the greatest potential for causing life-
➧ Stop, Think, and Respond Box 35-1 threatening changes should a drug reaction occur. If the cli-
ent’s condition changes for any reason, the administration is
What are some advantages of administering an IV
ceased immediately, and emergency measures are taken to
medication by a continuous infusion?
protect the client’s safety.
Using a Medication Lock

Gerontologic Considerations A medication lock is also called a saline or heparin lock
or an intermittent infusion device. The insertion and tech-
■ Older adults with dementia often experience more confu- nique for maintaining the patenc y of a medication lock are
sion and disorientation with an acute illness. An assessment
described in Chapter 16.
of confused older adults is required to ensure the safe admin-
istration of IV medications and maintenance of the IV insertion
Briefl y, a medication lock is a plug that, when inserted
site to ensure that the venipuncture device is not displaced. into the end of a IV catheter, allows for instant access to
the venous system. One of its best features is that it elimi-
nates the need for a continuous, and sometimes unnecessary,
Intermittent Administration administration of IV fl uid.
Intermittent infusion is a short-term (from minutes up Instilling IV medication through a lock is similar
to 1 hour), parenteral administration of medication. Inter-to the routine for keeping it patent (see Skill 16-7). The
mittent infusions are administered in three ways: bolustechnique varies depending on whether the agency’s policy
LWBK1004-C35_p783-808.indd 784 20/02/12 3:19 PM

CHAPTER 35 Intravenous Medications 785

Rationales
Administering Medications Through an Intravenous Port
• Prepare the medication in a syringe. This provides a means for • Pull back on the plunger of the syringe. Pulling back creates
accessing the port. negative pressure.
• Check the client’s identity using at least two methods; for • Observe for blood in the tubing near the IV catheter or inser-
example, checking the wristband and asking the client’s name. tion device. Blood validates that the IV catheter is in the vein.
Ensures that medications are given to the right client; complies • Gently instill a few tenths of a milliliter of medication. This
with the National Patient Safety Goals. amount initiates the bolus administration.
• Locate the port nearest the IV insertion site. This location pro- • Release the tubing. Releasing allows some IV fluid to flow.
vides the most rapid placement of medication in the circulatory • Continue the pattern of pinching the tubing, instilling a small
system. amount of drug, and releasing the tubing until the medication
• Swab the port with an alcohol sponge (see Fig. 35-2A). Alcohol has been administered over the specified period. This method
swabbing removes colonizing microorganisms. delivers the drug gradually and keeps the catheter or venous
• Pierce the port with the needle or a needleless adapter (see insertion device patent when medication is not being instilled.
Fig. 35-2B). Piercing provides access to inside the tubing. Pinching the tubing while instilling the drug ensures the
• Pinch the tubing above the access port (see Fig. 35-2C). Pinch- administration of the drug to the client rather than backfilling
ing temporarily stops the flow of the IV fluid. the tubing.
is to maintain patency with a 0.9% normal saline solution flush again with saline; SASH refers to flush with saline,
or heparin. The trend is to use saline. administer the drug, flush again with saline, instill heparin
Nurses use the mnemonic SAS or SASH as a guide to (see Nursing Guidelines 35-2 and Fig. 35-3).
the steps involved in administering IV medication into a To maintain patency, nurses usually flush medication
lock. SAS stands for flush with saline, administer the drug, locks after each use with saline or heparin or every 8 to 12 hours
A B
FIGURE 35-2 A. Swabbing the injection port on an infusing

C intravenous tubing. B. Inserting the syringe into the injection
port. C. Clamping the tubing above the injection port.
LWBK1004-C35_p783-808.indd 785 20/02/12 12:47 PM


Rationales
Administering Medications Through a Lock
• Prepare three syringes, two with at least 1 mL of sterile normal on the gauge of the needle, blood return may not always be
saline and one with the prescribed medication. This prepara- observed).
tion facilitates flushing the lock before and after medication • Instill the saline (the first “S” in the mnemonic). Saline clears
administration. the lock and the venous access device.
• Prepare a fourth syringe with heparin (10 U/mL), if it is the • Remove the syringe when empty, wipe the tip of the lock, and
agency’s policy to use it. Heparin maintains patency by inter- insert the syringe containing the drug. These steps facilitate
fering with clot formation. administering the medication.
• Label all the syringes in some way such as attaching pieces of • Gently and gradually administer the medication over the speci-
tape with the letters “S” and “H.” Labels can help to identify fied time period (the letter “A” in the mnemonic). Following
the contents of syringes. recommendations from an authoritative source ensures safety.
• Check the client’s identity using at least two methods; for • Remove the syringe when it is empty, wipe the lock again,
example, checking the wristband and asking the client’s name. insert the second syringe with saline, and instill the fluid (the
Ensures that medications are given to the right client; complies second “S” in the mnemonic). This pushes the medication that
with the National Patient Safety Goals. remains in the lock into the venous system and fills the lock
• Wipe the medication port with an alcohol swab. Alcohol swabs with saline.
remove colonizing microorganisms. • Begin to withdraw the syringe while instilling the last of the
• Insert the needle or needleless device from the syringe con- fluid in the syringe. Doing so prevents drawing blood, which
taining saline through the “bull’s eye” of the rubber seal on may clot, into the lumen of the IV catheter and ensures future
the medication lock (see Fig. 35-3). Such insertion provides patency.
the least resistance when introducing the needle or needleless • Wipe, insert, and instill the heparin (the “H” in the mnemonic),
device. if that is agency policy, using the same technique for with-
• Hold the lock and pull back on the plunger of the syringe. drawal as with the final flush with saline. Heparin maintains
Doing so stabilizes the lock while aspirating for blood. patency using an anticoagulant.
• Observe for blood in the tubing where the tubing connects • Deposit all uncapped syringes in the nearest puncture-resistant
to the venous catheter or in the barrel of the syringe. Blood biohazard container. Proper disposal prevents needlestick
verifies that the lock is still patent and in the vein (depending injuries.
if the lock has been unused. The flushing technique is the Gerontologic Considerations
same except only one syringe of flush solution is required.
Nurses change medication locks when changing the IV ■ Older adults comprise the largest age group of clients
site or at least every 72 hours. If the nurse cannot verify patency cared for in acute and long-term health care facilities. The
by obtaining a blood return, and if there is resistance or leaking administration of IV medications is quite common in older
when administering the flush solution, she or he removes the clients. Increasing the emphasis on early discharges may
IV catheter, changes the site, and replaces the lock. require teaching older adults, family caregivers, or both
how to flush venous access equipment.
■ Older adults who are discharged with a medication lock
may require additional time for repeated practice due to
normal age-related problems such as decreased visual
acuity and manual dexterity, or for a referral for skilled nurs-
ing care.
Secondary Infusions
A secondary infusion is the administration of a parenteral
drug that has been diluted in a small volume of IV solution,
usually 50 to 100 mL, over 30 to 60 minutes. It also is called
a piggyback infusion because it is administered in tandem
with a primary IV solution (Fig. 35-4). Both are misnomers
when the small volume of medicated solution is administered
through a medication lock or the port of a central venous
catheter (CVC; discussed later). When administered this
FIGURE 35-3 The bull’s eye on a medication lock. (Photo by way, the medications are actually independent of a primary
B. Proud.) infusion. There are also instances when small volumes of
LWBK1004-C35_p783-808.indd 786 2/6/12 7:16 PM

FIGURE 35-4 A piggyback arrangement.
medicated solution are given simultaneously with a primary FIGURE 35-5 A volume-control set. (Photo by B. Proud.)
infusion. This method involves using dual types of electronic
infusion devices. Skill 35-2 describes how nurses administer
secondary infusions by gravity in tandem with a currently CENTRAL VENOUS CATHETERS
infusing primary solution.
A central venous catheter (a venous access device that
➧ Stop, Think, and Respond Box 35-2 extends to the superior vena cava) provides a means of admin-
Other than using a drug reference book, whom or istering parenteral medication in a large volume of blood. A
what might you consult to determine the compat- CVC is used when:
ibility of two drugs that will infuse through the same
• Clients require long-term IV fluid or medication adminis-
IV tubing?
tration.
• IV medications are irritating to peripheral veins.
Volume-Control Set • It is difficult to insert or maintain a peripherally inserted
A volume-control set is a chamber in IV tubing that holds venous catheter.
a portion of the solution from a larger container (Fig. 35-5).
It is known by various commercial names such as Volutrol, CVCs have single or multiple lumens (Fig. 35-6). With
Soluset, and Buretrol. A volume-control set is used to admin- multiple lumens, incompatible substances or more than one
ister IV medication in a small volume of solution at intermit-
tent intervals and to avoid accidentally overloading the circu-
latory system. The volume-control set essentially substitutes
for the separate secondary container of solution, therefore
eliminating the need for additional fluid.
When caring for clients who are at risk for or manifest
signs of fluid excess, it is appropriate to consult the physi-
cian and pharmacy department about using a volume-control
set to administer intermittent IV medications (Skill 35-3).

Why might the administration of IV medications and
fluid with a volume-control set be preferable to a sec-
ondary or continuous infusion when the client is an
FIGURE 35-6 A triple-lumen central venous catheter. (Photo by
infant or small child? B. Proud.)
LWBK1004-C35_p783-808.indd 787 2/6/12 7:16 PM

solution or drug can be given simultaneously. Each infuses (PICC) line. Nontunneled percutaneous catheters are used
through a separate channel and exits the catheter at a dif- when clients require short-term fluid therapy, parenteral
ferent location near the heart. Thus, the drugs or solutions nutrition, or medication therapy lasting a few days or weeks.
never interact. When a lumen is used only intermittently, it PICCs are safer than catheters inserted in the subclavian
is capped with a medication lock. The unused lumen is kept or jugular veins because there is a reduced potential for a
patent by scheduled flushes with normal saline or heparin. pneumothorax (punctured pleura resulting in the collapse of
a lung) at the time of insertion. Catheter-related complica-
tions such as venous thrombosis (clot formation), and bac-
Pharmacologic Considerations teremia (bacterial infection in the bloodstream) are inherent
risks when CVCs are used.
■ Heparin 100 U/mL is the usual strength used for flushing
a CVC. As with all medications, be sure to read the label on
the supplied flush solution three times because the com-
monly available strength is 10 U/mL.
■ The veins of older adults tend to be quite fragile.

There are three types of CVCs: percutaneous, tunneled, Inserting a percutaneous central venous line is often better
and implanted. than risking the trauma of repeated attempts at restarting
or changing peripheral IV sites.
Nontunneled Percutaneous Catheters
A nontunneled percutaneous catheter is inserted through the
skin in a peripheral vein (eg, the basilic, cephalic, jugular, or Tunneled Catheters
subclavian vein) with the distal end terminating in the supe- Tunneled catheters are inserted into a central vein with part
rior vena cava; see Chap. 16) (Fig. 35-7). Nurses who are of the catheter secured in the subcutaneous tissue. The end of
certified may insert a peripherally inserted central catheter the catheter exits from the skin lateral to the xiphoid process
Internal jugular vein
Subclavian vein
Median basilic vein
Median cephalic vein Cephalic vein
PICC
Basilic vein
Axillary vein
Brachiocephalic vein
Superior vena cava
A
Insertion Catheter
Subclavian vein
Insertion
Termination Internal jugular vein
Superior FIGURE 35-7 A. The location of a
vena cava Termination peripherally inserted central cathe-
Superior ter (PICC). B. The location of a per-
Catheter vena cava cutaneous catheter inserted in the
subclavian vein. C. The location of a
percutaneous catheter inserted in
B C the jugular vein.
LWBK1004-C35_p783-808.indd 788 2/6/12 7:17 PM

Termination Subclavian vein

Superior
vena cava
Dacron cuff
Insertion
Through a
Catheter
subcutaneous
tunnel to the Clamp
subclavian vein Angled
Clamp needle
Catheter tip
in sublcavian
vein
FIGURE 35-8 A tunneled catheter.
(Fig. 35-8). Tunneled catheters are used when the client

requires extended therapy. Tunneling helps to stabilize the
catheter and also reduces the potential for infection because Implanted port
in subcutaneous
an internal cuff acts as a barrier against migrating micro- pocket
organisms. Some examples of tunneled catheters are the
Hickman, Broviac, and Groshong catheters.
Implanted Catheters
An implanted catheter (eg, the Porta-Cath) is sealed beneath FIGURE 35-9 The placement of an implanted catheter with
the skin (Fig. 35-9) and provides the greatest protection access via a port and angled needle.
against infection because it is totally confined internally
without any exposed external portion. catheter is being used. Implanted catheters remain patent
Implanted catheters have a self-sealing port pierced with a periodic flushing with heparin.
through the skin with a special needle when administering
IV medications or solutions. To reduce skin discomfort, a Medication Administration Using
local anesthetic is first applied topically. Implanted ports can a Central Venous Catheter
sustain approximately 2,000 punctures; thus, the catheter IV medications may be instilled through any type of CVC.
can remain in place for several years, barring complications. Continuous or intermittent infusions may be used (see Nurs-
A dressing is applied only when the port is pierced and the ing Guidelines 35-3 and Fig. 35-10).

Rationales
Using a Central Venous Catheter
• Prepare the IV solution, tubing, and drug using the steps for • Swab again and insert the needle, the recessed needle, or the
administering a continuous or secondary infusion. Preparation needleless adapter that connects to the prepared IV medication
principles are similar. through the port. Doing so provides access to the circulatory
• Prepare a syringe with 3–5 mL of sterile normal saline solution. system.
Saline facilitates clearing the catheter of heparin if used to • Tape the connection. Taping prevents displacement.
maintain patency; a larger volume displaces the current fluid • Release the clamp on the tubing and regulate the rate of infu-
within the lumen of the catheter. sion. These steps administer the medication according to the
• Release the clamp, if there is one, on the exposed section of prescribed rate.
the catheter. Releasing the clamp facilitates flushing the • Remove the needle or adapter from the port when the medi-
catheter. cated solution has instilled. Removal terminates the current use
• Swab the sealed port at the end of the catheter with alcohol. of the catheter.
Alcohol swabbing removes colonizing microorganisms. • Flush the catheter with saline or heparin or both according to
• Insert the syringe containing the saline into the port and instill agency protocol. Flushing maintains catheter patency.
the flush solution (see Fig. 35-10). Piercing clears the catheter • Reclamp the catheter. Reclamping prevents complications such
of previous flush solution. as air embolism (see Chap. 16).
LWBK1004-C35_p783-808.indd 789 2/6/12 7:17 PM

FIGURE 35-10 Flushing the lumen. (Photo by B. Proud.)
Antineoplastic drugs (medications used to destroy

or slow the growth of malignant cells) also are commonly
referred to as chemotherapy or just chemo. CVCs often are
used to administer antineoplastic drugs to clients with cancer.
Antineoplastic agents are toxic to both normal and
abnormal cells. These drugs can even cause adverse effects FIGURE 35-11 A pharmacy preparation of antineoplastic drugs
in the pharmacists who mix them and in the nurses who using self-protective garments and equipment. (Photo by
administer them. Caregivers can absorb antineoplastic drugs B. Proud.)
through skin contact, inhalation of tiny fluid droplets or dust
particles on which the droplets fall, or oral absorption of drug
residue during hand-to-mouth contact. When transferred to • Clean the spill area with detergent and water at least three
the caregiver, these drugs can cause headaches, nausea, diz- times, and then rinse with clean water.
ziness, and burning or itching of the skin. Long-term expo- • Dispose of all substances that contain drug material in a
sure can lead to changes in fast-growing body cells, includ- biohazard container.
ing sperm, ova, or fetal tissue. It is important, therefore, that • Perform scrupulous hand washing after removing gloves.
nurses use safety measures when administering these drugs
and avoid exposure and contact with hazardous materials.
In most cases, these drugs are reconstituted or diluted
with sterile IV solutions in the pharmacy. The pharmacist
wears protective clothing when preparing the drugs under
Although the administration of all parenteral drugs involves
a vertical flow containment hood or biologic safety cabinet
specialized skills, the administration of IV medications in
(Fig. 35-11). The pharmacist usually attaches a special label
general and antineoplastic drugs in particular requires extreme
to warn nurses to take special precautions during drug admin-
caution. Nurses may identify the following nursing diagnoses:
istration.
Common recommendations for avoiding self-contami- • Anxiety
nation with antineoplastic drugs include the following: • Risk for Infection
• Fear
• Cover the drug preparation area with a disposable paper
• Excess Fluid Volume
pad, which will absorb small drug spills.
• Risk for Injury
• Wear a long-sleeved, cuffed, low-permeability gown with
a closed front.
• Wear one or two pairs of surgical latex, nonpowdered Nursing Care Plan 35-1 demonstrates the nursing proc-
gloves to reduce the potential for skin contact and inhala- ess as applied to a client with the nursing diagnosis Inef-
tion of drug powder. fective Protection, defined in the 2012 NANDA-I taxonomy
• Cover the cuffs of the gown with the cuffs of the gloves. (p. 160) as “a decrease in the ability to guard self from inter-
• Wear a mask or respirator and goggles if there is a poten- nal or external threats such as illness or injury.” This diag-
tial for aerosolization or drug splash. nosis may be associated with the undesirable consequences
• Pour 70% alcohol over any drug spill to inactivate the of antineoplastic medication therapy; an example might be
drug. deficient immunity or a decreased ability to control bleeding.
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N U R S I N G C A R E P L A N 3 5 - 1 Ineffective Protection
Assessment • Analyze the client’s weight in relation to height or calculate
• Review laboratory findings for evidence of decreased body mass index (BMI) for evidence of inadequate nutrition.
mature white blood cells, reduced platelets, insufficient • Refer to the client’s medical record for current diagnoses
erythrocytes and hemoglobin, or the potential for such as cancer, alcohol or other forms of substance abuse, and
prolonged clotting. immune-related disorders.
• Read the client’s history for information indicating a bleeding • Determine if the client is undergoing therapeutic management
disorder from an acquired or inherited condition in which a of disorders with drugs that suppress bone marrow function,
clotting factor is missing. cause immunosuppression, or interfere with clot formation.
Nursing Diagnosis. Ineffective Protection related to a debilitated state and a tendency to bleed secondary to chemotherapy for
Hodgkin’s lymphoma as manifested by enlarged cervical and axillary lymph nodes, complete blood count that reveals thrombocytopenia,
and the client’s statement: “I haven’t been eating much. It’s difficult to swallow; as a result I’m losing weight and feeling very weak.”
Expected Outcome. The client will maintain effective protection from bleeding as evidenced by minimal blood loss, platelet
count within a normal range, and negative occult blood tests on urine and stool throughout the hospital stay.
Monitor platelet count from a specimen drawn from CVC. Platelets play a role in blood clotting; the normal range of
platelets is 150,000–250,000/mm3.
Report platelet counts below normal and expect that chemo- The nurse informs the physician of data that put the client at
therapy will be withheld if count is less than 100,000/mm3. risk for complications; withholding a chemotherapeutic drug
that suppresses bone marrow function protects the client by
avoiding a further decline in platelets.
Assess skin for bruising and the catheter site for bleeding, and Physical assessments provide data that indicate evidence of
test urine and stool for occult blood every day. blood loss and decreased clotting ability.
Consult the physician if he or she inadvertently prescribes Questioning an order for a medication that interferes with
aspirin, products containing salicylates, or other types of clotting protects the client from factors that increase the risk
drugs that interfere with clotting. for bleeding.
Use a soft-bristle toothbrush or foam swabs for mouth care. These devices avoid oral and dental trauma that can result in
blood loss.
Apply pressure for at least 3 minutes to control bleeding at an Direct pressure helps to control bleeding.
injection site if parenteral medications must be given by a
route other than through the CVC.

• Platelet count remains in low normal range or higher. • Urine and stool test negative for occult blood.
• There is no evidence of bleeding from CVC insertion site. • There is no evidence of active bleeding from gums after mouth
• No bruises are noted on the skin. care with soft-bristled toothbrush.

1. Discuss the advantages and disadvantages of giving 1. Which of the following actions is essential before
IV medications to older adults. a nurse administers an IV medication by bolus (IV
2. When preparing to administer an IV medication push) through a port of an infusing solution that also
through an IV port or lock, you find no blood return contains a medication?
on aspiration. Discuss the significance of this finding 1. Dilute the bolus drug in a small volume of
and appropriate actions. solution.
3. If the volume of an IV medication is 4 mL by bolus 2. Check that the bolus and the infusing drugs are
administration, but there is no published recom- compatible.
mended period of time for its administration, how 3. Stop the infusing solution for approximately
long should the nurse allow when instilling the drug? 3 minutes.
4. Why do many oncology departments have a policy of 4. Flush the port with 5 mL of sterile normal
excluding the employment of nurses who are cur- saline.
rently pregnant?
LWBK1004-C35_p783-808.indd 791 2/6/12 7:17 PM

2. When the nurse instills a medication intravenously 4. What is the best answer the nurse can provide when a
by bolus administration (IV push), which technique is client asks why the physician recommended inserting
correct for determining that the IV catheter is within an implanted CVC for administering cancer medica-
the vein? tions?
1. The nurse increases the rate of infusion and looks 1. An implanted catheter has the lowest incidence of
for edema at the site. infection.
2. The nurse inspects the site looking for redness 2. An implanted catheter is best for short-term use.
along the course of the vein. 3. An implanted catheter will never need to be
3. The nurse palpates the area of the infusion to note removed.
a difference in temperature. 4. An implanted catheter is easy to cover with a
4. The nurse pulls back on the plunger of the syringe dressing.
and looks for a blood return. 5. Which of the following techniques is best for avoid-
3. What does the nurse instill first before administering self-contamination with IV antineoplastic drugs?
ing an IV medication through a peripherally inserted 1. Stay at least 5 ft away from a client receiving an
intermittent infusion device (medication lock)? infusion of an antineoplastic drug.
1. Sterile bacteriostatic water 2. Wear a high efficiency air filter respirator while
2. Sterile normal saline in the area where an antineoplastic drug is being
3. Sterile isopropyl alcohol given.
4. Sterile hydrogen peroxide 3. Perform meticulous hand washing for about
5 minutes after handling a container of antine-
oplastic drugs.
4. Don two pairs of nonpowdered gloves when pre-
paring to administer the antineoplastic drug.
LWBK1004-C35_p783-808.indd 792 2/6/12 7:17 PM

SKILL 35-1 Administering IV Medication by Continuous Infusion
ASSESSMENT
Check the medical orders. Collaborates nursing activities with medical treatment.
Read the label on the drug and compare it with the MAR (see Fig. A). Prevents errors.
Comparing the drug label with the medication administration record (Photo by B. Proud.)
Make sure the drug label indicates that it is for IV use. Prevents injuring the client.
Review the drug action and side effects. Promotes safe client care.
Consult a compatibility chart or drug reference. Determines if the solution and drug are known to interact when
mixed.
and technique for administering the medication.
Perform assessments that will provide a basis for evaluating the Provides a baseline for future comparisons.
drug’s effectiveness.
Inspect the current infusion site for swelling, redness, and Determines if a site change is needed.
tenderness.
PLANNING
Prepare the medication, taking care to read the medication label Avoids medication errors.
at least three times.
Have a second nurse double check your drug calculations. Ensures accuracy.
IMPLEMENTATION
Chap. 10).
Identify the client using at least two methods; for example, check- Ensures that medications are given to the right client; complies
ing the wristband and asking the client’s name (see Fig. B). with the National Patient Safety Goals.
Checking the client’s identification band. (Photo by B. Proud.)
(continued)
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Administering Intravenous Medication by Continuous Infusion (continued)
IMPLEMENTATI ON (CONTINUED)
Clamp or stop the current infusion of fluid. Prevents administering a concentrated amount of medication
while it is being added to the solution.
Swab the appropriate port on the container of IV fluid Removes colonizing microorganisms.
(see Fig. C).
Swabbing the port on the container. (Photo by B. Proud.)
Instill the medication through the port into the full container of Promotes the dilution of concentrated additive.
infusing fluid (see Fig. D).
Lower the bag and gently rotate it back and forth. Distributes the medication equally throughout the fluid.
Suspend the solution and release the clamp. Facilitates infusion.
(continued)
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Administering Intravenous Medication by Continuous Infusion (continued)
Regulate the rate of flow by using the roller clamp or program- Promotes a continuous infusion at the prescribed rate.
ming the rate on the electronic infusion device (see Fig. E).
Programming the rate. (Photo by B. Proud.)
Attach a label to the container of fluid identifying the drug, its Provides information for others and demonstrates accountability
dose, the time it was added, and your initials (see Fig. F). for nursing actions.
Attaching the drug label. (Photo by B. Proud.)
Record the medication administration in the MAR. Documents the nursing care; avoids medication errors.
Check the client and the progress of the infusion at least hourly. Promotes early intervention for complications.
Evaluation
• Medication instills at a prescribed rate.
• Client remains free of any adverse effects.
Document
• Client and site assessment data
• The date, time, drug, dose, and initials
• Solution to which the drug has been added
Date and Time IV infusing in L. forearm. No tenderness, swelling, or redness observed. KCl 20 mEq added to 1,000 mL
of D5/W. IV infusing at 125 mL/h. Heart rate is regular and ranges between 65 and 75 bpm.
_______________________________________________________________________________ SIGNATURE/TITLE
a
LWBK1004-C35_p783-808.indd 795 2/6/12 7:17 PM

SKILL 35-2 Administering an Intermittent Secondary Infusion
ASSESSMENT
Check the medical orders. Collaborates nursing activities with the medical treatment
Read the label on the medicated solution and compare it with Prevents errors.
the MAR.
tenderness.
Consult a compatibility chart or drug reference. Determines if the drug in the secondary solution may interact
when mixed with the solution in the primary tubing.
Perform assessments that will provide a basis for evaluating the Provides a baseline for future comparisons.
PLANNING
Plan to administer the secondary infusion within 30–60 minutes Complies with agency policy.
of the scheduled time for drug administration established by
the agency.
Remove a refrigerated secondary solution at least 30 minutes Warms the solution slightly to promote comfort during instillation.
before administration.
Check the drop factor on the package of secondary (short) IV Ensures that the secondary infusion will be instilled within the
tubing and calculate the rate for infusion (see Chap. 16). specified time.
Have a second nurse double check your calculations for the rate Ensures accuracy.
of infusion.
Attach the tubing to the solution (see Skill 15-2), fill the drip Prepares the medicated solution for administration.
chamber, and purge the air from the tubing.
Attach a needle, a recessed needle, or a needleless adapter. Facilitates accessing the port while minimizing the risk for needle-
stick injury.
IMPLEMENTATION
Chap. 10).
Hang the secondary solution on the IV pole or standard. Prepares the solution for administration.
Lower the container of primary solution approximately 10 in. Positions the secondary solution to instill under greater hydro-
(25 cm) below the height of the secondary solution using a static pressure.
plastic or metal hanger.
Wipe the uppermost port on the primary tubing with an alcohol Removes colonized microorganisms.
swab.
Insert the needle or modified adapter within the port. Provides access to the venous system.
Lock the connection. Prevents separation from the port.
Release the roller clamp on the secondary solution. Initiates the infusion.
Regulate the rate of flow by counting the drip rate and adjusting Establishes the maintenance rate of flow to instill the solution in
the roller clamp or by programming an electronic infusion the time specified.
device.
Clamp the tubing when the solution has instilled. Prevents backfilling with the primary solution.
Rehang the primary container of solution and readjust the rate Continues the fluid replacement therapy at its appropriate rate.
of flow.
Leave the secondary tubing in place within the port if another Controls health care costs without jeopardizing client safety; dif-
secondary infusion of the same medication is scheduled ferent tubing, however, is used if other drugs are administered
again within the next 24 hours. as secondary infusions.
(continued)
LWBK1004-C35_p783-808.indd 796 2/6/12 7:17 PM

Administering an Intermittent Secondary Infusion (continued)
Evaluation
• The secondary infusion instills at the prescribed rate.
• The client remains free of any adverse effects.
Document
Date and Time IV infusing in L. forearm. No tenderness, swelling, or redness observed. Vancomycin 1 g administered in 100 mL
of NSS as a secondary infusion over 60 minutes without signs of a reaction. __________ SIGNATURE/TITLE
a
SKILL 35-3 Using a Volume-Control Set
ASSESSMENT
Check the medical orders. Collaborates nursing activities with medical treatment.
Consult a compatibility chart or drug reference. Determines if the medication interacts when diluted with the IV
solution.
Read the label on the medication and compare it with the MAR. Prevents errors.
Assess the client’s fluid status (see Chap. 16) and perform Provides a baseline for future comparisons.
other assessments that will provide a basis for evaluating the
tenderness.
PLANNING
Plan to administer the medication within 30–60 minutes of the Complies with agency policy.
scheduled time for drug administration established by the
agency.
Obtain a volume-control set. Provides the means for instilling an intermittent infusion.
Determine the drop factor on the volume-control set and calcu- Differs, in some instances, from the drop size on IV tubing.
late the rate of infusion.
Have a second nurse double check your calculations for the rate Ensures accuracy.
of infusion.
IMPLEMENTATION
Chap. 10).
(continued)
LWBK1004-C35_p783-808.indd 797 2/6/12 7:17 PM

Using a Volume-Control Set (continued)
Close all the clamps on the volume-control set and insert the Prepares the equipment for medication administration.
spike into the IV solution (see Fig. A).
Inserting the spike. (Photo by B. Proud.)
Seal the air vent located to the side of the spike on the volume- Facilitates the administration of fluid from collapsible or noncol-
control set if the solution is in a plastic bag; if the container is lapsible containers.
glass, leave the air vent open.
Release the clamp above the fluid chamber. Permits fluid to enter the calibrated container.
Fill the calibrated chamber with approximately 30 mL of IV solu- Provides a small volume with which to fill the drip chamber and
tion and retighten the clamp. purge air from the distal tubing.
Squeeze and release the drip chamber until it is half full (see Fills the drip chamber with fluid.
Fig. B). Note: For volume-control sets with a membrane filter,
the clamp below the drip chamber must be open when the
drip chamber is filled or the set will be damaged.
Squeezing the drip chamber. (Photo by B. Proud.)
Open the lower clamp until the tubing is filled with fluid; then Purges air from the tubing.
reclamp.
Open the clamp above the calibrated container, fill the chamber Provides diluent for the medication.
with the desired volume of fluid, and reclamp.
Swab the injection port on the calibrated container. Removes colonizing microorganisms.
(continued)
LWBK1004-C35_p783-808.indd 798 2/6/12 7:17 PM

Instill the prepared medication (see Fig. C). Prepares the drug for administration.
Rotate the fluid chamber back and forth. Mixes the drug throughout the fluid.
Connect the tubing to the client’s IV catheter. Completes the circuit for administering an IV medication.
Release the lower clamp and regulate the drip rate. Continues the administration of fluid replacement.
Add a label to the fluid chamber identifying the name of the Provides information for other health professionals.
drug, dose, time it was added, and your initials (see Fig. D).
Attaching a drug label. (Photo by B. Proud.)
Return before the time the medication is due to finish instilling. Facilitates further fluid therapy.
Release the upper clamp when the fluid chamber is empty and Continues the administration of fluid replacement.
refill it with the next hour’s worth of fluid.
Readjust the rate if necessary. Accommodates for differences between the rates for medication
and fluid administration.
Remove the drug label from the fluid chamber. No longer applies after the medication is instilled.
(continued)
LWBK1004-C35_p783-808.indd 799 2/6/12 7:17 PM

Evaluation
• The medicated solution instills within the specified period.
• The client experiences no adverse effects.
Document
• Solution to which drug has been added
Date and Time Azactam 1 g added to 100 mL of D5/W within volume-control chamber and instilled IV over 60 min. Site
is neither irritated, tender, nor swollen. Lungs sound clear. 100 mL urine output in the past hour.
_______________________________________________________________________________ SIGNATURE/TITLE
a
LWBK1004-C35_p783-808.indd 800 2/6/12 7:17 PM

UNIT 9
1. Drugs have a __________________ name, which is the chemical name and is not protected by a company’s trademark.
(brand, generic, proprietary)
2. The application of a drug to the skin or mucous membrane is an example of the __________________ route of drug
administration. (inhalant, parental, topical)
3. __________________ application is the method of applying a drug on the skin and allowing it to be passively absorbed.
(Cutaneous, Inunction, Transdermal)
4. __________________ is a drug used to dilate the coronary arteries. (Estrogen, Nitroglycerin, Scopolamine)
5. The part of the syringe that holds the medication is called the __________________. (barrel, plunger, tip)
6. With a/an __________________ injection, a drug is administered parenterally between the layers of the skin.
(intradermal, intravenous, subcutaneous)
7. An undiluted medication given quickly into a vein is called a __________________ administration. (bolus, piggyback,
soluset)
8. __________________ catheters are inserted into a central vein, with part of the catheter secured in the subcutaneous
tissue. (Implanted, Percutaneous, Tunneled)
1. T____F____ Drugs that dissolve at timed intervals are called sustained-release medications.
2. T____F____ A scored tablet is a solid drug manufactured with a groove in the center.
3. T____F____ The nurse asks the client to swallow the drug during sublingual or buccal administration.
4. T____F____ Needle lengths vary from approximately 21⁄2 to 31⁄2 inches.
5. T____F____ Lipoatrophy is an accumulation of subcutaneous fat at the site of repeated insulin injections.
6. T____F____ Volume-control set infusions require connecting a second bag of intravenous solution to a primary infusing
solution.
7. T____F____ Hickman and Broviac catheters are examples of implanted catheters.

1. Chemical substances that change body function __________________
2. The term given to drugs covered with a substance that dissolves beyond the stomach __________________
3. Swelling of the nasal mucosa that accompanies the overuse of nasal decongestants __________________
4. The chamber attached to an inhaler __________________
5. The process of adding a diluent to a powdered drug before parenteral administration __________________
6. Medications used to destroy or slow the growth of malignant cells __________________
801
LWBK1004-C35_p783-808.indd 801 20/02/12 12:48 PM

Activity D: 1. Match the terms related to intramuscular injection sites in Column A with their explanations in Column B.
Column A Column B
1. __________________ Dorsogluteal site A. Muscles in the quadriceps group of the outer thigh
2. __________________ Ventrogluteal site B. Lateral aspect of the upper arm
3. __________________ Vastus lateralis site C. Anterior aspect of the thigh
4. __________________ Rectus femoris site D. Upper outer quadrant of the buttock
5. __________________ Deltoid site E. Medius and minimus muscles in the hip
2. Match the terms related to intravenous medications in Column A with their explanations in Column B.
Column A Column B
1. __________________ Central venous catheter A. Instillation of parenteral drug over several hours
2. __________________ Intravenous route B. Instillation of parenteral drug over several minutes up
to 1 hour
3. __________________ Continuous administration C. A device that extends to the superior vena cava
4. __________________ Intermittent administration D. Drug administration via peripheral veins
Activity E: 1. Differentiate between turbo and metered-dose inhalers based on the categories given below.
Turbo Inhaler Metered-Dose Inhaler
Description
Method of Medication Delivery
Ease of Use
2. Differentiate between tunneled and percutaneous catheters based on the categories given below.
Tunneled Catheters Percutaneous Catheters
Method of Insertion
Uses
LWBK1004-C35_p783-808.indd 802 20/02/12 12:48 PM

1. Identify what is shown in the figure.

2. Explain the technique being used.
Activity G: When administering topical drugs, the nurse takes steps to maintain the integrity of the skin and mucous
membranes. Write in the boxes provided below the correct sequence for topical vaginal administration.
1. Depress the plunger once it reaches the proper distance within the vagina.
2. Insert the applicator into the vagina to the length recommended in the package directions.
3. Apply a sanitary pad and ask the client to remain recumbent for at least 10 to 30 minutes.
4. Place the drug in the applicator and apply lubricant to the tip.
5. Remove the applicator and place it on a clean tissue.
6. Have the client empty the bladder before inserting the medication.

1. What are the seven components of a medication order?
2. What is the purpose of a medication administration record?
3. What is an inunction application?
LWBK1004-C35_p783-808.indd 803 2/6/12 7:17 PM

4. What are ophthalmic applications?
5. What are five factors to consider when selecting a syringe and needle?
6. What are prefilled cartridges?
7. When are intravenous administrations appropriate for clients?
8. What are the advantages of using a medication lock?

1. Why are enteric-coated tablets never cut, crushed, or chewed?
2. When are metric doses converted to household measurements?
3. Why are certain drugs administered by application to the skin?
4. Why should extremely hairy areas be clipped before applying skin patches?
LWBK1004-C35_p783-808.indd 804 20/02/12 12:48 PM

5. Why is an 18-gauge needle wider than a 27-gauge needle?
6. Why are conventional syringes and needles being redesigned?
7. Why is the intravenous route of drug administration considered the most dangerous?
8. Why do some central venous catheters have multiple lumens?
1. A physician has listed drug names and directions for administering them in a client’s medication order. The nurse, while
transcribing the medication order, observes that the drug order is incomplete.
a. What immediate actions should the nurse perform in this situation?
b. What are the five rights of medication administration?
2. A nurse is caring for an adult client recovering from an appendectomy who is experiencing postoperative pain and
discomfort. The physician provides telephone instructions for follow-up care to the nurse. What steps should the
nurse take when receiving telephone orders from the physician?
3. A client undergoing nicotine withdrawal therapy has been ordered medication in the form of skin patches. How should
these skin patches be applied?
LWBK1004-C35_p783-808.indd 805 2/6/12 7:17 PM

4. A physician has prescribed otic application of neomycin for a client with severe itching in his ear.
a. How will the nurse instill this application?
b. How does administration of otic drugs differ for adults and children?
5. A client with diabetes has been prescribed a combination of regular and intermediate-acting insulin.
a. What interventions should the nurse follow when mixing insulins?
b. What actions should the nurse take if needlestick injuries occur?
6. A nurse is preparing to give a client an intramuscular injection at the dorsogluteal site.

a. What process will the nurse follow to identify an appropriate landmark?
b. What damage could result if the nurse does not identify the dorsogluteal site correctly?
7. A physician has prescribed a bolus drug administration for a client. What interventions should the nurse perform when
using a medication lock?
1. A nurse is caring for a teenager who has been prescribed antibiotics.
a. What actions can the nurse take if the client cannot swallow the drugs?
b. Can the nurse use intestinal or gastric tubes to administer medications to the client?
2. A physician has prescribed timolol (Timoptic) for a client with glaucoma.
a. What care should the nurse take when administering an ophthalmic application?
b. What should the nurse do if the applicator tip becomes contaminated?
3. What actions should a nurse take if a client shows signs of an allergic reaction to a drug given parenterally?
4. A nurse is caring for a client with severe burns for whom the physician has prescribed pain medication by the intravenous
route. What is a possible rationale for administering pain medication by this route?
LWBK1004-C35_p783-808.indd 806 2/6/12 7:17 PM


1. A nurse is caring for a client whose medication administration record reads amoxicillin t.i.d. How often should the nurse
administer this drug?
a. Three times a day
b. Every 3 hours
c. Every 3rd day
d. For 3 days
2. Which of the following interventions should the nurse perform when administering liquid oral medications?
a. Pour liquids with the drug label toward the palm of the hand.
b. Leave the medication cup on a side table if the client is absent.
c. Offer a cup of water along with the medication.
d. Ask the client to hyperextend the neck when taking the drug.
3. What instructions should the nurse provide when teaching a client to use a metered-dose inhaler? Select all that apply.
a. Shake the canister prior to use.
b. Exhale quickly through open lips.
c. Float the canister in a water bowl.
d. Inhale while depressing the canister.
e. Ask the client to hold his or her breath for 20 seconds.
4. What is the most accurate instruction the nurse can provide when teaching a client how to use prescribed nasal
medication?
a. Place a rolled towel or pillow beneath the neck before administration.
b. Place the tip of the container in front of the nostril.
c. Ensure that both the nostrils are open during administration.
d. Remain in position for 1 full minute after administration.
5. What important considerations should the nurse keep in mind when using the Z-track technique to inject medications?
a. Use the Z-track technique only in the deltoid muscles.
b. Massage the injection site after Z-track administration.
c. Insert the needle, aspirate, and inject the medication.
d. Select a large muscular site for injection.
e. Withdraw the needle and immediately release the taut skin.
6. A nurse is preparing to perform a subcutaneous injection. What important measures should the nurse take when drawing
up this medication from an ampule?
a. Hold the ampule at an angle of 45 degrees from the body.
b. Avoid tapping the top of the ampule.
c. Insert the filter needle along the rim of the ampule.
d. Snap off the ampule’s neck away from the body.
LWBK1004-C35_p783-808.indd 807 20/02/12 12:48 PM

7. A nurse is caring for a client with a malignant tumor who has been prescribed antineoplastic drugs. Which of the
following measures should the nurse take to avoid self-contamination with antineoplastic drugs?
a. Wear one or two pairs of nonpowdered surgical gloves.
b. Pour 10% alcohol over every drug spill.
c. Wear a short-sleeved gown with a closed front.
d. Clean the spilled drug area with water.
8. A nurse is caring for a client receiving a piggyback infusion along with a primary intravenous solution. What action
should the nurse perform when administering the secondary infusion?
a. Remove a refrigerated secondary solution 10 minutes before the infusion.
b. Administer the secondary infusion at the same rate as that of the primary infusion.
c. Set the height of the secondary solution 10 inches below the primary solution.
d. Wipe the uppermost port of the primary tubing with an alcohol swab.
LWBK1004-C35_p783-808.indd 808 2/6/12 7:17 PM

UNIT 10
Intervening in Emergency Situations
36 Airway Management 810
37 Resuscitation 825
809
LWBK1004-C36_p809-824.indd 809 04/02/12 3:37 PM

36 Airway Management
airway
airway management
chest physiotherapy 1. Define airway management.
inhalation therapy 2. Identify the structural components of the airway.
mucus 3. Discuss four natural mechanisms that protect the airway.
nasopharyngeal suctioning 4. Explain the methods nurses use to help maintain the natural
nasotracheal suctioning airway.
oral airway 5. Name two techniques for liquefying respiratory secretions.
oral suctioning 6. Explain the three techniques of chest physiotherapy.
oropharyngeal suctioning 7. Describe at least three suctioning techniques used to clear
percussion secretions from the airway.
postural drainage 8. Discuss two indications for inserting an artificial airway.
sputum 9. Name two examples of artificial airways.
suctioning 10. Identify three components of tracheostomy care.
tracheostomy
tracheostomy care
tracheostomy tube
he primary function of the respiratory system is to permit
T
vibration
ventilation (the movement of air in and out of the lungs) for an
appropriate exchange of oxygen and carbon dioxide at the cel-
lular level (see Chap. 21). A clear airway (the collective system
of tubes in the upper and lower respiratory tracts) is necessary for
adequate ventilation. Many factors can jeopardize airway patency:
• An increased volume of mucus (a mixture of water, mucin, white
blood cells, electrolytes, and cells that have been shed through the
natural process of tissue replacement)
• Thick mucus
• Fatigue or weakness
• A decreased level of consciousness
• An ineffective cough
• An impaired airway
Consequently, nurses sometimes need to assist clients with meas-
ures that support or replace their own natural efforts. This chapter
focuses on airway management, or those essential nursing skills that
maintain natural or artificial airways for compromised clients.
■ Conditions affecting the respiratory system are among the most

common life-threatening disorders that older adults experience. The
severity of chronic pulmonary diseases increases with age.
■ Many older adults with pathologic pulmonary changes have a his-
tory of smoking cigarettes since their youth, working in occupations
810
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CHAPTER 36 Airway Management 811
where they inhaled pollutants that affected their lungs, or From pulmonary
living for an extended time in industrial areas known for artery
toxic emissions. Alveolar
Terminal
■ Inquiring about a current history of coughing, determin- duct
bronchiole
ing how long the cough has been present, and observing
and describing any sputum are important when assessing Alveoli
older adults. To pulmonary
■ If not relieved quickly, a persistent, dry cough may con- vein
sume the older adult’s energy and result in fatigue.
Capillaries
THE AIRWAY
Section of lung enlarged
The upper airway consists of the nose and pharynx, which
FIGURE 36-1 The airway and related structures.
is subdivided into the nasopharynx, oropharynx, and laryn-
gopharynx. The lower airway consists of the trachea, bron-
chi, bronchioles, and alveoli. Gases travel through these
structures to and from the blood (Fig. 36-1). NATURAL AIRWAY MANAGEMENT
Certain structures protect the airway from a wide variety
of inhaled substances. These structures include the epiglottis, The most common methods of maintaining the natural air-
tracheal cartilage, mucous membrane, and cilia. The epiglot- way are keeping respiratory secretions lique ed,fi promoting
tis is a protrusion of flexible cartilage above the larynx. It acts their mobilization and expectoration with chest physiother-
as a lid that closes during swallowing, helping to direct uid fl apy, and mechanically clearing mucus from the airway by
and food toward the esophagus rather than the respiratory suctioning.
tract. The rings oftracheal cartilage ensure that the trachea,
the portion of the airway beneath the larynx, remains open. Liquefying Secretions
The mucous membrane, a type of tissue from which mucus The body continuously produces mucus. The volume of
is secreted, lines the respiratory passages. The sticky mucus water in mucus affects its viscosity, or thickness. Hydration,
traps particulate matter. Hair-like projections called cilia beatthe process of providing adequate uidfl intake, tends to keep
debris that collects in the lower airway upward (Fig. 36-2). mucous membranes moist and mucus thin. A thin consist-
Various mechanisms keep the airway open. For exam- ency promotes expectoration (see Chap. 16). An essential
ple, sneezing or blowing the nose can clear debris there. nursing activity is ensuring that clients are well hydrated.
Coughing, expectoration, or swallowing clears sputum In addition, nurses may assist with
inhalation therapy
(mucus raised to the level of the upper airways). (respiratory treatments that provide a mixture of oxygen,
humidifi cation, and aerosolized medications directly to the
lungs). Theaerosol is delivered through a mask or a handheld
Gerontologic Considerations mouthpiece (Fig. 36-3; also see Chap. 33). Aerosol therapy
■ Reduced air exchange and a reduced efficiency in ventila-

tion are the primary age-related changes affecting the older
adult’s respiratory system.
■ The muscular structures of the larynx tend to atrophy
with age, which can affect the ability to clear the airway.
■ Usually, the bases of the older adult’s lungs receive less
ventilation, contributing to the retention of secretions,
decreased air exchange, and compromised ventilation.
Respiratory cilia become less efficient with age, predispos-
ing older adults to a high incidence of pneumonia.
■ Diminished strength of accessory muscles for respira-
tion, an increased rigidity of the chest wall, and a dimin-
ished cough reflex make it difficult for older adults to cough
productively and effectively.
■ Older adults with difficulty swallowing (dysphagia), often
associated with strokes or middle and late stages of
dementia, are more vulnerable to aspiration pneumonia. An
evaluation of the dysphagia is important for implementing
appropriate interventions to prevent aspiration.
FIGURE 36-2 The cilia and mucus-producing cells.
LWBK1004-C36_p809-824.indd 811 04/02/12 3:37 PM

812 UNIT 10 Intervening in Emergency Situations

Performing Postural Drainage
The nurse teaches the client and family as follows:
● Plan to perform postural drainage two to four times daily
(eg, before meals and at bedtime).
● Administer the prescribed inhalant medications (see
Chap. 33) before performing postural drainage.
● Have paper tissues and waterproof container nearby for
collecting expectorated sputum.
● Position yourself to drain the appropriate lung areas.
● Cough and expectorate secretions that drain into the
upper airway.
● Remain in each prescribed position for 15–30 minutes (no
longer than 45 minutes).
● Resume a comfortable position after expectorating the usual
volume of sputum or if you become tired, feel lightheaded,
or have a rapid pulse rate, difficulty breathing, or chest pain.
FIGURE 36-3 Aerosol therapy. (Photo by B. Proud.)
■ Deep-breathing exercises may improve an older adult’s
ability to eliminate respiratory secretions.
improves breathing, encourages spontaneous coughing, and
helps clients to raise sputum for diagnostic purposes (see
Nursing Guidelines 36-1). Postural Drainage
Postural drainage is a positioning technique that promotes the
Mobilizing Secretions drainage of secretions from various lobes or gments
se of the
To help clients mobilize secretions from distal airways,lungs with the use of gravity (Fig. 36-4). In most hospitals, res-
health care professionals often use chest physiotherapypiratory therapists are responsible for postural drainage. In long-
(techniques including postural drainage, percussion, and term care facilities and home health care, however, nurses may
vibration). Chest physiotherapy usually is indicated for cli-teach clients and families to perform this technique (see Client
ents with chronic respiratory diseases who havecultydiffi and Family Teaching 36-1). Combining postural drainage with
coughing or raising thick mucus. percussion and vibration enhances overall effectiveness.

Rationales
Collecting a Sputum Specimen
• Plan to collect a sputum specimen just after the client awakens• Collect at least a 1- to 3-mL (nearly a half teaspoon) specimen.
or after an aerosol treatment. This timing allows for a collec- This quantity is sufficient for analysis.
tion when more mucus is available or is in a thinner state. • Wear gloves and cover and enclose the specimen container
• Obtain a sterile sputum specimen cup. Sterility prevents con- in a clear plastic bag. These steps reduce the potential for the
tamination of the specimen. transmission of microorganisms.
• Help the client to a sitting position. Sitting provides for an • Offer oral hygiene.It promotes comfort and well-being.
increased volume of inspired air and more forceful coughing • Attach a label and laboratory request form to the specimen.
to expel mucus. Doing so ensures the correct specimen identification and test
• Encourage the client to rinse the mouth with tap water. Tap procedure.
water removes some microorganisms and food residue. • Take the specimen to the laboratory immediately. Prompt
• Explain that the desired specimen should be from deep within the delivery facilitates a timely and accurate analysis of the
respiratory passages, not saliva from within the mouth. The correct specimen.
instruction helps to prevent inconclusive or invalid test results. • Document in the client’s medical record the appearance of the
• Instruct the client to take several deep breaths, attempt a force- specimen and its delivery to the laboratory. Such recording
ful cough, and expectorate into the specimen container. These provides assessment data and information about the disposi-
measures help to mobilize secretions from the lower airway. tion of the specimen.
LWBK1004-C36_p809-824.indd 812 20/02/12 12:51 PM

FIGURE 36-6 Performing vibration.
the fingers and thumb together, as if carrying water. He or

she then applies the cupped hands to the client’s chest as if
trapping air between them and the thoracic wall (Fig. 36-5).
The nurse performs percussion for 3 to 5 minutes in each
postural drainage position, taking care to avoid striking the
breasts of female clients and any areas of chest injury or
bone disease.
Vibration
Vibration uses the palms of the hands to shake underlying
tissue and loosen retained secretions. The nurse positions the
hands on the client’s chest or back during inhalation and then
vibrates them as the client exhales to increase the intensity of
expiration (Fig. 36-6). Vibration is used with or as an alter-
native to percussion, especially for frail clients.
FIGURE 36-4 The lung segments and corresponding postural
drainage positions. (Rosdahl, C. [2007]. Textbook of basic nurs- Suctioning Secretions
ing, 9th ed. Philadelphia: Lippincott Williams & Wilkins.) Suctioning relies on negative (vacuum) pressure to remove
liquid secretions with a catheter. The amount of negative
pressure varies depending on the client and the type of suc-
Percussion
tion equipment (Table 36-1). Nurses may suction the upper
Percussion (the rhythmic striking of the chest wall) helps to
airway, lower airway, or both. In all cases, they suction the
dislodge respiratory secretions that adhere to the bronchial
airway from the nose or mouth (Skill 36-1).
walls. To perform percussion, the nurse cups the hands, keeping
Nasopharyngeal suctioning (removing secretions
from the throat through a nasally inserted catheter) is more
common than nasotracheal suctioning (removing secre-
tions from the upper portion of the lower airway through a
nasally inserted catheter). A nasopharyngeal airway, some-
times called a trumpet (Fig. 36-7), can be used to protect the
nostril if frequent suctioning is necessary. An alternative
method is oropharyngeal suctioning (removing secretions
TABLE 36-1 Variations in Suction Pressure

PORTABLE
AGE WALL SUCTION SUCTION MACHINE
Adults 100–140 mm Hg 10–15 mm Hg
Children 95–100 mm Hg 5–10 mm Hg
Infants 50–95 mm Hg 2–5 mm Hg
FIGURE 36-5 Performing percussion.
LWBK1004-C36_p809-824.indd 813 04/02/12 3:38 PM

A
FIGURE 36-7 The placement of a nasopharyngeal trumpet.
from the throat through an orally inserted catheter). Nurses

perform oral suctioning (removing secretions from the
mouth) with a suctioning device called a Yankauer-tip or
tonsil-tip catheter (Fig. 36-8).

In addition to an SpO2 less than 90%, what signs or
symptoms does a person with hypoxia manifest?
ARTIFICIAL AIRWAY MANAGEMENT B
Clients at risk for airway obstruction or who require long-

term mechanical ventilation are candidates for an artificial
airway. Two common types are an oral airway and a trache-
ostomy tube.
Oral Airway
An oral airway is a curved device that keeps a relaxed
tongue positioned forward within the mouth, preventing the
tongue from obstructing the upper airway (Fig. 36-9). It is
most commonly used in clients who are unconscious and
cannot protect their own airway, such as those recovering
from general anesthesia or a seizure. Nurses insert oral air- C
ways, which usually are in place for a brief time only (see FIGURE 36-9 A. Examples of oral airways. B. The initial inser-
Nursing Guidelines 36-2). tion position. C. The final position after rotation.
Tracheostomy
Clients who are less stable, have an upper airway obstruc-
tion, or who require prolonged mechanical ventilation and
oxygenation are more likely to be candidates for a tracheos-
tomy (a surgically created opening into the trachea). A tube
is inserted through the opening to maintain the airway and
provide a new route for ventilation.
Tracheostomy Tube
A tracheostomy tube (a curved, hollow plastic tube) is also
FIGURE 36-8 A Yankauer-tip suction device for oral suctioning. called a cannula. Some devices have an inner and an outer
(Photo by B. Proud.) cannula. Tracheostomy tubes also may have a balloon cuff
LWBK1004-C36_p809-824.indd 814 04/02/12 3:38 PM


Rationales
Inserting an Oral Airway
• Gather the following supplies: various sizes of oral airways • Open the client’s mouth using a gloved finger and thumb or
(most adults can accommodate an 80-mm airway), gloves, a a tongue blade. Doing so prevents injury to the teeth during
tongue blade, and suction equipment. Gathering equipment insertion.
promotes organization and efficient time management. • Hold the airway so that the curved tip points upward toward
• Place the airway on the outside of the client’s cheek so that the the roof of the mouth (see Fig. 36-9B) or the side of the cheek.
front portion is parallel with the front teeth. Note whether or not Insert it about halfway. Such placement prevents pushing the
the back of the airway reaches the angle of the jaw. Assessment tongue into the pharynx during insertion.
determines the appropriate size to use. (An airway that is too • Rotate the airway over the top of the tongue and continue
short will be ineffective. An airway that is too long will depress inserting it until the front flange is flush with the lips (see Fig.
the epiglottis, increasing the risk of airway obstruction.) 36-9C). This ensures that the artificial airway follows the
• Wash your hands or perform an alcohol-based hand rub (see natural curve of the upper airway.
Chap. 10); don clean gloves. These measures reduce the trans- • Assess breathing. Checking breathing validates that the natu-
mission of microorganisms. ral airway is patent.
• Explain the procedure to the client. Instruction provides infor- • Remove the airway every 4 hours, provide oral hygiene,
mation that even unconscious clients may comprehend, despite and clean and reinsert the airway. Hygiene and cleaning
being unable to respond verbally. remove transient bacteria and promote the integrity of the
• Perform oral suctioning if necessary. Doing so clears saliva oral mucosa.
from the mouth and prevents aspiration. • As the client’s level of consciousness improves, many clients
• Position the client supine with the neck hyperextended unless extubate themselves independently.
contraindicated. This position opens the airway and facilitates
insertion.
(Fig. 36-10); when inflated, the cuff seals the upper airway Tracheostomy Suctioning
to prevent aspiration of oral fluids and to provide more effi- Most clients with a tracheostomy require frequent suction-
cient ventilation. During insertion of a tracheostomy tube, an ing. Although they can cough, the force of the cough may be
obturator, a curved guide, is used. Once the tube is in place, ineffective in completely clearing the airway, or the cough
the obturator is removed. may be inadequate to clear the volume of respiratory secre-
Because a tracheostomy tube is below the level of the tions. Therefore, suctioning is necessary when secretions are
larynx, clients usually cannot speak. Communication may copious.
involve writing or reading the client’s lips. Being unable to call Tracheostomy suctioning is similar to nasotracheal suc-
for help is frightening; therefore, the nurse should check these tioning except that catheter insertion is through the tracheos-
clients frequently and respond immediately when they signal. tomy tube rather than the nose (Fig. 36-11). When suctioning
a tracheostomy, the nurse inserts the catheter a shorter dis-
➧ Stop, Think, and Respond Box 36-2 tance (approximately 4 to 5 in. [10 to 12.5 cm] or until resist-
Discuss the physical and psychological effects a ance is felt) because the tube already lies in the trachea. The
client with a tracheostomy may develop as a conse-
quence of being unable to speak.
FIGURE 36-11 Suctioning through a tracheostomy tube.

FIGURE 36-10 A cuffed tracheostomy tube. (Photo by B. Proud.) (Courtesy of Swedish Hospital Medical Center.)
LWBK1004-C36_p809-824.indd 815 04/02/12 3:38 PM

resistance is caused by contact between the catheter tip and airway. They may do tracheal suctioning separately from or
the carina, the ridge at the lower end of the tracheal cartilage at the same time as tracheostomy care.
where the main bronchi are located. The nurse then raises the
catheter about 0.5 in. (1.25 cm) and applies suction.
Gerontologic Considerations Maintaining an open and patent airway is a priority for nurs-
ing care. Lack of oxygen for more than 4 to 6 minutes can
■ Older adults are at increased risk for cardiac dysrhythmias result in death or permanent brain damage. Therefore, it is
during suctioning because many have preexisting hypox- essential to identify nursing diagnoses that apply to respira-
emia from illnesses and age-related changes in ventilation.
tory problems and to plan care accordingly for clients at risk.
Some possible nursing diagnoses include the following:
Tracheostomy Care • Ineffective Airway Clearance
Tracheostomy care means cleaning the skin around the • Impaired Gas Exchange
stoma, changing the dressing, and cleaning the inner can- • Risk for Infection
nula (Skill 36-2). Nurses perform tracheostomy care at least • Impaired Spontaneous Ventilation
every 8 hours or as often as clients need to keep the secre- • Anxiety
tions from becoming dried, then narrowing or occluding the • Deficient Knowledge
N U R S I N G C A R E P L A N 3 6 - 1 Ineffective Airway Clearance

Assessment • Review the client’s medical record for conditions that may
• Observe characteristics of the client’s breathing and ability to alter the ability to protect and clear the airway, such as a
cough forcefully. decreased level of consciousness, unusual weakness or easy
• Inspect the sputum for evidence of a viscid consistency. fatigability, moderate-to-severe pain, and a surgical incision
• Auscultate the lungs to detect adventitious breath sounds about the thorax or abdomen.
suggestive of retained secretions. • Note if the client’s fluid intake is adequate.
• Assess vital signs to detect manifestations of impaired
oxygenation.
Nursing Diagnosis. Ineffective Airway Clearance related to retained secretions as manifested by weak and persistent cough
without raising sputum, rapid and shallow respirations, use of accessory muscles, inspiratory gurgles heard in distal right upper lobe
both anteriorly and posteriorly, and history of smoking two packs of cigarettes a day.
Expected Outcome. The client’s airway will be effectively cleared as evidenced by raising sputum sufficiently to keep lung
sounds clear by 12/4.
Auscultate the lungs every shift and before and after coughing Auscultation provides data indicating the presence or absence
or other respiratory therapy. of retained respiratory secretions.
Elevate the head of the bed at all times. The Fowler’s position helps to provide maximum room for
lung expansion.
Maintain 2,000–3,000 mL fluid intake of client’s choice (avoid Keeping the client well hydrated helps thin respiratory mucus.
milk) for 24 hours.
Instruct client to take three deep breaths in through the nose Deep breathing dilates the airways, stimulates surfactant
and out the mouth, lean forward, and cough forcefully. production, and expands the lung surface. Coughing loosens
Repeat every 1–2 hours while the client is awake. and forces secretions into the bronchi (Carpenito-Moyet,
2005).
Perform oral/pharyngeal suctioning if secretions are loose but Negative pressure produces a pulling effect, which can
the client does not expectorate them. remove mucoid secretions that the client cannot clear
independently.

• Client is instructed on deep breathing and the coughing • Client can raise tenacious, purulent sputum after breathing and
technique. coughing.
• Lungs sound less congested.
LWBK1004-C36_p809-824.indd 816 04/02/12 3:38 PM

Nursing Care Plan 36-1 shows how the nursing process 2. If all the following nursing measures are possible,
applies to a client with the nursing diagnosis of Ineffective which helps most when planning to obtain a sputum
Airway Clearance, defined in the 2012 NANDA-I taxonomy specimen?
(p. 421) as the “inability to clear secretions or obstructions 1. Provide the client with a generous fluid intake.
from the respiratory tract to maintain a clear airway.” 2. Assist the client to change positions regularly.
3. Ask the dietitian to send a high-protein diet.
4. Ensure that the client has sufficient rest periods.
CRITICAL THINKING EXERCISE 3. What time of the day is it best for the nurse to
attempt to obtain a sputum specimen?
1. What suggestions would you offer an individual to
1. Before bedtime
discourage him or her from continuing to smoke
2. After a meal
cigarettes?
3. Between meals
2. What pulmonary diseases are likely to be diagnosed
4. Upon awakening
by examining a sputum specimen, and what nursing
4. When suctioning a client with a tracheostomy tube,
actions facilitate an accurate examination of the col-
when is the best time to occlude the vent on the suc-
lected specimen?
tion catheter?
3. Why do body positions that place the head lower than
1. When inserting the catheter
the chest facilitate the expectoration of pulmonary
2. When inside the inner cannula
secretions?
3. When withdrawing the catheter
4. Discuss ways to relieve the anxiety of a client with
4. When the client begins coughing
a tracheostomy who needs frequent suctioning but
5. When suctioning the airway of a client with a trache-
fears he or she will be unable to obtain assistance
ostomy, the nurse applies suction for no longer than
when needed.
how long?
1. 5 to 7 seconds
2. 10 to 15 seconds
3. 15 to 20 seconds
1. Besides describing the characteristics of a client’s 4. 20 to 30 seconds
cough, what other information is most important to
document?
1. The client’s family history of respiratory disease
2. A current assessment of the client’s vital signs
3. The appearance of the respiratory secretions
4. The types of self-treatments that the client is using
LWBK1004-C36_p809-824.indd 817 20/02/12 12:51 PM

SKILL 36-1 Suctioning the Airway
ASSESSMENT
Assess the client’s lung sounds, respiratory effort, and oxygen Determines the need for suctioning.
saturation level.
Determine how much the client understands about suctioning Provides an opportunity for health teaching.
the airway.
Inspect the nose to determine which nostril is more patent. Eases insertion of the catheter.
PLANNING
Consider using a face shield and wearing a cover gown in addi- The nurse can choose to wear a face shield and cover gown as
tion to gloves when suctioning a client. part of standard precautions.
Obtain a suction kit. All kits contain a basin and one or two ster- Promotes organization and efficient time management.
ile gloves. Some also contain a sterile suction catheter.
If the kit does not include a catheter, select one that will not Promotes comfort and reduces the potential for injury.
occlude the nostril; usually a 12–18 F catheter is appropriate
for adults.
Obtain a flask of sterile normal saline and a suction machine if a Provides items that are not prepackaged.
wall outlet is unavailable.
Attach the suction canister to the wall outlet or plug a portable Provides a source for negative pressure.
suction machine into an electrical outlet.
Connect the suction tubing to the canister. Provides a means for connecting the canister to the suction
catheter.
Turn on the suction machine, occlude the suction tubing, and Ensures safe pressure during suctioning.
adjust the pressure gauge to the desired amount.
Open the container of saline. Reduces the risk for later contamination.
IMPLEMENTATION
Pull the privacy curtains. Demonstrates respect for the client.
Elevate the head of the bed unless contraindicated. Aids in ventilation.
Chap. 10).
Preoxygenate the client for 1–2 minutes until the SpO2 is main- Reduces the risk for hypoxemia.
tained at 95%–100%.
Open the suction kit without contaminating the contents. Follows the principles of asepsis.
Don sterile glove(s). If the kit provides only one, don a clean Prevents the transmission of microorganisms.
glove on the nondominant hand and then don the sterile
glove on the dominant hand.
Pour sterile normal saline into the basin with your nondominant Prepares the solution for wetting and rinsing the suction catheter.
hand.
Consider the nondominant hand contaminated. Follows principles of asepsis.
Pick up the suction catheter with your sterile (dominant) hand Completes the circuit for applying suction.
and connect it to the suction tubing (Fig. A).
Connecting the catheter. (Photo by B. Proud.)
A
(continued)
LWBK1004-C36_p809-824.indd 818 04/02/12 3:38 PM

Suctioning the Airway (continued)
Place the catheter tip in the saline and occlude the vent (Fig. B). Wets the outer and inner surfaces of the catheter, which reduces
friction and facilitates insertion.
Wetting the catheter. (Photo by B. Proud.)
Insert the catheter without applying suction along the floor of Reduces the potential for sneezing or gagging.
the nose or side of the mouth (Fig. C).
C
Catheter placement: nasopharyngeal (left), oropharyngeal (center), and nasotracheal (right).
Advance the catheter 5–6 in. (12.5–15 cm) in the nose or 3–4 in. Places the distal tip in the pharynx.
(7.5–10 cm) in the mouth.
For tracheal suctioning, wait until the client takes a breath and Eases insertion below the larynx.
then advance the tubing 8–10 in. (20–25 cm).
Encourage the client to cough if coughing does not occur spon- Breaks up mucus and raises secretions.
taneously.
Occlude the air vent and rotate the catheter as it is withdrawn. Maximizes the effectiveness of suctioning.
Complete the process in no more than 15 seconds from inser- Prevents hypoxemia.
tion to removal of the catheter, occluding the vent no longer
than 10 seconds.
Rinse secretions from the catheter by inserting its tip in the Flushes the mucus from the inner lumen.
basin of saline and applying suction.
Provide 2–3 minutes of rest while the client continues to Reoxygenates the blood.
breathe oxygen.
Suction again if necessary. Bases decision on individual assessment data.
(continued)
LWBK1004-C36_p809-824.indd 819 04/02/12 3:38 PM

Suctioning the Airway (continued)
Remove the gloves to enclose the suction catheter in an Encloses the soiled catheter, reducing the transmission of micro-
inverted glove (Fig. D). organisms.
Enclosing the catheter. (Photo by B. Proud.)
Discard suction kit, catheter, and gloves in a lined waste Follows principles of asepsis.
receptacle.
Evaluation
• The airway is cleared of secretions.
• The SpO2 level remains at 95% or higher.
• The client demonstrates breathing that requires less effort.
Document
• Type of suctioning performed
• Appearance of secretions
Date and Time Respirations are moist and noisy. SpO2 shows a drop from 95% to 90% during the last 15 minutes. Coughing
effort is weak and ineffective. Raised to a high Fowler’s position and oxygenated at 4 L per nasal cannula.
Tracheal suctioning performed and reoxygenated. Lungs sound clear at this time. Pulse oximeter indicates
SpO2 at 95% at this time. ____________________________________________________________ SIGNATURE/TITLE
SKILL 36-2 Providing Tracheostomy Care
ASSESSMENT
Check the nursing care plan to determine the schedule for Provides continuity of care.
providing tracheostomy care.
Review the client’s record for documentation concerning previ- Provides a data base for comparison.
ous tracheostomy care.
Assess the condition of the dressing and the skin around the Determines the need for a dressing change and skin care.
tracheostomy tube.
Determine the client’s understanding of tracheostomy care. Provides an opportunity for health teaching.
(continued)
LWBK1004-C36_p809-824.indd 820 20/02/12 12:51 PM

Providing Tracheostomy Care (continued)
PLANNING
Consult with the client on an appropriate time for tracheostomy Demonstrates respect for the client’s right to participate in deci-
care if only routine care is needed. sions.
Consider using a face shield and wearing a cover gown in addi- The nurse can choose to wear a face shield and cover gown as
tion to gloves when suctioning a client. part of standard precautions.
Obtain a container of hydrogen peroxide and a flask of normal Provides items that are not prepackaged and prevents the con-
saline. Remove the cap from each container. tamination of one gloved hand later in the procedure.
IMPLEMENTATION
Chap. 10).
Raise the bed to an appropriate height. Prevents back strain.
Place the client in a supine or low Fowler’s position. Facilitates access to the tracheostomy tube.
Don a clean glove; remove the soiled stomal dressing and dis- Follows the principles of asepsis.
card it, glove and all, in a lined waste receptacle.
Wash your hands or perform an alcohol-based hand rub again. Reduces the transmission of microorganisms.
Open the tracheostomy kit, taking care not to contaminate its Provides access to and maintains the sterility of supplies.
contents.
Don sterile gloves. Prevents transferring microorganisms to the lower airway.
Add equal parts of sterile normal saline and sterile hydrogen per- The diluted hydrogen peroxide cleans mucoid secretions; the
oxide to one basin and sterile normal saline to the other (Fig. A). sterile normal saline rinses the peroxide solution from the skin
and inner cannula.
Adding the cleaning solutions. (Courtesy of Swedish Hospital Medical Center.)
Unlock the inner cannula (using one hand, which is now consid- Loosens protein secretions and reduces colonizing
ered contaminated) by turning it counterclockwise; deposit it microorganisms.
in the basin with the hydrogen peroxide and saline solution
(Fig. B).
Removing the inner cannula. (Courtesy of Swedish Hospital Medical Center.)
B
(continued)
LWBK1004-C36_p809-824.indd 821 04/02/12 3:38 PM

Clean the inside and outside of a plastic cannula with pipe Removes gross debris; pipe cleaners are less likely to scratch a
cleaners; use pipe cleaners or a soft brush for a metal plastic cannula.
cannula (Fig. C).
Cleaning the inner cannula. (Courtesy of Swedish Hospital Medical Center.)
Deposit contaminated supplies in a lined or waterproof waste Reduces the potential for contaminating sterile supplies.
receptacle.
Rinse the cleaned cannula in the basin of normal saline. Removes remnants of hydrogen peroxide.
Tap the rinsed cannula against the edge of the basin and wipe Removes large droplets of fluid.
the excess solution with a gauze square.
Replace the inner cannula and turn it clockwise within the outer Secures the inner cannula.
cannula (Fig. D).
Replacing the inner cannula. (Courtesy of Swedish Hospital Medical Center.)
Clean around the stoma with an applicator moistened with the Removes secretions and colonizing microorganisms from the
diluted peroxide (Fig. E). tracheal opening.
Never go back over an area once you have cleaned it.
Cleaning the stoma. (Courtesy of Swedish Hospital Medical Center.)
E
(continued)
LWBK1004-C36_p809-824.indd 822 04/02/12 3:38 PM

Wipe the same area in the same manner with another applica- Removes hydrogen peroxide from the skin.
tor moistened with saline.
Place the sterile stomal dressing beneath the flanges and outer Absorbs secretions and keeps the stomal area clean.
cannula of the tracheostomy tube (Fig. F).
Applying the stomal dressing. (Photo by B. Proud.)
Change the tracheostomy ties by threading them through the Holds the tracheostomy tube in place.
slits of each flange of the tracheostomy tube and tying them
in place (Fig. G).
Securing the tracheostomy ties. (Courtesy of Swedish Hospital Medical Center.)
Wait to remove the previous ties until after the new ones are Prevents accidental extubation.
secure, if working alone. Otherwise, have an assistant stabi-
lize the tracheostomy tube while you cut the soiled ties and
apply the new ties.
Tie the two ends snugly, but not tightly, at the side of the neck. Prevents skin impairment.
Make sure there is room to insert your little finger within the
ties before securing the ends.
Discard all soiled supplies, remove your gloves, and wash your Follows the principles of asepsis.
hands or perform an alcohol-based hand rub.
Return the client to a safe and comfortable position. Demonstrates concern for the client’s well-being.
Restore a means that the client can use to signal for assistance Facilitates meeting the client’s needs in emergencies and non-
(eg, call button, bell). emergencies.
(continued)
LWBK1004-C36_p809-824.indd 823 04/02/12 3:38 PM

Evaluation
• The tracheostomy tube remains patent.
• The stomal opening is clean and without evidence of infection.
• The dressing is clean and dry.
• The skin around the neck is intact.
Document
• Procedure as it was performed
• Appearance of skin and secretions
Date and Time Respirations are quiet and effortless. Routine tracheostomy care provided. Moderate amount of clear
mucus removed from inner cannula during cleaning. Stomal skin is pink, but there is no redness,
tenderness, swelling, or purulent drainage. Neck skin is intact; skin color is comparable to surrounding
areas. _________________________________________________________________________ SIGNATURE/TITLE
LWBK1004-C36_p809-824.indd 824 20/02/12 12:51 PM

Photo to
Come
FPO
37# Resuscitation
asystole
automated external defibrillator
cardiac arrest 1. Explain why an airway obstruction is life threatening, and give at
cardiopulmonary resuscitation least three signs of an airway obstruction.
Chain of Survival 2. Describe appropriate actions if a client has a partial airway
code obstruction.
head-tilt/chin-lift technique 3. Explain the purpose of the Heimlich maneuver and describe the
Heimlich maneuver circumstances for using subdiaphragmatic and chest thrusts.
jaw-thrust maneuver 4. Identify the recommended action for relieving an airway obstruc-
recovery position tion in an infant and in an unconscious person.
rescue breathing 5. List the five steps in the Chain of Survival.
resuscitation team 6. Explain cardiopulmonary resuscitation (CPR) and its associated
subdiaphragmatic thrust Circulation, Airway, Breathing (CAB).
ventricular fibrillation 7. Describe the purpose of chest compression.
8. Name two techniques for opening the airway and list three ways
a trained rescuer administers rescue breathing.
9. Discuss the appropriate use of an automated external defibrilla-
tor (AED).
10. Name at least three criteria used in the decision to discontinue
resuscitation efforts.
N
urses are often the first to respond to pulmonary or cardiac emer-
gencies. The information in this chapter reflects the American Heart
Association’s (AHA) International CPR and Emergency Cardio-
vascular Care (ECC) Guidelines of 2010 for performing basic life-
support techniques.
AIRWAY OBSTRUCTION
The upper airway, can become occluded for various reasons (Box
37-1). Sometimes, the airway swells because of injury; in such cases,
the client may need an artificial airway to promote and sustain breath-
ing (see Chap. 36). A bolus of food or some other foreign object may
cause mechanical airway obstruction. Regardless of the cause, airway
obstruction compromises air exchange and subsequent oxygenation of
cells and tissues. For this reason, unrelieved airway obstruction will
lead to a loss of consciousness, and, eventually, death.

Discuss circumstances in which a person is at high risk for me-
chanical airway obstruction.
825
LWBK1004-C37_p825-840.indd 825 2/6/12 7:09 PM

B OX 3 7- 1 Common Causes of Airway

Obstruction
• Compromised swallowing
• Aspiration of vomitus
• Insufficient chewing
• Consuming large pieces of food
• Laughing or talking while chewing
• Eating when intoxicated
• Inhaling foreign objects from the mouth
Identifying Signs of Airway Obstruction

Signs of airway obstruction (Box 37-2) generally occur
while the person is eating. The victim immediately may
grasp his or her throat with the hands (Fig. 37-1) and make
aggressive efforts to cough and breathe. He or she may make
a high-pitched sound while inhaling. The face initially red-
dens then becomes pale or blue.
FIGURE 37-1 The universal sign for choking. (Photo by B. Proud.)
Relieving an Obstruction
If the victim can speak or cough, he or she is exchanging
some air, which indicates only a partial obstruction. Because • For infants (children younger than 1 year of age), the res-
infants cannot talk or make the universal choking sign, the cuer supports the baby over his or her forearm. Holding
ability to cry is the best evidence of partial obstruction in the infant prone with the head downward, the rescuer
this age group. Other than encouraging and supporting the uses the heel of one hand to administer five back slaps
victim, a partial obstruction requires no additional resuscita- between the shoulder blades (Fig. 37-2A). The rescuer
tion efforts. turns the infant supine and uses two fingers to give five
If the victim’s independent efforts to relieve a partial chest thrusts at approximately one per second to the mid-
obstruction are unsuccessful or if the situation worsens, acti- dle of the breastbone, just below the nipple line (see Fig.
vating the emergency medical system is appropriate. In the 37-2B). He or she repeatedly alternates five back blows
hospital, staff members do this by calling a code (summon- and chest thrusts until the object is dislodged or the infant
ing personnel trained in advanced life support techniques). fails to respond. The rescuer does not use finger sweeps
In the community, people can obtain assistance by dialing unless he or she can see the obstructing object. If the
911 or another emergency number. infant becomes unconscious, the rescuer performs CPR
If an obstruction becomes complete, immediate action (described later).
is necessary to dislodge the obstruction. When the victim • For all people older than 1 year of age, the rescuer gives a
is conscious, the Heimlich maneuver (the method for series of five quick subdiaphragmatic (abdominal) upward
relieving a mechanical airway obstruction) is appropriate. It thrusts slightly above the navel to increase intrathoracic
involves the use of subdiaphragmatic thrusts (pressure to pressure equivalent to a cough (Fig. 37-3). The rescuer
the abdomen) or chest thrusts. The victim’s age determines opens the victim’s airway with the head-tilt/chin-lift
how these thrusts should be performed. maneuver (described later) and continues administering
upward thrusts if initial efforts are not successful. He or
she avoids blind finger sweeps unless the object in the air-
B OX 3 7- 2 Signs of a Partial or Complete Airway way is visible. If the person becomes unconscious, the res-
Obstruction cuer supports the victim to the floor, activates the emer-
• Coughing or gagging while eating gency response system, and begins performing CPR
• Audibly wheezing (described later). The victim’s mouth is checked for any
• Persistently attempting to clear throat visible object when each attempt at ventilation is made.
• Making hoarse or wet vocal sounds
• Resisting efforts to be fed
When the victim is unconscious, the AHA recommends
• Being unable to speak the use of basic CPR (described later in this chapter), using
• Holding throat chest compressions rather than abdominal thrusts. Chest
• Being unable to breathe compressions in CPR creates enough pressure in uncon-
• Exhibiting cyanosis scious victims to eject a foreign body from the airway (Berg
et al., 2010; Salati, 2006).
LWBK1004-C37_p825-840.indd 826 2/6/12 7:09 PM

CHAPTER 37 Resuscitation 827
steps occur, the better the victim’s chances. Outcomes are

best when rescuers perform these steps rapidly.
■ Congress legislated a person’s right to refuse medical

treatment in 1990. All states implemented the Patient Self-
Determination Act in 1991. This act recognizes that the cli-
ent, not the health care provider, is the ultimate authority in
making decisions related to life-sustaining treatments.
■ Federal law mandates that all health care institutions that
participate in Medicare and Medicaid provide information
about the Patient Self-Determination Act as it applies to
establishing an advance directive or living will.
A B ■ Older adults may need very clear and pertinent descrip-
FIGURE 37-2 Assisting an infant with an obstruction. A. Giving tions of various treatments and measures for resuscitation
back blows. B. Delivering chest thrusts. addressed in advance directives. An older adult’s advance
directive should specify exactly the type of resuscitation he
or she wishes. For example, some clients approve the use
of emergency drugs but refuse mechanical ventilation.
CHAIN OF SURVIVAL
■ When possible, it is important to allow several days for
older adults to consider advance directives before they sign
If a person’s unresponsiveness may be the result of cardiac legal documents. They may benefit from consulting trusted
arrest (the cessation of heart contraction or a life-sustaining members of their religious affiliation or trusted medical
heart rhythm), rescuers implement a five-step intervention authorities. Also, discussing the implications of advance
process known as the Chain of Survival. The steps involve directives as they apply to various settings is important. For
(1) immediate recognition and access of emergency services, example, if a person at home has an advance directive pro-
(2) early CPR with a focus on compressions, (3) rapid defi- hibiting resuscitation, family members and caregivers need
brillation if appropriate, (4) effective advanced life support, to understand that it may not be appropriate to call 911 or
and (5) integrated postcardiac arrest care. Survival rates begin basic life-support procedures.
following cardiac arrest depend greatly on the speed with ■ Nurses are responsible for ascertaining whether an older
client has an existing advance directive and ensuring that
which rescuers initiate the Chain of Survival. The faster the
the directions continue to reflect the client’s wishes.
■ Family caregivers, particularly those designated as having
health care powers of attorney, should be included in dis-
cussions about resuscitation efforts. A helpful booklet, Hard
Choices for Loving People: CPR, Artificial Feeding, Comfort
Measures Only and the Elderly Patient by Hank Dunn, is
available at http://www.hardchoices.com.
■ Some older adults fear that if they specify that they do
not wish to be resuscitated, they will receive less-than-
appropriate care and treatment of their illness. The client’s
record must contain his or her resuscitation status. If no
information is documented, CPR is administered in any
life-threatening situation regardless of the client’s age.
■ Advance directives are to be reviewed periodically (at
least annually and whenever a major change occurs in the
older adult’s health status) and updated according to the
current situation and living arrangement. For example, if an
older adult is in a long-term care institutional setting, the
staff needs specific directives about when to send him or
her to an emergency room. Similarly, in home care situa-
tions, caregivers need very specific guidelines about what
course of action to take under various circumstances.
■ Older adults need to be informed that they may change
their mind about advance directives and instructions for
resuscitation at any time. All changes must be communi-
cated to the physician, and a written copy should be stored
in a safe location.
FIGURE 37-3 Giving subdiaphragmatic thrusts.
LWBK1004-C37_p825-840.indd 827 2/6/12 7:09 PM

Early Recognition and Access of ■ Older adults who take a daily dose of aspirin or some
Emergency Services other anticoagulant drug are more apt to bleed internally
With the victim in a supine position on a dry, firm surface, a during chest compressions.
quick assessment taking no more than 10 seconds is performed
to determine unresponsiveness and the absence of normal The correct sequence is 30 chest compressions fol-
breathing. Responsiveness is determined by shouting and shak- lowed by two rescue breaths for rescuers who are able to
ing the victim. If the victim appears lifeless or is not breath- do so, or a ratio of 30:2 (whether by one or two rescu-
ing normally, it is essential to activate the emergency medical ers) for children older than 1 year of age. If there are two
response system, whether outside or within a health care facil- rescuers and the victim is younger than 1 year of age, the
ity. This can be done by a bystander or second rescuer as well. ratio is 15 compressions to 2 breaths (15:2); if the rescuer
In most locations, emergency medical assistance is obtained is alone, a 30:2 ratio is maintained.
by dialing 911 and providing information to a central phone Correct placement of the hands and the body is essential
operator. The person making the call gives the following facts: during chest compressions. The rescuer puts the heel of one
hand over the lower half of the victim’s sternum but above
• The address where assistance is needed
the xiphoid process and the other hand on top, then inter-
• A description of the situation
locking or extending his or her fingers. The rescuer positions
• The victim’s current condition
his or her body over the hands to deliver a straight downward
• What actions have been taken
motion with each compression and allowing the chest wall
Emergency medical technicians or paramedics are then to recoil afterwards (Fig. 37-4). The hands remain in contact
dispatched to the scene. If the emergency involves someone with the chest, and the elbows stay locked to avoid rocking
within a health care agency, the resuscitation team (a group back and forth over the victim. Table 37-1 lists variations in
of people who have been trained and certified in advanced rescue breathing and chest compressions to accommodate
cardiac life-support [ACLS] techniques) is alerted by notify- anatomic differences and the physiologic needs of various
ing the switchboard operator that assistance is needed and age groups.
the location of the emergency. Basic CPR is not interrupted for more than 10 seconds
except when:
Early Cardiopulmonary Resuscitation
• There is a pulse and the victim resumes breathing.
Resuscitation must proceed with CAB (circulation, airway,
• The rescuer becomes exhausted.
breathing if the rescuer is a trained health provider, or hands-
• The victim’s condition deteriorates despite resuscitation
only chest compressions if untrained in defibrillation) or
efforts.
cardiopulmonary resuscitation (CPR), a technique used to
• There is written evidence that resuscitation is contrary to
restore circulation and breathing.
the victim’s wishes.
Promoting Circulation • ACLS measures such as defibrillation are administered.
Circulation is achieved by performing chest compressions.
Chest compression promotes circulation in one of two ways.
Squeezing the heart between the sternum and the vertebrae
increases pressure in the ventricles, which is thought to push
blood into the pulmonary arteries and aorta. Chest compres-
sions also are thought to increase pressure in thoracic blood
vessels, promoting systemic blood flow. For chest compres-
sions to be effective, the rescuer must deliver them hard and
fast. Thirty chest compressions should be administered ini-
tially before attempting to open the airway and give rescue
breaths. The chest of an adult victim should be depressed to at
least 2 in. at a rate of 100 times per minute, a pace that com-
pares to the beat in the Bee Gees’ disco song, “Stayin’ Alive.”
■ In the performance of chest compressions, older adults

are at a greater risk for fractured ribs because of the
increased likelihood of osteoporosis. Similarly, those with
vascular disease may not receive adequate blood perfusion
of the brain during CPR, and they may experience brain
damage as a result. FIGURE 37-4 The correct hand and body position.
LWBK1004-C37_p825-840.indd 828 2/6/12 7:09 PM

TABLE 37-1 Differences in CPR Among Infants, Children, and Adults

TECHNIQUE INFANT (UP TO 1 YEAR OF AGE) CHILD (1–8 YEARS) ADULT (OVER 8 YEARS OF AGE)
Compressions
Location In the midline, one finger Center of the chest between the Center of the chest between the
width below the nipples nipples nipples
Hand use Two thumbs with the hands Heel of one hand with second Two hands; heel of one hand with
encircling the chest for hand on top, or heel of one other hand on top
two rescuers or two hand only
fingers on the breastbone
if alone
Rate 100/min 100/min 100/min
Depth At least one-third the depth At least one-third the depth of the 2 in. or more
of the chest, about 1½ in. chest, about 2 in.
Rescue Breaths
Compressions only when
rescuer is untrained
or trained but not
proficient
Ratio of compressions 30:2 (one rescuer) 30:2 (one rescuer) 30:2 (one or two rescuers)
to ventilation until 15:2 (two rescuers) 15:2 (two rescuers)
advanced airway is in
place
Duration 1 second with visible rise in 1 second with visible rise in chest 1 second with visible rise in chest
chest
Opening the Airway

In the absence of head or neck trauma and taking care not
to twist the spine in case there is unidentified trauma, a res-
cuer can use the head-tilt/chin-lift technique (a method of
choice for opening the airway; Fig. 37-5A) or the jaw-thrust
maneuver (an alternative method for opening the airway by
grasping the lower jaw and lifting it while tilting the head
backward; Fig. 37-5B). The jaw-thrust maneuver is not rec-
ommended for lay rescuers because it is difficult to perform
safely and may cause injury to the spine. When the airway is
opened, rescuers remove any foreign material that is visible
within the victim’s mouth.
After opening the airway, the presence of spontaneous
breathing can be determined, but minimizing hands-off time
is essential. Rescuers observe for the rising and falling of the
chest and listen and feel for air escaping from the nose or A
mouth. A breathing victim is placed in the recovery position
(a side-lying position that helps to maintain an open airway
and prevent aspiration of fluid). If breathing is not restored
within 10 seconds, the victim remains supine and CPR is
continued.
Performing Rescue Breathing

Rescuers who are health professionals perform rescue breath-
ing (the process of ventilating the lungs) through the victim’s
mouth, nose, or stoma. They should use a one-way valve mask
or other protective face shield if available. These devices theo-
retically reduce the potential for acquiring infectious diseases B
(eg, hepatitis, AIDS); however, the lack of a barrier device FIGURE 37-5 Techniques to open the airway. A. The head-tilt/
should not interfere with attempting rescue breathing. chin-lift technique. B. The jaw-thrust technique.
LWBK1004-C37_p825-840.indd 829 2/6/12 7:09 PM

Because many lay bystanders are unwilling to performthe rescuer closes the victim’s mouth and blows air into the
mouth-to-mouth ventilation because of fears of disease trans-nose.
mission, continuous chest compressions alone are better than
totally avoiding efforts at resuscitation. Continuous chestMouth-to-Stoma Breathing
compressions by laypersons produce similar survival when The rescuer can give rescue breathing to a client with a
compared with those who receive rescue breathing combined laryngectomy by sealing his or her mouth over the victim’ s
with chest compressions (Cone, 2010; Bobrow et al., 2010). stoma. Because the upper airway is essentially a blind path-
When the rescuer is trained, each rescue breath should way, the nose does not require sealing.
last 1 second and should cause the chest to rise visibly. Res- For clients with a tracheostomy tube, rescue breathing
cue breathing continues at the rate of two breaths for every is through the tube with the mouth or a one-way valve mask.
30 compressions for an adult for one or two rescuers; for If the tracheostomy tube does not have anated infl cuff, the
children or infants, the rate is two breaths for every 30 com-rescuer must seal the victim’s nose.
pressions for a single trained rescuer or two breaths for every
15 compressions when administered by two trained rescuers.
Once an advanced airway is in place, rescue breathing Early Defibrillation
If there is no circulation, breathing or movement after ve fi
is administered at a rate of 8 to 10 breaths per minute for
cycles of cardiac compressions and rescue breathing, an
infants, children, and adults without a pause in chest com-
AED is attached without exceeding a 10-second interruption
pressions.
in CPR. An automated external defibrillator (AED) is a
portable, battery-operated device that analyzes heart rhythms
Mouth-to-Mouth Breathing and delivers an electrical shock to restore a functional heart-
In mouth-to-mouth breathing, a rescuer seals the victim’sbeat. With the exception of newborns, defibrillation is per-
nose, uses his or her mouth to cover the victim’ s mouth, formed as soon as possible in victims experiencing ventricu-
and blows air into the victim (Fig. 37-6). Giving a breath lar fibrillation, an ineffective heart rhythm (Fig. 37-7). In
that lasts a full second reduces the potential for distendingchildren from 1 to 8 years of age or who weigh less than
the esophagus and stomach, which may promote regurgita- 55 lb, the AED must be capable of delivering a pediatric
tion and aspiration. If breathing is not restored, the victimshockable dose using cables that reduce the amount of energy
remains supine, an advanced airway is placed, and rescue directed at the heart (Schiammarella & Stoppler, 2007).
breathing continues at the rate of one breath every 6 to 8 Ideally, an AED is used as rapidly as possible. Survival
seconds without interrupting chest compressions. rates after cardiac arrest decrease signi cantly
fi with every
minute that defi brillation is delayed. Asystole, the absence
Mouth-to-Nose Breathing of any heart rhythm, quickly follows ventricularbrillation.
fi
Mouth-to-nose breathing is necessary when the victim is an Outcomes are best when defi brillation occurs within 3 min-
infant or a small child or when mouth-to-mouth breathingutes of chest compressions (Berg et al., 2010; Link et al.,
is impossible or unsuccessful. In mouth-to-nose breathing, 2010).
AEDs are located in many public access locations, such
as schools, airports, and police stations. Once obtained, the
user turns on the AED, so that he or she can observe its mon-
itor screen. Most AEDs have pictorial instructions and the
capacity to provide voice instructions.
Attaching the Electrode Pads

The rescuer attaches the preconnected electrode pads to the
victim’s skin (Fig. 37-8). If the monitor displays an error
message, it may be because the victim’s skin is diaphoretic
or extremely hairy, which interferes with effective contact.
2 inches
The rescuer can wipe the skin with a towel, shave or clip
chest hair, and apply a second set of electrode pads.
■ If a person has an implanted defibrillator or a pacemaker

evidenced by a hard object beneath the skin with an overly-
ing scar, the AED pad must be placed at least 1 in. to the
side of the implanted device.
FIGURE 37-6 Mouth-to-mouth rescue breathing.
LWBK1004-C37_p825-840.indd 830 20/02/12 3:16 PM

ASSESS VICTIM
within 10 seconds
ACCESS ADVANCED LIFE SUPPORT TEAM
BEGIN CPR
Within 2 minutes
Attach electrode pads
Turn defibrillator on
Follow directions
GIVE SHOCK*, if indicated If no shock indicated*
Administer 5 cycles Continue 5 cycles

(2 minutes) CPR (2 minutes) CPR
Reanalyze Reanalyze
Continue from * until Continue from * until

ADVANCED LIFE SUPPORT is available
or the victim starts to move
FIGURE 37-7 An algorithm for resuscita-
tion.
Analyzing the Rhythm provides a message indicating that the victim needs “shock”
When the electrode pads are in place and the victim is motion- or “no shock.”
less, the rescuer presses an analyze button on the AED or the
process occurs automatically. After 5 to 15 seconds, the AED Administering a Shock
When the AED indicates “shock,” the rescuer looks to make
sure that no one is touching the victim. Saying “clear” or
“everybody clear” in a loud voice is recommended before
pressing the shock button. The AED discharges the shock,
which is confirmed by the victim’s sudden muscle contrac-
tion. CPR resumes immediately after the shock and contin-
ues for five cycles (approximately 2 minutes) before ana-
lyzing the rhythm again with the AED. The rescuer then
facilitates another analysis of the rhythm and waits for the
next message to shock or not shock. The rescuer repeats
the shock, if indicated, then 2 minutes of CPR, and then the
analysis steps again and again until either the AED gives a
“no shock” message, the victim begins to move, or personnel
with ACLS skills arrive to assist.
■ Some older adults with a history of chronic, life-

threatening dysrhythmias who are unresponsive to drug
FIGURE 37-8 An automated external defibrillator (AED). therapy have an automatic internal cardiac defibrillator sur-
(Courtesy of Medtronic, Inc.) gically inserted within their chest. The device senses the
LWBK1004-C37_p825-840.indd 831 2/6/12 7:09 PM

dysrhythmia and almost instantaneously delivers an electri- resuscitation efforts in the future. Health care facility per-
cal current to restore normal heart rhythm. Wait 30 to sonnel are admonished to follow the steps in the Chain of
60 seconds after an implanted defibrillator finishes giving Survival and use an AED as soon as possible when discover-
a shock before using an AED. ing an unresponsive client rather than waiting for the arrival
of the resuscitation team.

Review the differences in resuscitating infants, chil- DISCONTINUING RESUSCITATION
dren, and adults.
Not every resuscitation attempt is successful. Severe neuro-
Continuing CPR without Defibrillation logic deficits often result even when a victim’s life is saved.
When an AED is not available and the arrival of emergency Success is measured more appropriately by the victim’s
resuscitation personnel is delayed, those trained and profi- quality of life rather than its quantity. Therefore, there often
cient in CPR continue at a rate of 30 compressions to two comes a time, in the absence of a “Do Not Resuscitate” order
ventilations. Periodically, rescuers assess the victim to or advanced directive, when a team must decide to discon-
determine whether CPR is effective. They should perform tinue both basic and advanced life-support efforts.
an assessment initially after five cycles (2 minutes) of com-
pressions and ventilations. An assessment for signs of spon-
taneous breathing can take place only by interrupting chest Gerontologic Considerations
compressions; such interruptions should last no more than
10 seconds and preferably less. Resuscitation should con- ■ Because no clear-cut guidelines for suspending resuscita-
tinue until there are signs of movement or emergency medi- tion have been established, efforts may extend for long
cal personnel arrive and assume care of the victim. periods. The decision in a health care facility to stop resus-
citation is a medical judgment made by the physician or
Early Advanced Life Support leader of the code.
■ The decision to stop resuscitation efforts often is based
Emergency medical support personnel such as paramed-
on the time that elapsed before resuscitation was begun,
ics provide early advanced life support. They are trained in the length of time that resuscitation has continued without
techniques for inserting endotracheal tubes and administer- any change in the victim’s condition, the age and diagnosis
ing supplemental oxygen. They also carry an AED as part of of the victim, and objective data such as arterial blood gas
their resuscitative equipment and can administer defibrilla- results and electrolyte studies. Regardless of the basis for
tion if a public access defibrillator is unavailable. Paramed- the decision, it is not made lightly, and those involved in an
ics administer emergency medications that can improve the unsuccessful code need support from their colleagues. It
potential for resuscitation before and during the transport of has been noted that family presence during resuscitation
the victim to a hospital’s emergency department. has positive psychological value regardless of the outcome.
It is also important that a staff member supports the
observers throughout the experience as well as afterward.
RECOVERY
When there is evidence of circulation and breathing, rescu-

ers place the victim in a recovery position (Fig. 37-9). If an NURSING IMPLICATIONS
AED has been used, the electrodes remain in place. Rescuers
continue to monitor the victim and stand prepared to reacti- Nurses have several responsibilities associated with resusci-
vate the defibrillator if the victim’s condition worsens again. tation. They must learn to perform basic cardiac life-support
Once the victim is stable, rescuers evaluate their inter- measures, which includes the correct use of an AED, and
ventions and operation of the AED for quality assurance. they must maintain their certification to do so. If nurses do
Internal self-evaluation provides a means to improve similar not use or refresh these skills at least every 2 years, their
FIGURE 37-9 The recovery

position.
LWBK1004-C37_p825-840.indd 832 2/6/12 7:09 PM

abilities may be less than adequate. They also must support • Impaired Gas Exchange
and participate in efforts to teach lay people, both adults and • Decreased Cardiac Output
children, how to perform CPR and carry out the Chain of • Ineffective Cardiopulmonary Tissue Perfusion
Survival. Nurses must discuss advance directives (see Chap. • Ineffective Cerebral Tissue Perfusion
3) with all clients regardless of the reason for admission to a • Ineffective Renal Tissue Perfusion
health care agency. Honoring the client’s right to participate • Decisional Conflict
in the decision-making process is important.
Nursing Care Plan 37-1 shows how nurses can use the
The following nursing diagnoses may be relevant in a
steps in the nursing process for a client with Impaired Sponta-
resuscitation situation:
neous Ventilation, defined in the NANDA-I taxonomy (2012,
• Ineffective Airway Clearance p. 239) as “decreased energy reserves (that) result in an individ-
• Impaired Spontaneous Ventilation ual’s inability to maintain breathing adequate to support life.”
Risk for Inability to Sustain Spontaneous

NURSING CARE PLAN 37-1
Ventilation
Assessment • Apply a pulse oximeter and note the SpO2 level.
• Monitor respiratory rate and breathing pattern. • Obtain and analyze the findings of an arterial blood gas.
• Observe for tachypnea, bradypnea, and periods of apnea. • Determine if the client has received medication that causes
• Note signs of respiratory distress such as the use of accessory respiratory depression.
muscles, sitting upright, nasal flaring, restlessness, and • Check the cause for high- or low-pressure alarms on a
cyanosis. mechanical ventilator; it could be malfunctioning.
• Ask the client if he or she is choking or look for the universal • Assess the client’s level of consciousness and responsiveness.
sign of the hand to the throat. • Determine if there is an absence of breathing, coughing, and
• Check for tachycardia. movement.
Nursing Diagnosis. Risk for Inability to Sustain Spontaneous Ventilation related to progressive respiratory muscle weakness
secondary to amyotrophic lateral sclerosis (Lou Gehrig’s disease) as manifested by shallow respirations of 32 per minute; SpO2 of
85% with oxygen at 6 L per Venturi mask; difficulty talking and swallowing; resuscitation by paramedics who responded to the fam-
ily’s 911 call for assistance; and statement, “It has been more and more difficult for me to breathe. My doctor told me that’s the usual
outcome from this disease.”
Expected Outcome. The client will breathe spontaneously at a ventilation rate to sustain life.
Monitor SpO2 with pulse oximeter at all times. The pulse oximeter measures the amount of oxygen bound
to hemoglobin; sustained SpO2 levels of <90% indicate a
need for supplemental oxygen. An SpO2 level of 80% equals
an approximate PaO2 of 45 mm Hg. This finding indicates
moderate-to-severe hypoxemia and the need for mechanical
ventilation.
Administer oxygen at 45% using a Venturi mask. A Venturi mask delivers the exact amount of prescribed oxy-
gen; 45% oxygen is slightly double the amount of oxygen in
room air; supplemental oxygen helps to relieve hypoxemia.
Maintain the client in a Fowler’s position. It facilitates chest expansion by lowering abdominal organs
away from the diaphragm, thus increasing the potential for a
greater volume of inspired air.
Replace the Venturi mask with a non-rebreather mask if SpO2 A non-rebreather mask can deliver 90%–100% oxygen until
falls below 80%. the client can receive ventilation assistance.
Obtain arterial blood gas when SpO2 is sustained below 80% An arterial blood gas identifies several important measure-
for more than 10 min. ments, such as pH of the blood, PaO2, PaCO2, and HCO3.
Findings will facilitate the subsequent medical management
of the client.
Follow the Chain of Survival if respiratory or cardiac arrest The Chain of Survival has the greatest potential for resuscitat-
occurs. ing a lifeless person.

• Client continues to breathe spontaneously. • The client’s SpO2 is 90% with 45% oxygen via a Venturi mask.
LWBK1004-C37_p825-840.indd 833 20/02/12 12:54 PM

CRITICAL THINKING EXERCISE 2. Which of the following should the nurse instruct par-
ents of a 6-month-old child to avoid when purchas-
1. Arrange the following adult resuscitation steps in the ing a toy because of the risk for accidental choking?
correct sequence: activate the emergency medical sys- 1. A teething ring with gel filling
tem; open the airway; administer chest compressions 2. A stuffed animal with button eyes
at a rate of 100 per minute; assess responsiveness and 3. A mobile with suspended objects
presence of breathing; attach an automated external 4. A ball measuring 5⬙ in diameter
defibrillator and follow instructions; give cardiop- 3. Which of the following is the best evidence that the
ulmonary resuscitation for 2 minutes and reanalyze nurse should implement the Heimlich maneuver to
heart rhythm; combine compressions with ventila- relieve an airway obstruction in a conscious person?
tions at a rate of 30:2. 1. Forceful coughing
2. Explain the reason chest compressions are now 2. Attempts to clear throat
initially preferable before administering two quick 3. Inability to speak
breaths upon finding someone who is unresponsive 4. Audible wheezing
and not breathing normally. 4. When a person is in cardiac arrest, which is the first
3. Give a reason for the de-emphasis on checking a step the nurse takes in the Chain of Survival?
pulse as a method for determining heart contractions 1. Early cardiopulmonary resuscitation
on individuals who are unresponsive. 2. Early cardiac defibrillation
4. What criteria are used to determine if rescue breath- 3. Early activation of emergency services
ing is being delivered effectively? 4. Early advanced life support
5. Before administering the shock from an automated
external defibrillator (AED), which of the following
NCLEX-STYLE REVIEW QUESTIONS actions should the nurse take?
1. A nurse is managing care for all the following clients. 1. Place the victim in the recovery position.
For whom would the nurse most anticipate an airway 2. Loosen the victim’s belt.
obstruction? 3. Shout, “Everybody clear.”
1. Client A, who has had a cerebral vascular accident 4. Give three rescue breaths.
(stroke)
2. Client B, who has had a full mouth extraction of
teeth
3. Client C, who has had a biopsy of a tongue lesion
4. Client D, who has had facial cosmetic surgery
LWBK1004-C37_p825-840.indd 834 2/6/12 7:09 PM

UNIT 10
1. The lower airway contains the __________________. (alveoli, laryngopharynx, oropharynx)
2. Removing secretions from the upper portion of the lower airway through a nasally inserted catheter is called
__________________ suctioning. (nasopharyngeal, nasotracheal, oropharyngeal)
3. Health professionals use the __________________ artery to assess circulation in infants. (brachial, carotid, femoral)
4. The CAB of cardiopulmonary resuscitation are __________________ airway, and breathing. (circulation, congestion,
cyanosis)
1. T____F____ Nurses perform nasotracheal suctioning with a device called the Yankauer tip.
2. T____F____ Tracheal cartilage is a protrusion of flexible cartilage above the larynx.
3. T____F____ The jaw-thrust maneuver helps to remove any foreign material within the client’s mouth.

1. The collective system of tubes in the upper and lower respiratory tracts __________________
2. A surgically created opening in the trachea __________________
3. In a hospital, the summoning of personnel trained in advanced life-support techniques __________________
4. A side-lying position in resuscitation that helps a breathing person maintain an open airway and prevent aspiration of
fluid __________________
Activity D: Match the terms related to resuscitation in Column A with their explanations in Column B.
Column A Column B
1. __________________ Heimlich maneuver A. Using techniques to restore breathing and circulation
2. __________________ Subdiaphragmatic thrusts B. Ventilating the lungs
3. __________________ Cardiopulmonary resuscitation C. The preferred method for opening the airway
4. __________________ Head-tilt/chin-lift technique D. Relieving a mechanical airway obstruction
5. __________________ Rescue breathing E. Applying pressure to the abdomen
835
LWBK1004-C37_p825-840.indd 835 2/6/12 7:09 PM

Activity E: Differentiate between mouth-to-mouth breathing and mouth-to-stoma breathing based on the categories
given below.
Mouth-to-Mouth Breathing Mouth-to-Stoma Breathing
Technique
Sealing of the Client’s Nose
1. Identify and label the figure.

2. What is the function of these structures?
Activity G: Cardiac arrest may lead to unresponsiveness. Rescuers implement a five-step survival process
known as the Chain of Survival. Write in the boxes provided below the correct sequence of the chain
of survival.
1. Effective advanced life support
2. Integrated post-cardiac arrest care
3. Early cardiopulmonary resuscitation with a focus on compressions
4. Immediate recognition and access to emergency services
5. Rapid defibrillation
LWBK1004-C37_p825-840.indd 836 2/6/12 7:09 PM


1. What four natural mechanisms protect the airway?
2. What conditions may result in the need to insert an artificial airway?
3. What are various signs of a partial and complete airway obstruction?
4. For how long and for what reasons can basic cardiopulmonary resuscitation be interrupted?

1. Why it is important for the nurse to frequently assess clients who have a tracheostomy?
2. Why should nurses ensure adequate hydration in clients with a severe cough?
3. Why is a one-way valve mask used for rescue breathing?
4. In what cases would a monitor display an error message during the attachment of an AED’s electrode pad?
LWBK1004-C37_p825-840.indd 837 2/6/12 7:09 PM

1. A physician has asked a nurse to perform chest physiotherapy using percussion and vibration techniques for a client with
a chronic respiratory disorder.
a. What interventions should the nurse perform during the percussion technique?
b. What interventions should the nurse perform during the vibration technique?
2. Describe instructions that a nurse should provide when teaching postural drainage to a client with thick mucus and the
family.
3. An 8-year-old client develops an obstructed airway.

a. What immediate steps should the nurse take to relieve the client’s obstruction?
b. What should the nurse do if the child is unconscious?
1. A 9-month-old infant accidentally inhales a button used for an eye on a toy.
a. How is clearing the airway for an infant different than clearing the airway of an adult?
b. What suggestions should the nurse impart to the client’s family to prevent such a situation?

1. A nurse is to obtain a sputum specimen from a client who has been receiving aerosol treatments for a respiratory disease.
Which of the following should the nurse do when collecting the sputum specimen?
a. Tell the client to avoid rinsing the mouth before the specimen collection.
b. Instruct the client to attempt a forceful cough and expectorate.
c. Obtain the sputum specimen before an aerosol treatment.
d. Obtain saliva from within the mouth.
LWBK1004-C37_p825-840.indd 838 2/6/12 7:09 PM

2. A nurse is caring for a client with a weak and persistent cough. Which intervention should the nurse follow when caring
for this client?
a. Maintain 2,000 to 3,000 mL fluid intake for 24 hours.
b. Instruct the client to breathe through the mouth.
c. Ensure that the client is supine at all times.
d. Provide the client with warm milk 3 to 4 times a day.
3. A client has undergone a tracheotomy for an upper airway obstruction. Which intervention should the nurse perform
when providing tracheostomy care for this client?
a. Remove the inner cannula and place it in a saline solution.
b. Clean the area around the stoma with diluted peroxide.
c. Blow-dry the cannula after cleaning it with a saline solution.
d. Remove the used ties before applying new ties.
4. A triage nurse is examining an unresponsive 6-year-old child. When performing CPR, which of the following should the
nurse do?
a. Apply compression in the midline one finger width below the nipples.
b. Compress using two thumbs with the hands encircling the chest.
c. Place the heel of the hand at the center of the chest between the nipples.
d. Provide one breath every 5 seconds at the rate of 10 breaths per minute.
5. A nurse is caring for a client with impaired ventilation. Which intervention should the nurse perform for this client?
a. Administer oxygen at 20% using a Venturi mask.
b. Ensure that the client is supine at all times.
c. Replace the Venturi mask with a non-rebreather mask if SpO2 is 90%.
d. Continually monitor the client’s SpO2 with a pulse oximeter.
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LWBK1004-C37_p825-840.indd 840 2/6/12 7:09 PM
U N I T 11
Caring for the Terminally Ill
38 End-of-Life Care 842
841
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38 End-of-Life Care
acceptance
anger
anticipatory grieving 1. Define terminal illness.
autopsy 2. Name the five stages of dying.
bargaining 3. Describe two methods by which nurses can promote
brain death the acceptance of death in dying clients.
coroner 4. Define respite care.
death certificate 5. Discuss the philosophy of hospice care.
denial 6. List at least five aspects of terminal care.
depression 7. Name at least five signs of multiple organ failure.
dying with dignity 8. Explain why a discussion of organ donation must take place
grief response as expeditiously as possible following a client’s death.
grief work 9. Name three components of postmortem care.
grieving 10. Discuss the benefit of grieving and one sign that grief is being
hospice resolved.
morgue
mortician
multiple organ failure
I
paranormal experiences n the United States, life expectancy continues to lengthen each
pathologic grief year (Fig. 38-1). Nevertheless, death remains a certainty for all
postmortem care people; the only unknowns are when, where, and how it will
respite care occur.
shroud
terminal illness
waiting for permission phenomenon
■ Older adults may read obituaries and death notices in the newspa-
per daily in an effort to keep up with acquaintances. Families may
view this activity as potentially depressing, but it may actually be an
effective coping mechanism in helping to develop a peaceful and
accepting attitude toward death.
Nurses and other health care personnel probably are more

involved than any other group with people who experience impend-
ing death. This chapter deals with aspects of caring for terminally ill
clients and the grieving experience for all those involved in the dying
process.
TERMINAL ILLNESS AND CARE
A terminal illness means a condition from which recovery is beyond

a reasonable expectation. Such a diagnosis is devastating news. On
learning that death is imminent, clients tend to experience several
stages as they process the information.
842
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CHAPTER 38 End-of-Life Care 843
85 Bargaining
Bargaining, a psychological mechanism for delaying the
inevitable, involves a process of negotiation, usually with
80 White females
God or some other higher power. Usually, dying clients have
come to terms with their death, but want to extend their lives
temporarily until some significant event takes place (eg, a
Life expectancy at birth
75 Black females child’s wedding).

White males Depression
70
Depression (a sad mood) indicates the realization that death
will come sooner rather than later. The sad mood is a result
65 of confronting potential losses.
Black males Acceptance
60
Acceptance (an attitude of complacency) occurs after cli-
ents have dealt with their losses and completed nished unfi
business. Kübler-Ross describes unfinished business in two
55 ways. Literally, it refers to completing legal andnancial
fi
1970 1974 1978 1982 1986 1990 1994 1998 2002 2006 2010
matters to provide the best security for survivors. It also
Years refers to addressing social and spiritual matters, such as say-
FIGURE 38-1 Life expectancy in the United States, 1970–2010. ing goodbye to loved ones and making peace with God. It is
as important for dying clients as it is for their families to say,
“Thank you for. . . .” and “I’m sorry for. . . .”
Stages of Dying After tying up all loose ends, dying clients feel prepared
Dr. Elisabeth Kübler-Ross (1969), an authority on dying,to die. Some even happily anticipate death, viewing it as a
described stages through which many terminally ill clientsbridge to a better dimension.
progress. These are denial, anger, bargaining, depression,
and acceptance (Table 38-1). These stages may occur inPromoting a Acceptance
progressive fashion, or a person can move back and forth Nurses can help clients to pass from one stage to another by
through the stages. There is no specific time period for theproviding emotional support and by supporting the client’s
rate of progression, duration, or completion of the stages. choices concerning terminal care. Facilitating the client’s
directives helps to maintain the client’s personal dignity and
Denial
locus of control.
Denial, the psychological defense mechanism by which a
person refuses to believe certain information, helps people to
cope initially with the reality of death.
Terminally ill clients Gerontologic Considerations
may first refuse to believe that their diagnosis is accurate.
They may speculate that test results are wrong or that their ■ Include all older adults, as well as others who are dying,
reports have been confused with those of others. in as many aspects of care as possible. The emphasis is on
maintaining self-esteem and personal dignity.
Anger ■ Clients of all ages may feel that the use of machines and
Anger (the emotional response to feeling victimized) equipment designed to maintain life support threatens their
occurs because there is no way to retaliate againstate. f dignity.
Clients often displace their anger onto nurses, physicians,
■ Death is a very individualized experience that is highly
family members, even God. They may express anger in influenced by prior experiences, cultural practices, and level
less-than-obvious ways; for example, by complainingof personal development. Many older adults are realistically
about care or overreacting to even the slightest annoyances.
aware of their pending and inevitable death. Often, they are
relieved when health care providers are comfortable dis-
cussing death with them. Older adults may benefit from
counseling regarding their own death and dying, especially
TABLE 38-1 Stages of Dying
if they have a history of accepting help in coping with chal-
TYPICAL EMOTIONAL TYPICAL lenging issues.
STAGE RESPONSE COMMENT
First stage Denial “No, not me” Emotional Support
Second stage Anger “Why me?”
Emotional support is always part of nursing care; however,
Third stage Bargaining “Yes, me, but if only…”
Fourth stage Depression “Yes, me.” it may be more necessary for dying clients than in any other
Fifth stage Acceptance “I am ready.” situation. Sometimes a dying client simply wants an opportu-
nity to express his or her feelings and verbally work through
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844 UNIT 11 Caring for the Terminally Ill
NURSING GUIDELINES 38-1 B OX 3 8 - 1 The Dying Person’s Bill of Rights

• I have the right to be treated as a living human being until
Helping Dying Clients Cope I die.
• Accept the client’s behavior, no matter what it is. Doing so • I have the right to maintain a sense of hopefulness, however
demonstrates respect for individuality. changing its focus may be.
• Provide opportunities for the client to express feelings freely. • I have the right to be cared for by those who can maintain a
Giving such opportunities demonstrates an attention to meet- sense of hopefulness, however changing this might be.
ing individual needs. • I have the right to express my feelings and emotions about
• Try to understand the client’s feelings. Understanding rein- my approaching death in my own way.
forces the client’s uniqueness. • I have the right to participate in decisions concerning my care.
• Use statements with broad openings such as “It must be • I have the right to expect continuing medical and nursing
difficult for you” and “Do you want to talk about it?” Such attention even though “cure” goals must be changed to
language encourages communication and allows the client to “comfort” goals.
choose the topic or manner of response. • I have the right not to die alone.
• I have the right to be free from pain.
• I have the right to have my questions answered honestly.
• I have the right not to be deceived.
emotions. Nurses can act as a nonjudgmental sounding board • I have the right to have help from and for my family in
in such instances (see Nursing Guidelines 38-1). accepting my death.
In addition to being available for conversation, nurses • I have the right to die in peace and dignity.
provide emotional support to dying clients by acknowledg- • I have the right to retain my individuality and not be judged
for my decisions which may be contrary to beliefs of others.
ing them as unique and worthwhile. Dying with dignity
• I have the right to discuss and enlarge my religious and/or
means the process by which the nurse cares for dying clients spiritual experiences, whatever these may mean to others.
with respect, no matter what their emotional, physical, or • I have the right to expect that the sanctity of the human body
cognitive state. This process reflects the concepts stated in will be respected after death.
the Dying Patient’s Bill of Rights (Box 38-1). • I have the right to be cared for by caring, sensitive, knowl-
edgeable people who will attempt to understand my needs
Arrangements for Care and will be able to gain some satisfaction in helping me face
Respecting the rights of dying clients includes helping them my death.
to choose how and where they want to receive terminal care.
Clients may find it comforting to prepare an advance direc- From Barbus AJ. The Dying Person’s Bill of Rights. © 1975, American
tive (see Chap. 3). Many also appreciate learning about avail- Journal of Nursing Company. Reprinted with permission from the
able settings for care. In general, clients have four choices: American Journal of Nursing, January 1975;75(1):99.
home care, hospice care (which may be the same as home
care), residential care, and acute care.
such care itself. The word originally derives from a place of
Home Care refuge for travelers. Today’s hospice movement is modeled
Many clients with a terminal illness remain at home (Fig. 38-2). after facilities established by Dr. Cicely Saunders in England
They may travel to and from a hospital or clinic for brief in the late 1960s; the movement spread to the United States in
treatments, tests, and medical evaluations. Nurses may help
to coordinate community services, secure home equipment,
and arrange for home nursing visits.
Because the major burden of home care often falls on a
spouse, family member, or significant other, nurses who care
for home-bound clients periodically assess the toll this burden
takes on the primary caregiver. The focus of support may shift
back and forth from the client to the caregiver. Respite care
(relief for the caregiver by a surrogate) is important because it
gives the caregiver an opportunity to enjoy brief periods away
from home. Nurses can encourage the caregiver to identify
relatives or friends who will volunteer relief time with the
client. If no one is available, nurses can refer the caregiver to
services through a home health care agency or hospice care.
Hospice Care
The term hospice is used to indicate both a facility for pro-
viding the care of terminally ill clients and the concept of FIGURE 38-2 Home care.
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B OX 3 8 - 2 Medicare Home Hospice Benefitsa

• Hospice nurse and physician on-call 24 hours a day/7 days
a week
• Hospice aide and homemaker services
• Medications for symptom control or pain relief b
• Medical supplies and equipment
• Physical therapy, occupational therapy, and speech-
language pathology services
• Social work and counseling services for the client and
caregivers
• Dietary counseling services
• Short-term respite careb
• Short-term inpatient care for pain and symptom
management
• Grief and loss counseling for client and family
• Any other Medicare-covered services needed to manage
pain and other symptoms as recommended by the hospice
team
a
Medicare will pay for hospice care if all the following requirements are
met: (1) the terminal illness is certified by physician; (2) the client elects
the hospice benefit; and (3) the hospice program is Medicare-certified.
b
There may be a small copayment.
Source: U.S. Department of Health and Human Services. (2010).
Medicare hospice benefits. Publication 02154. http://www.medicare.gov/
publications/pubs/pdf02154.pdf
FIGURE 38-3 A hospice patient and nurse.
the 1970s. The National Hospice Organization, now known Gerontologic Considerations
as the National Hospice and Palliative Care Organization,
was formed in 1978. Its goals are providing relief from dis- ■ Older adults with chronic illnesses, such as dementia,
tressing symptoms, easing pain, and enhancing quality of and their family may benefit from the hospice approach to
life. In 1982, the US Congress adopted the Medicare Hospice care and available support services. Often, families and
Benefits program to provide funds for hospice care (Hall, older adults are relieved when providers discuss hospice
2003). Hospice care involves helping clients to live their final care so they can be involved in choices about the type of
days in comfort, with dignity, and in a caring environment care they receive.
(Fig. 38-3).
Terminating Hospice Care. According to Hall (2007),
Eligibility for Hospice Care. In general, clients
hospice services can be terminated in one of two ways: (1) when
with 6 months or less to live as certified by a physician are
the client withdraws for any reason to receive treatment not
accepted for hospice care in the United States. If a client sur-
covered in the hospice plan of care or (2) when the client no
vives beyond 6 months, he or she continues to receive care
longer meets the Medicare criteria. Once Medicare Hospice
as long as the physician certifies that the client continues to
Benefits are discontinued, the client forfeits the remaining
meet hospice criteria. While receiving hospice care, the cli-
days of the benefit period; however, he or she can reapply for
ent can “transfer to another hospice program, but may not
benefits if circumstances change.
be discharged because of inability to pay, high cost of treat-
ment, ‘high-tech’ palliative care ordered by the physician, or Residential Care. Residential care is a form of intermedi-
‘difficult’ behavior” (Hall, 2007, p. 5). ate care. Nursing homes or long-term care facilities are the
usual settings for this type of subacute care. These facili-
Hospice Services. Most hospice clients receive care in ties provide around-the-clock nursing care for clients who
their own homes. A multidisciplinary team of hospice pro- cannot live independently (Fig. 38-4). Family members
fessionals and volunteers supports care given by the family have peace of mind knowing that their loved one is receiv-
(Box 38-2). Hospice organizations also provide support pro- ing care, and they enjoy the opportunity to visit as much as
grams for family members and significant others. They offer possible. Such care, however, is costly. Once clients have
individual and group counseling both during and after the exhausted their savings, programs such as Medicaid may
client’s death to help survivors cope with grief. pay their expenses.
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and comfort. Nurses implement many of the skills described

throughout this text to meet the multiple problems that dying
clients experience.
■ Many older adults and other adults with foresight pre-

pare advance directives concerning their health care and
identify a person with a durable power of health care at the
same time they prepare a will. These advance directives
must be reviewed and updated periodically and should be
accessible to all those involved in care.
Hydration
Hydration involves the maintenance of an adequate fluid
volume. If the client’s swallowing reflex remains intact, the
nurse offers water and other beverages frequently. As swal-
lowing becomes impaired, the client is at risk for aspiration,
followed by pneumonia. Sucking is one of the last reflexes
to disappear as death approaches. Therefore, the nurse can
provide a moist cloth or wrapped ice cubes for the client to
suck. Eventually, the client may need intravenous fluids.
FIGURE 38-4 Residential care. Nourishment
Some terminally ill clients have little interest in eating. The
effort may be too exhausting, or nausea and vomiting may
Acute Care. A client needs acute care, with its sophisti- result in inadequate consumption of food. Poor nutrition
cated technology and labor-intensive treatment, if his or her leads to weakness, infection, and other complications, such
condition is unstable (Fig. 38-5). This form of care is the most as pressure sores. Consequently, the client may need tube
expensive. Expenses for acute care provided in the hours, feedings or total parenteral nutrition to maintain nutritional
days, or weeks before a client’s death can be significant. and fluid intake.
Providing Terminal Care

Throughout a terminal illness and immediately before a cli- Nutrition Notes
ent’s death, nurses meet his or her basic physical needs for
hydration, nourishment, elimination, hygiene, positioning, ■ Clients who are dying should not be made to feel guilty
for not wanting to eat or drink. Nutritionists recommend
comfort measures such as relieving a dry mouth with oral
hygiene measures and artificial saliva, providing humidified
air, and offering hard candies (Servodidio & Steed, 2007).
Elimination
Some terminally ill clients are incontinent of urine and stool;
others experience urinary retention and constipation. All
these conditions are uncomfortable. A physician may order
cleansing enemas or suppositories. Catheterization also may
be necessary. Skin care becomes particularly important for
incontinent clients because urine and stool left in contact with
the skin contribute to skin breakdown and produce foul odors.
Hygiene
The dignity of clients is related largely to their personal
appearance. Therefore, nurses strive to keep dying clients
FIGURE 38-5 Acute care. clean, well groomed, and free of unpleasant odors.
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Frequent mouth care may be necessary. Suctioning helps appropriate. Older adults have the highest rate of suicide
to remove mucus and saliva that the client cannot swallow as well as the highest rate of completed suicides in propor-
or expectorate. A lateral position keeps the mouth and throat tion to unsuccessful attempts. Health care professionals
free of accumulating secretions. The lips may need periodic need to assess the client’s suicide risk and implement
appropriate precautions.
lubrication because they may become dried from mouth
breathing or the administration of oxygen.
Positioning Family Involvement

The lateral position helps to prevent choking and aspiration. Family members may appreciate involvement in the client’s
Nevertheless, the nurse changes the client’s position at least care because they often feel helpless. Involvement tends
every 2 hours (as for any other client) to promote comfort to maintain family bonds and helps survivors to cope with
and circulation. future grief. Many welcome the opportunity to assist. Nev-
ertheless, nurses should not burden family members with
Comfort major responsibilities.
Relieving pain may be the most challenging problem when Some terminally ill clients forestall dying when they
caring for dying clients. The goal is to keep clients free from feel that their loved ones are not yet prepared to deal with
pain but not to dull consciousness, suppress respirations, or their death. This has been described as the waiting for per-
inhibit the ability to communicate. mission phenomenon, because death often occurs shortly
Most clients initially receive non-narcotics for pain; after a significant family member communicates that he or
later, the physician may change the drug order to a combina- she is strong enough and ready to “let go.” Nurses must sup-
tion of a non-narcotic and narcotic analgesic or, eventually, port family members at this time because family members
a potent narcotic. He or she also may change the route from may feel as though they have given up and let down their
oral to parenteral or transdermal (refer to Chap. 20). loved one.
Analgesia may be more effective when the client
receives the drug on a routine schedule. Giving pain medica-
tion regularly, such as every 4 hours or by continuous release Approaching Death
through a transdermal patch rather than on an as-needed As death nears, the client exhibits signs indicating a
(p.r.n.) basis maintains a consistent level of pain relief. The decrease then, ultimately, a cessation of function. As these
dosage will probably need to be increased because of drug signs appear, the nurse informs the client’s family that death
tolerance (see Chap. 20). is approaching.
Fear of addiction should not interfere with efforts to
relieve pain. The frequency of addiction in previously Multiple Organ Failure
non-drug-abusing clients is rare (National Cancer Insti- The signs of approaching death are the result of multiple
tute, 2008; McCaffery et al., 1990). Unfortunately, nurses organ failure (a condition in which two or more organ sys-
and physicians often misinterpret increased requests for tems gradually cease to function), which directly relates to the
pain medication as evidence of addiction. In reality, an quality of cellular oxygenation. When the supply of oxygen
increased desire for pain medication may be the result of begins to fall below levels required to sustain life, cells, fol-
the development of drug tolerance or an increase in pain lowed by tissues and organs, begin to deteriorate. The car-
related to disease progression. diovascular, pulmonary, hepatic, and renal systems are most
Clients develop tolerance to the pain-relieving property vulnerable to failure.
of analgesic drugs; however, clients who are tolerant to opio- As they cease to function, cells release their intracel-
ids concomitantly develop resistance to respiratory depres- lular chemicals. Preexisting hypoxia is first complicated by
sion, a common side effect of narcotic analgesics (Hall, 2007; a localized rather then a generalized inflammatory response
McCaffery & Beebe, 1989). Sedation generally precedes res- (see Chap. 28) that causes the signs of multiple organ failure,
piratory depression. Therefore, as long as the client is alert, heralding approaching death (Table 38-2). This process may
the potential for respiratory depression is minimized. Nar- take place gradually over hours or days.
cotic antagonists can be given for severe respiratory depres-
sion, should it develop, but the dosage must be reduced to Family Notification
avoid producing withdrawal symptoms and eliminating the As the client shows signs of approaching death, the nurse
desired analgesic state. Constipation may be a more common must make the family aware that the end is near. The nurse
consequence of continuous narcotic analgesia. informs the physician first, however. See Nursing Guide-
lines 38-2.
If death has already occurred, the physician is responsi-
Pharmacologic Considerations ble for contacting the family and releasing that information.
Sometimes, the physician delays the news until he or she can
■ Evaluating the use of antidepressants and other talk with the family in person to avoid precipitating acts such
therapies for adults who are seriously depressed often is as suicide or contributing to a traffic accident.
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TABLE 38-2 Signs of Multiple Organ Failure TABLE 38-3 Age Criteria for Organ Donation
ORGAN SIGNS ORGAN AGE RANGE
Heart • Hypotension Kidney 6 months–55 years
• Irregular, weak, and rapid pulse Liver <50 years
• Cold, clammy, and mottled skin Heart <40 years
Liver • Internal bleeding Pancreas 2–50 years
• Edema Corneas Any age
• Jaundice Skin 15–74 years
• Impaired digestion, distention, anorexia,
nausea, and vomiting Guidelines established by the Organ Procurement Agency of Michigan, Ann
Lungs • Dyspnea Arbor, MI.
• Accumulation of fluid (“death rattle”)
Kidneys • Oliguria
• Anuria
• Pruritus (itching skin) For example, Native American Lakota Sioux females wail
Brain • Fever loudly while the males sing mourning songs at the bedside.
• Confusion and disorientation Buddhists and Hindu from Indian cultures maintain a calm
• Hypoesthesia (reduced sensation) presence and chant to promote the client’s passage into nir-
• Hyporeflexia (reduced reflexes)
• Stupor
vana, a state of being free from suffering (Servodidio &
• Coma Steed, 2007). Similarly, people from Bali, whose religion
is a combination of Hinduism, Buddhism, and Islamic con-
cepts mixed with ancient beliefs and customs, control the
demonstration of emotions in the belief that their gods will
Meeting Relatives not hear prayers that are offered hysterically.
To promote a smooth transition, relatives of the dying client
are met by the nurse who informed them. If that is not pos- Discussing Organ Donation
sible, another support person is designated. Virtually anyone, from the very young to older adults, may
On arrival, the nurse shows family members to a private be an organ donor. If the donor is younger than 18 years of
room or area or takes them directly to the client’s bedside, age, he or she must sign a donor card, along with the parents
depending on their wishes. Privacy allows people the free- or legal guardian. Age requirements and organ acceptance
dom to express feelings without social inhibitions. People are determined on an individual basis at the time of organ
have different ways of expressing grief. Some weep and sob procurement (Table 38-3).
uncontrollably; others do not. Nurses remember that those Some people have the foresight to communicate
with less outward signs of grief may be feeling sorrow that is whether they are interested in organ donation; others do
just as strong as those who cry and grieve openly. not. In either case, if the dying or dead client meets the
It is important that nurses remain objective and support- donation criteria, the possibility of harvesting organs is
ive when there are cultural differences surrounding a death. considered.

Summoning the Family of a Dying Client
• Plan to notify the family in a timely manner. Prompt attention • Explain that the client’s condition is deteriorating. This expla-
allows the family to be with the client at death. nation clarifies the purpose for the call.
• Check the client’s medical record for the next of kin or a • Pause after giving the most important information. A pause
responsible party. Doing so ensures that the nurse notifies allows the family member to respond.
someone significantly involved in the client’s well-being. • Give brief answers to questions. Emphasize the level of care
• Identify yourself by name, title, and location. Identification that the client is receiving. Such responses reinforce that the
provides more personal communication. client is receiving appropriate care.
• Ask for the family member by name. Doing so ensures that • Urge family members to come as soon as possible. This
you communicate information to the appropriate person. ensures that the people most important to the client are there
• Speak in a calm and controlled voice. Doing so conveys a seri- at death.
ous, competent demeanor. • Document the time, the person to whom you communicated
• Use short sentences to provide small bits of information. This the information, and the message. Appropriate documentation
technique helps the listener to process and comprehend the provides a permanent record.
news.
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Organ donation may or may not be discussed with brain death have appeared in the medical literature since
the next of kin based on the 2006 revision of the Uniform 1978, the following standards commonly are used as guide-
Anatomical Gift Act (UAGA). The UAGA, which has been lines to ensure that brain activity is assessed consistently
adopted by almost all states, stipulates that (1) if a dying or and accurately. Irreversible brain death is considered to be
deceased person has a document identifying an intention to present if, in the absence of hypothermia, central nervous
donate organs or has expressly refused organ donation, the system depressants, or conditions that may simulate brain
next of kin or someone with a power of attorney for health death, there is
care need not be involved; (2) if no documentation of intent
• Unreceptiveness and unresponsiveness to even intense
is available, consent for organ donation on behalf of the cli-
painful stimuli.
ent can be sought; (3) without a signed refusal, life support
• No movement or spontaneous respiration after being dis-
may not be withdrawn until the potential for organ dona-
connected for 8 minutes from a mechanical ventilator.
tion is determined even if doing so contradicts a person’s
• PaCO2 greater than or equal to 60 mm Hg (in the absence
advanced directives because life support that has the poten-
of metabolic alkalosis) after being preoxygenated with
tial to save lives overrides the desire to withhold or withdraw
100% oxygen.
life support (Verheijde et al., 2007).
• Complete absence of central and deep tendon reflexes.
Involving the next of kin or the person with a power of
• Flat electroencephalogram for at least 10 minutes or con-
attorney for health care concerning organ donation is gener-
firmation of neurologic inactivity using other standard
ally a courtesy even when it is not absolutely required. This
neuroimaging techniques.
is done delicately by an organ procurement officer. This
• No change in clinical findings on a second assessment 6, 12,
person is trained in techniques for sensitively requesting
or 24 hours later (Byrne, 1999; Sullivan et al., 1999). The
organ donations from family members grieving the death of
time frame relates to each state’s medical standard.
a loved one. The health care agency selects the person who
will solicit organ donations. Typically, the facility’s trans- Once death is confirmed, the physician issues a death
plant coordinator is the organ procurement officer. certificate and obtains written permission for an autopsy if
Solicitation for organ donation cannot be delayed; one is desirable.
some organs, such as the heart and lungs, must be harvested
within a few hours to ensure a successful transplant. In Death Certificate
some cases, the client is kept on life support prior to remov- A death certificate (a legal document attesting that the
ing organs. To protect the health care facility from any person named on the form has been found dead) also indi-
legal consequences, permission may be obtained in writing cates the presumptive cause of the person’s death. Death
(Fig. 38-6). certificates are sent to local health departments that use the
information to compile mortality statistics. The statistics are
Confirming Death important in identifying trends, needs, and problems in the
Death is generally determined on the basis that breathing fields of health and medicine.
and circulation have ceased. In most cases, when these cri- The mortician (the person who prepares the body for
teria are met, there is no question that the person is dead. burial or cremation) is responsible for filing the death cer-
Legally, a physician is responsible for pronouncing a client tificate with the proper authorities. The death certificate also
dead, but in a few states, nurses are authorized to do so. carries the mortician’s signature and, in some states, his or
her license number.
Brain Death
In some situations involving irreversible brain damage, a Permission for Autopsy
mechanical ventilator can sustain breathing and circulation An autopsy is an examination of the organs and tissues
that continues reflexively. In 1968, the Ad Hoc Commit- of a human body after death. It is not necessary after all
tee of the Harvard Medical School released a report on the deaths, but it is useful for determining more conclusively
definition of brain death, a condition in which there is an the cause of death. The findings may affect the medical care
irreversible loss of function of the whole brain, including of blood relatives who may be at risk for a similar disorder,
the brainstem. Their recommendations served as the basis for or the results may contribute to medical science. It is usu-
the Uniform Definition of Death Act drafted by the National ally the physician’s responsibility to obtain permission for
Conference of Commissioners on Uniform State Laws and an autopsy.
approved by the American Medical Association and Ameri- A coroner (the person legally designated to investigate
can Bar Association in 1980. deaths that may not be the result of natural causes) has the
Consequently, an irreversible cessation of circulatory authority to order an autopsy. The coroner, who may or may
and respiratory functions or a cessation of all brain func- not be a physician, does not need permission from the next
tions is now considered the most incontestable criterion for of kin to do so. In general, a coroner orders an autopsy if
establishing whether a person is dead or alive. Although the death involved a crime, was of a suspicious nature, or
more than 30 different sets of criteria for determining occurred without any recent medical consultation.
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FIGURE 38-6 An organ procurement form.
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Performing Postmortem Care Pathologic Grief

Postmortem care (care of the body after death) involves In pathologic grief, also called dysfunctional grief, a person
cleaning and preparing the body to enhance its appearance cannot accept someone’s death. Sometimes, people manifest
during viewing at the funeral home, ensuring proper iden- pathologic grief by bizarre or morbid behaviors. For exam-
tification, and releasing the body to mortuary personnel ple, survivors may keep the possessions of a deceased loved
(Skill 38-1). one exactly as they were at the time of death for a prolonged
period. Others may attempt to contact the deceased through
➧ Stop, Think, and Respond Box 38-1 séances. In rare instances, survivors may keep a corpse in the
Discuss nursing activities that demonstrate dignity home for an extended period after death.
and respect for the dead person’s body.
Resolution of Grief
Mourning takes longer for some than for others; there is
GRIEVING no standard length of time for “normal” grieving. One sign
that a person is resolving his or her grief is an ability to talk
Grieving means the process of feeling acute sorrow over about the dead person without becoming emotionally over-
a loss. It is a painful experience, but it helps survivors to whelmed. Another sign is that the grieving person describes
resolve the loss. Some people experience anticipatory the good and bad qualities of the deceased.
grieving, or grieving that begins before the loss occurs. The
longer people have to anticipate a loss, the sooner they even-
tually resolve it. Grief work (activities involved in griev- NURSING IMPLICATIONS
ing) includes participating in the burial rituals common to
a culture. Although such rituals differ, the grief response Nurses who care for dying clients, their family members,
(the psychological and physical phenomena experienced by and their friends may identify many different nursing diag-
those grieving) is universal. Psychological reactions com- noses:
monly are identified as the stages of grief:
• Acute (or Chronic) Pain
• Shock and disbelief: the refusal to accept that a loved one • Fear
is about to die or has died • Spiritual Distress
• Developing awareness: the physical and emotional • Social Isolation
responses such as feeling sick, sad, empty, or angry • Ineffective Role Performance
• Restitution period: a recognition of the loss • Interrupted Family Processes
• Idealization: an exaggeration of the good qualities of the • Ineffective Coping
deceased • Disabled Family Coping
Some survivors have paranormal experiences (experi- • Decisional Conflict
ences outside scientific explanation), such as seeing, hear- • Hopelessness
ing, or feeling the continued presence of the deceased. • Powerlessness
Survivors feel physical symptoms more acutely imme- • Grieving
diately after the death of a loved one. Some grieving people • Complicated Grieving
report symptoms such as anorexia, tightness in the chest and • Caregiver Role Strain
throat, difficulty breathing, lack of strength, and sleep distur- • Death Anxiety
bances. No identifiable pathologic state other than grief can • Chronic Sorrow
explain these symptoms. Nursing Care Plan 38-1 applies the nursing process to
the care of a client with a diagnosis of Hopelessness, defined
in NANDA-I’s 2012 taxonomy (p. 279) as a “subjective state
Gerontologic Considerations in which an individual sees limited or no alternatives or per-
sonal choices available and is unable to mobilize energy on
■ Research has shown that some people develop life- (his or her) own behalf.” Lynda Carpenito-Moyet (2009) fur-
threatening illnesses and die within 6 months of the death ther explains, “Hopelessness differs from powerlessness in
of a spouse. Encouraging older adults who have experi-
that a hopeless person sees no solution to his problem and/
enced the death of a close friend or family member to
express feelings associated with grieving is important.
or way to achieve what is desired, even if he has control of
Referrals for individual counseling or grief support groups his life. A powerless person, on the other hand, may see an
are appropriate. alternative or answer to the problem, yet be unable to do
anything about it because of lack of control and resources.”
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N U R S I N G C A R E P L A N 3 8 - 1 Hopelessness
Assessment • Observe cognitive manifestations such as suicidal ideation,
• Monitor the client’s physical manifestations such as loss of decreased attention and concentration, illogical thinking,
appetite, weight loss, fatigue, and sleep disturbances. decreased ability to process or integrate information, and
• Observe behavioral manifestations such as reduced motiva- fixation on loss(es).
• Listen for verbal cues that suggest despair, resignation, and
tion, passivity, neglect of hygiene, withdrawal, reduced verbal
interaction, and disinterest in the future. surrender.
• Observe emotional manifestations such as feelings of helpless-
ness, apathy, sadness, defeat, and abandonment.
Nursing Diagnosis. Hopelessness related to psychological distresserovthe de velopment of HIV-related complication (Pneumo-
cystis carinii pneumonia) as manifested by little eye contact during interaction, staring out of window, and the statement, “It doesn’t
matter what’s done or not done anymore. One of these days you won’t be able to stop the infections,” and partner’s statement, “I’m
afraid he’ll just stop eating and taking his medications.”
Expected Outcome. The client will regain hope as evidenced by identifying interest in one future-related activity or achievement
by the time of transfer to home health care service.
Reinforce at appropriate times that drug therapy can cure the Remaining compliant with HIV drug therapy reduces the
pneumonia and control the primary illness indefinitely. potential for drug resistance and extends survival.
Share normal as well as abnormal findings after periodic Sharing positive information may encourage the client to
physical examinations or laboratory tests. believe in the likelihood for an improved health status.
Explore the goals the client hoped to accomplish before the Assisting with reminiscence may motivate the client toward
illness. future-related activities.
Ask the client to identify goals that could be realistically Focusing on short-term goals offers an alternative to defeat
accomplished in the next 6–12 months. that the client may feel over accomplishing unrealistic long-
term goals.
Encourage the client to develop a plan for accomplishing one Developing a plan provides a tool for accomplishing goals.
future-related goal.

• The client lists evidence that the current health problem is • The client describes plans to contact a publisher who was
resolving, such as clearer lung sounds and slight weight gain. interested in a collection of his poems.
• The client discusses various literary works that he has pub-
lished and was working on prior to this illness.

1. Does being maintained on life-support equipment 1. When the nurse cares for a client with no hope
contradict the right to die in peace and dignity (see of recovery, which of the following is the most
the Dying Person’s Bill of Rights)? conclusive criterion for declaring the person
2. Select a right from the Dying Person’s Bill of Rights brain dead?
and explain how it might be violated. How can nurses 1. A lack of response to verbal stimulation
protect this right? 2. Urine output less than 100 mL/24 hours
3. What qualities would be helpful for someone who is 3. No spontaneous respiratory efforts
an organ procurement officer? 4. Unequal pupils in response to light
4. How is grieving an unexpected death different than
grieving the death of a person suffering from a pro-
longed illness or disorder?
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2. Place the stages of dying in their usual sequence as 4. When a terminally ill client refuses to eat or drink,
identified by Dr. Elisabeth Kübler-Ross. Use all the what nursing measures can be independently imple-
options. mented? Select all that apply.
1. Depression 1. Inserting a nasogastric feeding tube
2. Anger 2. Providing frequent oral hygiene measures
3. Acceptance 3. Humidifying the room air
4. Denial 4. Offering hard candies periodically
5. Bargaining 5. Administering intravenous fluids
3. If a terminally ill client made the following state- 5. When a client has died, under what circumstance can
ments to a nurse, which is the best evidence that the health care professionals proceed with the protocol
client is in the bargaining stage? for harvesting organs for transplantation?
1. “There must be some mistake in the pathology 1. The deceased client has a document indicating his
report.” or her desire to be an organ donor.
2. “If I can just live until my son graduates, I won’t 2. The nursing supervisor believes the deceased has
ask for anything else.” suitable organs for transplantation.
3. “I don’t know why I would deserve to die at such a 3. The deceased client’s next of kin gives permission
young age.” to harvest the organs.
4. “I hope my death comes quickly; I’m ready to go.” 4. The physician has declared and documented the
client’s time of death.
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SKILL 38-1 Performing Postmortem Care
ASSESSMENT
Determine that the client is dead by assessing breathing and Confirms that the client is lifeless in all but cases in which life
circulation. support equipment is used.
Determine if the physician and family have been notified. Establishes the chain of communication.
Notify the nursing supervisor and switchboard of the client’s Makes others aware of a change in the client’s status.
death.
Check the medical record for the name of the mortuary where Facilitates collaboration.
the body will be taken.
PLANNING
Inform mortuary personnel that the family has chosen them to Communicates a need for services.
manage the burial.
Ask when to expect mortuary personnel. Facilitates efficient time management.
Contact any individuals involved in organ procurement. Promotes the timely harvesting of organs.
Obtain a postmortem kit or supplies for cleaning, wrapping, and Promotes organization when preparing a body that will be
identifying the body if there will be a delay in transport to a temporarily held in the morgue (an area where bodies of dead
mortuary. persons are temporarily held or examined).
IMPLEMENTATION
Pull the curtains around the bed. Ensures privacy.
Don gloves. Follows standard precautions.
Place the body supine with the arms extended at the sides or Prevents skin discoloration in areas that will be visible in a casket.
folded over the abdomen.
Remove all medical equipmenta such as intravenous catheters, Eliminates unnecessary equipment.
urinary catheters, and dressings.
Remove hairpins or clips. Prevents accidental trauma to the face.
Close the eyelids. Ensures that eyes will close when the body is prepared.
Replace or keep dentures in the mouth. Maintains the natural contour of the face.
Place a small rolled towel beneath the chin to close the mouth. Promotes a natural appearance.
Cleanse secretions and drainage from the skin. Ensures the delivery of a hygienic body.
Apply one or more disposable pads between the legs and under Absorbs urine or stool should they escape.
the buttocks.
Attach an identification tag to the ankle or wrist; pad the wrist Facilitates the accurate identification of the body; prevents dam-
first if it is used. age to tissue that will be visible.
Wrap the body in a paper shroud (a covering for the body); Demonstrates respect for the dignity of the deceased person.
cover the body with a sheet.
Tidy the bedside area; dispose of soiled equipment. Follows the principles of medical asepsis.
Remove gloves and wash your hands. Removes colonizing microorganisms.
Leave the room and close the door, or transport the body to the Provides a temporary location for the body until mortuary person-
morgue (Fig. A). nel arrive.
A morgue cart. (Photo by B. Proud.)
A
(continued)
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Performing Postmortem Care (continued)
Make an inventory of valuables and send them to an administra- Ensures the safekeeping and accountability for valuables until a
tive office for placement in a safe. family member can claim them.
Notify housekeeping after the body is removed from the room. Facilitates cleaning and the preparation for another admission.
Evaluation
• The body is cleaned and prepared appropriately.
• The body is transferred to mortuary personnel.
Document
• Assessments that indicate the client is dead
• Time of death
• People notified of death
• Care of the body
• Time body is transported to the morgue or transferred to mortuary personnel
Date and Time No breathing noted and no pulse at 1400. Dr. Williams notified at 1415. Dr. Williams pronounced death and
called client’s wife. Foster’s Funeral Home notified. Mortuary personnel unavailable until 1800. Postmor-
tem care provided. Body transported to morgue after wife and children departed.
__________________________________________________________________________________ SIGNATURE/TITLE
a
Except in coroner’s cases.
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UNIT 11
End of Unit Exercises for Chapter 38
1. __________________ involves a process of negotiation, usually with God or some higher power, in an attempt to delay
the inevitability of death. (Bargaining, Denial, Depression)
2. __________________ care provides around-the-clock nursing care for clients who cannot live independently. (Hospice,
Residential, Respite)
3. The ability to __________________ is one of the last reflexes to disappear as death approaches. (hear, smell, suck)
1. T____F____ Diarrhea may be a common consequence of continuous narcotic analgesia.
2. T____F____ An autopsy is the examination of human organs and tissues to treat a disease.

1. A person legally designated to investigate an unnatural death __________________
2. A legal document attesting that the person named on the form is deceased __________________
3. A condition in which two or more organ systems gradually cease to function __________________
Activity D: Match the terms related to grieving in Column A with their explanations in Column B.
Column A Column B
1. __________________ Anticipatory grief A. Activities involved in grieving
2. __________________ Pathologic grief B. Psychological and physical experiences while grieving
3. __________________ Grief work C. Inability to accept someone’s death
4. __________________ Grief response D. Feeling sad before someone’s death
Activity E: Differentiate between home care and residential care based on the categories given below.
Home Care Residential Care
Role of Nurses
Delivery of Care
856
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Activity F: Dr. Elisabeth Kübler-Ross described stages through which terminally ill clients progress. Write in the boxes
provided below the usual sequence of typical comments during the stages of dying.
1. “Why me?”
2. “Yes, me.”
3. “Yes, me, but if only . . .”
4. “I am ready.”
5. “No, not me.”
Activity G: Answer the following questions.

1. What classifies an illness as terminal?
2. When can hospice care be terminated?
Activity H: Give rationales for the following questions.

1. Why is skin care important for terminally ill, incontinent clients?
2. Why do the lips of terminally ill clients need periodic lubrication?
3. Why are death certificates sent to the local health department?
LWBK1004-C38_p841-860.indd 857 2/6/12 7:10 PM

Activity I: Answer the following questions focusing on nursing roles and responsibilities.
1. What are two methods that nurses can use to promote an acceptance of death in dying clients? What interventions can
nurses use to provide emotional support to these clients?
2. A nurse is caring for a client in the last stages of terminal brain cancer. What nursing diagnoses might apply for this client
and his or her family members?
3. A nurse is caring for a dying client.

a. What nursing actions are appropriate related to the client’s hygiene and nourishment?
b. How can the nurse ensure that the client receives adequate fluids?
Activity J: Consider the following questions. Discuss them with your instructor or peers.
1. A nurse is providing postmortem care for an elderly client who has died of cancer. How can the nurse demonstrate dignity
and respect for the client’s body?
2. A nurse is caring for a client who is unresponsive to even painful stimuli, cannot breathe independently, and has com-
pletely absent central and deep tendon reflexes. The physician has confirmed that the client is brain dead.
a. What should the nurse do if the family asks to discontinue life support systems for the client?
b. What information should the nurse provide to the family about the legal implications of their request?
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S e c t i o n I I I : Getting Ready For NCLEX
Activity K: Answer the following questions.

1. A nurse at an extended care facility is caring for a client with cancer and a limited prognosis for long-term survival.
Which of the following interventions is most appropriate when caring for this client?
a. Share information, such as trends in vital signs, with the client.
b. Ask the client to identify goals that could be accomplished in 24 months.
c. Encourage the client to seek alternative forms of treatment.
d. Ask the client not to dwell on old memories and goals previously established.
2. A nurse is caring for a client who had medical equipment attached to her at the time of death. What measures will the
nurse implement when providing postmortem care of the client’s body? Select all that apply.
a. Obtain supplies for cleaning and wrapping the body.
b. Keep all the medical equipment attached to the body.
c. Contact individuals involved in organ procurement.
d. Ask for the approximate arrival time of the mortuary personnel.
e. Remove the disposable pads from between the legs.
3. When caring for a dying client, which of the following are appropriate for procuring organ or tissue donations? Select all
that apply.
a. Determine the dying client’s wishes concerning organ and tissue donation.
b. Obtain permission from the next of kin as the client nears death.
c. Inform the mortician to remove specific organs when preparing the body.
d. Contact the pathologist in charge of performing autopsies.
e. Enlist the assistance of an organ procurement coordinator.
4. A nurse is caring for a stuporous and cold client who has developed mottled skin. Failure of which of the following body
parts could have led to this condition?
a. Brain and heart
b. Liver and kidney
c. Pancreas and stomach
d. Intestine and bladder
LWBK1004-C38_p841-860.indd 859 2/6/12 7:10 PM

LWBK1004-C38_p841-860.indd 860 2/6/12 7:10 PM
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APPENDIX
A Chapter Summaries
CHAPTER 1 • To address the nursing shortage, the federal Nurse Reinvestment Act,
• The art of nursing declined in England with the exile of Catholic reli- renamed the American Recovery and Reinvestment Act and signed into
gious orders, forcing the government to assume responsibility for caring law in 2009, authorizes loan repayment programs and scholarships; fund-
for the sick, aged, and inrm.fi Eventually, the state delegated this care to ing for public service announcements; career ladder programs; and grants
untrained and generally uninterested people of questionable character. for nurse retention, client safety enhancement, and gerontology. Nurses
• Florence Nightingale changed the image of nursing by training nurses toare proactively pursuing post-licensure education; training for advanced
care for the sick, selecting only those with upstanding character as poten-practice; cross-training; learning more about multicultural diversity;
tial nurses, improving the sanitary conditions within clients’ environ- supporting national health insurance legislation; promoting community-
ments, signifi cantly reducing the morbidity and mortality rates of British based programs; emphasizing health promotion; referring clients with
soldiers, providing formal nursing classes separate from clinical experi- health problems for early treatment; coordinating nursing services across
ence, and arguing that nursing education should be a lifelong process. care settings; developing and implementing clinical pathways; participat-
• Training schools in the United States deviated from the pattern establisheding in quality assurance; and focusing on geriatric populations.
by Nightingale. No criteria established which hospitals were to train• Regardless of educational background, all nurses use assessment, caring,
nurses. Students staffed the hospitals without being paid. There was nocounseling, and comforting skills in clinical practice.
uniformity in what was taught; students learned more by experience than
by formal instruction. Nursing students were taught from a physician’sCHAPTER 2
perspective. Students were required to work and to live at the beck and • The nursing process is an organized sequence of steps used to identify
call of the hospital administrator and after graduation students were left to health problems and to manage client care.
seek employment elsewhere. • Characteristics of the nursing process are that it is within the legal scope
• In addition to employment within hospitals, early graduates of nursing of nursing practice, based on unique knowledge, planned, client centered,
programs met the health needs of poor immigrants by living among them goal directed, prioritized, and dynamic.
in settlement houses in the ghettos of large cities, by serving as midwives • The steps in the nursing process are assessment, diagnosis, planning,
for rural women who lacked medical care, and by caring for sick and implementation, and evaluation.
wounded soldiers. • Resources for data include the client, the client’s family, medical records,
• What started as an art, passing on the skills of nursing from one prac-and other health care workers.
titioner to another, was soon augmented by science, a unique body •ofData base assessments provide vast information about a client at the
knowledge that made it possible to predict which nursing interventions time of admission. Focus assessments, which are ongoing, expand the
would be most appropriate for producing desired outcomes, a processdata base with additional information. Functional assessments, which
referred to as evidence-based practice. are performed on a cyclical basis, provide a comprehensive appraisal of
• Most recently, nursing has become theory based, which means that nurs-a client’s physical, psychological, and social status to maintain current
ing scholars are proposing what the process of nursing encompasses by strengths and avoid potential decline.
explaining the relationship between four essential components: humans, • A nursing diagnosis is a health problem that nurses can treat independ-
health, environment, and nursing. ently. A collaborative problem is a physiologic complication that requires
• One of the earliest definitions of nursing outlined the scope of practice as the skills and interventions of both nurses and physicians.
caring for the sick. More recently, the definition has been refined with the • A nursing diagnostic statement generally consists of three parts: the prob-
addition of the nurse’s role in health promotion and independent practice. lem, the etiology for the problem, and the signs and symptoms or evidence
• Those who wish to pursue a career in nursing may choose among a practi-for the problem.
cal/vocational nursing program or a registered nursing program taught in•aSetting priorities for care helps to maximize efficiency in minimal time.
career center, hospital school, community or junior college, or university.• Short-term goals are those the nurse expects to accomplish in a few days to
• The choice of nursing educational program depends on one’s career goals, 1 week, usually when caring for clients in acute care settings (eg, hospitals).
location of schools, costs involved, length of the program, reputation and Long-term goals may take weeks to months to accomplish after discharge
success of graduates,exibility
fl in course scheduling, opportunities for from the health care agency. They are identified when caring for clients
part-time or full-time enrollment, and ease of articulation to the next level with chronic problems who are receiving nursing care in a long-term health
of education. facility or through community health agencies or home health care.
• Continuing education is necessary for contemporary nurses because• itMethods of documentation include writing the problems, goals, and nursing
demonstrates personal accountability, promotes the public’s trust, ensuresorders by hand; individualizing a standardized or computer-generated care
competence in current nursing practice, and keeps the nurse abreast of plan; or following an agency’s written standards for care or clinical pathways.
how technology is affecting client care. • Nurses demonstrate implementation of the plan of care by correlating the
• Several trends are affecting health care. One of the major issues is thewritten plan with nursing documentation in the medical record.
growing shortage of nurses. In addition, many people, such as older • When evaluating the client’s progress, nursing orders are discontinued if
adults, minorities, and the poor, are not receiving adequate health care.the client has met the goal and the problem no longer exists. The nurse
The number of uninsured people is rising. Various cost-containment prac- revises the care plan if the client has made progress but the goal remains
tices reduce access to tests, treatment, and services, increase ratios of cli- unmet or if there has been no progress in reaching a desired outcome.
ents per nurse in employment settings, and contribute to a higher acuity •ofConcept mapping (also known as care mapping) is a method of organ-
clients in previously nonacute settings. izing information in a graphic or pictorial form. The process involves
875
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876 APPENDIX A Chapter Summaries
drawing lines or arrows to link or correlate relationships within the map. illness is one that comes on suddenly and lasts a short time. A chronic ill-
This foundation provides a bridge for developing more complex skills ness is one that comes on slowly and lasts a long time. A terminal illness
like identifying nursing diagnoses, setting goals and expected outcomes, is one in which there is no potential for cure. A primary illness is one that
implementing nursing interventions, and evaluating the results of care. developed independently of another disease. Any subsequent disorder that
develops from a preexisting condition is referred to as a secondary illness.
CHAPTER 3 Remission refers to the disappearance of the signs and symptoms associ-
• The six types of laws are constitutional, statutory, administrative, com- ated with a particular disease. An exacerbation refers to the time when the
mon, criminal, and civil. disorder becomes reactivated or reverts from a chronic to an acute state.
• Each state’s nurse practice act defines the unique role of the nurse and A hereditary condition is one acquired from the genetic codes of one or
differentiates it from that of other health care practitioners. Each state’s both parents. Congenital disorders are those that are present at birth but
board of nursing is the regulatory agency for managing its nurse practice result from faulty embryonic development. An idiopathic illness’s cause
act. is unexplained.
• Violations of civil laws include intentional and unintentional torts. In an • Primary care refers to the services provided by the first health care pro-
intentional tort, a private citizen sues another for a deliberately aggressive fessional or agency an individual contacts. Secondary care pertains to the
act. In an unintentional tort, the lawsuit charges that harm resulted from a services to which primary caregivers refer clients for consultation and
person’s negligence even though he or she intended no harm. additional testing, such as a cardiac catheterization laboratory. Tertiary
• Negligence lawsuits allege that a person’s actions, or lack thereof, care takes place in a hospital where complex technology and specialists
caused harm. The defendant is held to a standard expected of any other are available. Extended care involves meeting the health needs of clients
reasonable person. In the case of malpractice, the plaintiff alleges that who no longer require hospital care but who continue to need health
a professional’s actions, or lack thereof, caused harm. The defendant services.
is held to the standard expected of others with similar knowledge and • Two programs that help to finance health care for the aged, disabled, and
education. poor are Medicare and Medicaid.
• Professional liability insurance is advantageous for nurses to obtain • Methods for controlling escalating health care costs include a system
because (1) nurses are increasingly being named in medical lawsuits, of prospective payment known as the diagnosis-related group, managed
(2) financial damages, when awarded, can be extremely high, and (3) it care, health maintenance organizations, preferred provider organizations,
ensures having an attorney working on the nurse’s behalf. and capitation.
• A nurse’s professional liability can be mitigated by laws such as a state’s • National health goals for 2020 include: (1) Attain high quality, longer
Good Samaritan Act, expiration of the statute of limitations, legal princi- lives free of preventable disease, disability, injury, and premature death;
ples such as a client’s assumption of risk, accurate and complete docu- (2) achieve health equity, eliminate disparities, and improve the health
mentation, and aggressive risk management. of all groups; (3) create social and physical environments that promote
• Ethics refers to moral or philosophical principles that classify actions as good health for all; and (4) promote quality of life, healthy development,
right or wrong. and healthy behaviors across all life stages.
• A code of ethics is a written statement that describes ideal behavior for • One of several patterns may be used when providing nursing care for cli-
members of a particular discipline. ents. In functional nursing, each nurse on a unit is assigned specific tasks.
• There are two ethical theories: teleology and deontology. Teleology pro- The case method involves assigning one nurse to administer all the care a
poses that the best ethical decision is the one that will result in benefits client needs for a designated period of time. In team nursing, many nurs-
for the majority of individuals. Deontology proposes that the basis for an ing personnel divide the client care and all work until everything is com-
ethical decision is simply whether the action is morally right or wrong. pleted. Primary nursing is a method in which the admitting nurse assumes
• Six principles that form a foundation for ethical practice are beneficence, responsibility for planning client care and evaluating the progress of the
nonmaleficence, autonomy, veracity, fidelity, and justice. client. In managed care, a nurse manager plans the nursing care of clients
• Some common ethical issues that nurses encounter in everyday practice based on their illness or medical diagnosis and evaluates client progress so
include telling the truth, protecting clients’ confidentiality, ensuring that that each client is ready for discharge by the time designated by prospec-
clients’ wishes for withholding and withdrawing treatment are followed, tive payment systems.
advocating for the nondiscriminatory allocation of scarce resources, and
reporting incompetent or unethical practices. CHAPTER 5
• Homeostasis refers to a relatively stable state of physiologic equilibrium.
CHAPTER 4 • Physiologic, psychological, social, and spiritual stressors affect homeos-
• The World Health Organization (WHO) defines health as “a state of com- tasis.
plete physical, mental, and social well-being and not merely the absence • The philosophic concept of holism leads to two commonly held beliefs:
of disease or infirmity.” both the mind and the body directly influence humans, and the relation-
• Values are the ideals that an individual believes are honorable attributes. ship between the mind and the body has the potential for sustaining health
Beliefs are concepts that individuals hold to be true. as well as causing illness.
• Most Americans believe that health is a resource, a right, and a personal • Adaptation refers to how an organism responds to change. Successful
responsibility. adaptation is the key to maintaining and preserving homeostasis. Unsuc-
• How “whole” or well a person feels is the sum of his or her physical, cessful adaptation leads to illness and death.
emotional, social, and spiritual health, a concept referred to as holism. • Adaptive changes occur through the cortex, which communicates with
Any change in one component, positive or negative, automatically creates and through the reticular activating system, the hypothalamus, the auto-
repercussions in the others. nomic nervous system, and the pituitary gland along with other endocrine
• There are five levels of human needs: physiologic (first level), safety and glands under its control.
security (second level), love and belonging (third level), esteem and self- • The sympathetic nervous system, a division of the autonomic nervous
esteem (fourth level), and self-actualization (fifth level). By satisfying system, accelerates the physiologic functions that ensure survival through
needs at each subsequent level, individuals can realize their maximum strength or a rapid escape. The parasympathetic nervous system, a second
potential for health and well-being. division of the autonomic nervous system, inhibits physiologic stimula-
• Illness is a state of discomfort that results when a person’s health becomes tion, which restores homeostasis and provides an alternative mechanism
impaired through disease, stress, or an accident or injury. for dealing with stressors.
• Morbidity refers to the incidence of a specific disease, disorder, or injury. • Stress involves the physiologic and behavioral reactions that occur when
Mortality refers to the death rate from a specific condition. An acute the body’s equilibrium is disturbed.

APPENDIX A Chapter Summaries 877
• People vary in their response to stressors depending on the intensity and CHAPTER 7
duration of the stressor, the number of stressors at one time, physical sta- • In a nurse–client relationship, nurses meet client needs by performing
tus, life experiences, coping strategies, social support system, and per- any or all of the following roles: caregiver, educator, collaborator, and
sonal beliefs, attitudes, and values. delegator.
• The general adaptation syndrome, a physiologic stress response described • The role of clients is to be actively involved in their care, to communicate,
by Hans Selye, consists of the alarm stage, stage of resistance, and stage of to ask questions, to assist in planning their care, and above all to retain as
exhaustion. In most cases, the alarm stage and stage of resistance restore much independence as possible.
homeostasis. When the stage of resistance is prolonged, however, adaptive • Some principles underlying a therapeutic nurse–client relationship include
resources are overwhelmed and the person enters the stage of exhaus- treating each client as a unique person; respecting the client’s feelings;
tion, which is characterized by stress-related disorders and, in some cases, striving to promote the client’s physical, emotional, social, and spiritual
death. well-being; encouraging the client to participate in problem solving and
• Stress-related disorders and their consequences are minimized at three decision making; and accepting that a client has the potential for growth
levels. Primary prevention involves reducing the potential for a disorder. and change.
Secondary prevention involves public screening and early diagnosis. Ter- • A nurse–client relationship usually encompasses three phases: introduc-
tiary prevention uses rehabilitation and aggressive management when a tory, working, and termination.
disorder develops. • Communication involves sending and receiving messages between two
• Psychological adaptation occurs through the use of coping mechanisms and or more people followed by feedback indicating that the information was
coping strategies. Healthy use of coping mechanisms and coping strategies understood or requires further clarification. Therapeutic communication
allows people to postpone the emotional effects of stress, permitting them refers to using words and gestures to accomplish a particular objective.
to deal with reality eventually and gain emotional maturity. Unhealthy use • Examples of therapeutic verbal communication techniques include ques-
of coping mechanisms tends to distort reality to such an extent that the tioning, reflecting, paraphrasing, sharing perceptions, and clarifying.
person fails to see or correct his or her weaknesses. Nontherapeutic coping Examples of nontherapeutic verbal communication techniques include
strategies provide temporary relief but eventually cause problems. giving false reassurance, using clichés, giving approval or disapproval,
• Nursing care of clients under stress includes identifying stressors, assess- demanding an explanation, and giving advice.
ing the client’s response to stressors, eliminating or reducing stressors, • Some factors that may affect oral communication include language com-
preventing additional stressors, promoting adaptive responses, supporting patibility; verbal skills; hearing and visual acuity; motor functions involv-
coping strategies, maintaining a client’s network of support, and imple- ing the throat, tongue, and teeth; sensory distractions; and interpersonal
menting stress reduction and stress management techniques. attitudes.
• Four methods for preventing, reducing, or eliminating a stress response • The four forms of nonverbal communication are kinesics (body lan-
include using stress reduction techniques such as providing adequate guage), paralanguage (vocal sounds), proxemics (how space is used in
explanations in understandable language; implementing stress manage- communication), and touch.
ment interventions such as progressive relaxation; promoting the release • Task-related touch involves the personal contact required when perform-
of endorphins through massage, for example; and manipulating sensory ing nursing procedures. Affective touch is used to demonstrate concern or
stimuli as might be done with aromatherapy. affection.
• Affective touch is appropriate in many situations. Examples include car-
CHAPTER 6 ing for clients who are lonely, uncomfortable, near death, or anxious and
• Culture refers to the values, beliefs, and practices of a particular group. those with sensory deprivation.
Race refers to biologic variations such as skin color, hair texture, and eye
shape. Ethnicity is the bond or kinship a person feels with his or her coun- CHAPTER 8
try of birth or place of ancestral origin. • Health teaching is nursing activity that is mandated by state nurse prac-
• Two factors that interfere with perceiving others as individuals are stere- tice acts, the Joint Commission (2010), which has made it a criterion for
otyping, which involves ascribing fixed beliefs about people based on accreditation, and the professional position published in the American
some general characteristic, and ethnocentrism, the belief that one’s own Nurses Association’s Social Policy Statement.
ethnicity is superior to all others. • Client teaching generally focuses on combinations of the following
• US culture is said to be Anglicized because many of the values, beliefs, subject areas: the plan of care, treatment and services; safe self-admin-
and practices evolved from the early English settlers. istration of medications; the pain assessment process and methods for
• Some examples of Anglo-American culture include speaking English; pain management; directions and practice in using equipment for self-
valuing work, time, and technology; holding parents responsible for the care; dietary instructions; rehabilitation program; available community
health care, behavior, and education of minor children; keeping govern- resources; plan for medical follow-up; and signs of complications and
ment separate from religion; and seeking assistance from licensed indi- actions to take.
viduals when health care is necessary. • Benefits of client teaching include (1) reduced length of stay, (2) cost-
• A subculture is a unique cultural group that coexists within the dominant effectiveness of health care, (3) better allocation of resources, (4) increased
culture. The four major US subcultures are African American, Latino, client satisfaction, and (5) decreased readmission rates.
Asian American, and Native American. • The three learning domains are the cognitive domain (information usually
• Subcultural groups differ from Anglo-Americans in one or more of the provided in oral or written forms), the affective domain (information that
following ways: language, communication style, biologic and physiologic appeals to a person’s feelings, beliefs, or values), and the psychomotor
variations, prevalence of diseases, and health beliefs and practices. domain (learning by doing).
• The four characteristics of culturally sensitive nursing care are data collection • Three age-related categories of learners are pedagogic (children),
of a cultural nature, acceptance of each client as an individual, knowledge androgogic (young and middle-aged adults), and gerogogic (older adults).
of health problems that affect particular cultural groups, and planning care • Examples of characteristics unique to gerogogic learners are that they are
within the client’s health belief system to achieve the best health outcomes. motivated to learn by a personal need, they may be experiencing degen-
• Some ways that nurses can demonstrate cultural sensitivity include learn- erative physical changes, and they can draw on a vast repertoire of past
ing a second language, performing physical assessments and care accord- experiences.
ing to the client’s unique biologic differences, consulting each client as • Before teaching a client, the nurse assesses the client’s learning style, age
to his or her cultural preferences, arranging for modifications in diet and and development, capacity to learn (includes level of literacy, any sensory
dress according to the client’s customs, and allowing clients to continue deficits, and cultural differences), ability to pay attention and concentrate,
relying on cultural health practices (if they are not harmful). motivation, learning readiness, and learning needs.

CHAPTER 9 • Nosocomial infections are those acquired by previously uninfected clients

• Medical records are used as a permanent account of a person’s health while they are being cared for in a health care facility.
problems, care, and progress; to share information among health care per- • Asepsis refers to practices that decrease the numbers of infectious agents,
sonnel; as a resource for investigating the quality of care in an institution; their reservoirs, and vehicles for transmission.
to acquire and maintain Joint Commission accreditation; to obtain reim- • Medical asepsis involves practices that confine or reduce microorganisms.
bursement for billed services and products; to conduct research; and as The most effective method of medical asepsis is hand hygiene, an essen-
legal evidence in malpractice cases. tial nursing activity that must be performed repeatedly when caring for
• Medical records generally contain an information sheet about the client, clients. Surgical asepsis involves measures that render supplies and equip-
medical information, a plan of care, nursing documentation, medication ment totally free of microorganisms and practices that avoid contamina-
administration records, and laboratory and diagnostic test results. tion during their use.
• Health care agencies may organize information in the medical record • Principles of medical asepsis include frequent handwashing or hand
using a source-oriented or a problem-oriented format. Source-oriented antisepsis and maintaining intact skin (the best methods for reducing the
records categorize information according to the source reporting it; transmission of microorganisms); using personal protective equipment
problem-oriented records are organized according to the client’s health (gloves, gown, mask, goggles, and hair and shoe covers); and maintaining
problems, regardless of who does the documentation. a clean environment.
• Nurses may document information in the medical record using one of • Surgical asepsis involves sterilization measures such as ultraviolet radia-
the following methods: narrative charting, SOAP charting, focus charting, tion, heat, or chemicals.
PIE charting, charting by exception, and computerized charting. • Three of the principles of surgical asepsis are as follows: sterility is
• HIPAA legislation was enacted originally to protect health information preserved by touching one sterile item with another sterile item; once
communicated from one insurance company to another when a person a sterile item touches something that is not sterile, it is considered con-
changed employment. Recent revisions to that legislation now regulate taminated; and any partially unwrapped sterile package is considered
methods for further ensuring the client’s privacy in the workplace and contaminated.
security of data. • Nurses apply principles of surgical asepsis when they create a sterile field,
• Regardless of the charting style, all documentation in an acute health care add supplies or liquids to a sterile field, and don sterile gloves.
agency includes ongoing assessment data, a plan of care, a record of the
care provided, and the outcomes of the implemented care. CHAPTER 11
• Nurses use only agency-approved abbreviations when documenting infor- • The process of admission involves obtaining authorization from a phy-
mation to promote clarity in communication among health professionals sician, obtaining billing information, completing nursing responsibilities
and to ensure accurate interpretation of the documented information if the such as orienting the client and obtaining a data base assessment, develop-
chart is subpoenaed as legal evidence. ing an initial plan for nursing care, and fulfilling medical responsibilities
• Military time is based on a 24-hour clock. Time is indicated using a dif- such as documenting the client’s history and results of a physical exami-
ferent four-digit number. After noon, the time is identified by adding 12 to nation.
each hour. • Some common reactions of newly admitted clients are anxiety, loneliness,
• Some principles of charting when it is hand-written include the following: potential for compromised privacy, and loss of identity.
ensure that the documentation form identifies the client; use a pen; print or • The discharge process consists of obtaining a written medical order
write legibly; record the time of each entry; fill all the space on a line; use for discharge, completing discharge instructions, notifying the busi-
only approved abbreviations; describe information objectively, providing ness office, helping the client leave the agency, writing a summary of
precise measurements when possible; avoid obliterating information; and the discharge in the medical record, and requesting that the room be
sign each entry by name and title. cleaned.
• Written forms of communication other than the medical record include • Examples of the use of transfers in client care include moving a client
the nursing care plan, nursing Kardex, checklists, and flow sheets. from one level of care to another when his or her condition improves,
• In addition to the written record, the health care team may exchange infor- worsens, or no longer meets the criteria initially established but still needs
mation during change of shift reports, client care assignments, team con- some type of attention.
ferences, rounds, and telephone calls. • A transfer involves discharging a client from one unit or agency and
admitting him or her to another without the client going home in the
CHAPTER 10 interim. A referral involves sending a client who will be discharged to
• Microorganisms are living animals or plants visible only with a micro- another person or agency for special services.
scope. • Nursing homes may provide skilled, intermediate, or basic care.
• Some examples of microorganisms are bacteria, viruses, fungi, rickett- • To determine the level of care a client requires, federal law requires
siae, protozoans, mycoplasmas, helminths, and prions. licensed extended care facilities to complete a Minimum Data Set assess-
• Nonpathogens are generally harmless microorganisms, whereas patho- ment form on admission and every 3 months thereafter or whenever the
gens have a high potential for causing infections and contagious diseases. client’s condition changes.
Resident microorganisms are generally nonpathogens that are always • The demand for home health care services has increased due to limits on
present on the skin. Transient microorganisms are generally pathogens insurance reimbursement for hospital stays and the growing number of
that are more easily removed through hand hygiene. Aerobic microorgan- older adults in the population who need health care assistance.
isms require oxygen for survival, whereas anaerobic microorganisms do
not. CHAPTER 12
• Some microorganisms have ensured their survival by developing the • Vital signs include temperature, pulse, respirations, and blood pressure.
capacity to form spores and resist antibiotic drug therapy. Pain is considered the fifth vital sign. Pain assessment, which is discussed
• The components of the chain of infection are an infectious agent, a reser- in Chapter 20, is performed at least daily and whenever vital signs are
voir for growth and reproduction, an exit route from the reservoir, a mode taken.
of transmission, a port of entry, and a susceptible host. • Shell temperature is the degree of warmth at the skin surface; core tem-
• Several biologic defenses reduce susceptibility to infectious agents. perature is the degree of warmth near the center of the body where vital
Examples include intact skin and mucous membranes; reflexes such as organs are located.
sneezing, coughing, and vomiting; infection-fighting blood cells; enzymes • Temperature is measured using the Celsius or Fahrenheit scale.
such as lysozyme which is present in tears, saliva, and other secretions; • The mouth, rectum, axilla, and ear are common sites for assessing body
the acidity of gastric acid; and antibodies. temperature; the temperature of the tympanic membrane in the ear and

behind the ear over the path of the temporal artery is the closest approxi- • Drapes during a physical examination protect the client’s modesty and
mation of core temperature. provide warmth.
• Electronic, infrared, chemical, and digital thermometers are used to assess • There are two approaches for data collection. The head-to-toe approach
body temperature; glass mercury thermometers are no longer recom- involves gathering data from the top of the body and then working toward
mended for use because mercury is an environmental and human toxin. the feet. The systems approach organizes data collection according to the
• A fever exists when a client has a body temperature that exceeds 99.3°F functional systems of the body.
(37.4°C). Hyperthermia is a life-threatening condition characterized by a • The body may be divided into six general components when organizing
body temperature that exceeds 105.8°F (40.6°C). data collection: the head and neck, the chest, the extremities, the abdo-
• A fever generally has four phases: prodromal, onset or invasion, station- men, the genitalia, and the anus and rectum.
ary, and resolution or defervescence. • Whenever an opportunity arises, nurses teach adult clients how to perform
• A fever is accompanied by chills, flushed skin, irritability, and headache, breast and testicular self-examinations.
as well as several other signs and symptoms.
• An infrared tympanic thermometer is the best assessment tool for measur- CHAPTER 14
ing subnormal temperatures because other common clinical thermometers • An examination is a procedure that involves the physical inspection of
cannot accurately measure temperatures in hypothermic ranges and the body structures and evidence of their functions. A test involves the exami-
blood flow in the mouth, rectum, and axilla is generally so low that meas- nation of body fluids or specimens.
urements taken from these sites are inaccurate. • Whenever clients undergo special examinations and tests, the nurse is
• Subnormal temperatures are accompanied by shivering, pale skin, listless- generally responsible for determining the client’s understanding of the
ness, and impaired muscle coordination as well as several other signs and procedure, checking that the consent form is signed, following test prepa-
symptoms. ration requirements or teaching outpatients how to prepare themselves,
• A pulse assessment includes the rate per minute, rhythm, and volume. obtaining equipment and supplies, arranging the examination area, posi-
• The radial artery is the most common pulse assessment site; however, tioning and draping clients, assisting the examiner, providing clients with
similar data may be obtained by assessing the apical heart rate or the physical and emotional support, caring for specimens, and recording and
apical-radial rate or by using a Doppler ultrasound device. reporting significant information.
• Respiration refers to the exchange of oxygen and carbon dioxide. Ventila- • The five common examination positions are dorsal recumbent, Sims’,
tion is the movement of air in and out of the chest. The rate of ventilation lithotomy, knee–chest, and modified standing.
is assessed when obtaining vital signs. • A pelvic examination involves the inspection and palpation of the vagina
• Some abnormal breathing characteristics that may be noted are tachypnea and adjacent organs. This examination often includes the collection of
(rapid breathing), bradypnea (slow breathing), dyspnea (labored breath- secretions for a Pap test to identify any abnormal cells, levels of hormone
ing), and apnea (absence of breathing). activity, and identity of infectious microorganisms.
• Blood pressure measurements reflect the ability of the arteries to stretch, • Tests and examinations commonly involve the use of specimens, x-rays,
the volume of circulating blood, and the amount of resistance the heart endoscopes, radioactive substances, sound waves, and electrical activity.
must overcome when it pumps blood. • When determining how particular tests are performed, it is helpful to
• Systolic pressure is the pressure within the arterial system when the heart understand four word endings: -graphy, as in angiography, means to
contracts. Diastolic pressure is the pressure within the arterial system record an image; -scopy, as in bronchoscopy, means to look through a
when the heart relaxes and fills with blood. lensed instrument; -centesis, as in amniocentesis, means to puncture; and
• A stethoscope, an inflatable cuff, and a sphygmomanometer are usually -metry, as in pelvimetry, means to measure with an instrument.
required for measuring blood pressure. • Nurses often are called on to assist with sigmoidoscopy (inspecting the rec-
• During an auscultated blood pressure assessment, five distinct sounds, tum and sigmoid section of the lower intestine with an endoscope), para-
called Korotkoff sounds, are heard. Phase I is characterized by faint tap- centesis (puncturing the skin and withdrawing fluid from the abdominal
ping sounds; in phase II, the sounds are swishing; in phase III, the sounds cavity), and lumbar puncture (inserting a needle between lumbar vertebrae
are loud and crisp; in phase IV, the sound becomes suddenly muffled; and in the spine but below the spinal cord itself); to collect a throat culture spec-
in phase V there is one last sound, followed by silence. imen; and to measure capillary blood glucose levels using a glucometer.
• Blood pressure may be measured with an electronic sphygmomanometer, • When the client undergoing special examinations and tests is an older
which provides a digital display of the pressure measurements. The blood adult, the nurse faces special challenges such as preventing fatigue and
pressure also can be measured by palpating the brachial pulse while releas- dehydration, maintaining or adjusting current drug therapy and avoiding
ing the air from the cuff bladder, by using a Doppler stethoscope or an misinterpretation of laboratory test results that are based on norms for
automated blood pressure machine, or taking the blood pressure at the younger adults.
thigh.
CHAPTER 15
CHAPTER 13 • Nutrition is the process by which the body uses food. Malnutrition results
• Physical assessments are performed to evaluate the client’s current physi- from inadequate consumption of nutrients.
cal condition, to detect early signs of developing health problems, to • The components of basic nutrition include adequate calories, proteins,
establish a database for future comparisons, and to evaluate responses to carbohydrates, fats, vitamins, and minerals.
medical and nursing interventions. • Some factors that affect nutritional needs include age, height and weight,
• There are four physical assessment techniques: inspection, percussion, growth, activity, and health status.
palpation, and auscultation. • MyPlate from the United States Department of Agriculture is a guide for
• Before performing a physical assessment, the nurse needs gloves, exami- promoting a healthy daily intake of food.
nation gown, cloth or paper drape, stethoscope, penlight, and tongue • Nutrition labels must indicate the serving size in household measurements
blade, as well as other assessment instruments for taking vital signs and and the daily value for specific nutrients per serving. They must meet
weighing and measuring the client. specified criteria if they make health-related claims for the product.
• The assessment environment should be near a restroom, private, warm, • Protein complementation is the practice of combining two or more plant
and adequately lit. There should be an adjustable examination table or protein sources to obtain all the essential amino acids required for healthy
bed. nutrition.
• During an initial survey of a client, the nurse observes physical appear- • Data that provide objective information about a person’s nutritional status
ance, level of consciousness, body size, posture, gait, movement, use of include anthropometric measurements, physical examination data, and
ambulatory aids, and mood and emotional tone. results from laboratory tests.

• A diet history is the information obtained by asking a person to describe normal saline solution, and Y-set tubing; and infuses the blood within
his or her eating habits and factors that may affect nutrition. 4 hours or less.
• Problems commonly identified after a nutritional assessment include • During a blood transfusion, the nurse monitors the client closely for
weight problems, anorexia, nausea, vomiting, and stomach gas. incompatibility; febrile, septic, and allergic reactions; chilling; circula-
• If a nutritional problem is beyond the scope of independent nursing prac- tory overload; and signs of hypocalcemia.
tice, the nurse consults with the physician. If the problem can be resolved • Parenteral nutrition is a technique for providing nutrients, such as protein,
through independent nursing measures, the nurse may proceed by col- carbohydrate, fat, vitamins, minerals, and trace elements, intravenously
laborating with the dietitian, selecting appropriate nursing interventions, rather than orally.
and continuing to monitor the client to evaluate the effectiveness of the
nursing care plan. CHAPTER 17
• Common hospital diets are regular, light, soft, mechanical soft, full liquid, • Hygiene refers to practices that promote health through personal cleanliness.
and clear liquid, and various therapeutic modifications to these diets. • Hygiene practices that most people perform regularly include bathing,
• Nurses are generally responsible for ordering and canceling diets for cli- shaving, oral hygiene, hair care, and nail care.
ents, serving and collecting meal trays, helping clients to eat, and record- • A partial bath is more appropriate for older adults than a daily tub bath or
ing the percentage of food eaten. shower, because they do not perspire as much as young adults and soap
• Nurses must know the type of diet prescribed for each client, the purpose tends to dry their skin.
for the diet, and its characteristics. • Towel and bag baths add lubrication to the skin; avoid friction to preserve
• Influences on the nutritional status of older adults include age-related skin integrity; reduce transmission of microorganisms from one part of
physical changes, underlying medical conditions, adverse effects of the body to another; save time; provide more opportunity for self-care;
medication therapy, functional impairments, psychosocial conditions, and and promote comfort because of the warmth of the liquid.
socioeconomic and environmental barriers. • Use of a safety razor is contraindicated for clients who have clotting dis-
orders, those receiving anticoagulants and thrombolytics, and those who
CHAPTER 16 are depressed and suicidal.
• Body fluid is a mixture of water, chemicals called electrolytes and none- • Most dentists recommend using a soft-bristled or electric toothbrush,
lectrolytes, and blood cells. tartar-control toothpaste with fluoride, and dental floss.
• Fluid and its components are distributed within each fluid compartment • The chief hazard in providing oral hygiene for unconscious clients is
by means of osmosis, filtration, passive diffusion, facilitated diffusion, aspiration of liquid into the lungs. To prevent aspiration, nurses position
and active transport. unconscious clients on the side with the head lower than the body. They
• The nurse assesses fluid volume status by measuring a client’s intake and use oral suction equipment to remove liquid from the mouth.
output, obtaining daily weights, obtaining vital signs, monitoring bowel • To prevent damage during cleaning, the nurse holds dentures over a plas-
elimination patterns and stool characteristics, observing the color of urine, tic or towel-lined container and uses cold or tepid water.
and assessing skin turgor, the condition of the oral mucous membranes, • The nurse can detangle a client’s hair by applying conditioner, using a
lung sounds, and level of consciousness. wide-toothed comb, and combing from the end of the hair toward the scalp.
• Fluid volume is restored by treating the underlying disorder, increasing • The nurse consults the physician about nail care for clients with diabetes
oral intake, administering IV fluid replacements, controlling fluid losses, or poor circulation.
or a combination of these measures. • Daily hygiene also includes cleaning and caring for visual or hearing
• Fluid volume excess is reduced or eliminated by treating the underlying dis- devices such as eyeglasses, contact lenses, artificial eyes, or hearing aids.
order, restricting or limiting oral fluids, reducing salt consumption, discontin- • Clients who cannot insert and care for contact lenses may consider wearing
uing IV fluid infusions or reducing the infusing volume, administering drugs eyeglasses, using a magnifying lens, or doing without while they are ill.
that promote urine elimination, or a combination of these interventions. • The sound that a hearing aid produces may be altered as a result of dead
• IV fluids are administered to maintain or restore fluid balance, maintain or or weak batteries, batteries that are not making full contact, corroded bat-
replace electrolytes, administer water-soluble vitamins, provide calories, teries, malposition within the ear, excessive volume, impacted cerumen,
administer drugs, and replace blood and blood products. and dirty or damaged components.
• Crystalloid solutions are mixtures of water and substances such as salt • Infrared listening devices are an alternative to hearing aids. They convert
and sugar that totally dissolve. Colloid solutions are mixtures of water and sound into infrared light and then reconvert the light into sound through a
suspended, undissolved substances such as blood cells. receiver worn in a headset with earphones.
• An isotonic solution has the same concentration of dissolved substances
as plasma; a hypotonic solution has fewer dissolved substances; and a CHAPTER 18
hypertonic solution is more concentrated than plasma. • Comfort is a state in which a person is relieved of distress. Rest is a wak-
• When selecting tubing for administering IV solutions, the nurse must con- ing state characterized by reduced activity and mental stimulation. Sleep
sider whether to use primary or secondary tubing and vented or unvented is a state of arousable unconsciousness.
tubing, which drop size is most appropriate, and whether or not a filter is • Some environmental factors that promote comfort, rest, and sleep are
needed. colorful walls and room decor, reduced noise, increased natural sunlight,
• IV fluids may be infused by gravity or with the assistance of an infusion and a comfortable climate.
device such as a pump or volumetric controller. • Standard furnishings in all client rooms are the bed, the overbed table, the
• When selecting a vein for venipuncture, the nurse gives priority to a vein bedside stand, and at least one chair.
in the nondominant hand or arm that is fairly straight, is larger than the • Sleep is a basic human need. Among other things, it reduces fatigue, sta-
needle or catheter gauge, is likely to be undisturbed by joint movement, bilizes mood, increases protein synthesis, promotes cellular growth and
and appears unimpaired by previous trauma or use. repair, and improves the capacity for learning and memory storage.
• Complications of IV fluid therapy include infiltration, phlebitis, infection, • The two phases of sleep are nonrapid and rapid eye movement sleep. Dur-
circulatory overload, thrombus formation, pulmonary embolus, and air ing nonrapid eye movement (NREM) sleep and its four subdivisions, the
embolism. body is active but the brain is not. During rapid eye movement (REM)
• An intermittent venous access device is used in clients who require inter- sleep, the body is physically inactive but the brain is highly active.
mittent IV fluid or medication administration or for emergency access to • As humans age, they sleep fewer hours and spend less time in REM sleep.
the vascular system. Newborns spend 16 to 20 hours of each day sleeping, approximately half
• When administering blood, the nurse assesses vital signs before and dur- in the REM phase. Older adults require 7 to 9 hours of sleep and spend
ing the transfusion; uses no smaller than a 20-gauge needle or catheter, only 13% to 15% in the REM phase.

• Circadian rhythms, activity, the environment, motivation, emotions and • Electrical shock may be prevented by using three-pronged grounded
moods, food and beverages, illness, and drugs can affect the amount and equipment, making sure all cover plates are intact, and replacing equip-
quality of sleep. ment with frayed electrical cords.
• Four major categories of drugs either promote or interfere with sleep. Sed- • Substances commonly implicated in poisonings include chemicals such as
atives and tranquilizers produce a relaxing and calming effect, hypnotics drugs, cleaning agents, paint solvents, heavy metals, cosmetics, and plants.
induce sleep, and stimulants excite structures in the brain, causing wake- • Poisonings may be prevented by using childproof caps on medication bot-
fulness. tles, installing latches on storage cupboards, and never transferring a toxic
• Sleep questionnaires, sleep diaries, polysomnographic evaluations, and substance to a container generally associated with food.
the multiple sleep latency test are techniques used to assess sleep patterns. • Although physical restraints prevent falls, they create concomitant risks
• Sleep disorders fall into four major categories: insomnia (difficulty fall- for constipation, incontinence, infections such as pneumonia, pressure
ing asleep or staying asleep, or early morning awakening), hypersomnias ulcers, and a progressive decline in the ability to perform activities of
(conditions resulting in daytime sleepiness despite adequate nighttime daily living.
sleep), sleep–wake cycle disturbances (resulting from desynchronized • The overuse of physical restraints in health care facilities has led to the
periods of sleeping and wakefulness), and parasomnias (associated with passage of legislation and accreditation standards regulating their use.
activities that cause arousal or partial arousal usually during transitions in • Restraints are devices that restrict movement; restraint alternatives are
NREM periods of sleep). protective and adaptive devices that clients can remove independently.
• Sleep is promoted by exercising regularly during the day; avoiding • Restraint use may be justified when clients have a history of previous falls
alcohol, nicotine, and caffeine; performing sleep rituals; going to bed or may experience life-threatening consequences, when there has been an
and getting up at about the same time every day; and getting out of bed unsatisfactory response to restraint alternatives, when clients are seriously
if sleep does not come easily and returning after some nonstimulating impaired mentally or physically, or if their movement must be restricted
activity. during a life-threatening event.
• To promote relaxation, which facilitates the onset of sleep, nurses assist • If an accident occurs, the nurse’s first concerns are the safety of the client
clients with progressive relaxation exercises or provide a back massage. and the potential for allegations of malpractice.
• Older adults tend to have more difficulty falling asleep, they awaken • Older adults in general are prone to falling because they have gait and
more readily, and they spend less time in the deeper stages of sleep. This balance problems resulting from age-related changes, visual impairment,
explains why some older adults feel tired even though they have slept an postural hypotension, and urinary urgency.
appropriate time.
CHAPTER 20
CHAPTER 19 • Pain is an unpleasant sensation usually associated with disease or injury.
• The Joint Commission considers safety a priority when caring for clients All clients should have access to the best pain relief that can safely be
by identifying National Patient Safety Goals. The purpose of these goals, provided.
is to help health care organizations obtain and retain their accreditation by • The four phases of pain are transduction, transmission, perception, and
demonstrating safe and effective care of the highest quality. Compliance modulation.
and achievement of the patient safety goals is evidenced by a reduced • The pain threshold is the point at which pain-transmitting neurochemicals
number of deaths and injuries among those being cared for in health agen- reach the brain and cause conscious awareness known as pain perception.
cies. Current examples of these goals can be obtained at http://www.joint- Pain tolerance is the amount of pain a person endures once the threshold
commission.org/standards_information/npsgs.aspx. has been reached.
• Accidental injuries vary according to the victim’s stage of development. • Endogenous opioids are naturally produced chemicals with morphine-
Because infants must rely on their caretakers, they are susceptible to falls. like characteristics. It is believed that these chemicals bind to sites on
Poisonings are common among toddlers. School-aged children suffer the nerve cell’s membrane, blocking the transmission of pain-producing
play-related injuries, and adolescents are often the victims of sport-related neurotransmitters.
injuries. Young adults commonly are involved in motor-vehicle accidents. • The five general types of pain are cutaneous pain, visceral pain, neuro-
Middle-aged adults suffer a variety of physical traumas such as back inju- pathic pain, acute pain, and chronic pain.
ries. Falls are common among older adults. • Acute pain differs from chronic pain in its duration, etiology, and response
• Environmental hazards often contribute to injuries and deaths from latex to therapeutic measures.
sensitization, burns, asphyxiation, electrical shock, poisoning, and falls. • When performing a basic pain assessment, the nurse asks the client to
• Measures to reduce latex sensitization include using nonlatex gloves describe the onset, quality, intensity, location, and duration of pain.
and medical equipment, washing hands after removing latex gloves, and • Four commonly used pain-intensity assessment tools are a numeric scale,
avoiding use of petroleum-based hand creams or lotions, which retain a word scale, a linear scale, and a picture scale like the Wong–Baker
latex protein on the skin. FACES Pain Rating Scale.
• Most fire plans incorporate four steps: rescue those in danger, sound an • A pain assessment is performed, at a minimum, on admission, whenever
alarm, confine the fire, and extinguish the blaze. vital signs are assessed, once per shift when pain is an actual or potential
• There are four classes of fire extinguishers. Class A extinguishers are used problem, and before and after implementing a pain-management interven-
for paper, wood, and cloth fires. Class B extinguishers are used on fuels tion.
and flammable liquids. Class C extinguishers are used for electrical fires. • The physiologic basis for pain management involves interrupting pain-
Class ABC extinguishers can be used on any type of fire. transmitting chemicals at the site of injury, altering pain transmission at
• Methods of preventing burns include installing and maintaining smoke the spinal cord, and blocking pain perception in the brain.
detectors, developing and practicing a fire evacuation plan, and never • Three categories of drugs used to manage pain are nonopioids, opio-
going back into a burning building. ids, and adjuvant drugs. The injection of botulinum toxin is a fairly new
• Common causes of asphyxiation include smoke inhalation, carbon mon- method for treating painful skeletal muscle conditions and headaches.
oxide poisoning, and drowning. • Rhizotomy and cordotomy are surgical pain-management techniques used
• Measures to prevent drowning are wearing approved flotation devices, when other methods are ineffective.
avoiding alcohol consumption when around water, and never swimming • Examples of nondrug/nonsurgical methods of pain management are edu-
alone. cating clients about pain and its control and using imagery, meditation,
• Humans are susceptible to injury from electrical shock because the human distraction, relaxation, and interventions such as applications of heat and
body is predominately composed of water and electrolytes, which are cold, transcutaneous electrical nerve stimulation, acupuncture and acupres-
good conductors of electrical current. sure, percutaneous electrical nerve stimulation, biofeedback, and hypnosis.

• Clients often request frequent doses of pain-relieving medications because tact precautions are used to block the transmission of pathogens by direct
the dosage or schedule for administration is not controlling the pain. or indirect contact.
• Addiction is “a pattern of compulsive drug use characterized by a contin- • Personal protective equipment is defined as garments that block the trans-
ued craving for an opioid and the need to use the opioid for effects other fer of pathogens from a person, place, or object to oneself or others.
than pain relief.” • When removing personal protective equipment, nurses perform an orderly
• The fear of addiction leads to inadequate pain management. sequence, accompanied by hand hygiene, to prevent self-contamination
• A placebo is an inactive substance given as a substitute for an actual drug. and transmission of pathogens to others.
The positive effect some clients have from placebos probably results from • Double-bagging is an infection control measure for removing contaminated
the trust they have in the physician or nurse. items such as trash or laundry from the client’s environment. It involves
placing one bag within another held by someone outside the client’s room.
CHAPTER 21 • Clients with infectious diseases often have decreased social interaction
• Ventilation is the act of moving air in and out of the lungs. Respiration and sensory deprivation because they are confined to their room.
refers to the mechanisms by which oxygen is delivered to the cells. • To prevent infections, people should obtain appropriate immunizations;
• External respiration takes place through alveolar–capillary membranes. practice a healthy lifestyle such as eating the recommended number of
Internal respiration occurs at the cellular level via hemoglobin and body cells. servings from the MyPlate nutrition guidelines; and avoid sharing per-
• The oxygenation status of clients can be determined at the bedside by sonal items such as washcloths and towels, razors, and cups.
performing focused physical assessments, monitoring ABGs, and using • Symptoms of infectious disorders tend to be subtler in older adults.
pulse oximetry.
• Five signs of inadequate oxygenation are restlessness, rapid breathing, CHAPTER 23
rapid heart rate, sitting up to breathe, and using accessory muscles. • When standing, keep the feet parallel and distribute weight equally on
• Nurses can improve the oxygenation of clients by positioning clients with both feet to provide a broad base of support. When sitting, the buttocks
the head and chest elevated and teaching them to perform breathing exer- and upper thighs are the base of support on the chair; both feet rest on the
cises. floor. Correct posture for lying down is the same as for standing but in the
• When oxygen therapy is prescribed, a source for the oxygen, a flowm- horizontal plane; body parts are in neutral position.
eter, an oxygen delivery device, and in some cases an oxygen analyzer or • Principles of correct body mechanics include the following: distribute
humidifier are all needed. gravity through the center of the body over a wide base of support; push, pull,
• Oxygen may be supplied through a wall outlet, in portable tanks, within a or roll objects rather than lifting them; and hold objects close to the body.
liquid oxygen unit, or with an oxygen concentrator. • Ergonomics is a field of engineering science devoted to promoting com-
• Most clients receive oxygen therapy through a nasal cannula, any one of fort, performance, and health in the workplace by improving the design of
several types of masks, or a face tent. Those who have had an opening cre- the work environment and equipment that is used.
ated in their trachea may receive oxygen through a tracheostomy collar, • Two examples of ergonomic recommendations are to use assistive devices
T-piece, or transtracheal catheter. when lifting or transporting heavy items and to use alternatives for tasks
• Whenever oxygen is administered, nurses must be concerned about two that require repetitive motions.
hazards: the potential for fire and oxygen toxicity. • Disuse syndrome is associated with weakness, atony, poor alignment,
• Water seal chest tube drainage and hyperbaric oxygen chambers are two contractures, foot drop, impaired circulation, atelectasis, urinary tract
therapeutic techniques related to oxygenation. infections, anorexia, and pressure sores.
• Older adults have unique respiratory risk factors for several reasons. They • Common client positions are supine (on the back), lateral (on the side),
often have age-related structural and functional changes that may compro- lateral oblique (on the side with slight hip and knee flexion), prone (on the
mise ventilation and respiration. abdomen), Sims’ (semiprone on the left side with the right knee drawn up
toward the chest), and Fowler’s (semisitting or sitting).
CHAPTER 22 • Positioning devices include the following: adjustable bed—allows the
• Infectious diseases, also called community-acquired, contagious, or composition of the head and knees to be changed; pillows—provide support
municable diseases, are spread from one person to another. and elevate a body part; trochanter rolls—prevent legs from turning out-
• An infection is a condition that results when microorganisms cause injury ward; hand rolls—maintain function of the hand and prevent contractures;
to their host. Colonization refers to a condition in which microorganisms and foot boards—keep the feet in normal walking position.
are present but the host is not damaged and has no signs or symptoms. • Pressure-relieving devices include the following: siderails—help clients
• Infectious diseases usually follow five stages: incubation, prodromal, to change position; mattress overlays—reduce pressure and promote skin
acute, convalescent, and resolution. integrity; and cradle—keeps linen off client’s feet or legs.
• Infection control measures are designed to curtail the spread of infectious • Devices used to help transfer clients include a transfer handle, a transfer
diseases. belt, a transfer board, and a mechanical lift.
• The two major categories of infection control measures are standard pre- • Guidelines to follow when transferring clients include the following:
cautions and transmission-based precautions. know the client’s diagnosis, capabilities, weaknesses, and activity level;
• Standard precautions are measures for reducing the risk of microorganism be realistic about how much you can safely lift; transfer clients across the
transmission from both recognized and unrecognized sources of infection. shortest distance possible; solicit the client’s help; and use smooth rather
Transmission-based precautions are measures to control the spread of than jerky movements.
infectious agents from clients known to be or suspected of being infected
with pathogens. CHAPTER 24
• Standard precautions include hand hygiene; use of gloves, gown, mask, • Regular exercise has many benefits including reduced blood pres-
and eye protection or face shield; and safe injection practices depending sure, blood glucose and blood lipid levels, tension, and depression and
on the nature of the client interaction and extent of anticipated blood, increased bone density.
body fluid, or pathogen exposure. • Fitness refers to a person’s capacity to perform physical activities.
• Transmission-based precautions are used to prevent spreading pathogens • Factors that interfere with fitness include chronic inactivity, concurrent
via air, droplets, or contact with clients or objects that contain infectious health problems, impaired musculoskeletal function, obesity, advancing
microorganisms. age, smoking, and high blood pressure.
• Airborne precautions are used to block very small pathogens that remain • Several approaches can be used to determine a person’s level of fitness.
suspended in the air or are attached to dust particles. Droplet precautions Two objective methods are a stress electrocardiogram and a submaximal
are used to block larger pathogens contained within moist droplets. Con- fitness test such as a step test.

• Exercise, regardless of type, should be performed within the person’s tar- ing a ball or spring grip, and performing modified hand push-ups while
get heart rate, which is calculated by subtracting the person’s age from in a bed or chair.
220 (maximum heart rate) and then multiplying that number by 60% (0.6) • Clients dangle or are placed on a tilt table to normalize their blood pres-
to 90% (0.9), based on the person’s fitness level. sure and help them adjust to being upright.
• Metabolic energy equivalent (MET) is the measure of energy and oxygen • Parallel bars and walking belts are devices used to assist clients with
consumption that a person’s cardiovascular system can support safely. ambulation.
When an exercise prescription is given, exercises are correlated with their • Three types of ambulatory aids are canes, walkers, and crutches.
MET value. • Walkers are the most stable form of ambulatory aid. Straight canes are the
• Fitness exercises are physical activities that develop and maintain cardi- least stable.
orespiratory function, muscular strength, and endurance in healthy adults. • Crutches should permit the client to stand upright with the shoulders
Therapeutic exercises involve physical activities designed to prevent relaxed, provide space for two fingers between the axilla and the axillary
health-related complications from an established medical condition or its bar, and facilitate approximately 30 degrees of elbow flexion and slight
treatment or to restore lost physical functions. hyperextension of the wrist.
• Isotonic exercise involves movement and work; an example is aero- • The four types of crutch-walking gaits are four-point, three-point (non-
bic exercise. Isometric exercise refers to stationary activities performed weight-bearing or partial weight-bearing), two-point, and swing-through.
against a resistive force; examples are body building and weight lifting. • A temporary prosthesis facilitates early ambulation, promotes an intact
• Active exercise is performed independently after proper instruction. Pas- body image, and controls stump swelling immediately after surgery.
sive exercise is performed with the assistance of another person. • The permanent prosthesis is constructed when the surgical wound heals
• Range-of-motion (ROM) exercise is a form of therapeutic exercise that and the stump size is relatively stable.
moves joints in the directions they normally permit. ROM exercises can • Components of permanent prostheses for BK amputees are a socket, a
be active or passive. Two common reasons for performing them are to shank, and an ankle/foot system; AK prostheses also include a knee sys-
maintain joint mobility and flexibility, especially in inactive clients, and tem and thigh socket.
to evaluate the client’s response to a therapeutic exercise program. • To apply a prosthetic limb, the client covers the stump with an optional
• Nurses encourage older adults to exercise by walking in shopping malls nylon sheath over which one or more stump socks are applied. A nylon
or joining social groups that include activities such as line dancing or stocking is used to ease the sock-covered stump into the socket and is
ballroom dancing. eventually removed. The client pumps the stump within the socket to
expel air and create a vacuum seal. If the socket has supportive belts or
CHAPTER 25 slings, they are fastened when the stump is well seated in the socket.
• Immobilization is used to relieve pain and muscle spasm, support and • Older adults tend to acquire flexion of the spine as they get older; this may
align skeletal injuries, and restrict movement while injuries heal. alter their center of gravity. They tend to compensate by flexing their hips
• Four types of splints include inflatable splints, traction splints, immobiliz- and knees when walking and may have a swaying or shuffling gait.
ers, and molded splints.
• Slings are cloth devices used to elevate and support parts of the body. CHAPTER 27
Braces are custom-made or custom-fitted devices designed to support • Perioperative care refers to the nursing care that clients receive before,
weakened structures during activity. during, and after surgery.
• Casts are rigid molds used to immobilize an injured structure that has been • Perioperative care spans the preoperative, intraoperative, and postopera-
restored to correct anatomic alignment. Casts are formed from plaster of tive periods.
Paris or fiberglass. • Inpatient surgery is performed on clients who remain in the hospital at
• Three types of casts are cylinder, body, and spica. least overnight. Outpatient surgery is performed on clients who return
• Appropriate nursing care of clients with casts includes checking circula- home the same day.
tion, mobility, and sensation in the area of the cast; using the palms of • Laser surgery, which can be performed on an outpatient basis, offers sev-
the hands to handle a wet cast; elevating the casted extremity to reduce eral advantages: it is cost-effective, requires smaller incisions, results in
swelling; circling areas where blood has seeped through; and padding and minimal blood loss, and produces less pain.
reinforcing the cast edges to prevent skin breakdown. • Some clients choose to donate their own blood before surgery or ask spe-
• Most casts are removed with an electric cast cutter, an instrument that cific donors to do so.
looks like a circular saw. • Four major activities for nurses to complete during the immediate preop-
• Traction is the application of a pulling effect on a part of the skeletal system. erative period are conducting a nursing assessment, providing preopera-
• Three types of traction are manual traction, skin traction, and skeletal tive teaching, preparing the skin, and completing the surgical checklist.
traction. • Nurses teach preoperative clients how to perform deep breathing, cough-
• To be effective, traction must produce a pulling effect on the body, counter- ing, and leg exercises.
traction must be maintained, the pull of traction and the counterpull must • Surgical clients wear antiembolism stockings to prevent thrombi and
be in exactly opposite directions, splints and slings must be suspended emboli.
without interference, ropes must move freely through each pulley, the pre- • Skin preparation involves cleansing the skin and in some cases hair
scribed amount of weight must be applied, and the weights must hang free. removal when it is likely to interfere with the incision. The goal is to
• An external fixator is used to stabilize fragments of broken bones during decrease transient and resident bacteria without compromising skin
healing. integrity.
• Pin site care is essential for preventing infection because the insertion of • When hair removal is required, electric clippers, depilatory agents, or
pins impairs skin integrity and provides a port of entry for pathogens. a safety razor may be used depending on agency policy and medical
orders.
CHAPTER 26 • On the preoperative checklist, the nurse verifies that the history and physi-
• Activities that help to prepare clients for ambulation include performing cal examination have been completed, the name of the procedure matches
isometric exercises with the lower limbs, strengthening the upper arms, the one scheduled, the surgical consent form has been signed and wit-
dangling at the bedside, and using a tilt table. nessed, the client is wearing an identification bracelet, and all laboratory
• Two isometric exercises that tone and strengthen the lower extremities are test results have been returned and reported if abnormal.
quadriceps setting and gluteal setting. • The receiving room, the operating room, and the surgical waiting room
• The upper arms are strengthened by a regimen of flexing and extending are three areas in the surgical department used during the intraoperative
the arms and wrists, raising and lowering weights with the hands, squeez- period.

• During immediate postoperative care, nurses focus on monitoring the cli- location of bowel sounds, the structure and integrity of the nose, and the
ent for complications, preparing the client’s room, and continuing assess- client’s ability to swallow, cough, and gag.
ments to detect developing problems. • A NEX measurement helps to determine how far to insert a tube for stom-
• Common postoperative complications are airway obstruction, hemor- ach placement. It is the distance from the nose to the earlobe and then to
rhage, pulmonary embolus, and shock. the xiphoid process.
• During recovery, a pneumatic compression device may be prescribed to • Nurses check stomach placement of tubes by aspirating gastric fluid, aus-
promote circulation of venous blood and relocation of excess fluid into the cultating the abdomen as they instill a bolus of air, and testing the pH of
lymphatic vessels. aspirated fluid.
• Discharge instructions for surgical clients include how to care for the inci- • Nasointestinal feeding tubes differ from their nasogastric counterparts in
sional site, signs of complications to report, and how to self-administer that they are longer, narrower, and more flexible; their lubricant is bonded
prescription drugs. to the tube; they are frequently inserted with a stylet; and an x-ray is used
• Older adults have unique surgical needs and problems. For example, to confirm their placement.
the period of fluid restriction before surgery may be shortened for older • Although transabdominal feeding tubes can be used for long periods, they
adults to reduce their risk for dehydration and hypotension. In addition, are prone to leaking and causing skin impairment.
the cardiac status of older adults must be monitored carefully after surgery • Enteral nutrition refers to nourishing clients by means of the stomach or
because they may not be able to circulate or eliminate intravenous fluids small intestine rather than the oral route.
given at standard rates. • Four common schedules for administering tube feedings are bolus, inter-
mittent, cyclic, and continuous.
CHAPTER 28 • Nurses check gastric residual to determine if the rate or volume of feeding
• A wound is damaged skin or soft tissue. exceeds the client’s physiologic capacity.
• Wound repair involves three sequential phases: inflammation, prolifera- • Caring for clients with feeding tubes involves maintaining tube patency,
tion, and remodeling. clearing any obstructions, providing adequate hydration, dealing with
• Signs and symptoms classically associated with inflammation are swell- common formula-related problems, and preparing clients for home care.
ing, redness, warmth, pain, and decreased function. • Before discharge, nurses provide clients who will administer their own
• Phagocytosis, a process that removes pathogens, coagulated blood, and tube feedings at home with written instructions on ways to obtain equip-
cellular debris, is performed by white blood cells known as neutrophils ment and formula, the amount and schedule for each feeding, guidelines
and monocytes. for delaying a feeding, and skin or nose care.
• The integrity of damaged skin and tissue is restored by resolution, regen- • When assisting with the insertion of a tungsten-weighted tube, nurses are
eration, or scar formation. responsible for promoting and monitoring its movement into the intestine.
• Wounds heal by first, second, or third intention.
• Two common types of wounds that require special care are pressure ulcers CHAPTER 30
and surgical wounds. • The urinary system is composed of the kidneys, ureters, bladder, and
• Some purposes for covering a wound with a dressing are keeping it clean, urethra. Collectively, these organs serve to produce urine, collect it, and
absorbing drainage, and controlling bleeding. excrete it from the body.
• A moist wound heals more quickly because new cells grow more rapidly • Various factors affect urination, such as a person’s neuromuscular
in a wet environment. development, the integrity of the spinal cord, the volume of fluid intake,
• Open or closed drains are placed in or near a wound to remove blood and fluid losses from other sources, and the amount and type of food con-
drainage. sumed.
• Sutures or staples hold the edges of an incision together. • The physical characteristics of urine include its volume, color, clarity, and
• A bandage or binder helps to hold a dressing in place, especially when odor.
tape cannot be used or the dressing is extremely large; reduces pain by • Nurses often collect voided urine specimens, clean-catch urine speci-
supporting the wound; or limits movement to promote healing. mens, catheter specimens, and 24-hour urine specimens.
• A T-binder is used to secure a dressing to the anus, perineum, or groin. • Some common abnormal patterns of urinary elimination include anuria,
• Four methods used to debride nonliving tissue from a wound are sharp deb- oliguria, polyuria, nocturia, dysuria, and incontinence.
ridement, enzymatic debridement, autolytic debridement, and mechanical • Other than a conventional toilet, a person may eliminate urine in a com-
debridement. A wound irrigation is an example of mechanical debridement. mode, urinal, or bedpan.
• An irrigation is used to flush debris from a wound or body area such as the • Continence training is the process used to restore the ability to empty the
eye, ear, or vagina. bladder at an appropriate time and place.
• Heat is applied to promote circulation and speed healing; cold is used to • The three general types of catheters are external, straight, and retention.
prevent swelling and control bleeding. • When using a closed drainage system, it is important to avoid dependent
• Methods for applying heat or cold include ice bags, compresses, soaks, loops in the tubing, and the collection bag must be kept below the level of
and therapeutic baths. the bladder.
• Five factors that place clients at risk for developing pressure ulcers are • Catheter care is important because it helps to deter the growth and spread
inactivity, immobility, malnutrition, dehydration, and incontinence. of colonizing pathogens.
• Techniques for preventing pressure ulcers include changing clients’ posi- • Catheters are irrigated to keep them patent, or free-flowing.
tions every 1 to 2 hours, keeping the skin clean and dry, and preventing • Catheters may be irrigated using an open or closed system or continuously
friction and shearing force on the skin. by way of a three-way catheter.
• A urinary diversion is a procedure in which one or both ureters are surgi-
CHAPTER 29 cally implanted elsewhere.
• Intubation refers to the insertion of a tube into a body structure. • Skin impairment is a common problem in clients with a urostomy because
• GI intubation is used to provide nourishment; administer medications; they require frequent appliance changes, and the contact of urine with the
obtain diagnostic samples; remove poisons, gases, and secretions; and skin causes skin irritation.
control bleeding.
• Four types of tubes used to intubate the GI system are orogastric, nasogas- CHAPTER 31
tric, nasointestinal, and transabdominal tubes. • Defecation, the elimination of stool, occurs when peristalsis moves fecal
• Common assessments performed before inserting a tube nasally include waste toward the rectum and the rectum distends, creating an urge to relax
determining the client’s level of consciousness, the characteristics and the anal sphincters; this releases stool.

• Two components of a bowel elimination assessment include elimination • The rebound effect is a phenomenon characterized by rapid swelling of
patterns and stool characteristics. the nasal mucosa. It is likely when clients chronically administer more
• Constipation, fecal impaction, flatulence, diarrhea, and fecal incontinence than the recommended amount of nasal decongestant or use the drug too
are common alterations in bowel elimination. frequently.
• The four types of constipation are primary constipation (which nurses can • For sublingual administration, the drug is placed under the tongue.
treat independently), secondary constipation, iatrogenic constipation, and For buccal administration, the medication is placed in contact with the
pseudoconstipation. mucous membrane of the cheek.
• When bowel elimination does not occur naturally, inserting a rectal sup- • Vaginal applications are used most often to treat local infections.
pository or administering an enema can promote defecation. • Drugs administered rectally usually are in the form of suppositories.
• Two categories of enemas are cleansing and oil retention. • The inhalant route is used for medication administration because the lungs
• Cleansing enemas are administered by instilling tap water, normal saline, provide an extensive area of tissue from which drugs may be absorbed.
soap and water, and other solutions. • Drugs are commonly inhaled using dry powder inhalers or metered-dose
• Oil retention enemas are given to lubricate and soften dry stool. inhalers. A dry powder inhaler delivers a burst of pulverized drug and a
• When caring for clients with intestinal ostomies, nursing activities are carrier substance at the time of inhalation. A metered-dose inhaler releases
likely to include providing peristomal care, applying an ostomy appliance, a measured volume of aerosolized drug when its canister is compressed.
draining a continent ileostomy, and irrigating a colostomy. • For clients who have difficulty mastering the use of an inhaler, a spacer
provides a reservoir for aerosol medication that can be inhaled beyond the
CHAPTER 32 time of the initial breath. As an alternative, a nebulizer that converts liq-
• A medication is a chemical substance that changes body function. uid inhalant medication to an aerosol using compressed air that is subse-
• A complete drug order contains the date and time of the order; the name of quently inhaled through a mouthpiece or face mask over 10 to 20 minutes
the client; the name of the drug, its dose, route, and frequency of adminis- may be used.
tration; and the signature or name of the writer.
• A drug’s trade name is the name by which a pharmaceutical company CHAPTER 34
identifies its drug. A drug’s generic name is a chemical name that is not • Three parts of a syringe are the barrel, plunger, and tip, which is some-
exclusively used by any drug company. times called the hub.
• Common routes of medication administration are oral, topical, inhalant, • When selecting a syringe and needle, the nurse considers the type of med-
and parenteral. ication, depth of tissue, volume of prescribed drug, viscosity of the drug,
• The oral route is used to administer drugs intended for absorption in the and size of the client.
gastrointestinal tract. Oral medications can be instilled by enteral tube • Conventional syringes and needles are being redesigned to reduce the
when clients cannot swallow them. potential for needlestick injuries and transmission of blood-borne patho-
• A medication administration record (MAR) is a form used to document gens.
and ensure timely and safe drug administration. • Pharmaceutical companies supply drugs for parenteral administration in
• Methods of supplying drugs to nursing units include an individual supply, ampules, vials, and prefilled cartridges.
a supply of unit dose packets, and a stock supply. • Before combining two drugs in a single syringe, it is important to consult
• Nurses are responsible for keeping the supply of narcotic medications a drug reference or a compatibility chart to determine whether or not a
locked and maintaining an accurate record of their use. chemical interaction may occur.
• The five rights involve making sure that the right client receives the right • Nurses use any of four parenteral injection routes: intradermal, subcutane-
drug, in the right dose, at the right time, and by the right route. ous, intramuscular, and intravenous.
• Once nurses have converted drug doses to the same system of measure- • A common site for an intradermal injection is the inner forearm; subcu-
ment and the same measurement within that system, they can calculate taneous injections are commonly given in the thigh, arm, or abdomen;
the amount to administer by dividing the desired dose by the dose on hand intramuscular injections are given in the buttocks, hip, thigh, or arm.
and then multiplying it by the quantity of the supply. • An intradermal injection is given with a tuberculin syringe. Insulin is
• The nurse checks drug labels three times before administering the medication. administered subcutaneously with an insulin syringe. Intramuscular injec-
• When teaching clients about taking medications, nurses advise them to tions are usually given with a syringe that holds a volume up to 3 mL.
inform each health care provider of all prescription and nonprescription • For an intradermal injection, the needle is inserted at a 10- to 15-degree
drugs currently being taken. angle. For a subcutaneous injection, a 45- or 90-degree angle is used,
• A common problem when administering drugs through an enteral tube is depending on the client’s size. For an intramuscular injection, a 90-degree
maintaining the tube’s patency. angle is used.
• If a medication error occurs, nurses must report it to the prescriber and • When two separate insulins are combined, they must be administered
supervisor, assess the client for ill effects, and document the situation on within 15 minutes to avoid equilibration (the loss of each insulin’s unique
an incident report or accident sheet. characteristics).
• To prevent bruising when heparin is administered, the nurse avoids aspi-
CHAPTER 33 rating with the plunger and massaging the site afterward.
• Topical medications are applied to the skin or mucous membranes.
• Common locations for topical medications are the skin, eye, ear, nose, CHAPTER 35
mouth, vagina, and rectum. • IV medications can be given into peripheral or central veins.
• An inunction is a medication incorporated into a vehicle, or transporting • The IV route is appropriate when a quick response is needed during an
agent, such as an ointment, oil, lotion, or cream. emergency, when clients have disorders that affect the absorption or
• Skin patches and applications of paste are two methods for administering metabolism of drugs, and when blood levels of drugs need to be main-
transdermal medications. tained at a consistent therapeutic level.
• Skin patches can be applied to any skin area with adequate circulation. • IV medications can be administered continuously or intermittently.
Each time a new patch is applied, it is placed in a different location. • Two methods for administering a bolus of IV medication are via a port on
• Eye medications are applied onto the mucous membrane, or conjunctiva, of the IV tubing and via a medication lock.
the eye, which lines the inner eyelids and the anterior surface of the sclera. • IV medication solutions may be administered intermittently using second-
• The major difference in the technique for administering ear medications ary (piggyback) infusions or a volume-control set.
to adults and children is how the ear is manipulated to straighten the audi- • A piggyback solution is a small volume of diluted medication that is con-
tory canal. nected to and positioned higher than the primary solution.

• A volume-control set is used to administer IV medication in a small vol- Heimlich maneuver because chest compressions create enough pressure
ume of solution at intermittent intervals to avoid overloading the circula- in unconscious victims to eject a foreign body from the airway.
tory system. • The Chain of Survival is a series of five steps that improves the outcome
• A central venous catheter is a venous access device that extends to the of resuscitating a person in cardiac arrest. The steps are (1) immediate
superior vena cava or right atrium. recognition and access of emergency services; (2) early CPR, techniques
• The three general types of central venous catheters are percutaneous, tun- used to restore circulation and breathing with a focus on compressions to
neled, and implanted. circulate blood quickly and systemically; (3) rapid defibrillation, if appro-
• When administering antineoplastic drugs, the nurse should wear a cover priate; (4) effective advanced life support; and (5) integrated post-cardiac
gown, one or two pairs of gloves, and a disposable or respirator mask to arrest care.
protect against contact with or inhalation of the medication. • Early cardiopulmonary resuscitation must proceed with CAB (Circulation,
Airway, Breathing) if the rescuer is a trained health provider or hands-only
CHAPTER 36 chest compressions if untrained in cardiopulmonary resuscitation.
• Airway management refers to skills that nurses use to maintain natural or • The CAB of resuscitation involves administering chest compressions hard
artificial airways for compromised clients. and fast, opening the airway to assess for the presence of spontaneous
• Structures of the airway are the nose, pharynx, trachea, bronchi, bronchi- breathing, and performing rescue breathing.
oles, and alveoli. • Rescuers can safely open a victim’s airway under most circumstances by
• The airway serves as the collective system of tubes in the upper and lower using the head tilt/chin lift technique or the jaw-thrust maneuver.
respiratory tract through which gases travel during their passage to and • Methods of administering rescue breathing are mouth-to-mouth, mouth-
from the blood. to-nose, and mouth-to-stoma.
• Structures to protect the airway include the epiglottis, which seals the • An automated external defibrillator is a portable, battery-operated device
airway when swallowing food and fluids; the rings of tracheal cartilage, that analyzes heart rhythm and can deliver a series of electrical shocks to
which keep the trachea from collapsing; the mucous membrane, which resuscitate a person who is lifeless or experiencing a lethal dysrhythmia.
traps particulate matter; and the cilia, which beat debris upward in the Ideally, an AED is used within 5 minutes of resuscitation efforts outside
airway so that it can be coughed, expectorated, or swallowed. the hospital and within 2 minutes of resuscitation efforts within a health
• Methods of airway management include liquefying secretions, mobilizing care facility.
secretions to promote their expectoration with chest physiotherapy, and • The decision to stop resuscitation efforts often is based on the time that
mechanically suctioning mucus from the airway. elapsed before resuscitation began, the length of time that resuscitation
• When suctioning the airway, nurses use one of several approaches: has continued without any change in the victim’s condition, and the age
nasopharyngeal, nasotracheal, oropharyngeal, oral, and tracheal suctioning. and diagnosis of the victim.
• Artificial airways are used when clients are at risk for airway obstruction
or when long-term mechanical ventilation is necessary. CHAPTER 38
• Two examples of artificial airways are an oral airway and a tracheostomy • A terminal illness is one from which recovery is beyond reasonable
tube. expectation.
• Tracheostomy care includes cleaning the skin around the stoma, changing • The five stages of dying, as described by Dr. Elisabeth Kübler-Ross, are
the dressing, and cleaning the inner cannula. denial, anger, bargaining, depression, and acceptance.
• Nurses can promote acceptance by providing emotional support to dying
CHAPTER 37 clients and helping them to arrange their care.
• Airway obstruction is life-threatening because it interferes with ventila- • Respite care provides temporary relief for caregivers of dying loved ones.
tion and subsequently deprives cells and tissues of oxygen. • Hospice care involves helping clients to live their final days in comfort,
• Signs of airway obstruction include grasping the throat with the hands, with dignity, and in a caring environment.
making aggressive efforts to cough and breathe, and producing a high- • Some aspects that nurses address when providing terminal care are hydra-
pitched sound while inhaling. tion, nourishment, elimination, hygiene, positioning, and comfort.
• In cases of partial airway obstruction, appropriate actions include encour- • Many terminal illnesses result in death from multiple organ failure. Signs
aging and supporting the victim’s efforts to clear the obstruction inde- of multiple organ failure include hypotension, rapid heart rate, difficulty
pendently and preparing to call for emergency assistance if the victim’s breathing, cold and mottled skin, and decreased urinary output.
condition worsens. • When the criteria for organ donation are met, permission for organ
• The Heimlich maneuver is the technique used to relieve a complete air- removal must be obtained in a timely manner to ensure a successful trans-
way obstruction by performing a series of subdiaphragmatic thrusts or plant.
chest thrusts on conscious victims. • Criteria used to confirm that a client has died include cessation of breath-
• Subdiaphragmatic thrusts are appropriate for almost all adults and chil- ing and heart beat and absence of whole brain function.
dren beyond infancy. Chest thrusts are appropriate for infants less than • Postmortem care involves cleaning the body, ensuring proper identifica-
1 year old, obese adults, and women in advanced pregnancy. tion, and releasing the body to mortuary personnel.
• To dislodge an object from an infant’s airway, the rescuer delivers a series • Although grieving is painful, it promotes resolution of the loss.
of back blows followed by a series of chest thrusts. • One sign that a person is resolving his or her grief is that he or she can
• When a person with an airway obstruction becomes unconscious, rescu- talk about the deceased person without becoming emotionally over-
ers perform basic cardiopulmonary resuscitation (CPR) rather than the whelmed.

APPENDIX
APPENDIX
AB Commonly Used Abbreviations

and Acronyms
SYMBOL mL milliliter (one-thousandth L)
° degree mm Hg millimeters of mercury
< lessthan mph miles per hour
≤ equal to or less than MRI magnetic resonance imaging
> morethan NANDA North American Nursing Diagnosis
≥ equal to or more than Association
± plus or minus NAPNES National Association for Practical Nurse
Education and Service
NCLEX-PN National Council Licensure Examination for
WORDS Practical Nurses
ADL activities of daily living NCLEX-RN National Council Licensure Examination for
AHCPR Agency for Health Care Policy and Research Registered Nurses
AIDS acquired immune deciency fi syndrome NEX nose, earlobe, xiphoid process
AMA against medical advice; also American Medical NKA no known allergies
Association NLN National League for Nursing
ANA American NursesAssociation NPO nil per os, nothing by mouth
BP bloodpressure NREM nonrapid eye movement (sleep phase)
bpm beats per minute NSS normal saline solution
cal calorie NWB non–weight-bearing
CBC complete blood count O2 oxygen
CDC Centers for Disease Control and Prevention OTC over the counter (eg, nonprescription)
CHO carbohydrate PACU postanesthesia care unit
CO2 carbondioxide PaCO2 partial pressure of carbon dioxide; that which is
CPR cardiopulmonary resuscitation dissolved in plasma
CT computed tomography (also CAT) PaO2 partial pressure of oxygen; that which is dissolved
CVC central venous catheter in plasma
dL deciliter (100 mL) PCA patient-controlledanalgesia
ECG electrocardiogram (also EKG) PEG percutaneous endoscopic gastrostomy
EEG electroencephalogram PEJ percutaneous endoscopic jejunostomy
EMG electromyography PERRLA pupils equally round and react to light and accom-
EOMs extraocularmovements modation
g gram PET positron emission tomography
GI gastrointestinal pH degree of acidity or alkalinity
HIV humanimmunodefi ciency virus PICC peripherally inserted central catheter
I&O intake and output PPN peripheral parenteral nutrition
ICN International Council of Nurses PWB partial weight bearing
IM intramuscular QA quality assurance
IV intravenous RBC red blood cell
IVP IV push REM rapid eye movement (sleep phase)
IVPB IV piggyback RN registerednurse
JCAHO Joint Commission on Accreditation of Healthcare R/O rule out; either confirm or eliminate
Organizations; now known as the Joint ROM range of motion
Commission SAD seasonal affective disorder
kcal kilocalorie SaO2 oxygen saturation; percent of hemoglobin
kg kilogram (1,000 g) molecules saturated with oxygen
L liter SNF skilled nursing facility
LPN licensed practical nurse (also LVN, licensed SSE soap suds enema
vocational nurse) TPN total parenteral nutrition
MAR medication administration record TPR temperature, pulse, and respirations
mEq milliequivalent WBC white blood cell
mg milligram (one-thousandth g) WHO World Health Organization
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Glossary of Key Terms
A Airborne precautions infection control measures that reduce the
ABO system method by which blood is identified as one of four risk for transmitting pathogens that remain infectious over long
blood types: A, B, AB, or O distances when suspended in the air
Abdominal circumference indirect measurement of fatty (adi- Airway collective system of tubes in the upper and lower respira-
pose) tissue that is distributed in and about the viscera of the tory tract
abdomen Airway management skills that maintain the patency of natural
Acceptance attitude of complacency; last stage of dying, accord- or artificial airways
ing to Dr. Kübler-Ross Alarm stage the immediate physiologic response to a stressor
Accommodation pupil constriction when looking at an object Alignment proper relation of one part to another
close by and dilation when looking at an object in the distance Allocation of scarce resources process of deciding how to distrib-
Active exercise therapeutic activity performed independently ute limited life-saving equipment or procedures
Active listening demonstrating full attention to what is being said; Allodynia exaggerated pain response due to increased sensitivity
hearing both the content being communicated and the unspoken to stimuli such as air currents, pressure of clothing, and vibra-
message tion
Active transport process of chemical distribution that requires an Alternative medical therapy treatment outside the mainstream of
energy source traditional medicine
Activities of daily living acts that people normally do every day Ambulatory electrocardiogram continuous recording of heart
Actual diagnosis problem that currently exists rate and rhythm during normal activity
Acultural nursing care care that lacks concern for cultural dif- Ampule sealed glass container for a drug
ferences Anaerobic bacteria microorganisms that exist without oxygen
Acupressure technique that involves tissue compression to reduce Analgesic pain-relieving drug
pain Anal sphincters ring-shaped bands of muscles in the anus
Acupuncture pain-management technique in which long, thin Anatomic position standing with arms at the sides and palms
needles are inserted into the skin forward
Acute illness one that comes on suddenly and lasts a short time Androgogy principles of teaching adult learners
Acute pain discomfort of short duration Anecdotal record personal, handwritten account of an incident
Adaptation manner in which an organism responds to change Anesthesiologist physician who administers chemical agents that
Adjuvants drugs that assist in accomplishing the desired effect of temporarily eliminate sensation and pain
a primary drug Anesthetist nurse specialist who administers anesthesia under the
Administrative laws legal provisions through which federal, direction of a physician
state, and local agencies maintain self-regulation Anger emotional response to feeling victimized
Admission entering a health care agency for nursing care and Anglo-Americans people who trace their ancestry to the United
medical or surgical treatment Kingdom or Western Europe
Advance directive written statement identifying a competent per- Anions electrolytes with a negative charge
son’s wishes concerning terminal care Ankylosis permanent loss of joint movement
Advanced practice specialized areas of nursing expertise, such as Anorexia loss of appetite
nurse practitioner and nurse midwifery Anorexia nervosa eating disorder characterized by an obsession
Aerobic bacteria microorganisms that require oxygen to live for thinness that is achieved through self-starvation
Aerobic exercise rhythmically moving all parts of the body at a Anthropometric data measurements of body size and composition
moderate to slow speed without hindering the ability to breathe Anticipatory grieving grieving that begins before a loss actually
Aerosol mist occurs
Afebrile absence of a fever Antiembolism stockings elastic stockings
Affective domain learning by appealing to a person’s feelings, Antimicrobial agents chemicals that limit the number of infec-
beliefs, or values tious microorganisms by destroying them or suppressing their
Affective touch touching that demonstrates concern or affection growth
African Americans those whose ancestral origin is Africa Antineoplastic drugs medications used to destroy or slow the
Afterload force against which the heart pumps when ejecting growth of malignant cells
blood Antipyretics drugs that reduce fever
Ageism form of negative stereotypical thinking about older adults Antiseptics chemicals such as alcohol that inhibit the growth of,
Air embolism bubble of air in the vascular system but do not kill, microorganisms
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890 Glossary of Key Terms
Anuria absence of urine, or up to a 100-mL volume in 24 hours Binder cloth covering applied to a body part such as the abdomen
Apical heart rate number of ventricular contractions per minute or breast
Apical-radial rate number of sounds heard at the apex of the heart Biofeedback technique in which the client learns to control or
and the rate of the radial pulse during the same period alter a physiologic phenomenon
Apnea absence of breathing Biologic defense mechanisms methods that prevent microorgan-
Appliance collection bag over a stoma isms from causing an infectious disorder
Aquathermia pad electrical heating or cooling device Bivalved cast cast that is cut into two lengthwise pieces
Arrhythmia irregular pattern of heartbeats Blood pressure force exerted by blood in the arteries
Art ability to perform an act skillfully Blood substitutes fluids that when transfused carry and distrib-
Arterial blood gas laboratory test using blood from an artery ute oxygen to cells, tissues, and organs; also known as oxygen
Asepsis practices that decrease or eliminate infectious agents, therapeutics
their reservoirs, and vehicles for transmission Board of nursing regulatory agency that manages the provisions
Aseptic techniques measures that reduce or eliminate microor- of a state’s nurse practice act
ganisms Body cast form of a cylinder cast that encircles the trunk of the
Asian Americans people who come from China, Japan, Korea, the body instead of an extremity
Philippines, Thailand, Indochina, and Vietnam Body composition amount of body tissue that is lean versus fat
Asphyxiation inability to breathe Body mass index numeric data used to compare a person’s size in
Assault act in which there is a threat or attempt to do bodily harm relation to norms for the adult population
Assessment systematic collection of information Body mechanics efficient use of the musculoskeletal system
Assessment skills acts that involve collecting data Body systems approach collection of data according to the func-
Asystole absence of heart rhythm tional systems of the body
Atelectasis airless, collapsed lung areas Bolus larger dose of a drug administered initially or when pain is intense
Audiometry measurement of hearing acuity at various sound Bolus administration undiluted or diluted medication given into a
frequencies vein in one or more minutes of time
Auditors inspectors who examine client records Bolus feeding instillation of liquid nourishment four to six times a
Auscultation listening to body sounds day in less than 30 minutes
Auscultatory gap period during which sound disappears and then Braces custom-made or custom-fitted devices designed to support
reappears when taking a blood pressure measurement weakened structures
Autologous transfusion self-donated blood Bradycardia a pulse rate less than 60 beats per minute (bpm) in
Automated external defibrillator device that delivers an electri- an adult
cal charge to the heart Bradypnea slower-than-normal respiratory rate at rest
Automated monitoring devices equipment that allows the simul- Breakthrough pain acute pain that occasionally develops in those
taneous collection of multiple vital sign data who have chronic pain
Autopsy postmortem examination Bridge dental device that replaces one or several teeth
Axillary crutches standard type of crutches Bruxism grinding of the teeth
Buccal application drug placement against the mucous mem-
B branes of the inner cheek
Bag bath technique for bathing that involves the use of 8 to 10 pre-
moistened, warmed, disposable cloths contained in a plastic bag C
Balance steady position Cachexia general wasting of body tissue
Bandage strip or roll of cloth Calorie amount of heat that raises the temperature of 1 gram of
Barcode medication administration system point of care soft- water by 1°C
ware that verifies that the name of the medication, administra- Cane hand-held ambulatory device made of wood or aluminum
tion time, dosage, drug form, and client for whom the drug is with a rubber tip
prescribed are accurate by scanning a barcode on the drug and Capillary action movement of a liquid at the point of contact with
identification band on the client a solid
Bargaining psychological mechanism for delaying the inevitable Capillary refill time time duration for blood to resume flowing in
Bariatric client person who is severely overweight with a body the base of the nail beds
mass index (BMI) of 30 to 39.9 or morbidly obese with a BMI Capitation strategy for controlling health care costs by paying a
over 40 fixed amount per member
Barrel part of a syringe that holds the medication Carbohydrates nutrients that contain molecules of carbon, hydro-
Base of support area on which an object rests gen, and oxygen
Basic care facility agency that provides extended custodial care Cardiac arrest cessation of heart contraction or life-sustaining
Battery unauthorized physical contact heart rhythm
Bed bath washing with a basin of water at the bedside Cardiac ischemia impaired blood flow to the heart
Bed board rigid structure placed under a mattress Cardiac output volume of blood ejected from the left ventricle
Bedpan seat-like container for elimination per minute
Beliefs concepts that a person holds to be true Cardiopulmonary resuscitation techniques used to restore circu-
Beneficial disclosure an exemption whereby an agency can release lation and breathing for lifeless victims
private health information without a client’s prior authorization Caregiver one who performs health-related activities that a sick
Bilingual able to speak a second language person cannot perform independently

Caries dental cavities Clinical pathways standardized multidisciplinary plans for a spe-
Caring skills nursing interventions that restore or maintain a per- cific diagnosis or procedure that identify specific aspects of care
son’s health to be performed during a designated length of stay
Carriers asymptomatic clients or animals who harbor pathogens Clinical resume summary of previous care
but do not show evidence of an infectious disease Clinical thermometers instruments used to measure body
Case method pattern in which one nurse manages a client’s care temperature
for a designated period Closed drainage system device used to collect urine from a cath-
Cast rigid mold around a body part eter
Cataplexy sudden loss of muscle tone, triggered by an emotional Closed wound one in which there is no opening in the skin or
change such as laughing or anger mucous membrane
Catastrophize choosing to focus on all the potentially negative Code summoning personnel to administer advanced life support
outcomes that may result from stressors techniques
Catheter care hygiene measures used to keep the meatus and Code of ethics statements describing ideal behavior
adjacent area of the catheter clean Code status manner in which nurses or health care personnel
Catheter irrigation flushing the lumen of a catheter must manage the care of a client during cardiac or respira-
Catheterization act of applying or inserting a hollow tube tory arrest
Cations electrolytes with a positive charge Cognitive domain style of processing information by listening or
Cellulose undigestible fiber in the stems, skin, and leaves of fruits reading facts and descriptions
and vegetables Cold spot area with little or no radionuclide concentration
Center of gravity point at which the mass of an object is centered Collaborative problem physiologic complication whose treatment
Centigrade scale scale that uses 0°C as the temperature at which requires both nurse- and physician-prescribed interventions
water freezes and 100°C as the point at which it boils Collaborator one who works with others to achieve a common
Central venous catheter venous access device that extends to the goal
superior vena cava Collagen protein substance that is tough and inelastic
Certified interpreter translator who is certified by a professional Colloidal osmotic pressure force for attracting water
organization through rigorous testing based on appropriate and Colloids undissolved protein substances
consistent criteria Colloid solutions water and molecules of suspended substances,
Cerumen ear wax such as blood cells, and blood products such as albumin
Cervical collar foam or rigid splint around the neck Colonization condition in which microorganisms are present but
Chain of infection sequence that enables the spread of disease- the host manifests no signs or symptoms of infection
producing microorganisms Colostomy opening to some portion of the colon
Chain of Survival intervention and rescue process including Comfort state in which a person is relieved of distress
(1) immediate recognition and access of emergency services; Comforting skills interventions that provide stability and security
(2) early CPR with a focus on compressions; (3) rapid defibril- during a health crisis
lation, if appropriate; (4) effective advanced life support; and Commode portable chair used for elimination
(5) integrated post-cardiac arrest care Common law decisions based on prior cases of a similar nature
Change of shift report discussion between a nurse from the shift Communicable diseases infectious diseases that can be transmit-
that is ending and personnel coming on duty ted to other people
Chart binder or folder that enables the orderly collection, storage, Communication exchange of information
and safekeeping of a client’s medical records Community-acquired infections infectious diseases that can be
Charting process of entering information transmitted to other people
Charting by exception documentation method in which only Compartment syndrome complication following the application
abnormal assessment findings or care that deviates from the of a cast caused by pressure due to swelling within inelastic
standard is charted fascia that surrounds muscles
Checklist form of documentation in which the nurse indicates with Complete proteins those that contain all of the essential amino
a check mark or initials that routine care has been performed acids
Chemical restraint sedative medication that is not a standard Compresses moist cloths that may be warm or cool
treatment or dosage for the client’s condition that is used to Computed tomography form of roentgenography that shows
manage a violent or self-destructive client’s behavior or free- planes of tissue
dom of movement Computerized charting documenting client information elec-
Chest physiotherapy techniques for mobilizing pulmonary secretions tronically
Chronic illness one that comes on slowly and lasts a long time Concept mapping organizing information in a graphic or picto-
Chronic pain discomfort that lasts longer than 6 months rial form
Circadian rhythm phenomena that cycle on a 24-hour basis Concurrent disinfection measures that keep the client environ-
Circulatory overload severely compromised heart function ment clean on a daily basis
Civil laws statutes that protect the personal freedoms and rights Confidentiality safeguarding a client’s health information from
of individuals public disclosure
Clean-catch specimen voided sample of urine that is considered Congenital disorder disorder present at birth that results from
sterile faulty embryonic development
Climate control mechanisms for maintaining temperature, humid- Conscious sedation state in which clients are sedated, relaxed,
ity, and ventilation and emotionally comfortable, but not unconscious

Consensual response brisk, equal, and simultaneous constriction Cultural shock bewilderment over behavior that is culturally
of both pupils when one eye and then the other are stimulated atypical
with light Culturally sensitive nursing care care that is respectful of and is
Constipation condition in which dry, hard stool is difficult to pass compatible with each client’s culture
Contact precautions infection control measures used to block Culture (1) values, beliefs, and practices of a particular group; (2)
the transmission of pathogens by skin-to-skin contact with an incubation of microorganisms
infected or colonized person or touching a contaminated inter- Cutaneous application drug administration by rubbing medica-
mediate object in the client’s environment tion into or placing it in contact with the skin
Contagious diseases infectious diseases that can be transmitted Cutaneous pain discomfort that originates at the skin level
to other people Cutaneous triggering the act of lightly massaging or tapping the
Continence training process of restoring control of urination skin above the pubic area to stimulate urination
Continent ostomy surgically created opening in which liquid Cuticles thin edge of skin at the base of the nail
stool or urine is removed by siphoning Cyclic feeding continuous instillation of liquid nourishment for
Continuity of care uninterrupted client care despite the change 8 to 12 hours
in caregivers Cylinder cast rigid mold that encircles an arm or leg
Continuous feeding instillation of liquid nutrition without inter-
ruption D
Continuous infusion parenteral instillation over several hours Dangling sitting on the edge of a bed
Continuous irrigation ongoing instillation of solution Data base assessment initial information about the client’s physi-
Continuous passive motion machine electrical device that exer- cal, emotional, social, and spiritual health
cises joints Deaf unable to hear well enough to process information
Continuous quality improvement process of promoting care that Death certificate legal document confirming a person’s death
reflects established agency standards Debridement removal of dead tissue
Contractures permanently shortened muscles that resist Decompression removal of gas and secretions from the stomach
stretching or bowel
Contrast medium substance that adds density to a body organ or Defamation act in which untrue information harms a person’s
cavity, such as barium sulfate or iodine reputation
Controlled substances drugs whose prescription and dispensing Defecation bowel elimination
are regulated by federal law because they have the potential for Defendant person charged with violating the law
abuse Dehydration fluid deficit in both extracellular and intracellular
Coping mechanisms unconscious tactics used to protect the compartments
psyche Delegator one who assigns a task to someone
Coping strategies stress-reduction activities selected on a con- Deltoid site injection area in the lateral upper arm
scious level Denial psychological defense mechanism in which a person
Cordotomy surgical interruption of pain pathways in the spinal refuses to believe that certain information is true
cord Dentures artificial teeth
Core temperature warmth at the center of the body Deontology ethical study based on duty or moral obligations
Coroner person legally designated to investigate deaths that may Depilatory agent chemical that removes hair
not be the result of natural causes Depression sad mood
Counseling skills interventions that include communicating Diagnosis identification of health-related problems
with clients, actively listening to the exchange of information, Diagnostic examination procedure that involves physical inspec-
offering pertinent health teaching, and providing emotional tion of body structures and evidence of their function
support Diagnostic-related group classification system used to group cli-
CPAP mask device that maintains positive pressure in the airway ents with similar diagnoses
throughout the respiratory cycle Diaphragmatic breathing breathing that promotes the use of the
Credé maneuver act of bending forward and applying hand pres- diaphragm rather than upper chest muscles
sure over the bladder to stimulate urination Diarrhea urgent passage of watery stools
Criminal laws penal codes that protect citizens from persons who Diastolic pressure pressure in the arterial system when the heart
are a threat to the public good relaxes and fills with blood
Critical thinking process of objective reasoning; analyzing facts Diet history assessment technique used to obtain facts about a
to reach a valid conclusion person’s eating habits and factors that affect nutrition
Cross-trained ability to assume a non-nursing job position, Directed donors relatives and friends who donate blood for a
depending on the census or levels of client acuity on any given client
day Discharge termination of care from a health care agency
Crutches ambulatory aid, generally in pairs, constructed of wood Discharge instructions directions for managing self-care and
or aluminum medical follow-up
Crutch palsy weakening of forearm, wrist, and hand muscles Discharge planning predetermining a client’s post-discharge
because of nerve impairment in the axilla caused by incorrectly needs and coordinating the use of appropriate community
fitted crutches or poor posture resources to provide a continuum of care
Crystalloid solution water and other uniformly dissolved crystals, Disinfectants chemicals that destroy active microorganisms but
such as salt and sugar not spores

Distraction intentional diversion of attention Electrochemical neutrality balance of cations with anions
Disuse syndrome signs and symptoms that result from inactivity Electroencephalography examination of the energy emitted by
Diversity differences among groups of people the brain
Documenting process of entering information Electrolytes chemical compounds, such as sodium and chloride,
Doppler stethoscope device that helps detect sounds created by that are dissolved, absorbed, and distributed in body fluid and
the velocity of blood moving through a blood vessel possess an electrical charge
Dorsal recumbent position reclining posture with the knees bent, Electromyography examination of the energy produced by stimu-
hips rotated outward, and feet flat lated muscles
Dorsogluteal site injection area in the upper outer quadrant of the Emaciation excessive leanness
buttocks Emancipated minor adolescent living independent of parents or
Dose amount of drug guardians and supporting himself or herself
Double-bagging infection control measure in which one bag of Emboli moving clots
contaminated items, such as trash or laundry, is placed within Emesis substance that is vomited
another, keeping the outer surface of the second bag clean Empathy intuitive awareness of what the client is experiencing
Double charting repetitious entry of the same information in the Emulsion mixture of two liquids, one of which is insoluble in the
medical record other
Douche procedure for cleansing the vaginal canal Endogenous opioids naturally produced morphine-like chemicals
Drains tubes that provide a means for removing blood and drain- Endorphins natural body chemicals that produce effects similar to
age from a wound those of opiate drugs such as morphine
Drape sheet of soft cloth or paper Endoscopy visual examination of internal structures
Drawdown effect cooling of the ear when it comes in contact with Enema introduction of a solution into the rectum
a thermometer probe Energy capacity to do work
Dressing cover over a wound Enteral nutrition nourishment provided via the stomach or small
Drop factor number of drops per milliliter in intravenous tubing intestine rather than via the oral route
Droplet precautions measures that block transmission of infec- Enteric-coated tablet tablet covered with a substance that does
tious pathogens within moist droplets larger than 5 microns that not dissolve until it is past the stomach
are present in respiratory secretions or mucous membranes Enterostomal therapist a nurse certified in caring for ostomies
Drowning situation in which fluid occupies the airway and inter- and related skin problems
feres with ventilation Environmental hazards potentially dangerous conditions in the
Drug diversion obtaining a drug through illicit methods such as physical surroundings
theft from a person for whom the drug has been prescribed, Environmental psychologist specialist who studies how the envi-
“doctor shopping,” purchase from illegal internet pharmacies, ronment affects behavior
prescription forgery, or unnecessary prescriptions from less Equianalgesic dose oral dose that provides the same level of pain
than ethical physicians relief as a parenteral dose
Drug tolerance diminished effect of a drug at its usual dosage Ergonomics field of engineering science devoted to promoting
range comfort, performance, and health in the workplace
Dry powder inhaler device containing a reservoir of pulverized Eructation belching
drug and a carrier substance that relies on the client’s inspiratory Essential amino acids protein components that must be obtained
effort to deliver the drug into the lungs from food because they cannot be synthesized by the body
Dumping syndrome cluster of symptoms resulting from the rapid Ethical dilemma choice between two undesirable alternatives
deposition of calorie-dense nourishment into the small intestine Ethics moral or philosophical principles
Durable power of attorney for healthcare proxy for making Ethnicity bond or kinship a person feels with his or her country of
medical decisions when a client becomes incompetent or inca- birth or place of ancestral origin
pacitated and cannot make decisions independently Ethnocentrism belief that one’s own ethnicity is superior to all
Duty obligation to provide care for a person claiming injury or others
harm Evaluation process of determining whether a goal has been
Dying with dignity treating a terminally ill person with respect reached
regardless of his or her emotional, physical, or cognitive state Evidence-based practice scientific knowledge used to predict
Dysphagia difficult swallowing nursing interventions most likely to produce a desired out-
Dyspnea difficult or labored breathing come
Dysrhythmia irregular pattern of heartbeats Exacerbation reactivation of a disorder, or one that reverts from a
Dysuria difficult or uncomfortable voiding chronic to an acute state
Excoriation chemical skin injury
E Exercise purposeful physical activity
Echography soft tissue examination that uses sound waves in Exit route means by which microorganisms escape from their
ranges beyond human hearing original reservoir
Edema excessive fluid in tissue Expiration exhalation; breathing out
Educator one who provides information Extended care services that meet the health needs of clients who
Electrical shock discharge of electricity through the body no longer require acute hospital care
Electrocardiography examination of the electrical activity in the Extended care facility health care agency that provides long-term
heart care

External catheter device applied to the skin that collects urine Focus assessment information that provides more details about
External fixator metal device inserted into and through one or specific problems
more bones Focus charting modified form of SOAP charting
Extracellular fluid fluid outside cells Folk medicine health practices unique to a particular group of
Extraocular movements eye movements controlled by several people
pairs of eye muscles Fomites nonliving reservoirs of pathogens
Foot drop permanent dysfunctional position caused by shortening
F of the calf muscles and lengthening of the opposing muscles on
Face tent device that provides oxygen in an area around the nose the anterior leg
and mouth Forced coughing coughing that is purposely produced
Facilitated diffusion process in which certain dissolved sub- Forearm crutches crutches with an arm cuff but no axillary bar
stances require the assistance of a carrier molecule to pass from Fowler’s position upright seated position
one side of a semipermeable membrane to the other Fraction of inspired oxygen portion of oxygen in relation to total
Fahrenheit scale scale that uses 32°F as the temperature at which inspired gas
water freezes and 212°F as the point at which it boils Frenulum structure that attaches the undersurface of the tongue to
False imprisonment interference with a person’s freedom to the fleshy portion of the mouth
move about at will without legal authority to do so Frequency need to urinate often
Fat nutrient that contains molecules composed of glycerol and Functional assessment determining a person’s ability to perform
fatty acids called glycerides self-care task
Fat-soluble vitamins those carried and stored in fat; vitamins A, Functional braces braces that provide stability for a joint
D, E, and K Functional mobility alignment that maintains the potential for
Febrile elevated body temperature movement and ambulation
Fecal impaction condition in which it is impossible to pass feces Functional nursing pattern in which each nurse on a unit is
voluntarily assigned specific tasks
Fecal incontinence inability to control the elimination of stool Functional position position that promotes continued use and
Feces stool mobility
Feedback loop mechanism that turns hormone production off and Functionally illiterate possessing minimal literacy skills
on
Felony serious criminal offense G
Fenestrated drape one with an open circle at its center Gastric reflux reverse flow of gastric contents
Fever body temperature that exceeds 99.3°F (37.4°C) Gastric residual volume of liquid remaining in the stomach
Fifth vital sign client’s pain assessment that is checked and docu- Gastrocolic reflex increased peristaltic activity
mented, in addition to his or her temperature, pulse, respira- Gastrostomy tube, G-tube transabdominal tube located in the
tions, and blood pressure stomach
Filtration process that regulates the movement of water and sub- Gauge diameter
stances from a compartment where the pressure is high to one Gavage provision of nourishment
where the pressure is lower General adaptation syndrome collective physiologic processes
Fingerspelling in sign language, alphabetical substitute for words that occur in response to a stressor
that have no sign Generalization supposition that a person shares cultural charac-
Finger sweep insertion of the index finger into the mouth along teristics with others of a similar background
the inside of the cheek and deeply into the throat to the base of Generic name chemical drug name that is not protected by a man-
the tongue ufacturer’s trademark
Fire plan procedure followed if there is a fire Gerogogy techniques that enhance learning among older adults
First-intention healing reparative process when wound edges are Gingivitis inflammation of the gums
directly next to one another Glucometer instrument that measures the amount of glucose in
Fitness capacity to exercise capillary blood
Fitness exercise physical activity performed by healthy adults Gluteal setting contraction and relaxation of the gluteus muscles
Flatulence accumulation of intestinal gas to strengthen and tone them
Flatus gas formed in the intestine and released from the rectum Goal expected or desired outcome
Fight or flight response physiologic process used to attack a Good Samaritan laws legal immunity for passersby who provide
stressor in an effort to overcome the danger it represents, or flee emergency first aid to accident victims
from the stressor to escape its threat Gram staining process of adding dye to a microscopic speci-
Flow sheet form of documentation that contains sections for men
recording frequently repeated assessment data Granulation tissue combination of new blood vessels, fibroblasts,
Flowmeter gauge used to regulate the number of liters of oxygen and epithelial cells
delivered to the client Gravity force that pulls objects toward the center of the earth
Fluid imbalance condition in which the body’s water is not in Grief response psychological and physical phenomena experi-
proper volume or location in the body enced by those who grieve
Fluoroscopy form of radiography that displays an image in real Grief work activities involved in grieving
time Grieving process of feeling acute sorrow over a loss

H Hypnotic agent that produces sleep

Hand antisepsis removal and destruction of transient microorgan- Hypoalbuminemia deficit of albumin in the blood
isms from the hands Hypopnea hypoventilation
Hand hygiene methods for removing surface contaminants on the Hypotension low blood pressure
skin Hypothalamus temperature-regulating structure in the brain
Handwashing aseptic practice that involves scrubbing the hands Hypothalamus-pituitary-adrenal (HPA) axis pathway of physi-
with plain soap or detergent, water, and friction ologic communication among the central nervous, endocrine,
Hard of hearing state of having limited hearing, in which com- and immune systems
munication is nonetheless possible Hypothermia core body temperature less than 95°F (35°C)
Head tilt/chin lift technique preferred method for opening the Hypotonic solution one that contains fewer dissolved substances
airway than normally found in plasma
Head-to-toe approach gathering data from the top of the body Hypoventilation diminished breathing
to the feet Hypovolemia low volume in the extracellular fluid compartments
Health state of complete physical, mental, and social well-being; Hypoxemia insufficient oxygen in arterial blood
not merely the absence of disease or infirmity Hypoxia inadequate oxygen at the cellular level
Health care system network of available health services
Health literacy degree to which individuals have the capacity to I
obtain, process, and understand basic health information and Idiopathic illness one in which the cause is unexplained
services needed to make appropriate health decisions Ileostomy surgically created opening to the ileum
Health maintenance organizations corporations that charge Illiterate unable to read or write
members preset, fixed, yearly fees in exchange for providing Illness state of being unwell
health care Imagery using the mind to visualize an experience
Hearing acuity ability to hear and to discriminate sound Immobilizers commercial splints made from cloth and foam
Heimlich maneuver method for removing a mechanical airway Implementation carrying out a plan of care
obstruction Incentive spirometry technique for deep breathing using a cali-
Hereditary condition disorder acquired from the genetic codes of brated device
one or both parents Incident report written account of an unusual event involving a cli-
Holism philosophical concept of interrelatedness ent, employee, or visitor that has the potential for being injurious
Home health care in-home health care provided by an employee Incomplete proteins those that contain some, but not all, of the
of a home health agency essential amino acids
Homeostasis relatively stable state of physiologic equilibrium Incontinence inability to control either urinary or bowel elimination
Hospice facility for or concept addressing the care of terminally Individual supply single container of drugs with several days’
ill clients worth of doses
Hot spot area where radionuclide is intensely concentrated Induration area of hardness
Human needs factors that motivate behavior Infection condition that results when microorganisms cause injury
Humidifier device that produces small water droplets to a host
Humidity amount of moisture in the air Infection control precautions physical measures designed to cur-
Hydrostatic pressure pressure exerted against a membrane tail the spread of infectious diseases
Hydrotherapy therapeutic use of water Infectious diseases diseases spread from one person to another
Hygiene personal cleanliness practices that promote health Infiltration escape of intravenous fluid into the tissue
Hyperalgesia amplified pain experience Inflammation physiologic defense that occurs immediately after
Hyperbaric oxygen therapy delivery of 100% oxygen at three tissue injury
times the normal atmospheric pressure in an airtight chamber Inflatable splints immobilizing devices that become rigid when
Hypercarbia excessive levels of carbon dioxide in the blood filled with air
Hyperendemic infections infections that are considered highly Informed consent permission that a person gives after having the
dangerous in all age groups risks, benefits, and alternatives explained
Hypersomnia sleep disorder characterized by feeling sleepy Infusion pump device that uses pressure to infuse solutions
despite getting a normal amount of sleep Inhalant route drug administration into the lower airways
Hypersomnolence excessive sleeping Inhalation therapy respiratory treatments that provide a mixture
Hypertension high blood pressure of oxygen, humidification, and aerosolized medication
Hyperthermia excessively high core temperature Inhalers hand-held devices for delivering medication to the respi-
Hypertonic solution solution that is more concentrated than body ratory passages
fluid Inpatient surgery operative procedures performed on persons
Hyperventilation rapid or deep breathing, or both admitted to a hospital and expected to remain for a period of time
Hypervolemia higher-than-normal volume of water in the intra- Insomnia sleep disorder involving early awakening or difficulty
vascular fluid compartment falling asleep or staying asleep
Hypnogogic hallucinations dream-like auditory or visual experi- Inspection purposeful observation
ences while dozing or falling asleep Inspiration inhalation; breathing in
Hypnosis therapeutic technique in which a person enters a trance- Insulin syringe syringe that is calibrated in units and holds a vol-
like state ume of 0.5 to 1 mL of medication

Intake and output record of a client’s fluid intake and fluid loss K
over a 24-hour period Kardex quick reference for current information about the client
Integrated delivery system network that provides a full range and the client’s care
of healthcare services in a highly coordinated, cost-effective Kegel exercises isometric exercises to improve the ability to retain
manner urine within the bladder
Integument covering, the skin Kilocalories 1,000 calories, or the amount of heat that raises the
Intentional tort lawsuit in which a plaintiff charges that a defend- temperature of 1 kg of water by 1°C
ant committed a deliberately aggressive act Kinesics body language
Intermediate care facility agency that provides health-related Knee-chest position position in which the client rests on the knees
care and services to people who, because of their mental or and chest
physical condition, require institutional care but not 24-hour Korotkoff sounds sounds that result from the vibrations of blood
nursing care in the arterial wall or changes in blood flow
Intermittent feeding gradual instillation of liquid nourishment
four to six times a day L
Intermittent infusion parenteral administration of medication Laboratory test procedure that involves the examination of body
over a relatively short period fluids or specimens
Intermittent venous access device sealed chamber that provides Lateral oblique position variation of a side-lying position
a means for administering intravenous medications or solutions Lateral position side-lying position
on a periodic basis Latex-safe environment room stocked with latex-free equipment
Interstitial fluid fluid in tissue space between and around cells and wiped clean of glove powder
Intestinal decompression removal of gas and intestinal contents Latex sensitivity allergic response to the proteins in latex
Intimate space distance within 6 in. of a person Latinos people who trace their ethnic origin to South America
Intracellular fluid fluid inside cells Lavage wash out; remove poisonous substances
Intractable pain pain unresponsive to methods of pain manage- Laws rules of conduct established and enforced by the govern-
ment ment of a society
Intradermal injection parenteral drug administration between the Leukocytes white blood cells
layers of the skin Leukocytosis increased production of white blood cells
Intramuscular injection parenteral drug administration into the Liability insurance contract between a person or corporation and
muscle a company who is willing to provide legal services and financial
Intraoperative period time when a client undergoes surgery assistance when a policyholder is involved in a malpractice lawsuit
Intraspinal analgesia method of relieving pain by instilling a nar- Libel damaging statement that is written and read by others
cotic or local anesthetic via a catheter into the subarachnoid or Limited English proficiency (LEP) inability to speak, read, write,
epidural space of the spinal cord or understand English at a level that permits effective interaction
Intravascular fluid watery plasma, or serum, portion of blood Line of gravity imaginary vertical line that passes through the
Intravenous fluids solutions infused into a client’s vein center of gravity
Intravenous injection parenteral drug administration into a vein Lipoatrophy breakdown of subcutaneous fat at the site of repeated
Intravenous route drug administration via peripheral and central insulin injections
veins Lipohypertrophy thickening of subcutaneous fat at insulin injec-
Introductory phase period of getting acquainted tion sites
Intubation placement of a tube into a structure of the body Lipoproteins combinations of fats and proteins
Inunction medication incorporated into an agent, such as an oint- Liquid oxygen unit device that converts cooled liquid oxygen to a
ment, oil, lotion, or cream gas by passing it through heated coils
Invasion of privacy failure to leave people and their property Literacy ability to read and write
alone Lithotomy position reclining posture with the feet in metal sup-
Ions substances that carry either a positive or a negative electrical ports called stirrups
charge Living will a person’s advance, written directive identifying medical
Irrigation technique for flushing debris interventions to use or not to use in cases of terminal condition,
Isometric exercise stationary exercises that are generally per- irreversible coma, or vegetative state with no hope of recovery
formed against a resistive force Loading dose larger dose of a drug administered initially or when
Isotonic exercise activity that involves movement and work pain is intense
Isotonic solution solution that contains the same concentration of Long-term goals desirable outcomes that take weeks or months
dissolved substances as normally found in plasma to accomplish
Lumbar puncture procedure that involves insertion of a needle
J between lumbar vertebrae in the spine but below the spinal cord
Jaeger chart visual assessment tool with small print itself
Jaw-thrust maneuver alternative method for opening the Lumen channel
airway
Jejunostomy tube; J-tube transabdominal tube that leads to the M
jejunum of the small intestine Macrophages white blood cells that consume cellular debris
Jet lag emotional and physical changes experienced when arriving Macroshock harmless distribution of low-amperage electricity
in a different time zone over a large area of the body

Magnetic resonance imaging diagnostic tool used to identify Minority people who differ from the majority in cultural char-
disorders that affect structures in the body without performing acteristics like language, physical characteristics such as skin
surgery; a magnetic field excites hydrogen atoms within the color, or both
body creating a radio signal that is converted into an image on Misdemeanor minor criminal offense
a computer monitor Mode of transmission manner in which infectious microorgan-
Malingerer someone who pretends to be sick or in pain isms move to another location
Malnutrition condition resulting from a lack of proper nutrients Modified standing position position in which the upper half of
in the diet the body leans forward
Malpractice professional negligence Modulation last phase of pain impulse transmission when the brain
Managed care organizations private insurers who carefully plan interacts downward with spinal nerves to alter a pain experience
and closely supervise distribution of their clients’ health care Molded splints orthotic devices made of rigid material
services Montgomery straps strips of tape with eyelets
Managed care practices cost-containment strategies used to plan Morbidity incidence of a specific disease, disorder, or injury
and coordinate a client’s care to avoid delays, unnecessary serv- Morgue area where dead bodies are temporarily held or examined
ices, or overuse of expensive resources Mortality incidence of deaths
Manual traction pulling on the body using a person’s hands and Mortician person who prepares the body for burial or cremation
muscular strength Mucus substance that keeps mucous membranes moist
Massage stroking the skin Multicultural diversity unique characteristics of ethnic groups
Mattress overlay layer of foam or other devices placed on top of Multiple organ failure condition in which two or more organ sys-
the mattress tems gradually cease to function
Maximum heart rate highest limit for heart rate during exercise Multiple sleep latency test assessment of daytime sleepiness
Medicaid state-administered program designed to meet the needs Muscle spasms sudden, forceful, involuntary muscle contractions
of low-income residents MyPlate color-coded diagram showing percentages of food that
Medical asepsis practices that confine or reduce the numbers of should be consumed each day
microorganisms
Medical records written collection of information about a per- N
son’s health problems, the care provided by health practitioners, N95 respirator device that is individually fitted to each caregiver
and the progress of the client and can filter particles 1 micron in size, with a filter efficiency
Medicare federal program that finances health care costs of per- of 95% or more, provided it fits the face snugly
sons who are 65 years and older, permanently disabled work- Narcolepsy sleep disorder characterized by the sudden onset
ers and their dependents, and people with end-stage renal of daytime sleep, a short NREM period before the first REM
disease phase, and pathologic manifestations of REM sleep
Medication administration record agency form used to docu- Narrative charting style of documentation generally used in
ment drug administration source-oriented records
Medication order directions for administering a drug Nasal cannula hollow tube with prongs that are placed into the
Medications chemical substances that change body function client’s nostrils for delivering oxygen
Meditation concentrating on a word or idea that promotes tran- Nasal catheter tube for delivering oxygen that is inserted through
quility the nose into the posterior nasal pharynx
Megadoses amounts exceeding those considered adequate for Nasogastric intubation insertion of a tube through the nose into
health the stomach
Melatonin hormone that induces drowsiness and sleep Nasogastric tube tube that is placed in the nose and advanced to
Mental status assessment technique for determining the level of a the stomach
client’s cognitive functioning Nasointestinal intubation insertion of a tube through the nose to
Metabolic energy equivalent measure of energy and oxygen con- the intestine
sumption during exercise Nasointestinal tube tube inserted through the nose for distal
Metabolic rate use of calories for sustaining body functions placement below the stomach
Metered-dose inhaler canister that contains medication under Nasopharyngeal suctioning removal of secretions from the throat
pressure through a nasally inserted catheter
Microabrasions tiny cuts in the skin that provide an entrance for Nasotracheal suctioning removal of secretions from the trachea
microorganisms through a nasally inserted catheter
Microorganisms living animals or plants visible only with a National Patient Safety Goals objectives designed to reduce the
microscope incidence of injuries to those being cared for in health agencies
Microshock low-voltage but high-amperage electricity Native Americans Indian nations found in North America, includ-
Microsleep unintentional sleep lasting 20 to 30 seconds ing the Eskimos and Aleuts
Midarm circumference measurement used to assess skeletal Nausea feeling that usually precedes vomiting
muscle mass Nebulizer device that converts liquid inhalant medication to an
Military time time based on a 24-hour clock aerosol using compressed air
Minerals noncaloric substances in food that are essential to all Necrotic tissue nonliving tissue
cells Needleless systems equipment that eliminates the need for nee-
Minimum disclosure portions or isolated pieces of information dles
necessary for an immediate purpose Negligence harm that results because a person did not act reasonably

Neuropathic pain pain with atypical characteristics Opportunistic infections disorders caused by nonpathogens that
Neurotransmitters chemical messengers synthesized in neu- occur in people with compromised health
rons Optometrist person who prescribes corrective vision lenses
Neutral position limb that is turned neither toward nor away from Oral airway curved device that keeps the tongue positioned for-
the body’s midline ward within the mouth
NEX measurement distance from the nose to the earlobe to the Oral hygiene practices used to clean the mouth, especially the
xiphoid process teeth
Nociceptors nerve receptors that transmit pain impulses Oral route drug administration by swallowing or instillation
Nocturia nighttime urination through an enteral tube
Nocturnal enuresis bedwetting Oral suctioning removal of secretions from the mouth
Nocturnal polysomnography technique used to obtain physi- Orientation helping a person to become familiar with a new envi-
ologic data during nighttime sleep ronment
Nonelectrolytes chemical compounds that remain bound together Orogastric intubation insertion of a tube through the mouth into
when dissolved in solution the stomach
Nonessential amino acids protein components manufactured in Orogastric tube tube that is inserted from the mouth into the
the body stomach
Nonopioids nonnarcotic drugs Oropharyngeal suctioning removal of secretions from the throat
Nonpathogens harmless and beneficial microorganisms through a catheter inserted through the mouth
Nonrebreather mask oxygen delivery device in which all the Orthopnea breathing that is facilitated by sitting up or standing
exhaled air leaves the mask rather than partially entering the Orthopneic position seated position with the arms supported on
reservoir bag pillows or the arm rests of a chair
Nonverbal communication exchange of information without Orthoses orthopedic devices that support or align a body part and
using spoken or written words prevent or correct deformities
Normal flora microorganisms that reside in and on humans Orthostatic hypotension sudden but temporary drop in blood
Nosocomial infections infections acquired while a person is being pressure when rising from a reclining or seated position
cared for in a hospital or other health care agency Osmosis process that regulates the distribution of water
Nuclear medicine department unit responsible for radionuclide Ostomy surgically created opening
imaging Otic application drug instillation in the outer ear
Nurse-managed care pattern in which a nurse manager plans the Outpatient surgery operative procedures from which clients
nursing care of clients based on their illness or medical diag- recover and return home on the same day
nosis Over-the-counter medication nonprescription drug
Nurse practice act statute that legally defines the unique role Oxygen analyzer device that measures the percentage of oxygen
of the nurse and differentiates it from that of other health care a client is receiving
practitioners, such as physicians Oxygen concentrator machine that collects and concentrates
Nursing care plan written list of the client’s problems, goals, and oxygen from room air and stores it for client use
nursing orders for client care Oxygen tent clear plastic enclosure that provides cooled, humidi-
Nursing diagnosis health problem that can be prevented, reduced, fied oxygen
or resolved through independent nursing measures Oxygen therapeutics fluids that when transfused carry and dis-
Nursing orders directions for a client’s nursing care tribute oxygen to cells, tissues, and organs; also known as blood
Nursing process organized sequence of problem-solving steps: substitutes
assessment, diagnosis, planning, implementation, and evalua- Oxygen therapy therapeutic intervention for administering more
tion oxygen than exists in the atmosphere
Nursing skills activities unique to the practice of nursing Oxygen toxicity lung damage that develops when oxygen concen-
Nursing team personnel who care for clients directly trations of more than 50% are administered for longer than 48
Nursing theory proposal of what is involved in the process of to 72 hours
nursing
Nutrition process by which the body uses food P
Pack commercial device for applying moist heat
O Pain unpleasant sensation usually associated with disease or injury
Obesity condition in which a person’s body mass index exceeds Pain management techniques for preventing, reducing, or reliev-
30 or the triceps skinfold measurement exceeds 15 mm ing pain
Objective data facts that are observable and measurable Pain threshold point at which sufficient pain-transmitting neuro-
Occupied bed changing linen while the client remains in bed chemicals reach the brain to cause awareness of discomfort
Offsets predictive mathematical conversions Pain tolerance amount of pain a person endures once the pain
Oliguria urine output of less than 400 mL per 24 hours threshold is surpassed
Open wound wound in which the surface of the skin or mucous Palpation lightly touching the body or applying pressure
membrane is no longer intact Palpitation awareness of one’s own heart contraction without hav-
Ophthalmic application method of applying drugs onto the ing to feel the pulse
mucous membrane of one or both eyes Pap test screening test that detects abnormal cervical cells, the sta-
Ophthalmologist medical doctor who treats eye disorders tus of reproductive hormone activity, or the presence of normal
Opioids narcotic drugs; synthetic narcotics or infectious microorganisms in the uterus or vagina

Paracentesis procedure for withdrawing fluid from the abdominal Phagocytosis process in which white blood cells consume cellular
cavity debris
Paralanguage vocal sounds that are not actually words Phlebitis inflammation of a vein
Parallel bars double row of stationary bars Photoperiod number of daylight hours
Paranormal experiences those outside scientific explanation Phototherapy technique for suppressing melatonin by stimulating
Parasomnia condition associated with activities that cause arousal light receptors in the eye
or partial arousal, usually during transitions in NREM periods Physical assessment systematic examination of body structures
of sleep Physical restraint method of immobilization that reduces the
Parenteral nutrition nutrients, such as proteins, carbohydrate, ability of a client to freely move his or her arms, legs, body,
fat, vitamins, minerals, and trace elements, which are adminis- or head
tered intravenously PIE charting method of recording the client’s progress under the
Parenteral route route of drug administration other than oral or headings of problem, intervention, and evaluation
through the gastrointestinal tract; administration by injection Piloerection contraction of arrector pili muscles in skin follicles
Partial bath washing only the areas of the body that are subject to Pin site location where pins, wires, or tongs enter or exit the skin
the greatest soiling or that are sources of body odor Placebo inactive substance or treatment measure that charades as
Partial rebreather mask oxygen delivery device through which one that is legitimate
a client inhales a mixture of atmospheric air, oxygen from its Plaintiff person who claims injury
source, and oxygen contained in a reservoir bag Planning process of prioritizing nursing diagnoses and collabo-
Passive diffusion physiologic process in which dissolved sub- rative problems, identifying measurable goals or outcomes,
stances, such as electrolytes and gases, move from an area of selecting appropriate interventions, and documenting the plan
higher concentration to one of lower concentration through a for care
semipermeable membrane Plaque substance composed of mucin and other gritty substances
Passive exercise therapeutic activity performed with assistance that deposits on teeth
Paste vehicle that contains a drug in a viscous base Platform crutches crutches that support the forearm
Pathogens microorganisms that cause illness Plume vaporized tissue, carbon, and water released during laser
Pathologic grief condition in which a person cannot accept some- surgery
one’s death Plunger part of a syringe inside the barrel that moves back and
Patient-controlled analgesia intervention that allows clients to forth to withdraw and instill medication
self-administer pain medication Pneumatic compression device machine that promotes circula-
Pedagogy the science of teaching children or those with cognitive tion of venous blood and the movement of excess fluid into the
ability comparable to children lymphatic vessels
Pelvic examination physical inspection of the vagina and cervix, Pneumonia lung infection
with palpation of the uterus and ovaries Podiatrist person with special training in caring for feet
Perception conscious experience of discomfort Poisoning injury caused by the ingestion, inhalation, or absorption
Percussion (1) striking or tapping a part of the body; (2) type of of a toxic substance
chest physiotherapy performed by rhythmically striking the Polypharmacy administration of multiple drugs to the same per-
chest wall son
Percutaneous electrical nerve stimulation pain management Polyuria larger-than-normal urinary volume
technique involving a combination of acupuncture needles and Port sealed opening
transcutaneous electrical nerve stimulation Port of entry site where microorganisms find their way onto or
Percutaneous endoscopic gastrostomy (PEG) tube transabdom- into a host
inal tube inserted into the stomach under endoscopic guidance Positron emission tomography radionuclide scanning with the
Percutaneous endoscopic jejunostomy (PEJ) tube tube that is layered analysis of tomography
passed through a PEG tube into the jejunum Possible diagnosis problem that may be present, but more infor-
Perineal care techniques used for cleansing the perineum mation is needed to rule out or confirm its existence
Periodontal disease condition that results in destruction of the Postanesthesia care unit area in the surgical department where
tooth-supporting structures and jawbone clients are intensively monitored
Perioperative care care that clients receive before, during, and Postmortem care care of the body after death
after surgery Postoperative care nursing care after surgery
Peripheral parenteral nutrition isotonic or hypotonic intrave- Postoperative period interval that begins after surgery is com-
nous nutrient solution instilled in a vein distant from the heart pleted
Peristalsis rhythmic contractions of gastrointestinal smooth muscle Postural drainage positioning technique that facilitates drainage
Peristomal skin skin around a stoma of secretions from the lungs
Persistent vegetative state condition in which there is no cogni- Postural hypotension sudden but temporary drop in blood pres-
tive function or capacity to experience emotions sure when rising from a reclining or seated position
Personal protective equipment garments that block the transfer Posture position of the body, or the way in which it is held
of pathogens from one person, place, or object to oneself or Potential diagnosis problem a client is at risk for developing
others Powered Air Purifying Respirator alternative device for a car-
Personal space distance of 6 in. to 4 ft egiver who has not been fitted for an N95 respirator; works by
Petals strips of adhesive tape or moleskin applied to the rough blowing atmospheric air through belt-mounted, air-purifying
edges of a cast for the purpose of reducing skin irritation canisters to the facepiece via a flexible tube

Preferred provider organizations agents for health insurance Q

companies that control health care costs on the basis of com- Quadriceps setting isometric exercise in which a client alter-
petition nately tenses and relaxes the quadriceps muscles
Prefilled cartridge sealed glass cylinder of parenteral medication Quality assurance process of promoting care that reflects estab-
with a preattached needle lished agency standards
Preload volume of blood that fills the heart and stretches the heart
muscle fibers during its resting phase R
Preoperative checklist form that identifies the status of essential Race biologic variations
presurgical activities Radiography diagnostic procedures that use x-rays
Preoperative period time that starts when the client is informed Radionuclides elements whose molecular structures are altered to
that surgery is necessary and ends when he or she is transported produce radiation
to the operating room Range-of-motion exercises therapeutic activity in which joints
Pressure ulcer wound caused by prolonged capillary compres- are moved
sion sufficient to impair circulation to the skin and underlying Rebound effect swelling of the nasal mucosa within a short time
tissue of inhaled decongestant drug administration
Primary care first health care worker or agency to assess a person Receiving room presurgical holding area
with a health need Reciprocity licensure based on evidence of having met licensing
Primary illness one that develops independently of any other dis- criteria in another state
ease Reconstitution process of adding liquid to a powdered sub-
Primary nursing pattern in which the admitting nurse assumes stance
responsibility for planning client care and evaluating the Recording process of writing information
progress of the client Recovery index guide for determining a person’s fitness level
Problem-oriented records records organized according to the cli- Recovery position side-lying position that helps to maintain an
ent’s health problems open airway and prevent aspiration of liquids
Primary prevention actions used to eliminate the potential for ill- Rectus femoris site injection area in the anterior thigh
ness before it occurs Referral process of sending someone to another person or agency
Progressive care units units for clients who were once in critical for special services
condition but have recovered sufficiently to require less inten- Referred pain discomfort perceived in an area of the body away
sive nursing care from the site of origin
Progressive relaxation therapeutic exercise whereby a person Regeneration cell duplication
actively contracts and then relaxes muscle groups Regurgitation bringing stomach contents to the throat and mouth
Projectile vomiting vomiting that occurs with great force without the effort of vomiting
Proliferation period during which new cells fill and seal a wound Rehabilitative braces braces that allow protected motion of an
Prone position position in which the client lies on the abdomen injured joint that has been treated surgically
Prophylactic braces braces used to prevent or reduce the severity Relationship association between two people
of a joint injury Relative humidity ratio between the amount of moisture in the
Prosthetic limb substitute for an arm or leg air and the greatest amount of water vapor the air can hold at a
Prosthetist person who constructs prosthetic limbs given temperature
Protein nutrient composed of amino acids; chemical compounds Relaxation technique for releasing muscle tension and quieting
made up of nitrogen, carbon, hydrogen, and oxygen the mind
Protein complementation combining plant sources of protein Remission disappearance of signs and symptoms associated with
Proxemics relation of space to communication a particular disease
Psychomotor domain learning by doing Remodeling period during which a wound undergoes changes and
Public space distance of 12 ft or more maturation
Pulmonary embolus blood clot that travels to the lung Repetitive strain injuries disorders that result from cumulative
Pulse wave-like sensation that can be palpated in a peripheral trauma to musculoskeletal structures
artery Rescue breathing process of ventilating a nonbreathing victim’s
Pulse deficit difference between the apical and radial pulse rates lungs
Pulse oximetry noninvasive, transcutaneous technique for peri- Reservoir place where microbes grow and reproduce providing a
odically or continuously monitoring the oxygen saturation of haven for sustaining microbial survival
blood Resident microorganisms generally nonpathogens that are con-
Pulse pressure difference between systolic and diastolic blood stantly present on the skin
pressure measurements Residual urine urine that remains in the bladder after voiding
Pulse rate number of peripheral arterial pulsations palpated in a Resolution process by which damaged cells recover and reestab-
minute lish their normal function
Pulse rhythm pattern of the pulsations and pauses between them Respiration exchange of oxygen and carbon dioxide
Pulse volume quality of the pulsations that are felt Respiratory hygiene/cough etiquette infection control measures
Pursed-lip breathing form of controlled ventilation in which the used when there are signs of illness suggesting an undiagnosed
expiration phase of breathing is consciously prolonged transmissible respiratory infection
Purulent drainage white- or green-tinged fluid Respiratory rate number of ventilations per minute
Pyrexia fever Respite care relief for a caregiver

Rest waking state characterized by reduced activity and reduced Shaft long portion of a needle
mental stimulation Shearing force exerted against the surface and layers of the skin as
Restless legs syndrome movement, typically in the legs, but occa- tissues slide in opposite but parallel directions
sionally in the arms or other body parts, to relieve disturbing Shearing force effect that moves layers of tissue in opposite direc-
skin sensations tions
Restraint alternatives protective or adaptive devices that pro- Shell temperature warmth at the skin surface
mote client safety and postural support, but which the client can Short-term goals outcomes that can be met in a few days to a
release independently week
Restraints devices or chemicals that restrict movement or access Shroud covering for a dead body
to one’s body Signing shortened term for American Sign Language communica-
Resuscitation team group of people trained and certified in tion
advanced cardiac life support (ACLS) techniques Signs objective data; information that is observable and measur-
Retching act of vomiting without producing vomitus able
Retention catheter urinary tube that is left in place for a period Silence intentionally withholding verbal comments
of time Simple mask device for administering oxygen that fits over the
Retention enema solution held temporarily in the large intestine nose and mouth
Reversal drugs medications that counteract the effects of those Sims’ position lying on the left side with the chest leaning for-
used for conscious sedation ward, the right knee bent toward the head, the right arm for-
Rh factor protein surface marker on red blood cells ward, and the left arm extended behind the body
Rhizotomy surgical sectioning of a nerve root close to the spinal Sitz bath soak of the perianal area
cord Skeletal traction pull exerted directly on the skeletal system by
Rinne test assessment technique for comparing air versus bone attaching wires, pins, or tongs into or through a bone
conduction of sound Skilled nursing facility nursing home that provides 24-hour nurs-
Risk management process of identifying and reducing the costs ing care under the direction of a registered nurse
of anticipated losses Skin patches drugs that are bonded to an adhesive bandage
Roentgenography general term for procedures that use x-rays Skin tear shallow break in the skin
Rounds visits to clients on an individual basis or as a group Skin traction pulling effect on the skeletal system by applying
Route of administration oral, topical, inhalant, or parenteral devices to the skin
route where a drug is administered Slander character attack uttered in the presence of others
Sleep state of arousable unconsciousness
S Sleep apnea/hypopnea syndrome sleep disorder in which the
Safe injection practices infection control measures that prevent sleeper stops breathing or the breathing slows for 10 seconds or
the transmission of blood borne pathogens through the use of longer, five or more times per hour
aseptic techniques involving the preparation and administration Sleep diary daily account of sleeping and waking activities
of parenteral medications Sleep paralysis inability to move for a few minutes just before
Safety measures that prevent accidents or unintentional injuries falling asleep or awakening
Saturated fats lipids that contain as much hydrogen as their Sleep rituals habitual activities performed before retiring
molecular structure can hold Sleep-wake cycle disturbance condition that results from a sleep
Scar formation replacement of damaged cells with fibrous tissue schedule that involves daytime sleeping
Science body of knowledge unique to a particular subject Sling cloth device used to elevate, cradle, and support parts of the
Scoop method technique for threading the needle of a syringe into body
the cap without touching the cap itself Slough dead tissue on a wound surface that is moist, stringy, yel-
Scored tablet tablet with a groove in its center low tan, gray, or green
Secondary care health services to which primary caregivers refer Smelling acuity ability to smell and identify odors
clients for consultation and additional testing Snellen eye chart tool for assessing far vision
Secondary illness disorder that develops from a preexisting con- Soak procedure in which a part of the body is submerged in fluid
dition SOAP charting documentation style more likely to be used in a
Secondary infusion administration of a diluted intravenous drug problem-oriented record
at the same time a solution is infusing, or intermittently with an Social space distance of 4 to 12 ft
infusing solution Somatic pain discomfort generated from deeper connective tissue
Secondary prevention actions used to screen for risk factors that Somnambulism sleepwalking
provide a means for early diagnosis of disease Sordes dried crusts around the mouth containing mucus, microor-
Second-intention healing reparative process when wound edges ganisms, and epithelial cells shed from the oral mucous mem-
are widely separated brane
Sedative drug that produces a relaxing and calming effect Source-oriented records records organized according to the
Sensory manipulation using sensory stimuli to alter moods, feel- source of information
ings, and physiologic responses Spacer chamber that is attached to an inhaler
Sepsis potentially fatal systemic infection Specimens samples of tissue or body fluids
Sequelae consequences of a disease or its treatment Speculum metal or plastic instrument for widening the vagina or
Serous drainage leaking plasma other body cavity
Set point optimal body temperature Sphygmomanometer device for measuring blood pressure

Spica cast rigid mold that encircles one or both arms or legs and Subcultures unique cultural groups that coexist within the domi-
the chest or trunk nant culture
Spinal tap procedure that involves insertion of a needle Subcutaneous injection parenteral drug administration beneath
between lumbar vertebrae in the spine but below the spinal the skin but above the muscle
cord itself Subdiaphragmatic thrust pressure to the abdomen
Splint device that immobilizes and protects an injured part of the Subjective data information that only the client feels and can
body describe
Spore temporarily inactive microbial life form Sublingual application placement of a drug under the tongue
Sputum mucus raised to the level of the upper airways Submaximal fitness test exercise test that does not stress a person
Stage of exhaustion the last phase in the general adaptation to exhaustion
syndrome that develops when one or more adaptive or resis- Substituted judgment court belief that a client would issue con-
tive mechanisms can no longer protect a person experiencing sent if he or she had the capacity to do so
a stressor Suctioning technique for removing liquid secretions with a cath-
Stage of resistance second phase in the general adaptation syn- eter
drome characterized by physiologic changes designed to restore Suffering emotional component of pain
homeostasis Sump tubes tubes that contain a double lumen
Standard precautions infection control measures for reducing the Sundown syndrome onset of disorientation as the sun sets
risk of transmission among all clients, regardless of suspected Sunrise syndrome early morning confusion
or confirmed infection status Supine position position in which the person lies on the back
Standards for care policies that ensure quality client care Suppository medicated oval or cone-shaped mass
Staples wide metal clips Surfactant lipoprotein produced by cells in the alveoli that pro-
Stasis lack of movement motes elasticity of the lungs and enhances gas diffusion
Statute of limitations designated amount of time within which a Surgical asepsis measures that render supplies and equipment
person can file a lawsuit totally free of microorganisms
Statutory laws laws enacted by federal, state, or local legislatures Surgical hand antisepsis medically aseptic hand hygiene proce-
Stent tube that keeps a channel open dure that is performed prior to the nurse’s donning sterile gloves
Stepdown units units for clients who were once in critical con- and garments in an operative or obstetrical procedure
dition but have recovered sufficiently to require less intensive Surgical waiting area room where family and friends await infor-
nursing care mation about the surgical client
Step test submaximal fitness test involving a timed stepping activity Susceptible host one whose biologic defense mechanisms are
Stereotypes fixed attitudes about all people who share a common weakened in some way
characteristic Sustained release drug that dissolves at timed intervals
Sterile field work area free of microorganisms Sutures knotted ties that hold an incision together
Sterile technique practices that avoid contaminating microbe-free Sympathy feeling as emotionally distraught as the client
items Symptoms subjective data; that which only the client can identify
Sterilization physical and chemical techniques that destroy all Syndrome diagnosis cluster of problems that is present due to an
microorganisms, including spores event or situation
Stertorous breathing noisy ventilation Systolic pressure pressure in the arterial system when the heart
Stethoscope instrument that carries sound to the ears contracts
Stimulants drugs that excite structures in the brain
Stock supply drugs kept in a nursing unit for use in an emergency T
Stoma entrance to a surgically created opening Tachycardia heart rate between 100 and 150 beats per minute
Straight catheter urine drainage tube that is inserted but not left (bpm) at rest
in place Tachypnea rapid respiratory rate
Strength power to perform Tamponade controlling gastric bleeding with internal pressure via
Stress physiologic and behavioral reactions that occur in response a tube
to disequilibrium Target heart rate goal for heart rate during exercise
Stress electrocardiogram test of electrical conduction through Tartar hardened plaque
the heart during maximal activity Task-oriented touch personal contact that is required when per-
Stress management techniques therapeutic activities used to forming nursing procedures
reestablish balance between the sympathetic and parasympa- Team nursing pattern in which nursing personnel divide the cli-
thetic nervous systems ents into groups and complete their care together
Stress-reduction techniques methods that promote physiologic Telehome care visiting clients electronically in their home for the
comfort and emotional well-being purpose of seeing and communicating in real time
Stress-related disorders diseases that result from prolonged stim- Telehealth services technology that facilitates the transmission of
ulation of the autonomic nervous and endocrine systems health assessment and monitoring data with audio, video, and
Stressors changes that have the potential for disturbing equilib- Internet-based devices
rium Telephonic interpreting language translation via telephone
Stridor harsh, high-pitched sound heard on inspiration when there Teleology ethical theory based on final outcomes
is laryngeal obstruction Temperature translation conversion of tympanic temperature
Stylet metal guidewire into an oral, rectal, or core temperature

Tension pneumothorax extreme air pressure in the lung when Tracheostomy collar device that delivers oxygen near an artificial
there is no avenue for its escape opening in the neck
Terminal disinfection measures used to clean the client environ- Tracheostomy tube curved, hollow plastic tube in the trachea
ment after discharge Traction pulling on a part of the skeletal system
Terminal illness illness with no potential for cure Traction splints metal devices that immobilize and pull on mus-
Terminating phase ending of a nurse–client relationship when cles that are in a state of contraction
there is mutual agreement that the client’s immediate health Trade name name by which a pharmaceutical company identifies
problems have improved its drug
Tertiary care health services provided at hospitals or medical Traditional time time based on two 12-hour revolutions on a clock
centers that offer specialists and complex technology Training effect heart rate and consequently pulse rate become
Tertiary prevention actions that minimize the consequences of a consistently lower than average with regular exercise
disorder through aggressive rehabilitation or appropriate man- Tranquilizer drug that produce a relaxing and calming effect
agement of the disease Transabdominal tubes tubes placed through the abdominal wall
Theory opinion, belief, or view that explains a process Transcultural nursing providing nursing care in the context of
Therapeutic baths baths performed for other than hygiene pur- another’s culture
poses Transcutaneous electrical nerve stimulation medically pre-
Therapeutic exercise activity performed by people with health scribed pain management technique that delivers bursts of elec-
risks or those being treated for a health problem tricity to the skin and underlying nerves
Therapeutic relationship association between people whose Transdermal application method of applying a drug on the skin
objective is to achieve a higher state of health and allowing it to become passively absorbed
Therapeutic verbal communication using words and gestures to Transducer instrument that receives and transmits biophysical
accomplish a particular objective energy
Thermal burn skin injury caused by flames, hot liquids, or steam Transduction conversion of chemical information at the cellular
Thermister temperature sensor level into electrical impulses that move toward the spinal cord
Thermistor catheter heat-sensing device at the tip of an inter- Trans fats unsaturated, hydrogenated fats
nally placed tube Transfer (1) discharging a client from one unit or agency and
Thermogenesis heat production immediately admitting him or her to another; (2) moving a cli-
Thermoregulation ability to maintain stable body temperature ent from place to place
Third-intention healing reparative process when a wound is Transfer summary written review of the client’s previous care
widely separated and later brought together with some type of Transient microorganisms pathogens picked up during brief con-
closure material tact with contaminated reservoirs
Third-spacing movement of intravascular fluid to nonvascular Transitional care unit area for clients initially in a critical or
fluid compartments, where it becomes trapped and useless unstable condition, but sufficiently recovered to require less
Thrombophlebitis inflammation of a vein caused by a thrombus intensive nursing care
Thrombus stationary blood clot Transmission phase during which stimuli move from the periph-
Thrombus formation development of a stationary blood clot eral nervous system toward the brain
Tidaling rhythmic rise and fall of water in a chest tube drainage Transmission-based precautions measures for controlling the
system spread of highly transmissible or epidemiologically important
Tilt table device that raises client from a supine to a standing posi- infectious agents from clients when the known or suspected
tion route(s) of transmission is (are) not completely interrupted
Tip part of a syringe to which the needle is attached using standard precautions alone
Tone ability of muscles to respond when stimulated Transtracheal catheter hollow tube inserted into the trachea to
Topical route drug administration to the skin or mucous mem- deliver oxygen
branes Trauma injury
Tort litigation in which one person asserts that an injury, which Truth telling ethical principle proposing that all clients have the
may be physical, emotional, or financial, occurred as a conse- right to receive complete and accurate information
quence of another’s actions or failure to act Tuberculin syringe syringe that holds 1 mL of fluid and is cali-
Total parenteral nutrition hypertonic solution of nutrients brated in 0.01-mL increments
designed to meet almost all the caloric and nutritional needs Turgor resiliency of the skin
of clients Twenty-four-hour specimen collection of all the urine produced
Total quality improvement process of promoting care that in a full 24-hour period
reflects established agency standards
Touch tactile stimulus produced by making personal contact with U
another person or an object Ultrasonography soft tissue examination that uses sound waves
Towel bath technique for bathing in which a single large towel is in ranges beyond human hearing
used to cover and wash a client Undermining erosion of tissue from underneath intact skin at a
T-piece device that fits securely onto a tracheostomy tube or wound edge
endotracheal tube Unintentional tort situation that results in an injury, although the
Tracheostomy surgically created opening into the trachea person responsible did not mean to cause harm
Tracheostomy care hygiene and maintenance of a tracheostomy Unit dose self-contained packet that holds one tablet or capsule
and tracheostomy tube Universal donor person with Type O blood

Universal recipient person with Type AB blood Voided specimen freshly urinated sample of urine
Unoccupied bed changing the linen when the bed is empty Voiding reflex spontaneous relaxation of the urinary sphincter in
Unsaturated fats lipids that are missing some hydrogen response to physical stimulation
Urgency strong feeling that urine must be eliminated quickly Volume-control set chamber in intravenous tubing that holds a
Urinal cylindrical container for collecting urine portion from a larger volume of intravenous solution
Urinary diversion procedure in which one or both ureters are sur- Volumetric controller electronic infusion device that instills
gically implanted elsewhere intravenous solutions by gravity
Urinary elimination process of releasing excess fluid and meta- Vomiting loss of stomach contents through the mouth
bolic wastes Vomitus substance that is vomited
Urinary retention condition in which urine is produced but is not
released from the bladder W
Urine fluid in the bladder Waiting-for-permission phenomenon a terminally ill client’s
Urostomy urinary diversion that discharges urine from an opening forestalling of death when he or she feels that loved ones are not
on the abdomen yet prepared to deal with the client’s death
Walk-a-mile test fitness test that measures the time it takes a per-
V son to walk a mile
Valsalva maneuver act of closing the glottis and contracting the Walker ambulatory aid constructed of curved aluminum bars that
pelvic and abdominal muscles to increase abdominal pressure form a three-sided enclosure, with four legs for support
Values ideals that a person believes are important Walking belt safety device applied around the client’s waist used
Vastus lateralis site injection area in the outer thigh to provide ambulatory support and assistance
Vegan person who relies exclusively on plant sources for protein Water-seal chest tube drainage technique for evacuating air or
Vegetarian person who restricts consumption of animal food blood from the pleural cavity
sources Water-soluble vitamins vitamins present and carried in body
Venipuncture accessing the venous system by piercing a vein water; B complex and vitamin C
with a needle Webcam video camera that allows viewing via the Internet
Ventilation (1) movement of air in and out of the lungs; (2) move- Weber test assessment technique for determining equality or dis-
ment of air in the environment parity of bone-conducted sound
Ventricular fibrillation life-threatening dysrhythmia in which the Wellness full and balanced integration of all aspects of health
heart muscle quivers and cannot contract sufficiently to circu- Wellness diagnosis situation in which a healthy person obtains
late blood nursing assistance to maintain his or her health or perform at
Ventrogluteal site injection area in the hip a higher level
Venturi mask oxygen delivery device that mixes a precise amount Wheal elevated circle on the skin
of oxygen and atmospheric air Whistle-blowing reporting incompetent or unethical practices
Verbal communication communication that uses words Whitecoat hypertension condition in which the blood pressure is
Vial glass or plastic container of parenteral medication with a self- elevated when taken by a health care worker but is normal at
sealing rubber stopper other times
Vibration type of chest physiotherapy used to loosen retained Window square of plaster removed from a cast that provides an
secretions area for inspecting or treating underlying tissue.
Video interpreting communication in which a person signs in a Working phase period during which the nurse and the client plan
remote location yet is visible to the health team member and the client’s care and put the plan into action
client and vice versa Wound damaged skin or soft tissue
Viral load number of viral copies
Visceral pain discomfort arising from internal organs X
Visual acuity ability to see both far and near Xerostomia dry mouth
Visual field examination assessment of peripheral vision and
continuity in the visual field Z
Vital signs body temperature, pulse rate, respiratory rate, and Z-track technique injection method that prevents medication
blood pressure from leaking outside the muscle
Vitamins chemical substances that are necessary in minute
amounts for normal growth, maintenance of health, and func-
tioning of the body

Index
Note: Page numbers followed by f indicate figures; those followed by t indicate tables; those followed by b indicate box; and those
followed by d indicate display text.
A nursing plan for care, 171 in older adults, 811

Abbreviations responses to oral airway in, 814, 814f, 815d
in documentation, 122, 123t anxiety, 171–172, 173d–174d percussion, 813, 813f
Abdominal assessment, 242–245, 243f, decreased privacy, 172 postural drainage in, 812, 812d, 813f
244d, 244f loneliness, 172 in resuscitation, 827–833 (See also
Abdominal circumference, 294, 294f loss of identity, 172 Resuscitation)
Abdominal girth, 244, 244f room preparation in, 169, 170d suctioning secretions, 813–814, 813t,
Abdominal quadrants, 242, 243f types of, 169t 818d–820d
Abnormal blood pressure measurement, Admission assessment form, 20f tracheostomy, 814–816, 815f,
208–209, 209t Adolescents, safety concerns for, 400 820d–824d
Abrasion, 236 Adults, safety concerns for, 400, 401t vibration, 813, 813f
Acceptance, in terminal illness, 843 Advanced cardiac life-support (ACLS), 828 Airway obstruction
Accreditation, documentation in, 116 Advance directives, 47, 48d causes of, 825, 826d
Acculturation, 79 Adventitious sounds, 240 management of, 826, 827f (See also
Acne, 351t Aerobic bacteria, 141 Airway management; Resuscita-
Active exercise, 523 Aerobic exercise, 522 tion)
Active listening, 99 Aerosol, 757, 811–812, 812f signs of, 826, 826d, 826f
use of, 15 Affective domain, in learning, 106 Alarm stage of stress response, 66, 66t
Active transport, 307f, 308 Affective touch, 101, 101f Alcohol
Activities of daily living (ADL), 181f African Americans, 77 rubs, 146
Actual diagnosis, 21t Afterload, 203 sleep and, 381
Acupressure, 429 Ageism, 73 Alcohol dehydrogenase (ADH) de ciency,
fi
Acupuncture, 429 Airborne precautions, 471, 472, 473f 83
Acute care, 846, 846f Air bubbles in IV tubing, 317, 322d, 322f Alpha-tocopherol, 288t
Acute illness, 52–53 Air embolism, 321 Alternating air mattress, 503, 504f
Acute pain, 420, 421t Air-fluidized bed, 504t, 505, 505f Alternative ativities in stress management,
nursing care plan for, 431d Air pressure mattress, static, 504, 504f 69–70
Adaptation Airway Alternative medical therapy, 84d
physiologic, 61–64, 62f, 63f, 64fSee( anatomy of, 811, 811f Aluminum canes, 563
also Homeostatis) definition of, 810 Alzheimer’s disease, 104
to stress, 64–70, 65d, 66t, 67t, 70t occlusion, postoperative, 601t Ambulation. See also Crutches
Adaptation theory, 7t oral, 814, 814f, 815d assistive devices for
Adenosine triphosphate (ATP), 308 Airway management, 810–824 parallel bars, 562, 563f
Adipocytes, 190 anatomic aspects of, 811, 811f walking belt, 562–563, 563f, 564f
Adjustable bed, 500, 500f, 501f artifi cial, 814–816 preparation for
Adjuvant drugs, 426 cardiopulmonary resuscitation in, dangling, 561, 561f, 562f
Administrative laws. See under Law(s) 828–830, 828f, 829t exercises for, isometric, 561, 561d
Admission, 168–174 chest physiotherapy in, 812 tilt table, 561–562, 562f
admitting department, 169 client teaching, 812 upper arm strengthening, 561, 561f
client orientation in, 170 Heimlich maneuver, 826 prosthetic limbs for, 566–568, 566f,
client’s personal items in, 170 inhalation therapy in, 811 568f, 578d–579d
client welcome in, 170 liquefying secretions, 811–812, 812d, Ambulatory aids. See also Crutches
medical admission responsibilities, 171 812f cranes, 563–564, 564f, 571d–574d
medical authorization, 169 mobilizing secretions in, 812–813, 813f crutches, 565, 566f
nursing admission activities, 169–171 natural, 811–814 crutch-walking gaits, 566, 567t,
nursing data base, 171, 171f, nursing care plan for, 816 574d–577d
183d–184d nursing implications, 816 walkers, 565, 565f
905
LWBK1004-ind_905-930.indd 905 02/02/12 11:47 PM

906 Index
Ambulatory electrocardiogram, 520, 521f hand antisepsis, 146, 147d, 158d–159d occupied, 377, 395d–396d
Ambulatory surgery, 589 hand hygiene, 146, 147d, 156d–158d pillows, 376
American Nurses Association (ANA), 6, medical, 145 unoccupied hospital bed, 376,
17, 497 personal protective equipment, 389d–394d
American Pain Society, 421 148–150, 148f, 150f Bed bath, 349–350, 350d, 366d–369d
American Sign Language (ASL), 103 soiled articles, 150 bag bath, 349–350
American Society of Anesthesiology surgical, 151–153 (See also Surgical towel bath, 349
recommendation, 596 asepsis) Bedpans, 678, 678f, 688d–689d
Amino acids, 285 surgical hand antisepsis, 147, 147t, Bedside commode, 678f
Amniocentesis, 264d 159d–162d Bedside stand, 377
Ampules, 764, 764d, 765f Asian Americans, 77–78 Behind-the-ear devices, 357, 358
Amputation, 566 Asphyxiation, 404–405, 405d, 405f. See Belching, 297
Anaerobic bacteria, 141 also under Environmental hazards Beliefs, 50
Anecdotal record, 42 Assault, 37 Beliefs concerning illness, 79, 81
Aneroid manometer, 205, 205f, 206t Assessment skills (nursing), 15 Beneficence, 45
Anesthesia, 598 Associate degree programs, 10 Bergaining, in terminal illness, 843
for surgery, 590t, 598–599 Asystole, 830 Bill of rights, 45
for test, 257 Atelectasis, 593t, 594 Binders, 617
Anesthesiologist, 589 Audiometry, 234, 236t Biodegradable trash disposal, 476
Anesthetist, 589 Auditors, 116 Biofeedback in pain management, 429
Anger, in terminal illness, 843 Auscultation Biologic defense mechanisms, 144
Anions, 306 of body sounds, 229, 229f Biotin, 289t
Anorexia, 296, 297d Autoclave, 151, 152f Bivalved cast, 542
Anthropometric data, 292–294, 293f, 294t Autologous transfusions, 591–592, 592t Bladder retraining, 680
Antianxiety drugs, 596 Autolytic debridement, 617 Blood, 307, 315. See also Transfusion
Antibiotic drug resistance, causes of, 142d Automated external defibrillator (AED), clots, 594
Antibiotics, 596 831, 831f collection and storage of, 323
Anticholinergics, 596 Automated medication dispensing system, compatibility of, 323, 323t
Anticipatory grieving, 851 741 donation, 591–592, 592t
Anticoagulation therapy, 592 Automated monitoring devices, 196, 197f products, 315, 315t
Anticonvulsants, 426 Automatic behavior, 384 safety, 323
Antidepressants, 426 Autonomic nervous system, 62–64 substitutes, 315–316
Antiembolism stockings, 595, 605d–606d parasympathetic nervous system, 63–64, Blood-borne pathogens, 470d
Anti-infective drugs, 145–146 63t Blood pressure, 203–210
Antimicrobial agents, 145–151, 146t sympathetic nervous system, 63, 63t auscultatory gap, 207
Antineoplastic drugs, 789–790, 789d, 790f Autonomy, 45 diastolic, 204
Antipyretics, 198 Autopsy, 849 factors affecting, 204
Antiseptics, 145 Axillary temperature, 192 high, 208
Anuria, 677 low, 209
Anus, assessment of, 245, 245f B measurement of, 204, 204f, 220d–223d
Anxiety, 171–172 Baccalaureate programs, 10 abnormal pressure, 208–209, 209t
nursing care plan for, 173d–174d Back massage, 387, 397d–398d alternative assessment techniques,
Apical heart rate, 201, 201f Bacteria, 141, 141f 208, 208f
Apical-radial rate, 202, 202f Bactericides, 145 assessment errors in, 207t
Apnea, 203 Bacteriostatic agents, 145 assessment sites, 205
Aquathermia pad, 621–622, 622f Bag bath, 349–350 automatic monitoring in, 208
Arm sling, 540, 541f, 548d–551d advantages of, 350d Doppler stethoscope, 208, 208f
Arm strengthening exercises, 561, 561f Bandages, 616–617, 618f equipment for, 205–207, 205f, 206f,
Arrhythmia, 200 Barcode medication administration sys- 206t
Arterial blood gases (ABG), 440, 440t, tem, 741 inflatable cuff, 205, 206f
441d Barrel, 763 Korotkoff sounds in, 207–208, 207f
Artificial airway, 814–816 Barrel chest, 238f palpation in, 208
Artificial eyes, 357 Basic care facility, 179 sphygmomanometer, 205, 205f, 206t
Ascorbic acid, 288t Basic needs theory, 7t stethoscope, 206–207, 206f
Asepsis. See also Microorganisms Bathing. See under Hygiene at thigh, 208, 223d–224d
anti-infective drugs, 145–146 Bathing self-care deficit, 359 postural hypotension in, 209,
antimicrobial agents, use if, 145–151, Battery, 37, 38f 225d–226d
146t Bed, 376–377, 376f, 395d–396d pulse pressure and, 204
antiseptics, 145 board, 501, 501f systolic, 204
disinfectants, 145 linen, 376–377 Body-aid devices, 357
environment, cleaning of, 150–151 mattress, 376, 377f Body cast, 542
LWBK1004-ind_905-930.indd 906 02/02/12 11:47 PM

Index 907
Body composition, 519 Breathing Caregiver, nurse as, 95, 95d

Body fluid, 305–308 anatomy and physiology of, 438–439, Care mapping. See Concept mapping
active transport, 307f, 308 439f Caries (cavities), 347
blood, 307 apnea, 203 Caring skills (nursing), 15
electrolytes, 306–307, 307t diaphragmatic, 444, 444d Carriers, 143
facilitated diffusion, 307f, 308 dyspnea, 203 Case mehod, 58
filtration, 307–308, 307f hyperventilation, 203 Cast, 541–543
fluid compartments, 306, 306f, 306t hypoventilation, 203 application, 542, 551d–553d
fluid regulation, 308 machine, 757 basic cast care, 542–543, 543d, 543f,
nonelectrolytes, 306–307 stertorous, 203 554d–556d
osmosis, 307, 307f stridor, 203 bivalved, 542, 542f
passive diffusion, 307f, 308 Breathing techniques, 442–444, 444d body, 542
water, 305–306 deep, 442–443 cylinder, 542
Body image, disturbed, 603d diaphragmatic, 444, 444d materials, 541t
Body mass index (BMI), 293, 294f incentive spirometry, 443, 444d, 444f removal, 543, 544f
Body mechanics, 496–497, 497d. See also nasal strips, 444 spica, 542, 542f
Position; Positioning; Posture pursed-lip, 443–444 Cataplexy, 384
nursing implications of, 509 Brevity, 122 Catheter(s), 323. See Urinary catheters
terminology for, 495t Bronchial sounds, 240 central venous, 787–790, 787f, 788f,
Body substance isolation, 469 Bronchovesicular sounds, 240 789f, 790f
Body systems approach, 231 Buccal applications, 755 Catheterization. See Urinary catheters
Boiling water, for sterilizaton, 151 Buck’s traction, 545f Catheter specimen, 676, 676f
Bolus administration, 784 Bumpers, 638 Cations, 306
Bolus feedings, 646 Burns, 402–404. See also Environmental Cellulose, 286
Bolus (loading dose) of opioids, 426 hazards Centigrade scale, 188
Boots, 503, 503f Central nervous system, 62, 62f
Botulinum toxin, 426–427 C cortex, 62
Bowel elimination, 705–728 Cachexia, 296 reticular activating system (RAS), 62, 63f
alterations in, 707–709 Caffeine subcortex, 62
anatomic aspects of, 706f sleep and, 381 Central venous catheter (CVC), 787–790,
colostomy irrigation, 713, 725d–728d Calciferol, 288t 787f
constipation and, 707–708 Calcium alginate dressings, 619 antineoplastic drugs, 789–790, 789d,
nursing care plan, 714 Calories in diet, 285 790f
defecation, 705–706, 706t Canal aids, 357 implanted, 789, 789f
diarrhea and, 708–709 Cancer pain, 424d nontunneled percutaneous, 788, 788f
enema, 710–712, 711d, 719d–722d Candidiasis, 351t tunneled, 788–789, 789f
factors affecting, 706t Cannula, 814 Cerumen, 234
fecal impaction and, 708, 709d, 709f Capillary blood glucose testing, 261, 262, Cervical collar, 539–540, 540f
fecal incontinence and, 709, 710d 263 Cervical halter, 545f
flatulence, 708, 716d–717d Capillary refill time, 241 C-fibers, 419
with hip spica casts, 542, 542f Capitation, 56 Chain of survival, 827–832, 829t
nursing implications, 714 Carbohydrates, 286, 286d Chairs, 377
ostomy for, 712–713, 713f, 722d–725d Carbon monoxide poisoning, 404, 405d Change of shift report, 126, 126d, 126f
patterns of, 706 Cardiac output, 203 Chart forms, 114, 115t
peristalsis in, 705 Cardiac risks with fats, 287t Charting. See also Documentation
promotion of, 709–712 Cardiopulmonary resuscitation (CPR), 46, computerized, 119–120, 120f, 121t
pseudoconstipation and, 707–708 405, 405f, 828–830, 828f, 829t by exception, 119, 119f
rectal suppository insertion, 710, Cardiovascular endurance fitness, 521 focus, 119, 119f
718d–719d Care narrative, 117, 118f
stool characteristics, 706, 706t, 707d arrangements for PIE, 119, 119f
Valsalva maneuver in, 705 acute care, 846, 846f SOAP, 117, 118t, 119
Bowel sounds, 244, 244d, 244f home care, 844, 844f Checklists, 125
Braces, 541, 541f hospice care, 844–845, 845d, 845f Chemical defense mechanisms, 144
Bradycardia, 200 residential care, 845, 846f Chemical packs, 622
Bradypnea, 203 terminal Chemical restraints, 409
Brain death, 849 comfort, 847 Chemical sterilization, 152
Brawny edema, 243d elimination, 846 Chemical thermometers, 195, 195f, 196f
Breach of duty, 40, 40d hydration, 846 Chest
Breast examination, 237–238, 239f hygiene, 846–847 assessment of, 236, 238f
guidelines, 239t nourishment, 846 compression, 826, 828, 829t
self-examination, 239d positioning, 847 physiotherapy, 812
LWBK1004-ind_905-930.indd 907 02/02/12 11:47 PM

908 Index
Chicanos, 75 on infection prevention, 479 Comforting skills (nursing), 15, 16f

Childhood poisoning, 406–407. See also informal teaching, 110 Commercial splints. See under Splints
under Environmental hazards lactose, reducing/eliminating, 82d Commode, 678, 678f
Cholesterol, 286 learning needs, 110 Common law, 37
health risks with, 287 learning readiness, 109–110 Commuity services, 180t
Chronic illness, 53 learning styles, 106–107, 106d Communication
Chronic pain, 420–421, 420d, 421t literacy, 108 for continuity and collaboration,
Circadian rhythm, 204 for metered-dose inhaler use, 756 124–128
Circular bed, 504t, 505–506, 506f motivation, 109 interpersonal
Circulation promotion, 828 for nursing home selection, 180 change of shift report, 126, 126d,
Civil laws. See under Law(s) on pain management, 427 126f
Clean-catch specimen, 675–676, 676d on postural drainage, 812d client care assignments, 126, 127f
Cleansing enemas, 710, 710t on potentially infectious equipment client rounds, 126, 128, 128f
Clean technique, 145 cleaning, 151 team conferences, 126
Client belongings on preparation for special examinations/ telephone, 128
inventory of, 170, 170f tests, 251 nonverbal, 100–103, 100d, 101f, 101t,
return of quadriceps and gluteal setting exercises, 102f
storage of, 170 561 kinesics (body language), 100–101,
Client care assignments, 126, 127f on relaxation, 428 100d
Client environment, 374–377, 473–474, safe exercise program, 523 paralanguage (vocal sounds), 101
474f scope and consequences of, 106 proxemics, 101, 101t
client rooms sensory deficits, 108, 109d touch, 101, 101f
climate control, 375 sleep promotion, 383 with special populations
floors, 375 on taking medications, 742 Alzheimer’s disease, 104
lighting, 375 testicular self-examination, 245 deaf clients, 103–104, 103f
walls, 375 on topical vaginal application, 755 verbally impaired clients, 102f,
room furnishings, 375–377 on vegetarian diets, 292 103
bed, 376–377, 376f, 395d–396d for weight gain promotion, 296 verbal, 97–100
bedside stand, 377 for weight loss promotion, 295 listening, 99, 100, 100f
chairs, 377 Client transport in infection, 476–477 nontherapeutic verbal communica-
overbed table, 377 Climate and body temperature, 190 tion techniques, 99t
privacy curtain, 377 Climate control in hospital silence, 100
Client records. See under Medical records humidity, 375 therapeutic verbal communication,
Client rooms. See also under Client envi- temperature, 375 98–99, 98t
ronment ventilation, 375 written forms of
preparation for, 169, 170d Closed drains, 616, 616f checklists, 125
Client rounds, 126, 128, 128f Closed urine drainage systems, 682–683, flow sheets, 125
Client teaching 682f, 683f nursing care plans, 124–125, 125f
activity and mobility promotion, 508 Clostridium botulinum, 426–427 nursing Kardex, 125, 125f
on advance directives, 48 Clothing and hygiene in surgery, 596 zones, 101t
age/developmental level, 107, 107t Code for nurses, 44d Community health nurses, 5f
assessment in, 106–110, 106d, 106f, Codes of ethics, 42 Compartment syndrome, 555d
109f Code status, 48 Complete proteins, 286
attention and concentration, 108 Cognitive domain, in learning, 106 Computed tomography, 256, 256f
breast self-examination, 239 Cold application, 620–622, 621d, 622f. Computerized charting, 119–120, 120f,
on burn prevention, 403 See also Thermal therapy 121t
capacity to learn, 108, 109d for casts, 542, 555d Concept mapping, 26–28, 27f
on childhood poisoning prevention, 407 for pain, 428, 428d Concurrent disinfection, 151
on continent ileostomy drainage, 713d in wound management, 620–622, 621d, Condom catheters, 680–682, 681f,
cultural differences, 108 621f, 622f 689d–692d
for dental diseases/injuries, 353 Cold spot, 257 Confidentiality, 46–47
diaphragmatic breathing, 444 Collaborative problems, 22, 22f, 23t Congenital disorders, 53
on falls, prevention of, 408 goals of, 23 Conscious sedation, 599
on fecal incontinence management, 710 Collaborator, nurse as, 95, 95f Constipation, 707–708
on fluid intake/output recording, 311 Colloid solutions nursing care plan, 714
formal teaching, 110 blood, 315 Constitutional law, 34, 35t
for glass thermometer cleaning, 195d blood products, 315, 315t Contact dermatitis, 351t
for hearing aid maintenance, 358 blood substitutes, 315–316 Contact lenses, 355–357, 356f
on ice bag use, 621 plasma expanders, 316 removal of, 356–357, 356f, 357f
importance of, 105, 106d Colostomy irrigation, 713, 725d–728d Contact precautions, 473
on incentive spirometer, 444 Comfort (in terminal care), 847 Continence training, 680, 681d
LWBK1004-ind_905-930.indd 908 02/02/12 11:47 PM

Index 909
Continent ileostomy, 713, 713f of language and communication, 75–84, Deep breathing, 442–443
client teaching on, 713d 76f preoperative teaching of
Continuing education, 11, 11b of mortality, 52, 52t teaching, 593–594, 594f
Continuous feedings, 646 of personal space, 78 Deep palpation, 228, 229f
Continuous infusion, 784, 793d–795d of skin characteristics, 81 Defamation, 39–40
Continuous irrigation, 684, 684f of time perception, 79 Defecation, 705–706, 706t
Continuous passive motion machine, of touch, 78–79 Defendant, 37
524–525, 524f, 535d–536d Cultural assessment, 75–84, 76f, 77f, Defibrillation, 830–832, 831f
Continuous temperature monitoring 80t–81t. See also Language and Dehydration, 311
devices, 196 communication in older adults, 310
Contractures, 502 Cultural characteristics in US, 74d Delegator, nurse as, 96
Contrast media for tests, 256, 256f Cultural groups, 72–73, 73t Deltoid site, 772–773, 772f
Conviction, 37 Culturally sensitive nursing care, 76–77 Dementia, 301
Coping mechanisms, 67, 67t Cultural shock, 73 Denial, in terminal illness, 843
Cordotomy, 427 Culture Denture care, 354, 354f
Core temperature, 188 cultural groups in US, 73, 73t Dentures and prostheses, 596
Coroner, 849 Culturally sensitive nursing, 84–85 Deontologic theory, 44
Cortex, 62 definition of, 72 Depilatory agents, 595
Cortisol, 66, 66t ethnicity and, 73 Depression
Cosmetic surgery, 589t ethnocentrism, 74 sleep disorder in, 381
Cough etiquette, 469, 470, 471f generalization, 74 in terminal illness, 843
Coughing minority, 73 Dermis, 346
forced, 594 race, 73 Diagnostic examinations and tests,
preoperative teaching for, 594, 594f stereotyping, 73 249–272
splinting for, 594f and subcultures, 74–75, 74d, 74t amniocentesis, 264d
Counseling skills (nursing), 15 transcultural nursing, 75–84 (See also anesthesia for, 257
CPAP mask, 452, 452f Language and communication) arranging examination area for,
Crackles, 240 Curandero (Latino practitioner), 84 251–252, 252f
Cradle, 504, 504f Curative surgery, 589t capillary blood glucose testing, 261,
Cranes, 563–564, 564f, 571d–574d Cutaneous applications 262, 263
Crimean War, nursing care in, 3, 3f inunction, 751–752, 752d client positioning for, 252, 253t
Criminal laws, 37 transdermal, 752–753, 753f, 754d, 754f client preparation for, 251
Crutches, 565, 566f Cutaneous applications, 751–753 client teaching for, 251, 251d
arms strengthening exercises for, 561 Cutaneous pain, 420 computed tomography, 256, 256f
assisting with, 574d–577d Cyanocobalamin, 288t contrast media for, 256, 256f
axillary, 565, 566f Cyclic feedings, 646 definition for, 249
forarm, 565, 566f Cyclooxygenase (COX), 424 documentation of, 254
gait for, 566, 567f Cylinder cast, 542 draping for, 252, 253t
human, 404f electrocardiography, 258–259, 259f
measuring for, 571d–574d D electroencephalography, 258–259, 259f
platform, 565, 566f Daily value (DV) of food, 290–291 electromyography, 258–259, 259f
stair climbing with, 576 Dangling, 561, 561f, 562f endoscopy, 257, 257d
Crutch palsy, 574 Data base assessment, 19, 19t, 20f fluoroscopy, 256
Crutch-walking gaits, 566, 567t, Data security, 122 informed consent for, 250, 250d
574d–577d Deaf clients, 103–104, 103f lumbar puncture, 259, 261d, 261f
Crystalloid solutions, 314–315, 314t, 315f Death magnetic resonance imaging, 255–256,
hypertonic solution, 315 approaching, 847–849, 848t 256f
hypotonic solution, 314–315, 315f causes of, 83t nursing care plan for, 264d
isotonic solution, 314, 315f confirmation, 849 nursing responsibilities in
Cultural aspects leading causes of, 52t, 83t postprocedural, 254, 254d
of ADH deficiency, 83 Debridement, 617–620 preprocedural, 250–252, 250d, 252f
of client teaching, 82 autolytic, 617 procedural, 252–254, 253t
of diet, 79, 80t enzymatic, 617 for older adults, 251
of disease prevalence, 83–84, 83t mechanical, 617–620 Pap test, 254–255, 255t, 265d–267d
emotional expression, 79 ear irrigation, 619–620, 620f paracentesis, 259, 260d, 260f
of eye contact, 78 eye irrigation, 619, 619d, 620f pelvic examination, 254–255, 255t
G-6-PD deficiency, 83 vaginal irrigation, 620, 620d radiography, 255–257, 255t, 256f
of hair characteristics, 82 wound irrigation, 619, 630d–631d radionuclide imaging, 257–258
of health beliefs and practices, 84, 84t sharp, 617, 619f sigmoidoscopy, 268d–269d
of illness beliefs, 79, 81 Deciduous teeth (baby teeth), 347 specimens for, 254 (See also Specimen
of lactase deficiency, 82 Decubitus ulcers. See Pressure ulcer collection)
LWBK1004-ind_905-930.indd 909 02/02/12 11:47 PM

910 Index
Diagnostic examinations and tests (con- charting in, 117–121 (See also Charting) denial, 843
tinued) checklists, 125 depression, 843
terminology for, 249, 250t client care assignments, 126, 127f Dysfunctional grief, 851
throat culture, 260, 261, 262d, 262f client rounds, 126, 128, 128f Dysphagia, 299, 300d
ultrasonography, 258 data security, 122 Dyspnea, 203
Diagnostic-related group (DRG), 55 education/research, 116 Dysrhythmia, 200
Diagnostic surgery, 589t flow sheets, 125 Dysuria, 677
Diaphragmatic breathing, 444, 444d information sharing, 115
Diarrhea, 708–709 interpersonal communication, 126–128 E
Diastolic pressure, 204 Kardex, 125, 125f Ear, 233–234
Diet legal evidence, 116, 116d audiometry, 234, 236t
for anorexic clients, 296, 297d liability and, 42 cerumen, 234
calories in, 285 nursing care plans, 124–125, 124f hearing acuity, 234, 234f, 235d
carbohydrates, 286, 286d permanent account, 115 irrigation of, 619–620, 620f
cultural aspects of, 79, 80t privacy standards, 121, 121d Rinne test, 234, 235f
factors affecting, 291 quality assurance, 115–116 Weber test, 23f, 234
fats, 286–287, 287t reimbursement, 116 Echography. See Ultrasonography
hospital, 298–299 team conferences, 126 Edema, 241–242, 243d, 312–313, 313d,
minerals, 287, 287t telephone, 128 313f
for older adults, 296 traditional time vs. military time, 123, Education
protein in, 285–286, 286f 123f, 123t nursing (See under Nursing)
sodium sources in, 313d workplace applications, 121–122 for pain management, 427, 427d
vegan, 291 written forms of communication, and research (documantation), 116
vegetarian, 291, 292d 124–125 Educator, nurse as, 95
vitamins, 288t, 289 Donors, directed, 592, 592t Egg-crate foam mattresses, 503
for weight gain, 296, 296d Doppler stethoscope, 208, 208f Elective surgery, 589t
weight loss, 295, 295d Doppler ultrasound device, 202, 202f Electrical shock, 405–406
Dietary Approaches to Stop Hypertension Dorsal recumbent position, 252 Electric toothbrushes, 352
(DASH), 209 Dorsogluteal site, 771, 771f Electrocardiography, 258–259, 259f
Dietary customs and restrictions, 79, Dosage calculation, 741, 742d Electrochemical neutrality, 308
80t–81t nursing guidelines for, 742d Electrode pads, 830, 831f
Dietary minerals, 287t Double bagging technique, 475–476, 476f Electroencephalography, 258–259, 259f
Diet history, 292 Douching. See Vaginal irrigation Electrolyte distribution mechanisms
Diffusion Drains active transport, 307f, 308
facilitated, 307f, 308 closed, 616, 616f facilitated diffusion, 307f, 308
passive, 307f, 308 open, 615, 615f filtration, 307–308, 307f
Digital thermometers, 196, 196f Drawdown effect, 194 osmosis, 307, 307f
Directed blood donation, 592, 592t Dressings, 614–615, 615f passive diffusion, 307f, 308
Discharge changes of, 615 Electrolytes, 306–307, 307t
arranging transportation in, 176 gauze, 614, 614f, 627d–630d Electromyography, 258–259, 259f
authorization for, 175 hydrocolloid, 615, 615f Electronic infusion devices
business office notification of, 176 transparent, 615, 615f infusion pump, 318, 318f
definition of, 174 Droplet precautions, 473 volumetric controller, 318, 331d–333d
escorting client in, 176 Drowning, 405 Electronic medical records, 121t
instructions, 175–176, 176t Drug(s) Electronic oscillometric manometer, 205,
planning, 174, 175f and sleep, 381–382, 381t 205f, 206t
return of belongings in, 176 Drug diversion, 739 Electronic scales, 230
summary, 176, 184d–186d Drug paste, 753, 754d, 754f Electronic thermometer, 192, 194, 194f
terminal cleaning after, 177 Drug therapy for pain. See under Pain Elimination, in terminal care, 846
Discharge instructions in surgery, 602 management Emaciation, 296, 296d
Disease prevalence, 83–84, 83t Drug tolerance, 381 Emergency splints, 538, 538f
Disinfectants, 145 Dry heat, 151 Emergency surgery, 589t
Disposable chemical thermometer, 196f Dry powder inhaler, 756 Emesis, 297
Distraction, 428 Dumping syndrome, 644, 648t Emotional expression, 79
Disuse syndrome, 494 Duty, 40, 40d Emotional support, 843–844, 844d
risk for, 508d–509d Dying Empathy, 15, 95
Diuretic medications, 311 with dignity, 844 Emulsions, lipid, 325–326, 326f
Documentation stages of, 843t Enamel, 347
abbreviations in, 122, 123t acceptance, 843 Endocrine system
accreditation, 116 anger, 843 feedback loop, 64, 64f
change of shift report, 126, 126f bargaining, 843 neuroendocrine control, 64
LWBK1004-ind_905-930.indd 910 02/02/12 11:47 PM

Index 911
End-of-life care Environmental hazards, 400–405 Ethnicity, 73, 75t. See also Cultural
acute care, 846, 846f asphyxiation astects; Culture; Language and
advance directives, 47, 48d for carbon monoxide poisoning, 404, communication
approaching death, 847–849, 848t 405d Ethnocentrism, 74
arrangements for care, 844–846, 844f, for cardiopulmonary resuscitation Ethylene oxide gas, 152
845f (CPR), 405, 405f Evidence-based practice, 6
autopsy, 849 for drowning, 405 Exacerbation, 53
brain death, 849 smoke inhalation, 404, 405f Exercise. See also Fitness
code status, 48 burns active, 523
comfort, 847 fire extinguishers, 404, 404d, 404t fitness, 522, 522f
confirming death, 849 fire management, 402, 403f isometric, 561, 561d
death certificate, 849 fire plans, 402 nursing implications in, 524t, 525–526
discussing organ donation, 848, 848t prevention of, 402, 403d passive
durable power of attorney for health childhood poisoning, 406, 406d continuous passive motion machine,
care, 47 prevention of, 406, 406f, 407d, 524–525, 524f, 535d–536d
dying with dignity, 844 407f range-of-motion exercises, 523, 523t,
elimination, 846 treatment of, 406, 407f 527d–534d
emotional support, 843–844, 844d electrical shock, 405–406 prescriptions
ethical, 46–48 falls, 406–408, 408t metabolic energy equivalent (MET),
family involvement, 847 prevention of, 408d 522, 522t
family notification, 847–849, 848d, latex sensitization target heart rate, 521–522
850f latex reactions, types of, 401 safe exercise program, 523
grieving, 851 safeguarding clients and personnel, Exit route, for microorganisms, 144
home care, 844, 844f 401, 402t Exploratory surgery, 589t
hopelessness, 852 Environmental theory, 7t Extended care facilities, 178–180, 179f,
hospice care, 844–845, 845f Enzymatic debridement, 617 179t. See also under Transfer
hydration, 846 Enzymatic variations, 82 Extended health care, 54
hygiene, 846–847 Epidermis, 346 External catheters, 680–682, 681f
leading causes of death, 52t, 83t Epiglottis, 811 External fixator, 544, 546f, 558d–559d
life expectancy, 843f Episiotomy, 622 Extracellular fluid, 306
living wills, 47, 47f Ergonomics, 497–498 Extraocular movements, 233, 233f
multiple organ failure, 847, 848t assistive devices, advantages of, Extremities
nourishment, 846 498b assessment of, 241–242, 242d, 242f,
nursing implications, 851 Eructation, 297 243d
older adults, 843, 845 Essential amino acids, 285 edema, 241–242, 243d
paranormal experiences, 851 Ethics. See also Law(s) fingernails, 241, 242f
positioning, 847 bill of rights (patient’s), 45 muscle strength, 241, 242f
postmortem care, 851, 854d–855d codes of ethics, 42 skin sensation, 242, 242d
promoting acceptance, 843–846 ethical decision making, 46 toenails, 241, 242f
residential care, 845, 846f ethical dilemma, 42 Eye(s), 232–233, 232f, 234d
stages of dying, 843, 843f Ethics committees, 46 accommodation, 233, 233f
terminal care, 846–847 issues consensual response, 233, 233f
treatment withholding/withdrawal, advance directives, 47, 48d extraocular movements, 233, 233f
47–48, 48d allocation of scarce resources, 48 irrigation of, 619, 619d, 620f
waiting for permission, 847 code status, 48 Jaeger chart, 233, 233f
Endogenous opioids, 419 confidentiality, 46–47 normal vision, 232
Endorphins, 69 truth telling, 46 snellen eye chart, 232
Endoscopy, 257, 257d whistle-blowing, 48 visual acuity, 232
Enemas, 595, 710–712 withholding/withdrawing treatment, visual field examination, 233, 233f
cleansing, 710, 710t 47–48 Eye contact, 78
hypertonic saline, 711, 711d, 711f principles Eyeglasses, 355
normal saline, 710 autonomy, 45 Eye protection, 470d
reasons for, 710 beneficence, 45
retention, 711–712 fidelity, 46 F
soap and water, 710–711 justice, 46 Face shield, 470d
tap water, 710 nonmaleficence, 45 Face tent, 450t, 451–452
Enteral nutrition, 641 veracity, 46 Facial skin, 236
Enteral tube in oral medication, 743, theories Facilitated diffusion, 307f, 308
743d, 748d–750d deontology, 44 Fahrenheit scale, 188
Enteric-coated tablets, 738 teleology, 44 Falls, 406–408, 408t
Environment, cleaning of, 150–151 values, 46 prevention of, 408d
LWBK1004-ind_905-930.indd 911 02/02/12 11:47 PM

912 Index
False imprisonment, 37, 39, 39f Fluid(s). See also Body fluid Fungi, 141
Family involvement (end-of-life care), 847 aspiration of, 640, 640d, 640f Funnel chest, 238f
Family notification, 847–849, 848d, 850f distribution mechanisms OF Furuncle (boil), 351t
Fasting, 596 active transport, 307f, 308
Fats, 286–287, 287t facilitated diffusion, 307f, 308 G
cardiac risks with, 287t filtration, 307–308, 307f Gait belt, 507f
cholesterol, 286 osmosis, 307, 307f Gamma-aminobutyric acid, 62
health risks related to, 287, 287t passive diffusion, 307f, 308 Gas sterilization, 152
saturated, 286 electrolytes in, 306 Gastric decompression, 640–641, 641f
trans, 287 extracellular, 306, 306t Gastric residual, 646, 646d
unsaturated, 286 interstitial, 306, 306f, 306t Gastrointestinal intubation, 635–643. See
Fat-soluble vitamins, 289 intracellular, 306 also Tube feeding
Fecal impaction, 708, 709d, 709f intravascular, 306, 306t nasogastric
Fecal incontinence, 709, 710d in third-spacing, 313 for decompression, 640–641, 641f
Feedback loop, 64, 64f intravenous (See Intravenous infusion) fluid aspiration in, 640, 640d, 640f
Feeding. See also Diet; Nutrition nonelectrolytes in, 306–307 NEX measurement for, 639, 639f
assistance with Fluid compartments, 306, 306f, 306t troubleshooting for, 641t
dementia, client with, 301 Fluid imbalances tube insertion in, 639–640, 640f
dysphagia client, 299, 300d definition of, 311 tube irrigation in, 656d–657d
visually impaired client, 299, 301 in hypervolemia, 312–313, 313d, 313f tube maintenance in, 640–641
in dying client, 846 in hypovolemia, 312–313, 313d tube removal in, 642
tubes, 637–638 (See also Tube feeding) in insensible losses in, 308 nasointestinal
Felony, 37 in older adults, 312 for decompression, 638
Fentanyl, 425 signs of, 309t for feeding, 637–638
Fetal genetic disorder, 264d in third-spacing, 313, 314f tube insertion in, 642–643, 642d,
Fever, 188, 196–198, 197f, 198t Fluid intake, 308t, 309, 309d, 311f 642f, 643f
nursing care plan for, 199 and losses, daily, 308t tube placement assessment in, 643
nursing management of, 197 of older adults, 311 tube types for, 636–639, 636f, 637t
phases of, 197, 197f Fluid output, 311 orogastric, 636
variations in, 198t Fluid regulation, 308 ostomy, 635
Fidelity, 46 Fluid volume reasons for
Filtered tubing, 317, 317f assessment, 308–311, 309b, 309t, transabdominal tubes, 638, 638f
Filtration, 307–308, 307f 310f management of, 643, 644d, 644f
Fingernails, 347, 347f deficient, 327d Gastrostomy, 644d
Fingernails, 241, 242f Fluoroscopy, 256 leaks, causes of, 643d
Fire Foam mattresses, 503 Gauze dressings, 614, 614f, 627d–630d
extinguishers, 404, 404d, 404t Focus assessment, 19, 19t Gel mattresses, 503
management, 402, 403t Focus charting, 119, 119f Gel packs, 621
plans, 402 Foley catheter, 682, 682f, 685d. See also General adaptation syndrome, 65
potential, 453, 453d Indwelling catheter General anesthesia, 598
rescue and evacuation, 403, 403f Folic acid, 288t Generalization, 74
Fissure, 236 Folk medicine, 84 Generic name, 737
Fitness. See also Exercise Fomites, 143 Genitalia
assessment of, 519–521 Food assessment of, 244, 245d, 245f
ambulatory electrocardiogram in, high in salt (sodium), 313d Genupectoral position, 252
520, 521f intake and body temperature, 190 Germicides, 145
body composition in, 519 pyramid, 289, 289f Gingivitis, 347
recovery index in, 521 Foot boards, 502, 502f Glass thermometers, 195, 195d, 196d
step test in, 521, 521t Foot drop, 498, 503f Gloves, 149, 149d, 150f, 470d
stress electrocardiogram in, 520, 520f Forced confinement, 37 sterile, 153, 165d–167d
submaximal fitness tests in, 520 Forced coughing, 594 Glucometer, 263, 270d–272d
vital signs in, 520 Formal teaching, 110 Glucose 6-phosphate dehydrogenase, 83,
walk-a-mile test in, 521, 521t Fowler’s position, 442, 500 83t
exercise, 522, 522f Fraction of inspired oxygen, 446 Glycerides, 286
exercise prescriptions for, 521–522 Fracture pan, 678, 678f Good Samaritan laws, 41–42
Five rights, 740–741, 741f Free-flowing steam, 151 Gown, 470d
Flatulence, 708, 716d–717d Functional assessment, 19t, 21 Graduate nursing programs, 10
Floors in hospital Functional braces, 541 Gram-positive bacteria, 260
Flossing, 352, 352d, 353d, 353f Functional nursing, 58 Gram staining, 260
Flowmeter, 445–446, 446f Functional pain, 420 Gravity infusion, 318
Flow sheets, 125 Fungal nail infection, 351t Grieving, 851
LWBK1004-ind_905-930.indd 912 02/02/12 11:47 PM

Index 913
Gum inflammation, 347 Health information protection Humidifier, 446–447, 447f

Gurgles, 240 data security, 122 Hydration, 647, 811, 846
privacy standards, 121, 121d Hydraulic mechanical lift, 507f
H workplace applications, 121–122 Hydrocolloid dressings, 615, 615f
Hair, 236, 347 Health literacy, 108 Hydrogenated fats, 287
care (See under Hygiene) Health Maintenance Organizations Hydrostatic pressure, 308
characteristics, 82 (HMO), 55–56 Hydrotherapy, 619
covers, 149–150 Healthy People 2010, 56–57, 57d, 57f Hygiene, 345–373
grooming, 354 Healthy People 2020, 289, 290d bathing, 348–350, 351t
Hammock effect, 504 Hearing acuity, 234, 234f, 235d bed bath, 349–350, 350d,
Hand antisepsis, 146, 147d, 158d–159d Hearing aids, 357–358, 358d, 358t 366d–369d
Hand hygiene, 146, 147d, 156d–158d, Heart rate, target, 521 partial, 349, 363d–366d
470d Heart sounds, 238, 239, 240f therapeutic, 348t
Hand rolls, 502, 502f abnormal, 239 tub bath/shower, 348–349,
Head, 231–236 normal, 238 361d–362d
ears, 233, 234, 235d, 236d Heat application in pain, 428 for catheters, 683, 683d
eyes, 232–233, 232f, 233f, 234d Heat transfer mechanisms, 189t hair care
facial skin, 236 Heimlich maneuver, 826 hair grooming, 354
hair, 236 Helminths, 142 shampooing, 355, 372d–373d
mental status assessment, 231–232 Hemipelvectomy, 566 hearing aids, 357–358, 358d, 358t
mouth/oral mucous membranes, 235 Hemoglobin-based oxygen carriers infrared listening devices (IRLD), 359
nose, 235 (HBOC), 315 integumentary system, 345–347
scalp, 236 Hemorrhoidectomy, 622 disorders in, 351t
Head-tilt/chin-lift technique, 829, Hendrich Fall Risk tool, 408f hair, 347
829f Heparin, 769–770 mucous membranes, 346–347
Head-to-toe approach, 231 Hereditary illness, 53 nails, 347, 347f
Health. See also Health care; Illness, High blood pressure, 208 skin, 346, 346f, 346t
Nursing team High-density lipoprotein (HDL), 286 teeth, 347, 348
continuity of care, 58 Hip spica cast, 542, 542f nail care, 355, 355f
defined, 50 Hispanics, 75 nursing implications of, 359, 359d
illness and, 52–53 Histamine-2 receptor antagonists, 596 oral
limited resource, 51 HIV transmission, 468d care for unconscious clients, 353,
national goals for, 56–57 Holism, 51, 51f, 60–61, 61d 354t, 370d–371d
personal responsibility, 51 Holter monitor, 520 denture care, 354, 354f
as right, 51 Home care, 647, 844, 844f tooth brushing/flossing, 352, 352d,
trends in, 54d Home health care, 181, 181f, 182d 353d, 353f
wellness and Homeostasis practices, 347–355
hierarchy of human needs, 51–52, adaptation and shaving, 350, 352d, 352f
52f autonomic nervous system, 62–64, safety razor, use of, 350d
holism, 51, 51f 63t visual devices
Health beliefs and practices, 84, 84t central nervous system, 62, 62f, 63f artificial eyes, 357
Health care endocrine system, 64, 64f contact lenses, 355–357, 356f, 357f
access to, 54 neurotransmitters, 61–62, 61f eyeglasses, 355
extended, 54 definition, 60 Hyperbaric oxygen, 454, 454f
financing holism, 60–61, 61d Hyperbaric oxygen therapy (HBOT), 454,
managed care organizations (MCO), Homeostatic adaptive pathways, 63f 454f
55–56 Hopelessness, 852 Hypercarbia, 443–444
Medicaid, 55 Hospice care, 844–845, 845f Hyperpigmentation, 81
Medicare, 54–55, 55t Hospital-based diploma programs, 9–10, Hypersomnia, 383–384
prospective payment systems, 55 10f Hypertension, 208, 209t
government-funded, 54–55, 55t Hospital diet, 298–299 Hyperthermia, 197
and nursing, trends in, 12b clear liquid, 299 Hypertonic saline enemas, 711, 711d,
outcomes of structured reimbursement, convalescent/light, 298 711f
56, 56d full liquid, 299 Hypertonic solution, 315
primary, 53 mechanical soft, 298 Hyperventilation, 203
secondary, 53 regular, 298 Hypervolemia, 312–313, 313d, 313f
services, 54 soft, 298 Hypnogogic hallucinations, 384
tertiary, 53 therapeutic, 299 Hypnosis, 429–430
trends in, 54d Hot spot, 257 Hypoalbuminemia, 313
Health care team, members of, 26f Housing options for older adults, 179t Hypopigmentation, 81
Health–illness continuum, 51f Human needs, hierarchy of, 51–52, 52f Hypothalamus, 189, 190f
LWBK1004-ind_905-930.indd 913 02/02/12 11:47 PM

914 Index
Hypothalamus-pituitary-adrenal (HPA) susceptible host, 144d, 145 nursing implications of, 757
axis, 62 transmission methods, 144, 144t for older adults, 757
Hypothermia, 198 Infection control, 468–479 Inhalation therapy, 811
Hypotonic solution, 314–315, 315 airborne precautions in, 471, 472, 473f Inhalers, 756–757, 756d, 756f
Hypoventilation, 203 antimicrobial agents in, 145, 146t Injection. See also Parenteral medication
Hypovolemia, 312–313, 313d antiseptics in, 145 equipment, 766, 766f, 767–768
Hypoxemia, 440 asepsis in, 145–153 for pain, 427
Hypoxia, 440, 847 definition of, 145 routes, 766f
hand, 146–147, 147t sites, 766, 767, 767f, 771–773
I medical, 145 technique, 766, 768, 777d–778d
Iatrogenic constipation, 707 surgical, 151–153 Inpatient admission, 169t
Ice bags/collars, 621, 621d, 621f client environment in, 473–474, 474f Inpatient surgery, 589
Idiopathic illness, 53 client teaching for, 151, 479 Insomnia, 383, 383d
Illiterate, 108 client transport in, 476–477 Inspection, in physical assessment, 228,
Illness contact precautions in, 473 228f
acute, 52–53 disinfection in, 145 Insulin
chronic, 53 droplet precautions in, 473 administration, 768–769, 768f
congenital disorders, 53 environmental measures in, 150–151 mixing, 769, 769d, 770f
exacerbation, 53 housekeeping in, 151 preparation, 769
hereditary, 53 lumbar puncture procedures, 471 syringe, 767, 768f
idiopathic, 53 microorganisms and, 140–142 Integrated delivery systems, 56
morbidity, 52 nursing care plan for, 478 Integumentary system. See under Hygiene
mortality, 52, 52t nursing implications of, 153–154, 477 Intentional torts, 37–40
primary, 53 for older adults, 148, 468–469 assault, 37
remission, 53 personal protective equipment in, 148– battery, 37, 38f
secondary, 53 150, 474–476, 475f, 476f (See also defamation, 39–40
sequelae, 53 Personal protective equipment) false imprisonment, 37, 39, 39f
sleep and, 381 psychological implications of, 477, invasion of privacy, 39
terminal, 53 477d Intermediate care facility, 179
Imagery, 427, 428f respiratory hygiene/cough etiquette, Intermittent feedings, 646
Immediate postoperative prosthesis 469, 470, 471f Intermittent infusion, 796d–797d
(IPOP), 566 safe injection practices, 470–471 Intermittent venous access device,
Immobilizers, 539, 539f specimen handling in, 476 322–323, 322f
Impaired swallowing, 300d standard precautions in, 469–471, 469f, Interpersonal communication. See under
Implanted catheters, 789, 789f 470 Communication
Inactivity sterile technique in, 151–153 Interpreter
dangers of, 495t surgical scrub in, 148 certified, 76
disuse syndrome, 494 transmission-based precautions in, skilled, 76d
Incentive spirometry, 443, 444d, 444f 471–473, 472t, 473f, 478 telephonic, 76, 77f
Incident reports, 42, 43f waste disposal in, 150, 476 Interstitial fluid, 306
Incomplete proteins, 286 Infection control room, 474, 474f, 475f Intestinal decompression tube
Individual supply, 739 Inflatable cuff, 205, 206f removal of, 649
Individual supply of drugs, 739, 741f Inflatable splints, 538–539, 539f tube insertion, 649, 649d
Indwelling catheter, 682, 682f Informal teaching, 110 Intestinal decompression tubes, 638, 638f
removal of, 685, 685d Information sharing Intimate space, 101, 101t
Ineffective airway clearance, 816 in documentation, 115 Intracellular fluid, 306
Ineffective breathing pattern, 455, 758 Infrared listening devices (IRLD), 359 Intradermal injection, 766, 766f,
Infants Infrared temporal artery thermometer, 777d–778d
safety concerns for, 400 194–195, 194f, 195d Intramuscular injection, 770–773
Infection(s) Infrared tympanic thermometers, 194, administration, 770–773, 780d–782d
colonization in, 467–468 194f deltoid site, 772–773, 772f
course of, 468t Infusion pump, 318, 318f dorsogluteal site, 771, 771f
definition of, 467 Infusion rate equipment for, 773
stages of, 468, 468t calculation of, 321d rectus femoris site, 772, 772f
Infection(s) regulation, 319–320 vastus lateralis site, 772, 772f
nosocomial, 145 Inhalant medications, 755–758. See also ventrogluteal site, 771–772, 771f
Infection, chain of, 142–145, 143f Medication(s) Z-track technique, 773, 773d
agents, infectious, 142–143 aerosol, 757 Intraspinal analgesia, 426
exit route, 144 client teaching for, 756 Intravascular fluid, 306
portal of entry, 144 ineffetive breathing pattern, 758 Intravenous fluids, 314–323
reservoir, 143 inhalers for, 756, 756d, 756f colloid solutions, 315–316, 315t
LWBK1004-ind_905-930.indd 914 02/02/12 11:47 PM

Index 915
crystalloid solutions, 314–315, 314t, Invasion of privacy, 39 skin characteristics, 81–82, 81f, 82f
315f Isometric exercises, 522 space and distance, 78
discontinuation of infusion, 322, for ambulation, 561 time, 79
339d–340d gluteal setting, 561, 561d touch, 78–79
electronic infusion devices, 318, 318f quadriceps setting, 561d Laser surgery, 589–590
gravity infusion, 318 Isotonic exercise, 522 Lateral oblique position, 500, 500f
intermittent venous access device, Isotonic solution, 314, 315f Lateral position, 500
322–323, 322f Latex sensitization, 401, 402t
monitoring/maintenance of infusion, J Latinoamericano, 75
319–322, 321t, 322d Jackson-Pratt (closed) drain, 616, 616f Latinos, 77
nursing implications of, 326 Jaeger chart, 233, 233f Law(s)
preparation for administration, 316 Jejunostomy tube, 638 administrative laws, 35–37, 35t
preparation of, 331d–333d Jet lag, 385 nurse licensure compacts (NLC),
solution selection, 316 Joint positions, 523t 36–37, 36f
tubing for, 316–318, 316f, 318f Judicial law, 37 state boards of nursing, 35
air bubbles in, 317, 322d, 322f Justice, 46 civil
components of, 316 intentional torts, 37–40, 38f, 39f
filters in, 317, 317f K unintentional torts, 40, 41f
macrodrip vs. microdrip, 317 Kardex, 125, 125f common law, 37
needle/needleless systems, 317–318, Keratin, 347 constitutional law, 34, 35t
318f Kinesics (body language), 100–101, criminal, 37
primary vs. secondary, 316–317 100d ethical practice, 42–48, 43f, 47f (See
replacement of, 322, 338d–339d Knee–chest position, 252 also Ethics)
selection of, 316, 316f Kock pouch, 713 professional liability, 40–42
vented vs. unvented, 317, 317f Korotkoff sounds, 207–208, 207f anecdotal record, 42
venipuncture, 318–319, 319f, 320f, K-pad, 621 documentation, 42
334d–337d Kyphosis, 237, 238f Good Samaritan laws, 41–42
Intravenous infusion, 783–800. See also incident reports, 42, 43f
Medication(s) L liability insurance, 41
bolus, 784 Labeling, nutritional, 290–291, malpractice lawsuit, 42, 44d
central venous catheter for, 787–790, 290f, 291d risk management, 42
787f, 788f, 789f, 790f Laboratory data, 295 statute of limitations, 42
continuous, 784, 793d–795d Laboratory test, 250 statutory laws, 34–35, 36d
discontinuation of, 322, 339d–340d Laceration, 236 Learning
electronic infusion devices, 318, 318f Lactase deficiency, 82, 82d motivation in, 109
gravity infusion, 318 Language and communication, 75–84, needs, 110
intermittent, 796d–797d 76f promoting, 106d
intermittent venous access device, African Americans, 77 readiness for, 109–110
322–323, 322f alcohol dehydrogenase (ADH) defi- sensory deficits and, 108, 109d
medication lock insertion, 322, ciency, 83 styles, 106–107, 106d
341d–342d Asian Americans, 77–78 Legal advice, 44d
monitoring and maintenance beliefs concerning illness, 79, 81 Legal evidence
caring for site, 321–322 biologic and physiologic variations, 81 for documentation, 116–117, 116d
complications assessment, 321, 321t culturally sensitive nurse–client com- Leg exercise teaching, 594–595, 595f
equipment replacement, 322, 322d munication, 76–77 Liability insurance, 41
infusion rate regulation, 319–320, dietary customs and restrictions, 79, Libel, 40
321d 80t–81t Licensed practical nurses (LPN), 8, 18
nursing care plan for, 791 disease prevalence, 83–84, 83t Licensed vocational nurses (LVN), 8
nursing implications of, 790 emotional expression, 79 Life expectancy, 843f
for older adults, 783–784 enzymatic variations, 82 Light
piggyback, 786–787, 787f equal access, 76, 77f and sleep, 380, 380f
ports for, 784, 785f eye contact, 78 Lighting, 375
saline (medication) lock for, 784–786, glucose 6-phosphate dehydrogenase, Light palpation, 228, 229f
786d, 786f 83, 83t Limited English proficiency (LEP), 76
secondary, 786–787, 787f hair characteristics, 82 Linen, 470d
venipuncture, 318–319, 319f, 320f, health beliefs and practices, 84, 84t bed, 376–377
334d–337d lactase deficiency, 82, 82d Lipid emulsions, 325–326, 326f
volume-control set for, 787, 787f, Latinos, 77 Lipoatrophy, 769
797d–800d Native Americans, 77 Lipohypertrophy, 769
Intravenous injection, 766, 766f with non–English-speaking clients, 78 Lipoproteins, 286
Inunction application, 751–752, 752d nutrition notes, 78–79 Lipping, 153
LWBK1004-ind_905-930.indd 915 02/02/12 11:47 PM

916 Index
Liquid oxygen units, 445, 445f traction, 543–545, 544f, 545f, nasal, 755, 760d–761d
Listening, 99, 100, 100f 557d–558d noncompliance with, 744–745
Lithotomy position, 252 Mechanical lift, 507, 507f for older adults, 742–743
Living will, 47 Medicaid, 55 ophthalmic, 753–754, 754f, 759d–760d
Loneliness, 172 Medical admission responsibilities, 171 oral (See also Oral medications)
Lordosis, 237 Medical asepsis, 145 otic, 754–755
Loss of identity, in hospitalization, Medical gloves, types of, 402t overdose of, 407f
172 Medical records, 114–117. See also Docu- over-the-counter, 742
Low-air-loss bed, 504t, 505, 505f mentation; Health information parenteral (See also Parenteral medica-
Low blood pressure, 209 protection tions)
Low-density lipoprotein, 286 chart forms, 114, 115t pill organizers for, 269f
Lumbar puncture, 259, 261d, 261f client access to records, 117 polypharmacy and, 738
procedures, 471 client records reversal
Lung sounds, 239, 240d, 241, 241f problem-oriented, 117, 117t sleep and, 383
abnormal, 240 source-oriented, 117 stock supply, 739
normal, 239–240 definition of, 114 storage of, 739
electronic, advantages/disadvantages in tablet form, 738
M of, 121t topical, 751–755, 752t (See also Topical
Machismo, 79 making entries in, 129d–130d medications)
Macrodrip tubing, 317 uses trade name of, 737
Macroshock, 405 accreditation, 116 unit dose supply, 739
Magnetic resonance imaging, 255–256, education and research, 116 Medication administration record (MAR),
256f information sharing, 115 739, 740f
Maladaptation of stress response, 67 legal evidence, 116–117, 116d Medication errors, 744
Malnutrition, 285 permanent account, 115 Medication lock insertion, 322,
Malpractice, 40, 41f quality assurance, 115–116 341d–342d
Malpractice litigation, 42, 44d reimbursement, 116 Medication on body temperature, 191
Managed care organizations (MCO), Medicare, 54–55, 55t Medications in surgery, 596–597
55–56 Medication(s) Meditation, 428
capitation, 56 administration of Melatonin, 380
Health Maintenance Organizations client teaching for, 742 Menadione, 289t
(HMO), 55–56 documentation of, 739, 740f, 743, Mental status assessment, 231–232
Preferred Provider Organizations (PPO), 744f Menthol, 428
56 by enteral tube, 743, 743d, Mercury manometers, 205
Manual traction, 544, 544f 748d–750d Mercury Reduction Act (2002), 195
Masks, 148, 148d, 148f, 470d. See also errors in, 744 Metabolic energy equivalent (MET), 522,
Oxygen masks five rights of, 740–741, 741f 522t
Maslow’s hierarchy of human needs, frequency of, 738 Metabolic rate and temperature, 190
51–52, 52f by inhalant route, 755–757 Metered-dose inhaler, 756, 756d, 756f,
Mattress, 376, 377f, 500 by intravenous route, 784–787 757f
Mattress overlays by oral route, 737–738, 738t METHOD discharge planning guide,
alternating air mattress, 503, 504f parenteral route, 763–764 176t
foam mattresses, 503 routes of, 737–738, 737t Microdrip tubing, 317
static air pressure mattress, 503 safety concerns for, 739–740 Microorganisms, 140–142. See also
water mattress, 504 by topical route, 751–755, 752t Asepsis
Meal trays, 299, 302d transdermal, 752–753, 753f bacteria, 141, 141f
Mechanical debridement. See under in capsule form, 738 in chain of infection, 142–145, 143f
Debridement definition of, 737 definition of, 140
Mechanical immobilization dosage of exit route, 144
braces, 541, 541f calculation of, 741, 742d fungi, 141
casts in, 541–543, 541t, 542f, 543d, errors in, 740–741 helminths, 142
544f, 551d–556d dose of infectious agents, 142–143
external fixator, 544, 546f, 558d–559d equianalgesic, 430 mycoplasmas, 142
nursing implications in, 546 generic name, 737 nursing implications in, 153–154
peripheral neurovascular dysfunction, G-6-PD deficiency, 83 portal of entry, 144
risk for, 546d–547d individual supply, 739 prions, 142
purposes of, 537–538 inhalant, 755–757, 756d, 757f (See also protozoans, 141
slings, 540, 541f, 548d–551d Inhalant medications) reservoir, 143
splints intravenous (See also Intravenous infu- resident, 146
commercial, 538–540, 539f, 540f sion) rickettsiae, 141
emergency, 538, 538f inunction, 751–752, 752d survival of, 142, 142d
LWBK1004-ind_905-930.indd 916 02/02/12 11:47 PM

Index 917
susceptible host, 144d, 145 Nasointestinal tube, 637–638, 637t. See nursing roles in, 94–96
transient, 146 also under Gastrointestinal intuba- as caregiver, 95, 95d
transmission methods, 144, 144t tion; Tube(s) as collaborator, 95, 95f
virulence, 141 Nasopharyngeal suctioning, 813, 814f as delegator, 96
viruses, 141 Nasotracheal suctioning, 813 as educator, 95
Microshock, 405 National Council of State Boards of Nurs- therapeutic relationship
Microsleep, 384 ing, 95 barriers to, 97, 97d, 97f
Midarm circumference, 293–294, 294t National Institute for Occupational Safety introductory phase, 96
Military time conversions, 123, 123t and Health (NIOSH), 497 nonverbal communication, 100–103,
Minerals, 287, 287t National licensing examination (nursing), 100d, 101f, 101t, 102f
Minority, 73 9 phases of, 96–97
Misdemeanor, 37 National Patient Safety Goals 2009-2010, with special populations, 103–104
Mobility 400t terminating phase, 97
functional, 498 Native Americans, 77 underlying principles, 96
impaired, nursing care plan for, 569d Natural airway, 811–814 verbal communication, 97–100, 98t,
promotion of, 510 Nausea, 297, 297d 99t, 100f
Modulation, 419 Nebulizer, 757 working phase, 97
Moist packs, 622 Neck, 236 Nurse licensure compacts (NLC), 36–37,
Molded splints, 539, 539f Needle(s), 763, 763t 36f
Mongolian spots, 82, 82f Needle gauge, 323 Nurse-managed care, 58
Montgomery straps, 614, 614f Needleless access ports, 317, 318f Nursing
Morbidity, 52 Negligence, 40 as arts and science, 5–6
Mortality, 52, 52t Neuroendocrine control, 64 Crimean War, 3, 3f
Mortician, 849 Neuropathic pain, 420 definitions of, 6
Motivation, in learning, 109 Neurotransmitters, 61–62, 61f education
Mouth/oral mucous membranes, 235 NEX measurement, 639, 639f associate degree programs, 10
Mouth-to-mouth breathing, 830, 830f Niacin, 288t baccalaureate programs, 10
Mouth-to-stoma breathing, 830 Nightingale reformation, 3–4 continuing, 11, 11b
Mucous membrane, 346–347, 811 Nightingale schools, 4t Graduate nursing programs, 10
Multiple organ failure, 847, 848t Nitroglycerin paste, 754 hospital-based diploma programs,
Multiple sleep latency test, 383 N-methyl-D-aspartate (NMDA) receptor 9–10, 10f
Multisensory stimulation, 110f antagonists, 426 practical, 6–9
Muscle strength, 241, 242f Nociceptors, 418 registered nursing, 9–11, 9t, 10f
Mycoplasmas, 142 Nocturia, 677 vocational, 6–9
MyPlate guidelines, 289, 289f Nocturnal polysomnography, 382–383, functional, 58
382f future trends in, 11–15, 13f–14f
N Noncompliance with drugs, 744–734 governmental responses, 11
Nail care, 355, 355f Nonelectrolytes, 306–307 health care and nursing, trends in, 12b
Nails, 347, 347f Nonessential amino acids, 285 levels of responsibility, 9, 9t
NANDA list, 22 Nonmaleficence, 45 Nightingale reformation, 3–4
Narcolepsy, 384 Nonopioid drugs, 424–425 orders, 24
Narcotics, 425, 596 Nonpathogens, 141 origins, 2–3, 3b
Narrative charting, 117, 118f Nonprescription drugs, 742 practice, 4–5, 5f
Nasal application, 755, 760d–761d Nonrapid eye movement (NREM) sleep, proactive strategies, 11–15, 12b,
Nasal cannula, 447, 448t 378, 378f, 380f 13f–14f
Nasal catheter, 452, 452f Non-rebreather masks, 447, 452 schools, 4, 4t
Nasal strips, 444 Nontherapeutic verbal communication skills
Nasogastric tube. See also under Gastroin- techniques, 99t assessment, 15
testinal intubation Nontunneled percutaneous, 788, 788f caring, 15
insertion Norepinephrine, 62 comforting, 15, 16f
client preparation, 639 Normal saline solutions, 710 counseling, 15
nasal inspection, 639 Normal vision, 232 team, 58
preintubation assessment, 639 Normeperidine, 425 theory, 6, 7t
tube measurement, 639 Nose, 235 in United States, 4–5, 4t
tube placement, 639–640, 640f Nosocomial infections, 145 Nursing care plan, 124–125, 125f
maintenance Nourishment, 846 for aspiration, 650
enteral nutrition, 641 N95 respirator, 472, 473f deficient knowledge, 154
gastric decompression, 640–641, Nurse-client communication, culturally for diagnostic examinations and tests,
641f sensitive, 76–77 264d
removal, 642 Nurse-client relationship. See also Com- for hopelessness, 852
Nasogastric tubes, 636, 636f, 637t munication in hospitalization, 171
LWBK1004-ind_905-930.indd 917 02/02/12 11:47 PM

918 Index
Nursing care plan (continued) MyPlate and, 289, 289f surgery for, 601–602
impaired physical mobility, 569 goals for, 284–285 topical medications, 753
for ineffective breathing pattern, 455 for hospitalized client, 298–299 tube feeding, 645
for ineffective protection, 791 meal trays, 299, 302d urinary elimination, 677
for ineffetive breathing pattern, 758 notes, 78–79 wound healing, 612
for risk for disuse syndrome, 508–509 nutrient requirements in, 285–289 wound management, 622
for risk for inability to sustain spontane- in older adults, 296 Oliguria, 677
ous ventilation, 833 overview of, 285 Omnibus Budget Reconciliation Act
for risk for ineffective self health man- parenteral, 325–326, 325d, 325f, 326d, (OBRA), 39, 409
agement, 775 326f Open drains, 615, 615f
for risk for infection transmission, 478 in surgery, 596 Operating room in surgery, 598
on risk for injury, 411 vegetarian diet and, 286f, 291, 292d Ophthalmic application, 753–754, 754f,
for risk for peripheral neurovascular Nutritional problems 759d–760d
dysfunction, 546d–547d anorexia, 296, 297d Ophthalmoscope, 232, 232f
unilateral neglect, 525 emaciation, 296, 296d Opioid drugs
Nursing data base, 171, 171f, 183d–184d nausea, 297, 297d addiction to, 430
Nursing guidelines obesity, 295, 295d bolus (loading dose) of, 426
body mechanics, using, 497 stomach gas, 297, 298d as controlled substances, 425
client transfer, assisting with, 507 vomitting, 297, 298d intraspinal analgesia, 426
dangling, 562 Nutritional status assessment for pain, 425–426
on petal, 543 objective data, 292–295 patient-controlled analgesia (PCA), 425,
range-of-motion exercises, 524 abdominal circumference, 294, 294f 426f, 433d–435d
sputum specimen collection, 812 anthropometric data, 292–294, 293f, Optional surgery, 589t
on stool testing, 707 294t Oral airway, 814, 814f, 815d
trochanter roll, 502, 502f body mass index (BMI), 293, 294f Oral care in surgery, 596
Nursing Home Reform Act, 39 laboratory data, 295 Oral hygiene. See under Hygiene
Nursing home selection, 180, 180d midarm circumference, 293–294, Oral intake, 312d
Nursing process 294t Oral medications, 736–750
assessment in physical assessment, 295 accounting for narcotics, 739
data base, 19, 19t, 20f subjective data, 292 drug administration
focus, 19, 19t Nutritional strategies frequency of, 738
functional, 19t, 21 MyPlate guidelines, 289, 289f route of, 737–738, 738t
characteristics of, 18 nutritional labeling, 290–291, 290f drug dose, 737, 737t
concept mapping, 26–28, 27f nutrition and weight status objectives drug name, 737
data for healthy people 2020, 290d medication administration, 739–745,
organization of, 21 746d–750d (See also under
sources for, 19 O Medication(s))
types of, 19 Obesity, 295, 295d medication administration record
definition of, 17, 18t Objective data, 19. See under Nutritional (MAR), documentation in, 739,
diagnosis status assessment 740f
collaborative problems, 22, 22f, 23t Occupied bed in hospital, 377, 395d–396d medication orders, 736–739
nursing, 21–22, 21t Older adults polypharmacy, 738
evaluation, 26, 26t airway management, 811 storing of, 739
implementation, 25–26, 26f dehydration in, 310 supply of, 739, 741f
planning, 23–25, 23t, 25f diagnostic examinations and tests for, telephone orders, 738–739, 739d
steps in, 18–26, 18f 251 verbal orders, 738–739
use of, 26, 27d diet, 296 Oral suctioning, 814
Nursing team, 57–58, 58f end-of-life care, 843, 845 Oral thermometer, 192
case mehod, 58 fluid imbalance, 312 Organ donation, 848–849, 848t
functional nursing, 58 fluid intake, 311 Organ procurement form, 850f
nurse-managed care, 58 housing options for, 179t Orogastric tube, 636
primary nursing, 58 infection control, 148, 468–469 Oropharyngeal suctioning, 813
team nursing, 58 inhalant medications, 757 Orthopneic position, 442
Nutrition, 284–304. See also Diet; Feed- intravenous infusion, 783–784 Oscillating support bed, 504t, 505, 505f
ing; Parenteral nutrition medications, 742–743 Osmosis, 307, 307f
calories in, 285 nutrition, 296 Osteoporosis, 407
definition of, 285 oxygenation, 445 Ostomy, 635
in dying client, 846 pain management, 428 appliance, 713, 713f
eating habits and, 291, 291f parenteral medication, 773 changing of, 722d–725d
enteral (See Tube Feeding) resuscitation, 827 definition of, 712
feeding assistance and, 299, 303d–304d sleep, 378, 379 locations of, 712f
LWBK1004-ind_905-930.indd 918 02/02/12 11:47 PM

Index 919
Ostomy care Oxygen tent, 452 cold application in pain, 428

appliance change in, 722d–725d Oxygen therapeutics, 315 cordotomy in, 427
for colostomy, 713–714, 725d–728d Oxygen therapy definition of, 423
drainage in, 713, 713d ambulatory, 445 distraction in, 428
for ileostomy, 713, 713d CPAP mask in, 452, 452f drug therapy in
irrigation in, 713–714, 725d–728d definition of, 444 adjuvant drugs in, 426
peristomal care, 712–713 equipment for, 445–447 botulinum toxin in, 426–427
for urostomy, 685 face tent in, 450t, 451–452 nonopioids in, 424–425
Otic applications, 754–755 fire potential, 453, 453d opioids in, 425–426 (See also Opioid
Otoscope, 233 hyperbaric oxygen, 454, 454f drugs)
Outpatient admission, 169t liquid oxygen units for, 445, 445f WHO guidelines for, 423–424, 424f
Outpatient surgery, 589–590, 590t nasal cannula in, 447, 448t education for, 427, 427d
advantages and disadvantages of, 590t nasal catheter in, 452, 452f heat application in, 428
Overbed table, 377 oxygen concentrator in, 445, 446f hypnosis in, 429–430
Over-the-counter medications, 742 oxygen hazards, 453–454, 453d, 454f imagery in, 427, 428f
Oxycyte, 316 oxygen masks in, 447, 448t, 451 for injections, 427
Oxygen analyzer, 446, 446f oxygen sources in, 444–445, 445f meditation in, 428
Oxygenation, 438–466. See also Breath- oxygen tent in, 452 nursng care plan for, 431
ing procedures in, 454–455 for older adults, 428
assessment of safety concerns in, 453d patient-controlled analgesia (PCA) in,
arterial blood gases (ABG) in, 440, T-piece in, 452 429, 429f, 433d–435d
440t, 441d tracheostomy collar in, 452 percutaneous electrical nerve stimula-
physical examination in, 440, 440d transtracheal oxygen in, 452–453, 453f tion (PENS), 429, 429f
pulse oximetry in, 440, 442, wall outlet in, 444 placebo effect in, 430, 432
457d–459d Oxygen toxicity, 453, 453d relaxation in, 428, 428d
factors affecting, 443t rhizotomy, 427
inadequate P surgery approaches for, 427
breathing techniques for, 442–444, Pain, 417–423 transcutaneous electrical nerve stimula-
444d acute, 420, 421t tion (TENS), 428–429, 435d–437d
causes of, 443d nursing care plan for, 431d Palliative surgery, 589t
hyperbaric oxygen therapy (HBOT), assessment of, 422–423, 422t, 423f Palpation
454, 454f chronic, 420–421, 420d, 421t deep, 228, 229f
hypercarbia in, 443–444 cutaneous, 420 light, 228, 229f
hypoxemia, 440 definition of, 417 Palpitation, 200
hypoxia in, 440 malingering and, 432 Pantothenic acid, 288t
nursing care plan for, 455 modulation of, 419 Papanicolaou test. See Pap test
oxygen therapy for, 444–453 (See neuropathic, 420 Pap test, 254–255, 255t, 265d–267d
also Oxygen therapy) nursing implications of, 430 Paracentesis, 259, 260d, 260f
positioning for, 442, 443f perception of, 419 Paradoxical sleep, 378
signs of, 440d phantom limb, 420 Paralanguage (vocal sounds), 101
water-seal chest tube drainage for, phases of, 418–419, 418f Parallel bars, 562, 563f
453–454, 461d–466d receptors for, 419 Parasomnias, 385
nursing implications of, 454–455 referred, 420 Parasympathetic nervous system, 63–64,
in older adults, 445 somatic, 420 63t
oxygen administration, 459d–461d suffering and, 417 Parenteral medication, 762–782. See also
promotion of, 442–444 theories of, 419, 419f Medication(s)
Oxygen concentrator, 445, 446f tolerance to, 419 in ampules, 764, 764d, 765f
Oxygen flowmeter, 445–446, 446f transduction of, 418, 418f combined in one syringe, 765–766
Oxygen hazards, 453–454, 453d, 454f transmission of, 418–419 definition of, 762
Oxygen humidifier, 446–447, 447f types of, 419–421, 421t injection of, 766–774
Oxygen masks visceral, 420, 420f intradermal, 766, 766f, 777d–778d
non-rebreather, 447, 452 Pain intensity scales, 422–423, 423f intramuscular, 770–773, 780d–782d
partial rebreather, 447, 449f Pain management, 423–432 intravenous, 766, 766f
simple, 447, 448t acupressure in, 429 reducing comfort of, 774, 774d
venturi mask, 451 acupuncture in, 429 subcutaneous, 767–770, 767f, 769d,
Oxygen sources, 444–445, 445f addiction concerns in, 430 770f, 779–780d
liquid oxygen unit, 445, 445f alternative therapies in, 426 Z-track, 773, 773d, 774f
oxygen concentrator, 445, 446f biases in, 423 modified safety injection devices for,
portable tanks, 444–445, 445f biofeedback in, 429 763, 763f, 764f
wall outlet, 444 client teaching in, 427 needles for, 763, 763t
Oxygen tanks, portable, 444–445, 445f cold application in, 428 nursing care plan for, 775d
LWBK1004-ind_905-930.indd 919 02/02/12 11:47 PM

920 Index
Parenteral medication (continued) face-protection devices, 476 Placebo effect, 430, 432
nursing implications, 774 gloves, 476 Plaintiff, 37
for older adults, 773 removal of, 475, 476f, 477d, 480d–482 Plaque, 347
in prefilled cartridges, 765, 766f Personal space, 101, 101t Plasma expanders, 316
preparation of, 764–766, 764f, 765d Phantom limb, 420 Plume, 590
reconstitution of, 764–765 Phil-e-slide patient handling system, 498f Plunger, 763
syringes for, 763, 763f, 763t Photoperiod, 385 Pneumatic compression device, 600, 602f
in vials, 764–765, 765d, 765f Phototherapy, 385 Pneumatic splints. See Inflatable splints
Parenteral nutrition, 325–326 components of, 385d Pneumonia in surgery, 593t, 594
lipid emulsions, 325–326, 326f Physical activity. See also Exercise Podiatrist, 355
peripheral, 325 guidelines for Americans, 524t Polypharmacy, 738
total, 325, 325d, 325f, 326d levels of, 522t Polysaccharides, 316
Partial bath, 349, 363d–366d Physical assessment, 227, 248d Polyuria, 677
Partial rebreather masks, 447, 449f of abdomen, 242–245, 243f, 244d, 244f Portable computers, 119
Passive diffusion, 307f, 308 of anus, 245, 245f Portal of entry, 144
Passive exercises. See under Exercise auscultation, 229, 229f Position
Pathologic grief, 851 body systems approach, 231 anatomic, 495t
Patient-care equipment, 470d breasts, 237–238, 239d, 239f, 239t dorsal recumbent, 252, 253t
Patient-controlled analgesia (PCA), 429, chest, 236, 238f Fowler’s, 500, 501f
429f, 433d–435d data collection, 231–242 functional, 495t
Pediculosis (lice infestation), 351t draping in, 230–231, 231f joint, 523t
Pelvic belt, 545f environment, 229 knee-chest, 252, 253t
Pelvic examination, 254–255, 255t equipment, 229, 229d lateral, 500, 500f
Peracetic acid, 152 extremities, 241–242, 242d, 242f, 243d lateral oblique, 500, 500f
Percussion, 813, 813f general data for, 229–230, 230d, 230f lithotomy, 252
in physical assessment, 228, 228f, 228t of genitalia, 244, 245d, 245f modified standing, 252
Percutaneous electrical nerve stimulation head, 231–236, 232f, 233f, 234d, 234f, neutral, 495t
(PENS), 429, 429f 235d, 235f, 236t orthopneic, 442, 443f
Percutaneous endoscopic gastrostomy head-to-toe approach, 231 prone, 500, 500f
(PEG) tube, 638, 638f heart sounds, 238, 239, 240f recovery, 832, 832f
Percutaneous endoscopic jejunostomy of height, 229–230, 230d, 230f side-lying, 500, 508f
(PEJ) tube, 638f, 639 inspection, 228, 228f Sim’s, 500
Perfluorocarbons (PFC), 315 lung sounds, 239, 240d, 241, 241f supine, 498–500, 499f, 500f
Perineal care, 349 neck, 236 Trendelenburg, 500, 500f
Periodontal disease, 347 nursing implications in, 245, 246d Positioning, 498–502, 498f, 499f, 500f,
Peripherally inserted central catheter palpation, 228, 229f 501f, 502f, 847
(PICC), 788 mass characteristics on, 244d in cardiopulmonary resuscitation
Peripheral neurovascular dysfunction, risk percussion, 228, 228f, 228t devices for
for, 546d–547d positioning in, 230–231, 231f adjustable bed, 500, 500f, 501f
Peripheral parenteral nutrition, 325 purposes of, 227 bed board, 501, 501f
Peripheral pulse sites, 201f readiness for enhanced self-health man- mattress, 500
Peristalsis, 705 agement, 246d pillows, 501
Peristomal care, 712–713 of rectum, 245 roller sheet, 501, 501f
Peristomal skin, 685 spine, 237, 238f for examinations and tests, 250–252,
Permanent account of taste, 235–236 253t
for documentation, 115 techniques, 228–229 for oxygenation, 442, 443f
Permanent prostheses, 566, 568 of vision, 232–233 for physical assessment, 230–231
Permanent teeth, 347 of weight, 229–230, 230d, 230f turning and moving methods for,
Personal protective equipment Physical mobility, impaired, 569 501–503, 502f, 503f, 511d–515d
gloves, 149, 149d, 150f Physical preparation for surgery, 595–597 foot boards, boots, and splints, 502,
hair covers, 149–150 Physical restraints, 408, 413d–416d 502f
masks, 148, 148d, 148f Physical sterilization, 151 hand rolls, 502, 502f
protective eyewear, 150, 150f Physiologic stress response. See under trapeze, 503, 503f
respirators, 149, 149f Stress trochanter rolls, 502, 502f
scrub suits and gowns, 148 PIE charting, 119, 119f in wheelchair, 410t
shoe covers, 149–150 Pigeon chest, 238f Positron emission tomography, 257–258
uniforms, 148 Piggyback infusion, 786–787, 787f Possible diagnosis, 21t, 22
Personal protective equipment (PPE), Pillows, 376, 501 Postanesthesia care unit (PACU), 599,
474–476, 475f Piloerection, 189 599f
cover gowns, 475–476 Pin site care, 546 Postanesthesia reacting (PAR) room, 599
disposal of, 475–476, 476f Pitting edema, 242, 243d Postmortem care, 851, 854d–855d
LWBK1004-ind_905-930.indd 920 02/02/12 11:47 PM

Index 921
Postoperative period in surgery. See under Protein in diet, 285–286, 286f Rectal application, 755
Surgery Protozoans, 141 Rectal suppository insertion, 710,
Postprocedural care, 254, 254d Proxemics, 101, 101t 718d–719d
Postural drainage, 812, 812d, 813f Pseudoconstipation, 707–708 Rectal temperature, 192
Postural hypotension, 209, 225d–226d Psoriasis, 351t Rectal tube insertion, 716d–717d
Posture, 495–496, 495f, 496f Psychological stress responses. See under Rectus femoris site, 772, 772f
lying, 496, 496f Stress Referral, 180–182, 180t
sitting, 496, 496f Psychomotor domain, in learning, 106 commuity services, 180t
standing, 495, 495f Psychosocial preparation for surgery, 597 home health care, 181, 181f
Powered air purifying respirator (PAPR), Public space, 101, 101t home health nurses, 182d
472 Pulse Referred pain, 420
Practical nursing, 6–9 apical heart rate, 201, 201f Regional anesthesia, 599
Preferred Provider Organizations (PPO), 56 apical–radial rate, 202, 202f Registered nurses (RN), 18
Prefilled cartridges, 765, 766f assessment of Registered nursing, 9–11, 9t, 10f
Preload, 203 procedure for, 218d–219d Regurgitation, 297
Preoperative checklist, 597, 597f sites for, 201–202, 201f Rehabilitative braces, 541, 541f
Preoperative period in surgery. See under deficit, 202 Reimbursement
Surgery definition of, 200 documentation for, 116
Preprocedural care, 250–252, 250d, 252f peripheral pulse sites, 201f Relaxation technique, 428, 428d
Preprocedural responsibilities of nurse, radial, 201, 201f, 202f Remission, 53
250–252, 250d, 252f rate Rescue breathing, 829–830
Pressure-relieving devices, 504t factors on pulse/heart rate, 200, 200t mouth-to-mouth breathing, 830, 830f
Pressure ulcers, 622–624 rapid, 200 mouth-to-stoma breathing, 830
locations, 623f slow, 200 Reservoir, of infection, 143
management of, 614 rhythm, 200 Residential care, 845, 846f
prevention of, 624, 624d, 624f training effect on, 200 Residual urine, 677
risk factors for, 624d volume, 200–201, 201t Respiration. See also Breathing; Oxygena-
shearing forces and, 624 Pulse oximetry, 440, 442, 457d–459d tion; Ventilation
sites of, 622, 623f Pulse pressure, 204 Cheyne–Stokes, 203
stages of, 622, 623f, 624f Pursed-lip breathing, 443–444 definition of, 202
Primary care by nurses, 12 Purulent drainage, 623 external, 438–439, 439f
Primary constipation, 707 Pyrexia, 196 internal, 438, 439f
Primary health care, 53 Pyridoxine, 288t ventilation, 438
Primary illness, 53 ventilation and, 202
Primary nursing, 58 Q Respirators, 149, 149f
Primary prevention of stressors, 68 Quad cane, 564f Respiratory hygiene, 469, 470, 471f
Primary tubing, 316–317 Quality assurance Respiratory rate, 202–203
Prions, 142 in documentation, 115–116 normal, 202t
Privacy, decreased, 172 Questionnaires, 382 rapid, 203
Privacy curtain, 377 slow, 203
Privacy standards R Respite care, 844
for documentation, 121 Race, 73 Restraints, 39
Problem-oriented records, 117, 117t Radial pulse, 201, 201f, 202f accreditation standards
Professional liability. See under Law(s) assessment of, 218d–219d medical orders, 409–410
Progressive relaxation, 387, 387d Radiation, 151 monitoring and documentation, 410
Projectile vomiting, 297 Radiography, 255–257, 255t, 256f restraint protocol, 409
Prone position, 500 Radionuclide imaging, 257–258 alternatives, 410, 410f, 410t
Prophylactic braces, 542 Rales, 240 chemical, 409
Prospective payment systems, 55 Range-of-motion exercises, 523, 523t, legislation, 409, 409d
Prostaglandin, 419 524d, 527d–534d physical, 408
Prosthetic limbs for, 566–568, 566f, 568f, Rapid eye movement (REM) sleep, 378, use of, 410, 413d–416d
578d–579d 378f, 380f Resuscitation, 825–833
Protective devices Rapid pulse rate, 200 algorithm for, 831f
for clients Rapid respiratory rates, 203 cardiopulmonary, 828–830, 828f, 829t
cradle, 504, 504f Rebound effect, 755 chest compression in, 826, 828, 829t
mattress overlays, 503–504, 504f Receiving room in surgery, 598, 598f contacting emergency services in, 828
side rails, 503, 504f Records. See Charting; Documentation; defibrillation, 830–832, 831f
specialty beds, 504–506, 504t, 505f, Medical records discontinuation of, 832
506f Recovery index, 521 early, 828
for health care workers (See Personal Recovery position, 832, 832f early advanced life support in, 828, 831f
protective equipment) Recovery room, 599 fluid (See Intravenous infusion)
LWBK1004-ind_905-930.indd 921 02/02/12 11:47 PM

922 Index
Resuscitation (continued) Safety razor, use of, 350d preparation, predsurgical, 595, 607d
head-tilt/chin-lift technique, 829, 829f Saline (medication) lock, 784–786, 786d, sensation, 242, 242d
jaw-thrust maneuver, 829, 829f 786f tear, 622
nursing care plan for, 833 Same-day surgery, 589 traction, 544, 545f
nursing implications of, 832 Saturated fat, 286 Sleep
of older adults, 827 Scabies, 351t activity and, 380
rapid assessment in, 827f Scalp, 236 alcohol and, 381
recovery in, 832 Scar, 236 caffeine and, 381
recovery position, 832, 832f Scarce resources, allocation of, 48 circadian rhythms and, 380
removable headboard for, 376, 376f School-aged children cycles, 378, 379t
rescue breathing in, 829–830 safety concerns for, 400 in depression, 381
Resuscitation team, 828 Schools, nursing, 4, 4t deprivation, chronic, 378d
Retching, 297 Scoliosis, 237 emotions and, 381
Retention (Foley), 682, 682f Scoop method, 763, 764f environmental factors in, 380–381
Retention enemas, 711–712 Scored tablet, 738 factors affecting, 379–382, 379t
Reticular activating system (RAS), 62, 63f Scrub suits and gowns, 148 food and drink and, 381
Retinol, 288t Seasonal affective disorder, 385 functions and, 377–378, 378d
Reusable items removal, 476 Sebaceous glands, 347 in illness, 381
Reversal drugs, 599 Secondary constipation, 707 light and, 380, 380f
Rhizotomy, 427 Secondary health care, 53 medications and, 381–382, 381t
Rhonchi, 240 Secondary illness, 53 mood and, 381
Riboflavin, 288t Secondary infusion, 786–787, 787f motivation and, 381
Rickettsiae, 141 Secondary prevention of stressors, 68 non-REM, 378, 378f
Rinne test, 234, 235f Secondary tubing, 316–317 nursing implications in, 385
Risk diagnosis, 21t, 22 Secretions back massage, 387, 397d–398d
Risk management, 42 liquefaction of, 811–812, 812d, 812f progressive relaxation, 387, 387d
Roentgenography. See Radiography mobilization of, 812–813, 813f in older adults, 378, 379
Roller bandage application, 617, 618f suctioning, 813–814, 813t, 818d–820d paradoxical, 378
Roller sheet, 501, 501f Sedatives, 381, 596 paralysis, 384
Room furnishings in hospital. See under Self-care deficit, 359 phases of, 378, 378f, 379t
Client environment Self-care theory, 7t promotion of, 383d
Rounds, 126, 128, 128f Self-donated blood, 591 REM, 378, 378f
Route of administration, 737–738, 738t Sensory deficits, 108, 109d requirements for, 378, 379t, 380f
Rubs, 241 Sensory manipulation, 69 rituals, 381
Russell’s traction, 545f Sensory stimulation, 477 slow wave, 378
Sepsis, 623 walking, 385
S Sequelae, 53 Sleep apnea/hypopnea syndrome,
Safe exercise program, 523 Serotonin, 62 383–384
Safe injection practices, 470–471 Serous drainage, 623 Sleep assessment
Safety, 399–416 Serum electrolytes, 307t multiple sleep latency test, 383
adolescents, 400 Shaman, 84 nocturnal polysomnography, 382–383,
for adults, 400, 401t Shampooing, 355, 372d–373d 382f
for burns, 402–404, 403d, 403f, 404t Sharp debridement, 617, 619f questionnaires, 382
for carbon monoxide poisoning, 404, Shaving, 350, 350d, 352d, 352f sleep diary, 382
405d Shell temperature, 188 Sleep disorders. See also Sleep-wake
for cardiopulmonary resuscitation Shift workers cycle disturbances
(CPR), 405, 405f sleep disorder in, 384 in depression, 381
for drowning, 405 Shock, 831 hypersomnia, 383–384
for electrical shock, 405–406 Shoe covers, 149–150 insomnia, 383, 383d
for falls, 406–407, 408d Shoulder spica, 542 jet lag, 385
for fires, 402–404, 404d, 404t Sigmoidoscopy, 268d–269d narcolepsy, 384
for infants, 400 Silence, in communication, 100 nursing care plan for, 386
National Patient Safety Goals 2009– Simple masks, 447, 448t parasomnias, 385
2010, 400t Sims’ position, 252, 500 seasonal affective disorder, 385
nursing implications for, 411, 411d Sitz bath, 622, 632d–634d in shift workers, 384
for poisoning, 406, 406d Skeletal traction, 544, 545f sleep apnea/hypopnea syndrome,
restraints, 408–410, 409d, 410t Skin, 346, 346f, 346t 383–384
school-aged children, 400 cancer, 351t Sleep-wake cycle disturbances, 384–385
for smoke inhalation, 404, 405f characteristics, 81–82, 81f, 82f jet travel, 385
for toddlers, 400 glands, types of, 346t phototherapy, 385, 385d
Safety injection devices, 763, 763f, 764f patches, 753, 753f seasonal affective disorder, 385
LWBK1004-ind_905-930.indd 922 02/02/12 11:47 PM

Index 923
shift work, 384 State boards of nursing, 35 Surgery

sundown syndrome, 384, 384d Static air pressure mattress, 503 ambulatory, 589
Slider sheet, 501 Statute of limitations, 42 anesthesia for, 590t, 598–599
Slings, 540, 541f, 548d–551d Statutory laws, 34–35, 36d complications of, 593, 593t
Slow pulse rate, 200 Steam under pressure, 151, 152f cosmetic, 589t
Slow respiratory rates, 203 Step test, 521, 521t curative, 589t
Slow wave sleep, 378 Stereotyping, 73 diagnostic, 589t
Smelling acuity, 235 Sterile field, 152, 162d–165d elective, 589t
Smoke inhalation, 404, 405f Sterile gloves, 153, 165d–167d emergency, 589t
Snellen eye chart, 232 Sterile gown, 153, 153d error prevention for, 598d
Soaks, 622 Sterile items, 152, 162d–165d exploratory, 589t
SOAP charting, 117, 118t, 119 Sterilization. See under Surgical asepsis informed consent for, 590–591, 591f
Soap solution enema, 710–711 Stertorous breathing, 203 inpatient, 589
Social readjustment rating scale, 68, 68t Stethoscope, 206–207, 206f intraoperative period in, 598–599, 598f
Social space, 101, 101t Stimulants, 381 laser, 589–590
Sodium–potassium pump system, 308 Stock supply, 739 nursing implications of, 603, 603d
Sodium sources in diet, 313d Stomach gas, 297, 298d in older adults, 601–602
Soiled articles, 150 Stool operating room in, 598
utility rooms, 150 characteristics, 706, 706t optional, 589t
waste receptacles, 150f testing for occult blood, 707d outpatient, 589–590, 590t
Somatic pain, 420 Straight catheters, 682, 682f palliative, 589t
Sordes, 353 Strength, 561 postanesthesia care unit (PACU) in, 599,
Source-oriented records, 117 Stress, 64–70, 68–70, 70t 599f
Space and distance, 78 management techniques postoperative period in, 599–603
Spacer, 757, 757f adaptive activities, 69–70 complications in, 600, 601t
Specialty beds, 504–506 endorphins, 69 continuing care in, 600–602, 601t
air-fluidized bed, 504t, 505, 505f interventions for, 70t discharge instructions in, 602
circular bed, 504t, 505–506, 506f sensory manipulation, 69 food and fluids in, 600
low–air-loss bed, 504t, 505, 505f physiologic stress response, 65–68, immediate care in, 599–600
oscillating support bed, 504t, 505, 505f 65f initial assessment in, 599–600
pressure-relieving devices, 505t alarm stage, 66, 66t nursing implications in, 603
Specimen collection stage of exhaustion, 66 nursing implications of, 603
24-hour specimen, 676 stage of resistance, 66 pneumonia in, 594
for Pap test, 254–255, 255t, 265d–267d psychological stress responses room preparation in, 600
sputum, 812d coping mechanisms, 67, 67t thrombosis in
stool, 707 coping strategies, 67 venous circulation in, 600, 602f
for throat culture, 260, 261, 262d, 262f signs and symptoms, 65b wound management in, 601
urine, 682 stressors preoperative period in, 589–598
Sphygmomanometer, 205, 205f, 206t assessment of, 68, 68b atelectasis in, 593t, 594
aneroid manometer, 205, 205f, 206t client-related, 68d blood donation in, 591–592, 592t
electronic oscillometric manometer, prevention of, 68 care of valuables in, 596
205, 205f, 206t stress-reduction techniques, 69 checklist for, 597, 597f
Spica cast, 542, 542f stress-related disorders, 67–68, 67b client teaching in, 593–595, 594f, 595f
Spinal tap. See Lumbar puncture Stress electrocardiogram, 520, 520f clothing and hygiene in, 596
Spine, 237, 238f Stressors. See also under Stress coughing, 594, 594f
Splinting methods, 594, 594f common, 61b deep breathing teaching for,
Splints, 502, 502f Stridor, 203 593–594, 594f
commercial Stylet, 637 dentures and prostheses, 596
cervical collar, 539–540, 540f Subcortex, 62 fluid intake in, 596
immobilizers, 539, 539f Subcultures, 74–75, 74d, 74t leg exercise teaching in, 594–595, 595f
inflatable splints, 538–539, 539f Subcutaneous injection, 767–770, 767f, medications in, 596–597
molded splints, 539, 539f 769d, 770f, 779–780d nursing assessment in, 592–593, 593t
traction splints, 539, 539f Subcutaneous layer, 346 nutrition in, 596
emergency, 538, 538f Subdiaphragmatic thrusts, 826, 827f oral care in, 596
foot, 502, 502f Subjective data, 19, 292 physical preparation for, 595–597
Sputum, 811, 812d Sublingual application, 755 pneumonia in, 593t, 594
Stage of exhaustion, 66 Submaximal fitness tests, 520 psychosocial preparation for, 597
Stage of resistance, 66 Suction pressure, 813t reasons for, 589t
Standard precautions, 469–471, 469f, 470 Sundown syndrome, 384, 384d receiving room in, 598, 598f
Standing position, 252 Supine position, 498–500, 499f, 500f recovery room in, 599
Starling’s law of heart, 203 Surfactant, 349 required, 589t
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924 Index
Surgery (continued) within ear, 191–192, 191f Thermogenesis, 190

risk assessment for, 593, 593t elevated, 188, 196–198, 197f, 198t Thermometers, 192–196, 193t, 212d–217d
skin preparation in, 595, 607d emotions and, 191 automated monitoring devices, 196, 197f
thrombosis after, prevention of, 595, exercise and activity and, 190 chemical, 195, 195f, 196f
601, 601t factors affecting, 190–191 clinical, 192
urgency, 589t Fahrenheit, 188 continuous temperature monitoring
urgent, 589t food intake and, 190 devices, 196
waiting area for, 599 gender and, 190 digital, 196, 196f
Surgical asepsis heat transfer mechanisms, 189t electronic, 192, 194, 194f
principles of, 152–153, 153d illness/injury, 191 glass, 195, 195d, 196d
sterile field, 152, 162d–165d low, 198 infrared temporal artery, 194–195, 194f,
sterile gloves, 153, 165d–167d measurement of 195d
sterile items, 152, 162d–165d automated monitoring devices, 196, infrared tympanic, 194, 194f
sterilization 197f Thermoregulation, 375
boiling water, 151 procedure for, 212d–217d Thermostat, 621
chemical, 152 sites for, 191–192 Thiamine, 288t
dry heat, 151 thermometers for, 192–196, Thigh blood pressure measurement, 208,
ethylene oxide gas, 152 212d–217d 223d–224d
free-flowing steam, 151 medication effects on, 191 Third-spacing
peracetic acid, 152 metabolic rate and, 190 fluid imbalances in, 313, 314f
physical, 151 normal, 188 Thomas splint, 548
radiation, 151 oral, 192 Three-way catheters, 684, 684f
steam under pressure, 151, 152f rectal, 192 Throat culture, 260, 261, 262d, 262f
Surgical attire, 596 regulation of, 189, 190f Thrombocytes, 307
Surgical consent form, 591f set point for, 189 Thromboembolic disorder (TED), 595,
Surgical hand antisepsis, 147, 147t, shell, 188 605d–606d
159d–162d subnormal, 198, 198d Thrombus, 594
Surgical waiting area, 599 tympanic, 191, 191f Tilt table, 561–562, 562f
Syme’s amputation, 566 Temporal artery thermometry, 192, 192f Time, 79
Sympathetic nervous system, 63, 63t Temporary prosthetic limb, 566 Tissue integrity, 625
Sympathy, 15 Terminal care, 846–847 Toddlers
Syndrome diagnosis, 21t, 22 Terminal cleaning, 177 safety concerns for, 400
Syringes, 763, 763f, 763t Terminal disinfection, 151 Toenails, 241, 242f
Systolic pressure, 204 Terminal illness, 53 Tone, 561
Tertiary health are, 53 Tonsil-tip catheter, 814
T Tertiary prevention of stressors, 68 Tooth brushing, 352, 352d, 353d, 353f
Tachycardia, 200 Testicular self-examination, 244, 245d, 245f for unconscious clients, 353, 370d–371d
Tachypnea, 203 Tests. See Diagnostic examinations and Topical medications, 751–755, 752t. See
Tap water enemas, 710 tests also Medication(s)
Target heart rate, 521–522 T-handle cane, 564 buccal, 755
Tartar (hardened plaque), 347 Therapeutic bath, 348t, 622, 632d–634d client teaching, 755d
Task-oriented touch, 101, 101f Therapeutic exercise, 519–536. See also cutaneous, 751–753
T-binder, 617, 619f Exercise; Fitness drug paste, 753, 754d, 754f
Team conferences, 126 Therapeutic nurse–client relationship. See inunction, 751–752, 752d
Team nursing, 58 under Nurse-client relationship nasal, 755, 760d–761d
Teeth, 347, 348 Therapeutic verbal communication, nursing implications of, 757
Telehealth services, 36 98–99, 98t for older adults, 753
Telehome care, 110 Thermal therapy ophthalmic, 753–754, 754f, 759d–760d
Teleologic theory, 44 aquathermia pad in, 621–622, 622f otic, 754–755
Telephone, 128 baths in, 622, 632d–634d rectal, 755
Telephone orders (of medication), chemical packs in, 621 skin patches for, 753, 753f
738–739, 739d client teaching for, 621 sublingual, 755
Temperature, 188–199 common uses for, 621d transdermal, 752–753, 753f
age, 190 compresses in, 621 types of, 752t
axillary, 192 ice bags/collars in, 621, 621d, 621f vaginal, 755, 755d
centigrade, 188 moist packs in, 622 Total parenteral nutrition (TPN), 325,
circadian rhythms and, 190 for pain, 402 325d, 325f, 326d
in client room, 375 soaks in, 622 Touch, 78–79, 101, 101f
climate and, 190 temperature ranges for, 621t Towel bath, 349
conversion formulas for, 189d in wound management, 620–622, 621d, T-piece, 452
core, 188 622f Tracheal sounds, 240
LWBK1004-ind_905-930.indd 924 02/02/12 11:47 PM

Index 925
Tracheostomy, 814–816, 815f, 820d–824d nasointestinal, 637–638, 637t Universal precautions, 469
Tracheostomy collar, 452 feeding tubes, 637–638 Unlicensed assistive personnel (UAP), 8
Traction, 543–545 intestinal decompression tubes, 638, Unoccupied hospital bed, 376, 389d–394d
care, 544, 546b, 557d–558d 638f Unsaturated fat, 286
manual, 544, 544f orogastric, 636 Unvented tubing, 317, 317f
skeletal, 544, 545f removal of, 649, 658d–659d Upper arm strengthening exercises, 561, 561f
skin, 544, 545f selection of, 645t Urgency, urinary, 677
splints, 539, 539f transabdominal, 638–639, 638f Urgent surgery, 589t
Trade name, 737 Tube feeding, 643–650 Urinal, 678, 678f
Traditional time, 123 administration of, 660d–666d Urinary catheters, 680–685
Tranquilizers, 381 aspiration in, 648, 649d closed drainage systems for, 682–683,
Transabdominal tubes, 638, 638f benefits and risks of, 643, 645t 682f, 683f
management of, 643, 644d, 644f bolus, 646 condom, 680–682, 681f, 689d–692d
Transcultural nursing, 75–84. See also client assessment in, 646, 646d external, 680–682, 681f
Language and communication common problems in, 648t hygiene for, 683, 683d
Transcutaneous electrical nerve stimula- continuous, 646 insertion of, 682
tion (TENS), 428–429, 435d–437d cyclic, 646 in female, 692d–698d
Transdermal application, 752–753, 753f dumping syndrome in, 644, 648t in male, 698–701d
drug paste, 753, 754d, 754f formulas for, 644, 645, 645t irrigation
skin patches, 753, 753f gastric residual in, 646, 646d closed system, 684
Transducer, 258 in home care, 647 continuous, 684, 684f
Transduction of pain, 418, 418f hydration in, 647 open system, 684
Trans fats, 287 intermittent, 646 retention (Foley), 682, 682f
Transfer, 176f, 177–180 leaks in, 643d removal, 684, 685d
activities in, 177–178, 177f, 178d medication administration and, specimen collection from, 676, 676f
definition of, 177 660d–666d straight, 682, 682f
extended care facilities, 178–180, 179f, nursing guidelines for, 644d, 646d, three-way, 684, 684f
179t 647d, 649d U-bag, 680, 681f, 682
basic care facility, 179 nursing management in, 647, 648, 649d Urinary diversions, 685, 685f
housing options for older adults, 179t in older adults, 645 Urinary elimination, 674–704
intermediate care facility, 179 schedule for, 645–646 abnormal, 676–678
level of care, determination of, 179–180 tube insertion in, 649, 649d, 652d–655d anatomic aspects of, 675f
nursing home selection, 180, 180d tube irrigation in, 656d–657d anuria and, 677
skilled nursing facility, 178–179 tube obstruction in, 647, 647d assisting with, 678, 678f
stepdown unit, 177 tube patency in, 647 bedpans for, 678, 678f, 688d–689d
summary, 177, 177f tube removal in, 649, 658d–659d commode for, 678, 678f
Transfer belt, 506, 506f tube selection for, 645t definition of, 674
Transfer boards, 506–507, 507f Tube obstruction, 647, 647d in dying client, 846
Transfer devices, 506–507, 506f, 507f Tube patency, 647 dysuria and, 677
Transfer handle, 506, 506f Tuberculin syringe, 766, 766f with hip spica casts, 542, 542f
Transfusion. See also Blood Tubing. See under Intravenous fluids nocturia and, 677
equipment for Tunneled catheters, 788–789, 789f nursing implications of, 685
catheter, 323 Turgor, 236 in older adults, 677
needle gauge, 323 Tympanic membrane thermometry, oliguria and, 677
tubing, 324, 324f, 343d–344d 191–192, 191f overview of, 674, 675f
reactions, 324, 324t polyuria and, 677
Transmission-based precautions, 471–473, U urinal for, 678, 678f
472t, 473f, 478 U (urinary)-bag, 680, 681f, 682 Urinary incontinence, 677, 678–680
Transmission of pain, 418–419 Ulcer, 236 continence training for, 680, 681d
Transparent dressings, 615, 615f Ultrasonography, 258 functional, 679t
Transtracheal oxygen, 452–453, 453f Ultraviolet radiation, 151 management of, 678–680, 679t
Trapeze, 503, 503f Unconscious clients, oral care for, 353, in nocturnal enuresis, 385
Trendelenburg position, 500, 500f 354t, 370d–371d nursing care plan for, 686
Triple-lumen central venous catheter, 787f Uniform Anatomical Gift Act (UAGA), overflow, 679t
Trochanter rolls, 502, 502f 849 reflex, 679t
nursing guidelines, 502d Uniforms, 148 stress, 679t
Truth telling, 46 Unilateral neglect, 525d total, 679t
Tub bath/shower, 348–349, 361d–362d Unintentional torts, 40, 41f types of, 679t
Tube(s) malpractice, 40, 41f urge, 679t, 686d
irrigation of, 656d–657d negligence, 40 Urinary retention, 677
nasogastric, 636, 636f, 637t Unit dose supply, 739 postoperative, 601t
LWBK1004-ind_905-930.indd 925 02/02/12 11:47 PM

926 Index
Urinary statis, 677 Vibration, 813, 813f White-coat hypertension, 208

Urinary urgency, 677 Virulence, 141 WHO guidelines for drug therapy,
Urine Viruses, 141 423–424, 424f
characteristics of, 675, 675t Visceral pain, 420, 420f Wong-Baker FACES pain rating scale,
abnormal, 676 Visual acuity, 232 423f
clarity of, 675t Visual devices. See under Hygiene Wound(s), 236. See also Pressure ulcers
color of, 675t Visual field examination, 233, 233f closed, 610, 611t
odor of, 675t Visually impaired client, 299, 301 definition of, 610
residual, 677 Vital signs, 187–210 nursing implications of
volume of, 675t automated monitoring devices for, 196, in older adults, 622
Urine collection. See Urine specimens 196f open, 610, 611t
Urine drainage system blood pressure, 203–210 types of, 611t
closed, 682–683, 682f, 683f definition of, 187 Wound dehiscence, 613, 614f
irrigation of, 684 documenting, 209, 210f Wound evisceration, 613, 614f
open, 684 measurement of, 188d Wound healing, 612–613, 612f
Urine specimens nursing implications in, 210 complications, 613–614, 613f, 614f
catheter, 676, 676f pulse, 200–202 first-intention, 612
clean-catch, 675–676, 676d respiratory rate, 202–203 nutritional requirements for, 613
24-hour, 676 temperature, 188–199 in older adults, 612
voided, 675 Vitamins, 288t–289t, 289 second-intention, 612
Urostomy, 685, 685f Vitiligo of forearm, 82f third-intention, 612
Utilitarianism, 44 Vocational nursing, 6–9 Wound irrigation, 619, 630d–631d
Utility rooms, in infection control, 150 Voided specimen, 675 Wound management
Volume-control set, 787, 787f, 797d–800d bandages, 616–617, 618f
V Volumetric controller, 318, 331d–333d binders, 616–617, 619f
Vaginal application, 755, 755d Vomitting, 297, 298d cold applications, 620–622, 621d, 621f,
Vaginal irrigation, 620, 620d Vomitus, 297 621t
Valsalva maneuver, 705 debridement, 617–620, 619f, 620f
Values, 46 W drains, 615–616, 615f, 616f
Vastus lateralis site, 772, 772f Waiting for permission phenomenon, 847 dressings, 614–615, 615f
Vegan diet, 291 Walk-a-mile test, 521, 521t heat applications, 620–622, 621d, 621f,
Vegetarian diet, 286f, 291, 292d Walkers, 565, 565f 621t, 622f
Vegetarianism, 291, 292d Walking belt, 562–563, 563f, 564f irrigation in, 619–620, 619d, 620f,
Venipuncture Wall outlet, 444 631d
device insertion, 319, 334d–337d Walls, 375 staples, 616, 616f
devices for, 318–319, 319f Waste receptacles, in infection control, in surgery, 601
vein selection, 319, 319f, 320f 150f sutures, 616, 616f
Venous circulation in surgery, 600, 602f Water, 305–306 Wound repair
Vented tubing, 317, 317f Water mattress, 504 inflammation, 611, 611f
Ventilation Water-seal chest tube drainage, 453–454, proliferation, 611–612
anatomy and physiology of, 438–439, 461d–466d remodeling, 612
439f Water-soluble vitamins, 289 Written forms of communication. See
respiration and, 438 Weber test, 23f, 234 under Communication
Ventricular fibrillation, 830 Weight gain, diet for, 296, 296d
Ventrogluteal site, 771–772, 771f Weight loss, diet for, 295, 295d X
Venturi mask, 451 Weight status determination, 293f Xerostomia (dry mouth), 742
Veracity, 46 Wellness, 51–52, 51f, 52f. See also under X-ray. See Radiography
Verbal communication. See under Com- Health
munication Wellness syndrome, 21t, 22 Y
Verbally impaired clients, 102f, 103 Wheelchair positioning principles, 410t Yankauer-tip catheter, 814, 814f
Verbal orders, 738–739 Wheezes, 241
Vesicular sounds, 240 Whiplash injury, 539 Z
Vials, 764–765, 765d, 765f Whistle-blowing, 48 Z-track, 773, 773d, 774f
LWBK1004-ind_905-930.indd 926 02/02/12 11:47 PM

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E D I T I O N 1 0

LWBK1004-FM_pi-xxii.indd i 2/6/12 8:51 PM

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Library of Congress Cataloging-in-Publication Data

Timby, Barbara Kuhn.

LWBK1004-FM_pi-xxii.indd ii 2/6/12 8:51 PM

LWBK1004-FM_pi-xxii.indd iii 2/6/12 8:51 PM

Contributor Tammy McKinney , MSN, FNP-C, RNC

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LWBK1004-FM_pi-xxii.indd vii 2/6/12 8:51 PM

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It is my belief that this text and its ancillary package will

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Exploring Contemporary Nursing 1

Integrating Basic Concepts 33

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Protecting Health Information 121 Communication for Continuity and

Performing Basic Client Care 139

11 Admission, Discharge, Transfer,

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Performing a Physical Assessment

Assisting With Basic Needs 283

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Visual and Hearing Devices 355 Pain Assessment Standards 421

Age-Related Safety Factors 400 22 Infection Control 467

20 Pain Management 417

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Assisting the Inactive Client 493

The Surgical Client 587

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28 Wound Care 610 Nasogastric Tube Management 639

Promoting Elimination 673

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Common Alterations in Bowel Elimination 707 Ostomy Care 712

Medication Administration 735

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Intervening in Emergency Situations 809

Caring for the Terminally Ill 841

References and Suggested Readings 861

Chapter Summaries 875

Commonly Used Abbreviations and Acronyms 887

Glossary of Key Terms 889

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B OX 1- 1 Rules of Employment for Nursing

From Goodnow, M. (1933). Outlines of nursing history

combined their efforts to save souls with a commitment to

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Nightingale’s Contributions Applicants also had to submit two letters of recommen-

TABLE 1-1 Differences in Nightingale Schools and US Training Schools

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rate of US soldiers in Vietnam. More recently, nurses again

Combining Nursing Art With Science

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Henderson proposed that nursing is more than carry-

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