Fundamental of Nursing

Fundamental Nursing
Skills and Concepts

Fundamental Nursing
Skills and Concepts
NINTH EDITION
Barbara Kuhn Timby, RN, BC, BSN, MA

Nursing Professor
Glen Oaks Community College
Centreville, Michigan
Acquisitions Editor: Elizabeth Nieginski
Development Editor: Renee Gagliardi
Production Editor: Mary Kinsella
Director of Nursing Production: Helen Ewan
Senior Managing Editor/Production: Erika Kors
Art Director, Design: Joan Wendt
Art Director, Illustration: Brett MacNaughton
Manufacturing Coordinator: Karin Duffield
Indexer: Ellen Brennan
Compositor: Circle Graphics
Ninth Edition
Copyright  2009 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 transmitted in any form or by any means, including as
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and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. gov-
ernment employees are not covered by the above-mentioned copyright. To request permission, please contact Lip-
pincott Williams & Wilkins at 530 Walnut Street, Philadelphia PA 19106, via email at [email protected]
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9 8 7 6 5 4 3 2 1
Printed in Malaysia
Library of Congress Cataloging-in-Publication Data
Timby, Barbara Kuhn.

Fundamental nursing skills and concepts / Barbara Kuhn Timby.—9th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-7909-8
1. Nursing. I. Title.
[DNLM: 1. Nursing Care. WY 100 T583f 2009]
RT41.T54 2009
610.73—dc22
2007037307
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 application 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 professional responsibility of the practitioner; the clinical treat-
ments 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. How-
ever, 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 status of each drug or device planned for use in his or her clinical practice.
LWW.COM
This edition of Fundamental Nursing Skills and Concepts
is dedicated to all 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.
P R E F A C E
Fundamental Nursing Skills and Concepts is designed to from simple to complex, with special sections designed
assist beginning nursing students in acquiring a founda- to help readers apply their knowledge and prepare for
tion of basic nursing theory and developing clinical skills. the NCLEX-PN. Answers are provided on the Instruc-
In addition, its content can serve as a ready reference for tor CD-ROM and on .
updating the skills of currently employed nurses or those • Bibliography. A comprehensive listing of references
returning to work after a period of inactive practice. and suggested readings, including general recommen-
dations as well as unit-specific citations, provides a
streamlined guide to current literature about topics
PHILOSOPHICAL FOUNDATIONS OF THE TEXT discussed in the text.
• New Content. The entire text has been revised and
Several philosophical concepts are the basis for this text:
updated to reflect current medical and nursing prac-
• The human experience is a composite of physiologic, tice. Additionally, several skills and sections contain
emotional, social, and spiritual aspects that affect health brand new content. The following are some highlights:
and healing. • Chapter 1, “Nursing Foundations,” reflects changes
• Caring is the essence of nursing and is extended to to Nursing: A Social Policy Statement, 2nd edition
every client. (2003), in which the American Nurses Association
• Each client is unique, and nurses must adapt their (ANA) provides the most recent definition of nurs-
care to meet the individual needs of every person with- ing and its six essential characteristics. Chapter 1
out compromising safety or achievement of desired also includes discussion of future proposals for con-
outcomes. sistency in the preparation and practice of licensed
• A supportive network of health care providers, family, practical nurses (LPNs), as described in the Prac-
and friends promotes health restoration and health tical Nurse Scope of Practice White Paper (2005).
promotion. Therefore, it is essential to include the Because LPNs, as well as RNs, delegate care to un-
client’s significant others in teaching, formal discus- licensed assistive personnel (UAPs), Chapter 1 pro-
sions, and provision of services. vides criteria for appropriate delegation. The content
• Licensed and student nurses are accountable for their reiterates the crises in health care resulting from
actions and clinical decisions; consequently, each must the shortage of nursing faculty and its effect on lim-
be aware of legislation as it affects nursing practice. iting the acceptance of qualified applicants to nursing
education programs. It also identifies methods that
In today’s changing health care environment, nurses
the federal government had proposed via the Nurse
face many challenges and opportunities. The ninth edi-
Reinvestment Act of 2003 to reduce the nursing
tion of Fundamental Nursing Skills and Concepts was
shortage.
written to help nurses meet these challenges and take
• Chapter 3, “Laws and Ethics,” contains information
advantage of expanding opportunities.
on nurse licensure compacts, agreements between
one or more states in which a nurse licensed in one
state can practice in another without obtaining an
NEW TO THIS EDITION
additional license. Additionally, the material contains
• Reorganized Table of Contents. Based on market feed- an expanded discussion of the foundations of ethical
back, the ninth edition presents a revised Table of practice as based on the six principles of beneficence,
Contents. Section II, “Fundamental Nursing Skills,” nonmaleficence, autonomy, veracity, fidelity, and
now begins with Chapter 10, “Asepsis,” to underscore justice.
the importance of hand hygiene and other aseptic prac- • Chapter 4, “Health and Illness,” includes informa-
tices when providing nursing care. tion about the Medicare drug benefit (Medicare
• End of Unit Exercises. Found at the end of each unit, Part D), which became available in 2006 to relieve
these challenging groups of activities consolidate infor- the financial burden on older Americans and those
mation found in previous chapters to assist students to with low incomes and disabilities who require pre-
review and master critical material. The problems build scription drugs.
vii
viii Preface
• Chapter 7, “The Nurse–Client Relationship,” • Chapter 37, “Resuscitation,” contains the American
expands its discussion of nonverbal communica- Heart Association’s International Cardiopulmonary
tion by providing suggestions the nurse can use to Resuscitation (CPR) and Emergency Cardiovascular
create a positive impression during interactions Care (ECC) Guidelines of 2006 for performing basic
with clients. life support techniques.
• Chapter 8, “Client Teaching,” includes more infor- • Art and Photography Program. More than 100 new
mation about the learning styles and characteristics full-color photos and line drawings have been added.
of the Net Generation (“cyberkids”), or those born These illustrations assist visual learners to become
after 1981. familiar with the latest equipment, techniques, and
• Chapter 10, “Asepsis” includes a brand new skill on practices in today’s health care environment.
how to perform a surgical scrub.
• Chapter 11, “Admission, Discharge, Transfer and
Referrals,” identifies ways to help identify clients FEATURES AND LEARNING TOOLS
who are likely candidates for early and ongoing
discharge planning. It also discusses the qualifying Many of the features that long-time users of Timby love
criteria and coverage for Medicare benefits in a are found in the ninth edition as well:
nursing home. • Words to Know. These key terms are listed at the
• Chapter 12, “Vital Signs,” discusses the effects of the beginning of each chapter and set in color type within
Mercury Reduction Act, which was passed in 2002 the text where they appear with or near their defini-
and amended in 2005, on the use of thermometers tion. Additional technical terms are italicized through-
and sphygmomanometers that contain this potential out the text.
environmental toxin. • Learning Objectives. These student-oriented objec-
• Chapter 15, “Nutrition,” presents the latest guide- tives appear at the beginning of each chapter to serve
lines from the American Dietary Association, includ- as guidelines for acquiring specific information.
ing MyPyramid. • Nursing Process Focus. The focus on the Nursing
• Chapter 22, “Infection Control,” contains new Process continues to be strong. The concepts and par-
information about the N95 and Powered Air Puri-
adigm for the nursing process appear in Chapter 2.
fying Masks required for the care of clients with
The premise is that early familiarity with its compo-
tuberculosis.
nents will reinforce its use in the Skills and sample
• Chapter 23, “Body Mechanics, Positioning, and Mov-
Nursing Care Plans throughout the text. Each skill
ing,” explains the ANA’s “Handle With Care Cam-
chapter has the most recent Applicable Nursing Diag-
paign” to reduce injuries to nurses and their clients.
noses that correlate with the types of problems recipi-
The skills, procedures, and guidelines in this chap-
ents of the respective skills may have.
ter have been fully updated for consistency with the
• Nursing Care Plans. The diagnostic statements con-
ANA’s “no lift” policy.
• Chapter 27, “Perioperative Care,” contains recom- tain three parts for actual diagnoses and two parts for
mendations from the American Society of Anes- potential diagnoses. A double-column format lists inter-
thesiology concerning modifications in fasting and ventions on one side and corresponding rationales on
prohibition of fluids for healthy preoperative clients. the other. The evaluation step is reinforced by evidence
It also contains the 2003 Universal Protocol for Pre- indicating expected outcome achievement.
venting Wrong Site, Wrong Procedure, Wrong Per- • Skills. The Skills continue to be clustered at the end
son Surgery guidelines from the Joint Commission of each chapter for ease of access and to avoid inter-
International Center for Patient Safety. rupting the narrative and distancing related Tables
• Chapter 28, “Wound Care,” has a new discussion on and Boxes to locations where they previously seemed
the complications of wound healing and revised infor- out of context. In addition, each illustration within
mation on wet-to-dry dressings used for debridement. the skills has been closely reviewed to ensure that it
• Chapter 32, “Oral Medications,” has new informa- complies with Standard Precautions, infection control
tion about documenting medication administration guidelines from the Centers for Disease Control and
using a point-of-care computer. The chapter also Prevention.
includes the latest “Do Not Use” list of abbrevia- • Nursing Guidelines. These mini-procedures provide
tions from the Joint Commission on Accreditation of directions for performing various kinds of nursing
Healthcare Organizations. care or suggestions for managing client care problems.
• Chapter 34, “Parenteral Medications” includes the • Client and Family Teaching boxes. These specially
2003 recommendations from the American Diabetes numbered boxes found throughout chapters highlight
Association concerning the techniques for adminis- essential education points for nurses to communicate
tering subcutaneous insulin. to clients and their families.
Preface ix
• General Gerontologic Considerations. The ninth • Case Studies help students apply their learning about
edition continues to emphasize the geriatric popula- nursing concepts and skills to client-oriented scenarios.
tion, who comprise the fastest-growing age group in • Answer Keys for the Stop, Think, and Respond boxes,
the United States. Two experts in gerontology and NCLEX-Style Review Questions, Critical Thinking
long-term care have extensively updated these recur- Exercises, and End of Unit Exercises allow students to
ring sections at the end of most chapters to explain the check their comprehension of textbook presentations
unique characteristics and problems of aging adults as desired.
and ways for nurses to address them, as related to the
specific related content. RESOURCES FOR INSTRUCTORS
• Critical Thinking Exercises. These questions at the
ends of each chapter aim to facilitate application of The above student-oriented materials are available for
the material, using clinical situations or rhetorical instructors on at http://thepoint.lww.com/timby
questions. fundamentals9e. Additionally, instructors have access to
• Glossary. Found at the back of the book, this is a quick the following tools to assist with teaching:
reference of definitions for Words to Know that are
• An extensive collection of materials is provided for
used throughout the text.
each book chapter:
• Detailed Table of Contents. Located at the beginning
• Pre-Lecture Quizzes and Answers are quick,
of the textbook, this provides an outline of each unit’s
knowledge-based assessments that allow instructors
and chapter’s subject matter.
to check students’ reading.
• PowerPoint presentations provide an easy way to
USE WITH INTRODUCTORY MEDICAL-SURGICAL NURSING integrate the textbook with students’ classroom
Fundamental Nursing Skills and Concepts may be adopted experience, either via slide shows or handouts.
as a single text for students in a nursing program. Addi- • Guided Lecture Notes walk instructors through the
tionally, the book may be adopted with Introductory chapters, objective by objective, and provide corre-
Medical–Surgical Nursing by Timby and Smith. The con- sponding PowerPoint slide numbers.
tent, designs, features, and styles of these two texts have • Discussion Topics (and suggested answers) are
been coordinated closely to facilitate understanding and organized by learning objective and can be used as
to present a consistent approach to learning. classroom conversation starters.
• Assignments (and suggested answers) include
group, written, clinical, and web-based activities.
TEACHING—LEARNING PACKAGE
• An Image Bank provides the photographs and illustra-
The ninth edition of Fundamental Nursing Skills and tions from this textbook to be used as best suits
Concepts features a compelling and comprehensive com- instructor needs, including in PowerPoint slides.
plement of additional resources to help students learn • A sample syllabus provides guidance for structuring
and instructors teach. an LPN/LVN course.
• The Test Generator lets teachers assemble exclusive
RESOURCES FOR STUDENTS new tests from a bank containing more than 500 ques-
tions to help assess students’ understanding of the
Valuable learning tools for students are available both
material. These questions are formatted to match
on and on the free Student’s Resource CD-ROM
the NCLEX, so students can practice preparing for
bound in this book:
this important examination.
• Concepts in Action animations and Watch and Learn
video clips demonstrate important concepts related to STUDENT STUDY GUIDE
various topics explored in the accompanying text.
• NCLEX-style review questions that correspond with The Study Guide to Accompany Fundamental Nursing
each book chapter help students review important Skills and Concepts, 9th edition, has been redesigned and is
concepts and practice for the NCLEX. now presented in vibrant four-color to provide an engag-
• A Spanish-English glossary lists words commonly ing review of important material. Featuring images from
encountered or needed in the nurse’s practice. the text, review exercises, application activities, and
• Journal Articles about relevant topics enable students more NCLEX-PN practice questions, the Study Guide
to stay aware of the latest research and information complements this textbook and provides dynamic re-
available in the current literature. inforcement of everything students need to learn from it.
A C K N O W L E D G M E N T S
It is my belief that this text and its ancillary package will • Renee A. Gagliardi, Senior Developmental Editor, who
facilitate learning and produce safe, effective practition- has worked with the highest level of expertise to ensure
ers, capable of providing quality care for diverse clients that the additions to this edition are current and coher-
in a variety of settings. Thanks go to the following peo- ently explained
ple at Lippincott Williams & Wilkins for their help in • Mary Kinsella, Senior Production Editor, for editing
preparing this book: manuscript and preparing it for publication
• Charles Gagliardi, freelance editor, who organized and
• Elizabeth Nieginski, Senior Acquisitions Editor, for
prepared manuscript and art with detailed precision.
supporting the revision and new ideas and organiza-
tion of text material
xi
C O NTR I B UTO R S & R E V I E W E R S
Contributors Muriel Greene, BSN, Med

Nurse Educator
Linda Pousson, RN, MN
VN Program Director
Chicago Public Schools Practical Nursing Advanced Pro Nursing Institute
Debbie Faulk, PhD, RN
Program Hayward, California
Distinguished Teaching Associate
Chicago, Illinois
Professor of Nursing Lori Riden, RN, MSN
Auburn Montgomery School of Nursing Pamela Hinckley, RN, MSN Instructor
Montgomery, Alabama Chairperson—Health Programs GateWay Community College
Redlands Adult School Phoenix, Arizona
Arlene H. Morris, RN, EdD(c)
Redlands, California
Assistant Professor of Nursing Elaine M. Rissel-Muscarella, BSN
Auburn Montgomery School of Nursing Charla Hollin, RN Instructor
Montgomery, Alabama Nursing Program Director Erie 2-Chautauqua-Cattaraugus Board of
Rich Mountain Community College Cooperative Educational Services
Mena, Arkansas Angola, New York
Reviewers Dionne Jackson, LVN Sherri Smith, RN

Fundamentals of Nursing Instructor Instructor, Practical Nursing
Naomi Adams, RN Dallas Nursing Institute Arkansas State University Technical Center
Instructor Dallas, Texas Jonesboro, Arkansas
Northern Virginia Community College—
Woodbridge Campus Janet Massoglia, MSN Jackie Spriggs, BSN, Med
Woodbridge, Virginia Instructor Practical Nursing Program Coordinator
Delta College Valdosta Technical College
Priscilla Anderson, BSN, RN University Center, Michigan Valdosta, Georgia
Assistant Professor of Nursing
New Hampshire Technical Institute Linda Mollino, BSN Dori L. Steers, BSN
Concord, New Hampshire Instructor, Practical Nursing Instructor, Practical Nursing
Rogue Community College Rogue Community College
Margaret S. Argentine, PhD, RN Grants Pass, Oregon Grants Pass, Oregon
Director of Health Occupations
Madison-Oneida Board of Cooperative Wanda Morris, RN Patricia Thompson, RN
Educational Services Dean of Human Services, Nursing Program Director, Practical Nursing
Oneida, New York Compton Community College West Central Technical College
Compton, California Waco, Georgia
Anne L. Bishop, RN
Practical Nursing Educator Debbie Nolder, BSN, MC Margaret Walker, BSN
Cayuga-Onondaga Board of Cooperative Program Coordinator, Practical Nursing Nursing Administrator
Educational Services Maysville Community and Technical Educational Opportunity Center—PN Program
Auburn, New York College Rochester, New York
Maysville, Kentucky
Mary Ann Cosgarea, RN, BSN Patricia Wickham, MSN, RN
Practical Nursing/Health Program Gwendolyn Parker, RN, MSN Practical Nursing Program
Coordinator Instructor, Practical Nursing Center for Arts and Technology
Portage Lakes Career Center Chicago Public Schools Coatesville, Pennsylvania
Green, Ohio Chicago, Illinois
Sally Flesch, PhD Deborah W. Potter, RN, MSN

Chairperson, Allied Health Department Instructor, Practical Nursing
Black Hawk College Mississippi Delta Community College
Moline, Illinois Moorhead, Kansas
xiii
C O N T E N T S
Section I • Fundamental Nursing Concepts Common Law 37

Criminal Laws 37
UNIT 1 EXPLORING CONTEMPORARY NURSING 1 Civil Laws 37
Professional Liability 41
1 NURSING FOUNDATIONS 2 Liability Insurance 41
Nursing Origins 2 Reducing Liability 42
The Nightingale Reformation 3 Malpractice Litigation 42
The Crimean War 3 Ethics 44
Nightingale’s Contributions 4 Codes of Ethics 44
Nursing in the United States 4 Ethical Dilemmas 44
U.S. Nursing Schools 4 Ethical Theories 44
Expanding Horizons of Practice 4 Ethical Principles 45
Contemporary Nursing 6 Values and Ethical Decision Making 46
Combining Nursing Art With Science 6 Ethics Committees 46
Integrating Nursing Theory 6 Common Ethical Issues 47
Defining Nursing 6
4 HEALTH AND ILLNESS 50
The Educational Ladder 6
Practical/Vocational Nursing 7 Health 50
Registered Nursing 9 Health: A Limited Resource 51
Baccalaureate Programs 10 Health: A Right 51
Graduate Nursing Programs 10 Health: A Personal Responsibility 51
Continuing Education 11 Wellness 51
Future Trends 11 Holism 51
Governmental Responses 11 Hierarchy of Human Needs 52
Proactive Strategies 11 Illness 52
Unique Nursing Skills 12 Morbidity and Mortality 52
Assessment Skills 12 Acute, Chronic, and Terminal Illnesses 52
Caring Skills 12 Primary and Secondary Illnesses 52
Counseling Skills 15 Remission and Exacerbation 53
Comforting Skills 15 Hereditary, Congenital, and Idiopathic Illnesses 53
Health Care System 53
2 NURSING PROCESS 16 Primary, Secondary, and Tertiary Care 53
Definition of the Nursing Process 16 Extended Care 54
Characteristics of the Nursing Process 17 Health Care Services 54
Steps of the Nursing Process 17 Access to Care 54
Assessment 17 Financing Health Care 54
Diagnosis 20 Outcomes of Structured Reimbursement 56
Planning 21 National Health Goals 56
Implementation 23 Nursing Team 57
Evaluation 25 Functional Nursing 58
Use of the Nursing Process 25 Case Method 58
Concept Mapping 25 Team Nursing 58
End of Unit Exercises 28 Primary Nursing 58
Nurse-Managed Care 58
UNIT 2 INTEGRATING BASIC CONCEPTS 33 Continuity of Health Care 59
3 LAWS AND ETHICS 34 5 HOMEOSTASIS, ADAPTATION,
Laws 35 AND STRESS 60
Constitutional Law 35 Homeostasis 60
Statutory Laws 35 Holism 60
Administrative Laws 35 Adaptation 61
xv
xvi Contents
Stress 64 Types of Client Records 112

Physiologic Stress Response 65 Methods of Charting 112
Psychological Stress Responses 66 Narrative Charting 112
Stress-Related Disorders 67 SOAP Charting 113
Nursing Implications 67 Focus Charting 113
Assessment of Stressors 68 PIE Charting 114
Prevention of Stressors 68 Charting by Exception 114
Stress-Reduction Techniques 68 Computerized Charting 114
Stress-Management Techniques 68 Protecting Health Information 115
Privacy Standards 115
6 CULTURE AND ETHNICITY 71
Workplace Applications 115
Culture 71 Data Security 117
Race 72 Documenting Information 117
Minority 72 Using Abbreviations 117
Ethnicity 72 Indicating Documentation Time 118
Stereotyping 72 Communication for Continuity
Generalizing 72 and Collaboration 119
Ethnocentrism 73 Written Forms of Communication 119
Culture of the United States 73 Interpersonal Communication 121
Transcultural Nursing 74 Skill 9-1 Making Entries in a Client’s Record 124
Cultural Assessment 74 End of Unit Exercises 126
Biologic and Physiologic Variations 77
Disease Prevalence 81
Health Beliefs and Practices 81 Section II • Fundamental Nursing Skills
Culturally Sensitive Nursing 82
End of Unit Exercises 84 UNIT 4 PERFORMING BASIC CLIENT CARE 133
10 ASEPSIS 134
UNIT 3 FOSTERING COMMUNICATION 91
Microorganisms 134
7 THE NURSE–CLIENT RELATIONSHIP 92 Types of Microorganisms 135
Nursing Roles Within the Nurse–Client Survival of Microorganisms 136
Relationship 92 Chain of Infection 136
The Nurse as Caregiver 93 Infectious Agents 137
The Nurse as Educator 93 Reservoir 137
The Nurse as Collaborator 93 Exit Route 137
The Nurse as Delegator 93 Mode of Transmission 137
The Therapeutic Nurse–Client Port of Entry 137
Relationship 94 Susceptible Host 138
Underlying Principles 94 Asepsis 138
Phases of the Nurse–Client Relationship 94 Medical Asepsis 138
Barriers to a Therapeutic Relationship 95 Surgical Asepsis 144
Communication 95 Nursing Implications 146
Verbal Communication 95 Skill 10-1 Handwashing 150
Nonverbal Communication 98 Skill 10-2 Performing a Surgical Scrub 153
Skill 10-3 Creating a Sterile Field and Adding Sterile Items 157
8 CLIENT TEACHING 101 Skill 10-4 Donning Sterile Gloves 160
Importance of Client Teaching 101
Assessing the Learner 102 11 ADMISSION, DISCHARGE,
Learning Styles 102 TRANSFER, AND REFERRALS 163
Age and Developmental Level 103 The Admission Process 163
Capacity to Learn 104 Medical Authorization 164
Motivation 105 The Admitting Department 164
Learning Readiness 105 Nursing Admission Activities 164
Learning Needs 105 Initial Nursing Plan for Care 166
Informal and Formal Teaching 105 Medical Admission Responsibilities 166
Common Responses to Admission 166
Skill 8-1 Teaching Adult Clients 107
The Discharge Process 168
9 RECORDING AND REPORTING 109 Discharge Planning 168
Medical Records 109 Obtaining Authorization for
Uses 110 Medical Discharge 168
Client Access to Records 111 Providing Discharge Instructions 169
Contents xvii
Notifying the Business Office 169 Extremities 244

Discharging a Client 170 Abdomen 245
Writing a Discharge Summary 170 Genitalia 246
Terminal Cleaning 170 Anus and Rectum 246
The Transfer Process 170 Nursing Implications 247
Transfer Activities 171 Skill 13-1 Performing a Physical Assessment 250
Extended Care Facilities 171
The Referral Process 173 14 SPECIAL EXAMINATIONS AND TESTS 252
Considering Referrals 174 Examinations and Tests 252
Home Health Care 174 General Nursing Responsibilities 253
Skill 11-1 Admitting a Client 179
Common Diagnostic Examinations 257
Skill 11-2 Discharging a Client 181 Diagnostic Laboratory Tests 262
Nursing Implications 266
12 VITAL SIGNS 184 Skill 14-1 Assisting With a Pelvic Examination 269
Body Temperature 185 Skill 14-2 Assisting With a Sigmoidoscopy 272
Temperature Measurement 185 Skill 14-3 Using a Glucometer 275
Normal Body Temperature 186 End of Unit Exercises 279
Assessment Sites 187
Thermometers 189 UNIT 5 ASSISTING WITH BASIC NEEDS 287
Elevated Body Temperature 192
Subnormal Body Temperature 194 15 NUTRITION 288
Pulse 194 Overview of Nutrition 288
Pulse Rate 194 Human Nutritional Needs 289
Pulse Rhythm 195 Nutritional Strategies 293
Pulse Volume 195 Nutritional Patterns and Practice 296
Assessment Sites 195 Influences on Eating Habits 296
Respiration 197 Vegetarianism 296
Respiratory Rate 197 Nutritional Status Assessment 297
Breathing Patterns and Abnormal Subjective Data 297
Characteristics 198 Objective Data 297
Blood Pressure 198 Management of Problems Interfering
Factors Affecting Blood Pressure 199 with Nutrition 299
Pressure Measurements 199 Obesity 299
Assessment Sites 200 Emaciation 300
Equipment for Measuring Blood Pressure 200 Anorexia 300
Measuring Blood Pressure 202 Nausea 300
Alternative Assessment Techniques 203 Vomiting 301
Abnormal Blood Pressure Measurements 204 Stomach Gas 302
Documenting Vital Signs 205 Management of Client Nutrition 302
Nursing Implications 205 Common Hospital Diets 302
Skill 12-1 Assessing Body Temperature 209 Meal Trays 302
Skill 12-2 Assessing the Radial Pulse 216 Feeding Assistance 302
Skill 12-3 Assessing the Respiratory Rate 218 Skill 15-1 Serving and Removing Meal Trays 307
Skill 12-4 Assessing Blood Pressure 219 Skill 15-2 Feeding a Client 308
Skill 12-5 Obtaining a Thigh Blood Pressure 224
Skill 12-6 Assessing for Postural Hypotension 226 16 FLUID AND CHEMICAL BALANCE 311
Body Fluid 312
13 PHYSICAL ASSESSMENT 229 Water 312
Overview of Physical Assessment 229 Fluid Compartments 312
Purposes 229 Electrolytes 312
Techniques 230 Nonelectrolytes 312
Equipment 231 Blood 313
Environment 231 Fluid and Electrolyte Distribution Mechanisms 313
Performing a Physical Assessment 232 Fluid Regulation 314
Gathering General Data 232 Fluid Volume Assessment 315
Draping and Positioning 232 Fluid Intake 315
Selecting an Approach for Data Collection 233 Fluid Output 317
Examining the Client 233 Common Fluid Imbalances 317
Data Collection 233 Hypovolemia 318
Head and Neck 234 Hypervolemia 318
Chest and Spine 240 Third-Spacing 319
xviii Contents
Intravenous Fluid Administration 320 Sleep Requirements 392

Types of Solutions 320 Factors Affecting Sleep 392
Preparation for Administration 322 Sleep Assessment 394
Infusion Techniques 324 Questionnaires 395
Venipuncture 325 Sleep Diary 395
Infusion Monitoring and Maintenance 326 Nocturnal Polysomnography 395
Discontinuation of an Intravenous Infusion 329 Multiple Sleep Latency Test 396
Insertion of an Intermittent Sleep Disorders 396
Venous Access Device 329 Insomnia 396
Blood Administration 329 Hypersomnia 397
Blood Collection and Storage 329 Sleep–Wake Cycle Disturbances 397
Blood Safety 329 Parasomnia 398
Blood Compatibility 330 Nursing Implications 398
Blood Transfusion 330 Progressive Relaxation 398
Parenteral Nutrition 331 Back Massage 398
Peripheral Parenteral Nutrition 332 Skill 18-1 Making an Unoccupied Bed 403
Total Parenteral Nutrition 332 Skill 18-2 Making an Occupied Bed 409
Lipid Emulsions 332 Skill 18-3 Giving a Back Massage 411
Skill 16-1 Recording Intake and Output 337 19 SAFETY 415
Skill 16-2 Preparing Intravenous Solutions 339 Age-Related Safety Factors 415
Skill 16-3 Starting an Intravenous Infusion 343 Infants and Toddlers 416
Skill 16-4 Changing IV Solution Containers 347 School-Aged Children and Adolescents 416
Skill 16-5 Changing IV Tubing 349 Adults 416
Skill 16-6 Discontinuing an Intravenous Infusion 350 Environmental Hazards 416
Skill 16-7 Inserting a Medication Lock 352
Latex Sensitization 416
Skill 16-8 Administering a Blood Transfusion 355
Burns 417
17 HYGIENE 358 Asphyxiation 419
The Integumentary System 358 Electrical Shock 421
Skin 359 Poisoning 422
Mucous Membranes 359 Falls 422
Hair 360 Restraints 423
Nails 360 Legislation 424
Teeth 360 Accreditation Standards 425
Hygiene Practices 361 Restraint Alternatives 425
Bathing 361 Use of Restraints 425
Shaving 364 Nursing Implications 426
Oral Hygiene 364 Skill 19-1 Using Physical Restraints 429
Hair Care 366
Nail Care 367 20 PAIN MANAGEMENT 434
Visual and Hearing Devices 368 Pain 435
Eyeglasses 368 The Process of Pain 435
Contact Lenses 368 Pain Theories 436
Artificial Eyes 369 Types of Pain 436
Hearing Aids 369 Pain Assessment Standards 438
Infrared Listening Devices 369 Pain Assessment Data 439
Nursing Implications 371 Pain Intensity Assessment Tools 439
Skill 17-1 Providing a Tub Bath or Shower 374 Pain Management 440
Skill 17-2 Administering Perineal Care 376 Treatment Biases 440
Skill 17-3 Giving a Bed Bath 380
Pain Management Techniques 440
Skill 17-4 Giving Oral Care to Unconscious Clients 383
Skill 17-5 Shampooing Hair 385 Drug Therapy 440
Surgical Approaches 443
18 COMFORT, REST, AND SLEEP 387 Nondrug and Nonsurgical Interventions 443
The Client Environment 388 Nursing Implications 446
Client Rooms 388 Addiction 446
Room Furnishings 388 Placebos 447
Sleep and Rest 391 Skill 20-1 Preparing a Patient-Controlled
Functions of Sleep 391 Analgesia (PCA) Infuser 451
Sleep Phases 391 Skill 20-2 Operating a Transcutaneous Electrical Nerve
Sleep Cycles 391 Stimulation (TENS) Unit 454
Contents xix
21 OXYGENATION 458 Cradle 525

Anatomy and Physiology of Breathing 458 Specialty Beds 525
Assessing Oxygenation 459 Transferring Clients 526
Physical Assessment 459 Transfer Handle 527
Arterial Blood Gases 460 Transfer Belt 527
Pulse Oximetry 460 Transfer Boards 528
Promoting Oxygenation 462 Nursing Implications 528
Positioning 462 Skill 23-1 Turning and Moving a Client 533
Breathing Techniques 462 Skill 23-2 Transferring Clients 537
Oxygen Therapy 465 24 THERAPEUTIC EXERCISE 543
Oxygen Sources 465
Fitness Assessment 543
Equipment Used in Oxygen Administration 466
Body Composition 543
Common Delivery Devices 467 Vital Signs 544
Additional Delivery Devices 472 Fitness Tests 544
Oxygen Hazards 473
Exercise Prescriptions 546
Related Oxygenation Techniques 474 Target Heart Rate 546
Water-Seal Chest Tube Drainage 474 Metabolic Energy Equivalent 546
Hyperbaric Oxygen Therapy 475
Types of Exercise 546
Nursing Implications 475 Fitness Exercise 546
Skill 21-1 Using a Pulse Oximeter 478 Therapeutic Exercise 547
Skill 21-2 Administering Oxygen 480
Skill 21-3 Maintaining a Water-Seal Chest Tube
Drainage System 483 Skill 24-1 Performing Range-of-Motion (ROM) Exercises 552
Skill 24-2 Using a Continuous Passive Motion (CPM) Machine 560
22 INFECTION CONTROL 488
Infection 488 25 MECHANICAL IMMOBILIZATION 563
Infection Control Precautions 489 Purposes of Mechanical Immobilization 563
Standard Precautions 489 Mechanical Immobilizing Devices 564
Transmission-Based Precautions 490 Splints 564
Slings 566
Infection Control Measures 492
Braces 566
Client Environment 493
Casts 567
Personal Protective Equipment 494
Traction 570
Discarding Biodegradable Trash 496
External Fixators 572
Removing Reusable Items 496
Delivering Laboratory Specimens 496
Transporting Clients 496 Skill 25-1 Applying an Arm Sling 576
Skill 25-2 Assisting With a Cast Application 579
Psychological Implications 496 Skill 25-3 Providing Pin Site Care 581
Promoting Social Interaction 496
Combating Sensory Deprivation 496 26 AMBULATORY AIDS 584
Nursing Implications 496 Preparing for Ambulation 584
Skill 22-1 Removing Personal Protective Equipment 501 Isometric Exercises 584
End of Unit Exercises 503 Upper Arm Strengthening 585
Dangling 585
UNIT 6 ASSISTING THE INACTIVE CLIENT 515 Using a Tilt Table 585
Assistive Devices 586
23 BODY MECHANICS, POSITIONING, Ambulatory AIDS 587
AND MOVING 516 Canes 587
Maintaining Good Posture 516 Walkers 588
Standing 518 Crutches 588
Sitting 518 Crutch-Walking Gaits 589
Lying Down 518 Prosthetic Limbs 589
Body Mechanics 519 Temporary Prosthetic Limb 589
Ergonomics 519 Permanent Prosthetic Components 589
Positioning Clients 520 Client Care 591
Common Positions 520 Ambulation With a Lower Limb Prosthesis 591
Positioning Devices 522 Nursing Implications 591
Turning and Moving Clients 523 Skill 26-1 Measuring for Crutches, Canes, and Walkers 595
Protective Devices 524 Skill 26-2 Assisting With Crutch-Walking 599
Side Rails 524 Skill 26-3 Applying a Leg Prosthesis 602
Mattress Overlays 524 End of Unit Exercises 605
xx Contents
UNIT 7 THE SURGICAL CLIENT 613 Benefits and Risks 672

Formula Considerations 674
27 PERIOPERATIVE CARE 614
Tube-Feeding Schedules 675
Preoperative Period 614 Client Assessment 675
Inpatient Surgery 614 Nursing Management 676
Outpatient Surgery 615
Intestinal Decompression 678
Informed Consent 616
Tube Insertion 678
Preoperative Blood Donation 618
Removal 678
Immediate Preoperative Care 618
Intraoperative Period 624
Skill 29-1 Inserting a Nasogastric Tube 682
Receiving Room 624
Skill 29-2 Irrigating a Nasogastric Tube 686
Operating Room 624 Skill 29-3 Removing a Nasogastric Tube 688
Anesthesia 624 Skill 29-4 Administering Tube Feedings 690
Surgical Waiting Area 625 End of Unit Exercises 696
Postoperative Period 625
Immediate Postoperative Care 625 UNIT 8 PROMOTING ELIMINATION 703
Continuing Postoperative Care 626
Nursing Implications 627 30 URINARY ELIMINATION 704
Skill 27-1 Applying Antiembolism Stockings 631 Overview of Urinary Elimination 704
Skill 27-2 Performing Presurgical Skin Preparation 633 Characteristics of Urine 705
Skill 27-3 Applying a Pneumatic Compression Device 635 Urine Specimen Collection 705
Abnormal Urine Characteristics 706
28 WOUND CARE 638
Abnormal Urinary Elimination Patterns 707
Wounds 638 Anuria 707
Wound Repair 639 Oliguria 707
Inflammation 639 Polyuria 707
Proliferation 640 Nocturia 707
Remodeling 640 Dysuria 707
Wound Healing 640 Incontinence 707
Wound Healing Complications 641 Assisting Clients With Urinary Elimination 707
Wound Management 641 Commode 707
Dressings 642 Urinal 707
Drains 643 Using a Bedpan 708
Sutures and Staples 644 Managing Incontinence 708
Bandages and Binders 644 Catheterization 709
Débridement 646 Types of Catheters 710
Heat and Cold Applications 647 Inserting a Catheter 712
Pressure Ulcers 650 Connecting a Closed Drainage System 712
Stages of Pressure Ulcers 650 Providing Catheter Care 712
Prevention of Pressure Ulcers 651 Catheter Irrigation 712
Nursing Implications 651 Indwelling Catheter Removal 714
Skill 28-1 Changing a Gauze Dressing 655 Urinary Diversions 714
Skill 28-2 Irrigating a Wound 658 Nursing Implications 715
Skill 28-3 Providing a Sitz Bath 660
Skill 30-1 Placing and Removing a Bedpan 719
29 GASTROINTESTINAL INTUBATION 664 Skill 30-2 Applying a Condom Catheter 721
Skill 30-3 Inserting a Foley Catheter in a Female 723
Intubation 664
Skill 30-4 Inserting a Foley Catheter in a Male 729
Types of Tubes 665 Skill 30-5 Irrigating a Foley Catheter 733
Orogastric Tubes 665
Nasogastric Tubes 665 31 BOWEL ELIMINATION 736
Nasointestinal Tubes 665 Defecation 736
Transabdominal Tubes 667 Assessment of Bowel Elimination 737
Nasogastric Tube Management 667 Elimination Patterns 737
Insertion 667 Stool Characteristics 737
Use and Maintenance 670 Common Alterations in Bowel
Removal 671 Elimination 737
Nasointestinal Tube Management 671 Constipation 737
Insertion 671 Fecal Impaction 738
Checking Tube Placement 672 Flatulence 739
Transabdominal Tube Management 672 Diarrhea 739
Tube Feedings 672 Fecal Incontinence 740
Contents xxi
Measures to Promote Bowel Drug Preparation 798

Elimination 740 Ampules 798
Inserting a Rectal Suppository 740 Vials 798
Administering an Enema 740 Prefilled Cartridges 799
Ostomy Care 742 Combining Medications in One Syringe 800
Providing Peristomal Care 742 Injection Routes 800
Applying an Ostomy Appliance 742 Intradermal Injections 800
Draining a Continent Ileostomy 742 Subcutaneous Injections 800
Irrigating a Colostomy 743 Intramuscular Injections 803
Nursing Implications 744 Reducing Injection Discomfort 806
Skill 31-1 Inserting a Rectal Tube 747 Nursing Implications 807
Skill 31-2 Inserting a Rectal Suppository 749 Skill 34-1 Administering Intradermal Injections 810
Skill 31-3 Administering a Cleansing Enema 751 Skill 34-2 Administering Subcutaneous Injections 812
Skill 31-4 Changing an Ostomy Appliance 754 Skill 34-3 Administering Intramuscular Injections 814
Skill 31-5 Irrigating a Colostomy 757
End of Unit Exercises 760 35 INTRAVENOUS MEDICATIONS 816
Intravenous Medication Administration 816
Continuous Administration 817
UNIT 9 MEDICATION ADMINISTRATION 767
Intermittent Administration 817
32 ORAL MEDICATIONS 768 Central Venous Catheters 819
Medication Orders 768 Percutaneous Catheters 820
Components of a Medication Order 768 Tunneled Catheters 820
Verbal and Telephone Orders 770 Implanted Catheters 820
Documentation in the Medication Medication Administration Using a CVC 821
Administration Record 771 Nursing Implications 822
Methods of Supplying Medications 771 Skill 35-1 Administering Intravenous Medication by
Storing Medications 771 Continuous Infusion 825
Accounting for Narcotics 771 Skill 35-2 Administering an Intermittent
Medication Administration 771 Secondary Infusion 828
Applying the Five Rights 771 Skill 35-3 Using a Volume-Control Set 830
Calculating Dosages 771 End of Unit Exercises 834
Administering Oral Medications 771
Administering Oral Medications UNIT 10 INTERVENING IN EMERGENCY SITUATIONS 843
by Enteral Tube 774
36 AIRWAY MANAGEMENT 844
Documentation 774
The Airway 844
Medication Errors 775
Natural Airway Management 845
Liquefying Secretions 845
Skill 32-1 Administering Oral Medications 779
Mobilizing Secretions 845
Skill 32-2 Administering Medications
Suctioning Secretions 847
Through an Enteral Tube 781
Artificial Airway Management 847
33 TOPICAL AND INHALANT Oral Airway 847
MEDICATIONS 784 Tracheostomy 848
Topical Route 784 Nursing Implications 849
Cutaneous Applications 784 Skill 36-1 Suctioning the Airway 852
Ophthalmic Applications 786 Skill 36-2 Providing Tracheostomy Care 855
Otic Applications 786
37 RESUSCITATION 859
Nasal Applications 787
Sublingual and Buccal Applications 787
Airway Obstruction 859
Identifying Signs of Airway Obstruction 860
Vaginal Applications 787
Relieving an Obstruction 860
Rectal Applications 787
Chain of Survival 861
Inhalant Route 787
Early Recognition and Access of
Nursing Implications 789 Emergency Services 861
Skill 33-1 Instilling Eye Medications 792 Early Cardiopulmonary Resuscitation 861
Skill 33-2 Administering Nasal Medications 794
Early Defibrillation 863
34 PARENTERAL MEDICATIONS 796 Early Advanced Life Support 865
Parenteral Administration Equipment 796 Recovery 865
Syringes 796 Discontinuing Resuscitation 866
Needles 797 Nursing Implications 866
Modified Safety Injection Equipment 797 End of Unit Exercises 869
xxii Contents
UNIT 11 CARING FOR THE TERMINALLY ILL 875 Resolution of Grief 884
38 END-OF-LIFE CARE 876 Nursing Implications 884
Skill 38-1 Performing Postmortem Care 887
Terminal Illness and Care 876
Stages of Dying 876 End of Unit Exercises 889
Promoting Acceptance 877
Providing Terminal Care 879 REFERENCES AND
Family Involvement 880 SUGGESTED READINGS 893
Approaching Death 881 APPENDIX A—CHAPTER SUMMARIES 914
Confirming Death 882 APPENDIX B—COMMONLY USED
Performing Postmortem Care 884 ABBREVIATIONS AND ACRONYMS 927
Grieving 884 GLOSSARY OF KEY TERMS 928
Pathologic Grief 884 INDEX 945
UNIT 1
Exploring
Contemporary
Nursing
1 Nursing Foundations
2 Nursing Process
1
Chapter
Nursing
Foundations
LEARNING OBJECTIVES
On completion of this chapter, the reader will
● Name one historical event that led to the demise of nursing in England before the time of
Florence Nightingale.
● Identify four reforms for which Florence Nightingale is responsible.
● Describe at least five ways in which early U.S. training schools deviated from those established
under the direction of Florence Nightingale.
● Name three ways that nurses used their skills in the early history of U.S. nursing.
● Explain how art, science, and nursing theory have been incorporated into contemporary
nursing practice.
● Discuss the evolution of definitions of nursing.
● List four types of educational programs that prepare students for beginning levels of nursing
practice.
● Identify at least five factors that influence choice of educational nursing program.
● State three reasons that support the need for continuing education in nursing.
● List examples of current trends affecting nursing and health care.
● Discuss the shortage of nurses and methods to reduce the crisis.
● Describe four skills that all nurses use in clinical practice.
THIS chapter traces the historical development of nursing from its unorganized begin-
WORDS TO KNOW ning to current sophisticated practice. Nurses in the 21st century owe a debt of grat-
itude to their pioneering counterparts who served clients on battlefields, in urban
active listening settlement houses, in Boston’s harbor on a floating “children’s hospital,” and on
activities of daily living
horseback in the Appalachian frontier. Ironically, nursing is returning to its original
advanced practice
art community-based practice model.
assessment skills
capitation
caring skills
clinical pathways NURSING ORIGINS
comforting skills
counseling skills
cross-trained Nursing is one of the youngest professions but one of the oldest arts. It evolved from
discharge planning the familial roles of nurturing and caretaking. Early responsibilities included assist-
empathy
managed care practices
ing women during childbirth, suckling healthy newborns, and ministering to the ill,
multicultural diversity aged, and helpless within households and surrounding communities. Its hallmark
nursing skills was caring more than curing.
nursing theory During the Middle Ages in Europe, religious groups assumed many of the roles of
primary care nursing. Nuns, priests, and brothers combined their efforts to save souls with a commit-
quality assurance
science
ment to care for the sick. Despite their zeal, they were overworked and overwhelmed
sympathy as a result of their limited numbers, especially during periods when plagues and pesti-
theory lence spread quickly in communities. Consequently, some convents and monasteries
2
C H A P T E R 1 ● Nursing Foundations 3
BOX 1-1 ● Rules of Employment for

war casualties caused outrage among the British people.
Nursing Attendants—1789 As a result, the government became the object of national
criticism.
❙ No dirt, rags, or bones may be thrown from the windows.
It was then that Florence Nightingale offered a strate-
❙ Nurses are to punctually shift the bed and body linen of patients, viz., once in
a fortnight (2 weeks), their shirts once in four days, their drawers and stock- gic plan to Sidney Herbert, Secretary of War and an old
ings once a week or oftener, if found necessary. family friend. She proposed that the sick and injured
❙ All nurses who disobey orders, get drunk, neglect their patients, quarrel with British soldiers at Scutari, a military barracks in Turkey,
men, shall be immediately discharged. would fare better if a team of women trained in nursing
skills could care for them (Fig. 1-1). With Herbert’s
From Goodnow, M. (1933). Outlines of nursing history (5th ed., pp. 57–58).
Philadelphia and London: W. B. Saunders. approval, Nightingale selected women with reputations
beyond reproach. She realized intuitively that only peo-
ple with devotion and idealism could accept the disci-
pline and hard work necessary for the looming task.
engaged conscientious penitent and disadvantaged lay To the British medical staff at Scutari, the arrival of
people to assist with the burden of physical care. this group of women implied that they were incapable of
In England, the character and quality of nursing care providing adequate care. Jealousy and rivalry caused them
changed dramatically when religious groups were exiled to refuse any help from Nightingale and her 38 volun-
to Western Europe during the schism between King teers. When it became clear that the daily death rate,
Henry VIII and the Catholic Church. The management of which averaged about 60%, was not subsiding, the med-
parochial hospitals and the ill within them fell to the state. ical staff allowed Nightingale’s nurses to work. Under
Hospitals became poorhouses, which some characterized Nightingale’s supervision, the women cleaned the filth,
more accurately as “pest houses.” The English state eliminated the vermin, and improved ventilation, nutri-
recruited the hospital labor force from the ranks of crimi- tion, and sanitation. They helped control infection and
nals, widows, and orphans, who repaid the Crown for gangrene and lowered the death rate to 1%.
their meager food and shelter by tending to the un- Servicemen and their families alike were grateful, and
fortunate sick. An example of the menial requirements for England adored Nightingale. To show their apprecia-
employment appears in Box 1-1. Generally, nursing attention, many donated funds to sustain her great work.
dants were ignorant, uncouth, and apathetic to the needs Nightingale used this money to start the first training
of their charges. Without supervision, they rarely per- school for nurses at St. Thomas Hospital in England. This
formed even minimal duties. Infections, pressure sores, school became the model for others in Europe and the
and malnutrition were a testimony to their neglect. United States.
THE NIGHTINGALE REFORMATION
In the midst of deplorable health care conditions, Florence

Nightingale, an Englishwoman born of wealthy parents,
announced that God had called her to become a nurse.
Despite her family’s protests, she worked with nursing
deaconesses, a Protestant order of women who cared
for the sick in Kaiserwerth, Germany. After becoming
suitably prepared through her nursing apprenticeship,
Nightingale embarked on the next phase of her career.
The Crimean War

While Nightingale was providing nursing care for res-
idents at the Institution for the Care of Sick Gentle-
women in Distressed Circumstances, England found
itself allied with Turkey, France, and Sardinia in de-
fending the Crimea, a peninsula on the north shore of
FIGURE 1-1 • Florence Nightingale (center), her brother-in-law,
the Black Sea (1854–1856). The British military suf-
Sir Harry Verney, and Miss Crossland, the nurse in charge of the
fered terribly, and war correspondents at the front lines Nightingale Training School at St. Thomas Hospital, with a class of
made public the dire circumstances of the soldiers. Re- student nurses. (Courtesy of The Florence Nightingale Museum Trust,
ports of high death rates and complications among the London, England.)
4 U N I T 1 ● Exploring Contemporary Nursing
Nightingale’s Contributions 1862, Dix followed Nightingale’s advice and established

the following selection criteria. Applicants were to be
Nightingale changed the negative image of nursing to a • 35 to 50 years old.
positive one. She is credited with the following: • Matronly and plain-looking.
• Training people for their future work • Educated.
• Selecting only those with upstanding characters as • Neat, orderly, sober, and industrious, with a serious
potential nurses disposition.
• Improving sanitary conditions for the sick and injured Applicants also had to submit two letters of recommen-
• Significantly reducing the death rate of British soldiers dation attesting to their moral character, integrity, and
• Providing classroom education and clinical teaching capacity to care for the sick. Once selected, a volunteer
• Advocating that nursing education should be lifelong nurse was to dress plainly in brown, gray, or black and had
to agree to serve for at least 6 months (Donahue, 1985).
Stop • Think + Respond BOX 1-1

How did Florence Nightingale convince the English and U.S. Nursing Schools
others that formal education of people who cared for the
sick and injured was essential? After the Civil War, U.S. training schools for nurses began
to be established. Unfortunately, however, the standards
of these schools deviated substantially from those of the
Nightingale paradigm (Table 1-1). Whereas planned,
NURSING IN THE UNITED STATES consistent, formal education was the priority in the
Nightingale schools, the training of U.S. nurses was like
an unsubsidized apprenticeship. Eventually, the curricula
The Civil War occurred around the same time as the and content of U.S. training schools became more orga-
Nightingale reformation. Like England, the United States nized and uniform. Training periods lengthened from
found itself involved in a war with no organized or sub- 6 months to 3 full years. Graduate nurses received a di-
stantial staff of trained nurses to care for the sick and ploma attesting to their successful completion of training.
wounded. The military had to rely on untrained corps-
men and civilian volunteers, often the mothers, wives,
and sisters of soldiers. Expanding Horizons of Practice
The Union government appointed Dorothea Lynde
Dix, a social worker who had proved her worth by reform- Diplomas in hand, U.S. nurses began the 20th century
ing health conditions for the mentally ill, to select and by distinguishing themselves in caring for the sick and
organize women volunteers to care for the troops. In disadvantaged outside hospitals (Fig. 1-2). Some nurses
TABLE 1-1 DIFFERENCES IN NIGHTINGALE SCHOOLS AND U.S. TRAINING SCHOOLS

NIGHTINGALE SCHOOLS U.S. 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
Nightingale Trust Fund. usually consisted of chores.
Training of nurses provided no financial advantages to the Hospitals profited by eliminating the need to pay employees.
hospital.
Class schedules were planned separately from practical experiences. No formal classes were held; training was an outcome of work.
Curricular content was uniform. Curricular content was unplanned and varied according to
current cases.
A previously trained nurse provided formal instruction, focusing Instruction was usually informal, at the bedside, and from a
on nursing care. physician’s perspective.
The number of clinical hours during training was restricted. Students were expected to work 12 hours a day and to live in or
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 students
were hired to train others. took their places. Most graduates sought private-duty positions.
FIGURE 1-2 • Community health nurses circa late 1800s to early 1900s. (Courtesy of Visiting Nurse
Association, Inc., Detroit, MI.)
moved into communities and established “settlement

houses” where they lived and worked among poor immi-
grants. Others provided midwifery services, especially in
rural Appalachia. The success of their public health efforts
in administering prenatal and obstetric care, teaching
child care, and immunizing children is well documented.
Like previous counterparts, nurses continued to vol-
unteer during wars. They offered their services to fight
yellow fever, typhoid, malaria, and dysentery during the
Spanish-American War. They replenished the nursing
staff in military hospitals during World Wars I and II
(Fig. 1-3). They worked alongside physicians in Mobile
Army Service Hospitals (MASH) during the Korean
War, acquiring knowledge about trauma care that later
would help to reduce the mortality rate of U.S. soldiers
in Vietnam. More recently, nurses answered the call
during the conflicts in Iraq. Whenever and wherever
there has been a need, nurses have put their own lives FIGURE 1-3 • A military nurse comforts a soldier during World War II.
on the line. (Courtesy of the National Archives, Washington, DC.)
Other definitions have been offered by nurses recog-

CONTEMPORARY NURSING nized as authorities and therefore qualified spokesper-
sons on the practice of nursing. One such authority is
Combining Nursing Art With Science Virginia Henderson. Her definition, adopted by the Inter-
national Council of Nurses, broadened the description of
At first, the training of nurses consisted of learning the nursing to include health promotion, not just illness
art (ability to perform an act skillfully) of nursing. Stu- care. She stated in 1966:
dents learned this art by watching and imitating the tech- The unique function of the nurse is to assist the individ-
niques performed by other, more experienced nurses. In ual, sick or well, in the performance of those activities con-
this way, mentors informally passed skills to students. tributing to health or its recovery (or to a peaceful death)
Contemporary nursing practice has added another that he could perform unaided if he had the necessary
dimension: science. The English word “science” comes strength, will or knowledge. And to do this in such a way
from the Latin word scio, which means, “I know.” A sci- as to help him gain independence as rapidly as possible.
ence (body of knowledge unique to a particular subject) Henderson proposed that nursing is more than carrying
develops from observing and studying the relationship of out medical orders. It involves a special relationship and
one phenomenon to another. By developing a unique service between the nurse and the client (and his or her
body of scientific knowledge, it is now possible to predict family). According to Henderson, the nurse acts as a
which nursing interventions are most likely to produce temporary proxy, meeting the client’s health needs with
desired outcomes. knowledge and skills that neither the client nor family
members can provide.
In Nursing: A Social Policy Statement, 2nd edition
Integrating Nursing Theory (2003), the American Nurses Association (ANA) defines
nursing as follows:
The word theory (opinion, belief, or view that explains a
process) comes from a Greek word that means vision. • Protection, promotion, and optimization of health and
For example, a scientist may study the relation between abilities
sunlight and plants and derive a theory of photosynthe- • Prevention of illness and injury
sis that explains how plants grow. Others who believe in • Alleviation of suffering through the diagnosis and
treatment of human response
the theorist’s view may then apply the theory for their
• Advocacy in the care of individuals, families, commu-
own practical use.
nities, and populations
Nursing has undergone a similar scientific review.
Florence Nightingale and others have examined the The ANA (2003) further attests that six essential features
relationships among humans, health, the environment, characterize nursing: (1) provision of a caring relationship
and nursing. The outcome of such analysis becomes the that facilitates health and healing, (2) attention to the range
basis for nursing theory (proposed ideas about what is of human experiences and responses to health and illness
involved in the process called nursing). Nursing programs within the physical and social environments, (3) integra-
then adopt a theory to serve as the conceptual frame- tion of objective data with knowledge gained from an ap-
work or model for their philosophy, curriculum, and most preciation of the client’s or group’s subjective experience,
importantly, approach to clients. Similarly, psychol- (4) application of scientific knowledge to the processes of
ogists have adopted and used Freud’s psychoanalytic diagnosis and treatment through the use of judgment and
theory or Skinner’s behavioral theory, for example, as critical thinking, (5) advancement of professional nursing
a model for diagnostic and therapeutic interventions knowledge through scholarly inquiry, and (6) influence
with clients. on social and public policy to promote 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 tional dependent and interdependent functions involving
current nursing literature. physicians. As the role of the nurse evolves, the definition
of nursing and the scope of nursing practice will undergo
further revisions.
Defining Nursing
To clarify for the public, and nurses themselves, what

THE EDUCATIONAL LADDER
nursing encompasses, various working definitions have
been proposed. Nightingale is credited with the earliest Two basic educational options are available to those inter-
modern definition: “putting individuals in the best pos- ested in a nursing career: practical (vocational) nursing
sible condition for nature to restore and preserve health.” and registered nursing. Several types of programs prepare
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 contribut-
ing 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 Practice Nurses modify unhealthy aspects of the environment to put the client in the
best 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 Practice Nurses assist in performing those activities that the client would perform if
he or she had strength, will, and knowledge.
Dorothea Orem Self-Care Theory
1914– Man An individual who uses self-care to sustain life and health, recover from
disease or injury, or 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 man interacts 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 Practice Nurses assist clients with self-care to improve or to maintain health.
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 Practice Nurses assess biologic, psychological, and social factors interfering with
health; alter the stimuli causing the maladaptation; and evaluate the
effectiveness of the action taken.
graduates in registered nursing. Each educational track • Opportunity for part-time versus full-time enrollment
provides the knowledge and skills for a particular entry • Ease of movement into the next level of education
level of practice. The following factors influence the choice
of a nursing program:
Practical/Vocational Nursing
• Career goals
• Geographic location of schools During World War II, many registered nurses enlisted
• Costs involved in the military. As a result, civilian hospitals, clinics,
• Length of programs schools, and other health care agencies faced an acute
• Reputation and success of graduates shortage of trained nurses. To fill the void expeditiously,
• Flexibility in course scheduling abbreviated programs in practical nursing were developed
across the country to teach essential nursing skills. The preparatory program is the shortest, many consider it the
goal was to prepare graduates to care for the health needs most economical.
of infants, children, and adults who were mildly or Licensed graduates are a vital link between the regis-
chronically ill or convalescing so that registered nurses tered nurse and unlicensed assistive personnel (UAP).
could be used effectively to care for acutely ill clients. They work under the supervision of a registered nurse,
After the war, many registered nurses opted for part- physician, or dentist. LPNs or LVNs provide nursing
time employment or resigned to become full-time house- care to clients with common health needs that have a
wives. Thus, the need for practical nurses persisted. It predictable outcome. Their scope of practice is described
became obvious that the role of practical nurses would not in the nurse practice act in the state in which the nurse
be temporary. Consequently, leaders in practical nursing is licensed. Each state interprets the limits of practice dif-
programs organized to form the National Association ferently. For example, in one state, an LPN may monitor
for Practical Nurse Education and Service, Inc. This and hang intravenous solutions, discontinue the infu-
group worked to standardize practical nurse education sion, and dress the site. The same may not be true in
and to facilitate the licensure of graduates. By 1945, eight another state. An LPN also may delegate tasks to UAPs,
states had approved practical nurse programs (Mitchell who may or may not have acquired state certification.
& Grippando, 1993). In 1995, enrollments in licensed The LPN, therefore, must know the extent to which
practical nurse (LPN)/licensed vocation nurse (LVN) nursing assistants can function and the outcomes of their
programs peaked at 47,684, declining to 34,650 in 2001. actions (see guidelines for delegation under “Registered
In 2002, a slight and continuing increase began (Fig. 1-4). Nursing”). Because of the geographic disparities in LPN
The Bureau of Labor Statistics (2005) predicts that job practice, educational programs, and state regulations,
opportunities in practical nursing will increase by up to the National Council of State Boards of Nursing is
17% by 2014. researching and pursuing strategies to promote more
Career centers, vocational schools, hospitals, indepen- consistency (Practical Nurse Scope of Practice White
dent agencies, and community colleges generally offer Paper [2005]; http://www.ncsbn.org/pdfs/Final_11_05_
practical nursing programs, arranging clinical experiences Practical_Nurse_Scope_Practice_White_Paper.pdf). Addi-
at local community hospitals, clinics, and nursing homes. tional information on nursing practice standards for the
The length of a practical nursing program averages from licensed practical/vocational nurse can be obtained from
12 to 18 months, after which graduates are qualified to the National Federation of Licensed Practical Nurses Web
take their licensing examination. Because this nursing site: http://www.nflpn.org. To provide career mobility,
125,000
96,610
100,000 94,321
89,619
83,239
76,523 76,688
75,000 71,392 70,692
68,759
50,000 47,684
44,942 44,075
43,351
40,195 38,297
37,372 35,572 34,650
25,000
0
1995 1996 1997 1998 1999 2000 2001 2002 2003
LPN/ LVN RN
FIGURE 1-4 • Trends in LPN/LVN and RN enrollments, 1995–2003. Numbers are based on U.S. candi-
dates taking the NCLEX for the first time in respective years, as reported by the National Council of State
Boards of Nursing.
many schools of practical nursing have developed “artic- • Right person . . . knowing the unique competencies
ulation agreements” to help graduates enroll in another of the caregiver
school that offers a path to registered nursing through • Right direction (communication) . . . providing suf-
associate or baccalaureate degrees. ficient information
• Right supervision . . . being available for assistance
(Aucoin, 2004)
Registered Nursing Students can choose one of three paths to become a reg-
istered nurse: a hospital-based diploma program, a pro-
Registered nurses work under the direction of a physi- gram that awards an associate degree in nursing, or a
cian or dentist in various health care settings ranging baccalaureate nursing program. All three meet the re-
from preventive to acute care. They manage or provide quirements for taking the national licensing examination
direct care to clients who are stable but may have com- (NCLEX-RN). A person licensed as a registered nurse
plex health needs, or who are unstable with unpredict- may work directly at the bedside or supervise others in
able outcomes. In addition to managing client care, RNs managing the care of groups of clients.
educate clients and the public about various medical Table 1-3 describes how educational programs pre-
conditions and provide emotional support to clients and pare graduates to assume separate but coordinated re-
their family members (U.S. Department of Labor, 2006). sponsibilities. When hiring new graduates, however, many
RNs delegate client care to LPNs and UAPs when appro- employers do not differentiate between these educational
priate. Delegation requires adhering to the following programs, arguing that “a nurse is a nurse.”
guidelines:
• Right task . . . matching the client’s needs with the
Hospital-Based Diploma Programs
caregiver’s skills Diploma programs were the traditional route for nurses
• Right circumstance . . . ensuring that the situation is through the middle of the 20th century. Their decline
appropriate became obvious in the 1970s, and the number of diploma
TABLE 1-3 LEVELS OF RESPONSIBILITIES FOR THE NURSING PROCESS*

PRACTICAL/VOCATIONAL NURSE ASSOCIATE DEGREE NURSE BACCALAUREATE NURSE
Assessing Gathers data by interviewing, Collects data from people with com- Identifies the information needed
observing, and performing a basic plex health problems with unpre- from individuals or groups to
physical examination of people dictable outcomes, their family, provide an appropriate nursing
with common health problems medical records, and other health database
with predictable outcomes team members
Diagnosing Contributes to the development of Uses a classification list to write a Conducts clinical testing of
nursing diagnoses by reporting nursing diagnostic statement, approved nursing diagnoses
abnormal assessment data including the problem, its etiol- Proposes new diagnostic cate-
ogy, and signs and symptoms gories for consideration and
Identifies problems that require col- approval
laboration 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 indi-
prevent, reduce, or eliminate orders that reflects the standards viduals 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 prob-
lems of individuals or groups
Evaluating Shares observations on the progress Evaluates the outcomes of nursing Conducts research on nursing
of the client in reaching estab- care routinely activities that may be improved
lished goals Revises the plan of care with further study
Contributes to the revision of the
plan of care
*Note that each more advanced practitioner can perform the responsibilities of those identified previously.
among all registered nurse programs. Despite the con-

Associate Degree densed curriculum, graduates of associate degree programs
59%
Baccalaureate have demonstrated a high level of competence in passing
37%
the NCLEX-RN.
Baccalaureate Programs
Although collegiate nursing programs were established
at the beginning of the 20th century, until recently they
did not attract many students. Their popularity has been
increasing, perhaps because of proposals by the ANA
Diploma and the National League for Nursing to establish bac-
4%
calaureate education as the entry level into nursing prac-
tice. The deadline for implementation of this goal, once
set for 1985, has been postponed for three reasons:
1 Associate Degree 2 Diploma 3 Baccalaureate • The date coincided with a national shortage of nurses.
• There was tremendous opposition from nurses with-
FIGURE 1-5 • Distribution of basic RN programs. Numbers are based out degrees, who believed that their titles and positions
on educational programs of U.S. candidates taking the NCLEX-RN would be jeopardized.
examination in 2003, as reported by the National Council of State
Boards of Nursing.
• Employers feared that paying higher salaries to per-
sonnel with degrees would escalate budgets beyond
their financial limits.
programs continues to be lowest in relation to other basic Consequently, the adoption of a unified entry level into
nursing educational programs (Fig. 1-5). The reasons for practice remains in limbo.
their decline are twofold. First, there has been a movement Although this preparatory program is the longest and
to increase professionalism in nursing by encouraging most expensive, baccalaureate-prepared nurses have the
education in colleges and universities. Second, hospitals greatest flexibility in qualifying for nursing positions,
can no longer financially subsidize schools of nursing. both staff and managerial. Nurses with a baccalaureate
Diploma nurses were, and are, well trained. Because degree usually are preferred in areas requiring substan-
of their vast clinical experience (compared with students tial independent decision making, such as public health
from other types of programs), they often are character- and home health nursing.
ized as more self-confident and easily socialized into the Currently, many nurses are returning to school to earn
role requirements of a graduate nurse. baccalaureate degrees. Articulation has been difficult for
A hospital-based diploma program generally lasts some because of problems transferring credits for courses
3 years. Many hospital schools of nursing collaborate they took during their diploma or associate degree pro-
with nearby colleges to provide basic science and human- grams. To increase enrollment, some collegiate programs
ities courses; graduates can transfer these credits if they are offering nurses an opportunity to obtain credit by pass-
choose to pursue associate or baccalaureate degrees later. ing “challenge examinations.” In addition, many colleges
and universities provide satellite or outreach programs to
Associate Degree Programs accommodate nurses who cannot go to school full-time or
travel long distances. Despite a renewed interest in acquir-
During World War II, when qualified nurses were being ing a nursing education, approximately 125,000 qualified
used for the military effort, hospital-based schools accel- applicants for admission were rejected in 2004 because
erated the education of some registered nursing students too few nursing faculty were available to teach the requi-
through the Cadet Nurse Corps. After the war ended, site courses (National League for Nursing, 2004).
Mildred Montag, a doctoral nursing student, began to
question whether it was necessary for students in regis-
tered nursing programs to spend 3 years acquiring a basic Graduate Nursing Programs
education. She believed that nursing education could be
shortened to 2 years and relocated to vocational schools Graduate nursing programs are available at both the mas-
or junior or community colleges. The graduate from this ter’s and doctoral levels. Master’s-prepared nurses fill roles
type of program would acquire an associate degree in as clinical specialists, nurse practitioners, administrators,
nursing, would be referred to as a technical nurse, and and educators. Nurses with doctoral degrees conduct re-
would not be expected to work in a management position. search and advise, administer, and instruct nurses pur-
This type of nursing preparation has proved extremely suing undergraduate and graduate degrees. Although a
popular and now commands the highest enrollment graduate degree in nursing is preferred, some nurses pur-
BOX 1-2 ● Rationales for Acquiring

• Negative stereotypes for traditionally female occupa-
Continuing Education tions like nursing (Donley et al., 2002; National Council
of State Boards of Nursing, 2003).
❙ No basic program provides all the knowledge and skills needed for a lifetime
career.
❙ Current advances in technology make previous methods of practice obsolete.
❙ Assuming responsibility for self-learning demonstrates personal accountability. Governmental Responses
❙ To ensure the public’s confidence, nurses must demonstrate evidence of current
competence. The federal government attempted to address the shortage
❙ Practicing according to current nursing standards helps to ensure that care is
of nurses by proposing and approving the Nurse Reinvest-
legally safe.
❙ Renewal of state licensure often is contingent on evidence of continuing
ment Act. This legislation authorizes the following:
education. 1. Loan repayment programs and scholarships for nurs-
ing students
2. Funding for public service announcements to en-
sue advanced education in fields outside nursing, such courage more people to enter nursing
as business, leadership, and education, to enhance their 3. Career ladder programs to facilitate advancement
nursing career. to higher levels of nursing practice
4. Establishment of nurse retention and client safety
enhancement grants
Continuing Education 5. Grants to incorporate gerontology into nursing
curricula
Continuing education in nursing is defined as any planned 6. Loan repayment programs for nursing students who
learning experience beyond the basic nursing program agree to teach after graduation (American Asso-
(ANA, 1974, 2003). Nightingale is credited with having ciation of Colleges of Nursing, 2005; U.S. Depart-
said, “to stand still is to move backwards.” The principle ment of Health and Human Services, 2002)
that learning is a lifelong process still applies. Box 1-2 lists
reasons why nurses, in particular, pursue continuing edu-
cation. Many states now require nurses to show proof of Proactive Strategies
continuing education to renew their nursing license.
Rather than taking a “wait-and-see” position about the
nursing shortage and the ramifications of the Nurse Re-
FUTURE TRENDS investment Act, many nurses are proactively responding
to the trends affecting their role in health care (Table 1-4).
Two major issues dominate nursing today. The first con- Nurses are dealing with the unique challenges of the
cerns methods of eliminating the shortage of nurses. The 21st century by
second involves strategies for responding to a growing
• Pursuing post-licensure education.
aging population with chronic health problems.
• Training for advanced practice roles (nurse practitioner,
Health care officials hope that enrollment in all nursing
nurse midwifery) to provide cost-effective health care
programs and continuing education will improve to reduce
in areas in which numbers of primary care physicians
the current and projected critical shortage of nurses. In
are inadequate.
2002, a shortage of 110,000 registered nurses represented
• Becoming cross-trained (able to assume non-nursing
a 6% deficit. The future looks even more alarming. The
jobs, depending on the census or levels of client acuity
nursing shortage is projected to double to 12% by 2010,
on any given day). For example, nurses may be trained
triple to 20% by 2015, and reach 29% by 2020 (U.S. Depart-
to provide respiratory treatments and to obtain elec-
ment of Health and Human Services, 2002). Some factors
trocardiograms, duties that non-nursing health care
contributing to the nursing shortage include the following:
workers previously performed.
• Retirement rate of nurses that exceeds their replacement • Learning more about multicultural diversity (unique char-
• Attrition of aging faculty, which restricts numbers of acteristics of ethnic groups) as it affects health beliefs
student applicants and values, food preferences, language, communication,
• Increased aging population requiring health care roles, and relationships.
• Disappointing salaries for nurses with longevity • Supporting legislative efforts toward national health
employment insurance that involves nurses in primary care (the
• Job dissatisfaction as a result of stress and the un- first health care worker to assess a person with a health
relenting rigor of working in health care need).
• Heavier workloads and sicker clients • Promoting wellness through home health and
• Publicity about mandatory overtime community-based programs.
• Downsizing nursing staff from dwindling revenues • Helping clients with chronic diseases learn techniques
and managed care policies for living healthier and, consequently, longer lives.
TABLE 1-4 TRENDS IN HEALTH CARE AND NURSING

HEALTH CARE NURSING
The most underserved health care populations include older adults, Enrollments and numbers of graduates from
ethnic minorities, and the poor, who delay seeking early treatment LPN/LVN and RN educational programs are not
because they cannot afford it. keeping pace with projected shortages.
The number of uninsured rose from 37 million in 1995 to 41.2 million More licensed nurses are earning master’s and doc-
in 2002. This figure could exceed 48 million by 2009. toral degrees.
Medicare and Medicaid benefits are being modified and reduced. There continues to be a shortage of nurses in various
Chronic illness is the major health problem. health care settings because of decreased enroll-
ments, retirement, attrition, and cost-containment
Disease and injury prevention and health promotion are priorities.
measures.
Medicine tends to focus on high technology, which improves outcomes
Hospital employment is decreasing.
for a select few.
Client-to-nurse ratios in employment settings are
Hospitals are downsizing and hiring unlicensed personnel to perform
higher.
procedures once in the exclusive domain of licensed nurses for cost
containment. More high-acuity clients are in previously nonacute
settings such as long-term and intermediate health
There are fewer primary care physicians in rural areas.
care facilities.
Changes in reimbursement practices have created a shift in decision
Job opportunities have expanded to outpatient ser-
making from hospitals, nurses, and physicians to insurance companies.
vices, home health care, hospice programs, com-
Health care costs continue to increase despite managed care practices munity health, and mental health agencies.
(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 paying 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.
• Referring clients with health problems for early treat- include assessment skills, caring skills, counseling skills,
ment, a practice that requires the fewest resources and and comforting skills.
thus minimizes expenses.
• Coordinating nursing services across health care
settings—that is, discharge planning (managing transi- Assessment Skills
tional needs and ensuring continuity).
• Developing and implementing clinical pathways, stan- Before the nurse can determine what care a person re-
dardized multidisciplinary plans for a specific diagnosis quires, he or she must determine the client’s needs and
or procedure that identify aspects of care to be per- problems. This requires the use of assessment skills (acts
formed during a designated length of stay (Fig. 1-6). that involve collecting data), which include interviewing,
• Participating in quality assurance (process of identifying observing, and examining the client and in some cases the
and evaluating outcomes). client’s family ( family is used loosely to refer to the peo-
• Concentrating on the knowledge and skills to manage ple with whom the client lives and associates). Although
the health needs of older Americans whose numbers will the client and the family are the primary sources of infor-
reach 70 million by 2030 (National Center for Chronic mation, the nurse also reviews the client’s medical record
Disease Prevention and Health Promotion, 2005). and talks with other health care workers to obtain facts.
Assessment skills are discussed in more detail in Unit 4.
UNIQUE NURSING SKILLS Caring Skills

Although employment location and how they carry out (nursing interventions that restore or main-
Caring skills
nursing skills (activities unique to the practice of nursing) tain a person’s health) may involve actions as simple as
differ according to educational preparation, all nurses assisting with activities of daily living (ADLs), the acts that
share the same philosophy. In keeping with Nightingale’s people normally do every day. Examples of ADLs in-
traditions, contemporary nursing practice continues to clude bathing, grooming, dressing, toileting, and eating.
C H A P T E R 1 ● Nursing Foundations
FIGURE 1-6 • Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.)
(continued)
13
(Continued).
•
FIGURE 1-6
Increasingly, however, the nurse’s role is expanding to

include the safe care of clients who require invasive or
highly technical equipment. This textbook introduces
beginning nurses to the concepts and skills needed to
provide care for clients whose disorders have fairly pre-
dictable outcomes. After this foundation has been estab-
lished, students may add to their initial knowledge base.
Traditionally, nurses always have been providers of
physical care for people unable to meet their own health
needs independently. But caring also involves the con-
cern and attachment that result from the close relation-
ship of one human being with another. Nevertheless, the
nurse ultimately wants clients to become self-reliant.
The nurse who assumes too much care for clients, like a
parent who continues to tie a child’s shoes, often delays
their independence. FIGURE 1-7 • This nurse offers comfort and emotional support.
(Copyright B. Proud.)
Counseling Skills
Comforting Skills
A counselor is one who listens to a client’s needs, responds
with information based on his or her area of expertise, and Nightingale’s presence and the light from her lamp com-
facilitates the outcome that a client desires. Nurses imple- municated comfort to the frightened British soldiers. As
ment counseling skills (interventions that include communi- a result of that heritage, contemporary nurses understand
cating with clients, actively listening during exchanges of that illness often causes feelings of insecurity that may
information, offering pertinent health teaching, and pro- threaten the client’s or family’s ability to cope; they may
viding emotional support) in relationships with clients. feel very vulnerable. It is then that the nurse uses comfort-
To understand the client’s perspective, the nurse uses ing skills (interventions that provide stability and security
therapeutic communication techniques to encourage ver- during a health-related crisis) (Fig. 1-7). The nurse be-
bal expression (see Chap. 7). The use of active listening comes the client’s guide, companion, and interpreter.
(demonstrating full attention to what is being said, hearing This supportive relationship generally increases trust and
both the content being communicated and the unspoken reduces fear and worry.
message) facilitates therapeutic interactions. Giving clients As a result of one woman’s efforts, modern nursing
the opportunity to be heard helps them to organize their was born. It has continued to mature and flourish ever
thoughts and to evaluate their situation more realistically. since. The skills that Nightingale performed on a very
When the client’s perspective is clear, the nurse pro- grand scale are repeated today during each and every
vides pertinent health information without offering nurse–client relationship.
specific advice. By reserving personal opinions, nurses
promote the right of every person to make his or her own
decisions and choices on matters affecting health and ill-
ness care. The role of the nurse is to share information
about potential alternatives, allow clients the freedom to Identify which of the following nursing actions is an
choose, and support the final decision. assessment skill, caring skill, counseling skill, and comfort-
While giving care, the nurse finds many opportunities ing skill: (a) the nurse discusses with a family the progress
of a client undergoing surgery; (b) the nurse provides
to teach clients how to promote healing processes, stay
information on advanced directives, which allows a client
well, prevent illness, and carry out ADLs in the best pos-
to identify his or her end-of-life decisions; (c) the nurse
sible way. People know much more about health and asks a client to identify his or her current health problems;
health care today, and they expect nurses to share accu- (d) the nurse provides medication for a client in pain.
rate information with them.
Because clients do not always communicate their feel-
ings to strangers, nurses use empathy (intuitive aware-
ness of what the client is experiencing) to perceive the CRITICAL THINKING E X E R C I S E S
client’s emotional state and need for support. This skill
differs from sympathy (feeling as emotionally distraught 1. Explain the reason that Congress enacted the Nurse Re-
as the client). Empathy helps the nurse become effective investment Act.
in providing for the client’s needs while remaining com- 2. Name four types of skills that all nurses perform when
passionately detached. caring for clients.
2
Chapter
Nursing
Process
LEARNING OBJECTIVES
● Define nursing process.
● Describe six characteristics of the nursing process.
● List five steps in the nursing process.
● Identify four sources for assessment data.
● Differentiate between a data base assessment and a focus assessment.
● Distinguish between a nursing diagnosis and a collaborative problem.
● List three parts of a nursing diagnostic statement.
● Describe the rationale for setting priorities.
● Discuss appropriate circumstances for short-term and long-term goals.
● Identify four ways to document a plan of care.
● Describe the information that is documented in reference to the plan of care.
● Discuss three outcomes that result from evaluation.
● Describe the process of concept mapping as an alternative learning strategy for student clinical
experiences.
WORDS TO KNOW
IN the past, nursing practice consisted of actions based mostly on common sense and
actual diagnosis the examples set by older, more experienced nurses. The actual care of clients tended
assessment to be limited to the physician’s medical orders. Although nurses today continue to
collaborative problems
work interdependently with physicians and other health care practitioners, they now
concept mapping
critical thinking plan and implement client care more independently. In even stronger terms, nurses
data base assessment are held responsible and accountable for providing client care that is safe and appro-
diagnosis priate and reflects currently accepted standards for nursing practice.
evaluation
focus assessment
goal
implementation DEFINITION OF THE NURSING PROCESS
long-term goals
nursing diagnosis
nursing orders A process is a set of actions leading to a particular goal. The nursing process is an orga-
nursing process nized sequence of problem-solving steps used to identify and to manage the health
objective data problems of clients (Fig. 2-1). It is the accepted standard for clinical practice estab-
planning lished by the American Nurses Association (ANA) (Box 2-1).
possible diagnosis
risk diagnosis
The nursing process is the framework for nursing care in all health care settings.
short-term goals When nursing practice follows the nursing process, clients receive quality care in
signs minimal time with maximal efficiency.
standards for care
subjective data
symptoms
syndrome diagnosis
wellness diagnosis
16
C H A P T E R 2 ● Nursing Process 17
Assessment
• Based on knowledge. The ability to identify and to re-
1. Collect data
solve client problems requires critical thinking, which is
2. Organize data a process of objective reasoning or analyzing facts
to reach a valid conclusion. Critical thinking enables
nurses to determine which problems necessitate col-
Evaluation Diagnosis laboration with the physician and which fall within
1. Monitor client 1. Analyze data the independent domain of nursing. Critical thinking
outcomes 2. Identify nursing helps nurses select appropriate nursing interventions
2. Resolve, continue, diagnoses and
revise the current collaborative problems for achieving predictable outcomes.
plan for care • Planned. The steps of the nursing process are orga-
nized and systematic. One step leads to the next in an
orderly fashion.
• Client-centered. The nursing process makes it easier to
Implementation Planning formulate a comprehensive and unique plan of care for
1. Carry out the 1. Prioritize problems each client. Clients are expected, whenever possible, to
nursing orders 2. Identify measurable actively participate in their care.
2. Document the outcomes (goals) • Goal-directed. The nursing process involves a united
nursing care and 3. Select nursing effort between the client and the nursing team to achieve
client responses interventions
4. Document the plan of desired outcomes.
care • Prioritized. The nursing process provides a focused way
to resolve the problems that represent the greatest threat
FIGURE 2-1 • The steps in the nursing process. to health.
• Dynamic. Because the health status of any client is con-
stantly changing, the nursing process acts like a con-
tinuous loop. Evaluation, the last step in the nursing
CHARACTERISTICS OF process, involves data collection, beginning the process
THE NURSING PROCESS again.
The nursing process has seven distinct characteristics:

STEPS OF THE NURSING PROCESS
• Within the legal scope of nursing. Most state nurse
practice acts define nursing as an independent problem-
The steps of the nursing process, each of which is dis-
solving role that involves the diagnosis and treat-
cussed in detail throughout this chapter, are as follows:
ment of human responses to actual or potential health
problems. 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
BOX 2-1 ● Standards of Clinical Nursing Practice 5. Evaluation
Standard I. Assessment LPNs and RNs have different responsibilities related to
The nurse collects patient health data. the nursing process. For example, RNs may delegate some
Standard II. Diagnosis parts of an initial assessment to an LPN, but the RN is
The nurse analyzes the assessment data in determining diagnoses. still responsible for ensuring that data collection is com-
Standard III. Outcome Identification plete. After the assessment data are obtained, the RN
The nurse identifies expected outcomes individualized to the patient. develops the initial plan of care. Differences exist in var-
ious locales as to whether the LPN makes changes to the
Standard IV. Planning
The nurse develops a plan of care that prescribes interventions to attain plan of care independently or collaboratively with the
expected outcomes. RN (National Council of State Boards of Nursing, 2005,
Standard V. Implementation
Practical Nurse Scope of Practice White Paper). Also
The nurse implements the interventions identified in the plan of care. refer to Table 1-3, Levels of Responsibility for the Nurs-
ing Process, in Chapter 1.
Standard VI. Evaluation
The nurse evaluates the patient’s progress toward attainment of outcomes.
Assessment
Reprinted with permission from American Nurses Association. (1998).
Standards of clinical nursing practice, (2nd ed.). Washington, DC:
American Nurses Association. Assessment, the first step in the nursing process, is the
systematic collection of facts, or data. Assessment begins
BOX 2-2 ● Examples of Objective and Subjective Data Sources for Data
The primary source for information is the client. Sec-
OBJECTIVE DATA SUBJECTIVE DATA
ondary sources include the client’s family, reports, test
Weight Pain results, information in current and past medical records,
Temperature Nausea and discussions with other health care workers.
Skin color Depression
Blood cell count Fatigue Types of Assessments
Vomiting Anxiety
Bleeding Loneliness There are two types of assessments: a data base assess-
ment and a focus assessment (Table 2-1).
DATA BASE ASSESSMENT. A data base assessment (initial

with the nurse’s first contact with a client and continues information about the client’s physical, emotional, social,
as long as a need for health care exists. During assess- and spiritual health) is lengthy and comprehensive. The
ment, the nurse collects information to determine areas nurse obtains data base information during the admis-
of abnormal function, risk factors that contribute to health sion interview and physical examination (see Chap. 13).
problems, and client strengths (Alfaro-LeFevre, 2005). Health care facilities generally provide a printed form to
use as a guide (Fig. 2-2). Information obtained during a
data base assessment serves as a reference for comparing
Types of Data
all future data and provides the evidence used to iden-
Data are either objective or subjective (Box 2-2). Objective tify the client’s initial problems. Comparisons of ongoing
data are observable and measurable facts and are referred assessments with baseline data help determine whether
to as signs of a disorder. An example is a client’s blood the client’s health is improving, deteriorating, or remain-
pressure measurement. Subjective data consist of informa- ing unchanged.
tion that only the client feels and can describe, and are
called symptoms. An example is pain. FOCUS ASSESSMENT. A focus assessment is information
that provides more details about specific problems and
expands the original data base. For instance, if during the
initial interview the client tells the nurse that constipa-
Stop • Think + Respond BOX 2-1 tion is the rule rather than the exception, more questions
Which of the following represent objective data? follow. The nurse obtains data about the client’s dietary
habits, level of activity, fluid intake, current medications,
1. A client rates his pain as 8 on a scale of 0 to10, with 10
frequency of bowel elimination, and stool characteris-
being the most pain he has ever experienced.
2. A client has an incisional scar in the right lower quad- tics. The nurse may ask the client to save a stool speci-
rant of the abdomen. men for inspection.
3. A client says she slept very well and feels rested. Focus assessments generally are repeated frequently or
4. A client’s blood pressure is 165/86 mm Hg. on a scheduled basis to determine trends in a client’s con-
5. A client’s heart rate is irregular. dition and responses to therapeutic interventions. Exam-
ples include conducting postoperative surgical assessments
TABLE 2-1 COMPARISON OF DATA BASE AND FOCUS ASSESSMENTS

DATA BASE ASSESSMENT FOCUS ASSESSMENT
Obtained on admission Compiled throughout subsequent care

Consists of predetermined questions and systematic Consists of unstructured questions and collection of physical
head-to-toe examination assessments
Performed once Repeated each shift or more often
Suggests possible problems Rules out or confirms problems
Findings documented on an admission assessment form Findings documented on a checklist or in progress notes
Time-consuming; may take 1 hour or more Completed in a brief amount of time (about 15 minutes)
Supplies a broad, comprehensive volume of data Collects limited data
Provides breadth for future comparisons Adds depth to the initial data base
Reflects the client’s condition on entering the health Provides comparative trends for evaluating the client’s response
care system to treatment
FIGURE 2-2 • One page of a multipage admission assessment form is shown. (Courtesy of the Commu-
nity Health Center of Branch County, Coldwater, MI.)
(see Chap. 27), monitoring the client’s level of pain before five groups: actual, risk, possible, syndrome, and wellness
and after administering medications, and checking the (Table 2-2).
neurologic status of a client with a head injury.
THE NANDA LIST. The ANA has designated the North
Organization of Data American Nursing Diagnosis Association (NANDA) as
the authoritative organization for developing and approv-
Interpreting data is easier if information is organized. ing nursing diagnoses. NANDA is the clearinghouse for
Organization involves grouping related information. For proposals suggesting diagnoses that fall within the inde-
example, consider the following list of words: apple, pendent domain of nursing practice. NANDA reviews the
wheels, orchard, pedals, tree, and handlebars. At first proposals for appropriateness. While research is ongoing,
glance, they appear to be a jumble of terms. If asked to NANDA incorporates its findings into a list published for
cluster the related terms, however, most people would clinical use. The most recent index, which is revised every
correctly group apple, tree, and orchard together, and 2 years, is provided on the inside back cover.
wheels, pedals, and handlebars together. Although entries in the NANDA list change, most
Nurses organize assessment data similarly. Using authorities believe that nurses should use the language of
knowledge and past experiences, they cluster related approved diagnoses whenever possible. When a client’s
data (Box 2-3). Data organized into small groups is eas- problem does not fit into any of the NANDA-approved
ier to analyze and takes on more significance than when categories, the nurse can use his or her own terminology
the nurse considers each fact separately or examines the when stating the nursing diagnosis.
entire group at once.
DIAGNOSTIC STATEMENTS. An actual nursing diagnostic
statement contains three parts:
1. Name of the health-related issue or problem as iden-
Stop • Think + Respond BOX 2-2 tified in the NANDA list
Organize the following data into two related clusters: 2. Etiology (its cause)
cough, dry skin, infrequent urination, fever, nasal 3. Signs and symptoms
congestion, thirst.
The name of the nursing diagnosis is linked to the eti-
ology with the phrase “related to,” and the signs and
Diagnosis TABLE 2-2

CATEGORIES OF NURSING
DIAGNOSES
Diagnosis, the second step in the nursing process, is the TYPE EXPLANATION AND EXAMPLE
identification of health-related problems. Diagnosis re-
Actual diagnosis A problem that currently exists
sults from analyzing the collected data and determining
Impaired Physical Mobility related to
whether they suggest normal or abnormal findings. pain as evidenced by limited range
of motion, reluctance to move
Nursing Diagnoses Risk diagnosis A problem the client is uniquely
at risk for developing
Nurses analyze data to identify one or more nursing Risk for Deficient Fluid Volume
diagnoses. A nursing diagnosis is a health issue that can related to persistent vomiting
be prevented, reduced, resolved, or enhanced through Possible diagnosis A problem may be present, but
independent nursing measures. It is an exclusive nursing requires more data collection to
responsibility. Nursing diagnoses are categorized into rule out or confirm its existence
Possible Parental Role Conflict
related to impending divorce
Syndrome diagnosis Cluster of problems predicted to
be present because of an event
BOX 2-3 ● Organization of Data
or situation (Carpenito-Moyet,
2007)
Assessment Findings
Rape Trauma Syndrome and Disuse
Lassitude; distended abdomen; dry, hard stool passed with difficulty; fever;
Syndrome
weak cough; thick sputum
Wellness diagnosis A health-related problem with
Related Clusters which a healthy person obtains
Lassitude, fever nursing assistance to maintain
Weak cough, thick sputum or perform at a higher level
Distended abdomen; dry, hard stool passed with difficulty Potential for Enhanced Breastfeeding
BOX 2-4 ● Parts of a Nursing Diagnostic Statement

• Documenting the complications for which clients are
at risk.
1. Disturbed Sleep Pattern = problem • Making pertinent assessments to detect complications.
2. Related to excessive intake of coffee = etiology • Reporting trends that suggest development of compli-
3. As manifested by difficulty in falling asleep, feeling tired during the day, and cations.
irritability with others = signs and symptoms
• Managing the emerging problem with nurse- and
physician-prescribed measures.
• Evaluating the outcomes.
symptoms are identified with the phrase “as manifested Collaborative problems are identified on a client’s
(or evidenced) by” (Box 2-4). plan for care with the abbreviation PC, which stands for
Different types of diagnoses have different stems. Risk Potential Complication (Table 2-3). Because a collabora-
diagnoses are prefaced with the term “risk for,” as in Risk tive problem requires the nurse to use diagnostic processes,
for Impaired Skin Integrity related to inactivity. The some nursing leaders are proposing the use of the term
word “possible” is used in a diagnostic statement to indi- “collaborative diagnosis” instead (Alfaro-LeFevre, 2005).
cate uncertainty—for example, Possible Sexual Dysfunc-
tion related to anxiety. Wellness diagnoses are prefaced
with the phrase “Potential for enhanced.”
Risk and possible nursing diagnoses do not include the Stop • Think + Respond BOX 2-3
third part of the statement. In risk nursing diagnoses, the Which of the following nursing diagnostic statements is
signs or symptoms have not yet manifested; in possible written correctly based on the data and the information
nursing diagnoses, the data are incomplete. The factors in this chapter?
that place the client at risk or make the nurse suspect such Data: The client eats only bites of the food served. She
a diagnosis, however, are identified in the nursing assess- has lost 15 lbs in the last 3 weeks and currently weighs
ment documentation. Syndrome diagnoses and wellness 130 lbs, which is more than 10% underweight for her
diagnoses are one-part statements; they are not linked height. She has been experiencing chronic vomiting after
eating for the last 3 weeks and is physically weak.
with an etiology or signs and symptoms.
1. Risk for Imbalanced Nutrition: Less than Body Require-
Collaborative Problems ments related to vomiting
2. Imbalanced Nutrition: Less than Body Requirements
Collaborative problems are physiologic complications that related to inadequate intake of food secondary to
require both nurse- and physician-prescribed interven- vomiting as manifested by caloric intake below daily
tions. They represent an interdependent domain of nurs- requirements, recent weight loss of 15 lbs, and current
ing practice (Fig. 2-3). The nurse is specifically responsible weakness
and accountable for 3. Weight Loss related to vomiting as evidenced by
reduced intake of food
• Correlating medical diagnoses or medical treatment 4. Possible Malnutrition due to inadequate consumption
measures with the risk for unique complications. of nutrients
Planning
The third step in the nursing process is planning, or the

process of prioritizing nursing diagnoses and collabora-
Collaborative tive problems, identifying measurable goals or outcomes,
Nursing diagnoses Medical diagnoses selecting appropriate interventions, and documenting
problems
the plan of care. Whenever possible, the nurse consults
the client while developing and revising the plan.
Setting Priorities
Not all clients’ problems can be resolved in a brief time.
Nursing Other health care professionals Therefore, it is important to determine which problems
(medicine, social services, etc.) require the most immediate attention. This is done by set-
FIGURE 2-3 • These two overlapping circles illustrate that the nurse ting priorities. Prioritization involves ranking from those
independently treats nursing diagnoses. Doctors, other health profes- that are most serious or immediate to those of lesser
sionals, and nurses work together on collaborative problems. importance.
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 PC: Hypovolemic shock
volume
HIV positive (infected with AIDS virus) Decreased blood cells that fight infection PC: Immunodeficiency
Gastric decompression Removes acid and electrolytes PC: Alkalosis
(suctioning stomach fluid) PC: Electrolyte imbalance
Cardiac catheterization (inserting a Arterial bleeding PC: Hemorrhage
catheter into the heart)
There is more than one way to determine priorities. ment or outcome contains the criteria or objective evidence
One method nurses frequently use is Maslow’s Hierarchy for verifying that the client has improved. Depending
of Human Needs (see Chap. 4). Problems interfering with on the agency, nurses may identify short-term goals,
physiologic needs have priority over those affecting other long-term goals, or both.
levels of needs (Table 2-4). The ranking can change as
problems are resolved or new problems develop. SHORT-TERM GOALS. Nurses use short-term goals (outcomes
achievable in a few days to 1 week) most often in acute
Establishing Goals care settings because most hospital stays are no longer
than 1 week. Short-term goals have the following char-
A goal (expected or desired outcome) helps the nursing acteristics (Box 2-6):
team know whether the nursing care has been appropri-
ate for managing the client’s nursing diagnoses and collab- • Developed from the problem portion of the diagnostic
orative problems. Therefore, a written goal accompanies statement
each one. Although the terms goal and outcome are some- • Client-centered, reflecting what the client will accom-
times used interchangeably, outcomes are generally more plish, not the nurse
specific (Box 2-5). What is important is that the goal state- • Measurable, identifying specific criteria that provide
evidence of goal achievement
• Realistic, to avoid setting unattainable goals, which can
PRIORITIZING NURSING be self-defeating and frustrating
TABLE 2-4 • Accompanied by a target date for accomplishment, the
DIAGNOSES
HUMAN NEED EXAMPLES OF NURSING DIAGNOSES predicted time when the goal will be met. Identifying
a target date establishes a time line for evaluation.
Physiologic Imbalanced Nutrition: Less Than Body
Requirements LONG-TERM GOALS. Nurses generally identify long-term
Ineffective Breathing Pattern goals (desirable outcomes that take weeks or months to
Pain accomplish) for clients with chronic health problems that
Impaired Swallowing
Urinary Retention
require extended care in a nursing home or who receive
Safety and security Risk for Injury
community health or home health services. An example
Impaired Verbal Communication of a long-term goal for the client with a cerebrovascular
Disturbed Thought Processes accident (stroke) is the return of full or partial function
Anxiety to a paralyzed limb. The client is unlikely to have achieved
Fear
Love and belonging Social Isolation
Impaired Social Interactions
Interrupted Family Processes BOX 2-5 ● Goals versus Outcomes
Parental Role Conflict
Goal
Esteem and Disturbed Body Image
The client will be well hydrated by 8/23.
self-esteem Powerlessness
Caregiver Role Strain Outcome
Ineffective Breastfeeding The client will have adequate hydration as evidenced by an oral intake
Self-actualization Delayed Growth and Development between 2,000–3,000 mL/24 hours and a urine output ± 500 mL of the
Spiritual Distress intake amount by 8/23.
BOX 2-6 ● Components of Short-Term Goals

written standards or clinical pathways. Whatever method
is used, the Joint Commission on Accreditation of Health-
Nursing Diagnostic Statement care Organizations (JCAHO) requires that every client’s
Constipation related to decreased fluid intake, lack of dietary fiber, and lack of medical record provide evidence of the planned nursing
exercise as manifested by no normal bowel movement for the past 3 days, interventions for meeting the client’s needs (Carpenito-
abdominal cramping, and straining to pass stool
Moyet, 2007).
Short-Term Goal Nursing orders (directions for a client’s care) identify
The client will_________________ client–centered
the what, when, where, and how for performing nursing
have a bowel movement _________ identifies measurable criteria that
reflect the problem portion of the interventions. They provide specific instructions so that
diagnostic statement all health team members understand exactly what to do
in 2 days (specify date) __________ identifies a target date for achieve- for the client (Box 2-7). Nursing orders are also signed to
ment within a realistic time frame indicate accountability.
Standardized care plans are preprinted. Both com-
puter-generated and standardized plans provide general
suggestions for managing the nursing care of clients
this goal by discharge. If a client achieves short-term goals
with a particular problem. It is up to the nurse to trans-
in the hospital, however, he or she is more likely to
form the generalized interventions into specific nursing
achieve long-term goals during care at home or in other
orders and to eliminate whatever is inappropriate or
community settings.
unnecessary.
GOALS FOR COLLABORATIVE PROBLEMS. Goals for collab- Agency-specific standards for care (policies that indicate
orative problems are written from a nursing rather than which activities will be provided to ensure quality client
a client perspective. They focus on what the nurse will care) and clinical pathways (see Chap. 1) relieve the nurse
monitor, report, record, or do to promote early detection from writing time-consuming plans. Both tools help
and treatment (Alfaro-LeFevre, 2005). nurses use their time efficiently and ensure consistent
The format for writing a nursing goal is, “The nurse client care.
will manage and minimize (identify complication) by
(insert evidence of assessment, communication, and treat- Communicating the Plan of Care
ment activities),” or “(identify complication) will be man- Clients need consistency and continuity of care to
aged and minimized by (evidence).” For example, if the achieve goals. Therefore, the nurse shares the plan of
nurse identifies gastrointestinal bleeding as a PC, he or she care with nursing team members, the client, and the
may state the goal, “The nurse will examine emesis and client’s family. In some agencies, the client signs the
stools for blood and report positive test findings, changes plan of care.
in vital signs, and decreased red blood cell counts to the The plan of care is a permanent part of the client’s med-
physician” or “Gastrointestinal bleeding will be managed ical record. It is placed in the client’s chart, kept separately
and minimized as evidenced by negative Hemoccult tests, at the client’s bedside, or located in a temporary folder at
red blood cell count greater than 2.5 million/dL, and vital the nurses’ station for easy access. Wherever it is located,
signs within normal ranges.” each nurse assigned to the client refers to it daily, reviews
it for appropriateness, and revises it according to changes
Selecting Nursing Interventions in the client’s condition.
Planning the measures that the client and nurse will use
to accomplish identified goals involves critical thinking. Implementation
Nursing interventions are directed at eliminating the eti-
ologies. The nurse selects strategies based on the knowl- Implementation, the fourth step in the nursing process,
edge that certain nursing actions produce desired effects. means carrying out the plan of care. The nurse imple-
Whatever interventions are planned, they must be safe, ments medical orders as well as nursing orders, which
within the legal scope of nursing practice, and compati- should complement each other. Implementing the plan
ble with medical orders. involves the client and one or more members of the
Initial interventions generally are limited to selected health care team. A wide circle of care providers with
measures with the potential for success. Nurses should assorted roles may be called on to participate, either
reserve some interventions in case a client does not accom- directly or indirectly, in carrying out one client’s plan
plish the goal. of care (Fig. 2-5).
The medical record is legal evidence that the plan of
Documenting the Plan of Care
care has been more than just a paper trail. The information
Plans of care can be written by hand (Fig. 2-4), standard- in the chart shows a correlation between the plan and the
ized forms, computer generated, or based on an agency’s care that has been provided. In other words, the nurse’s
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 examples of improved interrupting.
others as manifested 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.
charting (see Chap. 9) reflects the written plan. Nurses

BOX 2-7 ● Nursing Orders
are just as accountable for carrying out nursing orders as
Nursing Order they are for physician’s orders.
Encourage fluids. In addition to identifying the nursing interventions that
Weaknesses have been provided, the record also describes the quantity
Lacks specificity and quality of the client’s response. Quoting the client
Likely to be interpreted differently helps identify his or her point of view and safeguards
May result in inconsistent or less than adequate care against incorrect assumptions. In short, appropriate
Improvement documentation maintains open lines of communication
Provide 100 mL of oral fluid every hour while awake. among members of the health care team, ensures the
client’s continuing progress, complies with accreditation
both nurse and client can speculate on what activities

need to be discontinued, added, or changed. Other health
team members who are familiar with a particular client
or problems similar to those of the client may offer their
Pharmacist Laboratory expertise as well. The evaluation of a client’s progress
Technician may be the subject of a nursing team conference. Some
units even invite the client and family to participate.
Dietitian USE OF THE NURSING PROCESS

LPN MD
Use of the nursing process is the standard for clinical
nursing practice. Nurse practice acts hold nurses account-
RN Physical able for demonstrating all the steps in the nursing process
Therapist when caring for clients. To do less implies negligence.
More detailed discussions of the nursing process can be
CLIENT found in specialty texts and in some of the suggested read-
Unlicensed Respiratory
ings at the end of this chapter. Nursing Guidelines 2-1
Assistive Personnel Therapist reiterate the sequence of the nursing process.
FIGURE 2-5 • Members of the health care team.
CONCEPT MAPPING
standards, and helps ensure reimbursement from gov-
ernment or private insurance companies. Concept mapping (also known as care mapping) is a method
of organizing information in graphic or pictorial form
(Jitlakoat, 2005). This strategy promotes learning by
Evaluation having the student gather data from the client and med-
ical record or a written case study, select significant
Evaluation,the fifth and final step in the nursing process, information, and organize related concepts on a one-
is the way by which nurses determine whether a client has or two-page working document. Various formats used
reached a goal. Although this is considered the last step, include a spider diagram with a central theme such as
the entire process is ongoing. By analyzing the client’s the client’s medical diagnosis, a hierarchy moving from
response, evaluation helps to determine the effective- general to specific, or a linear flow chart (Fig. 2-6). With
ness of nursing care (Table 2-5). additional knowledge, students draw lines or arrows to
Before revising a plan of care, it is important to dis- link or correlate relationships within the map. Organizing
cuss any lack of progress with the client. In this way, the data then facilitates identifying nursing diagnoses,
TABLE 2-5 OUTCOMES FROM EVALUATION

ANALYSIS REASON ACTION
The client has reached the goals. Plan was effective and implemented Discontinue the nursing orders.
consistently.
The client has made some progress. Care has been inconsistent. Check that nursing orders are clear and specific.
Target date was too ambitious. Continue care as planned; readjust target date.
Client’s response has been less than Revise the plan by adding nursing interventions or
expected. more frequent implementation.
The client has made no progress. The initial diagnosis was inaccurate. Revise problem list; write new goals and nursing
orders.
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.
NURSING GUIDELINES 2-1

Using the Nursing Process
❙ Collect information about the client. Data collection is the basis for
identifying problems.
❙ Organize the data. Organizing related data simplifies the process of
analysis.
❙ Analyze the data for what is normal and abnormal. Abnormalities
provide clues to the client’s problems.
❙ Identify actual, risk, possible, syndrome, and wellness nursing diag-
noses and collaborative problems. Problem identification directs the A
nurse to select methods for maintaining or restoring the client’s health.
❙ Prioritize the problem list. Setting priorities targets problems that
require the most immediate attention.
❙ Set goals with specific criteria for evaluating whether the problems
have been prevented, reduced, or resolved. Goals predict the
expected outcomes from nursing care.
❙ Select a limited number of appropriate nursing interventions. The
nurse uses scientific knowledge to determine which measures will
be most effective in accomplishing the goals of care.
❙ Give specific directions for nursing care. Specific directions promote
consistency and continuity among caregivers.
❙ Document the plan for care using whatever written format is
acceptable. A written plan provides a means of communication and
reference for the nursing team to follow. B
❙ Discuss the plan with nursing team members, the client, and family.
Verbally sharing the plan ensures that everyone is informed and
goal-directed.
❙ Put the plan into action. Work produces results.
❙ Observe the client’s responses. Evaluating outcomes is the basis for
determining the effectiveness of the plan of care.
❙ Chart all nursing activities and the client’s responses.
Documentation demonstrates that the planned care has been
implemented and provides information about the client’s progress.
❙ Compare the client’s responses with the goal criteria. If the planned
care is appropriate, there should be some measure of progress
toward accomplishing goals. C
❙ Discuss the progress, or lack of it, with the client, family, and other FIGURE 2-6 • Three formats used in concept mapping. (A) Spider dia-
nursing team members. Pooling resources may provide better gram. (B) Hierarchical arrangement. (C) Linear flow chart.
alternatives when revising the plan of care.
❙ Change the plan in areas that are no longer appropriate. The
nursing care plan changes according to the needs of the client.
❙ Continue to implement and evaluate the revised plan of care. The
• Enables students to organize and visualize relationships
nursing process is a continuous sequence of actions that is repeated between their current academic learning and new,
until the goals have been met. unique client assignments.
• Increases critical thinking and clinical reasoning skills.
• Enhances retention of knowledge.
• Correlates theoretical knowledge with nursing practice.
• Helps students recognize information that they must
setting goals and expected outcomes, and evaluating the review or learn to promote safe, appropriate client
results of the care provided. care.
Those who use concept mapping report that the
• Promotes better time management for beginning stu-
technique
dents otherwise focused on the composition require-
• Allows students to integrate previous knowledge with ments of nursing care plans rather than use of the
newly acquired information. nursing process itself.
2. According to most nurse practice acts, if a charge nurse

CRITICAL THINKING E X E R C I S E S
assigns a licensed practical nurse to admit a new client,
1. If an unconscious client is brought to the nursing unit, the licensed practical nurse’s primary role is to
how can a nurse gather data? 1. Create an initial nursing care plan.
2. Gather basic information from the client.
2. Three nursing diagnoses are on a client’s plan of care:
3. Develop a list of the client’s nursing diagnoses.
Ineffective Breathing Pattern, Social Isolation, and Anxiety.
4. Report assessment data to the client’s physician.
Which has the highest priority, and why?
3. At a team conference, staff members discuss a client’s
3. A nurse, while reviewing a client’s plan of care, notices
nursing diagnoses. A nursing assistant questions which
that the client has made no progress in accomplishing
nursing diagnosis is of highest priority. From the list that
the goal by its projected target date. What actions are
follows, the licensed practical nurse is most accurate in
appropriate at this time?
identifying
1. Ineffective Airway Clearance
NCLEX-STYLE REVIEW Q U E S T I O N S 2. Ineffective Coping
3. Deficient Diversional Activity
1. When managing the care of a client, which of the follow- 4. Interrupted Family Processes
ing 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.
UNIT 1
End of Unit Exercises

for Chapters 1 and 2
SECTION 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 below.

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
28
U N I T 1 ● End of Unit Exercises for Chapters 1 and 2 29
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
Activity E: Differentiate between a data base assessment and a focus assessment based
on the criteria given below.
Data Base 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 below 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?
SECTION II: 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 above 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 and one possible long-term goal for this client.
U N I T 1 ● End of Unit Exercises for Chapters 1 and 2 31
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 also has 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.
SECTION III: 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 licensing examination (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
UNIT 2
Integrating Basic
Concepts
3 Laws and Ethics
4 Health and Illness
5 Homeostasis, Adaptation, and Stress
6 Culture and Ethnicity
3
Chapter
Laws and
Ethics
WORDS TO KNOW
administrative laws intentional tort
advance directive invasion of privacy
allocation of scarce resources justice
anecdotal record laws
assault liability insurance
autonomy libel
battery living will
beneficence malpractice
board of nursing misdemeanor
civil laws negligence
code of ethics nonmaleficence
code status nurse licensure compacts
common law nurse practice act
confidentiality plaintiff
criminal laws reciprocity
defamation restraints
defendant risk management
deontology slander
durable power of attorney statute of limitations
for health care statutory laws
duty telenursing
ethical dilemma teleology
ethics tort
false imprisonment truth telling
felony unintentional tort
fidelity values
Good Samaritan laws veracity
incident report whistle blowing
LEARNING OBJECTIVES
● Name six types of laws.
● Discuss the purpose of nurse practice acts and the role of the state board of nursing.
● Explain the difference between intentional and unintentional torts.
● Describe the difference between negligence and malpractice.
● Identify three reasons a nurse should obtain professional liability insurance.
● List five ways that a nurse’s professional liability can be mitigated in the case of a lawsuit.
● Define the term ethics.
● Explain the purpose for a code of ethics.
● Describe two types of ethical theories.
● Name and explain six ethical principles that apply to health care.
● List five ethical issues common in nursing practice.
34
CHAPTER 3 ● Laws and Ethics 35
LAWS, ethics, client rights, and nursing duties affect nurses defines the unique role of the nurse and differentiates
throughout their careers. This chapter introduces basic it from that of other health care practitioners, such as
legal and ethical concepts and issues that affect the prac- physicians) is one example of a statutory law (Box 3-1).
tice of nursing. Although each state’s nurse practice act is unique, all gen-
erally contain common elements:
• They define the scope of nursing practice.
LAWS • They establish the limits to that practice.
• They identify the titles that nurses may use, such as
Laws (rules of conduct established and enforced by gov- licensed practical nurse (LPN), licensed vocational
ernment) are intended to protect both the general public nurse (LVN), or registered nurse (RN).
and each person. The six categories of laws are constitu- • They authorize a board of nursing to oversee nursing
tional, statutory, administrative, common, criminal, and practice.
civil (Table 3-1). • They determine what constitutes grounds for discipli-
nary action.
Constitutional Law
Administrative Laws
The founders of the United States wrote the country’s
first formal laws within the Constitution. This docu- Administrative laws (legal provisions through which federal,
ment, which has endured with few amendments, divides state, and local agencies maintain self-regulation) affect the
power among three branches of government and estab- power to manage governmental agencies. Some adminis-
lishes checks and balances that protect the entire nation. trative laws authorize federal and state governments to
It also identifies the rights and privileges to which all U.S. ensure citizen health and safety.
citizens are entitled. Two examples of rights protected by
constitutional law are free speech and privacy. State Boards of Nursing
The state board of nursing is an example of an admin-
istrative agency that enforces administrative law. Each
Statutory Laws state’s board of nursing (regulatory agency for managing
the provisions of a state’s nurse practice act) has a primary
Statutory laws (laws enacted by federal, state, or local legis- responsibility to protect the public receiving nursing care
latures) sometimes are identified as public acts, codes, or within the state. Some activities of the state’s board of
ordinances. For example, state legislatures are responsible nursing include (1) reviewing and approving nursing
for enacting statutes that ensure the competence of health education programs in the state, (2) establishing criteria
care providers. A nurse practice act (statute that legally for licensing nurses, (3) overseeing procedures for nurse
TABLE 3-1 TYPES OF LAWS

CATEGORY PURPOSE EXAMPLES
Constitutional law Protects fundamental rights and freedoms of U.S. citizens Bill of Rights, freedom of speech
Defines the duties and limitations of the executive,
legislative, 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 State boards of nursing, which enact and enforce
of a public agency rules as they relate to nurse practice acts
Common law Interprets legal issues based on previous court decisions Tarasoff vs. Board of Regents of University of
in 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 Identifies the differences in first-degree and
all 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
36 U N I T 2 ● Integrating Basic Concepts
BOX 3-1 ● Scope of Nursing Practice as Defined Nurse Licensure Compacts

in Sample Nurse Practice Act Several states are considering nurse licensure compacts, agree-
The practice of nursing means the performance of services provided for purposes ments between states in which a nurse licensed in one can
of nursing diagnosis and treatment of human responses to actual or potential practice in another without obtaining an additional license
health problems consistent with educational preparation. Knowledge and skill are (Fig. 3-1). Under this agreement, the nurse acknowledges
the basis for assessment, analysis, planning, intervention, and evaluation used
in the promotion and maintenance of health and nursing management of illness,
that he or she is subject to each state’s nurse practice act
injury, infirmity, restoration of optional function, or death with dignity. Practice and discipline. Advantages include the following:
is based on understanding the human condition across the human life span and
understanding the relationship of the individual within the environment. This • Simplifies the licensing process and removes barriers,
practice includes execution of the medical regime including the administration of thus increasing employability and access to nursing care
medications and treatments prescribed by any person authorized by state law to • Is more cost effective than multiple licensing fees
so prescribe. • Decreases barriers for nurses who live in one state and
want to work in another nearby
From Oklahoma Nursing Practice Act, 2001. Oklahoma Statutes, Title 59,
Chapter 12, Section 567.1 et seq. http://www.ncsbn.org/public/regulation/
• Reduces the need for duplicate listings of nurses work-
nursing_practice_acts.htm. ing in more than one state for disaster planning and
preparedness or other times of need for qualified nurs-
ing services
• Facilitates a cost-effective alternative when a nurse is
licensing examinations, (4) issuing and transferring employed to provide telenursing, health triage, or infor-
nursing licenses, (5) investigating allegations against mation from his or her state through electronic or tele-
nurses licensed in that state, and (6) disciplining nurses phonic access to residents in another state. More than
who violate legal and ethical standards. The state’s board 1 million Americans currently are estimated to have
of nursing is responsible for suspending and revoking access to a nurse through an 800 number (Hutcherson
licenses and reviewing applications asking for recip- & Williamson, 1999).
rocity (licensure based on evidence of having met licens- • Responds to the health care delivery trend in which
ing criteria in another state). A license in one state nurses are employed in small hospitals or satellite
does not give a person a right to automatic licensure in agencies that have merged with multistate health care
another. systems
ME
ND
NH
ID WI
SD
NJ
IA
NE DE
UT VA MD
CO KY
NC
TN
AR SC
AZ NM
MS
TX
RN & LPN/VN
Pending Implementation
APRN (Advanced Practice RN)
FIGURE 3-1 • Status of Nurse Licensure Compacts by state as of January 2007. (From https://www.
ncsbn.org/158.htm)
The traditional method of separate licenses for each alone, freedom from threats of injury, freedom from
state of practice provides a legal loophole when one state offensive contact, and freedom from character attacks. In
revokes a nurse’s license as a disciplinary measure. Some civil cases, the plaintiff (person claiming injury) brings
nurses move to the state where their license is still active charges against the defendant (person charged with vio-
and continue to work. Legislation has been enacted, how- lating the law). The case is referred to as a tort (litigation
ever, to track incompetent practitioners. Since 1989, the in which one person asserts that a physical, emotional, or
names of licensed health care workers who have been dis- financial injury was a consequence of another person’s
ciplined by hospitals, courts, licensing boards, profes- actions or failure to act). A tort implies that a person
sional associations, insurers, and peer review committees breached his or her duty to another person. A duty is an
are submitted to a computerized National Practitioner expected action based on moral or legal obligations.
Data Bank. The information is made available nation- It does not take the same quality or quantity of evidence
wide to licensing boards and health care facilities that to be convicted in a civil lawsuit as in a criminal case. If
hire nurses, should they choose to check it. Under the a defendant is found guilty of a tort, he or she is required
nurse licensure compact, the state of licensure and the to pay the plaintiff restitution for damages. Torts are
state where the client was located during an incident may classified as intentional or unintentional.
take disciplinary action against a nurse working under a
multistate agreement. Some employers also are requiring Intentional Torts
that potential and current employees undergo a state or
are lawsuits in which a plaintiff charges
Intentional torts
federal background check and drug screen.
that a defendant committed a deliberately aggressive act.
Examples include assault, battery, false imprisonment,
Common Law invasion of privacy, and defamation.
ASSAULT. Assault is an act in which bodily harm is threat-

Common law (decisions based on prior similar cases) is also
known as judicial law. It is based on the principle of stare ened or attempted. Such harm may be physical intimida-
decisis (“let the decision stand”), in which prior outcomes tion, remarks, or gestures. The plaintiff interprets the
guide decisions in other jurisdictions dealing with com- threat to mean that force may be forthcoming. A nurse
parable circumstances. Common law refers to litigation may be accused of assault if he or she verbally threatens
that falls outside the realm of constitutional, statutory, and to restrain a client unnecessarily (e.g., to curtail the use
administrative laws. of the signal light).
BATTERY. Battery (unauthorized physical contact) can

Criminal Laws include touching a person’s body, clothing, chair, or bed.
A plaintiff can claim battery even if contact causes no
Criminal laws (penal codes that protect all citizens from peo- actual physical harm. The criterion is that contact hap-
ple who pose a threat to the public good) are used to pros- pened without the plaintiff’s consent.
ecute those who commit crimes. The state represents “the Sometimes nonconsensual physical contact can be jus-
people” when prosecuting those accused of crimes. Crimes tified. For example, health professionals can use physical
are either misdemeanors or felonies. A misdemeanor is a force to subdue clients with mental illness or under the
minor criminal offense (e.g., shoplifting). If a person is con- influence of alcohol or drugs if their actions endanger their
victed of a misdemeanor, a small fine, a short period of own safety or that of others. Documentation must show,
incarceration, or both may be levied. The fine is paid to the however, that the situation required the degree of restraint
state. A felony is a serious criminal offense, such as murder, used. Excessive force is never appropriate when less would
falsifying medical records, insurance fraud, and stealing have been effective. When recording information about
narcotics. Conviction is punishable by a lengthy prison such situations, nurses must describe the behavior and
term or even execution. The state generally prohibits the client’s response when lesser forms of restraint were
felons from obtaining an occupational license, and the state used first.
will revoke such a license if its holder is convicted of a To protect health care workers from being charged with
felony. battery, adult clients are asked to sign a general permis-
sion for care and treatment during admission (Fig. 3-2)
and additional written consent forms for tests, procedures,
Civil Laws or surgery. When seeking a client’s consent for specific
treatments, the physician must describe the proposed
Civil laws(statutes that protect personal freedoms and intervention, potential benefits, risks involved, expected
rights) apply to disputes between individual citizens. Some outcome, available alternatives, and consequences if the
examples include laws that protect the right to be left intervention is not performed.
FIGURE 3-2 • Consent for treatment form. (From Timby, B. K., & Smith, N. E. [2007]. Introductory medical-
surgical nursing [9th ed.]. Philadelphia: Lippincott Williams & Wilkins, p. 37.)
Health care personnel obtain consent from a parent or activity. Types include cloth limb restraints, bedrails,
guardian if the client is a minor, mentally retarded, or men- chairs with locking lap trays, and sedative drugs. Unnec-
tally incompetent. In an emergency, consent can be im- essary or unprescribed restraints can lead to charges of
plied. In other words, it is assumed that in life-threatening false imprisonment, battery, or both.
circumstances, a client would give consent for treatment The Nursing Home Reform Act of the Omnibus Bud-
if he or she were able to understand the risks. In most get Reconciliation Act (OBRA) states that residents in
cases, another physician must concur that the emergency nursing homes have “the right to be free of, and the
procedure is essential (Marquis & Huston, 2003). facility must ensure freedom from, any restraints im-
posed or psychoactive drug administered for purposes of
FALSE IMPRISONMENT. A plaintiff can allege false imprison- discipline or convenience, and not required to treat the
ment (interference with a person’s freedom to move about residents’ medical symptoms.” This is not to say that
at will without legal authority to do so) if a nurse detains restraints cannot be used; rather, they should be used
a competent client from leaving the hospital or other health as a last resort. Use must be justified and accompanied
care agency. If a client wants to leave without being med- by informed consent from the client or a responsible
ically discharged, it is customary for him or her to sign a relative.
form indicating personal responsibility for leaving against Before using restraints, the best legal advice is to try
medical advice (AMA) (Fig. 3-3). If the client refuses to alternative measures for protecting wandering clients,
sign the paper, however, health care personnel cannot bar reducing the potential for falls (see Chap. 19), and ensur-
him or her from leaving. ing that clients do not jeopardize medical treatment by
Forced confinement is legal under two conditions: if pulling out feeding tubes or other therapeutic devices. If
there is a judicial restraining order (e.g., a prisoner admit- less restrictive alternatives are unsuccessful, nurses must
ted for medical care) or if there is a court-ordered commit- obtain a medical order before each and every instance in
ment (e.g., a client with mental illness who is dangerous which they use restraints. In acute care hospitals, medical
to self or others). orders for restraints are renewed every 24 hours. When
Restraints are devices or chemicals that restrict move- restraints are applied, charting must indicate regular client
ment. They are used with the intention to subdue a client’s assessment; provisions for fluids, nourishment, and bowel
FIGURE 3-3 • Release form for discharging oneself against medical advice.
and bladder elimination; and attempts to release the client MALPRACTICE. Malpractice is professional negligence,
from the restraints for a trial period. When the client is which differs from simple negligence. It holds profession-
no longer a danger to self or others, nurses must remove als to a higher standard of accountability. Rather than
the restraints. being held accountable for acting as an ordinary, reason-
able lay person, in a malpractice case the court determines
INVASION OF PRIVACY. Civil law protects citizens from whether a health care worker acted in a manner compa-
invasion of privacy(failure to leave people and their prop- rable to that of his or her peers. The plaintiff must prove
erty alone). Nonmedical examples include trespassing, four elements to win a malpractice lawsuit: duty, breach
illegal search and seizure, wiretapping, and revealing per- of duty, causation, and injury (Box 3-2).
sonal information about someone, even if true. Examples Because the jury may be unfamiliar with the scope of
of privacy violations in health care include photograph- nursing practice, the plaintiff may present other resources
ing a client without consent, revealing a client’s name in in court to prove breach of duty. Some examples include
a public report, and allowing an unauthorized person to the employing agency’s standards for care, written policies
observe the client’s care. To ensure and protect clients’ and procedures, care plans or clinical pathways, and the
rights to privacy, medical records and information are testimony of expert witnesses (Fig. 3-4).
kept confidential. Personal names and identities are con-
The best protection against malpractice lawsuits is
cealed or obliterated in case studies or research. Privacy
competent nursing. Nurses demonstrate competency by
curtains are used during care; permission is obtained if a
participating in continuing education programs, taking
nursing or medical student will observe a procedure.
nursing courses at colleges or universities, and becoming
DEFAMATION. Defamation (an act in which untrue infor- certified. Defensive nursing practice also involves thor-
mation harms a person’s reputation) is unlawful. Exam- ough and objective documentation (see Chap. 9).
ples include slander (character attack uttered orally in One of the best methods for avoiding lawsuits is to
the presence of others) and libel (damaging statements administer compassionate care. The “golden rule” of doing
written and read by others). Injury is considered to occur unto others as you would have them do unto you is a
because the derogatory remarks attack a person’s char- good principle to follow. Clients who perceive the nurse
acter and good name. as caring and concerned tend to be satisfied with their
If a client accuses a nurse of defamation of character, care. The following techniques communicate a caring and
the client must prove that there was malice, misuse of compassionate attitude:
privileged information, and spoken or written untruths. • Smiling
Nurses are at risk for defamation of character suits if they • Introducing yourself
make negative comments in public areas (e.g., elevators), • Calling the client by the name he or she prefers
or assert opinions regarding a client’s character in the med- • Touching the client appropriately to demonstrate
ical record. To avoid accusations of defamation, nurses concern
must avoid making or writing negative comments about • Responding quickly to the call light
clients, physicians, or other coworkers. • Telling the client how long you will be gone if you need
to leave the unit; informing the client who will provide
Unintentional Torts care in your absence; alerting the client when you return
Unintentional torts result in an injury, although the person • Spending time with the client other than while per-
responsible did not mean to cause harm. The two types forming required care
of unintentional torts involve allegations of negligence • Being a good listener
and malpractice. • Explaining everything so that the client can under-
stand it
NEGLIGENCE. Negligence (harm that results because a • Being a good host or hostess—offering visitors extra
person did not act reasonably) implies that a person acted chairs, letting them know where they can obtain snacks
carelessly. In cases of negligence, a jury decides whether
any other prudent person would have acted differently
than the defendant, given the same circumstances. For BOX 3-2 ● Elements in a Malpractice Case
example, a car breaks down on the highway. The driver
moves to the side of the road, raises the hood, and activates Duty—An obligation existed to provide care for the person who claims to have
the emergency flashing lights. If another vehicle strikes been injured or harmed.
Breach of Duty—The nurse failed to provide appropriate care, or the care pro-
the disabled car and the driver of the second car sues, the
vided was given negligently, that is, in a way that conflicts with how others
guilt or innocence of the driver of the disabled car depends with similar education would have acted given the same set of circumstances.
on whether the jury believes his or her action was rea- Causation—The professional’s action, or lack of it, caused the plaintiff harm.
sonable. Reasonableness is based on the jury’s opinion of Injury—Physical, psychological, or financial harm occurred.
what constitutes good common sense.
Stan
da Standards
Care rdized of Practice
P
Critic lan (ANA, JCAHO,
Path al specialty
w
Prac ay organizations)
Guid tice
eline
Hospital Policy
and
Procedure
Manual
Expert
Witness
Previous
Patient's Court
FIGURE 3-4 • Data that establish standards of care. Bill of Rulings
Rights
(From Timby, B. K., & Smith, N. E. [2007]. Introductory
medical-surgical nursing [9th ed.]. Philadelphia: Lippin-
cott Williams & Wilkins, p. 39.)
and beverages, and directing them to the restrooms to clients, they have a primary role in protecting clients
and parking areas from preventable or reversible complications.
• Accepting justifiable criticism without becoming The number of lawsuits involving nurses is increasing.
defensive It is to every nurse’s advantage to obtain liability insur-
• Saying “I’m sorry” ance and to become familiar with legal mechanisms, such
as Good Samaritan laws and statutes of limitations, that
Clients can sense when a nurse wants to do a good job,
rather than just get a job done. The relationship that may prevent or relieve culpability, as well as with strate-
develops is apt to reduce the potential for a lawsuit, even gies for providing a sound legal defense, such as written
if harm occurs. incident reports and anecdotal records.
Stop • Think + Respond BOX 3-1 Liability Insurance

A nurse warns a weak and debilitated older adult that if
she continues to get out of bed during the night without (a contract between a person or corpo-
Liability insurance
calling for assistance, it will be necessary to apply wrist ration and a company willing to provide legal services
restraints. Can the nurse legally restrain the client who and financial assistance when the policyholder is in-
may be harmed if the behavior does not change? volved in a malpractice lawsuit) is necessary for all nurses.
Although many agencies have liability insurance with an
umbrella clause that includes its employees, nurses should
obtain their own personal liability insurance. The advan-
PROFESSIONAL LIABILITY tage is that a nurse involved in a lawsuit will have a sepa-
rate attorney working on his or her sole behalf. Because
All professionals, including nurses, are held responsible the damages sought in malpractice lawsuits are so costly,
and accountable for providing safe, appropriate care. attorneys hired by health care facilities sometimes are
Because nurses have specialized knowledge and proximity more committed to defending the facility against liability
and negative publicity, rather than defending an employed mendation applies when nurses caution clients about
nurse whom they also are being paid to represent. ambulating only with assistance.
Student nurses are held accountable for their actions
during clinical practice and should also carry liability insur- Documentation
ance. Liability insurance is available through the National A major component to limiting liability is accurate, thor-
Federation for Licensed Practical Nurses, the National ough documentation. Nurses are held responsible or
Student Nurses’ Association, the American Nurses Asso- liable for information that they either include or exclude
ciation (ANA), and other private insurance companies. in reports and charting. Each health care setting requires
accurate and complete documentation. The medical record
is a legal document and is used as evidence in court.
Reducing Liability Records must be timely, objective, accurate, complete,
and legible (see Chap. 9). The quality of the documenta-
It is unrealistic to think that lawsuits can be avoided com-
tion, including neatness and spelling, can influence a
pletely. Some avenues protect nurses and other health
jury’s decision.
care workers from being sued or provide a foundation for
a sound legal defense. Examples include Good Samaritan Risk Management
laws, statutes of limitations, principles regarding assump-
tion of risk, appropriate documentation, risk management, Risk management (process of identifying and reducing the
incident reports, and anecdotal records. costs of anticipated losses) is a concept originally developed
by insurance companies. Health care institutions now
Good Samaritan Laws employ risk managers to review all the problems in the
Most states have enacted Good Samaritan laws, which pro- workplace, identify common elements, and then develop
vide legal immunity to passersby who provide emergency methods to reduce their risk. A primary tool of risk man-
first aid to victims of accidents. The legislation is based agement is the incident report.
on the Biblical story of the person who gave aid to a beaten
Incident Reports
stranger along a roadside. The law defines an emergency
as one occurring outside a hospital, not in an emergency An incident report is a written account of an unusual, poten-
department. tially injurious event involving a client, employee, or vis-
Although these laws are helpful, no Good Samaritan law itor (Fig. 3-5). It is kept separate from the medical record.
provides absolute exemption from prosecution in the event Incident reports determine how to prevent hazardous sit-
of injury. Paramedics, ambulance personnel, physicians, uations and serve as a reference in case of future litiga-
and nurses who stop to provide assistance are still held to tion. They must include five important pieces: (1) when
a higher standard of care because they have training above the incident occurred; (2) where it happened; (3) who
and beyond that of average lay people. In cases of gross neg- was involved; (4) what happened; and (5) what actions
ligence (total disregard for another’s safety), health care were taken.
workers may be charged with a criminal offense. All witnesses are identified by name. Any pertinent
statements made by the injured person, before or after
Statute of Limitations the incident, are quoted. Accurate and detailed documen-
Each state establishes a statute of limitations (designated tation often helps to prove that the nurse acted reason-
time within which a person can file a lawsuit). The length ably or appropriately in the circumstances.
varies among states and generally is calculated from when
the incident occurred. When the injured party is a minor, Anecdotal Records
however, the statute of limitations sometimes does not An anecdotal record (personal, handwritten account of an
commence until the victim reaches adulthood. When the incident) is not recorded on any official form, nor is it
time expires, an injured party can no longer sue, even if filed with administrative records. The nurse retains
his or her claim is legitimate. the information, which is safeguarded and may be used
later to refresh the nurse’s memory if a lawsuit develops.
Assumption of Risk
Anecdotal notes can be used in court on advice of an
If a client is forewarned of a potential safety hazard and attorney.
chooses to ignore the warning, the court may hold the
client responsible. For example, if a hospitalized client
objects to having the side rails up or lowers the rails inde- Malpractice Litigation
pendently, the nurse or health care facility may not be
held fully accountable for an injury. It is essential that A successful outcome in a malpractice lawsuit depends
the nurse document that he or she warned the client and on many variables, such as physical evidence and attor-
that the client disregarded the warning. The same recom- ney expertise. The appearance, demeanor, and conduct
FIGURE 3-5 • An incident report form.

BOX 3-3 ● Legal Advice BOX 3-4 ● Code for Nurses
1. Notify the claims agent of your professional liability insurance company. 1. The nurse, in all professional relationships, practices with compassion and
2. Contact the National Nurses Claims Data Base through the ANA. This respect for the inherent dignity, worth, and uniqueness of every individual,
confidential service provides information that supports nurses involved in unrestricted by considerations of social or economic status, personal
litigation. attributes, or the 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 an individual,
4. Tell your attorney everything. family, group, or community.
5. Avoid giving public statements. 3. The nurse promotes, advocates for, and strives to protect the health, safety,
6. Reread the client’s record, incident sheet, and your anecdotal notes before and rights of the patient.
testifying. 4. The nurse is responsible and accountable for individual nursing practice
7. Ask to reread information in court if it will help to refresh your memory. and determines the appropriate delegation of tasks consistent with the
8. Dress conservatively, in a businesslike manner. Avoid excesses in nurse’s obligation to provide optimum patient care.
makeup, hairstyle, or jewelry. 5. The nurse owes the same duties to self as to others, including the responsi-
9. Look directly at whomever asks a question. bility to preserve integrity and safety, to maintain competence, and to
10. Speak in a modulated but audible voice that the jury and others in the continue personal and professional growth.
court can hear easily. 6. The nurse participates in establishing, maintaining, and improving health
11. Tell the truth. care environments and conditions of employment conducive to the provi-
12. Use language with which you are comfortable. Do not try to impress the sion of quality health care and consistent with the values of the profession
court with legal or medical terms. through individual and collective action.
13. Say as little as possible in court under cross-examination. 7. The nurse participates in the advancement of the profession through
14. Answer the prosecuting lawyer’s questions with “Yes” or “No”; limit contributions to practice, education, administration, and knowledge
answers to only the questions asked. development.
15. If you do not know or cannot remember information, say so. 8. The nurse collaborates with other health professionals and the public
16. Wait to expand on information if asked by your defense attorney. in promoting community, national, and international efforts to meet
17. Remain calm, objective, and cooperative. 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 practice, and for shaping social policy.
of the nurse defendant inside and outside the courtroom, Reprinted with permission from American Nurses Association. (2001).
however, can help or damage the case. Suggestions in Code of ethics for nurses with interpretive statements. Washington, DC:
American Nurses Publishing.
Box 3-3 may help if a nurse becomes involved in mal-
practice litigation.
ETHICS Ethical Dilemmas
An ethical dilemma (choice between two undesirable alter-

The word ethics comes from the Greek word ethos, mean- natives) occurs when individual values and laws conflict.
ing customs or modes of conduct. Ethics (moral or philo- This is especially true in relation to health care. Occasion-
sophical principles) direct actions as being either right or ally, nurses find themselves in situations that are legal
wrong. Various organizations, such as those represent- but are personally unethical, or are ethical but illegal. For
ing nurses, have identified standards for ethical practice, instance, abortion is legal, but some believe it is unethical.
known as a code of ethics, for members within their Assisted suicide is illegal (except in Oregon), but some
discipline. believe it is ethical.
Codes of Ethics Ethical Theories
A code of ethics (a list of written statements describing Nurses generally use one of two ethical problem-solving
ideal behavior) serves as a model for personal conduct. The theories to guide them in solving ethical dilemmas. These
National Association for Practical Nurse Education and are teleology and deontology.
Services, the National Federation for Licensed Practical
Nurses, and the International Council of Nurses all have Teleologic Theory
composed codes of ethics. Box 3-4 shows the ANA’s cur- Teleology is ethical theory based on final outcomes. It is also
rent code of ethics. Because of rapidly changing technol- known as utilitarianism because the ultimate ethical test
ogy, no code is ever specific enough to provide guidelines for any decision is based on what is best for the most peo-
for every dilemma that nurses may face. ple. Stated from a different perspective, teleologists believe
“the end justifies the means.” Thus, the choice that bene- BOX 3-5 ● A Patient’s Bill of Rights
fits many people justifies harm that may come to a few. A
teleologist would argue that selective abortion (destroying 1. The patient has the right to considerate and respectful care.
some embryos in a multiple pregnancy) is ethical because 2. The patient has the right to and is encouraged to obtain from physicians
it is done to ensure the full-term birth of those that remain. and other direct caregivers relevant, current, and understandable
information concerning diagnosis, treatment, and prognosis.
In other words, termination can be justified in some situ-
3. The patient has the right to make decisions about the plan of care prior to
ations but may not be justified in all cases. and during the course of treatment and to refuse a recommended treat-
Teleologists analyze ethical dilemmas on a case-by-case ment or plan of care to the extent permitted by law and hospital policy and
basis. They propose that an action is not good or bad in to be informed of the medical consequences of this action.
and of itself. Instead, the consequences determine whether 4. The patient has the right to have an advance directive (such as a living
will, health care proxy, or durable power of attorney for health care)
the action is good or bad. The primary consideration is a concerning treatment or designating a surrogate decision maker with the
desirable outcome for those most affected. expectation that the hospital will honor the intent of that directive to the
extent permitted by law and hospital policy.
Deontologic Theory 5. The patient has the right to every consideration of privacy. Case discussion,
consultation, examination, and treatment should be conducted so as to
Deontology is ethical study based on duty or moral obli- protect each patient’s privacy.
gations. It proposes that the outcome is not the primary 6. The patient has the right to expect that all communications and records
pertaining to his or her care will be treated as confidential by the hospital,
issue; rather, decisions must be based on the morality of
except in cases such as suspected abuse and public health hazards when
the act itself. In other words, certain actions are always reporting is permitted or required by law.
right or wrong regardless of circumstances. Deontologists 7. The patient has the right to review the records pertaining to his or her
would argue that destroying any fetus is wrong, whether medical care and to have the information explained or interpreted as
done to save others or not, because killing is immoral. necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacity and policies, a
Deontology proposes that health care providers have a hospital will make reasonable response to the request of a patient for appro-
moral duty to maintain and preserve life. Thus, deontol- priate and medically indicated care and services. The hospital must provide
ogists would consider it immoral for a nurse to assist with evaluation, service, and/or referral as indicated by the urgency of the case.
abortion, suicide for the terminally ill, or execution of a 9. The patient has the right to ask and be informed of the existence of business
relationships among the hospital, educational institutions, other health care
convicted prisoner.
providers, or payers that may influence the patient’s treatment and care.
Deontology also proposes that moral duty to others is 10. The patient has the right to consent to or decline to participate in proposed
equally as important as consequences. A duty is an obli- research studies or human experimentation affecting care and treatment or
gation to perform or to avoid an action to which others requiring direct patient involvement, and to have those studies fully
are entitled. For example, deontologists believe that lying explained prior to consent.
11. The patient has the right to expect reasonable continuity of care when
is never acceptable because it violates the duty to tell the appropriate and to be informed by physicians and other caregivers of
truth to those entitled to honest information. Nurses ulti- available and realistic patient care options when hospital care is no longer
mately have a professional duty to their clients, and clients appropriate.
have rights to which they are entitled (Box 3-5). 12. The patient has the right to be informed of hospital policies and practices
that relate to patient care, treatment, and responsibilities. The patient has
the right to be informed of available resources for resolving disputes,
grievances, and conflicts. The patient has the right to be informed of the
Stop • Think + Respond BOX 3-2 hospital’s charges for services and available payment methods.
How might a teleologist and a deontologist approach © 1992 with permission of the American Hospital Association.
an ethical dilemma such as managing the care of an
infant with microcephaly (small brain and severe mental
retardation) who develops a very high fever as a result
of infection? Beneficence and Nonmaleficence
Beneficence means “doing good” or acting for another’s
benefit. To do good, an ethical person prevents or removes
Ethical Principles any potentially harmful factor. For example, if a client
has cancer, the beneficent act is to eliminate the cancer
It is sometimes impossible or impractical to analyze ethical with surgery, drugs, or radiation. The difficulty, however,
issues from a teleologic or deontologic point of view. Most is that a health care worker’s approach to “doing good”
nurses do not exclusively use one theory’s principles. may not be what the client feels is best. The client may
They also can base ethical decisions on six principles that prefer no treatment of the cancer.
form a foundation for ethical practice: beneficence, non- Nonmaleficence means “doing no harm” or avoiding an
maleficence, autonomy, veracity, fidelity, and justice. action that deliberately harms a person. Sometimes, how-
These principles sometimes conflict with each other. ever, “harm” is necessary to promote “good.” In the pre-
vious example of cancer, available treatments can cause Justice

pain, nausea, vomiting, hair loss, and susceptibility to
Justice mandates that clients be treated impartially without
infection. Yet, the ultimate benefit is eradicating the
discrimination according to age, gender, race, religion,
cancer. This is an example of the principle of double effect.
socioeconomic status, weight, marital status, or sexual
The following criteria can help to resolve cases involving
orientation. In other words, everyone should have equal
double effect:
distribution of goods and services.
• The action itself must not be intrinsically wrong; it In reality, circumstances may force nurses to devote
must be good or neutral. more attention to an unstable client. For example, a
• Only the good effect must be intended, even though person arrives in the emergency department with a
the harmful effect is foreseen. fever and vomiting. Shortly thereafter, another person
• The harmful effect must not be the means of the good presents with chest pain. The nurse decides to attend
effect. to the client with chest pain first. Another example of
• The good effect must outweigh the harmful effect inequity is when more than one client needs a scarce
(McCormick, 1999). resource, such as an organ for transplantation. Although
several clients have the right to the organ, only one can
Autonomy receive it.
When goods and services cannot be allocated equally,
Autonomy refers to a competent person’s right to make his
decisions are based on need, merit, or potential for con-
or her own choices without intimidation or influence. For
tribution. In the example of the transplant organ, based
a person to make a decision, he or she must have all rele-
on need, the most critically ill person would receive
vant information, including treatment options, in language
it. Based on merit, the organ would be given to the per-
he or she understands. The client always has the option of
son who worked hardest or made the greatest effort at
obtaining a second opinion from another practitioner. One
this point in his or her life. Based on contribution, the
outcome may be that the client declines all possible options
person with the greatest potential for positively influ-
for treatment, a decision that must be respected.
encing society in the future would receive the organ
Conflict can arise if the client’s choice poses more risk
(Maiese, 2003).
than potential benefit; is illegal (e.g., requesting assistance
with suicide), morally objectionable, or medically inappro-
priate; or interferes with the needs of another person
whose case merits higher priority. An example is a young
Values and Ethical Decision Making
woman who seeks the removal of both breasts because
When a nurse has not taken a course in ethics, his or her
she fears breast cancer. In such a case, the duty to respect
ethical decisions are often the result of values. Values are a
the client’s wishes can be nullified. One option may be to
person’s most meaningful beliefs and the basis on which he
refer the client to another practitioner.
or she makes most decisions about right or wrong. Values
commonly are (1) acquired from parental models, life expe-
Veracity
riences, and religious tenets; (2) reinforced by a person’s
Veracity means the duty to be honest and avoid deceiv- world view; (3) modeled in personal behavior; (4) consis-
ing or misleading a client. This principle causes conflict tent over time; and (5) defended when challenged.
when the truth may harm the client by interfering with The following serve as guidelines to ethical decision
recovery or worsening the present condition. Avoiding making:
the truth, however, is never justified when it is used to
• Make sure that whatever is done is in the client’s best
shield the caregiver’s discomfort with sharing “bad news”
interest.
(Aiken, 2004).
• Preserve and support the Patient’s Bill of Rights.
• Work cooperatively with the client and other health
Fidelity
practitioners.
Fidelity means being faithful to work-related commitments • Follow written policies, codes of ethics, and laws.
and obligations. Its application relates to the caregiver’s • Follow your conscience.
obligation to clients. For example, nurses are obligated to
be competent in performing skills and services required
for safe and appropriate care. This implies that nurses Ethics Committees
pursue continuing education and maintain current cer-
tification for cardiopulmonary resuscitation (CPR). It also Ethical decisions are complex, especially when they affect
requires that nurses respect clients, provide compassionate the lives of clients. Because making a judgment for another
care, protect confidentiality, honor promises, and follow is a weighty responsibility, many health care agencies
their employer’s policies. have established ethics committees. These committees
consist of a broad cross-section of professionals and non- directives and determining a client’s code status ensure
professionals within the community with varying view- that a person’s health care is in accordance with his or
points. Their diversity encourages healthy debate about her wishes.
ethics issues. Ethics committees are best used in a policy-
making capacity before any specific dilemma. They are ADVANCE DIRECTIVES. Legislation now mandates the
also called on to offer advice, however, to protect clients’ discussion of terminal care with clients. Since Congress
best interests and to avoid legal battles. approved the Patient Self-Determination Act in 1990,
health care agencies reimbursed through Medicare must
ask clients whether they have executed an advance direc-
Common Ethical Issues tive (written statement identifying a competent person’s
wishes concerning terminal care). The two types of ad-
Several ethical issues recur in nursing practice. Examples vance directives are a living will and a durable power of
include telling the truth, maintaining confidentiality, attorney for health care.
withholding or withdrawing treatment, advocating for A living will is an instructive form of an advance direc-
ethical allocation of scarce resources, and protecting vul- tive; that is, it is a written document that identifies a
nerable people from unsafe practices or practitioners. person’s preferences regarding medical interventions to
use—or not to use—in a terminal condition, irreversible
Truth Telling coma, or persistent vegetative state with no hope of recov-
ery (Fig. 3-6). Clients must share advance directives with
Truth telling proposes that all clients have the right to com-
health care providers to ensure that they are implemented.
plete and accurate information. It implies that physicians
See Client and Family Teaching 3-1.
and nurses have a duty to tell clients the truth about
A durable power of attorney for health care designates a
matters concerning their health. Personnel demonstrate
proxy for making medical decisions when the client
respect for this right by explaining to the client the status
becomes so incompetent or incapacitated that he or she
of his or her health problem, benefits and risks of treat-
cannot make decisions independently. The designee can
ment, alternative forms of treatment, and consequences
give or withhold permission for treatments on the client’s
if the treatment is not administered.
behalf in end-of-life circumstances or when the client is
It is the physician’s duty to inform clients. Conflict
temporarily unconscious.
occurs when the client has not been given full informa-
Living will and durable power of attorney for health
tion, when facts have been misrepresented, or when a
care are not measures reserved for older adults; any com-
client misunderstands information. In some cases, physi-
petent adult can initiate them. They are best composed
cians are reluctant to talk honestly with clients or present
before a health crisis develops to assist care providers and
the proposed treatment in a biased manner. Often the
significant others to enact the client’s wishes. A living will
nurse is forced to choose between remaining silent in
and health care proxy can avoid legal expenses, delays in
allegiance to the physician or providing the client with the
obtaining guardianship, or unwanted decisions made by
truth. Either action may have frustrating consequences.
an ethics committee or court. Thus, nurses should inform
all clients about their right to self-determination, encour-
Confidentiality age them to compose advance directives, and support
Confidentiality, or safeguarding a person’s health informa- their decisions.
tion from public disclosure, is the foundation for trust.
Nurses must not divulge health information to unautho- Code Status
rized people without the client’s written permission. Even
Code status refers to how health care personnel are required
giving medical information to a client’s health insurance
company requires a signed release. Consequently, nurses to manage care in case of cardiac or respiratory arrest.
must use discretion when sharing verbal information so Without a written order from the physician to the con-
that others do not hear it indiscriminately. Now that vast trary, the client is designated as a full code. A full code
information about clients is stored on computers, the means that all measures to resuscitate the client are used.
duty to protect confidentiality extends to safeguarding After a discussion with the physician, some clients
written and electronic data. indicate that they want no resuscitative efforts, that is,
“no code” or “do not resuscitate (DNR).” Or they may
select a combination of interventions that constitute less
Withholding and Withdrawing Treatment
than a full code. Some clients specify using drugs, but
Technology often is used to prolong life at all costs, refuse cardiac defibrillation or endotracheal intubation
beyond justifying its benefits. Decisions involving life for mechanical ventilation. For anything less than a full
and death may sometimes continue to circumvent clients, code, the physician must write an order to that effect in
a clear violation of ethical principles. Completing advance the client’s medical record.
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 • Living will.
3-1 • CLIENT AND FAMILY TEACHING
Advance Directives your instructions may be different if you are

The nurse teaches the following points: pregnant.
• Obtain the signatures of two witnesses, other than
• An advance directive is not required, but it is
your physician or spouse.
encouraged.
• Give a copy to your physician for your medical file.
• A lawyer is not needed to create an advance
• Tell family members or your lawyer that you have
directive; printed forms are available from health
an advance directive and its location.
care agencies, organizations such as the Ameri-
• Keep the original advance directive in a place
can Association of Retired Persons, and various
where it can be found easily.
Internet sites such as http://www.ama-assn.org/
• Bring a copy of your advance directive whenever
publicbooklets/livgwill.htm.
you are hospitalized or admitted to a health care
• When filling out the form, indicate specific wishes
facility (e.g., nursing home, extended care facility).
for the initiation or withdrawal of life-sustaining
• Change your advance directive by revoking or adding
medical treatments such as cardiopulmonary
instructions at any time; share the revised copy with
resuscitation, kidney dialysis, mechanical ventila-
those who will carry out your instructions.
tion, use of a tube for administering food and
• A separate or different advance directive is not
water, obtaining comfort measures such as pain
needed for each state; they are generally recognized
medication, and donation of organs.
universally within the United States.
• Write additional instructions if something
is not addressed in the form; for example,
Allocation of Scarce Resources ority is protecting clients in general and the community
at large.
Allocation of scarce resources is the process of deciding how
to distribute limited life-saving equipment or procedures
among several who could benefit. Such decisions are dif- CRITICAL THINKING E X E R C I S E S
ficult. In effect, those who receive the resources have a 1. What actions might protect a nurse from being sued
greater chance to live, whereas those who do not may die when a client assigned to his or her care falls out of bed?
prematurely. One strategy is “first come, first served.”
2. Two people need a liver transplant; only one liver is
Another is to project what would produce the most good available. What information might a teleologist and a
for the most people, although predicting the future is deontologist use to determine who should receive the
impossible. organ?
Whistle-Blowing NCLEX-STYLE REVIEW Q U E S T I O N S

Whistle-blowing (reporting incompetent or unethical prac- 1. If a nurse suspects that a colleague is stealing narcotics
tices), as the name implies, calls attention to unsafe or and recording their administration to assigned clients,
potentially harmful situations. Usually, it occurs in the the first action the nurse should take is to
institution where the reporting person is employed. For 1. Refer the nurse to the ethics committee.
instance, a nurse may report another nurse or physician 2. Notify the local police department.
who cares for clients while under the influence of alcohol 3. Share concerns with nursing peers.
4. Report suspicions to a supervisor.
or a controlled substance.
Whenever a problem is identified, the first step is 2. In a preoperative assessment, it is most appropriate for
to report the situation to an immediate supervisor. If the nurse to ask for the client’s
1. Birth certificate
the supervisor takes no action, the nurse faces an ethical
2. Social security number
dilemma about any further steps. Going beyond the ad- 3. Advance directive
ministrative hierarchy and making public revelations 4. Proof of insurance
may be necessary.
3. After checking the condition of a client who has fallen
The decision to “blow the whistle” involves personal out of bed, the nurse’s next action should be to
risks and may result in grave consequences such as 1. Institute fall precautions.
character assassination, retribution in the form of crimes 2. Complete an incident report.
against one’s person or property, negative evaluations, 3. Call the nursing supervisor.
demotions, or shunning. Nevertheless, the ethical pri- 4. Notify the client’s family.
4
Chapter
Health
and Illness
LEARNING OBJECTIVES
● Describe how the World Health Organization (WHO) defines health.
WORDS TO KNOW ● Discuss the difference between values and beliefs.
● List three health beliefs common among Americans.
acute illness ● Explain the concept of holism.
beliefs ● Identify five levels of human needs.
capitation ● Define illness.
case method ● Explain the meaning of the following terms used to describe illnesses: morbidity, mortality,
chronic illness acute, chronic, terminal, primary, secondary, remission, exacerbation, hereditary, congenital,
congenital disorder and idiopathic.
continuity of care ● Differentiate primary, secondary, tertiary, and extended care.
diagnostic-related group ● Name two programs that help finance health care for the aged, disabled, and poor.
exacerbation ● List four methods to control escalating health care costs.
extended care ● Identify two national health goals targeted for the year 2010.
functional nursing ● Discuss five patterns that nurses use to administer client care.
health
health care system
health maintenance
organizations
hereditary condition NEITHER health nor illness is an absolute state; rather, there are fluctuations along a
holism continuum throughout life (Fig. 4-1). Because it is impossible to be (or get) well and
human needs stay well forever, nurses are committed to helping people prevent illness and restore
idiopathic illness or improve their health. Nurses accomplish these goals by
illness
integrated delivery system
• Helping people live healthy lives.
managed care organizations
Medicaid • Encouraging early diagnosis of disease.
Medicare • Implementing measures to prevent complications of disorders.
morbidity
mortality
nurse-managed care
nursing team HEALTH
preferred provider
organizations
primary care The World Health Organization (WHO) is globally committed to “Health for All.” In
primary illness the preamble to its constitution, WHO defines health as “a state of complete physical,
primary nursing
remission
mental, and social well-being, not merely the absence of disease or infirmity.” Each
secondary care person perceives and defines health differently. Nurses must recognize the importance
secondary illness of respecting such differences rather than imposing standards that may be unrealistic
sequelae for the person.
team nursing A person’s behaviors are the outcomes of his or her values and belief system. Values
terminal illness
tertiary care
are ideals that a person feels are important. Examples include knowledge, wealth,
values financial security, marital fidelity, and health. Beliefs are concepts that a person holds
wellness to be true. Beliefs and values guide a person’s actions. Both health values and beliefs
50
CHAPTER 4 ● Health and Illness 51
Health: A Personal Responsibility

High-Level Wellness
Health requires continuous personal effort. There is as
Good Health
much potential for illness as there is for health. Each per-
son is instrumental in the outcome. Pilch (1981) said,
“No one can do wellness to or for another; you alone
Levels of health
Normal Health do it, but you don’t do it alone.” Nurses stand ready to
provide assistance and to advocate on behalf of others.
Illness
WELLNESS
Critical Illness
Wellness means a full and balanced integration of all

Death aspects of health. It involves physical, emotional, social,
and spiritual health. Physical health exists when body
Time span (life span)
organs function normally. Emotional health results when
FIGURE 4-1 • The health–illness continuum shows the different levels
one feels safe and copes effectively with the stressors of
of health a person experiences over a lifetime.
life. Social health is an outcome of feeling accepted and
useful. Spiritual health is characterized as believing that
one’s life has purpose. The four components are collec-
demonstrate or affirm what is personally significant. tively referred to as the concept of holism (Fig. 4-2).
When a person values health, he or she takes actions to
preserve it.
Most Americans believe one or all of the following: Holism
health is a resource, a right, and a personal responsibility.
Holism (the sum of physical, emotional, social, and spiritual
health) determines how “whole” or well a person feels.
Health: A Limited Resource Any change in one component, positive or negative, auto-
matically creates repercussions in the others. Take, for
A resource is a possession that is valuable because its example, the person who has a heart attack. Obviously
supply is limited and there is no substitute. Given that his or her physical health is immediately impaired. Addi-
definition, health is considered quite precious. People often
say, “as long as you have your health, you have every-
thing,” and “health is wealth.”
Health: A Right Physical Emotional
The United States was established on the principle that

everyone is equal and entitled to life, liberty, and the
pursuit of happiness. Based on this premise, everyone,
regardless of age, gender, level of education, religion, sex-
ual orientation, ethnic origin, social position, or wealth,
is entitled to equal services for sustaining health. Unfor-
tunately, as will be discussed later, health disparities
exist among various groups within the United States.
These groups include the poor, racial and ethnic minori- Social Spiritual
ties, those affected by gender differences, older adults, and
people with disabilities. Efforts are under way, however,
to eliminate health barriers and to promote equal access
to health care (see discussion of Healthy People 2010 later
in this chapter). If all are equally deserving of health, it
follows that the nation in general and nurses in particu-
lar have a duty to protect and preserve the health of those
who may be unable to assert this right for themselves. FIGURE 4-2 • Holism is a concept that considers all aspects of a person.
tionally the heart attack affects the emotional, social, and client’s physical needs such as managing pain as a priority.
spiritual aspects of health. For example, the client may The nurse addresses other needs, such as assisting the
experience psychological anxiety over this health change. client with a possible change in role performance or spir-
His or her social roles may temporarily or permanently itual distress, after the client’s health condition stabilizes.
change. The client may explore philosophical and spiritual
issues as he or she considers the potential for death.
Nurses profess to be “holistic practitioners” because ILLNESS
they are committed to restoring balance in each of the
four spheres that affect health. They base their strategies
Illness (a state of discomfort) results when disease, deteri-
for doing so on a hierarchy of human needs.
oration, or injury impairs a person’s health. Several terms
are used commonly when referring to illnesses: morbidity
Hierarchy of Human Needs and mortality; acute, chronic, and terminal; primary and
secondary; remission and exacerbation; and hereditary,
In the 1960s, Abraham Maslow, a psychologist, identified congenital, and idiopathic.
five levels of human needs (factors that motivate behavior).
He grouped the needs in tiers, or a sequential hierarchy
(Fig. 4-3), according to their significance: physiologic Morbidity and Mortality
(first level), safety and security (second level), love and
belonging (third level), esteem and self-esteem (fourth Morbidity (incidence of a specific disease, disorder, or
level), and self-actualization (fifth level). injury) refers to the rate or numbers of people affected.
The first-level physiologic needs are the most important. Federal statistics are compiled on the basis of age, gender,
They are the activities, such as breathing and eating, nec- or per 1,000 people within the population. Mortality (inci-
essary to sustain life. Each higher level is less important dence of deaths) denotes the number of people who died
to survival than the previous levels. Maslow believed that from a particular disease or condition. Table 4-1 lists the
until humans satisfied their physiologic needs, they could 10 leading causes of death among all Americans of all ages
not or would not seek to fulfill other needs. By progres- in 2004. Based on U.S. Government Statistics, the death
sively satisfying needs at each level, however, people will rate decreased almost 2% in 2004—the sharpest drop in
realize their maximum potential for health and well-being. 60 years (Gardner, 2006; Peterson, 2006).
Nurses have adopted Maslow’s hierarchy as a tool for
setting priorities for client care. For example, in the case
of the client with a heart attack, the nurse considers the Acute, Chronic, and Terminal Illnesses
An acute illness (one that comes on suddenly and lasts a

short time) is one method for classifying a change in
health. Influenza is an example of an acute illness. Many
acute illnesses are cured. Some lead to long-term problems
because of their sequelae (singular: sequela; ill effects that
result from permanent or progressive organ damage caused
by a disease or its treatment).
Chronic illness (one that comes on slowly and lasts a long
time) increases as people age. Arthritis, a joint disease, is
an example of a chronic illness. Many older adults live
with persistent health problems and disabilities because
they survived acute illnesses that killed others years ago.
A terminal illness (one in which there is no potential for
Need for self- cure) is one that eventually is fatal. The terminal stage of
actualization an illness is one in which a person is approaching death.
Need for esteem
and self-esteem
Need for love Primary and Secondary Illnesses
and belonging
Need for safety A primary illness (one that develops independently of any
and security other disease) differs from a secondary illness (disorder that
Physiologic needs develops from a preexisting condition). For example, pul-
FIGURE 4-3 • Maslow’s hierarchy of human needs. monary disease acquired from smoking is a primary illness.
TABLE 4-1 LEADING CAUSES OF DEATH IN THE UNITED STATES IN 2004

RANK CAUSE OF DEATH NUMBER PERCENTAGE OF TOTAL DEATHS
1 Diseases of the heart 654,092 27.2

2 Malignant neoplasms (cancer) 550,270 22.9
3 Cerebrovascular disease 150,147 6.2
4 Chronic lower respiratory diseases 123,884 5.1
5 Accidents (unintentional injuries) 108,694 4.5
6 Diabetes 72,815 3.0
7 Influenza and pneumonia 65,829 2.7
8 Alzheimer’s disease 61,472 2.5
9 Nephritis, nephritic syndrome, and nephrosis 42,762 1.7
10 Septicemia 33,464 1.3
From: Muñio, A. M., Heron, M., Smith, B. L. (2004). Deaths: Preliminary data for 2004. http://www.cdc.gov/nchs/products/
pubd/hestats/prelimdeaths04/preliminary deaths04.htm.
If pneumonia or heart failure occurs as a consequence of mide and subsequently gave birth to infants with miss-
smoke-damaged lung tissue, it is considered a secondary ing arms and legs. There is a great deal of concern about
problem. In essence, the primary condition predisposed the role of alcohol in producing fetal alcohol syndrome,
the smoker, in this case, to the secondary condition. a permanent but preventable form of retardation, and
the effects of exposure to other environmental toxins.
Although the etiologies for some congenital disorders are
Remission and Exacerbation well established, they can occur randomly.
An idiopathic illness is an illness whose cause is unex-
A remission means the disappearance of signs and symp- plained. Treatment focuses on relieving the signs and
toms associated with a particular disease. Although a symptoms because the etiology is unknown. Examples
remission resembles a cured state, the relief may be only of idiopathic conditions include hypertension for which
temporary. The duration of a remission is unpredictable. there is no known cause or a fever of undetermined
An exacerbation (reactivation of a disorder, or one that origin (FUO).
reverts from a chronic to an acute state) can occur peri-
odically in clients with long-standing diseases. Often,
remissions and exacerbations are related to how well or
poorly the immune system is functioning, the stressors HEALTH CARE SYSTEM
the client is facing, and the client’s overall health status
(e.g., nutrition, sleep, hydration). The health care system (network of available health services)
involves agencies and institutions where people seek treat-
ment for health problems or assistance with maintaining
Hereditary, Congenital, or promoting their health. The health care system, clients,
and Idiopathic Illnesses and their diseases have drastically changed during the past
25 years (Box 4-1). Advances in technology and discover-
A hereditary condition (disorder acquired from the genetic ies in science have created more elaborate methods of diag-
codes of one or both parents) may or may not produce nosing and treating diseases, creating a need for more
symptoms immediately after birth. Cystic fibrosis, a lung specialized care. What was once a system in which people
disease, and Huntington’s chorea, a neurologic disorder, sought medical advice and treatment from one physician,
are examples of inherited illnesses. The first is diag- clinic, or hospital has developed into a complex system
nosed soon after birth; the second is not manifested until involving primary, secondary, tertiary, and extended care.
adulthood.
Congenital disorders (those present at birth but which
are the result of faulty embryonic development) cannot Primary, Secondary, and Tertiary Care
be genetically predicted. Maternal illness, such as rubella
(German measles) or exposure to toxic chemicals or drugs, Primary care (health services provided by the first health
especially during the first 3 months of pregnancy, often care professional or agency a person contacts) usually is
predisposes the fetus to congenital disorders. Several given by a family practice physician, nurse practitioner, or
decades ago, many pregnant women took the drug thalido- physician’s assistant in an office or clinic. Cost-conscious
BOX 4-1 ● Trends in Health and Health Care

nursing home, and hospice care for dying clients. Extended
care is an important component of the health care system
❙ Increased older adult population because it allows earlier discharge from secondary and
❙ Greater ethnic diversity tertiary care agencies and reduces the overall expense of
❙ More chronic, but preventable, illnesses health care.
❙ More older adults with cognitive disorders (e.g., Alzheimer’s disease)
❙ Increased incidence of drug-resistant infections
❙ Decreased incidence of and death rates from HIV with increased life
expectancy associated with expensive drug therapy Health Care Services
❙ Expanding application of genetic engineering (treating diseases by altering
genetic codes) As a whole, health care services include those that offer
❙ Greater success in organ transplantation
health prevention, diagnosis, treatment, or rehabilitation.
❙ Major efforts at cost containment
❙ Continued rising costs of health care despite cost-containment measures As the types of health services expand, the health care
❙ Fewer insured and more underinsured citizens delivery system becomes more complex, costly, and in
❙ More outpatient or ambulatory (1-day stay) care many cases inaccessible.
❙ Shorter hospital stays
❙ Less invasive forms of treatment
❙ Shift to more home care
❙ Greater focus on disease prevention, health promotion, and health Access to Care
maintenance
❙ Movement toward more self-care and self-testing According to the U.S. Census Bureau, an estimated
❙ Approval of more prescription drugs for nonprescription use 45.8 million citizens do not have access to health care
❙ Greater interest in herbal supplements and other “complementary” or
because of the economic burden it poses. This number
alternative treatments
❙ Nationally linked computer information systems reflects an increase of almost 2% since 2003. As the
❙ Computerized medical record systems number of people covered by an employer’s group health
❙ Shift to criterion-based treatment (clients must meet established criteria to insurance has declined, reliance on government plans such
justify treatment measures) as Medicare, Medicaid, and military health care have
❙ Increased litigation against health professionals
increased (DeNavas-Walt et al., 2005). Children, older
adults, minorities, and the poor are likely to be under-
served. Many of these people delay seeking early treatment
for their health problems because they cannot afford to
health care reforms advocate the provision of primary care pay for services. When an illness becomes so severe that
by advanced practice nurses. the only choice is to seek medical attention, many turn
An example of secondary care (health services to which to their local hospital emergency departments for care.
primary caregivers refer clients for consultation and addi- Inappropriate use of emergency departments is expensive
tional testing) is the referral of a client to a cardiac catheter- and involves long waits and often no follow-up care.
ization laboratory. Tertiary care (health services provided
at hospitals or medical centers where complex technology
and specialists are available) may require the client to Financing Health Care
travel some distance from home. The growing trend is to
provide as many secondary and tertiary care services as Historically private insurance, self-insurance systems,
possible on an outpatient basis or to require no more than and Medicare paid for health care. Hospitals and approved
24 hours of inpatient care. providers received payment for what they charged; more
charges increased income and profits. These plans offered
no incentives to control costs. Disparities in access to
health care and the high costs prompted evaluation of the
Stop • Think + Respond BOX 4-1 entire health care system. Subsequently this led to inno-
A friend complains she has been having frequent bouts of vative cost-cutting approaches in government payment
indigestion. Explain how primary, secondary, and tertiary systems and those financed by private insurers and cor-
care might be involved in her care. porate health plans.
Government-Funded Health Care:

Medicare and Medicaid
Extended Care
Medicare (a federal program that finances health care
Extended care (services that meet the health needs of clients costs of persons 65 years and older, permanently dis-
who no longer require acute hospital care) includes reha- abled workers of any age and their dependents, and those
bilitation, skilled nursing care in a person’s home or a with end-stage renal disease) is funded primarily through
withholdings from an employed person’s income. Med- fixed rate basis. Reimbursement is based on the diagnostic-
icare has two parts: related group (DRG) (a classification system used to group
clients with similar diagnoses). For example, all clients
• Part A covers acute hospital care, rehabilitative care,
receiving a hip, knee, or shoulder replacement fall into
hospice, and home care services.
DRG 209, Total Joint Replacement, and the surgeries are
• Part B is purchased for an additional fee and covers
reimbursed at basically the same rate. If actual costs are less
physician services, outpatient hospital care, laboratory
than the reimbursed amount, the hospital keeps the dif-
tests, durable medical equipment, and other selected
ference. If costs exceed the reimbursed amount, the hos-
services. Although Medicare is primarily used by older
pital is left with the deficit. Hospitals that are inefficient
Americans, it does not cover long-term care and limits
in managing clients’ recovery and early discharge can
coverage for health promotion and illness prevention.
potentially lose vast revenue, possibly leading to closure
In 2006, the Medicare drug benefit (Medicare Part D) of the facility.
became available. This and similar plans are being pro- Since its inception, the DRG system has been largely
moted as a means of relieving the financial burden on older responsible for marked decreases in hospital lengths of
Americans and those with low incomes and disabilities stay. Subsequently three major criticisms have surfaced:
who require prescription drugs. Everyone eligible for (1) some older clients are discharged prematurely so as not
Medicare can receive prescription drug coverage regard- to exceed the fixed reimbursement, (2) families have had
less of income, resources, health status, or current pre- to assume responsibility for the care of clients who cannot
scription expenses. Nevertheless, gaps in the system function independently after discharge, and (3) increased
remain (Table 4-2). People are being advised to compare hospital care costs have been charged to clients with
Medicare benefits with stand-alone prescription drug plans private insurance to make up for the lost Medicare rev-
offered by private companies. Some may choose to pur- enues. In response to cost-shifting and other economic
chase an additional “Medicap” insurance plan to assist forces, private insurance companies have countered by
with the cost of deductible and co-payments. aggressively challenging hospital charges, refusing pay-
Medicaid (a state administered program designed to meet ment for unjustified billings, and developing their own
the needs of low-income residents) is supported by funds cost-containment reimbursement system known as
from federal, state, and local sources. Each state deter- managed care.
mines how the funds will be spent. In general, Medicaid
programs cover hospitalization, diagnostic tests, physi- Managed Care
cian visits, rehabilitation, and outpatient care. They also
may cover long-term care when a person exhausts his or Managed care organizations (private insurers who carefully
her private funds. plan and closely supervise the distribution of their clients’
health care services) control costs of health care and focus
Prospective Payment Systems on prevention as the best way to manage costs using the
following techniques:
In response to escalating health care costs, the federal
government implemented a system of prospective pay- • Using health care resources efficiently
ment in 1983 for people enrolled in Medicare. A prospec- • Bargaining with providers for quality care at reason-
tive payment system uses financial incentives to decrease able costs
total health care charges by reimbursing hospitals on a • Monitoring and managing fiscal and client outcomes
TABLE 4-2 MEDICARE PART D PRESCRIPTION DRUG BENEFITS

ANNUAL PRESCRIPTION COST TO PARTICIPANT MEDICARE CONTRIBUTION
$0 Monthly premium of $37, subject to increase based on date of enrolling

$0–$250 $250 deductible of initial = GAP/$0 prescription drug expenses
$250–$2,250 25% of prescription drugs; 75% of prescription drug costs
between $250 and $2,250 (up to $500) $2,250 (up to $1,500)
$2,250–$5,100 100% of drug costs = GAP/$0 between $2,250 and $5,100 (up to $2,850)
Subtotal: $3,600 + monthly $1500 premium
>$5,100 5% or $2 for generic; 95% of prescription drugs and $5 for name brand
drug costs
Data from Medicare fact sheet: http://www.kff.org/medicare/7044.cfm; and Understanding the new Medicare prescription
drug plan: http://familydoctor.org/848.xml. Accessed July 17, 2006.
• Preventing illness through screening and health pro- is difficult to obtain and to provide health care free from the
motion activities economic pressure of insurers. Many claim that the profits
• Providing client education to decrease the risk for of insurance companies come at the expense of quality
disease care. For example, hospitals are using unlicensed assistive
• Minimizing the number of hospitalizations of clients personnel (UAPs) to perform some duties that practical/
with chronic illness vocational and registered nurses once provided. Current
The two most common types of managed care systems evidence shows that deaths in health care agencies increase
are health maintenance organizations (HMOs) and pre- as the numbers of licensed nurses decrease (Aiken et al.,
ferred provider organizations (PPOs). Capitation is a third 2003; Clarke & Aiken, 2006; Tourangeau et al., 2006).
emerging Managed Care Organization (MCO) financial On the other hand, cost-driven changes have had pos-
strategy. itive effects as well. As concern for cost meets concern
for quality, health care institutions, nursing personnel,
HEALTH MAINTENANCE ORGANIZATIONS. Health mainte- and other providers search for ways to ensure that all
nance organizations are corporations that charge preset, care, teaching, and preparation before the discharge date
fixed, yearly fees in exchange for providing health care occur without overusing expensive resources.
for their members. The fee remains the same regardless of In an attempt to reduce duplication of health care
the type of health service required or the frequency of services and increase revenue, hospitals and other health
care. These organizations are able to remain fiscally sound care facilities are forming networks known as integrated
because they offer preventive services, periodic screen- delivery systems. Integrated delivery systems (networks that
ings, and health education to keep their members healthy provide a full range of health care services in a highly
and out of the hospital. coordinated, cost-effective manner) offer diverse options
Health maintenance organizations provide ambulatory, to clients (Box 4-2) and result in shorter hospital stays,
hospitalization, and home care services. Some HMOs have fewer complications such as hospital acquired infections,
their own health care facilities; others use facilities within and quicker return to self-care.
the community. A member of an HMO must receive per-
mission for seeking additional care such as second opin-
ions from specialists or unauthorized diagnostic tests.
Those members who fail to do so are responsible for the
NATIONAL HEALTH GOALS
entire bill. In this way, HMOs serve as gatekeepers for
health care services. A national ongoing health-promotion effort referred to as
Healthy People 2010 is a continuation of the 1979 Sur-
PREFERRED PROVIDER ORGANIZATIONS. Preferred provider geon General’s Report, Healthy People, and later, Healthy
organizations are agents for health insurance companies that People 2000: National Health Promotion and Disease Pre-
control health care costs on the basis of competition. PPOs vention. The emphasis of Healthy People 2010 is improv-
create a network of a community’s physicians who are ing the quality of life, not just increasing life expectancy,
willing to discount their fees for service in exchange for a and improving community health services to reduce dis-
steady supply of referred clients. The subscriber’s clients parities in disadvantaged populations.
can lower their health care costs by receiving care from any Healthy People 2010 identifies goals for improving the
of the preferred providers. If they select providers outside nation’s health in 10 areas, referred to as leading health
the network, they pay a higher percentage of the costs. indicators, that are considered the major U.S. health con-
cerns in the 21st century (Box 4-3). In all, it contains 28
CAPITATION. An approach that is fundamentally different
focus areas, each of which has identified objectives for
from HMOs and PPOs is capitation, a payment system in
which a preset fee per member is paid to a health care improvement; the target date for accomplishment is the
provider (usually a hospital or hospital system) regardless
of whether or not the member requires services. Capitation
provides an incentive to providers to control tests and BOX 4-2 ● Integrated Delivery Systems’ Services
services as a means of making a profit. If members do not
receive costly care, the provider makes money. Integrated delivery systems provide
❙ Wellness programs ❙ Rehabilitation
❙ Preventive care ❙ Long-term care
Outcomes of Structured Reimbursement ❙ Ambulatory care ❙ Assisted living facilities
❙ Outpatient diagnostic and labora- ❙ Psychiatric care
tory services ❙ Home health care services
In many cases, the changes in reimbursements have shifted ❙ Emergency care ❙ Hospice care
economic and decision-making power from hospitals and ❙ Secondary and tertiary services ❙ Outpatient pharmacies
physicians to insurance companies. One criticism is that it
BOX 4-3 ● Healthy People 2010 Goals

• Reduce infections caused by key food-borne pathogens.
and Health Indicators • Improve the visual and hearing health nationally
through prevention, early detection, treatment, and
GOALS
❙ Increase quality and years of healthy life rehabilitation (Healthy People 2010, http://www.
❙ Eliminate health disparities health.gov/healthypeople/About/goals.htm).
LEADING HEALTH INDICATORS The Healthy People 2010 campaign is being carried out
❙ Physical activity ❙ Injury and violence
❙ Overweight and obesity ❙ Environmental quality
with the combined expertise of the Public Health Service,
❙ Tobacco use ❙ Immunizations each state’s health department, national health organi-
❙ Substance abuse ❙ Improve occupational safety and health zations, the Institute of Medicine of the National Academy
❙ Mental health ❙ Access to health care of Sciences, and selected individuals from the public at
large. To meet the targeted goals, health care workers are
U.S. Department of Health and Human Services. (2000). Healthy people
2010. Washington, DC: U.S. Government Printing Office. challenged to implement strategies to improve the over-
all health of people living in the United States.
year 2010 (Fig. 4-4). Examples of targeted health goals are NURSING TEAM
as follows:
• Increase the proportion of people with health insurance. The goal of the nursing team (personnel who care for clients
• In the health professions, allied and associated health directly) is to help clients attain, maintain, or regain health
professions, and nursing, increase the proportion of all (Fig. 4-5). The team may include several types of profes-
degrees awarded to members of underrepresented racial sionals as well as allied health care workers with special
and ethnic groups. training such as respiratory therapists, physical therapists,
• Increase the proportion of health and wellness and and technicians.
treatment programs and facilities that provide full Nurses use their unique skills in the hospital as well
access for people with disabilities. as other employment areas. Because they have skills that
• Reduce the number of new cases of cancer as well as assist the healthy, the dying, and all in between, nurses
the illness, disability, and death caused by cancer. work in various settings such as health maintenance
13. Health Services

• Clinical Preventive Services
9. Food and Drug Safety (including immunizations)
10. Environmental Health • Emergency Medicine 18. Public
11. Occupational Health • Long Term Care Health
3. Physical 12. Infectious Diseases 14. Mental Health Services Infrastructure
Activity 15. Oral Health • Surveillance
4. Nutrition 16. Family Planning and Data Systems
5. Sexual Health 17. Maternal, Infant • Training
• HIV Infection and Child Health • Research
• STDs
19. Educational and Community
6. Unintentional Injuries
Based Programs
7. Tobacco
8. Substance Abuse 20. Violent and Abusive
Behavior
1. Mental and
Physical Impairment
and Disability SPECIAL POPULATIONS*
2. Chronic Diseases Low Income
• Heart Diseases Race/Ethnicity
• Cancer Gender
• Stroke Age
• Lung Disease People with Disabilities
• Diabetes
INCREASE ELIMINATE
QUALITY AND YEARS HEALTH
OF HEALTHY LIFE DISPARITIES
FOCUS AREAS Health for All FOCUS AREAS
* Special population groups need to be
Goals for the Nation considered as objectives are developed
in all focus areas.
FIGURE 4-4 • Components of proposed Healthy People 2010.

58 UNIT 2 ● Integrating Basic Concepts
Team Nursing
Licensed
Practical/ Registered Team nursing (pattern in which nursing personnel divide
Vocational Nurse
the clients into groups and complete their care together)
Nurse
is organized and directed by a nurse called the team leader.
The leader may assist with but usually assigns and super-
vises the care that other team members provide. All team
The Client members report the outcomes of their care to the team
and
Family leader. The team leader is responsible for evaluating
Nursing Nursing whether the goals of client care are met.
Assistant Students Conferences are an important part of team nursing.
They may cover a variety of subjects but are planned
with certain goals in mind such as determining the best
approaches to each client’s health problems, increasing the
Nursing team members’ knowledge, and promoting a cooperative
Volunteer spirit among nursing personnel.
FIGURE 4-5 • The nursing team. Primary Nursing

In primary nursing (pattern in which the admitting nurse
assumes responsibility for planning client care and eval-
organizations, physical fitness centers, weight-loss clinics, uating the client’s progress), the primary nurse may del-
public health departments, home health agencies, and egate the client’s care to someone else in his or her absence
hospices. Wherever nursing personnel work together, they but is consulted when new problems develop or the plan
use one of several patterns for managing client care. The of care requires modifications. The primary nurse remains
five common management patterns are functional nursing, responsible and accountable for specific clients until they
case method, team nursing, primary nursing, and nurse- are discharged.
managed care. Each has advantages and disadvantages.
Students are likely to encounter one or all of these meth-
ods in their clinical experience. Nurse-Managed Care
A new type of nursing care delivery system is being imple-
Functional Nursing mented in several areas of the United States. It is called
nurse-managed care (pattern in which a nurse manager
One method used when providing client care is functional plans the nursing care of clients based on their type of
nursing (pattern in which each nurse on a client unit is
case or medical diagnosis). A clinical pathway typically
assigned specific tasks). For example, one is assigned to is used in a managed care approach (see Chap. 1 for more
information on managed care and an example of a clinical
give all the medications, another performs all the treat-
pathway).
ments (such as dressing changes), and another works at
This innovative system was developed in response to
the desk transcribing physicians’ orders and communi-
several problems affecting health care delivery today such
cating with other nursing departments about client care
as the nursing shortage and the need to balance the costs of
issues. This pattern is being used less often because its medical care with limited reimbursement systems. Nurse-
focus tends to be more on completing the task rather managed care is similar to the principles used by suc-
than caring for individual clients. cessful businesses. In the business world, corporations pay
executives to forecast trends and determine the best strate-
gies for making profits. In nurse-managed care, a profes-
Case Method sional nurse evaluates whether predictable outcomes are
met on a daily basis. By meeting the outcomes in a timely
The case method (pattern in which one nurse manages all manner, the client is ready for discharge by the time desig-
the care a client or group of clients needs for a designated nated by prospective payment systems, if not before.
period of time) should not be confused with managed Pilot studies indicate that this approach ensures that
care, which is discussed later. The case method is most standards of care are met with greater efficiency and cost
often used in home health, public health, and community savings. Hospitals that are adopting case-managed care
mental health nursing. Nurses who deliver this type of report that they are operating within their budgets and
care are referred to as case managers. decreasing their financial losses.
CONTINUITY OF HEALTH CARE NCLEX-STYLE REVIEW Q U E S T I O N S

1. If all the following client problems exist, which is of highest
Continuity of care (maintenance of health care from one priority for nursing management?
level of health to another and from one agency to another) 1. Low self-esteem
ensures that the client navigates the complicated health 2. Labored breathing
care system with a maximum of efficiency and a mini- 3. Feeling powerlessness
mum of frustration. The goal is to avoid causing a client, 4. Lack of family support
whether healthy or ill, to feel isolated, fragmented, or 2. The most appropriate initial nursing referral of a person
abandoned. All too often this occurs when one health who is experiencing frequent headaches is to a
practitioner fails to consult or communicate with others 1. Drug company seeking clinical trial volunteers for
involved in the client’s care. Chapters 9 and 10 give exam- a headache medication
ples of how nurses communicate among themselves and 2. Neurologic institute conducting investigational
with personnel in other institutions to ensure that the research on headaches
client’s care is both continuous and goal directed. 3. Hospital’s emergency department for immediate
medical treatment
4. Family practice physician for a baseline physical
CRITICAL THINKING E X E R C I S E S examination
1. If you were asked to participate in planning the goals 3. Which of the following is the best example of promoting
and strategies for Healthy People 2010, what sugges- continuity of client care? A hospital nurse refers a client
tions would you make to promote health and reduce with terminal cancer to a
chronic illness? 1. Preferred provider organization
2. Which pattern for managing client care seems most advan- 2. Home health nursing organization
tageous for nurses? Which pattern might clients prefer? 3. Health maintenance organization
Give reasons for your selections. 4. Managed care organization
5
Chapter
Homeostasis,
Adaptation,
and Stress
LEARNING OBJECTIVES
● Explain homeostasis.
● List four categories of stressors that affect homeostasis.
● Identify two beliefs about the body and mind based on the concept of holism.
● Identify the purpose of adaptation and two possible outcomes of unsuccessful adaptation.
● Trace the structures through which adaptive changes take place.
● Differentiate between sympathetic and parasympathetic adaptive responses.
● Define stress.
● List 10 factors that affect the stress response.
● Discuss the three stages and consequences of the general adaptation syndrome.
● Name three levels of prevention that apply to the reduction or management of stress-related
disorders.
● Explain psychological adaptation and two possible outcomes.
● List eight nursing activities helpful to the care of clients prone to stress.
● List four approaches to preventing, reducing, or eliminating a stress response.
HEALTH is a tenuous state. To sustain it, the body continuously adapts 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 con-
stant physiologic activity. The body maintains constancy by adjusting and readjust-
WORDS TO KNOW ing in response to changes in the internal and external environment that foster
disequilibrium.
adaptation
coping mechanisms
coping strategies Holism
feedback loop
general adaptation Although homeostasis is associated primarily with a person’s physical status, emo-
syndrome tional, social, and spiritual components also affect it. As discussed in Chapter 4, holism
homeostasis
neurotransmitters
implies that entities in all these areas contribute to the whole of a person. Based on
stress the principles of holism, stressors may be physiologic, psychological, social, or spiritual
stressors (Table 5-1).
60
CHAPTER 5 ● Homeostasis, Adaptation, and Stress 61
TABLE 5-1 COMMON STRESSORS

PHYSIOLOGIC PSYCHOLOGICAL SOCIAL SPIRITUAL
Prematurity Fear Gender, racial, age Guilt

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

(1) both the mind and body directly influence humans,
and (2) the relationship between the mind and 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 adapta-
tion are discussed later in this chapter.

List physiologic, psychological, social, and spiritual stress-
ors that can affect homeostasis among nursing students.
Dendrites
Adaptation
Synapse
Axon
Adaptation (how an organism responds to change) requires
the use of self-protective properties and mechanisms
Dendrite
for regulating homeostasis. Neurotransmitters mediate Direction of
Axon
homeostatic adaptive responses by coordinating functions nerve impulse
of the central nervous system, autonomic nervous system,

and endocrine system.
Neurotransmitters
Axon
Neurotransmitters (chemical messengers synthesized in the
neurons) allow communication across the synaptic cleft
between neurons, subsequently affecting thinking, behav- Vesicles
ior, and bodily functions. When released, neurotransmit- Synaptic
ters temporarily bind to receptor sites on the postsynaptic cleft
neuron and transmit their information. After this is
accomplished, the neurotransmitter is broken down,
recaptured for later use, or weakened (Fig. 5-1).
Common neurotransmitters include serotonin, dopa- Receptor
Neurotransmitters Dendrite sites
mine, norepinephrine, acetylcholine, gamma-aminobutyric
acid, and glutamate. Other chemical messengers, called
neuropeptides, are actually a separate type of neuro- FIGURE 5-1 • Neurotransmitter activity. (From Timby, B. K., & Smith,
transmitter. Neuropeptides include substance P, endor- N. E. [2007]. Introductory medical-surgical nursing [9th ed.]. Philadel-
phins, enkephalins, and neurohormones. phia: Lippincott Williams and Wilkins)
Neurotransmitters and neuropeptides exert different include regulation of breathing, heart contraction, blood
effects. Serotonin stabilizes mood, induces sleep, and reg- pressure, body temperature, sleep, appetite, and stimula-
ulates temperature. Norepinephrine heightens arousal tion and inhibition of hormone production.
and increases energy. Acetylcholine and dopamine pro-
mote coordinated movement. Gamma-aminobutyric acid RETICULAR ACTIVATING SYSTEM. The reticular activating
inhibits the excitatory neurotransmitters, such as nor- system (RAS), an area of the brain through which a net-
epinephrine and dopamine, which are classified as cat- work of nerves passes, is the communication link between
echolamines. Substance P transmits the pain sensation, body and mind. Information about a person’s internal
whereas endorphins and enkephalins interrupt the trans- and external environment is funneled through the RAS
mission of substance P and promote a sense of well-being. to the cortex on both a conscious and an unconscious level
Different brain areas contain different neurons that (Fig. 5-3). The cortex processes the information and gen-
contain specific neurotransmitters. Receptors for these erates behavioral and physiologic responses through acti-
chemical messengers are found throughout the central ner- vation by the hypothalamus. The hypothalamus, in turn,
vous, endocrine, and immune systems, suggesting a highly influences the autonomic nervous system and endocrine
integrated communication system sometimes referred to as functions (Fig. 5-4).
the hypothalamus-pituitary-adrenal (HPA) axis.
Autonomic Nervous System
Central Nervous System
The autonomic nervous system is composed of peripheral
The central nervous system is composed of the brain and nerves affecting physiologic functions that are largely auto-
spinal cord. The brain is divided into the cortex and the matic and beyond voluntary control. It is subdivided into
structures that make up the subcortex (Fig. 5-2). the sympathetic and parasympathetic nervous systems.
Both the sympathetic and parasympathetic divisions
CORTEX. The cortex is considered the higher-functioning supply organs throughout the body with nerve pathways.
portion of the brain. It enables people to think abstractly, Each division takes a turn being functionally dominant,
use and understand language, accumulate and store mem- depending on the appropriate physiologic response. For
ories, and make decisions about information received. example, when increased heart rate is needed, the sym-
The cortex also influences other primitive areas of the pathetic division dominates; when heart rate needs to be
brain located in the subcortex. slowed, the parasympathetic division takes over.
SUBCORTEX. The subcortex consists of the structures in
SYMPATHETIC NERVOUS SYSTEM. When a situation occurs
the midbrain and brainstem. The midbrain, which lies
that the mind perceives as dangerous, the sympathetic
between the cortex and brainstem, includes the basal
nervous system prepares the body for fight or flight. It
ganglia, thalamus, and hypothalamus. The brainstem,
so named because it resembles a stalk, contains the cere-
bellum, medulla, and pons. The subcortical structures
are primarily responsible for regulating and maintaining
physiologic activities that promote survival. Examples
Cortex
Midbrain
Basal ganglia
Thalamus
Hypothalamus
Brain stem
Cerebellum
Pons
Medulla
Pituitary
gland
Spinal cord
FIGURE 5-3 • The reticular activating system is the link in the mind–
FIGURE 5-2 • Central nervous system structures. body connection.
however, does not produce an opposite reaction for every

sympathetic effect (Table 5-2). For this reason, some
Stress
believe that the parasympathetic nervous system offers an
Pituitary alternate but equally effective mechanism for responding
Hypothalamus
to threats from the internal or external environment. For
example, physiologic deceleration, produced by the para-
Autonomic sympathetic nervous system, has been likened to the
nervous system manner in which opossums and other animals “play dead”
Thymus when they sense that predators are stalking them. Simu-
lating the appearance of death often causes the predator
Thyroid
to leave the animal alone, thus saving its life. Therefore,
Parathyroid it has been proposed that humans, too, may respond to
Heart stimuli not only by speeding physiologic responses but
and lungs also by slowing them down (Nuernberger, 1981).
Catecholamines
Adrenocorticotrophic Endocrine System
hormone (ACTH)
Adrenal The autonomic nervous system provides the initial and
Adrenal medulla immediate response to a perceived threat through either
cortex sympathetic or parasympathetic pathways. The endocrine
Kidneys system, a group of glands found throughout the body that
produce hormones, sustains the response (Fig. 5-5). Hor-
Liver
mones are chemicals manufactured in one part of the body
Stomach whose actions have physiologic effects on target cells
Pancreas elsewhere.
Corticosteroids,
including cortisol Bone marrow
NEUROENDOCRINE CONTROL. The pituitary gland, located
FIGURE 5-4 • Homeostatic adaptive pathways. in the brain, is considered the master gland, producing
hormones that influence other endocrine glands. The pitu-
itary gland is connected to the hypothalamus, a subcortical
accelerates the physiologic functions that ensure survival structure, through both vascular connections and nerve
through enhanced strength or rapid escape. The person endings. For pituitary function to occur, the cortex first
becomes active, aroused, and emotionally charged. stimulates the hypothalamus that then activates the pitu-
itary gland.
PARASYMPATHETIC NERVOUS SYSTEM. The parasympa-
thetic nervous system restores equilibrium after danger is FEEDBACK LOOP. A feedback loop is the mechanism for
no longer apparent. It does so by inhibiting the physiologic controlling hormone production (Fig. 5-6). Feedback can
stimulation created by its counterpart, the sympathetic be negative or positive. Most hormones are secreted in
nervous system. The parasympathetic nervous system, response to negative feedback; when a hormone level
TABLE 5-2 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 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
FIGURE 5-5 • Endocrine glands.
decreases, the releasing gland is stimulated. In positive stress results. Stress is the physiologic and behavioral
feedback, the opposite occurs, keeping concentrations of responses to disequilibrium. It has physical, emotional,
hormones within a stable range at all times. Homeosta- and cognitive effects (Table 5-3).
sis is maintained when hormones are released as needed Although all humans have the capacity to adapt to
or inhibited when adequate. stress, not everyone responds to similar stressors exactly
the same. Differences vary according to (1) intensity of
STRESS
TABLE 5-3
COMMON SIGNS AND
As long as demands on the central nervous, autonomic SYMPTOMS OF STRESS
nervous, and endocrine systems are within adaptive capac- PHYSICAL EMOTIONAL COGNITIVE
ity, the body maintains homeostasis. When internal or
Rapid heart rate Irritability Impaired attention
external changes overwhelm homeostatic adaptation,
Rapid breathing Angry outbursts and concentration
Increased blood Hypercritical Forgetfulness
pressure Verbal abuse Preoccupation
Releasing Difficulty falling Withdrawal Poor judgment
gland asleep or Depression
excessive
sleep
Loss of appetite
or excessive
eating
Inhibition Stimulation Stiff muscles
Hyperactivity or
inactivity
Dry mouth
Constipation or
High Low diarrhea
level level Lack of interest
in sex
FIGURE 5-6 • A feedback loop regulates hormone levels.
the stressor, (2) number of stressors, (3) duration of 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.
Physiologic Stress Response
Hans Selye, a Canadian physician who lived in the early

1900s, devoted much of his life to researching the collec-
tive physiologic processes of the stress response, which
he called the general adaptation syndrome. Selye observed
that this syndrome occurs repeatedly and consistently
regardless of the nature of the stressor. He maintained
that (1) the body’s physical response is always the same,
and (2) it follows a one-, two-, or three-stage pattern: alarm
stage, stage of resistance, and in some cases, stage of ex-
haustion (Fig. 5-7). The first two stages parallel the adap-
tation processes of maintaining homeostasis (discussed
earlier). Therefore, brief stress responses generally have
adaptive outcomes, with restoration of equilibrium. If
the stage of resistance is prolonged, however, the process
can become maladaptive and pathologic. It can lead to
stress-related disorders and, in some cases, death.
Alarm Stage
At the immediate onset of a stress response, storage vesi-
cles within sympathetic nervous system neurons rapidly
release norepinephrine. Shortly thereafter, the adrenal
glands secrete additional norepinephrine and epinephrine.
These stimulating neurotransmitters and neurohormones
prepare the person for a “fight or flight” response. Almost
simultaneously, the hypothalamus releases corticotropin-
releasing factor (CRF), which triggers the pituitary gland
to secrete adrenocorticotropic hormone (ACTH). The
result is the release of cortisol, a stress hormone, from
the adrenal cortex.
Cortisol plays various important roles in responding
to a stressor such as raising blood glucose as a reserve for
meeting increased energy requirements (Table 5-4). Pro-
longed elevation of levels of norepinephrine, epinephrine,
and cortisol, however, can predispose clients to stress-
related disorders (discussed later).
Stage of Resistance
FIGURE 5-7 • Stages of the general adaptation syndrome.
The stage of resistance is characterized by restoration to
normalcy. Neuroendocrine hormones, although temporar-
ily excessive, endeavor to compensate for the physiologic
Stage of Exhaustion
changes of the alarm stage. The usual outcome is a return
to homeostasis. If stress is protracted, however, resistance Physiologic exhaustion occurs when one or more adap-
efforts remain activated. Consequently one or more organs tive or resistive mechanisms can no longer protect the
or physiologic processes may lead eventually to increased person experiencing a stressor. Once beneficial mecha-
vulnerability for stress-related disorders or progression nisms now become destructive. For example, the effects
to the stage of exhaustion. of stress-related neurohormones suppress the immune
TABLE 5-4 ACTIONS OR 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 Stabilizes membranes of inflamed cells, preventing release of proinflammatory mediators
action 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
Adapted from Porth, C. M. (2007). Essentials of pathophysiology: Concepts of altered health states (2nd ed.). Philadelphia:
Lippincott Williams & Wilkins, p. 692.
system. As a result, there are reduced natural killer Coping Mechanisms

(NK) cells, which attack viruses and cancer cells, and
Sigmund Freud posited that humans use coping mechanisms
decreased secretory immunoglobulin A (sIgA), an anti-
(unconscious tactics to defend the psyche) to prevent their
body involved in immune defense. These changes put
ego, or reality base, from feeling inadequate (Table 5-5).
the person at risk for frequent or severe infections or
These manipulations of reality act as psychological first
cancer. Additional disruptions to other organs include
aid, allowing people to avoid temporarily the emotional
reduced beneficial bowel microorganisms and increased
effects of stress. When appropriate and moderate, coping
bowel pathogens (Kelly, 1999). As resistance dwindles, mechanisms enable people to maintain their mental equi-
there is physical and mental deterioration, illness, and librium. Coping mechanisms that are overused or over-
death. extended may have maladaptive effects, distorting reality
to such an extent that the person fails to recognize and cor-
rect his or her weaknesses. Consequently the person may
Stop • Think + Respond BOX 5-2 avoid taking responsibility for solving personal problems.
List the following stress-related responses in sequential
Coping Strategies
order:
1. The adrenal cortex releases cortisol. Coping strategies(stress-reduction activities selected con-
2. The pituitary gland secretes ACTH. sciously) help people to deal with stress-provoking events
3. The body prepares for fight or flight. or situations. They can be therapeutic and nontherapeutic.
4. The blood glucose level rises. Therapeutic coping strategies usually help the person to
5. The adrenal glands release norepinephrine and acquire insight, gain confidence to confront reality, and
epinephrine. develop emotional maturity. Examples include seeking
6. The hypothalamus secretes CRF. professional assistance in a crisis, using problem-solving
7. The immune system becomes suppressed. techniques, demonstrating assertive behavior, practic-
8. Sympathetic neurons release norepinephrine. ing progressive relaxation, and turning to a comforting
other or higher power.
Maladaptation results when people use nontherapeutic
coping strategies such as mind- and mood-altering sub-
Psychological Stress Responses stances, hostility and aggression, excessive sleep, avoid-
ance of conflict, and abandonment of social activities.
Just as stress requires adaptation from the body, stress Negative coping strategies may provide immediate tem-
also affects the psyche (mind). The mind, in turn, mounts porary relief from a stressor, but they eventually cause
additional defenses. problems.
TABLE 5-5 COPING MECHANISMS

MECHANISM EXPLANATION EXAMPLE
Repression Forgetting about the stressor Wiping 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 like God
Denial Rejecting information Refusing to believe something like a life-threatening
diagnosis
Rationalization Relieving oneself of personal accountability by Blaming failure on a test to the manner in which the
attributing responsibility to someone or test was constructed
something else
Displacement Taking anger out on something or someone else Kicking the wastebasket after being reprimanded by
who is less likely to retaliate the boss
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
disorder from going to work
Compensation Excelling at something to make up for a weakness Becoming a motivational speaker although physically
of another kind handicapped
Sublimation Channeling one’s energies into an acceptable Turning to sportscasting when an athletic career is
alternative not 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 or speech of an actor or
musician
Stress-Related Disorders arthritis and other connective tissue disorders; (2) failure
to respond, as in immunosuppression; or (3) a weakened
Stress-related disorders are diseases that result from immune response, which may contribute to infections
prolonged stimulation of the autonomic nervous and and cancer. Even psychological variables such as prolonged
endocrine systems (Box 5-1). Many stress-related dis- anger, feelings of helplessness, and worry can potentially
eases involve allergic, inflammatory, or altered immune influence the onset and progression of immune system–
responses. They are characterized by physical conditions mediated diseases (Cohen & Herbert, 1996; Godbout &
that cycle through asymptomatic periods (absence of Glaser, 2006; Kuster & Merkle, 2004).
the disorder) to episodes that usually develop when the
person is under stress. The brain–immune connection
suggests that changes in body chemistry during periods of NURSING IMPLICATIONS
stress may trigger the following: (1) an autoimmune (self-
attacking) response like those associated with rheumatoid
Nurses must be aware of potential stressors affecting
clients because they add to the cumulative effect of other
stressful life events. When a person is experiencing a
BOX 5-1 ● Stress-Related Disorders stressor, nurses do one or several of the following:
❙ Hypertension ❙ Depressive disorders • Identify the stressors.

❙ Headaches ❙ Cancer • Assess the client’s response to stress.
❙ Gastritis ❙ Low back pain • Eliminate or reduce the stressors.
❙ Ulcerative colitis ❙ Irritable bowel syndrome • Prevent additional stressors.
❙ Asthma ❙ Allergies
• Promote the client’s physiologic adaptive responses.
❙ Rheumatoid arthritis ❙ Anxiety disorders
❙ Skin disorders ❙ Infertility • Support the client’s psychological coping strategies.
❙ Hyper/hypoinsulinism ❙ Impotence • Assist in maintaining a network of social support.
❙ Hyper/hypothyroidism ❙ Bruxism (tooth grinding) • Implement stress reduction and stress management
techniques.
Assessment of Stressors BOX 5-2 ● The Social Readjustment Rating Scale
Holmes and Rahe (1967) developed a tool, the Social RANK LIFE EVENT LCU VALUE
Readjustment Rating Scale, to predict a person’s poten-
tial for developing a stress-related disorder. The rating 1 Death of spouse 100
2 Divorce 73
scale is based on the number and significance of social 3 Marital separation 65
stressors a person has experienced within the previous 4 Jail term 63
6 months (Box 5-2). The risk for a stress-related disorder 5 Death of close family member 63
increases as the person’s score rises. Although the dollar 6 Personal injury or illness 53
amounts in the mortgage-related items of the scale are 7 Marriage 50
8 Fired at work 47
outdated, being in debt is still a major stressor. There-
9 Marital reconciliation 45
fore, with minor modifications, the assessment tool con- 10 Retirement 45
tinues to have diagnostic value. 11 Change in health of family member 44
One research study ranked the stressors clients expe- 12 Pregnancy 40
rience in a list modeled after the Social Readjustment 13 Sex difficulties 39
Rating Scale (Box 5-3). By being aware of how an illness 14 Gain of new family member 39
15 Business readjustment 39
or interactions with health care personnel and facilities 16 Change in financial state 38
can affect clients, nurses can be instrumental in support- 17 Death of close friend 37
ing those who are especially vulnerable. 18 Change to different line of work 36
19 Change in number of arguments with spouse 35
20 Mortgage over $10,000 31
21 Foreclosure of mortgage or loan 30
Prevention of Stressors 22 Change in responsibilities at work 29
23 Son or daughter leaving home 29
By offering appropriate interventions to people with severe 24 Trouble with in-laws 29
or accumulated stressors, nurses can help to prevent or 25 Outstanding personal achievement 28
minimize stress-related illness. Prevention takes place at 26 Wife begins or stops work 26
27 Begin or end school 26
three levels:
28 Change in living conditions 25
• Primary prevention involves eliminating the potential 29 Revision of personal habits 24
for illness before it occurs. An example is teaching prin- 30 Trouble with boss 23
31 Change in work hours or conditions 20
ciples of nutrition and methods to maintain normal 32 Change in residence 20
weight and blood pressure to adolescents. 33 Change in schools 20
• Secondary prevention includes screening for risk factors 34 Change in recreation 19
and providing a means for early diagnosis of disease. 35 Change in church activities 19
An example is regularly measuring the blood pressure 36 Change in social activities 18
37 Mortgage or loan less than $10,000 17
of a client with a family history of hypertension.
38 Change in sleeping habits 16
• Tertiary prevention minimizes the consequences of a 39 Change in number of family get-togethers 15
disorder through aggressive rehabilitation or appro- 40 Change in eating habits 15
priate management of the disease. An example is fre- 41 Vacation 13
quently turning, positioning, and exercising a client 42 Christmas 12
43 Minor violations of the law 11
who has had a stroke to help restore functional ability.
Social events are ranked from most stressful to least stressful. Each event is
assigned a life change unit (LCU) that correlates with the severity of the
Stress-Reduction Techniques 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
an indication of mild risk, moderate risk is associated with a score between
Stress-reduction techniques are methods that promote 200 and 299, and a score over 300 places the person at major risk.
physiologic comfort and emotional well-being. Some From Holmes, T. H., & Rahe, R. H. (1967). The Social Readjustment Rating
Scale. Journal of Psychosomatic Research, 11, 216. Copyright © 1967,
general interventions appropriate during the care of
Pergamon Press, Ltd.
any client include providing adequate explanations in
understandable language, keeping the client and family
informed, demonstrating confidence and expertise when
providing nursing care, remaining calm during crises, Stress-Management Techniques
being available to the client, responding promptly to the
client’s signal for assistance, encouraging family inter- People susceptible to intense stressors or likely to expe-
action, advocating on behalf of the client, and referring the rience stressors over a long period may benefit from addi-
client and family to organizations or people who provide tional stress-management approaches. Stress management
post-discharge assistance. refers to therapeutic activities used to reestablish balance
BOX 5-3 ● Client-Related Stressors TABLE 5-6

INTERVENTIONS FOR
STRESS MANAGEMENT
Thinking you might lose your sight INTERVENTION EXPLANATION
Thinking you might have cancer
Thinking you might lose a kidney or some other organ
Modeling Promotes the ability to learn an adaptive
Knowing you have a serious illness
response by exposing a person to
Thinking you might lose your hearing
someone who demonstrates a positive
Not being told what your diagnosis is
attitude or behavior
Not knowing for sure what illness you have
Not getting pain medication when you need it Progressive Eases tense muscles by clearing the mind
Not knowing the results or reasons for your treatments relaxation of stressful thoughts and focusing on
Not getting relief from pain medications consciously relaxing specific muscle
Being fed through tubes groups
Missing your spouse Imagery Uses the mind to visualize calming,
Not having your questions answered by the staff pleasurable, positive experiences
Not having enough insurance to pay for your hospitalization Biofeedback Alters autonomic nervous system func-
Not having your call light answered tions by responding to electronically
Having a sudden hospitalization you weren’t planning to have displayed physiologic data
Being hospitalized far from home
Yoga Reduces physical and emotional tension
Knowing you have to have an operation
through postural changes, muscular
Not having family visit you
stretching, and focused concentration
Feeling you are getting dependent on medications
Having nurses or doctors talk too fast or use words you can’t understand Meditation Reduces physiologic activation by placing
Having medications cause you discomfort and prayer one’s trust in a higher power
Thinking about losing income because of your illness Placebo effect Alters a negative physiologic response
Having the staff be in too much of a hurry through the power of suggestion
Not knowing when to expect things will be done to you
Being put in the hospital because of an accident
Being cared for by an unfamiliar doctor
Not being able to call family or friends on the phone physical and emotional responses to stress. Nurses help
Having to eat cold or tasteless food clients manage stress, for example, by teaching principles
Worrying about your spouse being away from you
Thinking you might have pain because of surgery or test procedures
of time management and assertiveness techniques.
Being in the hospital during holidays or special family occasions
Thinking your appearance might be changed after your hospitalization Endorphins
Being in a room that is too cold or too hot
Not having friends visit you Endorphins are natural body chemicals that produce
Having a roommate who is unfriendly effects similar to those of opiate drugs such as morphine.
Having to be assisted with a bedpan In addition to decreasing pain, these chemicals promote
Having a roommate who is seriously ill or cannot talk with you
a sense of pleasantness, tranquility, and well-being.
Being aware of unusual smells around you
Having to stay in bed or the same room all day Endorphins are manufactured in the pituitary gland
Having a roommate who has too many visitors but are present in the blood and other tissues (Porth,
Not being able to get newspapers, radio, or TV when you want them 2007). Some believe that certain activities, such as mas-
Having to be assisted with bathing sage, sustained aerobic exercise, and laughter, trigger the
Being awakened in the night by the nurse
Having strange machines around
release of endorphins. Once released, endorphins attach
Having to wear a hospital gown themselves to receptor sites in the brain—perhaps in the
Having to sleep in a strange bed limbic system, the center where emotions are experienced.
Having to eat at different times than you usually do
Having strangers sleep in the same room with you Sensory Manipulation
The events in this list are arranged in order of their perceived significance Sensory manipulation involves altering moods, feelings,
as a stressor. The first event is the most stressful, and the rest follow in and physiologic responses by stimulating pleasure centers
descending order.
Copyright © 1975, American Journal of Nursing Company. Reproduced, in the brain using sensory stimuli. Research is being
with permission from Nursing Research, 24(5). conducted on the stress-reducing effects of certain colors,
full-spectrum lighting in the home and workplace, music,
and specific aromas that conjure pleasant associations
such as the smell of baking bread.
between the sympathetic and parasympathetic nervous
systems (Table 5-6). Techniques that counter sympathetic
Adaptive Activities
stimulation have a calming effect; stimulating tactics
counterbalance parasympathetic dominance. Interven- To enhance adaptation, people experiencing stress may
tions that cause the release of endorphins, manipulation adopt techniques from the following categories: alternative
of sensory stimuli, and adaptive activities also mediate thinking, alternative behaviors, and alternative lifestyles.
ALTERNATIVE THINKING. Alternative thinking techniques that responds affectionately regardless of a person’s age,
are those that facilitate a change in a person’s percep- physical characteristics, or accomplishments. Pets seem
tions from negative to positive. Reframing helps a person to improve a person’s feelings of self-worth in a way that
to analyze a stressful situation from various perspectives extends to human relationships as well.
and ultimately conclude that the situation is not as bad
as it once seemed. For instance, instead of dwelling on the
CRITICAL THINKING E X E R C I S E
negative consequences of a minor car accident, such as
the expense and inconvenience of repairs, the person can 1. Identify at least five interventions that are both realistic
choose to focus on the positive aspect of being physically and helpful in reducing the stressors associated with
unharmed in the accident. being a student.
ALTERNATIVE BEHAVIORS. A behavioral technique for NCLEX-STYLE REVIEW Q U E S T I O N S

modifying stress is to take control rather than become
1. Which nursing intervention is considered primary in pre-
immobilized. Making choices and pursuing actions pro-
venting hypertension in a client with a family history of
mote self-confidence over feeling victimized. Procrasti- this disorder?
nation only prolongs and intensifies the original stressor. 1. Assess the client’s blood pressure monthly.
In addition, sharing frustrations with others who are 2. Provide information about antihypertensive
both objective and supportive is more therapeutic than medications.
brooding in isolation. Other behavioral approaches to 3. Explain stress-management techniques.
reduce stress include prioritizing what needs to be accom- 4. Teach the client the health hazards of hypertension.
plished and initially attending to that which is most 2. When caring for an older adult with all the following
important or difficult. Less important activities may be stressors, which has the highest priority for therapeutic
postponed or delegated to others. And although other interventions?
positive behaviors can be cultivated, it is also important 1. Death of a spouse
sometimes to say “no” to avoid becoming overwhelmed 2. Change in living conditions
and more stressed. 3. Retirement
4. Change in financial state
ALTERNATIVE LIFESTYLE. People prone to stress can make 3. At a team conference, the nurse is most correct in explain-
ing that the coping mechanism being demonstrated by a
a conscious effort to improve their diet, become more
client’s refusal for further treatment because she believes
physically active, cultivate humor, and take scheduled the breast biopsy indicating cancer is incorrect is
breaks throughout the day for leisure, power naps, or 1. Somatization
listening to uplifting music. Although pet ownership is 2. Regression
not possible for everyone, those who do have pets find 3. Displacement
it soothing and relaxing to stroke and touch an animal 4. Denial
6
Chapter
Culture and
Ethnicity
LEARNING OBJECTIVES
● Differentiate culture, race, and ethnicity.
● Discuss two factors that interfere with perceiving others as individuals.
● Explain why U.S. culture is described as being anglicized.
● List at least five characteristics of Anglo-American culture.
● Define the term subculture and list four major subcultures in the United States.
● List five ways in which people from subcultural groups differ from Anglo-Americans.
● Describe four characteristics of culturally sensitive care.
● List at least five ways to demonstrate cultural sensitivity.
CLIENTS vary according to age, gender, race, health status, education, religion, occupa-
tion, and economic level. Culture, the focus of this chapter, is yet another characteris-
tic that contributes to client diversity.
Nurses have always cared for clients with differences of some sort. Despite cultural
differences, the traditional tendency has been to treat clients as though none exist.
Although equal treatment may be politically correct, many nurses now believe that
ignoring differences contradicts the best interests of clients. Consequently there is a
movement toward eliminating acultural nursing care (care that avoids concern for cul-
tural differences) and promoting culturally sensitive nursing care (care that respects and
is compatible with each client’s culture).
WORDS TO KNOW This chapter provides information about cultural concepts, cultural variations among
acultural nursing care
different ethnic and racial groups, and intercultural communication. Although compo-
African Americans nents of culture are specific to a particular group of people, individual clients within each
Anglo-Americans cultural group may deviate from the collective norm. Therefore, nurses are advised to
Asian Americans always consider cultural needs from an individual’s perspective. Every human being is
bilingual in some ways “like all others, like some others, and like no other” (Andrews, 2005).
cultural shock
culturally sensitive nursing
care
culture CULTURE
ethnicity
ethnocentrism
folk medicine Culture (values, beliefs, and practices of a particular group; Giger & Davidhizar, 2004)
generalization incorporates the attitudes and customs learned through socialization with others. It
Latinos includes, but is not limited to, language, communication style, traditions, religion, art,
minority music, dress, health beliefs, and health practices.
Native Americans
A group’s culture is passed from one generation to the next. According to Smeltzer
race
stereotypes and Bare (2008), culture is (1) learned from birth; (2) shared by members of a group;
subcultures (3) influenced by environment, technology, and availability of resources; and (4) dy-
transcultural nursing namic and ever changing.
71
CULTURALLY DIVERSE GROUPS characteristics like skin color, or both. Minority does not
TABLE 6-1 necessarily imply that there are fewer group members in
WITHIN THE UNITED STATES
comparison with others in the society. Rather, it refers
PREDOMINANT
CITY OR REGION CULTURAL GROUP
to the group’s status in regard to power and control. For
example, men of European ancestry are the current
New England Irish “majority” in the United States. Slightly more women
Detroit, Buffalo, Chicago Polish than men are in the United States, yet women are con-
Upper Midwest (Minnesota, Scandinavians sidered a minority. By the year 2020, the number of Lati-
North Dakota) nos and Asian Americans living in the United States is
Ohio and Pennsylvania Amish
Washington State and Oregon Southeast Asians
expected to triple, and the number of African Americans
(Laotian, Vietnamese) will double (Andrews, 2005). Until these groups acquire
New York (Spanish Harlem) Puerto Rican more political and economic power in society, they will
Miami (Little Cuba) Cuban continue to be classified as minorities.
San Francisco (Chinatown) Chinese
Manhattan (Little Italy) Italian
Louisiana Cajun (French/Indian)
Southwest Latin American/ ETHNICITY
Native American
Hawaiian Islands Pacific Islanders/
Japanese/Chinese Ethnicity (bond or kinship a person feels with his or her
country of birth or place of ancestral origin) may exist
regardless of whether or not a person has ever lived out-
side the United States. Pride in one’s ethnicity is demon-
Although the United States has been described as a strated by valuing certain physical characteristics, giving
“melting pot” in which culturally diverse groups have children ethnic names, wearing unique items of clothing,
become assimilated, that is not the case. People from var- appreciating folk music and dance, and eating native
ious cultural groups have settled, lived, and worked in the dishes (Fig. 6-1).
United States while continuing to sustain their unique Because cultural characteristics and ethnic pride rep-
identities (Table 6-1). resent the norm in a homogeneous group, they tend to go
unnoticed. When two or more cultural groups mix, how-
ever, as often happens at the borders of various countries
RACE or through the process of immigration, unique differences
become more obvious. One or both groups may experience
cultural shock (bewilderment over behavior that is cultur-
Cultural groups tend to share biologic and physiologic
similarities. Race (biologic variations) is a term used to cat- ally atypical). Consequently many ethnic groups have
egorize people with genetically shared physical character- been victimized as a result of bigotry based on stereotypi-
istics. Some examples include skin color, eye shape, and cal assumptions and ethnocentrism.
hair texture. Despite wide ranges in physical variations,
skin color has traditionally been the chief, albeit impre-
cise, method for dividing races into Mongoloid, Negroid, Stereotyping
and Caucasian. Skin color is just one of a variety of inher-
ited traits. Stereotypes (fixed attitudes about all people who share a
More importantly, nurses should not equate race with common characteristic) develop with regard to age, gen-
any particular cultural group. To do so leads to two erro- der, race, sexual preference, or ethnicity. Because stereo-
neous assumptions: (1) all people with common physical types are preconceived ideas usually unsupported by facts,
features share the same culture, and (2) all people with they tend to be neither real nor accurate. In fact, they can
physical similarities have cultural values, beliefs, and be dangerous because they interfere with accepting others
practices that differ from those of Anglo-Americans (U.S. as unique individuals.
whites who trace their ancestry to the United Kingdom
and Western Europe).
Generalizing
Generalization(supposition that a person shares cultural
MINORITY
characteristics with others of a similar background) is
different than stereotyping. Stereotyping prevents seeing
The term minority is used when referring to those collec- and treating another person as unique, whereas general-
tive people who differ from the dominant group in terms izing suggests possible commonalities that may or may
of cultural characteristics such as language, physical not be individually valid. Assuming that all people who
CHAPTER 6 ● Culture and Ethnicity 73
FIGURE 6-1 • (A) A Latino woman prepares tortillas by using a Mayan-style stone roller and table.
(B) African Americans celebrate their ethnicity at a festival that includes folk costumes, dancing, and
music. ([A] Copyright Jeff Greenberg/Stock Boston. [B] Copyright Fabian Falcon/Stock Boston.)
affiliate themselves with a particular group behave alike in Rwanda; Islamic Arabs in Sudan; indigenous African
or hold the same beliefs is always incorrect. Diversity tribes in Darfur, and other regions where culturally
exists even within cultural groups. diverse groups live in close proximity. Similar conflicts
A generalization provides a springboard from which to also occur among U.S. ethnic groups.
explore a person’s individuality. For example, when a
nurse is assigned to care for a terminally ill client whose
last name is Vasquez, the nurse may assume that the client
CULTURE OF THE UNITED STATES
is Roman Catholic because Catholicism is the religion of
most Latinos. Before contacting a priest to assist with the
client’s spiritual needs, however, the nurse understands The U.S. culture can be described as anglicized, or English-
that the generalization concerning religion may not be based, because it evolved primarily from its early English
accurate. A culturally sensitive nurse strives to obtain settlers. Box 6-1 provides an overview of some common
information that confirms or contradicts the original characteristics of U.S. culture. To suggest that everyone
generalization. who lives in the United States embraces the totality of its
culture, however, would be foolhardy.
Although it is a gross oversimplification, four major
Ethnocentrism subcultures (unique cultural groups that coexist within the
dominant culture) exist in the United States. In addition
Ethnocentrism (belief that one’s own ethnicity is superior to to Anglo-Americans, there are African Americans, Lati-
all others) also interferes with intercultural relationships. nos, Asian Americans, and Native Americans (Table 6-2).
Ethnocentrism is manifested by treating anyone “differ- The term African Americans is used to identify those
ent” as deviant and undesirable. This form of cultural whose ancestral origin is Africa. It is sometimes used
intolerance was the basis for the Holocaust during which interchangeably with black Americans. Latinos (those
the Nazis attempted to carry out genocide, the planned who trace their ethnic origin to Latin or South America)
extinction of an entire ethnic group (in this case, Euro- are sometimes referred to as Hispanics, a term coined by
pean Jews). Ethnocentrism continues to play a role in the the U.S. Census Bureau, or Chicanos when speaking of
ethnic rivalries between Shiites, Sunnis, and Kurds in people from Mexico. Asian Americans (those who come
Iraq; Arabs and Jews in the Middle East; Tutsis and Hutus from China, Japan, Korea, the Philippines, Thailand,
BOX 6-1 ● Examples of U.S. Cultural Characteristics

United States (Department of Interior, Bureau of Indiana
Affairs, 2003; U.S. National Library of Medicine, 2000).
❙ English is the language of communication. Although Anglo-American culture predominates in
❙ The pronunciation or meaning of some words varies according to regions the United States, those of African, Asian, Hispanic, and
within the United States. Arabic descent outnumber those who trace their ancestry
❙ The customary greeting is a handshake.
❙ A distance of 4 to 12 feet is customary when interacting with strangers or
to the United Kingdom and Western Europe. As the pop-
doing business (Giger and Davidhizar, 1995). ulation becomes more diverse, the need for transcultural
❙ In casual situations, it is acceptable for women as well as men to wear pants; nursing is increasingly urgent.
blue jeans are a common mode of dress.
❙ Most Americans are Christians.
❙ Sunday is recognized as the Sabbath.
❙ Government is expected to remain separate from religion. TRANSCULTURAL NURSING
❙ Guilt or innocence for alleged crimes is decided by a jury of one’s peers.
❙ Selection of a marriage partner is an individual’s choice.
❙ Legally, men and women are equals. Madeline Leininger coined the term transcultural nursing
❙ Marriage is monogamous (only one spouse); fidelity is expected. (providing nursing care within the context of another’s
❙ Divorce and subsequent remarriages are common.
❙ Parents are responsible for their minor children. culture) in the 1970s. Aspects of transcultural nursing
❙ Aging adults live separately from their children. include the following:
❙ Status is related to occupation, wealth, and education.
❙ Common beliefs are that everyone has the potential for success and that hard • Assessments of a cultural nature
work leads to prosperity. • Acceptance of each client as an individual
❙ Daily bathing and use of a deodorant are standard hygiene practices. • Knowledge of health problems that affect particular
❙ Anglo-American women shave the hair from their legs and underarms; most
cultural groups
men shave their faces daily.
❙ Licensed practitioners provide health care. • Planning of care within the client’s health belief sys-
❙ Drugs and surgery are the traditional forms of medical treatment. tem to achieve the best health outcomes
❙ Americans tend to value technology and equate it with quality.
❙ As a whole, Americans are time oriented and, therefore, rigidly schedule their To provide culturally sensitive care, nurses must
activities according to clock hours. become skilled at managing language differences, under-
❙ Forks, knives, and spoons are used, except when eating “fast foods,” for standing biologic and physiologic variations, promoting
which the fingers are appropriate.
health teaching that will reduce prevalent diseases, and
respecting alternative health beliefs or practices.
Cambodia, Laos, and Vietnam) make up the third subcul-

ture. Native Americans (Indian nations found in North Cultural Assessment
America including the Eskimos and Aleuts) include
approximately 2.3 million American Indians and Alaskan To provide culturally sensitive care, the nurse strives to
Natives belonging to 545 federally recognized tribes in the gather data about the unique characteristics of clients.
Pertinent data include the following:
SUBCULTURAL GROUPS • Language and communication style

TABLE 6-2 • Hygiene practices including feelings about modesty
IN THE UNITED STATES*
and accepting help from others
PERCENT OF
REPRESENTATIVE AMERICAN • Special clothing or ornamentation
GROUP COUNTRIES POPULATION • Religion and religious practices
• Rituals surrounding birth, passage from adolescence
African American Africa, Haiti, Jamaica, 12.3 to adulthood, illness, and death
West Indies, • Family and gender roles including child-rearing prac-
Dominican Republic
Latino Mexico, Puerto Rico, 12.5
tices and kinship with older adults
Cuba, South and • Proper forms of greeting and showing respect
Central America • Food habits and dietary restrictions
Asian American China, Japan, Korea, 4.3 • Methods for making decisions
Philippines, Thailand,
• Health beliefs and medical practices
Cambodia, Laos,
Vietnam, Pacific Islands Assessment of these areas is likely to reveal many dif-
Native American North American Indian 0.9
nation and tribes,
ferences. Examples of variations include language and
Eskimos, Aleuts communication, eye contact, space and distance, touch,
emotional expressions, dietary customs and restrictions,
*As reported by the U.S. Census Bureau, 2004. time, and beliefs about the cause of illness.
Language and Communication Understanding some unique cultural characteristics

involving aspects of communication may ease the tran-
Because language is the primary way to share and gather
sition toward culturally sensitive care. It is helpful to be
information, the inability to communicate is one of the
aware of general communication patterns among the
biggest deterrents to providing culturally sensitive care.
major U.S. subcultures.
Foreign travelers and many residents in the United States
Native Americans tend to be private and may hesitate
do not speak English, or they have learned it as their sec-
to share personal information with strangers. They may
ond language and do not speak it well. Estimates are that
interpret questioning as prying or meddling. The nurse
13.8% of those who live in the United States speak a lan-
should be patient when awaiting an answer and listen
guage other than English at home (Perkins et al., 2003).
carefully because people of this culture may consider
Those who can communicate in English may still prefer
impatience disrespectful (Lipson, Dibble & Minarik,
to use their primary language, especially under stress.
2002). Navajos, currently the largest tribe of Native Amer-
EQUAL ACCESS. Federal law, specifically Title IV of the
icans, believe that no person has the right to speak for
Civil Rights Act of 1994, states that people with limited another and may refuse to comment on a family mem-
English proficiency are entitled to the same health care ber’s health problems.
and social services as those who speak English fluently. Because Native Americans traditionally preserved their
In other words, all clients have a right to unencumbered heritage through oral rather than written history, they may
communication with a health provider. Using children be skeptical of nurses who write down what they say. If
as interpreters or requiring clients to provide their own possible, the nurse should write notes after, rather than
interpreters is a civil rights violation. The Joint Com- during, the interview.
mission on Accreditation of Healthcare Organizations African Americans may be mistrustful of the medical
requires that hospitals provide effective communication establishment, possibly because of poor practices em-
for each client. ployed in past research projects such as the Tuskegee
The use of untrained interpreters, volunteers, or fam- syphilis experiment (Fourtner et al., 1994; Jones, 1993).
ily is considered inappropriate because it undermines They also have sometimes been treated as second-class cit-
confidentiality and privacy. It also violates family roles izens when seeking health care. The nurse must demon-
and boundaries. It increases the potential for modifying, strate professionalism by addressing clients by their last
condensing, omitting, or adding information or project- names and introducing himself or herself. He or she
ing the interpreter’s own values during communication should follow-up thoroughly with requests, respect the
between client and health care provider. To comply with client’s privacy, and ask open-ended rather than direct
the laws and accreditation requirements, health care questions until trust has been established. Because of their
agencies are strongly encouraged to train professional experiences as victims of discrimination, African Ameri-
interpreters. A competently trained interpreter demon- cans may hesitate to give any more information than what
strates the skills listed in Box 6-2. is asked.
Latinos are characteristically comfortable sitting close to
NURSE–CLIENT COMMUNICATION. If the nurse is not bilin- interviewers and letting interactions unfold slowly. Many
gual (able to speak a second language), he or she must use Latinos speak English but still have difficulty with medical
an alternative method for communicating. See Nursing terminology. They may be embarrassed to ask the inter-
Guidelines 6-1 for more information. viewer to speak slowly, so the nurse must provide infor-
mation and ask questions carefully. Latino men generally
are protective and authoritarian regarding women and
children. They expect to be consulted in decisions con-
BOX 6-2 ● Characteristics of a Skilled Interpreter cerning family members.
Asian Americans tend to respond with brief or more
❙ Learns the goals of the interaction
❙ Demonstrates courtesy and respect for the client
factual answers and little elaboration, perhaps because
❙ Explains his/her role to the client traditionally they value simplicity, meditation, and intro-
❙ Positions himself/herself to avoid disrupting direct communication between spection. Asian Americans may not openly disagree with
the health care worker and client authority figures, such as physicians and nurses, because
❙ Has a good memory for what is said of their respect for harmony. Such reticence can conceal
❙ Converts the information in one language accurately into the other without
disagreement or potential noncompliance with a partic-
commenting on the content
❙ Possesses knowledge of medical terminology and vocabulary ular therapeutic regimen that is unacceptable from their
❙ Attempts to preserve the emphasis and emotions that both people express perspective.
❙ Asks for clarification if verbalizations from either party are unclear
❙ Indicates instances in which a cultural difference has the potential to impair Eye Contact
communication
❙ Maintains confidentiality Anglo-Americans generally make and maintain eye con-
tact throughout communication. Although it may be

Communicating With Non–English-Speaking Clients
❙ Greet or say words and phrases in the client’s language, even if primary focus of the interaction and helps the nurse to interpret
carrying on a conversation is impossible. Using familiar words indicates nonverbal clues.
a desire to communicate with the client even if the nurse lacks the ❙ If the client speaks some English, speak slowly, not loudly, using simple
expertise to do so extensively. words and short sentences. Lengthy or complex sentences are barriers
❙ Use Web sites with the client that translate English to several when communicating with someone not skilled in a second language.
foreign languages and vice versa. Examples are found at ❙ Avoid using technical terms, slang, or phrases with a double or
http://ets.freetranslation.com and http://babel.altavista.com/tr. colloquial meaning. The client may not understand the spoken
A computer with Internet access provides sites with easy-to-use, vernacular, especially if he or she learned English from a textbook
rapid, free translations of up to 150 words at a time. rather than conversationally.
❙ Refer to an English/foreign language dictionary or use appendices in ❙ Ask questions that can be answered by a yes or no. Direct questions
references such as Tabers’ Cyclopedic Medical Dictionary. Some avoid the need to provide elaborate responses in English.
dictionaries provide medical words and phrases that may provide
pertinent information.
❙ If the client appears confused by a question, repeat it without changing
the words. Rephrasing tends to compound confusion because it forces
❙ Compile a loose-leaf folder or file cards of medical words in one or more the client to translate yet another group of unfamiliar words.
languages spoken by clients in the community. Place it with other
reference books on the nursing unit. A homemade reference provides a
❙ Give the client sufficient time to respond. The process of interpreting
readily available language resource for communicating with others in what has been said in English and then converting the response from
the local area. the native language back to English requires extra time.
❙ Request a trained interpreter. If that option is impossible, call ethnic
❙ Use nonverbal communication or pantomime. Body language is
organizations or church pastors to obtain a list of people who speak the universal and tends to be communicated and interpreted quite
client’s language and may be willing to act as emergency translators. accurately.
Someone proficient at speaking the language is more effective in ❙ Be patient. Anxiety is communicated interpersonally and tends to
obtaining necessary information and explaining proposed treatments heighten frustration.
than is someone relying on a rough translation. ❙ Show the client written English words. Some non–English-speaking
❙ Contact an international telephone operator in a crisis, if there is no people can read English better than they can understand it spoken.
other option for communicating with a client. International telephone ❙ Work with the health agency’s records committee to obtain consent
operators are generally available 24 hours a day; however, their main forms, authorization for health insurance benefits, and copies of client’s
responsibility is the job for which they were hired. rights written in languages other than English. Legally, clients must
❙ When several interpreters are available, select one who is the same understand what they are consenting to.
gender and approximately the same age as the client. Some clients are ❙ Develop or obtain foreign translations describing common procedures,
embarrassed relating personal information to people with whom they routine care, and health promotion. One resource is the Patient
have little in common. Education Resource Center in San Francisco, which provides
❙ Look at the client, not the interpreter, when asking questions and publications in many languages on numerous health topics. All clients
listening for responses. Eye contact indicates that the client is the are entitled to explanations and educational services.
natural for Anglo-Americans to look directly at a person fore, to provide explanations when close contact during
while speaking, that is not always true of people from procedures and personal care is necessary.
other cultures. It may offend Asian Americans or Native
Americans who are likely to believe that lingering eye con- Touch
tact is an invasion of privacy or a sign of disrespect. Arabs
Some Native Americans may interpret the Anglo-
may misinterpret direct eye contact as sexually suggestive.
American custom of a strong handshake as offensive.
They may be more comfortable with just a light passing of
Space and Distance
the hands. People from Southeast Asia consider the head
Providing personal care and performing nursing pro- to be a sacred body part that only close relatives can touch.
cedures often reduce personal space, which causes dis- Nurses and other health care workers should ask permis-
comfort for some cultural groups. For example, Asian sion before touching this area. Southeast Asians also
Americans may feel more comfortable with the nurse at believe that the area between a female’s waist and knees
more than an arm’s length away. The physical closeness is particularly private and should not be touched by any
of a nurse in an effort to provide comfort and support male other than the woman’s husband. Before doing so, a
may threaten clients from other cultures. It is best, there- male nurse can relieve the client’s anxiety by offering an
explanation, requesting permission, and allowing the remain healthy; illness is an outcome of disharmony.
client’s husband to stay in the room. Native Americans share this view. Another example is
Asian Americans who uphold the Yin/Yang theory, which
Emotional Expression refers to the belief that balanced forces promote health.
Latinos embrace a similar concept referred to as the hot/
Anglo-Americans and African Americans, in general,
cold theory. It implies that illness is an imbalance between
freely express positive and negative feelings. Asian Amer-
components ascribed as having hot or cold attributes.
icans, however, tend to control their emotions and expres-
sions of physical discomfort (Zborowski, 1952, 1969), Adding or subtracting heat or cold to restore balance also
especially among unfamiliar people. Similarly, Latino men can restore health.
may not demonstrate their feelings or readily discuss their Finally, there is the magico-religious perspective in which
symptoms because they may interpret doing so as less there is a cultural belief that supernatural forces con-
than manly (Andrews & Boyle, 2003). The Latino cul- tribute to disease or health. Some examples of the magico-
tural response can be attributed to machismo, a belief that religious perspective include cultural groups that accept
virile men are physically strong and must deal with emo- faith healing or practice forms of witchcraft or voodoo.
tions privately. Because this behavior is atypical from an Although nurses may disagree with a client’s belief’s con-
Anglo-American perspective, nurses may overlook the cerning the cause of health or illness, respect for the per-
emotional and physical needs of people from these cul- son helps to achieve health care goals.
tural groups.
Dietary Customs and Restrictions Stop • Think + Respond BOX 6-1
Basically, food is a means of survival: it relieves hunger, How might a culturally sensitive nurse respond to a
promotes health, and prevents disease. Eating also has Vietnamese client who practices coining, which involves
rubbing the skin in a symptomatic area with a heated or
social meanings that relate to communal togetherness,
oiled coin to draw an illness out of the body? Coining
celebration, reward and punishment, and relief of stress.
is not painful, but it produces redness of the skin and
Culture dictates the types of food and how frequently a superficial ecchymosis (bruising).
person eats, the types of utensils used, and the status of
individuals, such as who eats first and who gets the most.
Religious practices within some cultures impose certain
rules and restrictions such as times for fasting and foods Biologic and Physiologic Variations
that can and cannot be consumed (Table 6-3). Nurses can
jeopardize the compliance of clients with a therapeutic The biologic characteristics of primary importance to
diet for medical disorders if dietary teaching disregards nurses are those that involve the skin, hair, and certain
cultural and religious food preferences. physiologic enzymes.
Time Skin Characteristics

Throughout the world, people view clock time and social Skin assessment techniques commonly taught are biased
time differently (Giger & Davidhizar, 2004). Calendars toward white clients. To provide culturally sensitive care,
and clocks define clock time, dividing it into years, months, nurses must modify their techniques to include obtaining
weeks, days, hours, minutes, and seconds. Social time accurate data on nonwhite clients.
reflects attitudes concerning punctuality that vary among The best technique for observing baseline skin color
cultures. Punctuality is often less important to people from in a dark-skinned person is to use natural or bright arti-
other cultures than it is to Anglo-Americans. Tolerating ficial light. Because the palms of the hands, the feet, and
and accommodating cultural differences related to time the abdomen contain the least pigmentation and are less
facilitates culturally sensitive care. likely to have been tanned, they are often the best struc-
tures to inspect.
Beliefs Concerning Illness According to Giger and Davidhizar (2004), all skin,
Generally, people embrace one of three cultural views to regardless of a person’s ethnic origin, contains an under-
explain illness or disease. The biomedical or scientific per- lying red tone. Its absence or a lighter appearance indi-
spective is shared by those from developed countries who cates pallor, a characteristic of anemia or inadequate
base their beliefs about health and disease on research oxygenation. The color of the lips and nail beds, common
findings. An example of a scientific perspective is that sites for assessing cyanosis in whites, may be highly pig-
microorganisms cause infectious diseases, and frequent mented in other groups, and nurses may misinterpret
handwashing reduces the potential for infection. normal findings. The conjunctiva and oral mucous mem-
The naturalistic or holistic perspective espouses that branes are likely to provide more accurate data. The sclera
humans and nature must be in balance or harmony to or the hard palate, rather than the skin, is a better location
TABLE 6-3 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
8th day of life. before discharge.
Kosher dietary laws allow consumption of ani- Notify dietary department of the client’s food pref-
mals that chew their cud and have cloven erences. Packaged food labeled kosher indicates
hoofs. Animals are slaughtered according to it was “properly preserved.” Pareve means “made
defined procedures; dairy products and meat without meat or milk.”
are not eaten together.
Sabbath begins on Friday at sundown and ends Avoid scheduling nonemergency tests or
on Saturday at sundown. procedures during this time.
Autopsy is not allowed unless required by law. All organs removed and examined during an
autopsy must be returned to the body.
Burial is preferred within 24 hours of death; Judaic Contact the family to stay with the dying client.
law requires that the body not be left alone. Expect a son or relative to close the mouth and
eyes of the deceased.
Catholicism Statues and medals of religious figures provide Leave such items on or near the client; keep safe
spiritual comfort. and return promptly if removed.
Artificial birth control and abortion are forbidden. Explain how to avoid pregnancy through methods
such as checking basal body temperature and
characteristics of cervical mucus.
Baptism is necessary for salvation. In an emergency, any baptized Christian should per-
form 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 They refuse blood transfusions even in life- Refer to physicians who practice blood conserva-
threatening situations because they believe tion strategies such as autotransfusions and IV
that blood is the source of the soul. volume expanders (e.g., Dextran).
Seventh Day Adventists They follow strict dietary laws based on the Old Request a consult with the dietitian to facilitate
Testament. vegetarian diet without caffeine.
Saturday is the Sabbath. Avoid scheduling medical appointments or
procedures at this time.
Christian Scientists 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 is threatened by parental refusal for
medical care.
Church of Jesus Christ Coffee, tea, alcohol, tobacco, illegal drugs, and Notify the dietary department to provide non-
of Latter-Day Saints overuse of prescription drugs are prohibited. caffeinated beverages.
(Mormonism) Male members may anoint the sick with Facilitate anointing rituals before surgery or upon
consecrated olive oil. the client’s request.
Amish These clients may be reluctant to spend money Assess home remedies and folk healing being used.
on health care unnecessarily. Home 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
with faith and patience. rather that 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 the custom of photographing newborns.
Hinduism These 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 on Avoid removing or replace it as soon as possible.
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 birthing progress.
Cleansing of the body after death symbolizes Inquire if the family wishes to wash a deceased
cleansing of the soul. client’s body.
Most clients are vegetarians: beef is forbidden; Request a consult with the dietitian. Client may
some do not consume eggs. refuse medication in gelatin capsules because
gelatin is made from animal by-products.
(continued)
TABLE 6-3
EXAMPLES OF RELIGIOUS BELIEFS AND PRACTICES THAT AFFECT
HEALTH CARE (Continued)
RELIGION EXAMPLES NURSING IMPLICATIONS
Muslims (Islam) Prayer and washing are required five times a day. Plan care around prayer and washing rituals, which
occur at sunrise, mid-morning, noon, afternoon,
and sunset. Help clients face Mecca for prayer.
Pork and alcohol are forbidden. These clients may refuse medication in capsules
and pork insulin. Request that pharmacist omit
alcohol in liquid medications, which usually
contain this ingredient.
These clients prefer to die at home. Expect that life support will be unacceptable if there
is no hope for a reasonable recovery.
They require that only relatives touch or wash Consult the family before performing postmortem
the body of a deceased Muslim. care.
Adapted from Andrews, J. D. (1999). Cultural, ethnic and religious reference manual. Winston-Salem, NC: JAMARDA
Resources, Inc.
for assessing jaundice. In some nonwhites, however, the more obvious. Vitiligo, a disease that affects whites as
sclera may have a yellow cast from carotene and fatty well as those with darker skin, produces irregular white
deposits; nurses should not misconstrue this finding as patches on the skin as a result of an absence of melanin
jaundice (Spector, 2002, 2003). (Fig. 6-3). Other than hypopigmentation, there are no
Rashes, bruising, and inflammation may be less obvi- physical symptoms, but the cosmetic effects may create
ous among people with dark skin. Palpating for variations emotional distress. Clients concerned about the irregu-
in texture, warmth, and tenderness is a better assessment larity of their skin color may use a pigmented cream to
technique than inspection. Keloids (irregular, elevated disguise noticeable areas.
thick scars) are common among dark-skinned clients Mongolian spots, an example of hyperpigmentation,
(Fig. 6-2). They are thought to form from a genetic ten- are dark-blue areas on the lower back of darkly pigmented
dency to produce excessive transforming-growth factor- infants and children (Fig. 6-4). They are rare among
beta (TGF-β), a substance that promotes fibroblast whites and tend to fade by the time a child is 5 years old.
proliferation during tissue repair. Nurses unfamiliar with ethnic differences can mistake
Some nurses, when bathing a dark-skinned person, Mongolian spots as a sign of physical abuse or injury.
misinterpret the brown discoloration on a washcloth as They can differentiate between the two by pressing the
a sign of poor hygiene. In reality, the normal shedding of pigmented area: Mongolian spots will not produce pain
dead skin cells, which retain their pigmentation, causes when pressure is applied.
this finding.
Hypopigmentation and hyperpigmentation are con- Hair Characteristics
ditions in which the skin is not a uniform color. Hypo- Hair color and texture are also biologic variants. Dark-
pigmentation may result when the skin becomes damaged. skinned people usually have dark-brown or black hair.
Regardless of ethnic origin, damaged skin characteristi- Hair texture, also an inherited characteristic, results from
cally manifests temporary redness, which then fades to a
lighter hue; in dark-skinned clients, the effect is much
FIGURE 6-3 • Vitiligo of the forearm in an African American. (Courtesy

FIGURE 6-2 • Keloids are raised, thick scars. (Copyright B. Proud.) of Neutrogena Care Institute.)
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 (e.g., 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
Acidophilus organism, which changes lactose
into lactic acid.
FIGURE 6-4 • Mongolian spots. These bluish pigmented areas are • Drink LactAid, a commercial product in which
common in dark-skinned infants. (Copyright K. Timby.)
the lactose has been preconverted into other
absorbable sugars.
the amount of protein molecules within the hair. Varia- • Use kosher foods, which are prepared without
tions range from straight to very curly. The curlier the milk; they can be identified by the word pareve
hair, the more difficult it is to comb. In general, using a on the label.
wide-toothed comb or pick, wetting the hair with water
before combing, or applying a moisturizing cream makes enzyme. The disorder is manifested in males because the
grooming more manageable. Some clients with very curly gene is sex linked, but females can carry and transmit the
hair prefer to arrange it in small, tightly braided sections. faulty gene.
A G-6-PD deficiency makes red blood cells vulnerable
Enzymatic Variations
during stress, which increases metabolic needs. When
Three inherited enzymatic variations are prevalent this happens, red blood cells are destroyed at a much
among members of various U.S. subcultures. They involve greater rate than in unaffected people. If the production
absence or insufficiency of the enzymes lactase, glucose- of new red blood cells cannot match the rate of destruc-
6-phosphate dehydrogenase (G-6-PD), and alcohol dehy- tion, anemia develops.
drogenase (ADH). Because several drugs can precipitate the anemic
process (Table 6-4), it is important for the nurse to inter-
LACTASE DEFICIENCY. Lactase is a digestive enzyme that vene if these drugs or those that depress red cell produc-
converts lactose, the sugar in milk, into the simpler sug- tion are prescribed for the ethnic clients who are at
ars glucose and galactose. A lactase deficiency causes greatest risk. At the very least, the nurse must monitor
intolerance to dairy products. Without lactase, people susceptible clients and advocate for laboratory tests, such
have cramps, intestinal gas, and diarrhea approximately as red blood cell count and hemoglobin levels, that will
30 minutes after ingesting milk or foods that contain it. indicate any adverse effects.
Symptoms may continue for 2 hours (Dudek, 2006). Elim-
inating or reducing sources of lactose in the diet may pre- ADH DEFICIENCY. When a person consumes alcohol, a
vent the discomfort. Liquid tube-feeding formulas and process of chemical reactions involving enzymes, one of
those used for bottle-fed infants can be prepared using which is ADH, eventually breaks down the alcohol into
milk substitutes. Because milk is a good source of calcium, acetic acid and carbon dioxide. Asian Americans and
which is necessary for health, nurses should teach affected Native Americans often metabolize alcohol at a different
clients to obtain calcium from other sources, such as rate than other groups because of physiologic variations
green leafy vegetables, dates, prunes, canned sardines and in their enzyme system. The result is that affected clients
salmon with bones, egg yolk, whole grains, dried peas experience dramatic vascular effects, such as flushing and
and beans, and calcium supplements. Client and Family rapid heart rate, soon after consuming alcohol. In addi-
Teaching 6-1 provides additional points for education. tion, middle metabolites of alcohol (those formed before
acetic acid) remain unchanged for a prolonged period.
G-6-PD DEFICIENCY. G-6-PD is an enzyme that helps red Many scientists believe that the middle metabolites, such
blood cells to metabolize glucose. African Americans and as acetaldehyde, are extremely toxic and subsequently
people from Mediterranean countries commonly lack this play a primary role in causing organ damage. The rate of
TABLE 6-4
DRUGS THAT PRECIPITATE GLUCOSE 6-PHOSPHATE
DEHYDROGENASE ANEMIA
DRUG CATEGORY EXAMPLE USE
Quinine compounds Primaquine phosphate Prevention and treatment of malaria

Urocosurics Probenecid (Benemid) Treatment of gout
Sulfonamides Sulfasalazine (Azulfidine) Treatment of urinary infections
death from alcoholism among Native Americans is esti- With the knowledge that special populations are at
mated as eight times as great for those 25 to 34 years and increased risk for chronic diseases, culturally sensitive
6.5 times greater for those 35 to 44 years when compared nurses focus heavily on health teaching, participate in
with the general population (Manson, 2001). community health screenings, and campaign for more
equitable health services.
Disease Prevalence
Health Beliefs and Practices
Several diseases, including sickle cell anemia, hyper-
tension, diabetes, and stroke, occur with much greater Many differences in health beliefs exist among U.S. sub-
frequency among ethnic subcultures than in the general cultures. They persist as a result of strong ethnic influ-
population. The incidence of chronic illness affects mor- ences. Health beliefs, in turn, affect health practices
bidity differently as well (Table 6-5). (Table 6-6).
The incidence of some chronic diseases and their com- Folk medicine (health practices unique to a particular
plications may be related partly to variations in social fac- group of people) has come to mean the methods of dis-
tors such as poverty. Minority cultural groups tend to ease prevention or treatment outside mainstream con-
be less affluent; consequently, their access to expensive ventional practice. Generally, lay providers rather than
health care often is limited. Without preventive health formally educated and licensed individuals give such
care, early detection, and treatment, higher death rates are treatments. In addition to culturally specific health prac-
bound to occur. The United States has therefore commit- tices, such as those sought from a curandero (Latino prac-
ted itself to reducing the disparity in health care among all titioner who is thought to have spiritual and medicinal
Americans (see Chap. 4). powers), a shaman (holy man with curative powers), or
TABLE 6-5 LEADING CAUSES OF DEATH AMONG U.S. CULTURAL GROUPS

AFRICAN
RANK ALL AMERICANS AMERICANS* LATINOS† NATIVE AMERICANS* ASIANS
1 Heart disease Heart disease Heart disease Heart disease Cancer

2 Cancer Cancer Cancer Cancer Heart Disease
3 Cerebrovascular Cerebrovascular Accidents Accidents Cerebrovascular
disease disease disease
4 Chronic lower Diabetes Cerebrovascular Diabetes Accidents
respiratory disease disease
5 Accidents Accidents Diabetes Chronic liver disease Diabetes
6 Diabetes Homicide Chronic liver Cerebrovascular Influenza,
disease disease pneumonia
7 Alzheimer’s Nephritis Homicide Chronic lower Chronic lower
disease respiratory disease respiratory disease
8 Influenza, pneumonia Chronic lower Chronic lower Influenza, pneumonia Suicide
respiratory disease respiratory disease
9 Nephritis HIV Influenza, pneumonia Suicide Nephritis
10 Septicemia Septicemia Perinatal conditions Nephritis Septicemia
*Deaths, percentage of total deaths, and rank order for 113 selected causes of death, by race and sex, United States,
2003. Accessed July 31, 2006 from http://www.cdc.gov/nchs/data/dvs/lcwk10_2003.pdf.
†Deaths, percentage of total deaths, and rank order for 113 selected causes of death, by Hispanic origin, race for
non-Hispanic origin and sex, United States, 2003 accessed July 31, 2006, from http://www.cdc.gov/nchs/data/
dys/lcwk11_2003.pdf.
TABLE 6-6 COMMON HEALTH BELIEFS AND PRACTICES

CULTURAL GROUP HEALTH BELIEF HEALTH PRACTICES
Anglo-Americans Illness results from infectious microorganisms, Physicians are consulted for diagnosis and
organ degeneration, and unhealthy lifestyles. treatment; nurses provide physical care.
African Americans Supernatural forces can cause disease and influ- Individual and group prayer is used to speed
ence recovery. recovery.
Asian Americans Health results from a balance between yin and Acupuncture, acupressure, food, and herbs are
yang energy; illness results when equilibrium is used to restore balance.
disturbed.
Latinos Illness and misfortune are punishment from Prayer and penance are performed to receive
God, referred to as castigo de Dios, results from forgiveness; the services of lay practitioners
an imbalance of “hot” or “cold” forces within who are believed to possess spiritual healing
the body. power are used; foods that are “hot” or “cold”
are consumed to restore balance.
Native Americans Illness occurs when the harmony of nature A shaman, or medicine man, who has both spiri-
(Mother Earth) is disturbed. tual and healing power, is consulted to restore
harmony.
an herbalist, many people in the United States also turn ommendations are ways to demonstrate culturally sensi-
to alternative quasi-medical therapy (Box 6-3). tive nursing care:
Alternative medicine attracts people for various rea-
• Learn to speak a second language.
sons: the expense of mainstream medical care, dissatis-
• Use culturally sensitive techniques to improve inter-
faction with prior treatment or progress, or intimidation
actions such as sitting in the client’s comfort zone and
from the health care establishment.
making appropriate eye contact.
Just because a health belief or practice is different does
• Become familiar with physical differences among ethnic
not make it wrong. Culturally sensitive nurses respect the groups.
client’s belief system and integrate scientifically based • Perform physical assessments, especially of the skin,
treatment along with folk and quasi-medical practices. using techniques that provide accurate data.
Refer to Table 6-3 for additional health beliefs and prac- • Learn or ask clients about cultural beliefs concerning
tices as they relate to various religions. health, illness, and techniques for healing.
• Consult the client on ways to solve health problems.
• Never verbally or nonverbally ridicule a cultural belief
CULTURALLY SENSITIVE NURSING or practice.
• Integrate helpful or harmless cultural practices within
Accepting that the United States is multicultural is the the plan of care.
first step toward transcultural nursing. The following rec- • Modify or gradually change unsafe practices.
• Avoid removing religious medals or clothes that hold
symbolic meaning for the client. If they must be
removed, keep them safe and replace them as soon as
BOX 6-3 ● Examples of Alternative Medical Therapy
possible.
❙ Homeopathy is based on the principle of similars; it uses diluted herbal and • Provide customarily eaten food.
medicinal substances that cause similar symptoms of a particular illness in • Advocate routine screening for diseases to which
healthy people. For example, quinine is used to treat malaria because it causes clients are genetically or culturally prone.
chills, fever, and weakness (symptoms of malaria) when administered to • Facilitate rituals by the person the client identifies as
healthy people.
❙ Naturopathy uses botanicals, nutrition, homeopathy, acupuncture, hydrother-
a healer within his or her belief system.
apy, and manipulation to treat illness and restore a person to optimum balance. • Apologize if cultural traditions or beliefs are violated.
❙ Chiropractic is based on the belief that illnesses and pain result from spinal
malalignment; it uses manipulation and readjustments of joint articulations,
massage, and physiotherapy to correct dysfunction. CRITICAL THINKING E X E R C I S E S
❙ Environmental medicine proposes that allergies to environmental substances
in the home and workplace affect health, particularly for supersensitive 1. A nurse working for a home health agency is assigned
people. It advocates reduced exposure to chemicals to control conditions to care for a non–English-speaking client from Pakistan.
that mainstream physicians have failed to diagnose or underdiagnosed. How would a culturally sensitive nurse prepare for this
client’s care?
2. A pregnant Haitian woman explains to a nurse that she 3. While assessing an African-American infant during a
is wearing a chicken bone around her neck to protect her home visit, the nurse observes a bluish area on the baby’s
unborn child from birth defects. Discuss how it would be buttocks. The action that is best for the nurse to take is to
best to respond to this woman from a culturally sensitive 1. Document the information; it is a normal assess-
perspective. ment finding.
2. Report suspicion of physical abuse to Child Protec-
tive Services.
3. Notify the physician in charge of the infant’s care
NCLEX-STYLE REVIEW Q U E S T I O N S about the finding.
1. The first step the nurse takes when preparing to teach a 4. Examine any and all children in the home for addi-
Latino client about dietary measures to control diabetes tional signs of abuse.
mellitus is to 4. A Native American client reports that a tribal elder used
1. Monitor the client’s blood glucose level each day. “smudging,” a ritual in which a substance like sweet grass
2. Review prescribed drug therapy. is burned and the smoke is fanned about the body with
3. Obtain a copy of a calorie-controlled exchange list. an eagle feather, to cleanse him of negative energies
4. Determine the client’s food likes and dislikes. during his recent illness. Which response by the nurse is
most appropriate?
2. When interviewing an Asian American during admission 1. Explain that smudging will not help restore the
to a health agency, the best technique for a culturally client’s health.
sensitive nurse to use when asking questions is to posi- 2. Suggest that the client include the physician’s treat-
tion himself or herself ment regimen.
1. Directly next to the client 3. Report the tribal elder for practicing medicine with-
2. Just beyond an arm’s length away out a license.
3. Within the doorway to the room 4. Advise the client to avoid treatment prescribed by
4. To facilitate occasional touching the tribal elder.
UNIT 2

for Chapters 3, 4, 5, and 6
in parentheses.
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 ethnicity is called a . (belief, generalization, stereotype)

false statements.
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.”
84
U N I T 2 ● End of Unit Exercises for Chapters 3, 4, 5, and 6 85

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
5. A relatively stable state of physiologic equilibrium

6. Natural body chemicals that produce effects similar to those of opiate drugs
7. Disappearance of signs and symptoms associated with a disease
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 based on

the criteria given below.
Teleologic Theory Deontologic Theory
Definition
Ideology
Example
2. Differentiate between the sympathetic and parasympathetic nervous systems based on the criteria given below.
Sympathetic Nervous System Parasympathetic Nervous System
Function
Effect on physiologic functions
Example
Activity F: Consider the following figure.

1.
a. Identify the figure.

b. Label 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 four categories of stressors affect homeostasis?
6. What factors affect the stress response?
7. What is transcultural nursing care?
Activity I: Give rationales for 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?
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?
3. A nurse is caring for a client scheduled for minor surgery who is unusually quiet. The nurse understands that
the client is under stress.
a. What can the nurse do when 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 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?
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 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 also is responsible for planning the
client’s care and evaluating her 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 tells the nurse that he 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.
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 her role to the client
b. Expresses her 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
UNIT 3
Fostering
Communication
7 The Nurse–Client Relationship
8 Client Teaching
9 Recording and Reporting
7
Chapter
The
Nurse–Client
Relationship
LEARNING OBJECTIVES
● Name four roles that nurses perform in nurse–client relationships.
● Describe the current role expectations for clients.
● List at least five principles that form the basis of the nurse–client relationship.
● Identify the three phases of the nurse–client relationship.
● Differentiate between social communication and therapeutic verbal communication.
● Give five examples of therapeutic and nontherapeutic communication techniques.
● List at least five factors that affect oral communication.
● Describe the four forms of nonverbal communication.
● Differentiate task-related touch from affective touch.
● List at least five situations in which affective touch may be appropriate.
AN intangible factor that helps a client to hold a nurse in high regard is the relation-
ship that develops between them. One of the primary keys to establishing and main-
taining positive nurse–client relationships is the manner and style of the nurse’s
WORDS TO KNOW communication. This chapter offers information about techniques for communicat-
affective touch ing therapeutically, listening empathetically, sharing information, and providing
caregiver client education, all of which are among the most basic processes within the context
collaborator of nurse–client relationships.
communication
delegator
educator
empathy NURSING ROLES WITHIN THE NURSE–CLIENT RELATIONSHIP
intimate space
introductory phase
kinesics A relationship (association between two or more people) is established between the
nonverbal communication
paralanguage
nurse and client when nursing services are provided. Nurses provide services, or skills,
personal space that assist individuals, called clients or patients, to promote or restore health, cope
proxemics with disorders that will not improve, and die with dignity.
public space The nurse–client relationship requires the nurse to respond to the client’s needs.
relationship
The National Council of State Boards of Nursing, which develops the national
silence
social space licensing examination for practical nurses (NCLEX-PN), designates four categories
task-oriented touch of client needs as the structure for the test plan: (1) safe, effective care environment,
terminating phase (2) health promotion and maintenance, (3) psychosocial integrity, and (4) physio-
therapeutic verbal logic integrity. These four categories apply to all areas of nursing practice regardless
communication
touch
of the stage in the client’s life span or the setting for health care delivery. To meet
verbal communication these client needs, nurses perform four basic roles: caregiver, educator, collaborator,
working phase and delegator.
92
C H A P T E R 7 ● The Nurse–Client Relationship 93
The Nurse as Caregiver Consequently nurses are resources for information about
health services available in the community. This type of
A caregiver is one who performs health-related activities information empowers clients to become involved with
that a sick person cannot perform independently. Care- self-help groups or those that offer rehabilitation, finan-
givers provide physical and emotional services to restore cial assistance, or emotional support.
or maintain functional independence. Box 7-1 highlights
the many differences between the services that nurses
provide and those that other caring people provide. The Nurse as Collaborator
Although the traditional nursing role is associated with
physical care, it also involves developing close emotional The nurse also acts as a collaborator (one who works with
relationships. The contemporary caregiving role incorpo- others to achieve a common goal) (Fig. 7-1). The most
rates an understanding that illness and injury cause feel- obvious example of collaboration occurs between the
ings of insecurity that may threaten a person’s ability to nurse responsible for managing care and those to whom
cope. Nurses use empathy (an intuitive awareness of what he or she delegates care. Collaboration also occurs when
a client is experiencing) to perceive the client’s emotional the nurse and physician share information and exchange
state and need for support. Empathy helps nurses to findings with other health care workers.
become effective in providing for the client’s needs while
remaining compassionately detached.
With whom would the nurse collaborate when caring for
The Nurse as Educator an older adult with a fractured hip?
Being an educator (one who provides information) is a

necessity in today’s complex health care arena. Nurses pro-
vide health teaching pertinent to each client’s needs The Nurse as Delegator
and knowledge base (see Chap. 8). Some examples in-
clude explanations about diagnostic test procedures, self- Before the nurse performs the role of delegator (one who
administration of medications, techniques for managing assigns a task to someone), he or she must know what
wound care, and restorative exercises like those per- tasks are legal and appropriate for particular health care
formed after a mastectomy.
When it comes to treatment decisions, the nurse avoids
giving advice, reserving the right of each person to make
his or her own choices on matters affecting health and
illness care. The nurse shares information on potential
alternatives, promotes the client’s freedom to choose,
and supports the client’s ultimate decision.
Nursing is considered a practice “without walls” Pharmacist Laboratory
because it extends beyond the original treatment facility. technician
BOX 7-1 ● Differentiating Caring Acts

Dietitian
From Nursing Acts
CARING ACTS NURSING ACTS
Prompted by observing a person in Prompted by a concern for the well-being MD

LPN
distress of everyone
Motivated by sympathy Motivated by altruism
Spontaneous Planned Physical
Goal is to relieve crisis Goal is to promote self-reliance RN
therapist
Outcomes are short-term Outcomes are long-term
Assume major responsibility for Expect mutual cooperation in resolving
resolving the person’s problem health problems
Experience-based Knowledge-based
Modeled on a personal moral code Modeled on a formal code of ethics CLIENT
Guided by common sense Legally defined Unlicensed Respiratory
Accountability based on acting Accountability based on meeting assistive personnel therapist
reasonably prudent professional standards FIGURE 7-1 • Collaboration may involve many members of the health
care team.
94 U N I T 3 ● Fostering Communication
workers to perform. It is potentially litigious to delegate

a task to someone who does not have the knowledge or Stop • Think + Respond BOX 7-2
expertise to perform it correctly. Once a task is assigned, Before delegating the task of taking a client’s vital signs
it is still the delegator’s responsibility to check that the (temperature, pulse, respiratory rate, and blood pressure)
task has been completed and determine the resulting out- to a student nurse, how might the nurse determine
come. For example, if a nurse asks a nursing assistant to whether the task is appropriate for the student, and if
change a client’s position, the nurse verifies that the assis- appropriate, that it has been performed?
tant complied with the nurse’s request and obtains addi-
tional pertinent information such as the condition of the
client’s skin. If the delegated task is not performed or is Underlying Principles
performed incorrectly, the nurse is accountable for the
inadequate care. A therapeutic nurse–client relationship is more likely to
develop when the nurse treats each client as a unique per-
son and respects the client’s feelings. He or she should
THE THERAPEUTIC NURSE–CLIENT strive to promote the client’s physical, emotional, social,
RELATIONSHIP and spiritual well-being, as well as encourage the client to
participate in problem solving and decision making. The
nurse accepts that a client has the potential for growth
The nurse–client relationship also can be called a ther-
and change and communicates using terms and language
apeutic relationship because the desired outcome of the
the client understands. He or she uses the nursing process
association is almost always moving toward restored
to individualize the client’s care; incorporates people to
health. A therapeutic relationship differs from a social
whom the client turns for support, such as family and
relationship. A therapeutic relationship is client centered
friends, when providing care; and implements health
with a focus on goal achievement. It is also time limited:
care techniques compatible with the client’s value system
the relationship ends when goals are achieved.
and cultural heritage.
The relationship between nurses and clients has
changed. In the past, the role of a sick person was pas-
sive; this allowed others to make decisions and submit
Phases of the Nurse–Client Relationship
to treatments without question or protest. Nurses now
encourage and expect people for whom they care to
Nurse–client relationships are ordinarily brief. They
become actively involved, to communicate, to question,
begin when people seek services that will maintain or
to assist in planning their care, and to retain as much
restore health or prevent disease. They end when clients
independence as possible (Box 7-2).
can achieve their health-related goals independently.
This type of relationship generally is described as having
three phases: introductory, working, and terminating.
BOX 7-2 ● Responsibilities Within the
Nurse—Client Relationship Introductory Phase
Nursing Responsibilities
Possess current knowledge.
The relationship between client and nurse begins with
Be aware of unique age-related differences. the introductory phase (period of getting acquainted). Each
Perform technical skills safely. person usually brings preconceived ideas about the other
Be committed to client care. to the initial interaction. These assumptions eventually
Be available and courteous.
are confirmed or dismissed.
Facilitate participation of client and family in decisions.
Remain objective. The client initiates the relationship by identifying one
Advocate on the client’s behalf. or more health problems for which he or she is seeking
Provide explanations in easily understood language. help. It is important for the nurse to demonstrate courtesy,
Promote client’s independence. active listening, empathy, competency, and appropriate
Client Responsibilities communication skills to ensure that the relationship
Identify current problem. begins positively.
Describe desired outcomes.
Answer questions honestly.
Provide accurate historical and subjective data. Working Phase
Participate to the fullest extent possible.
Be open and flexible to alternatives. The working phase (period during which tasks are per-
Comply with the plan for care. formed) involves mutually planning the client’s care and
Keep appointments for follow-up care. enacting the plan. Both nurse and client participate. Each
shares in performing those tasks that lead to the desired
outcomes identified by the client. During the working BOX 7-3 ● Barriers to a Nurse—Client Relationship
phase, the nurse tries not to retard the client’s indepen-
dence: doing too much is as harmful as doing too little. ❙ Appearing unkempt: long hair that dangles on or over the client during care,
offensive body or breath odor, wrinkled or soiled uniform, dirty shoes
❙ Failing to identify oneself verbally and with a name tag
Terminating Phase ❙ Mispronouncing or avoiding the client’s name
The nurse–client relationship is self-limiting. The termi- ❙ Using the client’s first name without permission
❙ Showing disinterest in the client’s personal history and life experiences
nating phase (period when the relationship comes to an ❙ Sharing personal or work-related problems with the client or with staff in the
end) occurs when nurse and client mutually agree that client’s presence
the client’s immediate health problems have improved. A ❙ Using crude or distasteful language
caring attitude and compassion help facilitate the client’s ❙ Revealing confidential information or gossip about other clients, staff, or people
transition of care to other health care services or indepen- commonly known
❙ Focusing on nursing tasks rather than the client’s responses
dent living. ❙ Being inattentive to the client’s requests (e.g., food, pain relief, assistance
with toileting, bathing)
❙ Abandoning the client at stressful or emotional times
❙ Failing to keep promises such as consulting with the physician about a
Barriers to a Therapeutic Relationship current need or request
❙ Going on a break or to lunch without keeping the client informed and identi-
It is impossible for a nurse to develop a positive relation- fying who has been delegated for the client’s care during the temporary
ship with every client. Box 7-3 lists examples of behav- absence
iors that are likely to interfere. The best approach is to
treat clients in the manner one would like to be treated.
Verbal Communication
COMMUNICATION
Verbal communication (communication that uses words)
includes speaking, reading, and writing. Both nurse and
Communication (exchange of information) involves both client use verbal communication to gather facts. They also
sending and receiving messages between two or more use it to instruct, clarify, and exchange ideas.
people followed by feedback indicating that the infor- Many factors affect the ability to communicate by
mation was understood or requires further clarification speech or in writing. Examples include (1) attention
(Fig. 7-2). Communication takes place simultaneously and concentration; (2) language compatibility; (3) ver-
on a verbal and nonverbal level. Because no relationship bal skills; (4) hearing and visual acuity; (5) motor func-
can exist without verbal and nonverbal communication, tions involving the throat, tongue, and teeth; (6) sensory
nurses develop skills that enhance their therapeutic inter- distractions; (7) interpersonal attitudes; (8) literacy; and
actions with clients. (9) cultural similarities. The nurse promotes the factors
FIGURE 7-2 • Communication is a

two-way process between a sender
and a receiver.
that enhance the communication of verbal content and out fear of retaliation or censure contributes to a thera-
controls or eliminates those that interfere with the accu- peutic relationship.
rate perception of expressed ideas. Although nurses often have the best intentions of inter-
acting therapeutically with clients, some fall into traps
Therapeutic Verbal Communication that block or hinder verbal communication. Table 7-2 lists
common examples of nontherapeutic communication.
Communication can take place on a social or therapeutic
level. Social communication is superficial; it includes Listening
common courtesies and exchanges about general topics.
Therapeutic verbal communication (using words and gestures Listening is as important during communication as speak-
to accomplish a particular objective) is extremely impor- ing. Giving attention to what clients say provides a stim-
tant, especially when the nurse is exploring problems ulus for meaningful interaction. It is important to avoid
with the client or encouraging expression of feelings. giving signals that indicate boredom, impatience, or the
Techniques that the nurse may find helpful are described pretense of listening. For example, looking out a window
in Table 7-1. or interrupting is a sign of disinterest. When communi-
The nurse must never assume that a quiet, uncommu- cating with most people in the United States, it is best
nicative client has no problems or understands every- to position oneself at the person’s level and make fre-
thing. It is never appropriate to probe and pry; rather, quent eye contact (Fig. 7-3). Refer to Chapter 6 for cul-
it may be advantageous to wait and be patient. It is not tural exceptions. Nodding and making comments such
unusual for reticent clients to share their feelings and as, “Yes, I see,” encourages clients to continue and shows
concerns after they conclude that the nurse is sincere full involvement in what is being said.
and trustworthy.
Nurses must approach vocal, emotional clients deli- Silence
cately. For instance, when clients are angry or crying, the Silence(intentionally withholding verbal commentary)
best nursing response is to allow them to express their plays an important role in communication. It may seem
emotions. Allowing clients to display their feelings with- contradictory to include silence as a form of verbal com-
TABLE 7-1 THERAPEUTIC VERBAL COMMUNICATION TECHNIQUES

TECHNIQUE USE EXAMPLE
Broad opening Relieves tension before getting to the real purpose “Wonderful weather we’re having.”
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 conversation Client: “I haven’t been sleeping well.”
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 up.”
listening Nurse: “Eating makes you nauseous, but you don’t
actually vomit.”
Verbalizing what has Shares how the nurse has interpreted a statement Client: “All the nurses are so busy.”
been implied 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, “You’re concerned about your weight loss, but
or 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
TABLE 7-2 NONTHERAPEUTIC VERBAL COMMUNICATION TECHNIQUES

TECHNIQUE AND CONSEQUENCE EXAMPLE IMPROVEMENT
Giving False Reassurance

Trivializes the client’s unique feelings “You’ve got nothing to worry about. “Tell me your specific concerns.”
and 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; “I’m glad you’re exercising so regularly.” “Are you having any difficulty fitting
implies that future deviation may lead “You should be testing your blood regular exercise into your schedule?”
to subsequent rejection or disfavor glucose each morning.” “Let’s explore some ways that will help
you remember to test your blood glu-
cose 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 “Why didn’t you keep your appointment “I see you couldn’t keep your appoint-
she may be tempted to make up an last week?” ment last week.”
excuse rather than risk disapproval for
an honest answer
Giving Advice
Discourages independent problem solv- “If I were you, I’d try drug therapy before “Share with me the advantages and dis-
ing and decision making; provides a having surgery.” advantages of your options as you see
biased view that may prejudice the them.”
client’s choice
Defending
Indicates such a strong allegiance that “Ms. Johnson is my best nursing assis- “I’m sorry you had to wait so long.”
any disagreement is unacceptable tant. She wouldn’t have let your light
go unanswered that long.”
Belittling
Disregards how the client is responding “Lots of people learn to give themselves “You’re finding it especially difficult to
as an individual insulin.” stick yourself with a needle.”
Patronizing
Treats the client condescendingly (less “Are we ready for our bath yet?” “Would you like your bath now or
than capable of making an indepen- should I check with you later?”
dent 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 con-
cerns you the most?”
munication. Nevertheless, one of its uses is to encourage Clients may use silence to camouflage fears or to express
the client to participate in verbal discussions. Other ther- contentment. They also use silence for introspection when
apeutic uses for silence include relieving a client’s anxiety they need to explore feelings or pray. Interrupting some-
just by providing a personal presence and offering a brief one deep in concentration disturbs his or her thought
period during which clients can process information or process. A common obstacle to effective communication is
respond to questions. ignoring the importance of silence and talking excessively.
movements. Some add that clothing style and accessories

such as jewelry also affect the context of communication.
Box 7-4 describes various examples of nonverbal behavior
and their meaning.
Knowledge of kinesics is important for the nurse
being evaluated by his or her clients and vice versa. To
create a positive impression during a client interaction,
the nurse should:
• Stand tall.
• Relax arms, legs, and feet; do not cross any body part.
• 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
demonstrative nor reserved.
FIGURE 7-3 • Appropriate positioning, space, eye contact, and atten- • Keep the legs as still as possible.
tion promote therapeutic communication. (Copyright B. Proud.)
Paralanguage
Nonverbal Communication Paralanguage (vocal sounds that are not actually words)
also communicates a message. Some examples include
Nonverbal communication (exchange of information withdrawing in a deep breath to indicate surprise, clucking
out using words) involves what is not said. The manner the tongue to indicate disappointment, and whistling to
in which a person conveys verbal information affects its get someone’s attention. Vocal inflections, volume, pitch,
meaning. A person has less control over nonverbal than and rate of speech add another dimension to communica-
verbal communication. Words can be chosen with care, tion. Crying, laughing, and moaning are additional forms
but a facial expression is harder to control. As a result, of paralanguage.
people often communicate messages more accurately
through nonverbal communication. Proxemics
People communicate nonverbally through the tech-
Proxemics (use and relationship of space to communica-
niques described next: kinesics, paralanguage, proxemics,
tion) varies among people from different cultural back-
and touch.
grounds. Generally, four zones are observed in interactions
between Americans (Hall, 1959, 1963, 1966): intimate
Kinesics
space (within 6 inches), personal space (6 inches to 4 feet),
(body language) includes nonverbal techniques
Kinesics social space (4 to 12 feet), and public space (more than 12 feet;
such as facial expressions, posture, gestures, and body Table 7-3).
BOX 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.bodylanguagetraining.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.
TABLE 7-3 COMMUNICATION ZONES

ZONE DISTANCE PURPOSE
Intimate space Within 6 inches • Lovemaking

• Confiding secrets
• Sharing confidential
information
Personal space 6 inches to • Interviewing
4 feet • Physical assessment
• Therapeutic interven-
tions involving touch
• Private conversations
• Teaching one-on-one
Social space 4 to 12 feet • Group interactions
• Lecturing
• Conversations that
are not intended to be
private
Public space 12 or more feet • Giving speeches
• Gatherings of
strangers
FIGURE 7-4 • Examining a client involves task-oriented touch. (Copy-
right B. Proud.)
Most people in the United States comfortably tolerate
strangers in a 2- to 3-foot area. Venturing closer may • Near death
cause some to feel anxious. Understanding the client’s • Anxious, insecure, or frightened
comfort zone helps the nurse to know how spatial rela- • Disoriented
tions affect nonverbal communication. • Disfigured
Closeness is common in nursing because of the many • Semiconscious or comatose
times nurses and clients are in direct physical contact. • Visually impaired
Therefore, some clients can misinterpret physical near- • Sensory deprived
ness and touching within intimate and personal spaces
as having sexual connotations. Approaches that may pre-
vent such misunderstanding include explaining before- GENERAL GERONTOLOGIC
hand how a nursing procedure will be performed, ensuring CONSIDERATIONS
that a client is properly draped or covered, and asking
Demonstrating respect for older clients helps establish a
that another staff person of the client’s gender be present trusting relationship. Avoid approaching them quickly or
during an examination or procedure. presumptuously—doing so may create barriers to interaction.
Many older adults are more responsive to calmness and
Touch respectful demeanors.
Touch (tactile stimulus produced by making personal con-

tact with another person or object) occurs frequently in
nurse–client relationships. While caring for clients, touch
can be task-oriented, affective, or both. Task-oriented touch
involves the personal contact required when performing
nursing procedures (Fig. 7-4). Affective touch is used to
demonstrate concern or affection (Fig. 7-5).
Affective touch has different meanings to different
people depending on their upbringing and cultural back-
ground. Because nursing care involves a high degree of
touching, the nurse is sensitive as to how clients may per-
ceive it. Most people respond positively to touch, but
there are variations among individuals. Therefore, nurses
use affective touching cautiously even though its inten-
tion is to communicate caring and support. In general,
affective touch is therapeutic when a client is
• Lonely FIGURE 7-5 • This nurse uses affective touch as she talks with her
• Uncomfortable client. (Copyright B. Proud.)
Initially greet the client by giving your name and title. Address CRITICAL THINKING E X E R C I S E S
the older person using formal titles of respect such as “Mr.”
or “Mrs.” Find an appropriate time to ask the client how he 1. What specific services might a person expect within a
or she prefers to be addressed. Avoid using familiar or nurse–client relationship that differ from those within a
endearing terms such as “Dear/sweetie/honey.” Only use physician–client relationship?
terms such as “Grandma” or “Pop” if the older adult specifically
requests it from you personally. Be aware of subtle verbal 2. Studies have shown that older adults are not touched
messages that convey bias or inequality, such as calling white with the same frequency as clients in other age groups.
men “Mister” but men of other races by their first names, or Discuss reasons for this.
calling an older person “Baby.”
Avoid the “invisible client syndrome.” Talking with someone else
in the room as if the client is not there demonstrates disrespect.
Never treat older adults as if they are children or uneducated;
NCLEX-STYLE REVIEW Q U E S T I O N S
avoid using any terms that are demeaning or connote childlike 1. A discouraged client says, “I’m sure this surgery won’t
or infantile behavior or actions (e.g., remarks such as “I have to
help any more than the others.” The best initial nursing
feed him now,” “She can’t do it herself anymore,” or references
to incontinence products as “diapers”). Attempt to emphasize
response is
the abilities of the older adult and seek modifications that can 1. “You’re saying that you doubt you will improve.”
promote independence in self-care as much as possible, such as 2. “Do you want to talk to the surgeon again?”
“She selects her dress each morning, then I help her with. . . .” 3. “I’d recommend a more positive attitude.”
Although physical touch is an important form of nonverbal 4. “Of course it will; you’ll be up and around in no
communication, use it purposefully as the primary method time.”
to reinforce verbal messages. Recognize that touch as a form
of communication is usually more important to older adults 2. When a terminally ill client does not respond to medical
than to younger adults. treatment, which nursing action is most helpful in assist-
Gender and age differences between client and care provider ing the client to deal with his impending death?
may determine the acceptability of touch. Appropriate use of 1. Provide literature on death and dying.
touch, as with eye contact, requires culture awareness. 2. Allow him privacy to think by himself.
During interaction with the older client, sit in a face-to-face position 3. Listen to him talk about how he is feeling.
at eye level, provide good lighting while avoiding background
4. Encourage him to get a second opinion.
glare, and eliminate as much background noise as possible. Ask
if the client has any special needs, and if he or she can hear you 3. An alarm caused by a loose cardiac monitor lead startles
with ease. If not, identify which ear has the best hearing, and sit a client with chest pain. The best nursing intervention is to
on that side. Speak at a normal tone with distinct pronunciation 1. Identify the client’s current heart rhythm.
of beginning and ending consonants for each word, yet without 2. Explain the reason the alarm sounded.
distortion of your normal speech.
3. Give the client a prescribed tranquilizer.
Promote as much control over decisions as possible. Dependence
is often difficult to accept; participation in the discussion 4. Provide the client with a magazine to read.
helps to maintain self-esteem and dignity, even if changes in 4. A 2-year-old is admitted to the emergency department
independence are going to be needed. Allow older adults to with a high fever of unknown origin. Which of following
pace their own care and maintain as much independence as is the nurse correct to delegate to a nursing assistant?
possible even when this requires more time.
1. Administer an aspirin suppository to reduce the
Encourage reminiscing. Ask about past events and relationships
associated with positive experiences and feelings. Giving older
child’s fever.
adults an opportunity to talk about earlier times in their lives 2. Give the toddler a Popsicle or other fluid every
reinforces their value and unique identity and promotes recall 30 minutes.
of situations in which they have demonstrated coping or 3. Call the laboratory for the results of diagnostic tests.
adaptation. 4. Listen to the child’s lungs for sounds of congestion.
8
Chapter
Client
Teaching
LEARNING OBJECTIVES
● Describe the three domains of learning.
● Discuss three age-related categories of learners.
● Discuss at least five characteristics unique to older adult learners.
● Identify at least four factors that nurses assess before teaching clients.
TEACHING is one of the most important uses of communication for 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 man a fish
and he will eat for a day; teach a man to fish and he will eat for a lifetime.”
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 on Accreditation of Healthcare Organizations has
made it a criterion for accreditation. Likewise, the American Nurses Association’s
Social Policy Statement addresses it (Box 8-1).
If teaching standards are not met, nurses are at risk for being sued if clients dis-
charged from health care services are readmitted or harmed because they were un-
informed or failed to understand information that was taught. The best proof of
compliance with teaching standards is to document in the client’s medical record who
was taught, what was taught, the teaching method, and the evidence of learning.
Teaching generally focuses on combinations of the following subject areas:
WORDS TO KNOW • Self-administration of medications
affective domain • Directions and practice in using equipment for self-care
androgogy • Dietary instructions
cognitive domain • Rehabilitation program
functionally illiterate
gerogogy
• Available community resources
illiterate • Plan for medical follow-up
literacy • Signs of complications and actions to take
pedagogy
psychomotor domain
101
BOX 8-1 ● Social Policy Statement Regarding Teaching
Nursing practice includes, but is not limited to, initiating and maintaining com-
fort measures, promoting and supporting human functions and responses, estab-
lishing 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 Association.

(2003). Social Policy Statement (2nd ed.). Washington, DC: Author, p. 8.
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
learning needs is essential because learning takes place
in four progressive stages:
1. Recognition of what’s been taught FIGURE 8-1 • The nurse uses pamphlets and a book, which appeal
2. Recall or description of information to others to this client who prefers the cognitive domain of learning. (Copyright
3. Explanation or application of information B. Proud.)
4. Independent use of new learning (Bruccoliere, 2000)
A delay in teaching retards optimum learning outcomes. mation through a combination of teaching approaches.
Evidence supporting this method is that “learners retain
10% of what they read, 20% of what they hear, 30% of
ASSESSING THE LEARNER what they see, 50% of what they see and hear, 70% of
what they teach/talk, and 90% of what they talk/do”
(Heinrich et al., 2002; Rega, 1993).
To implement effective teaching, the nurse must deter-
mine the client’s
• Preferred learning style Stop • Think + Respond BOX 8-1
• Age and developmental level Identify the learning domain that relates to each of the
• Capacity to learn following teaching methods:
• Motivation 1. The nurse watches as a client with diabetes practices
• Learning readiness administering an injection.
• Learning needs 2. The nurse asks a client who had a mastectomy to
speak to women attending a health seminar about the
importance of monthly breast self-examinations.
Learning Styles 3. The nurse explains the technique for performing leg
exercises to a client scheduled for surgery.
Style of learning means how a person prefers to acquire 4. The nurse helps a client self-administer nutritional
knowledge. Learning styles fall within three general formula through a gastrostomy tube.
5. The nurse gives a client with back strain a pamphlet
domains: cognitive, affective, and psychomotor. The cog-
on using good posture and body mechanics.
nitive domain is a style of processing information by listen-
ing or reading facts and descriptions. It is illustrated in
Figure 8-1. The affective domain is a style of processing that
appeals to a person’s feelings, beliefs, or values. The psy-
BOX 8-2 ● Activities That Promote Learning
chomotor domain is a style of processing that focuses on
learning by doing. Box 8-2 lists some activities associated COGNITIVE PSYCHOMOTOR AFFECTIVE
with each learning domain. DOMAIN DOMAIN DOMAIN
One way to determine the client’s preferred learning
style is to ask a question such as, “When you learned to Listing Assembling Advocating
Identifying Changing Supporting
add fractions, what helped you most: hearing the teacher’s
Locating Emptying Accepting
explanation or reading about it in a mathematics book, Labeling Filling Promoting
recognizing the value of the exercise, or actually work- Summarizing Adding Refusing
ing sample problems?” Although most clients favor one Selecting Removing Defending
domain, nurses can optimize learning by presenting infor-
C H A P T E R 8 ● Client Teaching 103
Age and Developmental Level homes in which both parents work are greatly affecting
the learning characteristics of these groups (Brown, 1997;
Educators emphasize that learning takes place differ- Skiba & Barton, 2006; Tulgan & Martin, 2001). In gen-
ently depending on a person’s age and developmental eral, these groups share many of the following learning
level. Experts agree that teaching tends to be more effec- characteristics:
tive when it is designed to accommodate unique age- • They are technologically literate, having grown up with
related differences. computers.
Nurses and all those who provide instruction must • They crave stimulation and quick responses.
be aware of the learning characteristics of children, • They expect immediate answers and feedback.
adult, and older adult learners (Table 8-1). Recently a • They become bored with memorizing information and
distinction has been made between learners at the early doing repetitious tasks.
and later ends of the adult spectrum (Formosa, 2002; • They like a variety of instructional methods from which
Pearson & Wessman, 1996). Currently there are three they can choose.
major categories: • They respond best when they find the information to
be relevant.
• Pedagogyis the science of teaching children or those
• They prefer visualizations, simulations, and other meth-
with cognitive ability comparable to children.
ods of participatory learning.
• Androgogy is the principles of teaching adult learners.
• Gerogogy is the techniques that enhance learning among
older adults. Stop • Think + Respond BOX 8-2
Although most clients with health problems are in their Identify the age-related learner for whom the following
teaching techniques are most appropriate. Explain the
later years, nurse educators are advised to prepare them-
basis for your analysis.
selves to teach young adults who belong to “Generation X,”
1. The nurse’s goal is to limit the teaching session to no
“Generation Y,” and the “Net Generation,” as they age.
more than 20 minutes.
Generation X refers to those born between 1961 and 2. The nurse emphasizes knowledge or techniques that
1981; Generation Y refers to young adults who graduated the client is interested in learning.
from college in the late 1990s; and the Net Generation 3. The nurse reinforces that the client’s discharge from the
refers to those born after 1981 (sometimes called “cyber- health agency correlates with becoming competent in
kids”). Technology and imposed independence as a con- self-administering insulin injections.
sequence of growing up in single-parent households or
TABLE 8-1 AGE-RELATED DIFFERENCES AMONG LEARNERS*

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 Seek knowledge for its own sake or Motivated by a personal need or goal
rewards 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; Divergent thinkers (process multiple Practical thinkers (process new information as
e.g., see one application for new applications for new information) it applies to a unique personal problem)
information)
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
* Each learner is unique and may demonstrate characteristics associated with other age groups.
ical regimens, keep appointments or seek help early in

4. The nurse indicates that the client can use a computer-
the course of a disease.” Functional illiteracy may be the
ized game for 30 minutes when he or she can name
consequence of a learning disability, not a below-average
the number of recommended servings in each category
within the food pyramid.
intellectual capacity.
5. The nurse challenges the client to devise a plan for Because many illiterate or functionally illiterate people
managing her colostomy when she returns to work are not apt to volunteer information about their reading
following discharge. problems, literacy may be difficult to assess. Those who
are illiterate and functionally illiterate usually develop
elaborate mechanisms to disguise or compensate for their
learning deficits. To protect the client’s self-esteem, the
Capacity to Learn nurse can ask, “How do you learn best?” and plan accord-
ingly. Some useful approaches when teaching clients
For the person to receive, remember, analyze, and apply who are illiterate or functionally illiterate include the
new information, he or she must have a certain amount following:
of intellectual ability. Illiteracy, sensory deficits, cultural
differences, shortened attention span, and lack of moti- • Use verbal and visual modes for instruction.
vation and readiness require special adaptations when • Repeat directions several times in the same sequence
implementing health teaching. so the client can memorize the information.
• Provide pictures, diagrams, or tapes (audio and video)
Literacy for future review.
It is essential to determine a client’s level of literacy (abil- Sensory Deficits

ity to read and write) before developing a teaching plan.
The abilities to see and to hear are essential for almost
Approximately 21% of U.S. adults are illiterate (cannot
every learning situation. Older adults tend to have visual
read or write) (Davis et al., 1998; Toffler, 2002). An addi-
and auditory deficits, although such deficits are not
tional 27% are considered functionally illiterate (possess
exclusive to this population. Nursing Guidelines 8-1 pre-
minimal literacy skills), which means they can sign
sent some techniques for teaching clients with sensory
their name and perform simple mathematical tasks
impairment.
(e.g., make change) but read at or below a ninth-grade
level. Toffler (2002, p. 3) reports “at least 30% . . . could Cultural Differences
not comprehend the written instructions on prescrip-
tion bottles . . . and (because of their functional illiteracy) Because teaching and learning involve language, the
are less likely to use screening procedures, follow med- nurse must modify approaches if the client cannot speak

Teaching Clients With Sensory Impairments
Ensure that the client with visual impairment is wearing prescription eyeglasses ❙ Avoid using materials printed on glossy paper. Glossy paper reflects
or that the client with hearing impairment is wearing a hearing aid, if available. light, causing a glare that makes reading uncomfortable.
Visual and auditory aids maximize ability to perceive sensory stimuli. ❙ Select black print on white paper. This combination provides maximum
For clients with visual impairment:
contrast and makes letters more legible.
❙ Speak in a normal tone of voice. Clients with visual impairment do not
For clients with hearing impairment:
necessarily have hearing impairment. Increased volume does not
compensate for reduced vision. ❙ Use a magic slate, chalkboard, flash cards, and writing pads to
communicate. Writing can substitute for verbal instructions.
❙ Use at least a 75- to 100-watt light source, preferably in a lamp that
shines over the client’s shoulder. Ceiling lights tend to diffuse light rather ❙ Lower the voice pitch. Hearing loss is generally in the higher-pitch ranges.
than concentrate it on a small area where the client needs to focus. ❙ Try to select words that do not begin with “f,” “s,” “k,” and “sh.” These
❙ Avoid standing in front of a window through which bright sunlight is letters are formed with high-pitched sounds and are therefore difficult
shining. It is difficult to look into bright light. for clients with hearing impairment to discriminate.
❙ Provide a magnifying glass for reading. Magnification enlarges ❙ Rephrase rather than repeat when the client does not understand.
standard or small print to a comfortable size. Rephrasing may provide additional visual or auditory clues to facilitate
the client’s understanding.
❙ Obtain pamphlets in large (12- to 16-point) print and serif lettering,
which has horizontal lines at the bottom and top of each letter (Fig. 8-2). ❙ Insert a stethoscope into the client’s ears and speak into the bell with a
Letters and words are usually more distinct when set in large print with low voice. The stethoscope acts as a primitive hearing aid. It projects
a style that promotes visual discrimination. sounds directly to the ears and reduces background noise.
the comfort of home. Less desirable reasons are to please

12 pt. Times others and to avoid criticism.
Aa Bb Cc Dd Ee Ff Gg Hh Ii Jj Kk Ll
Oo Pp Qq Rr Ss Tt Uu Vv Ww Xx Yy
Learning Readiness
14 pt. Times
When capacity and motivation for learning exist, the
Aa Bb Cc Dd Ee Ff Gg Hh Ii Jj Kk nurse can determine the final component, learning readi-
ness. Readiness refers to the client’s physical and psy-
Oo Pp Qq Rr Ss Tt Uu Vv Ww Xx chological well-being. For example, a person who is in
pain, is too warm or cold, is having difficulty breathing,
16 pt. Times or is depressed or fearful is not in the best condition to
Aa Bb Cc Dd Ee Ff learn. In these situations, it is best to restore comfort and
then attend to teaching.
Oo Pp Qq Rr Ss Tt
Learning Needs
FIGURE 8-2 • Selecting printed materials with 12- to 16-point size
type, black print on white paper, and serif lettering helps to improve
The best teaching and learning take place when both are
visual clarity.
individualized. To be most efficient and personalized, the
nurse must gather pertinent information from the client.
English or if English is a second language (see Chap. 6, Second-guessing what the client wants and needs to know
Nursing Guidelines 6-1). Language barriers do not jus- often leads to wasted time and effort.
tify omitting health teaching. In most cases, if neither The following are questions the nurse can ask to assess
the nurse nor the client speaks a compatible language, the client’s learning needs:
a translator is used.
• What does being healthy mean to you?
• What things in your life interfere with being healthy?
Attention and Concentration • What don’t you understand as fully as you would like?
The client’s attention and concentration affect the dura- • What activities do you need help with?
tion, delivery, and teaching methods employed. Some • What do you hope to accomplish before being dis-
helpful approaches include the following: charged?
• How can we help you at this time?
• Observe the client, and implement health teaching
when he or she is most alert and comfortable.
• Keep the teaching session short. INFORMAL AND FORMAL TEACHING
• Use the client’s name frequently throughout the instruc-
tional period; this refocuses his or her attention. Informal teaching is unplanned and occurs sponta-
• Show enthusiasm, which you are likely to communicate neously at the bedside. Formal teaching requires a plan.
to the client. Without a plan, teaching becomes haphazard. Further-
• Use colorful materials, gestures, and variety to stimulate more, without some organization of time and content,
the client. the potential for reaching goals, providing adequate
• Involve the client in an active way. information, and ensuring comprehension is jeopar-
• Vary the tone and pitch of voice to stimulate the client dized. Potential teaching needs generally are identified at
aurally. the client’s admission, but they may be amended as care
and treatment progress.
A student nurse may work with a staff nurse or instruc-
Motivation tor in developing a teaching plan. Usually one or more
nurses carry out certain specific parts of a teaching plan
Learning is optimal when a person has a purpose for (Fig. 8-3). This approach is the most desirable so that a
acquiring new information. Relevance of learning depends client is not overwhelmed with processing volumes of
on individual variables. The desire for learning may be to new information or learning skills that are difficult for
satisfy intellectual curiosity, restore independence, pre- novices to perform. Skill 8-1 serves as a model when an
vent complications, or facilitate discharge and return to adult client needs teaching.
A calm demeanor and quiet environment can decrease anxiety

or distractions that prevent new learning. Peer teaching or
reinforcement in support group settings may be helpful.
Stating a belief that the older person can actually make the rec-
ommended health behavior changes and providing encour-
agement may increase the client’s perception of self-efficacy
with resultant increased learning.
1. How would the nurse teach techniques for toothbrush-
ing differently to a child; a person from the Y, X, or Net
generations; a young adult; a middle-aged adult; and an
older adult?
2. What teaching strategies could the nurse use to teach
toothbrushing within the cognitive, affective, and psy-
chomotor domains of learning?
3. Give two examples of how you could determine whether
a client actually learned information you taught such as
toothbrushing.
FIGURE 8-3 • The nurse performs teaching about diabetes at the
bedside. She promotes multisensory stimulation by giving the client 1. Which of the following is essential before teaching the
explanations and encouraging her to watch the technique for testing mother of a 6-year-old about nutrition?
blood sugar as it is being performed. (Copyright B. Proud.) 1. Assess the child’s height and weight.
2. Obtain a food pyramid pamphlet.
3. Develop a plan for 1 week’s menus.
GENERAL GERONTOLOGIC 4. Collect various nutritional recipes.
CONSIDERATIONS 2. After teaching a client how to perform breathing exer-
Refer to Table 8-1 for gerogogic learner characteristics. cises, the best method for evaluating the effectiveness of
Refer to Nursing Guidelines 8-1 for recommendations when the teaching is to
teaching clients with sensory impairments. 1. Request that the client explain the importance of
During initial assessment of levels of cognitive function, clients breathing exercises.
may interact in a socially appropriate manner and may indicate 2. Ask the client to perform the breathing exercises as
that they understand material being taught. Asking a client to they were taught.
recall what has been discussed after approximately 15 minutes 3. Ask the client if he is performing the breathing
have passed may help determine what information has actually
exercises as required.
been retained. A mental status examination may be indicated
(see Chap. 13). If there is cognitive impairment, a support per- 4. Monitor the client’s respiratory rate several times
son or caregiver should be present for the teaching sessions. a day.
Most people are “creatures of habit” and are reluctant to make 3. Which of the following teaching aids is developmentally
changes without understanding the benefit. Older people may appropriate when preparing a preschool child for a diag-
be creative in methods to incorporate needed changes in
nostic test such as a bone marrow puncture?
health behavior if the purposes or anticipated benefits are
made clear at the beginning of the teaching session. 1. Dolls or puppets
Beginning the teaching session with a reference to the older 2. Pamphlets or booklets
person’s actual experience will help provide a link to which 3. Colored diagrams
the new learning can connect. 4. Commercial videotapes
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 client on content, goals, and realistic Adult learners tend to prefer collaboration and active
time frame. involvement in the learning process.
Develop a written plan that builds from simple to Adult learners learn best by applying information from
complex, familiar to unfamiliar, and normal to present knowledge or past experiences.
abnormal.
Divide information into manageable amounts. Too much information at once tends to overwhelm
learners.
Select teaching strategies and resources that are Adult learners generally prefer one learning style, but
compatible with the client’s preferred style for learning. multiple approaches enhance learning.
Use a variety of instructional methods from the cognitive, Adults tend to retain more knowledge when a variety of
affective, and psychomotor domains. instructional 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 Learning takes place more easily when the client can focus
and emotionally ready to learn, if possible. on the task at hand.
Provide an environment that promotes learning. Learning is best in a well-lit room with a comfortable
temperature. Distractions and interruptions interfere
with concentration.
Identify how long the teaching session will last. Clarifying 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
understanding. is accountable for ensuring the client’s comprehension.
Explain any and all new terms. Clients sometimes are embarrassed to admit they do not
understand.
Involve the client actively by encouraging feedback and Adult learners prefer active rather than passive learning
handling of equipment. situations.
Stimulate as many senses as possible. Involvement of more than one sense enhances learning.
Invent songs, rhymes, or a series of key terms that Creativity stimulates the right hemisphere of the brain
correspond with the teaching content. where information is retrieved more easily.
Use equipment as similar as possible to what the client Becoming familiar with equipment is the best preparation
will use at home. for self-care at home.
(continued)
TEACHING ADULT CLIENTS (Continued)
Implementation (Continued)
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 Reviewing reinforces important concepts.
teaching.
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
session. which the client may review and practice what has
been taught.
Arrange an opportunity for the client to use or apply the Immediate application reinforces learning and promotes
new information as soon as possible after it was taught. long-term retention.
Document the information taught and evidence Documentation provides a written record of the client’s
demonstrating the client’s understanding. progress 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.
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
9
Chapter
Recording and
Reporting
LEARNING OBJECTIVES
● Identify seven uses for medical records.
● List six components generally found in any client’s medical record.
● Differentiate between source-oriented and problem-oriented records.
● Identify six methods of charting.
● Explain the purpose and applications associated with the Health Insurance Portability and
Accountability Act.
● List four aspects of documentation required in the medical records of all clients cared for in
acute settings.
● Discuss why it is important to use only approved abbreviations when charting.
● Explain how to convert traditional time to military time.
● List at least 10 guidelines that apply to charting.
● Identify four written forms used to communicate information about clients.
● List five ways that health care workers exchange client information other than by reading
the medical record.
WORDS TO KNOW
auditors
beneficial disclosure
change of shift report NURSES must communicate information clearly, concisely, and accurately, both
chart when writing and when speaking. This chapter describes various written and spo-
charting ken forms of communication and nursing responsibilities for record keeping and
charting by exception
checklist
reporting.
computerized charting
continuous quality
improvement MEDICAL RECORDS
documenting
flow sheet
focus charting Medical records are written collections of information about a person’s health, the care
Kardex
medical records
provided by health practitioners, and the client’s progress. They also are referred to
military time as health records or client records. The medical record may consist of various agency-
minimum disclosure approved paper forms (Table 9-1), or the forms may be stored on the hard drive of a
narrative charting computerized record.
nursing care plan
The hard copy paper forms are placed in a chart (binder or folder that promotes
PIE charting
problem-oriented record the orderly collection, storage, and safekeeping of a person’s medical records). The
quality assurance paper forms in the chart are color coded or separated by tabbed sheets. A comput-
recording erized medical record is accessed by using a password and selecting the desired
rounds form from a menu. Computerized records can be printed if a hard copy is desired.
SOAP charting
source-oriented record
All personnel involved in a client’s health care contribute to the medical record by
total quality improvement charting, recording, or documenting (process of entering information) on the health
traditional time agency’s forms.
109
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, 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 data base 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, 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
Uses sequent admissions so that the client’s health history can

be reviewed.
Besides serving as a permanent health record, the collec-
tive information about a client provides a means to share Sharing Information
information among health care workers, thus ensuring
Because it is impossible for all health care workers to
client safety and continuity of care. Occasionally medical
meet and to exchange information on a personal basis at
records also are used to investigate quality of care in a
the same time, the written record becomes central to com-
health agency, demonstrate compliance with national
munication (i.e., sharing information among personnel).
accreditation standards, promote reimbursement from
The documentation serves as a way to inform others
insurance companies, facilitate health education and re-
about the client’s status and plan for care.
search, and provide evidence during malpractice lawsuits.
Sharing information prevents duplication of care and
helps to reduce the chance of error or omission. For exam-
Permanent Account
ple, if a client requests medication for pain, the nurse
The medical record is a written, chronologic account of a checks the client’s chart to determine when the last pain-
person’s illness or injury and the health care provided relieving drug was administered. Accurate and timely
from the onset of the problem through discharge or death. documentation prevents medication from being admin-
The record is filed and maintained for future reference. istered too frequently or withheld unnecessarily. Main-
Previous health records often are requested during sub- taining immunization records is an example of how
C H A P T E R 9 ● Recording and Reporting 111
documentation promotes continuity: the record ensures Education and Research

the administration of subsequent immunizations accord-
The primary resource for health education is textbooks.
ing to an appropriate schedule.
Examining the medical records of clients with specific
Quality Assurance disorders, however, provides a valuable supplement that
enhances learning and future problem solving. Client
To maintain a high level of care, hospitals and other health records also facilitate research. For example, some types
care agencies use medical records to promote quality assur- of clinical investigations are difficult to conduct because
ance, continuous quality improvement, or total quality improve- few participants are in a particular locale or test facilities
ment (an agency’s internal process for self-improvement are limited. Consequently stored, microfilmed, or comput-
to ensure that the level of care reflects or exceeds estab- erized medical records serve as an alternative resource
lished standards). One quality assurance method involves for scientific data.
investigating the documentation in a sample of medical Nevertheless, to protect confidentiality, only autho-
records. If the analyzed data indicate less-than-acceptable rized persons are allowed access to client records (see later
compliance with standards of care, the committee rec- discussion on protecting health information). Formal
ommends corrective measures and re-evaluates the out- permission must be obtained from the client, the health
comes later. agency’s administrator, or other authority whenever a
client’s record is used for a purpose other than treat-
Accreditation ment and record keeping.
The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) is a private association that has Legal Evidence
established criteria reflecting high standards for institu- The medical record is considered a legal document. Por-
tional health care. Representatives of JCAHO periodi- tions of it can be subpoenaed as evidence by the defense
cally inspect health care agencies to determine whether or prosecuting attorney to prove or disprove allegations
they demonstrate evidence of quality care. of malpractice. Therefore, written entries in medical
The documentation in randomly selected medical records must follow legally defensible criteria (Box 9-1).
records is just one component examined during an Each person who writes in the client’s medical record
accreditation visit. As reported by Sheila Abood (2002), is responsible for the information he or she records and
a representative of the American Nurses Association, can be summoned as a witness to testify concerning what
JCAHO requires the following nursing documentation has been written. Any writing that cannot be clearly read
evidence to justify accreditation: or that is vague, scribbled through, whited out, written
• Initial assessment and reassessments of physical, psy- over, or erased makes for a poor legal defense.
chological, social, environmental, and self-care; educa-
tion; and discharge planning
• Identification of nursing diagnoses or client needs Stop • Think + Respond BOX 9-1
• Planned nursing interventions or nursing standards of Discuss how the nurse could improve each of the follow-
care for meeting the client’s nursing care needs ing documentation samples:
• Nursing care provided 1. 01/11 0800 Ate well.
• Client’s response to interventions and outcomes of 2. 1400 Hygiene provided and ambulated.
care, including pain management, discharge planning 3. 1500 Depressed all day. S. Rogers
activities, and the client’s or significant other’s ability
to manage continuing care needs
If documentation is substandard, JCAHO may withdraw Client Access to Records
or withhold accreditation.
Historically clients were not allowed to see their medical
Reimbursement
records. Since the passing of federal legislation in 1996
The costs of most clients’ hospital and home care are known as the Health Insurance Portability and Account-
billed to third-party payers such as Medicare, Medicaid, ability Act (HIPAA), with further revisions in 2001 and
and private insurance companies. Auditors (inspectors 2002, however, clients have the right to see their own med-
who examine client records) survey medical records to ical and billing records, request changes to anything they
determine whether the care provided meets established feel is inaccurate, and be informed about who has seen
criteria for reimbursement. Undocumented, incomplete, their medical records (Medcom Inc., 2003). Consequently
or inconsistent documentation of care may result in a many institutions have written policies that describe the
denial of payment. guidelines by which clients can access their own medical
BOX 9-1 ● Criteria for Legally Defensible Charting
When making an entry on a client’s medical record, the nurse should ❙ Never scribble over entries or use correction fluid to obliterate what has
❙ Ensure that the client’s name appears on each page. been written.
❙ Never chart for someone else. ❙ Draw a single line through erroneous information so that it remains readable,
❙ Use specified color of ink and ballpoint pen, or enter data on a computer. add the date, initial, and then document the correct information.
❙ Date and time each entry as it is made. ❙ Record facts, not subjective interpretations.
❙ Chart promptly after providing care. ❙ Quote the client’s verbal comments.
❙ Make entries in chronologic order. ❙ Write “duplicate” or “recopied” on documentation that is not original; include the
❙ Identify documentation that is out of chronologic sequence with the date, time, initials, and reason for the duplication.
words “late entry.” ❙ Never imply criticism of another’s care.
❙ Write or print legibly. ❙ Document the circumstances for notifying a physician, the specific data reported,
❙ Use correct grammar and spelling. and the physician’s recommendations.
❙ Reflect the plan of care. ❙ Identify specific information provided when teaching a client and the evidence
❙ Describe the outcomes of care. that indicates the client has understood the instructions.
❙ Record relevant details. ❙ Leave no empty spaces between entries and signature.
❙ Use only approved abbreviations. ❙ Sign each entry by name and title.
records. Policies range from complete, unrestricted access

on the client’s written request to arranging access in the
METHODS OF CHARTING
presence of the client’s physician or hospital administrator.
Nurses must follow established agency policy. Nurses use various styles to record information within the
client’s record. Examples include narrative notes, SOAP
charting, focus charting, PIE charting, charting by excep-
Types of Client Records tion, and computerized charting.
Health records in most agencies contain similar informa-

tion. They generally are organized in one of two ways:
either a source-oriented or a problem-oriented format.
Narrative Charting
Source-Oriented Records Narrative charting(style of documentation generally used

in source-oriented records) involves writing information
The traditional type of client record is a source-oriented about the client and client care in chronologic order.
record (organized according to the source of documented There is no established format for narrative notations;
information). This type of record contains separate forms the content resembles a log or journal (Fig. 9-1).
on which physicians, nurses, dietitians, physical thera- Narrative charting is time-consuming to write and
pists, and other health care providers make written read. The caregiver must sort through the lengthy nota-
entries about their own specific activities in relation to tion for specific information that correlates the client’s
the client’s care. problems with care and progress. Depending on the
One of the criticisms of source-oriented records is skill of the person writing the entries, he or she may
that it is difficult to demonstrate a unified, cooperative omit pertinent documentation or include insignificant
approach for resolving the client’s problems among care- information.
givers. Frequently the fragmented documentation gives
the impression that each professional is working inde-
pendently of the others.
TABLE 9-2
COMMON COMPONENTS OF A
Problem-Oriented Records PROBLEM-ORIENTED RECORD
A second type of client record is the problem-oriented record COMPONENT DESCRIPTION
(organized according to the client’s health problems). In
contrast to source-oriented records that contain numer- Data base Contains initial health information
ous locations for information, problem-oriented records Problem list Consists of a numeric list of the
client’s health problems
contain four major components: the data base, the prob-
Plan of care Identifies methods for solving each
lem list, the plan of care, and progress notes (Table 9-2).
identified health problem
The information is compiled and arranged to emphasize
Progress notes Describes the client’s responses to
goal-directed care, to promote recording of pertinent infor- what has been done and revisions
mation, and to facilitate communication among health to the initial plan
care professionals.
FIGURE 9-1 • Sample of narrative charting. (Courtesy of Three Rivers Area Hospital, Three Rivers, MI.)
SOAP Charting Any variations in the SOAP format tend to focus the
documentation on pertinent information. SOAP chart-
SOAP charting (documentation style more likely to be used ing also helps to demonstrate interdisciplinary coopera-
in a problem-oriented record) acquired its name from the tion because everyone involved in the care of a client
four essential components included in a progress note: makes entries in the same location in the chart.
• S = subjective data
• O = objective data
• A = analysis of the data
Focus Charting
• P = plan for care
Focus charting (modified form of SOAP charting) uses the
Some agencies have expanded the SOAP format to word focus rather than problem because some believe that
SOAPIE or SOAPIER (I = interventions, E = evaluation, the word problem carries negative connotations. A focus
R = revision to the plan of care) (Table 9-3). can be the client’s current or changed behavior, significant
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 = Implementation 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 1000 mL per shift until
temperature is ≤ 100°F.
events in the client’s care, or even a NANDA nursing diag- Computerized Charting
nosis category. Instead of using the SOAP format to make
entries, focus charting follows a DAR model (D = data, Computerized charting (documenting client information
A = action, R = response) (Fig. 9-2). DAR notations tend electronically) is most useful for nurses when a terminal
to reflect the steps in the nursing process. is available at the point of care or bedside (Fig. 9-4). Hav-
ing a terminal at the nursing station is a less desirable
option because this removes the nurse from the source of
PIE Charting the data; however, this may be the only alternative when
there are limited computer modules available. Central-
PIE charting (method of recording the client’s progress ized terminals generally are connected to large informa-
under the headings of problem, intervention, and eval- tion systems that link departments in the institution
uation) is similar to the SOAPIE format. The PIE style (e.g., pharmacy, laboratory, admissions office, account-
prompts the nurse to address specific content in a charted ing); therefore, they are less specific for nursing use.
progress note. Although each computer system varies, computerized
When nurses use the PIE method, they document charting generally is done by touching the monitor
assessments on a separate form and give the client’s prob- screen with a finger or using an electronic device such as
lems a corresponding number. They use the numbers a light pen to select from a list of menu options. Some sys-
subsequently in the progress notes when referring to tems require entering data by using a keyboard, as a typ-
interventions and the client’s responses (Fig. 9-3).
Charting by Exception
Charting by exception is a documentation method in which

nurses chart only abnormal assessment findings or care
that deviates from the standard. Proponents of this effi-
cient method say that charting by exception provides
quick access to abnormal findings because it does not
describe normal and routine information.
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. FIGURE 9-3 • Sample of PIE charting.
PROTECTING HEALTH
INFORMATION
Congress enacted the first HIPAA legislation to protect

the rights of U.S. citizens to retain their health insurance
when changing employment. To do so required trans-
mitting health records from one insurance company to
another. Transmission of the information resulted in the
disclosure of personal health information to nonclinical
individuals, a process that, in essence, jeopardized the
individual’s right to privacy. Subsequently the original
HIPAA legislation was expanded in 2001 and 2002 to
enact further measures to protect the privacy of health
records and the security of that data. All health care agen-
cies have been mandated to comply with the newest
HIPAA regulations since 2003.
FIGURE 9-4 • Using a bedside computer for charting. (Copyright
B. Proud.) Privacy Standards
HIPAA regulations require health care agencies to safe-
guard written, spoken, and electronic health information
ist would do, or by using a combination of keyboarding in the following ways:
and touch-screen technology. Data entry by voice activa-
1. Submit a written notice to all clients identifying
tion is on the horizon. A single keystroke saves the infor-
the uses and disclosures of their health information
mation displayed on the monitor to the client’s record
such as to third parties for use in treatment or pay-
(Fig. 9-5).
ment for services.
Computerized charting has many advantages:
2. Obtain the client’s signature indicating that they
• The information is always legible. have been informed of the disclosure of information
• It automatically records the date and time of the and their right to learn who has seen their records.
documentation. The law also indicates that agencies must limit
• The abbreviations and terms are consistent with agency- released information from a health record to min-
approved lists. imum disclosure, or information necessary for the
• It eliminates trivia. immediate purpose only. In other words, it is inap-
• Omissions are fewer because the computer prompts propriate to release the entire health record when
the nurse to enter specific information. only portions or isolated pieces of information are
• It saves time because it eliminates delays in obtaining needed.
the chart. Health care agencies must obtain specific authorization
• It reduces overtime costs for uncompleted end-of-shift from the client to release information to family or friends,
charting. attorneys, and other uses such as research, fundraising,
• Electronic data require less storage space and are quickly and marketing. The client retains the right to withhold
retrievable. health information for any of these. There are some excep-
tions when health information can be revealed without
The major disadvantages include the initial expense
the client’s prior approval. Box 9-2 identifies examples of
of purchasing a computer system and training personnel
beneficial disclosures (exemptions when agencies can release
to use it. In addition, during a power failure or electronic
private health information without the client’s prior
malfunction, nurses must resort to written documenta-
authorization).
tion until the emergency backup access reactivates the
computer system.
Besides charting, other computer applications benefit Workplace Applications
nursing. Computers are being used to generate nursing
care plans, develop staffing patterns that meet the cur- In an effort to limit casual access to the identity of clients
rent unit census and client acuity levels, analyze assess- and health information, HIPAA legislation has created
ment data from monitoring equipment, call attention to several changes that affect the workplace. Some exam-
drugs that have been newly ordered or not administered, ples of these regulations include the following:
and alert the nurse to incompatibilities or contraindica- • The names of clients on charts can no longer be visible
tions to prescribed drugs. to the public.
FIGURE 9-5 • Sample of computerized charting.
BOX 9-2 ● Exemptions for Beneficial Disclosures • Clipboards must obscure identifiable names of clients
and private information about them.
❙ Reporting vital statistics (births and deaths) • Whiteboards must be free of information linking a
❙ Informing the Food and Drug Administration (FDA) of adverse reactions
to drugs or medical devices
client with a diagnosis, procedure, or treatment.
❙ Disclosing information for organ or tissue donation • Computer screens must be oriented away from public
❙ Notifying the public health department about communicable diseases view; flat screen monitors are recommended because
they are more difficult to read at obtuse angles.
• Conversations regarding clients must take place in pri- each chart form, the people responsible for charting, and
vate places where they cannot be overheard. This has the frequency for making entries on the record. Box 9-3
led to a trend of providing private rooms for all hospi- lists the general content of nursing documentation. Cur-
talized clients so personal health information cannot rent JCAHO standards require that the medical records of
be overheard by someone else sharing the room. clients cared for in acute care agencies (e.g., hospitals)
• Facsimile (fax) machines, filing cabinets, and medical must identify the steps of the nursing process (assessment,
records must be located in areas off-limit to the public. diagnosis, planning, implementation, and evaluation of
• A cover sheet and a statement indicating that faxed outcomes).
data contain confidential information must accompany Because consistency in charting is important for legal
electronically transmitted information. purposes, nurses follow the agency’s documentation pol-
• Light boxes for examining x-rays or other diagnostic icy. Deviating from the charting policy reduces a nurse’s
scans on which the client’s name appears must be in protection if the record is subpoenaed (see Chap. 3).
private areas.
• Documentation must be kept of people who have
accessed a client’s record.
Using Abbreviations
Data Security Abbreviations shorten the length of documentation and

the time required for this task. Brevity, however, must
Maintaining confidentiality is more difficult with comput- never take priority over completeness and accuracy. It is
erized data keeping. Because multiple people who enter better to write at length than to omit information or make
and retrieve information from computer files can access vague entries.
electronically stored data, it has been difficult to monitor Many abbreviations have common meanings; however,
use or to limit access to only authorized people within and nurses cannot assume that all abbreviations are inter-
outside a health care institution. preted the same universally. Some may have one meaning
As a result of HIPAA legislation, health agencies are in one locale or agency but mean something different or
adopting the following methods to ensure the protection be unfamiliar in another. To avoid confusion among
of electronic data: caregivers and misinterpretation if the chart is subpoe-
naed as legal evidence, each agency provides a written or
• Assigning an access number and password to autho-
computerized list of approved abbreviations and their
rized personnel who use a computer for health records.
meanings. When documenting, nurses must use only
These are kept secret and changed regularly.
those abbreviations on the agency’s approved list (avail-
• Using automatic save, use of a screen saver, or return to
able at: http://www.jcaho.com). Some common standard
a menu if data have been displayed for a specific period
• Issuing a plastic card or key that authorized personnel
use to retrieve information BOX 9-3 ● Content of Nursing Documentation
• Locking out client information except to those who
have been authorized through a fingerprint or voice- Nurses or those to whom they delegate client care are responsible for documenting
❙ Assessment data*
activation device
❙ Client care needs
• Blocking the type of information that personnel in var- ❙ Routine care such as hygiene measures
ious departments can retrieve. For example, laboratory ❙ Safety precautions that have been used
employees can obtain information from the medical ❙ Nursing interventions described in the care plan
orders, but they cannot view information in the client’s ❙ Medical treatments prescribed by the physician
personal history. ❙ Outcomes of treatment and nursing interventions

❙ Client activity
• Storing the time and location from which the client’s
❙ Medication administration
record is accessed in case there is an allegation concern- ❙ Percentage of food consumed at each meal
ing a breech in confidentiality ❙ Visits or consults by physicians or other health professionals
• Encrypting any client information transmitted through ❙ Reasons for contacting the physician and the outcome of the communication
the Internet ❙ Transportation to other departments, like the radiography department, for
specialized care or diagnostic tests, and time of return
❙ Client teaching and discharge instructions
❙ Referrals to other health care agencies
DOCUMENTING INFORMATION
*In acute care settings, JCAHO requires a registered nurse to document
the admission nursing assessment findings and develop the initial plan
Each agency sets its own documentation policies. In addi- of care. The RN may delegate some aspects of the initial data collection
tion to identifying the method for charting, such policies to the practical or vocational nurse.
generally indicate the type of information recorded on
abbreviations are listed in Table 9-4; more can be found The use of military time avoids confusion because no
in Appendix A. number is ever duplicated, and the labels a.m., p.m.,
To avoid and reduce medical errors that relate to abbre- midnight, and noon are not needed. Military time begins
viations, symbols, and acronyms, JCAHO has issued a at midnight (2400 or 0000). One minute after midnight
“Do Not Use” list, which can be found at the following is 0001. A zero is placed before the hours of one through
website: http://www.jcaho.com. There may be future nine in the morning; for example, 0700 refers to 7 a.m.
deletions as JCAHO monitors and evaluates compliance. and is stated as “oh seven hundred.” After noon, 12 is
added to each hour; therefore, 1 p.m. is 1300. Minutes
Indicating Documentation Time are given as 1 to 59. See Skill 9-1.
The nurse dates and times each entry in the record. Some
hospitals use traditional time (time based on two 12-hour Stop • Think + Respond BOX 9-2
revolutions on a clock), which is identified with the hour Convert the following from traditional time to military time:
and minute, followed by a.m. or p.m. Other agencies pre- 1. 6:30 p.m.
fer military time (time based on a 24-hour clock), which 2. Midnight
uses a different four-digit number for each hour and 3. 8:45 a.m.
minute of the day (Fig. 9-6 and Table 9-5). The first two 4. 9:05 p.m.
digits indicate the hour within the 24-hour period; the 5. 4:15 a.m.
last two digits indicate the minutes.
TABLE 9-4 COMMONLY USED ABBREVIATIONS

ABBREVIATION MEANING ABBREVIATION MEANING
abd. abdomen O2 oxygen

a.c. before meals OB obstetrics
ad lib as desired OOB out of bed
AMA against medical advice OR operating room
amt. amount OU both eyes
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
H2O water s̄ without
I&O intake and output ss one half
IM intramuscular SS soap suds
IV intravenous stat immediately
kg kilogram t.i.d. three times a day
L, Lt, or L left TPR temperature, pulse, respirations
L liter UA urinalysis
lb pound via by way of
NKA no known allergies WC wheelchair
NPO nothing by mouth WNL within normal limits
NSS normal saline solution Wt. weight
2400
Nursing Care Plans
2300 1300 A nursing care plan is a written list of the client’s problems,
1200 goals, and nursing orders for client care. It promotes the
1100 0100 prevention, reduction, or resolution of health problems.
The principles and style for writing a diagnostic statement,
2200 1400
goals, and nursing orders are described in Chapter 2.
1000 0200 Present JCAHO standards require that the record show
evidence of a plan of care. Many agencies require a sep-
arate nursing care plan as a means of demonstrating com-
0900
AM
0300
pliance. Nurses revise the plan of care as the client’s
2100 1500
condition changes.
Most nursing care plans are handwritten on a form
that the agency develops (Fig. 9-7). Some agencies use
0800 0400 preprinted care plans, computer-generated care plans,
2000 1600 standards of care, or clinical pathways or cite the plan of
0700 0500 care within progress notes.
0600 Because the nursing care plan is part of the permanent
record and thus is a legal document, it is compiled and
1900 1700
maintained following documentation principles. All
1800 entries and revisions are dated. The written components
PM are clear, concise, and legible. The information is never
FIGURE 9-6 • Military time is based on a 24-hour numbering system. obliterated; only approved abbreviations are used. Each
addition or revision to the plan is signed.
Nursing Kardex
COMMUNICATION FOR CONTINUITY The nursing Kardex is a quick reference for current infor-
AND COLLABORATION mation about the client and his or her care (Fig. 9-8). The
Kardex forms for all clients are kept in a folder that allows
caregivers to flip from one to another. The Kardex has the
Although the record serves as an ongoing source of infor- following uses:
mation about the client’s status, nurses use other methods
• Locate clients by name and room number
of communication to promote continuity of care and col-
• Identify each client’s physician and medical diagnosis
laboration among the health personnel involved in the • Serve as a reference for a change of shift report
client’s care. These methods are in written or verbal form. • Serve as a guide for making nursing assignments
• Provide a rapid resource for current medical orders on
each client
Written Forms of Communication • Specify the client’s code or DNR (do not resuscitate)
status
Examples of written forms of communication include • Check quickly on a client’s diet
the nursing care plan, the nursing Kardex, checklists, • Alert nursing personnel to a client’s scheduled tests or
and flow sheets. test preparations
• Inform staff of a client’s current level of activity
• Identify comfort or assistive measures a client may
require
TABLE 9-5 MILITARY TIME CONVERSIONS • Provide a tool for estimating the personnel-to-client
ratio for a nursing unit
TRADITIONAL TIME MILITARY TIME
The information in the Kardex changes frequently,
Midnight 0000 or 2400
sometimes several times in one day. The Kardex form is
12:01 a.m. 0001 not a part of the permanent record. Therefore, nurses
1:30 a.m. 0130 can write information in pencil and erase.
Noon 1200
1:00 p.m. 1300 Checklists
3:15 p.m. 1515
7:59 p.m. 1959 A checklist is a form of documentation in which the nurse
10:47 p.m. 2247 indicates with a check mark or initials the performance of
routine care. It is an alternative to writing a narrative note.
FIGURE 9-7 • Sample nursing care plan.
FIGURE 9-8 • Sample of a Kardex form.

(Courtesy of Fairview Medical Care Facility,
Centreville, MI.)
Nurses use checklists primarily to avoid documenting

types of care that are regularly repeated such as bathing
and mouth care. This charting technique is especially help-
ful when the care is similar each day and the client’s con-
dition does not differ much for extended periods.
Flow Sheets
A flow sheet is a form of documentation with sections for
recording frequently repeated assessment data. It enables
nurses to evaluate trends because similar information is
located on one form. Some flow sheets provide room for
recording numbers or brief descriptions.
Interpersonal Communication
In addition to using written resources (e.g., the medical
record) to exchange information, communication also
takes place during personal interactions among health FIGURE 9-10 • Nurses begin their shift by receiving a report on their
professionals (Fig. 9-9). Some examples are as follows: clients. (Copyright Sharon Gynup.)
• Change of shift reports

• Client assignments • Take notes.
• Team conferences • Clarify unclear information.
• Rounds • Ask questions about pertinent information that may
• Telephone calls have been omitted.
Some agencies tape-record the report, which saves time
Change of Shift Report because there are no interruptions or digressions. In addi-
A change of shift report is a discussion between a nursing tion, nurses can replay portions of the tape if informa-
spokesperson from the shift that is ending and personnel tion needs to be repeated. A taped report, however, does
coming on duty (Fig. 9-10). It includes a summary of each not allow direct questions, elaboration, or clarification
client’s condition and current status of care (Box 9-4). with the person giving the report.
To maximize the efficiency of change of shift reports,
Client Care Assignments
nurses should do the following:
• Be prompt so that the report can start and end on time. Client care assignments are made at the beginning of
• Come prepared with a pen and paper or clipboard. each shift. Assignments are posted, discussed with team
• Avoid socializing during reporting sessions. members, or written on a worksheet (Fig. 9-11). Each
BOX 9-4 ● Change of Shift Report
A change of shift report usually includes:

❙ Name of client, age, and room number
❙ Name of physician
❙ Medical diagnosis or surgical procedure and date
❙ Range in vital signs
❙ Abnormal assessment data
❙ Characteristics of pain, medication, amount, time last administered,
and outcome achieved
❙ Type of diet and percentage consumed at each meal
❙ Special body position and level of activity, if applicable
❙ Scheduled diagnostic tests
❙ Test results, including those performed by the nurse, such as blood
glucose levels
❙ Changes in medical orders including newly prescribed drugs
❙ Intake and output totals
❙ Type and rate of infusing intravenous fluid
❙ Amount of intravenous fluid that remains
❙ Settings on electronic equipment such as amount of suction
❙ Condition of incision and dressing, if applicable
FIGURE 9-9 • Staff nurses discuss client care with a student nurse. ❙ Color and amount of wound or suction drainage
(Copyright Sharon Gynup.)

122
U N I T 3 ● Fostering Communication
FIGURE 9-11 • Sample of a nursing assignment sheet.

assignment identifies the clients for whom the staff person family members or friends who may be visiting to have
is responsible and describes their care. Meals and break access to their health information.
times also may be scheduled as well as special tasks such
as checking and restocking supplies. Telephone
Nurses use the telephone to exchange information when
Team Conferences it is difficult for people to get together or when they must
Conferences commonly are used to exchange information. communicate information quickly. When using the tele-
Topics generally include client care problems, personnel phone, the nurse does the following:
conflicts, new equipment or treatment methods, and • Answers as promptly as possible
changes in policies or procedures. Team conferences often • Speaks in a normal tone of voice
include the nursing staff, staff from other departments • Identifies himself or herself by name, title, and nurs-
involved in client care, physicians, social workers, person- ing unit
nel from community agencies, and, in some cases, clients • Obtains or states the reason for the call
and their significant others. Usually one person organizes • Discretely identifies the client being discussed to avoid
and directs the conference. Responsibilities for certain being publicly overheard
outcomes that result from the team conference may be del- • Spells the client’s name if there is any chance of
egated to various staff members who attend the meeting. confusion
• Converses in a courteous and business-like manner
Client Rounds • Repeats information to ensure it has been heard
Rounds (visit to clients on an individual basis or as a accurately
group) are used as a means of learning firsthand about When notifying a physician about a change in a client’s
clients. The client is a witness to and often an active par- condition, the nurse documents in the client’s record the
ticipant in the interaction (Fig. 9-12). information reported and the instructions received. If the
Some nurses use walking rounds as a method of giving nurse believes that the physician has not responded in a
a change of shift report. Giving the report in the client’s safe manner to the information given, he or she notifies the
presence provides oncoming staff with an opportunity to nursing supervisor or the head of the medical department.
survey the client’s condition and to determine the status
of equipment used in his or her care. It also tends to boost
the client’s confidence and security in the transition of CRITICAL THINKING E X E R C I S E
care. Since the passage of HIPAA regulations, however,
1. Explain the possible consequences if a nurse’s documen-
agencies avoid this type of communication if another tation contains illegible writing, unapproved abbrevia-
client shares the room or if the client has not authorized tions, and misspelled words. How would you help the
nurse improve his or her documentation?
1. If a charge nurse does all of the following, which practice
could jeopardize the health agency’s accreditation?
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 documentation
practices. Which one places the writer in the most legal
jeopardy?
1. The writer squeezes information into a line written
hours earlier.
2. The writer misspells several words while complet-
ing documentation.
3. The writer uses blue rather than black ink as the
agency specifies.
FIGURE 9-12 • Rounds help acquaint oncoming staff with the client. 4. The writer signs the documentation but omits his
(Copyright Sharon Gynup.) or her title.
Skill 9-1 • MAKING ENTRIES IN A CLIENT’S RECORD
Assessment
Review the agency’s policy for the type of charting it uses. Some agencies require personnel to use a specific style
(e.g., SOAP charting, narrative charting, PIE charting)
for documentation.
Locate the agency’s list of approved abbreviations. Abbreviations used must be compatible with those that
have been approved for legally defensible reasons.
Determine the paper form that is appropriate to use for Data obtained initially from the client is entered on the
documenting the information or locate the file within admission form; periodic additions about the client’s
an electronic record used for nursing documentation via condition and care are entered on a form commonly
a computer. 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 If a sheet of paper becomes separated from the chart,
form or computer file. proper 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 The potential for inaccuracies or omissions increases when
or at least every 1 to 2 hours. documentation is delayed.
Use a pen or keyboard to make entries; use the color of Ink is permanent. Black ink photocopies better than other
ink indicated by agency policy. colors.
Implementation
Record the date and time. Information is recorded in chronologic order. The time of
documentation is when the notation is written. Legal
issues often involve the timing of events.
Write, print, or type information so it can be read easily. The entry loses its value for exchanging information if it
Take care that keyboarding is accurate when a is unreadable. Illegible entries become questionable in a
computer is used. 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 It is understood that all the entries refer to the person
abbreviation for “patient.” identified on the chart form.
Use only agency-approved abbreviations and symbols. Using approved abbreviations promotes consistent
interpretation.
Document information clearly and accurately without any The chart is a record of facts, not opinions.
subjective 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
reasonable knowledge.
Never use ditto marks. Even if information is repetitious, it must be documented
separately.
Identify actual or approximate sizes when describing Nonspecific measurements are subject to wide interpretation
assessment data rather than using relative descriptions and are therefore less accurate and informative.
such as large, moderate, or small.
(continued)
MAKING ENTRIES IN A CLIENT’S RECORD (Continued)
Record adverse reactions; include the measures used to Documentation may be necessary to demonstrate that the
manage them. nurse acted reasonably and that the care was not
substandard.
Identify the specific information that is taught and the Ensures continuity in preparing the client for discharge.
evidence of the client’s learning.
Fill all the space on each line of the form; draw a line Filling space reduces the possibility that someone else will
through any blank space on an unfilled line. add information to the current documentation.
Never chart nursing activities before they have been Making early entries can cause legal problems especially if
performed. 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 Correlating time with actual events promotes logic and
(documentation of information that occurred earlier but order when evaluating the client’s progress.
was accidentally omitted); write “late entry for. . . . .”
identifying the date and time to which the
documentation refers.
Draw a line through a mistake rather than scribbling Corrections are done in such a way that all words are
through or in any other way obscuring the original readable. Obliterated words can cast suspicion that the
words. record was tampered with to conceal damaging
information.
Put the word error followed by a date and initials next to the A jury seeing the word error without any explanation
entry and immediately enter the corrected information. might assume that the nurse made an error in care
Some agencies specify that the nurse must indicate the rather than documentation.
nature of the error (e.g., “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 Logging off returns the computer to a home or menu page,
client record. which 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 viewing 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
UNIT 3

for Chapters 7, 8, and 9
in parentheses.
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, plan)
6. charting follows a data, action, response (DAR) model to reflect the steps in the nursing
process. (Exception, Flow, Focus)

false statements.
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 discussion between a nurse from a shift that is ending and personnel coming
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
126
U N I T 3 ● End of Unit Exercises for Chapters 7, 8, and 9 127
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
Activity D: 1. Match the terms in Column A with their explanations in Column B.

Column A Column B
1. Psychomotor domain A. The principle of teaching adult learners
2. Androgogy B. A style of processing that focuses on learning by doing
3. Gerogogy C. 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 enact 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 criteria
given below.
Informal Teaching Formal Teaching
Definition
Requirements
Disadvantages
2. Differentiate between source-oriented records and problem-oriented records based on the criteria given below.
Source-Oriented Records Problem-Oriented Records
Definition
Components
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?
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 in the boxes below the correct sequence of the progressive stages of
learning:
1. Applying new learning independently
2. Recalling and describing information to others
3. Recognizing what is being taught

4. Explaining and applying received 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?

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?
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?
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 of the following methods should the 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 because she believes that the fall could have been avoided if she had somebody to care for her at home.
Which of the following responses by the nurse is most appropriate when caring for this client?
a. Ask the client why she is staying alone.
b. Allow the client to express her emotions.
c. Ask the client to stop complaining.
d. Tell the client to stay calm and take her 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
provided, 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 fluids orally for 4 hours before scheduled surgery.
Which of the following abbreviations should the nurse note on the client’s chart?
a. AMA
b. NKA
c. NPO
d. NSS
UNIT 4
Performing Basic
Client Care
10 Asepsis
11 Admission, Discharge, Transfer, and Referrals
12 Vital Signs
13 Physical Assessment
14 Special Examinations and Tests
10
Chapter
Asepsis
LEARNING OBJECTIVES
● Describe microorganisms.
● Name eight specific types of microorganisms.
● Differentiate between nonpathogens and pathogens, resident and transient microorganisms,
WORDS TO KNOW and aerobic and anaerobic microorganisms.
● Give two examples of the ways some microorganisms have adapted for their survival.
aerobic bacteria ● Name the six components of the chain of infection.
anaerobic bacteria ● Cite examples of biologic defense mechanisms.
antimicrobial agents ● Define nosocomial infection.
antiseptics ● Discuss the concept of asepsis.
asepsis ● Differentiate between medical and surgical asepsis.
aseptic techniques ● Identify at least three principles of medical asepsis.
biologic defense ● List five examples of medical aseptic practices.
mechanisms ● Name at least three techniques for sterilizing equipment.
chain of infection ● Identify at least three principles of surgical asepsis.
communicable diseases ● List at least three nursing activities that require application of the principles of surgical asepsis.
community-acquired
infections
concurrent disinfection
contagious diseases
disinfectants PREVENTING infections is one of the most important priorities in nursing. The most
exit route effective method is handwashing, an essential nursing activity that must be per-
hand antisepsis formed repeatedly when caring for clients. This chapter discusses how microorgan-
handwashing isms survive and how to use aseptic techniques, or measures that reduce or eliminate
medical asepsis
microorganisms
microorganisms.
mode of transmission
nonpathogens
normal flora
nosocomial infections MICROORGANISMS
opportunistic infections
pathogens
port of entry Microorganisms, living animals or plants visible only with a microscope, are commonly
reservoir called germs. What they lack in size, they make up for in numbers. Microorganisms
resident microorganisms are everywhere: in the air, soil, and water, and on and within virtually everything
spore
sterile field
and everyone.
sterile technique Once microorganisms invade, one of three events occurs: the body’s immune
sterilization defense mechanisms eliminate them, they reside within the body without causing
surgical asepsis disease, or they cause an infection or infectious disease. Factors that influence
surgical scrub
whether an infection develops include the type and number of microorganisms,
susceptible host
terminal disinfection the characteristics of the microorganism (such as its virulence), and the person’s
transient microorganisms state of health.
viral load
virulence
134
C H A P T E R 1 0 ● Asepsis 135
Types of Microorganisms
Microorganisms are divided into two main groups: non-

pathogens or normal flora (harmless, beneficial micro-
organisms) and pathogens (microorganisms that cause
illness).
Nonpathogens live abundantly and perpetually on and A B C
in the human body, which is their host. They are found
FIGURE 10-1 • Classification of bacteria according to shape: cocci
in structures exposed to the external environment: skin, (A), bacilli (B), spirochetes (C).
nose, mouth, throat, lower urethra, and intestine. They
have adapted to human defense mechanisms like acidic
sweat and oil secretions on the skin. Most exist in the Viruses
large intestine, having been introduced from food or sub-
Viruses, the smallest microorganisms known to cause
stances on fingers, pencils, tableware, and other items
infectious diseases, are visible only with an electron micro-
placed in the mouth. Nonpathogens assume one of two
scope. They are filterable, meaning they pass through very
relationships with their human host: mutually beneficial
small barriers. Viruses are unique because they do not pos-
or neither harming nor helping the host. They inhibit
sess all the genetic information necessary to reproduce;
pathogenic growth and reproduction by competing for
they require metabolic and reproductive materials from
nutrients, vying for space, or producing substances that
other living species. Some can remain dormant in a human
interfere with the pathogens. They thus ensure a hos-
and reactivate sporadically, causing recurrence of an infec-
pitable habitat for themselves.
tious disorder. An example is the herpes simplex virus,
Pathogens have high potential for causing infectious
which can cause cold sores (fever blisters) to flare up years
communicable diseases (diseases that can be transmitted to
after an initial infection.
other people), also called contagious diseases and community-
Some viral infections, such as the common cold, are
acquired infections. Some examples of communicable dis-
minor and self-limited—that is, they terminate with or
eases are measles, streptococcal sore throat, sexually
without medical treatment. Others, such as rabies, polio-
transmitted infections, and tuberculosis (TB). Although
myelitis, hepatitis, and AIDS, are more serious or fatal.
pathogenic infections can result in death, most lead only
to temporary illness. They do so in various ways. They
Fungi
may become established, grow, and proliferate when num-
bers of nonpathogens are reduced, such as with use of Fungi include yeasts and molds. Only a few types of fungi
broad-spectrum antibiotics. Pathogens may cause infec- produce infectious diseases in humans. The three types
tions when the host is immunosuppressed from AIDS, of fungal (mycotic) infections are superficial, intermedi-
cancer chemotherapy, or steroid drug therapy. In addi- ate, and systemic. Superficial fungal infections affect
tion, their structures and functions may promote the viru- the skin, mucous membranes, hair, and nails. Examples
lence (extent of dangerousness) of pathogens. Some have include tinea corporis (ringworm), tinea pedis (athlete’s
fimbriae, tiny hairs used to attach themselves to the host’s foot), and candidiasis (a vaginal yeast infection). Inter-
tissue to avoid expulsion. Fimbriae prevent pathogens that mediate fungal infections affect subcutaneous tissues
reach the bladder from being eliminated during urination. such as fungal granuloma (an inflammatory lesion under
Some pathogens use flagella, long tails that promote motil- the skin). Systemic fungi infect deep tissues and organs
ity to reach a site less hostile to survival. Others release such as histoplasmosis in the lungs.
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, cannot survive outside another living species. Conse-
and prions. quently an intermediate life form, such as fleas, ticks,
lice, or mites, transmits rickettsial diseases to humans.
Bacteria For example, tiny deer ticks transmit Lyme disease, a
Bacteria are single-celled microorganisms. They appear problem found where people live, work, or enjoy activ-
in various shapes: round (cocci), rod shaped (bacilli), ities in wooded areas.
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 Protozoans are single-celled animals classified according
life forms have become. to their ability to move. Some use ameboid motion, by
136 U N I T 4 ● Performing Basic Client Care
which they extend their cell walls and their intracellular BOX 10-1 ● Causes of Antibiotic Drug Resistance
contents flow forward. Others move by cilia, hairlike pro-
jections, or flagella, whiplike appendages. Some cannot ❙ Prescribing antibiotics for minor or self-limited bacterial infections
move independently at all. ❙ Administering antibiotics prophylactically (for prevention) in the absence of
an infection
Mycoplasmas ❙ Failing to take the full course of antibiotic therapy
❙ Taking someone else’s prescribed antibiotic without knowing whether it is
Mycoplasmas lack a cell wall; they are referred to as pleo- effective for one’s illness or symptoms
morphic because they assume various shapes. Mycoplas- ❙ Prescribing antibiotics for viral infections (antibiotics are ineffective for treating
mas are similar, but not related, to bacteria. Primarily they infections caused by viruses)
infect the surface linings of the respiratory, genitourinary, ❙ Dispersing antibiotic solutions into the environment:
❙ depositing partially empty IV bags containing antibiotic drugs in waste
and gastrointestinal tracts.
containers
❙ releasing droplets while purging IV tubing attached to secondary bags of
Helminths
antibiotic solution
Helminths are infectious worms, some of which are ❙ expelling air from syringes before injecting antibiotics
microscopic. They are classified into three major groups: ❙ Administering antibiotics to livestock, leaving traces of drug residue that
humans consume after their slaughter
nematodes (roundworms), cestodes (tapeworms), and ❙ Spreading nosocomial pathogens via unwashed or poorly washed hands
trematodes (flukes). Some helminths enter the body in
the egg stage, whereas others spend the larval stage in
an intermediate life form before finding their way into
humans. Helminths mate and reproduce after they invade All they need is a favorable environment in which to sur-
a species; they are then excreted, and the cycle begins vive. Conditions that promote survival include warmth,
again. darkness, oxygen, water, and nourishment. Humans offer
all these and so are optimal hosts for supporting the growth
Prions and reproduction of microorganisms.
Until recently, it was believed that all infectious agents Many pathogens have mutated to adapt to hostile envi-
contain nucleic acid—either deoxyribonucleic acid (DNA) ronments and unfavorable living conditions. Such adapt-
or ribonucleic acid (RNA). The idea of an atypical infec- ability has ensured that they continue to pose a threat to
tious agent (initially referred to as rogue proteins) was humans. One example of biologic adaptation is the ability
proposed in 1967. Dr. Stanley Prusnier won a Nobel Prize of some microorganisms to form spores. A spore is a tem-
in 1997 for his discovery of such proteins, called prions. porarily inactive microbial life form that can resist heat
A prion is a protein containing no nucleic acid. and destructive chemicals and survive without moisture.
Research suggests that a normal prion, which is present Consequently spores are more difficult to destroy than
in brain cells, protects against dementia (diminished men- their more biologically active counterparts. When condi-
tal function). When a prion mutates, however, it can tions are favorable, spores can reactivate and reproduce.
become an infectious agent that alters other normal prion Another example of adaptation is the development
proteins into similar mutant copies. The mutants, which of antibiotic-resistant bacterial strains of Staphylococ-
can result either from genetic predisposition or transmis- cus aureus, Enterococcus faecalis and faecium, and Strep-
sion between same or similar infected animal species, tococcus pneumoniae. Such strains no longer respond to
cause transmissible spongiform encephalopathies (TSEs). drugs that once were effective against them (Box 10-1).
These are so named because they cause the brain to Researchers speculate that resistant species can transmit
become spongy (i.e., full of holes). As a result, brain tissue their resistant genes to totally different microbial species
withers, leading to uncoordinated movements. Examples (Andersson, 2004; National Institute of Allergy and Infec-
of TSEs include bovine spongiform encephalopathy (mad tious Diseases, 2006).
cow disease), scrapie in sheep, and Creutzfeldt-Jakob dis-
ease (CJD) in humans. Researchers are currently trying
to determine whether prions are the cause of neurologic
CHAIN OF INFECTION
disorders such as Alzheimer’s disease, Parkinson’s dis-
ease, and Huntington’s disease; if people with these By interfering with the conditions that perpetuate the
disorders lack prions; or if prions in people with these transmission of microorganisms, humans can avoid
problems are ineffective. acquiring infectious diseases. The six essential compo-
nents of the chain of infection (sequence that enables the
spread of disease-producing microorganisms) must be in
Survival of Microorganisms
place if pathogens are to be transmitted from one loca-
tion or person to another:
Each species of microorganism is unique, but all micro-
organisms share one characteristic: although infinitesi- 1. An infectious agent
mally small, they are powerful enough to cause disease. 2. A reservoir for growth and reproduction
uncooked and unrefrigerated food. They are present

in intestinal excreta and the earth’s organic material.
Infectious Goldmann and colleagues (1996) used the term “silent
Agent reservoir” to describe asymptomatic clients who harbor
pathogens, especially those resistant to antimicrobial
agents—the most dangerous type of all.
Susceptible Reservoir
Host
Exit Route
INFECTION The exit route is how microorganisms escape from their
original reservoir and move about. When present in or on
Port
of Entry humans, they are displaced by handling or touching
Exit objects or whenever blood, body fluids, secretions, and
Route
excretions are released. In the environment, factors
Mode such as flooding and soil erosion provide mechanisms
of for escape.
Transmission
Mode of Transmission
FIGURE 10-2 • Chain of infection.
A mode of transmission is how infectious microorganisms
move to another location. This component is important
3. An exit route from the reservoir to the microorganism’s survival because most micro-
4. A mode of transmission organisms cannot travel independently. Microorganisms
5. A port of entry are transmitted by one of five routes: contact, droplet,
6. A susceptible host (Fig. 10-2) airborne, vehicle, and vector (Table 10-1).
Infectious Agents Port of Entry
Some microorganisms are less dangerous than others. Just The port of entry is where microorganisms find their way
as some animal species coexist symbiotically (for mutual onto or into a new host, facilitating their relocation. One
benefit), some normal flora help to maintain healthy func- of the most common ports of entry is an opening in the
tioning. For example, intestinal bacteria help produce skin or mucous membranes. Microorganisms also can
vitamin K, which, in turn, helps control bleeding. Vaginal be inhaled, swallowed, introduced into the blood, or trans-
bacteria create an acid environment hostile to the growth ferred into body tissues or cavities through unclean hands
of pathogens. or contaminated medical equipment.
Unless the supporting host becomes weakened, nor- Although microorganisms exist in reservoirs every-
mal flora remain controlled. If the host’s defenses are where, biologic defense mechanisms (anatomic or phys-
weakened, however, even benign microorganisms can iologic methods that stop microorganisms from causing
cause opportunistic infections (infectious disorders among an infectious disorder) often prevent them from pro-
people with compromised health). More commonly, how- ducing infection. The two types of biologic defense mech-
ever, infections result from pathogens that by their very anisms are mechanical and chemical. Mechanical defense
nature produce illness after invading body tissues and mechanisms are physical barriers that prevent micro-
organs. organisms from entering the body or expel them before
they multiply. Examples include intact skin and mucous
membranes; reflexes such as sneezing and coughing;
Reservoir and infection-fighting blood cells called phagocytes or
macrophages. Chemical defense mechanisms destroy or
A reservoir is a place where microbes grow and reproduce, incapacitate microorganisms through natural biologic
providing a haven for their survival. Microorganisms substances. For example, lysozyme, an enzyme found in
thrive in reservoirs such as tissue within the superficial tears and other secretions, can dissolve the cell wall of
crevices of the skin, on shafts of hair, in open wounds, some microorganisms. Gastric acid creates an inhospitable
in the blood, inside the lower digestive tract, and in nasal microbial environment. Antibodies, complex proteins also
passages. Some grow abundantly in stagnant water and called immunoglobulins, form when macrophages con-
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 Inhalation of droplets released during sneezing,
who is within a radius of 3 feet coughing, or talking
Airborne transmission Movement of microorganisms attached to evapo- Inhalation of spores
rated water droplets or dust particles that have
been suspended and carried over distances
greater than 3 feet
Vehicle transmission Transfer of microorganisms present on or in Consumption of water contaminated with
contaminated items such as food, water, microorganisms
medications, devices, and equipment
Vector transmission Transfer of microorganisms from an infected Diseases spread by mosquitoes, fleas, ticks, or rats
animal carrier
sume microorganisms and display their distinct cellular

markers. Stop • Think + Respond BOX 10-1
Use the chain of infection to trace the transmission of a
common cold from one person to another.
Susceptible Host
Humans become susceptible to infections when their

defense mechanisms are diminished or impaired. A suscep- ASEPSIS
tible host, the last link in the chain of infection, is one whose
biologic defense mechanisms are weakened in some way Health care institutions are teeming reservoirs of micro-
(Box 10-2). Ill clients are prime targets for infectious organisms because of the sheer numbers of sick people
microorganisms because their health is already compro- there. Add to this the number of caretakers, equipment,
mised. Particularly susceptible clients include those who and treatment devices in constant use, and it is easy to
• Are burn victims understand why infection control is so important. Nurses
• Have suffered major trauma must understand and practice methods to prevent noso-
comial infections (infections acquired while a person is
• Require invasive procedures such as endoscopy (see
Chap. 14) receiving care in a health care agency).
Asepsis means those practices that decrease or elimi-
• Need indwelling equipment such as a urinary catheter
nate infectious agents, their reservoirs, and vehicles
• Receive implantable devices such as intravenous
for transmission. It is the major method for controlling
catheters
infection. Health care professionals use medical and sur-
• Are given antibiotics inappropriately, which promotes
gical asepsis to accomplish this goal.
microbial resistance
• Are receiving anticancer drugs and anti-inflammatory
drugs such as corticosteroids that suppress the immune Medical Asepsis
system
• Are infected with HIV Medical asepsis means those practices that confine or
reduce the numbers of microorganisms. Also called clean
technique, it involves measures that interfere with the
BOX 10-2 ● Factors Affecting Susceptibility chain of infection in various ways. The following princi-
to Infections ples underlie medical asepsis:
❙ Inadequate nutrition ❙ Prematurity
• Microorganisms exist everywhere except on sterilized
❙ Poor hygiene practices ❙ Advanced age
❙ Suppressed immune system ❙ Compromised skin integrity equipment.
❙ Chronic illness ❙ Weakened cough reflex • Frequent handwashing and maintaining intact skin
❙ Insufficient white blood cells ❙ Diminished blood circulation are the best methods for reducing the transmission of
microorganisms.
• Blood, body fluids, cells, and tissues are considered ples. Disinfectants rarely are applied to the skin because
major reservoirs of microorganisms. they are so strong. Rather, they are used to kill and remove
• Personal protective equipment such as gloves, gowns, microorganisms from equipment, walls, and floors.
masks, goggles, and hair and shoe covers serves as a
barrier to microbial transmission. ANTI-INFECTIVE DRUGS. The two groups of drugs used
• A clean environment reduces microorganisms. most often to combat infections are antibacterials and
• Certain areas—the floor, toilets, and insides of sinks— antivirals.
are more contaminated than others. Cleaning should The chemical actions of antibacterials, which consist
be done from cleaner to dirtier areas. of antibiotics and sulfonamides, alter the metabolic pro-
cesses of bacteria but not viruses. They damage or destroy
Examples of medical aseptic practices include using bacterial cell walls or the mechanisms that bacteria need
antimicrobial agents, performing hand hygiene, wear- to grow. They also, however, destroy normal bacterial
ing hospital garments, confining and containing soiled flora. Before the advent of antibacterial therapy, wound
materials appropriately, and keeping the environment as infections, dysentery, and many contagious diseases cut
clean as possible. Measures used to control the trans- short life expectancy. Some believe humans will return
mission of infectious microorganisms are discussed in to the days of epidemics, plagues, and pestilence if anti-
more detail in Chapter 22. bacterial agents can no longer control microorganisms.
Antiviral agents were developed more recently, most
Using Antimicrobial Agents likely in response to the rising incidence of blood-borne
Antimicrobial agents are chemicals that destroy or suppress viral diseases such as AIDS. Antivirals do not destroy the
the growth of infectious microorganisms (Table 10-2). infecting viruses; rather, they control viral replication
Some antimicrobial agents are used to clean equipment, (copying) or release from the infected cells. The virus
surfaces, and inanimate objects. Others are applied directly remains alive and still can cause reactivation of the ill-
to the skin or administered internally. Examples are anti- ness. The goal of antiviral therapy is to limit the viral load
septics, disinfectants, and anti-infective drugs. (numbers of viral copies).
ANTISEPTICS. Antiseptics, also known as bacteriostatic Handwashing

agents, inhibit the growth of, but do not kill, microorgan- Handwashing is an aseptic practice that involves scrubbing
isms. An example is alcohol. Antiseptics generally are the hands with soap, water, and friction. This process
applied to the skin or mucous membranes. Some also are mechanically removes dirt and organic substances. Plain
used as cleansing agents. soap or detergents do not have bactericidal activity. Hand-
washing removes resident microorganisms (generally non-
DISINFECTANTS. Disinfectants, also called germicides and pathogens constantly present on the skin) and transient
bactericides, destroy active microorganisms but not spores. microorganisms (pathogens picked up during brief contact
Phenol, household bleach, and formaldehyde are exam- with contaminated reservoirs).
TABLE 10-2 ANTIMICROBIAL AGENTS

TYPE MECHANISM EXAMPLE USE
Soap Lowers the surface tension of oil on the skin, which holds Dial, Safeguard Hygiene
microorganisms; facilitates removal during rinsing
Detergent Acts as soap, except detergents do not form Dreft, Tide Sanitizing eating
a precipitate when mixed with water utensils, laundry
Alcohol Injures the protein and lipid structures in the cellular mem- Isopropanol, ethanol Cleansing skin,
brane of some microorganisms (70% concentration) instruments
Iodine Damages the cell membrane of microorganisms and Betadine Cleansing skin
disrupts 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 Hibiclens Cleansing skin and
ineffective against spores and most viruses equipment
Mercury Alters microbial cellular proteins Merthiolate, Mercurochrome Disinfecting skin
Glutaraldehyde Inactivates cellular proteins of bacteria, viruses, and Cidex Sterilizing equipment
microbes that form spores
Although transient microorganisms are more patho- 2002) approved new guidelines for hand antisepsis with
genic, handwashing more easily removes them. They alcohol-based hand rubs. Hand antisepsis means the
tend to cling to grooves and gems in rings, the margins of removal and destruction of transient microorganisms
chipped nail polish and broken or separated artificial without soap and water. It involves products such as
nails, and long fingernails. Thus, these items are contra- alcohol-based liquids, thick gels, and foams. Alcohol-based
indicated when caring for clients. Without conscientious hand sanitizers are not substitutes for handwashing in all
handwashing, transient microorganisms become resi- situations (see Box 10-3). Alcohol does not remove soil or
dents, thereby increasing the potential for transmission dirt with organic material; however, it does produce anti-
of infection. One possible explanation for the increase sepsis when the hands are visibly clean. Alcohol rubs,
of antimicrobial-resistant pathogens is that nosocomial when used for a minimum of 5 seconds, remove 99% of
pathogens are replacing the normal flora of clients when microorganisms on the hands, including gram-positive
health care workers fail to wash their hands at appropri- and gram-negative bacteria, fungi, multidrug-resistant
ate times for a minimum of 15 seconds (Goldmann et al., pathogens, and viruses (Kovach, 2003; Paul-Cheadle,
1996; Paul-Cheadle, 2003). Considering how often health 2003). Because alcohol formulations have a brief rather
care personnel use their hands with clients, it is no sur- than sustained antiseptic effect, however, nurses must
prise that handwashing is the single most effective way reuse them over the course of a day (Kovach, 2003).
to prevent infections. Skill 10-1 describes the steps of Advantages of alcohol hand rubs are that they (1) take
handwashing. less time, (2) are more accessible because they do not
Certain situations require handwashing; in others, require sinks or water, (3) increase compliance because
nurses may substitute hand antisepsis (Box 10-3). they are easier to perform, (4) provide the fastest and great-
est reduction in microbial counts on the skin, (5) reduce
Performing Hand Antisepsis costs by eliminating paper towels and waste management,
and (6) are less irritating and drying than soap because
Because research has shown that approximately 40% to
they contain emollients (Hand Hygiene Resource Center,
50% of health care workers comply with the minimum
2004; Paul-Cheadle, 2003).
requirements for handwashing (Kovach, 2003), the Cen-
When decontaminating with an alcohol-based hand
ters for Disease Control and Prevention (Boyce & Pittet,
rub, the nurse
• Applies about a nickel- to quarter-sized volume of the
BOX 10-3 ● Handwashing and Hand product to the palm of one hand or the amount recom-
Antisepsis Guidelines mended by the manufacturer
• Distributes the product to cover all surfaces of the
Handwashing with either a non-antimicrobial or an antimicrobial soap and water
is performed: hands and fingers
❙ When hands are visibly dirty • Rubs the product between the hands until the hands
❙ When hands are contaminated with proteinaceous material are dry (Boyce & Pittet, 2002)
❙ When hands are visibly soiled with blood or other body fluids
❙ Before eating and after using a restroom The CDC believes that with higher compliance, the poten-
❙ If exposure to Bacillus anthracis is suspected or proven tial for reducing the rate of nosocomial infections is
Hand antisepsis with an alcohol-based hand rub can be substituted for hand- greater.
washing:
❙ Before having direct contact with clients
❙ After contact with a client’s intact skin (e.g., when taking a pulse or blood
pressure, lifting a client) Stop • Think + Respond BOX 10-2
❙ Before donning sterile gloves to insert invasive devices such as urinary
Discuss actions for ensuring appropriate handwashing
catheters, peripheral vascular catheters, central intravascular catheters, or
other devices that do not require a surgical procedure
before and after caring for a client in his or her home. Use
❙ After contact with body fluids or excretions, mucous membranes, nonintact a scenario in which the client has bar soap that rests on
skin, and wound dressings if hands are not visibly soiled the bathroom sink and terrycloth hand towels shared
❙ If moving from a contaminated body site to a clean body site during client among an entire family.
care
❙ After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the client
❙ After taking off gloves because gloves are not an impervious barrier Performing a Surgical Scrub
Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health- A surgical scrub, a type of skin and nail antisepsis, is per-
care settings. Recommendations of the Healthcare Control Practice formed before donning sterile gloves and garments when
Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene the nurse is actively involved in an operative or obstetric
Task Force. Morbidity & Mortality Weekly Report html51(RR16):1–44.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm Accessed procedure. The purpose is to more extensively remove
June 2003. transient microorganisms from the nails, hands, and fore-
arms. In fact, the cleanser should reduce microbial growth
for increasingly longer periods with successive numbers SCRUB SUITS AND GOWNS. Scrub suits and gowns are hos-
of scrubs. Table 10-3 lists several differences between a pital garments worn instead of a white uniform. Their use
surgical scrub and handwashing. is mandatory in some areas of a hospital—the nursery,
To reduce the numbers of microorganisms maximally, operating room, and delivery room. These garments pre-
the fingernails must be short—no more than 1⁄4 inch long, vent personnel from bringing microorganisms on their
which does not extend beyond the tip of the fingers clothes into the hospital environment. Employees in other
(Morantz & Torrey, 2003). Artificial nails are prohib- departments sometimes wear their own scrub suits or
ited. Nail polish is discouraged, especially if it is chipped, gowns because they are comfortable and practical. Person-
worn, or on for more than 4 days, because it is conducive nel who work in mandatory-wear areas don scrub suits
to increased microorganisms. All rings, watches, and and gowns when they arrive for work. They wear cover
jewelry are removed and safeguarded before the surgical gowns over the scrubs when taking coffee or lunch breaks.
scrub (Skill 10-2).
MASKS. Masks cover the nose and mouth (Fig. 10-3) and
Wearing Personal Protective Equipment help to prevent droplet and airborne transmission of
microorganisms. To prevent the transmission of TB, the
Health care personnel wear various garments to reduce CDC (Garner, 1996) recommends the use of a disposable
the transfer of microorganisms between themselves and or replaceable particulate air filter respirator (Fig. 10-4).
clients: uniforms, scrub suits or gowns, masks, gloves, The minimum specification for a particulate air filter
hair and shoe covers, and protective eyewear. They wear respirator is N-95; N refers to “not resistant to oil”
some of these items when caring for any client regardless (i.e., it is effective in blocking particulate aerosols that
of diagnosis or presumed infectious status (see Chap. 22). are free of oil) (CDC, 1999). An N-95 air filter respira-
tor can filter particles 0.3 micron with a minimum effi-
UNIFORMS. Health care professionals wear their uni- ciency of 95%. The respirator must have a label indicating
forms only while working with clients. Some nurses approval by the National Institute of Occupational Safety
wear a clean laboratory coat over their uniform to reduce and Health (NIOSH).
the spread of microorganisms onto or from the surface Particulate respirators are custom sized and fitted for
of clothing worn from home. When caring for clients, they each health care worker to obtain a face-seal leakage
wear a plastic apron or cover gown over the uniform if of less than 10% (Bartley & Pugliese, 2001). The same
there is a potential for soiling it with blood or body flu- health care worker can reuse a disposable N-95 respira-
ids. When not wearing a cover, nurses take care to avoid tor as long as it remains intact and clean. All particulate
touching the uniform with any soiled items such as bed air filter respirators are checked for leakage initially,
linen. After work, they change the uniform as soon as before each use, and if the user gains or loses 10 lbs.
possible to avoid exposing the public to the microorgan- In certain high-risk situations, such as when a bron-
isms present on work clothing. choscopy or autopsy is performed on a client with TB,
TABLE 10-3 DIFFERENCES BETWEEN HANDWASHING AND A SURGICAL SCRUB

HANDWASHING SURGICAL SCRUB
Plain wedding band may be worn. All hand jewelry, including watch, is removed.
Faucets with hand controls are used; elbow, knee, or foot Faucets are regulated with elbow, knee, or foot controls.
controls are preferred.
Liquid, bar, leaflet, or powdered soap or detergent is used. Liquid antibacterial soap is used; scrubbing devices may be
incorporated with antibacterial soap.
Washing lasts a minimum of 10 to 15 seconds. Scrubbing lasts 2 to 5 minutes, depending on the antibacterial
agent and time interval between subsequent scrubs.
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 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 Sterile gloves are donned immediately after the hands are
is a potential for contact with blood or body fluids. dried.

Using a Mask or Particulate Filter Respirator
❙ Wear a mask if there is a risk for coughing or sneezing within a
radius of 3 feet. The mask blocks the route of exit.
❙ Wear a mask or particulate filter respirator if there is a potential for
acquiring diseases caused by droplet or airborne transmission. The
mask blocks the port of entry.
❙ Position the mask or respirator so that it covers the nose and mouth.
The mask provides a barrier to nasal and oral ports of entry.
❙ Tie the upper strings of a mask snugly at the back of the head and
the lower strings at the back of the neck. Proper placement reduces
the exit and entry routes for microorganisms.
❙ Avoid touching the mask or respirator once it is in place. Touching
the mask transfers microorganisms to the hands.
❙ Change the mask or respirator every 20 to 30 minutes or when it
becomes damp; particulate filter respirators can be worn multiple
times, but they must be rechecked for leakage and fit. Changing the
mask preserves its effectiveness.
❙ Touch only the strings of the mask or the respirator strap during
FIGURE 10-3 • Face mask and hair cover. (Copyright B. Proud.)
removal. Touching the mask transfers microorganisms to the hands.
❙ Discard used masks or respirators into a lined or waterproof waste
a respirator that exceeds the minimum standard is used. container. Proper disposal reduces the transmission of
In those cases, a powered air-purifying respirator (PAPR) microorganisms to others.
or positive-pressure airline respirator equipped with a ❙ Perform handwashing or hand antisepsis after removing a mask or
half- or full-face mask is required (CDC, 1999). See Nurs- respirator. Handwashing and hand antisepsis remove
ing Guidelines 10-1. microorganisms from the hands.
GLOVES. Nurses wear clean gloves, sometimes called

examination gloves, in the following circumstances:
Latex and vinyl gloves are equally protective with non-
• As a barrier to prevent direct hand contact with blood,
vigorous use, but latex gloves have some advantages.
body fluids, secretions, excretions, mucous membranes,
They stretch and mold to fit the wearer almost like a sec-
and nonintact skin
ond layer of skin, permitting greater flexibility with move-
• As a barrier to protect clients from microorganisms
ment. Perhaps most importantly, they can reseal tiny
transmitted from nursing personnel when performing
punctures.
procedures or care involving contact with the client’s
Unfortunately some nurses and clients are allergic to
mucous membranes or nonintact skin
latex. Reactions vary and range from annoying symp-
• When there is a potential transfer of microorganisms
toms such as skin rash, flushing, itching and watery eyes,
from one client or object to another client during sub-
and nasal stuffiness to life-threatening swelling of the
sequent nursing care
airway and low blood pressure. Nurses who are sensitive
Examination gloves are generally made of latex or to latex can wear alternative types of gloves, or they can
vinyl, although other types are available (see Chap. 19). wear a double pair of vinyl gloves when the risk for con-
tact with blood or body fluids is high.
Nurses change gloves if they become perforated, after
a period of use, and between the care of clients. Vinyl
gloves are not as protective after 5 minutes of wear. By
using aseptic techniques, nurses remove gloves without
directly touching their more contaminated outer surface.
See Nursing Guidelines 10-2.

What is the best action to take if while donning sterile
gloves, a nurse touches the thumb of an already gloved
Disposable Replaceable finger to his or her ungloved wrist?
FIGURE 10-4 • Replaceable filter and disposable respirators.
NURSING GUIDELINES 10-2 Confining Soiled Articles

Removing Gloves Health care agencies use several medically aseptic prac-
tices to contain reservoirs of microorganisms, especially
❙ Grasp one of the gloves at the upper, outer edge at the wrist (Fig. 10-5). those on soiled equipment and supplies. They include
This position maintains a barrier between contaminated surfaces. using designated clean and dirty utility rooms and vari-
❙ Stretch and pull the upper edge of the glove downward while ous waste receptacles.
inverting the glove as it is removed. This action encloses the soiled
surface, blocking a potential exit route for microorganisms. UTILITY ROOMS. Health care agencies have at least two
utility rooms: one designated clean and the other consid-
❙ Insert the fingers of the ungloved hand within the inside edge of the
ered dirty. Personnel must not place soiled articles in the
other glove. The inside edge is the cleaner surface of the glove.
clean utility room.
❙ Pull the second glove inside out while enclosing the first glove within The dirty or soiled utility room contains covered waste
the palm. This action contains the reservoir of microorganisms. receptacles, at least one large laundry hamper, and a flush-
❙ Place the gloves within a lined waste container. Proper disposal able hopper. This room also houses equipment for test-
confines the reservoir of microorganisms. ing stool or urine. A sink is located in the soiled utility
❙ Wash hands or perform hand antisepsis with an alcohol rub room for handwashing and for rinsing grossly contami-
immediately after removing gloves. Handwashing and hand nated equipment.
antisepsis removes transient and resident microorganisms that
have proliferated within the warm, dark, moist environment inside WASTE RECEPTACLES. Agencies rely on various methods
the gloves. to contain soiled articles until they can be discarded.
Most clients have a paper bag at the bedside for tissues or
other small, burnable items. Wastebaskets generally are
HAIR AND SHOE COVERS. Hair and shoe covers reduce lined with plastic. Suction and drainage containers are
the transmission of pathogens present on the hair or kept covered and emptied at least once each shift. Most
shoes. Health care personnel generally wear these gar- client rooms have a wall-mounted puncture-resistant
ments during surgical or obstetric procedures. Shoe cov- container for needles or other sharp objects (Fig. 10-7).
ers are fastened so that they cover the open ends of pant
Keeping the Environment Clean
legs. Hair covers should envelop the entire head. Men
with beards or long sideburns wear specially designed Health agencies employ laundry staff and housekeeping
head covers that resemble a cloth or paper helmet. Even personnel to assist with cleaning. In general, if soiled
though hair covers are not required during general nurs- linen is bagged appropriately or handled with gloves, the
ing care, health care workers should keep their hair short detergents and heat from the water and the dryer pro-
or contained with a clip, band, or some other means. duce laundry that is sufficiently clean and free of patho-
genic organisms.
PROTECTIVE EYEWEAR. Protective eyewear is essential Housekeeping personnel are responsible for collecting
when there is a possibility that body fluids will splash and disposing of accumulated refuse and for perform-
into the eyes. Goggles are worn along with a mask, or a ing concurrent and terminal disinfection. Housekeepers
multipurpose face shield is used (Fig. 10-6). who follow the principles of medical asepsis carry out
A B C
FIGURE 10-5 • (A) Pulling at cuff. (B) Inverting the glove. (C) Enclosing contaminated surfaces. (Copyright
B. Proud.)
Nurses who work in home health can teach the client

and family simple aseptic practices for cleaning contam-
inated articles. See Client and Family Teaching 10-1.

Describe methods of medical asepsis that are helpful in
controlling the chain of infection of the common cold.
Surgical Asepsis
Surgical asepsis means those measures that render supplies

and equipment totally free of microorganisms. Sterile tech-
nique is those practices that avoid contaminating microbe-
free items. Both begin with the process of sterilization.
Sterilization
consists of physical and chemical techniques
Sterilization
that destroy all microorganisms including spores. Steril-
FIGURE 10-6 • Protective goggles. (Copyright B. Proud.)
concurrent disinfection,
or measures that keep the client
environment clean on a daily basis: Cleaning Potentially Infectious Equipment
• They clean less soiled areas before grossly dirty ones. The nurse teaches the client and family as follows:
• They wet-mop floors and damp-dust furniture to avoid • Wear waterproof gloves when handling heavily
distributing microorganisms on dust and air currents. contaminated items or if there are open skin
• They discard solutions used for mopping frequently in areas on the hands.
a flushable hopper. • Designate one container for the sole purpose of
• They never place clean items on the floor. cleaning contaminated articles.
• Disassemble and rinse reusable equipment as
Terminal disinfection is more thorough than concurrent
soon as possible after use.
disinfection and consists of measures used to clean the
• Rinse grossly contaminated items first under
client environment after discharge. It includes scrub-
cool, running water; hot water causes protein
bing the mattress and the insides of drawers and bed-
substances in body fluids to thicken or congeal.
side stands.
• 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 surface of contami-
nated 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.
• Wash hands for at least 15 seconds after cleaning
equipment if the hands are visibly dirty, soiled
with blood or other body fluids, or contaminated
with proteinaceous material; substitute an
alcohol-based hand rub in other circumstances.
• Store clean, dry items in a covered container or
FIGURE 10-7 • Sharps container. in a clean, folded towel.
ization of equipment is done within the health agency

or by manufacturers of hospital supplies. Labels on com-
mercially sterilized equipment identify a safe use date.
PHYSICAL STERILIZATION. Microorganisms and spores

are destroyed physically through radiation or heat (boil-
ing water, free-flowing steam, dry heat, and steam under
pressure).
Radiation. Ultraviolet radiation can kill bacteria, especially

the organism that transmits TB. This process generally is
combined with other aseptic methods, however, because
its efficiency depends on circulating organisms by air
currents from lower areas of a room to wall- or ceiling-
mounted units (CDC, 1994). Exposure to sunlight was
used in the past to eliminate microorganisms.
FIGURE 10-8 • Autoclave. (Copyright B. Proud.)
Boiling Water. Boiling water is a convenient way to steril-

ize items used in the home. To be effective, contaminated Gas sterilization using ethylene oxide gas is a traditional
equipment needs to be boiled for 15 minutes at 212°F method for destroying microorganisms. It is preferred if
(100°C)—longer in places at higher altitudes. heat or moisture is likely to damage items or if no better
method is available.
Free-Flowing Steam. Free-flowing steam is a method in
Peracetic Acid. Peracetic acid is a combination of acetic acid
which items are exposed to the heated vapor that escapes and hydrogen peroxide. Although early trials demon-
from boiling water. It requires the same time and temper- strated that peracetic acid is highly corrosive, new meth-
ature as the boiling method. Free-flowing steam is less ods of buffering it have eliminated this flaw. Peracetic
reliable than boiling because exposing all the surfaces of acid sterilizes equipment quickly—12 minutes at 122° to
some contaminated items to the steam is difficult. 131°F (50° to 55°C); the entire process takes approxi-
mately 30 minutes from start to finish (Alfa et al., 1998).
Dry Heat. Dry heat, or hot air sterilization, is similar to
baking items in an oven. To destroy microorganisms with Ethylene Oxide Gas. Ethylene oxide gas destroys a broad
dry heat, temperatures of 330°to 340°F (165° to 170°C) spectrum of microorganisms, including spores and viruses,
are maintained for at least 3 hours. Dry heat is a good when contaminated items are exposed for 3 hours at 86°F
technique for sterilizing sharp instruments and reusable (30°C). Gassed items, however, must be aired for 5 days
syringes because moist heat damages cutting edges and at room temperature or 8 hours at 248°F (120°C) to
the ground surfaces of glass. Dry heat prevents rusting of remove traces of the gas, which can cause chemical burns.
objects that are not made of stainless steel.
Principles of Surgical Asepsis
Steam Under Pressure. Steam under pressure is the most
dependable method for destroying all forms of organisms Surgical asepsis is based on the premise that once equip-
and spores. The autoclave is the type of pressure steam ment and areas are free of microorganisms, they can
sterilizer that most health care agencies use (Fig. 10-8). remain in that state if contamination is prevented. Con-
Pressure makes it possible to achieve much hotter tem- sequently health care professionals observe the follow-
peratures than the boiling point of water or free-flowing ing principles:
steam. Heat-sensitive tape that changes color or displays • They preserve sterility by touching one sterile item
a pattern when exposed to high temperatures is used on with another that is sterile.
sterilized packages as a visual indicator that the wrapped • Once a sterile item touches something that is not, it is
item is sterile. considered contaminated.
• Any partially unwrapped sterile package is considered
CHEMICAL STERILIZATION. Both gas and liquid chemi- contaminated.
cals are used to sterilize invasive equipment. Until per- • If there is a question about the sterility of an item, it is
acetic acid was perfected as a sterilizing agent, sterilization considered unsterile.
using liquid chemicals was difficult, and some questioned • The longer the time since sterilization, the more likely
its reliability. The use of peracetic acid, however, is gain- it is that the item is no longer sterile.
ing popularity as a reliable method for sterilizing heat- • A commercially packaged sterile item is not consid-
sensitive instruments such as endoscopes. ered sterile past its recommended expiration date.
• Once a sterile item is opened or uncovered, it is only a inside surface is contaminated. To avoid contamination,
matter of time before it becomes contaminated. the nurse places the cap upside down on a flat surface or
• The outer 1-inch margin of a sterile area is considered holds it during pouring.
a zone of contamination. Before each use of a sterile solution, the nurse pours
• A sterile wrapper, if it becomes wet, wicks micro- and discards a small amount to wash away airborne con-
organisms from its supporting surface, causing contaminants from the mouth of the container. This is called
tamination. lipping the container. While pouring, the nurse holds the
• Any opened sterile item or sterile area is considered container in front of himself or herself. The nurse avoids
contaminated if it is left unattended. touching any sterile areas within the field. He or she con-
• Coughing, sneezing, or excessive talking over a sterile trols the height of the container to avoid splashing the
field causes contamination. sterile field, causing a wet area of contamination. Agen-
• Reaching across an area that contains sterile equip- cies replace sterile solutions daily even if the entire vol-
ment has a high potential for causing contamination ume is not used.
and is therefore avoided.
• Sterile items that are located or lowered below waist DONNING STERILE GLOVES. When applied correctly
level are considered contaminated because they are (Skill 10-4), nurses can use sterile gloves to handle ster-
not within critical view. ile equipment and supplies without contaminating them.
Sterile gloves provide a barrier against transmitting
Health care professionals observe the principles of sur- microbes to clients. Some packages of supplies include
gical asepsis during surgery, when performing invasive sterile gloves; they also are packaged separately in glove
procedures such as inserting urinary catheters, and when wrappers.
caring for open wounds. Practices that involve surgical
asepsis include creating a sterile field, adding sterile items DONNING A STERILE GOWN. A sterile gown protects the
to the sterile field, and donning sterile gloves. client and sterile equipment from microorganisms that
collect on the surface of uniforms, scrub suits, or scrub
CREATING A STERILE FIELD. A sterile field means a work area gowns. Sterile gowns are required during surgery and
free of microorganisms. It is formed using the inner sur- childbirth. They are used during other sterile procedures
face of a cloth or paper wrapper that holds sterile items, as well.
much like a tablecloth. The field enlarges the area where Sterile gowns are made of cloth and are laundered
sterile equipment or supplies are placed. When opening and sterilized after each use. Before wrapping a gown
the sterile package, the nurse is careful to keep the inside for sterilization, it is folded so that the inside surface
of the wrapper and its contents sterile. Refer to Skill 10-3. can be touched while putting it on. To avoid contami-
nation, the nurse observes the steps presented in Nurs-
ADDING ITEMS TO A STERILE FIELD. Sometimes it is neces- ing Guidelines 10-3.
sary to add sterile items or sterile solutions to the sterile
field (see Skill 10-3).
NURSING IMPLICATIONS
Sterile Items. Agency-sterilized items or those that have
been commercially prepared may be added to the ster- Everyone is susceptible to infections, especially if sources
ile field. The former are generally wrapped in cloth. of microorganisms among personnel, clients, equipment,
The nurse unwraps the cloth by supporting the wrapped and the agency are not controlled. Nurses generally iden-
item in one hand rather than placing it on a solid surface. tify pertinent nursing diagnoses when caring for partic-
He or she holds each of the four corners to prevent the ularly susceptible clients:
edges of the wrap from hanging loosely. The nurse places
• Risk for Infection
the unwrapped item on the sterile field and discards the
• Risk for Infection Transmission
cloth cover.
• Ineffective Protection
Commercially prepared supplies, such as sterile gauze
• Delayed Surgical Recovery
squares, are enclosed in paper wrappers. The paper cover
• Deficient Knowledge
usually has two loose flaps that extend above the sealed
edges. After separating the flaps, the nurse drops the ster- Nursing Care Plan 10-1 illustrates how nurses incor-
ile contents onto the sterile field. porate aseptic principles into a teaching plan for the
nursing diagnosis of Deficient Knowledge. The NANDA
Sterile Solutions. Sterile solutions, such as normal saline, taxonomy (2005) defines Deficient Knowledge as an
come in various volumes. Some containers are sealed absence or deficiency of cognitive information related
with a rubber cap or screw top. Either is replaced if the to a specific topic. Carpenito-Moyet (2006, p. 458) uses
NURSING GUIDELINES 10-3 GENERAL GERONTOLOGIC

CONSIDERATIONS
Donning a Sterile Gown
Conscientious handwashing and standard precautions are neces-
❙ Apply a mask and hair cover. This sequence prevents contamination sary basic nursing interventions for all clients, and especially
of the hands after they are washed. for older adults who are more susceptible to infections
because of diminished immune system functioning.
❙ Perform a surgical scrub (see Skill 10-2). A surgical scrub removes
Older adults are more likely to have life-threatening consequences
resident and transient microorganisms. of infections than younger adults.
❙ Pick up the sterile gown at the inner neckline. This action preserves Thinning, drying, and decreased vascular supply to the skin predis-
the sterility of the outer gown. pose the older person to infections there. Maintaining intact skin
is an excellent first-line defense against nosocomial infections.
❙ Hold the gown away from the body and other unsterile objects People with chronic conditions who may be debilitated or older
(Fig. 10-9A). This prevents contamination. than 75 years are at higher risk for infections, particularly
❙ Allow the gown to unfold while holding it high enough to avoid antibiotic-resistant infections.
contact with the floor. This prevents contamination. Many long-term care residents, older hospitalized clients, and
health care personnel are colonized with antibiotic-resistant
❙ Insert an arm within each sleeve without touching the outer surface bacteria, possibly with little or no symptoms.
of the gown. This action maintains sterility. Long-term care residents tend to develop infections of the skin,
❙ Have an assistant pull at the inside of the gown to adjust the fit, urinary tract, and respiratory tract.
Pneumonia, influenza, urinary tract and skin infections, and
expose the hands, and then tie it closed (Fig. 10-9B). This action
tuberculosis are common in older adults. Most cases of TB
preserves the sterility of the front of the gown.
occur in people 65 years or older living in long-term care facil-
❙ Don sterile gloves. Wearing sterile gloves ensures the sterile ities (Ebersole et al., 2005). The incidence of TB in community-
condition of the hands and cuff of the gown. living older adults is twice that of the general population
(Miller, 2003).
Infections are often transmitted to vulnerable older adults through
equipment reservoirs such as indwelling urinary catheters,
humidifiers, and oxygen equipment or through incisional sites
the definition, “the state in which an individual or group such as those for intravenous tubing, parenteral nutrition, or
experiences a deficiency in cognitive knowledge or psy- tube feedings. Use of proper aseptic techniques is essential to
chomotor skills concerning the condition or treatment prevent the introduction of microorganisms. Daily assessment
plan.” Some have argued that this nursing diagnosis is for any signs of infection is imperative.
Prevention of urinary tract infections is best accomplished by
used erroneously because it is more often an etiology than prompt attention to perineal hygiene. Women should always
a nursing diagnosis (Carpenito-Moyet, 2006; Conley, clean from the urinary area back toward the rectal area to
1998; Jenny, 1987). prevent organisms from the stool entering the bladder.
FIGURE 10-9 • (A) Unfolding a sterile

gown. (B) Assisting with donning a ster- A B
ile gown. (Copyright B. Proud.)
10-1 N U R S I N G CAR E P L AN
Deficient Knowledge
ASSESSMENT
• Explore the client’s level of knowledge in a particular area of health care.
• Provide opportunities during which a client can request health-related information.
• Listen for statements that reflect inaccurate health information.
• Observe if a client performs health-related self-care incorrectly.
• Watch for signs of emotional distress that reflect inaccurate 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
end of office visit.
Interventions Rationales
Explain that hepatitis A is primarily transmitted from This discussion provides accurate information concerning
stool of an infected person to the oral route of the the mode of disease transmission.
susceptible person and that hepatitis B is spread by blood
and body fluids.
Provide health-related information about hepatitis A, Specific information increases the client’s knowledge,
which includes: clarifies misinformation, and helps to relieve anxiety.
• The incubation period for hepatitis A is 25 to 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 white portion of the eyes.
• Handwashing is an excellent preventive measure especially
when performed before eating and after using a toilet.
• An injection of immune serum globulin is a method of
providing temporary passive immunity when exposed to
hepatitis A.
Demonstrate handwashing and observe a return A demonstration provides health teaching by visual
demonstration emphasizing the following: learning; returning a demonstration reinforces learning
• Turn handles of faucet on and let water run. via a psychomotor activity.
• Wet hands and lather with soap.

• Rub lathered hands for at least 15 seconds.
• Rinse, letting water flow from wrists to fingers.
• Dry hands with a paper towel.
• Use paper towel to turn faucet off.
(continued)
N U R S I N G C A R E P L AN (Continued)
Deficient Knowledge
Evaluation of Expected Outcomes
• The client identifies the mode of transmitting hepatitis A as the fecal/oral route.
• The client lists low fever, loss of appetite, and yellow sclera as indications of hepatitis A infection.
• The client states that frequent and thorough handwashing is a method for preventing the acquisition of hepatitis A.
• The client demonstrates appropriate handwashing and is prepared to teach her daughter the same skill.
• The client makes an appointment for her daughter to receive an injection of immune serum globulin.
Additionally, thorough handwashing by the client and care- 1. “Include more sources of protein in your diet.”
giver is necessary. 2. “Keep your breasts supported in a tight brassiere.”
Indwelling catheters should be avoided if at all possible because 3. “Shower daily and wash your hands frequently.”
older people have increased susceptibility to urinary tract 4. “Apply warm compresses at least four times a day.”
infections. Bladder training is much more desirable. If
indwelling catheters are necessary, meticulous daily care is 2. The most important health teaching the nurse can pro-
required. The tubing should never be placed higher than the vide a client with an eye infection is to
bladder to prevent any backflow of urine into the bladder. 1. Eat a well-balanced, nutritious diet.
Older adults, family members in close contact with older people, 2. Wear sunglasses in bright light.
and all personnel in health care settings should obtain annual 3. Cease sharing towels and washcloths.
immunizations against influenza. Those 65 years and older 4. Avoid products containing aspirin.
should receive an initial dose of the pneumococcal vaccine.
Visitors with respiratory infections need to wear a mask or avoid 3. If the nurse provides the following information to a per-
contact with older adults in their home or long-term care set- son who has just had her earlobes pierced, which is most
tings until their symptoms have subsided. In addition to the important for reducing the potential for infection?
mask, frequent thorough handwashing can help prevent 1. Use earrings made of 14-carat gold.
transfer of organisms. 2. Leave the earrings in place for 2 weeks.
Ill health care workers should take sick leave rather than expose 3. Turn the earrings frequently.
susceptible clients to infectious organisms.
4. Swab the earlobes daily with alcohol.
4. When caring for an immunosuppressed client, it is most
CRITICAL THINKING E X E R C I S E S important for all caregivers to
1. Perform conscientious handwashing.
1. If the rate of infections increased on your nursing unit, 2. Limit personal contact with the client.
what would you investigate to determine the contribut- 3. Provide supplemental nourishment between meals.
ing factors? 4. Monitor blood pressure every 4 hours each shift.
2. If the cause of nosocomial infections is related to inade- 5. A client with pneumonia asks the nurse how he may
quate handwashing among health care personnel, give have acquired this infection. The most accurate explana-
some suggestions for correcting the problem. tion is that most people acquire pneumonia by
1. Transferring bacteria from unclean dental instru-
NCLEX-STYLE REVIEW Q U E S T I O N S ments
2. Having an unchecked growth of mouth organisms
1. A home health nurse visits a client on antibiotic therapy 3. Inhaling moist droplets when someone coughed
and drainage from a breast abscess. What information 4. Consuming contaminated water or tainted food
is most appropriate for preventing the spread of the
infectious microorganisms elsewhere?
Skill 10-1 • HANDWASHING
Assessment
Review the medical record to determine if it is appropriate Demonstrates concern for immunosuppressed clients,
to perform handwashing for longer than 15 seconds. newborns, or other susceptible hosts
Check that there are soap and paper towels near the sink Promotes effective handwashing and disposal of paper
and a waste receptacle nearby. towels; bar soap is supplied in small cakes, which are
changed frequently and placed on a drainable holder to
avoid colonization with microorganisms; liquid soap is
stored in closed containers that are replaced, or cleaned,
dried, and refilled on a regular schedule.
Planning
Trim long fingernails so they are less than 1⁄4 inch long. Reduces the reservoir where the majority of hand flora
reside; prevents tearing gloves
Remove all jewelry; a plain, smooth wedding band can be Facilitates removing transient and resident microorganisms;
worn; roll up long sleeves. bacterial counts are higher when rings are worn during
client care; this issue remains unresolved by the CDC’s
Healthcare Infection Control Practices Advisory
Committee and Hand Hygiene Task Force (2002).
Explain the purpose for handwashing to the client. Reinforces and demonstrates concern for client safety
Implementation
Turn on the water using faucet handles; automated faucet; Serves as a wetting agent and facilitates lathering;
or elbow, knee, or foot controls (Fig. A). enhances organization and prevents contamination of
hands after they are washed.
Using foot controls.
If a lever-operated paper towel dispenser is available, Sinks with electronic sensors decrease hand contamination
activate it to dispense the paper towel. before and after handwashing, but they are not generally
available in most health care agencies.
(continued)
HANDWASHING (Continued)
Wet your hands with comfortably warm water from the Allows water to flow from the least contaminated area to
wrists toward the fingers (Fig. B). the most contaminated area
Wetting hands.
Avoid splashing water from the sink onto your uniform. Prevents transferring microorganisms to clothing via a
wicking action
Dispense about 3 to 5 mL (1 tsp) of liquid soap into your Provides an agent for emulsifying body oils and releasing
hands, or wet a cake of bar soap. microorganisms
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 Flushes microorganisms from the surface of the soap;
drainable soap dish. drained bar soap is less likely to support growth of
microorganisms
Rub the lather vigorously over all surfaces of the hands Frees microorganisms that are lodged in skin creases and
including thumbs and backs of fingers and hands and crevices
under the fingernails (Fig. C).
Cleaning backs of fingers. (Copyright B. Proud.)
C
(continued)
Rinse the soap from your hands by letting the water run Avoids transferring microorganisms to cleaner areas
from the wrists toward the fingers (Fig. D).
Rinsing hands. (Copyright B. Proud.)
Stop the flow of water if it is controlled by an elbow or Terminates the flow of water without recontaminating the
knee lever, or a foot pedal. hands
Hold your draining hands lower than your wrists. Promotes drainage by gravity flow toward the fingers
Dry your hands thoroughly with paper towels or similar Prevents chapping
item (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. (Copyright B. Proud.)
Turn the hand controls of the faucet off using a paper Prevents recontamination of washed hands
towel.
(continued)
Apply hand lotion from time to time. Maintains the integrity of the skin because skin that
becomes irritated and abraded from frequent
handwashing increases the risk of acquiring pathogens
by direct skin contact.
Evaluation
• Handwashing has met time requirements.
• Hands are clean.
• Skin is intact.
Document
Because handwashing 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 • PERFORMING A SURGICAL SCRUB
Assessment
Locate the area designated for performing the surgical This action reduces the potential for recontamination or
scrub. Verify that the sink is deep and has a faucet with repeating the scrub procedure because of a lack of
either a knee or foot control. Ensure that there is a necessary supplies.
sufficient supply of liquid cleanser that can be dispensed
with a foot pump; also check to see if a hand sponge and
nail cleaner are available.
Planning
Change from uniform or street clothes into a scrub gown Changing attire decreases the number of microorganisms
or suit. transferred from other areas of the health care agency.
Place uniform and valuables, which may include rings and Such storage ensures safekeeping of items that contain
wristwatch, in a locker. abundant microorganisms.
Don a mask, and hair and shoe covers. These items prevent recontaminating the skin after the
hands have been scrubbed.
Verify that a sterile towel, gloves, and gown are in the Checking ensures that scrubbed areas can be dried and
operative or obstetric room adjacent to the scrub area. covered quickly to avoid transferring additional
microbes to the cleansed areas.
(continued)
PERFORMING A SURGICAL SCRUB (Continued)
Implementation
Turn on the water to a comfortably warm temperature; This measure removes surface debris, oil, and some
wet the hands to the forearms and lather the liquid microorganisms before beginning the actual surgical
cleanser to all the wet areas, using friction for scrub.
approximately 15 seconds.
Clean beneath each fingernail with a nail file or orange This device removes debris and microorganisms from
stick (Fig. A); dispose this item in a foot-operated waste beneath the nails.
container 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 scrubbing cleanser into the Doing so decreases microorganisms.
palm of a hand or use a wetted sponge that has been
presaturated with the cleanser.
Using friction, scrub the nails and all surfaces of each These steps follow the principle of cleaning from most to
finger; proceed to the thumb, palm, and back of the least contaminated areas.
hand (Fig. B).
Scrubbing all surfaces of the hands using friction.
Go over all areas with at least 10 strokes each; repeat on This amount ensures adequate scrubbing.
the other side.
Avoid splashing water or lather onto the surface of the Doing so wicks microorganisms beneath the surface of the
scrub gown or suit. cover gown or suit to the surface.
Proceed to scrub the forearms with circular strokes from Cleanse in the direction of cleaner areas of the body.
lower to middle to upper.
(continued)
Ensure that scrubbing continues for the time identified by Adequate time is necessary to reduce microorganisms.
the manufacturer of the scrubbing agent (generally a
total of 3 to 5 minutes) (Association of American
Operating Room Nurses, 2004).
Drop the soapy sponge in the sink or discard it within a These steps prevent touching unclean surfaces, as well as
foot-operated waste container. Rinse lather by allowing debris and loosened microorganisms from dripping over
the water to run from fingers to elbows (Fig. C). previously cleaned hands.
Rinse water flowing toward the elbows.
Keep the hands elevated above the waist well in front of Proceeding this way maintains cleanliness during
the scrub gown or suit with the elbows flexed; enter the relocation to the operating room or obstetric suite.
room where the sterile towel, gloves, and gown are
located (Fig. D).
Holding the hands and arms upward and away from the body.
D
(continued)
Walk to the table containing an unwrapped sterile towel This step prevents transferring organisms from the scrub
while keeping a slight distance from it. gown or suit to a sterile area.
Pick up the sterile towel by its folded edge. After allowing it This process avoids transferring organisms from an
to unfold without touching anything, use one end to dry unclean to a clean area.
the 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 This step keeps the front surface of the gown sterile and
another person (see Nursing Guidelines 10-3) and don covers the scrubbed hands.
sterile gloves.
Evaluation
• Nails, hands, and forearms have been scrubbed for
the designated time.
• The sequence of cleansing supports principles of
asepsis.
• The procedure and use of equipment have followed
principles to avoid recontamination.
Document
A surgical scrub 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 10-3 • CREATING A STERILE FIELD AND ADDING STERILE ITEMS
Assessment
Inspect the work area to determine the cleanliness and Working in a clean area is a principle of medical asepsis.
orderliness of the surface on which you will work.
Obtain the prepared package that contains items needed Contents within a prepared package contain sterile items.
for performing the clinical procedure.
Check that the package is sealed and that its use date has Items are not used if there is a question as to their
not expired. sterility.
Determine if additional sterile items are needed but not Gathering all necessary items facilitates organization and
contained in the sterile package. time management.
Planning
Explain what is about to take place to the client. Promotes understanding and cooperation
Plan to perform the procedure that requires a sterile Once a sterile field is created, it has a potential for
field when the client is comfortable and there are no contamination when items are uncovered and the field
potential interruptions. is exposed for any length of time.
Remove objects from the area where the field will be Removing unsterile items provides room for working and
created. reduces the potential for accidental contamination.
Implementation
Perform handwashing or hand antisepsis with an Removes transient microorganisms and reduces the
alcohol rub. potential for transmitting infection.
Place the wrapped package on a surface at or above Placement above the waist keeps the sterile field and its
waist level. contents within sight and reduces the potential for
contamination.
Position the package so that the outermost triangular This placement prevents reaching over the sterile area
edge of the wrapper can be moved away from the front while the package is opened and reduces the potential
of the body (Fig. A). for contamination.
Unfolding away from the body.
Unfold each side of the wrapper by touching the area that This action maintains a sterile area.
will be in direct contact with the table or stand, or
touch no more than the outer 1′′ of the edge of the
wrapper (Fig. B).
(continued)
CREATING A STERILE FIELD AND ADDING STERILE ITEMS (Continued)
Unfolding the sides.
Unfold the final corner of the wrapper by pulling it This action avoids reaching over an uncovered sterile
toward the body (Fig. C). area, which has the potential for contaminating the
sterile field and items that rest upon it.
Unfolding toward the body. (Copyright B. Proud.)
Add additional cloth-covered sterile items by unwrapping Placing sterile items on a sterile field without touching
them, securing the edges of the wrapper in one hand, anything that is unsterile preserves a sterile condition.
and placing them on the sterile field (Fig. D).
Adding an agency-sterilized item. (Copyright B. Proud.)
(continued)
Add additional paper-wrapped sterile items by separating Placing sterile items on a sterile field without touching
the sealed flaps and dropping the contents onto the anything that is unsterile preserves a sterile condition.
sterile field (Fig. E).
Adding sterile gauze. (Copyright B. Proud.)
Add a sterile solution to a sterile container, if it is needed, by Placing sterile items on a sterile field without touching
• Opening the cap on the solution without touching the anything that is unsterile preserves a sterile condition.
inner 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. (Copyright B. Proud.)
F (continued)
Evaluation
• The exposed area of the field is sterile; nothing unsterile
has touched the surface inside the 1-inch 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 10-4).
Skill 10-4 • DONNING STERILE GLOVES
Assessment
Determine if the procedure requires surgical asepsis. Complies with infection control measures
Read the contents of prepackaged sterile equipment to Indicates if extra supplies are needed
determine if 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 Ensures an adequate, clean work space
bedside stand.
Implementation
Perform handwashing or alcohol-rub antisepsis. Reduces the potential for transmitting microorganisms
Open the outer wrapper of the gloves (Fig. A). Provides access to inner wrapper
Opening outer package.
A
(continued)
DONNING STERILE GLOVES (Continued)
Carefully open the inner package and expose the sterile Facilitates donning gloves
glove with the cuff end closest to you (Fig. B).
Positioning 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 first glove.
Insert your fingers while pulling and stretching the glove Avoids contaminating the outer surface of the glove
over your hand, taking care not to touch the outside of
the glove to anything that is nonsterile.
Unfold the cuff so 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)
DONNING STERILE GLOVES (Continued)
Insert the gloved hand beneath the sterile folded edge of Maintains sterility of each glove
the remaining glove (Fig. D).
Picking up second glove.
Insert the fingers within the second glove while pulling Facilitates donning the glove
and stretching it over the hand (Fig. E).
Pulling on second glove.
Take care to avoid touching anything that is not sterile. 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
• 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
11 Admission,
Chapter
Discharge,
Transfer, and
Referrals
LEARNING OBJECTIVES
● List four major steps involved in the admission process.
● Identify four common psychosocial responses when clients are admitted to a health agency.
● List the steps involved in the discharge process.
● Give three examples of the use of transfers in client care.
● Explain the difference between transferring clients and referring clients.
● Describe three levels of care that nursing homes provide.
● Discuss the purpose of a Minimum Data Set.
● Identify two contributing factors to the increased demand for home health care.
EVERYONE experiences health changes. Several levels of health 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 subsequent discharge, transfer, or referral of clients to community agencies that
provide health care.
WORDS TO KNOW THE ADMISSION PROCESS

admission
basic care facility Admission means entering a health care agency for nursing care and medical or surgi-
clinical résumé cal treatment. It involves the following:
continuity of care
discharge • Authorization from a physician that the person requires specialized care and
discharge planning treatment
extended care facility
home health care • Collection of billing information by the admitting department of the health care
intermediate care facility agency
orientation • Completion of the agency’s admission data base by nursing personnel
progressive care unit • Documentation of the client’s medical history and findings from physical
referral
skilled nursing facility
examination
stepdown unit • Development of an initial nursing care plan
transfer • Initial medical orders for treatment
transfer summary
transitional care unit The various types of admissions are listed in Table 11-1.
163
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 admission Unplanned; stabilized in emergency department Unrelieved chest pain, major trauma
and 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 Minor surgery, cancer therapy, physical therapy
return on a regular basis for continued care or
treatment
Observational Monitoring required; need for inpatient admission Head injury, unstable vital signs, premature or
determined within 23 hours early labor
Medical Authorization Once personnel have collected preliminary data, they

notify the nursing unit and escort the client to the site
Before admission, a physician determines that a client’s where he or she will receive care. They deliver the form
condition requires special tests, technical care, or treat- initiated in the admitting department to the nursing unit
ment unavailable anywhere other than in a hospital or along with a plastic card called an Addressograph plate.
other health care agency. Some clients are scheduled for The card identifies the pages within the client’s medical
nonurgent care, such as some types of surgery, on a mutu- record. Nurses use it to stamp laboratory test request
ally agreeable date and time. Most clients, however, see forms, forms that accompany a laboratory specimen, and
a primary care or emergency department physician just charge slips for special items such as dressing supplies
before admission. The physician advises both the client used in the client’s care.
and nursing staff to proceed with the admission process.
Nursing Admission Activities
The Admitting Department
Preparing the Client’s Room
In the admitting department, clerical personnel begin When the admissions department informs the nursing
to gather information from the prospective client or his unit that the client is about to arrive, nurses check the
or her family. They initiate the medical record with data room to ensure it is clean and stocked with basic equip-
obtained at this time. They prepare a form with the ment for initial care (Box 11-1). They later provide per-
client’s address, place of employment (if the client works), sonal care items such as soap, skin lotion, toothbrush,
insurance company and policy numbers, Medicare infor- toothpaste, razor, paper tissues, and denture containers
mation, and other personal data. The hospital’s business for clients who do not have them. They place oxygen
office uses this information for record keeping and billing. administration equipment, a stand for supporting intra-
Clients who are extremely unstable or in severe dis-
comfort may bypass the admitting department and go
directly to the nursing unit. Personnel eventually will
direct someone from the family to the admitting depart-
ment on the client’s behalf or go to the client’s bedside to
obtain needed information.
Generally the admissions clerk prepares an identifica-
tion bracelet for the client, which contains the client’s
name, 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 (Fig. 11-1). For the client’s safety, he or she
must wear the bracelet throughout the stay. Other than
asking a client’s name, the bracelet is the single most
important method for identifying the client. If the iden-
tification bracelet is missing or has been removed, the
nurse is responsible for replacing it as soon as possible. FIGURE 11-1 • Applying an identification bracelet.
C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 165
BOX 11-1 ● Basic Room Supplies

possible, the nurse must carefully observe the agency’s
policies. Some institutions provide clients who are not
Each bedside stand is generally stocked with expected to stay longer than 24 hours with a locker to
❙ Wash basin
store personal effects. The nurse may place the clients’
❙ Soap dish valuables in the hospital’s safe temporarily. He or she notes
❙ Emesis basin in the medical record the type of valuables and how they
❙ Water carafe have been safeguarded. It is best to be as descriptive as
❙ Bedpan and urinal
possible. For example, rather than indicating that the
nurse placed a ring in the safe, it is better to describe the
type of metal and stones in the ring.
venous fluids, and anything else required at the time of Losing a client’s personal items can have serious legal
initial treatment. implications for both the nurse and health care agency.
The client may sue, claiming the belongings were lost or
Welcoming the Client stolen because of careless handling. Therefore, it is best to
have a second nurse’s, supervisor’s, or security person’s
One of the most important steps in admission is to make signature on the envelope containing secured valuables.
the client feel welcome. On arrival, the admitting nurse One method for avoiding discrepancies between the
greets the client warmly with a smile and handshake. He items entrusted to the nurse and those eventually returned
or she wears a name tag, introduces himself or herself, is to make an inventory (Fig. 11-2), which both nurse
and also introduces clients sharing the room. Being treated and client sign. The nurse gives one copy to the client and
courteously helps relax the client. A client who feels un- attaches another copy to the chart. When adding items or
expected or unwanted is likely to have a poor, and last- returning them to the client, the nurse revises the list, and
ing, first impression of the unit.
Orienting the Client

Orientation (helping a person become familiar with a new
environment) facilitates comfort and adaptation. When
orienting a client, the nurse describes the following:
• The location of the nursing station, toilet, shower or
bathing 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 divert-
ing incoming calls to the nursing station during the
night
• How to operate the television
• The daily routine such as meal times
• When the doctor usually visits
• When surgery is scheduled
• When laboratory or diagnostic tests are performed
Some hospitals provide booklets with information
about the agency, such as gift shop hours, newspaper
deliveries, and location of the chapel or name of the
chaplain. Such booklets, however, should never replace
a nurse’s individualized explanations.
Safeguarding Valuables and Clothing

Nurses give certain items, such as prescription and non-
prescription medications, valuable jewelry, and large sums
of money, to family members to take home. If this is not FIGURE 11-2 • Inventory of the client’s personal belongings.
the client signs the new inventory. Problems with theft or the registered nurse is responsible for the admission assess-
loss may occur without subsequent documentation. ment, he or she may delegate some aspects to the practical
The nurse identifies client-owned equipment, such nurse, nursing student, or other ancillary staff. Physical
as a walker or wheelchair, with a large, easily read label. assessment skills, which include taking vital signs, are
Doing so helps prevent confusing such equipment with discussed in more depth in Chapters 12 and 13.
that of the facility. Most agencies have places in the client’s Skill 11-1 describes the basic steps in admitting a client.
room for storing street clothing. Additions or modifications to the procedure depend largely
Because clients remove eyeglasses and dentures occa- on the client’s condition and agency policies.
sionally, such items may be lost or broken. Generally the
health care agency is responsible for replacing these items
if negligence of the staff causes accidental damage or loss. Stop • Think + Respond BOX 11-1
What aspects of admission could the registered nurse
Helping the Client Undress delegate to a practical nurse, nursing student, or nursing
To facilitate a physical examination, the client must assistant? What are the responsibilities of the nurse who
undress. If the client cannot undress without the nurse’s has delegated admission tasks?
help, the nurse does the following:
• Provides privacy
• Has the client sit on the edge of the bed, which has Initial Nursing Plan for Care
already been lowered
• Removes the client’s shoes Once all admission data are collected, the nurse devel-
• Gathers each stocking, sliding it down the leg and over ops an initial plan for the client’s care as soon as possi-
the foot ble but no later than 24 hours following admission (see
• Helps the client lie down if weak or tired Chap. 2). The initial plan generally identifies priority
• Releases fasteners such as zippers and buttons and problems and may include the client’s projected needs
removes the item of clothing in whatever way is most for teaching and discharge planning. The nurse revises
comfortable and least disturbing. For example, the nurse the care plan as more data accumulate or the client’s con-
folds or gathers a garment and works it up and over dition changes.
the body. He or she has the client lift the hips to slide
clothes up or down.
• Lifts the client’s head to guide garments over it Medical Admission Responsibilities
• Rolls the client from side to side to remove clothes that
fasten up the front or back The nurse notifies the physician once the admission pro-
• Covers the client with a bath blanket after removing the cedure is completed. The physician provides medical
outer clothing, or puts a hospital gown on the client, orders for medications and other treatments, laboratory
explaining that hospital gowns fasten in the back and diagnostic tests, activity, and diet. He or she also
obtains a medical history and performs a physical exami-
Compiling the Nursing Data Base nation within 24 hours of admission. The physician may
At admission, the nurse begins assessing the client and col- delegate this task to another member of the medical team
lecting information for the data base (Fig. 11-3). Although such as a medical student, intern, or resident.
The medical history and physical examination gener-
ally include identifying data, reason for seeking care,
history of present illness, personal history, past health
history, family history, review of body systems, and con-
clusions (Box 11-2). If the physician is unsure of the actual
medical diagnosis, he or she uses the term rule out or the
abbreviation R/O to indicate that the condition is sus-
pected, but additional diagnostic data must be obtained
before confirmation.
Common Responses to Admission
Nurses and physicians must remember that no matter

how often they have admitted clients, it is a unique and
FIGURE 11-3 • Beginning to compile the nursing data base. emotionally traumatic experience for each client. Leaving
BOX 11-2 ● Components of a Medical History and Physical Examination
Identifying Data Past Health History

❙ Age, gender, marital status ❙ Childhood disease summary
❙ General appearance ❙ Physical injuries
❙ Circumstances surrounding physician involvement ❙ Major illnesses and surgeries
❙ Reliability of client as historian ❙ Previous hospitalizations (medical or psychiatric)
❙ Others providing information about the client’s history ❙ Drug history
❙ Alcohol and tobacco use
Chief Complaint ❙ Allergy history
❙ Reason for seeking care (from client’s perspective)
Family History
Present Illness ❙ Health problems in immediate family members (living and deceased)
❙ Chronologic description of onset, frequency, and duration of current signs
❙ Longevity and cause of death among deceased blood relatives (especially parents
and symptoms
❙ Outcomes of earlier attempts at self-treatment and medical treatment
and grandparents)
Review of Body Systems
Personal History ❙ Results of physical examination
❙ Occupation
❙ Highest level of education Conclusions
❙ Religious affiliation ❙ Primary diagnosis (from chief complaint and physical examination)
❙ Residence ❙ Secondary diagnoses reflecting stable or pre-existing conditions possibly
❙ Country of origin affecting client’s treatment
❙ Primary language
❙ Military service
❙ Foreign travel or residence (date, location, length)
the security of home and entering an unfamiliar envi- it is helpful to acknowledge their uneasiness and to pro-
ronment compound the stress of physical illness and con- vide explanations and instructions before any new expe-
tribute to emotional and social distress. rience. Nursing Care Plan 11-1 provides an example of
Although specific responses to admission are unique, how to use the nursing process when planning the care
common reactions include anxiety, loneliness, decreased of a client with anxiety.
privacy, and loss of identity. In addition, the nurse may
identify one or more of the following nursing diagnoses Loneliness
as a consequence of admission:
Loneliness occurs when a client cannot interact with
• Anxiety family and friends. Although nurses can never replace
• Fear significant others, they act as temporary surrogates and
• Decisional Conflict should make frequent contact with the client. To help
• Situational Low Self-esteem combat loneliness, many hospitals and nursing homes
• Powerlessness have adopted liberal visiting hours. They also are lifting
• Social Isolation age restrictions to allow more contact between children
• Risk for Ineffective Therapeutic Regimen Management and their sick relatives.
Anxiety Decreased Privacy

Anxiety is an uncomfortable feeling caused by insecu- Privacy is at a premium in most health care agencies.
rity. The North American Nursing Diagnosis Associa- Providing private rooms for all hospitalized clients is
tion (NANDA, 2005, p. 9) has defined it as “a vague becoming a trend because of Health Insurance Portability
uneasy feeling of discomfort or dread accompanied by an and Accountability Act (HIPAA) legislation (see Chap. 9).
autonomic response (the source is often nonspecific or Although most prefer a private room, not all clients have
unknown to the individual); a feeling of apprehension one; in fact, clients may have little more than a few feet
caused by anticipation of danger. It is an alerting signal that they can consider their personal space. For most, it
that warns of impending danger and enables the individ- is stressful to share a room with a stranger. To ensure
ual to take measures to deal with threat.” privacy, the nurse closes room doors unless safety issues
Many adults do not manifest their anxiety in obvious require observation. Doors may be open at the client’s
ways. Observant nurses may note that adults appear sad request, but this results in being observed by many people
or worried, are restless, have a reduced appetite, and who pass by at all hours.
have trouble sleeping (see Chap. 5). Because adults have Nurses demonstrate respect for and protect each client’s
a greater capacity to process information than children, right to privacy. They always shield clients from the view
of others when giving personal care. If a client’s door is reduces the necessity for readmission, and eases the tran-
closed or the curtains are pulled, the nurse knocks and sition between the hospital and the next level of care.
asks permission to enter. If the health care agency has a Activities involved in discharge planning, which are
place where clients can find solitude, such as a chapel or incorporated within the plan of care, ideally begin at
reading room, the nurse includes this information in the admission or shortly thereafter (Fig. 11-4). Although the
admission orientation. discharge planner may be a nurse consultant or social
worker, the planning often involves a multidisciplinary
team of personnel from a skilled intermediate or basic
Stop • Think + Respond BOX 11-2 care nursing facility, home health agency, and hospice
provider; a physical, occupational, or speech therapist; a
What actions are appropriate if a family member or
medical equipment supplier; and others.
significant other chooses to remain with the client after
he or she has been escorted to a room on the nursing unit
Discharge planning usually is simple and routine.
at admission? Clients with one or more of the following characteris-
tics may have special considerations related to discharge
planning:
• Aged older than 75 years
Loss of Identity
• Multiple, chronic, or terminal health problems
Admission to a health care facility may temporarily • Cognitive impairment, motivational problems, or con-
deprive a person of his or her identity. For example, fusion
clients required to wear hospital gowns tend to look • Inability to perform self-care
somewhat alike. As a result, personnel may treat clients • Impaired mobility
impersonally—simply as a face or a warm body with no • Safety risks associated with independent living or that
name. This attitude makes clients feel like they are pose a burden to potential caregivers
receiving care but without caring. • A treatment regimen involving multiple medications,
Nurses learn and use the client’s name. They use first dietary management, or complicated medical equipment
names only at the client’s request. They encourage clients • History of past multiple treatments in the emergency
to display pictures or other small personal objects that department
reaffirm their unique life and personality. Many long-term
care facilities urge clients to dress in their own clothing
and invite them to furnish their rooms with personal Obtaining Authorization for
items from home.
Medical Discharge
The physician determines when the client is well enough
THE DISCHARGE PROCESS for discharge. Generally he or she waits to write the
medical order until after examining the client. Before
Regardless of where or why clients are admitted, the goal leaving the nursing unit, the physician writes the dis-
is to keep the admission as brief as possible and to discharge order, provides written prescriptions for the client,
charge clients to home or to another health care facility and indicates when and where a follow-up appointment
of their choice as soon as possible. Discharge (termination should occur.
of care from a health care agency) generally consists of Leaving against medical advice (AMA) is a term that
discharge planning, obtaining a written medical order, applies to situations in which the client leaves before the
completing discharge instructions, notifying the business physician authorizes the discharge. Many times, it hap-
office, helping the client leave the agency, writing a sum- pens because the client is unhappy with an aspect of care.
mary of the client’s condition at discharge, and request- In some cases, the nurse may negotiate a compromise or
ing that the room be cleaned. persuade the client to delay such action. In the mean-
time, the nurse informs the physician and nursing super-
visor of the client’s wish to leave.
Discharge Planning If the client is determined to leave, the nurse asks him
or her to sign a special form (see Chap. 3). This signed
Discharge planning is a process that improves client out- form releases the physician and agency from future respon-
comes by (1) predetermining his or her postdischarge sibility for any complications. If the client refuses to
needs in a timely manner, and (2) coordinating the use sign, personnel cannot prevent him or her from leaving.
of appropriate community resources to provide a contin- They note in the client’s medical record, however, that
uum of care. If effective, discharge planning shortens they presented the form and that the client subsequently
the hospital stay, decreases the cost of in-hospital care, refused it.
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: _________________________
_______________________________
_______________________________
_______________________________
_______________________________________________
Client/Significant other signature
FIGURE 11-4 • Discharge care plan.
_______________________________________________
(Used with permission of RN Central. RN signature
Available at: http://www.rncentral.com/
careplans/plans/dc.html.)
Providing Discharge Instructions for the date specified by the physician. He or she provides
a written summary of discharge instructions. The client
When the nurse anticipates that a client will be discharged signs and keeps one sheet; the nurse attaches a copy to
home, he or she establishes the anticipated knowledge, the client’s medical record.
skills, and community resources that the client will need
to maintain a safe level of self-care. One discharge plan-
ning technique uses the acronym METHOD (Table 11-2). Notifying the Business Office
The nurse provides the teaching identified in the dis-
charge plan periodically during the client’s stay and doc- Before the client leaves the agency, the nurse notifies the
uments it in the record (see Chap. 8). business office. At that time, clerical personnel verify
Before the client leaves, the nurse reviews teaching that that all insurance information is complete and that the
has been provided, gives the client prescriptions to have client has signed a consent form authorizing the release
filled, and advises the client to make an office appointment of medical information to the insurance carrier. If records
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 Explain what community services are available that may ease the client’s transition Physical therapy
referral 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.
are incomplete or the client has no health insurance, the in the lobby for a ride. Skill 11-2 provides a step-by-step
client must make arrangements for future financial pay- description of the discharge process.
ments before discharge.

Discharging a Client
What information is helpful to obtain to ensure a safe
transition from a health agency to self-management
When all the preliminary business is complete, the nurse
before discharge?
helps the client to gather his or her belongings, plan for
transportation, and actually leave the agency.
Gathering Belongings Writing a Discharge Summary

If necessary, the nurse helps the client to repack personal
items. The nurse uses the inventory of valuables to After the client has left the health care agency, the nurse
ensure that nothing has been lost or forgotten. Because documents the discharge activities and client’s condition
most hospitals dispose of the plastic supplies (e.g., basin, (see Skill 11-2).
bedpan, urinal), 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 Terminal Cleaning
belongings.
Except in unusual circumstances, housekeeping person-
Arranging Transportation nel prepare the client’s room for the next admission. They
strip the bed of linen and clean it with disinfectant;
The nurse informs clients about the agency’s “check- they restock the bedside cabinet with basic equipment.
out time”—the time before which they can avoid being They then notify the admitting department that the unit
charged for another full day. In most cases, the client con- is ready. These measures stop a client from being assigned
tacts a family member or friend for assistance with trans- to a room that still requires cleaning.
portation. If no transportation is available, the client may
use public transportation, a taxicab, or an ambulance
to get home. Van transportation may be available for THE TRANSFER PROCESS
older adults through the local Commission on Aging,
but 24-hour advance notification usually is needed.
A transfer (discharging a client from one unit or agency
Escorting the Client and admitting him or her to another without going
home in the interim) may occur when a client’s condi-
When the client is ready, the nurse takes him or her to tion improves or worsens. Generally a transfer has some
the door in a wheelchair or allows the client to walk advantage for the client. It may facilitate more special-
there with assistance. The client may choose to have dis- ized care in a life-threatening situation (Fig. 11-5), or it
charge prescriptions filled at the hospital’s pharmacy may reduce health care costs. Many hospitals are creating
before leaving. Generally the nurse remains with the stepdown units, progressive care units, or transitional care units.
client until he or she is safely inside a vehicle or waiting These units are for clients who were once in a critical or

Transferring a Client
❙ Be sure to inform client and family of the need for a transfer as early
as possible. Communication promotes cooperation.
❙ If time permits and the client and family have some choice, encourage
them to investigate various facilities and collaborate on the one they
prefer. The people most affected always should make the decisions.
❙ Communicate with the agency or unit where the client will be
transferred. Other personnel need time to prepare for the client’s
arrival.
❙ Make a photocopy of the medical record. A copy aids in continuity of
care and avoids duplicating services.
❙ Provide a written clinical résumé, which is a summary of previous
care (Fig. 11-6). It should include (1) reason for the hospitalization,
(2) significant findings, (3) treatment rendered, (4) current condition,
and (5) instructions, if any, to the client and family (JCAHO, 1998).
Check that the client has been notified and given consent for the
release of his or her personal health information. To comply with
privacy rules and data security standards set by the Health Insurance
Portability and Accountability Act (HIPAA) in 1996 and further
FIGURE 11-5 • Transferring a client rapidly may be a life-saving modified in 2001 and 2002 (see Chap. 9), the client must be
measure. informed and approve the release of health information among
third parties for routine use in treatment.
❙ Place the written information in a large manila envelope or send
unstable condition but have recovered sufficiently to them via facsimile (fax) machine with a cover sheet. Call the transfer
require less intensive nursing care. agency to inform them to momentarily expect the fax. Under the
revisions to the HIPAA privacy rules (2002), agencies must
systematically protect the client’s personal health information
Transfer Activities within and outside the institution.
❙ Collect all the client’s belongings. Carelessness can lead to the loss of the
Transferring a client to a different nursing unit is less client’s clothing or valuables and cause inconvenience in returning
complex than to another agency. In a transfer within the them.
same agency, the nurse does the following: ❙ Accompany emergency medical staff or paramedics to the client’s
room. Seeing a familiar face may reduce the client’s anxiety.
• Informs the client and family about the transfer
• Completes a transfer summary (written review of the ❙ Help transfer the client onto the stretcher. Assistance reduces
client’s current status) briefly describing the client’s physical demands on the client.
current condition and reason for transfer (Fig. 11-6) ❙ Give the transfer personnel a copy of the medical record in a folder
• Speaks with a nurse on the transfer unit to coordinate or envelope. Enclosing the record protects confidentiality and
the transfer (the change of shift report in Chap. 9 can prevents loss.
be used as a model) ❙ Complete the original medical record by adding a summary of
• Transports the client and his or her belongings, med- the client’s discharge. Each medical record includes a discharge
ications, nursing supplies, and chart to the other unit summary.
❙ Send the completed chart within a file folder to the medical records
When transferring the client to a nursing home or department. All charts are filed for future reference.
other facility, the nurse conducts the process similarly
❙ Notify the business office, admitting office, and housekeeping
to a discharge: the client is discharged from the hospi-
department of the client’s transfer. Each department has its own
tal and admitted to the transfer facility. See Nursing
responsibilities when a client leaves.
Guidelines 11-1.
Extended Care Facilities people who do not meet the criteria for hospitalization.
Although group homes for assisted living, adult day care
Older adults, in particular, may be transferred directly centers, senior residential communities, home health care
from an acute care hospital to a facility that provides agencies, and hospice organizations (see Chap. 38) all
extended care (Fig. 11-7). An extended care facility (health fit this description, extended care generally is associ-
care agency that provides long-term care) is designed for ated with nursing homes. Nursing homes are classified
FIGURE 11-6 • A transfer summary

provides information that promotes
continuity of care.
as skilled nursing facilities or those that provide interme- • Injectable medications

diate or basic care. • Sterile dressing changes
• Tracheostomy care
Skilled Nursing Facilities
Skilled care is provided from a multidisciplinary per-
A nursing home licensed as a skilled nursing facility prospective. In addition to a 24-hour team of nurses, a skilled
vides 24-hour nursing care under the direction of a reg- nursing facility must provide rehabilitation services such
istered nurse. The facility is reimbursed for the care of as physical therapy and occupational therapy, pharma-
clients who require specific technical nursing skills. To ceutical services, dietary services, diversional and ther-
qualify for skilled care, the client must be referred by a apeutic activities, and routine and emergency dental
physician and require daily skilled nursing care. The fol- services. Many of the latter services are provided by qual-
lowing are examples of common procedures that qualify: ified people on a contractual basis rather than through
• Care for a pressure sore full-time employment.
• Enteral feedings or intravenous fluids To qualify for Medicare benefits in a nursing home, a
• Bowel or bladder retraining person must have been hospitalized for 3 or more days
Hospital Discharges Basic Care Facilities

Against medical
In-hospital A third type of nursing home is a basic care facility (agency
deaths
advice (0.88%)
(2.13%) Long-term care that provides extended custodial care). The emphasis is
Home health and other facilities on providing shelter, food, and laundry services in a
(12.01%)
care (8.72%) group setting. These clients assume much responsibility
Another for their own activities of daily living such as hygiene
Missing data short-term
(0.04%) hospital
and dressing, preparing for sleep, and joining others for
(2.5%) meals. Intermediate and basic care may be provided at a
skilled nursing facility but usually in separate wings.
Determining the Level of Care

The level of care is determined at admission. Each client
is assessed using a standard form developed by the Health
Care Financing Association called a Minimum Data Set
for Nursing Home Resident Assessment and Care Screening.
By federal law, the Minimum Data Set (MDS) is repeated
Routine
every 3 months or whenever a client’s condition changes.
discharges The MDS requires assessment of the following:
(73.92%)
• Cognitive patterns
FIGURE 11-7 • More than 22% of all clients admitted to hospitals • Communication and hearing patterns
require additional health care services after discharge. (From Agency
for Healthcare Research and Quality. [2004]. Hospitalization in the • Vision patterns
United States, 2004: National and regional statistics from the National • Physical functioning and structural problems
Inpatient Sample. Available at: http://hcupnet.ahrq.gov. Accessed • Continence patterns in the last 14 days
September 26, 2006.) • Psychosocial well-being
• Mood and behavior patterns
within 30 days before needing skilled nursing care. • Activity pursuit patterns
Clients who meet the criteria are eligible for 100 days of • Disease diagnoses
assistance with the costs. There is no charge for the first • Health conditions
20 days; for the next 80 days, Medicare pays all but • Oral and nutritional status
$119.00 a day (United States Department of Health and • Oral and dental status
Human Services). • Skin condition
Some older adults have private insurance policies that • Medication use
assist with Medicare co-payments. If not, or if clients • Special treatments and procedures
continue to require skilled care beyond 100 days, they
must bear the cost personally until they are considered Problems identified on the MDS are then reflected in the
indigent. After clients have exhausted their own finan- nursing care plan.
cial resources and those of their spouse, they may apply
to the state for Medicaid or its equivalent. Selecting a Nursing Home
Intermediate Care Facilities When the need arises, family members are often ill pre-
pared for selecting a nursing home. A discharge planner
A nursing home also may be licensed as an intermediate can assist with arranging nursing home care. Brochures
care facility.
This type of agency provides health-related on selection are available from the American Association
care and services to people who, because of their mental of Retired Persons, the Commission on Aging, and each
or physical condition, require institutional care but not state’s public health and welfare departments. Websites
24-hour nursing. Clients who require intermediate care also provide valuable information. See Client and Family
may need supervision because they tend to wander or are Teaching 11-1.
confused. They need assistance with oral medications,
bathing, dressing, toileting, and mobility.
Medicare does not provide reimbursement for inter- THE REFERRAL PROCESS
mediate care. Clients assume the costs. For impoverished
residents, state welfare programs, such as Medicaid, will
pay. Some nursing homes do not accept Medicaid clients, A referral is the process of sending someone to another
however, because states fix the fees for reimbursement at person or agency for special services. Referrals generally
much lower amounts than Medicare and private insur- are made to private practitioners or community agencies.
ance provide. Table 11-3 lists some common community services to
Selecting a Nursing Home

The nurse teaches the client or family to do the
following:
• Find out the levels of care (skilled, intermediate,
or basic) that the nursing home is licensed
to provide.
• Review inspection reports on each home. This
information is available from the state’s public
health department on a fee-per-page basis.
• Ask others in the community, including the
family physician, for recommendations.
• Visit nursing homes with, and again without,
an appointment. Go at least once during a meal.
• Note the appearance of residents and how staff
members respond to their needs.
• Observe the cleanliness of the surroundings
and any unpleasant odors.
• Request brochures that identify medical care,
nursing services, rehabilitation therapy, social FIGURE 11-8 • Home health care assessment.
services, activities programs, religious obser-
vances, and residents’ rights and privileges.
• Clarify charges and billing procedures. charge planner may help refer clients for home health
• Analyze if the overall impression of the home is care. Because planning, coordinating, and communicat-
positive or negative. ing take time, personnel initiate referrals as soon as pos-
sible once a need is identified. Early planning helps to
ensure continuity of care (uninterrupted client care despite
which people with declining health, physical disabilities, the change in caregivers), thus avoiding any loss of
or special needs are referred. progress that has been made.
Considering Referrals Home Health Care
Considering referrals is part of good discharge plan- is health care provided in the home by
Home health care
ning. For example, a nurse, case manager, or agency dis- an employee of a home health agency (Fig. 11-8). Pub-
TABLE 11-3 COMMON COMMUNITY SERVICES

ORGANIZATION SERVICE
Commission on Aging Assists older adults with transportation to medical appointments, outpatient therapy,
and community meal sites
Hospice Supports the family and terminally ill clients who choose to stay at home
Visiting Nurses’ Association Offers intermittent nursing care to homebound clients
Meals on Wheels Provides one or two hot meals per day delivered either at home or at a community meal site
Homemaker Services Sends adults to the home to assist in shopping, meal preparation, and light housekeeping
Home health aides Assist with bathing, hygiene, and medications
Adult protective services Make social, legal, and accounting services available to incompetent adults who may be
victimized by others
Respite care Provides short-term, temporary relief to full-time caregivers of homebound clients
Older Americans’ Ombudsman Investigates and resolves complaints made by, or on behalf of, nursing home residents;
at least one full-time ombudsman is mandated for each state
50
45
40
35
30
25
20
15
10
5
FIGURE 11-9 • Percentage of people with
limitations in activities of daily living (ADLs) 0
Bathing/ Dressing Eating Getting in/out Walking Using toilet
by age: 2003. (From Administration on Aging,
showering of bed/chairs
Department of Health and Human Services.
[2005]. A profile of older Americans. Available Type of ADL
at: http://www.aoa.gov/PROF/Statistics/profile/
2005/profiles2005.asp. Accessed September
65–74 yr 75–84 yr ≥ 85 yr
26, 2006.)
lic agencies (regional, state, or federal, such as the pub- Some older adults have difficulty accepting help from others even
lic health department) or private agencies may provide though they recognize the need for it. They may resist
changes related to how they accomplish familiar tasks. Nurses
home health care. should consider methods to facilitate required changes and
The number of clients who receive home health care minimize any unnecessary alterations when planning a transi-
continues to rise, partly as an outcome of limitations tion to an institutional setting.
imposed by Medicare and insurance companies on the Aging directly correlates with increased incidence of acute disease
number of hospital and nursing home days for which and exacerbations of chronic conditions.
In 2003, adults 65 years and older accounted for one third of hos-
they reimburse care. Another factor is the growing num-
pital admissions.
ber of chronically ill older adults in the population in When admitting, discharging, or transferring older adults,
need of assistance. nurses allow additional time because of possible functional
According to Profiles of Older Americans (American impairments.
Association of Retired Persons, 2004), approximately 45% Pets are an integral social support system and contribute to the
general well-being of older adults. Those who live alone may
of people 65 years or older and 75% of those 80 years or
be concerned about the welfare of pets. This should be con-
older have at least one disability. With advancing age, the sidered during admission, with arrangements made for care
need for assistance increased from 8% to 35% (Fig. 11-9). of the pet.
Types of assistance older adults may need include basic
activities of daily living (bathing, dressing, eating, and
getting around the house), preparing meals, shopping,
housework, managing money, using the phone, and BOX 11-3 ● Responsibilities of Home Health Nurses
taking medications. ❙ Assess the readiness of the client and home environment
Home care nursing services help shorten the time ❙ Treat each client with respect regardless of the person’s standard of living
spent recovering in the hospital, prevent admissions to ❙ Identify health or social problems that require nursing, allied health, or
extended care facilities, and reduce readmissions to acute supportive care services
care facilities. Box 11-3 identifies the responsibilities ❙ Plan, coordinate, and monitor home care
❙ Give skilled care to clients requiring part-time nursing services
assumed by home health nurses who provide community- ❙ Teach and supervise the client in self-care activities and family members who
based care. participate in the client’s home care
❙ Assess the safety of health practices that are being used
❙ Observe, evaluate, and modify environmental and social factors that affect
GENERAL GERONTOLOGIC the client’s progress
Evaluate the urgency and complexity of each client’s changing health needs
CONSIDERATIONS ❙
❙ Keep accurate written records and submit documentation to the agency for
Many older adults fear that admission to a hospital or long-term the purpose of reimbursement
care facility will eventually prevent their return to independent ❙ Arrange for referrals to other health care agencies
living. They may therefore minimize symptoms to protect their ❙ Discharge clients who have reached a level of self-reliance
independent-living situation.
TABLE 11-4 HOUSING OPTIONS FOR OLDER ADULTS

TYPE DESCRIPTION
Shared housing The older person shares a house or apartment and living expenses with one or more
unrelated people.
Foster care or board-and-care home The older person lives in a residence where an unrelated person provides a room,
meals, housekeeping, and supervision or assistance with activities of daily living.
Congregate housing Older adults occupy individual apartments and receive supportive services within a
multiunit dwelling.
Retirement community Self-sufficient older people live in owned or rented units within a residential
development exclusively for retired people.
Life care or continuing care community Older adults live in a residential complex that provides services 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.
(Adapted from Miller, C. A. [2004]. Nursing care of older adults [4th ed.]. Philadelphia: Lippincott Williams & Wilkins.)
Early discharge planning and appropriate use of community Councils on Aging, Parkinson’s support groups, and American
resources may return many older adults to their own homes. Cancer Society.
Discharge planning for older adults should consider the needs Approximately 5% of U.S. adults 65 years or older reside in long-
of caregivers, which may include family, friends, or paid term care facilities. The range of housing options for older
helpers. Delaying discharge planning or teaching until adults is increasing (Table 11-4).
immediately before the discharge may not meet the educa- Medicare requires that a client meet all the following eligibility
tional needs of older clients and family members, which can criteria for coverage of home care services:
result in readmissions.
Barriers to the use of community-based services include the 1. A physician has signed or will sign a care plan.
following: 2. The person is homebound. Homebound status is met if leav-
ing home requires a considerable and taxing effort, such as
• Lack of financial assets to pay for services needing personal assistance or the help of a wheelchair,
• Reluctance to spend assets for services crutches, etc. Occasional but infrequent “walks around the
• Unwillingness to acknowledge or accept the need for services block” are allowable. Attendance at an adult day care center
• Mistrust of service providers
or religious services is not an automatic bar to meeting the
• Lack of time, energy, or problem-solving ability to select appro-
homebound requirement.
priate services
3. The person needs skilled nursing care or physical or speech
Resources available to discharged older adults include senior therapy intermittently. Intermittent may vary from every day
centers, adult day care centers, churches, and care management to once every 60 days.
services. Additionally, support and education may come from 4. The care must be provided by, or under arrangements with,
advocacy groups such the Alzheimer’s Association, Area a Medicare-certified provider.
Anxiety
ASSESSMENT
• Observe evidence of anxiety such as rapid heart rate, elevated blood pressure, sleep disturbance, restlessness, worry,
irritability, facial tension, impaired attention, difficulty concentrating, talking excessively, crying, or being withdrawn.
• Encourage the client to validate observations by asking open-ended questions such as “How are you feeling now?” If
anxiety exists, ask the client to rate the level of anxiety by using a scale from 0 to 10 in which 0 represents no anxiety and
10 represents the most anxiety the client has ever experienced.
• Also ask the client to indicate the level at which he or she can tolerate or cope with anxiety.
• Inquire as to methods the client uses to control anxiety when it exists and the effectiveness of the identified methods.
Nursing Diagnosis: Anxiety related to perception of danger as evidenced by heart rate

of 92 beats/min at rest, elevated blood pressure, awareness of feelings of apprehension in
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
relieved anxiety in the past. had beneficial outcomes can increase the potential for
effectiveness in current and future episodes of anxiety.
Reduce external stimuli such as bright lights, noise, Numerous stimuli escalate anxiety because they interfere
sudden movement, and unnecessary activity. with 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
client. his 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 that anxiety is de-escalated, the sooner the
supportive person when feeling the effects of anxiety. client will experience relief of symptoms.
Stay with the client during periods of severe anxiety. The nurse’s presence can help the client to 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 to manage time and cope with personal demands.
Encourage the client to identify what he or she perceives Processing situations verbally may give the client
to be a threat to emotional equilibrium. perspective on perceived threats so that they are more
realistic and less exaggerated.
Use a soft voice, short sentences, and clear messages when Anxious clients have a short attention span and reduced
exchanging information. ability to concentrate; they may be unable to follow
lengthy or complicated information.
(continued)
Anxiety
Provide specific, succinct directions for tasks the client Anxious clients have difficulty following instructions and
should complete or assist the client who becomes agitated. performing tasks in correct sequence. Assistance relieves
unnecessary distress.
Instruct and help the client with moderate or severe
anxiety 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
through the mouth. subsequent 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).
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-
music. provoking stimuli.
Advise the client to reduce dietary intake of substances Caffeine is a central nervous system stimulant that
that contain caffeine such as colas and coffee. contributes to the symptoms the client experiences
with anxiety.

• The client deals with anxiety-provoking stimuli realistically and implements interventions that reduce anxiety.
• The client has extended periods during which his or her anxiety is at a tolerable level.
• The client has a reduced perception of being apprehensive.
2. Which of the following information is essential for the

nurse to obtain at the time of a client’s admission to a
1. Discuss how the admission of a child might differ from health care agency?
that of an adult. 1. Social security number
2. Medicare status
2. Compare and contrast admission to a hospital and
3. Advance directive
admission to a nursing home.
4. Health insurance policy
3. Which of the following observations is most suggestive
NCLEX-STYLE REVIEW Q U E S T I O N S that a newly admitted client is anxious?
1. The client is unusually quiet and withdrawn.
1. Which of the following is essential for complying with fed-
2. The client is restless and awakens frequently.
eral regulations that ensure the client’s right to privacy?
3. The client eats very little food at each meal.
1. Addressing clients by their first names only
4. The client misses his/her spouse and children.
2. Obtaining consent for releasing information
3. Referring to the client as the person in Room 201
4. Using a code number rather than name in the med-
ical record
Skill 11-1 • ADMITTING A CLIENT
Assessment
Obtain the name, admitting diagnosis, and condition of Provides preliminary data from which to plan the
the client and the room to which he or she has been activities that may be involved in admitting the client
assigned.
Check the appearance of the room and presence of basic Demonstrates concern for cleanliness, order, and client
supplies. convenience
Planning
Assemble 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 IV pole or oxygen, Facilitates immediate care of the client without causing
that may be needed according to the client’s needs. unnecessary delay or discomfort
Arrange the height of the bed to coordinate with the Reduces the physical effort in moving from a wheelchair
expected mode of arrival. or stretcher to the bed
Fold the top linen to the bottom of the bed if the client Reduces obstacles that may interfere with the client’s
will be immediately confined to bed. comfort and ease of transfer
Implementation
Greet the client by name and demonstrate a friendly Promotes feelings of friendliness and personal regard to
smile; extend a hand as a symbol of welcome. help reduce initial anxiety
Introduce yourself to the client and those who have Establishes the nurse–client relationship on a personal
accompanied the client. basis
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 Promotes a sense of familiarity to relieve social
one, and anyone else who enters the room. awkwardness; demonstrates concern for the client’s
emotional comfort
Offer the client a chair unless the client requires Demonstrates concern for the client’s physical comfort
immediate bed rest.
Check the client’s identification bracelet. Enhances safety by accurately identifying the client
Orient the client to the physical environment of the room Aids in adapting to unfamiliar surroundings
and the nursing unit.
Demonstrate how to use the equipment in the room such Promotes comfort and self-reliance; ensures safety
as the adjustments for the bed, how to signal for a
nurse, use of the telephone and television.
Explain the general routines and schedules that are Reduces uncertainty about when to expect activities
followed for visiting hours, meals, and care.
Explain the need to examine the client and ask personal Prepares the client for what will follow next
health questions.
Ask if the client would like family members to leave or Promotes a sense of control over decisions and outcomes
remain.
Make provisions for privacy. Demonstrates respect for the client’s dignity
(continued)
ADMITTING A CLIENT (Continued)
Request that the client undress and don a hospital or Facilitates physical assessment
examination gown; assist as necessary.
Ask the client about the need to urinate at the present Shows concern for the client’s immediate comfort;
time, and obtain a urine specimen if ordered. facilitates 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
examination
Take care of the client’s clothing and valuables according Provides safeguards for the client’s possessions
to agency policy.
Ask the client to identify allergies to food, drugs, or other Aids in preventing the potential for an allergic reaction
substances and to describe the type of symptoms that during care; prepares staff for the manner in which the
accompany a typical allergic reaction. client reacts to the allergen
Apply a second bracelet that is color coded to the client’s Calls staff’s attention to the fact that the client has
arm that identifies the client’s allergies. allergies
Wash hands or perform hand antisepsis with an alcohol Reduces the direct transmission of microorganisms from
rub (see Chap. 10). the nurse’s hands to the client
Obtain the client’s temperature, pulse, respiratory rate, Contributes to the initial data base assessment
and blood pressure.
Place the signal cord where it can be conveniently Reduces the potential for accidents by ensuring that the
reached. client can make his or her needs known
Make sure the bed is in low position, and follow agency Promotes safety. Side rails are considered a form of
policy about raising the side rails on the bed. physical restraint in a nursing home; their use may
require written permission from the client.
Remove the urine specimen if obtained at this time, attach Ensures proper identification of the specimen, specifies
a laboratory request form, and place it in the the test to be performed, and prevents changes that may
refrigerator or take it to the laboratory. affect test results
Wash hands or perform hand antisepsis with an alcohol Removes microorganisms acquired from contact with the
rub (see Chap. 10). client or the urine specimen
Report the progress of the client’s admission to the Complies with JCAHO standards; the entire admission
registered nurse, who may perform the nursing assessment must be completed within 24 hours; parts of
interview and physical assessment or delegate the assessment may be performed at periodic intervals
components at this time. until it is completed
Inform family or friends that they may resume visiting Facilitates the client’s network of support
when the nursing activities are completed.
Evaluation
• Client is comfortable and oriented to room
and routines.
• Safety measures are implemented.
• Data base assessments are initiated.
• Status and progress are communicated to nursing team.
(continued)
ADMITTING A CLIENT (Continued)
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 aller-
gies by using the abbreviation NKA (no known aller-
gies) or whatever abbreviation is acceptable
• Disposition of urine specimen
• Present condition of client
Date and Time 68-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 lbs. 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 peni-
cillin, 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 Enables the client to continue self-care
discharge instructions.
Note if any new medical orders must be carried out before Ensures that the client will leave in the best possible
the client’s discharge. condition
Review the nursing discharge plan. Determines if the client needs more health teaching or
instructions have been completed
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 Facilitates continuity of care
agency, 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
(continued)
DISCHARGING A CLIENT (Continued)
Planning* (Continued)
*Notify the business office of the client’s impending Allows time for the clerical department to review the
discharge. client’s billing information and determine the necessity
for further actions
*Inform the housekeeping department that the client will Alerts cleaning staff that the unit will need terminal
be leaving. cleaning
*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 Reduces transmission of microorganisms
rub (see Chap. 10).
Provide for hygiene but omit changing the bed linen. Eliminates unnecessary work
Complete medical treatment and nursing interventions Promotes continuation of nursing care
according to the plan for care.
Help the client dress in street clothing or clothing Demonstrates concern for the client’s appearance and
appropriate for leaving the agency. appropriateness for the weather
Review discharge instructions and complete health teaching. Promotes safe self-care
Have the client sign the discharge instruction sheet and Validates that the client has understood instructions for
paraphrase the information it contains. maintaining health
Assist the client with packing personal items; if Reduces claims that personal items were lost or stolen;
appropriate, have the client sign the clothing inventory signing a clothing inventory or valuables list is more
or valuables list. 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 Reduces the potential for a fall if the client is weak or
available. unsteady
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 Makes equipment available for others to use
nursing unit.
Wash hands or perform hand antisepsis with an alcohol Reduces the transmission of microorganisms
rub (see 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. (continued)
DISCHARGING A CLIENT (Continued)
Document
• Date and time of discharge
• Condition at time of discharge
• Summary of discharge instructions
• Mode of transportation
• Identity of person(s) who accompanied client
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, appro-
priate 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 lbs. Informed 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
*Starred activities may be delegated to a clerk.

12
Chapter
Vital Signs
WORDS TO KNOW
afebrile diastolic pressure offsets set point
afterload Doppler stethoscope orthopnea shell temperature
antipyretics drawdown effect orthostatic speculum
apical heart rate dyspnea hypotension sphygmomanometer
apical–radial rate dysrhythmia palpitation stertorous breathing
apnea Fahrenheit scale piloerection stethoscope
arrhythmia febrile postural stridor
auscultatory gap fever hypotension systolic pressure
automated monitoring frenulum preload tachycardia
devices hypertension pulse tachypnea
blood pressure hyperthermia pulse deficit temperature translation
bradycardia hyperventilation pulse pressure thermistor catheter
bradypnea hypotension pulse rate thermogenesis
cardiac output hypothalamus pulse rhythm training effect
centigrade scale hypothermia pulse volume ventilation
cerumen hypoventilation pyrexia vital signs
clinical thermometers Korotkoff sounds respiration white-coat
core temperature metabolic rate respiratory rate hypertension
LEARNING OBJECTIVES
● List four physiologic components measured during assessment of vital signs.
● Differentiate between shell and core body temperature.
● Identify the two scales used to measure temperature.
● List four temperature assessment sites and indicate the site considered the closest to core
temperature.
● Name four types of clinical thermometers.
● Discuss the difference between fever and hyperthermia.
● Name the four phases of a fever.
● List at least four signs or symptoms that accompany a fever.
● Give two reasons for using an infrared tympanic thermometer when body temperature is
subnormal.
● List at least four signs and symptoms that accompany subnormal body temperature.
● Identify three characteristics noted when assessing a client’s pulse.
● Name the most commonly used site for pulse assessment and three other assessment
techniques that may be used.
● Explain the difference between systolic and diastolic blood pressure.
● Name and explain at least four terms used to describe abnormal breathing characteristics.
● Discuss the physiologic data that can be inferred from a blood pressure assessment.
● Name three pieces of equipment for assessing blood pressure.
● Describe the five phases of Korotkoff sounds.
● Identify three alternative techniques for assessing blood pressure.
184
C H A P T E R 12 ● Vital Signs 185
Vital signs (body temperature, pulse rate, respiratory rate,

and blood pressure) are four objective assessment data
BODY TEMPERATURE
that indicate how well or poorly the body is functioning.
Pain assessment is considered a fifth vital sign. This sub- Body temperature refers to the warmth of the human
jective assessment is performed at least daily and when- body. Body heat is produced primarily from exercise
ever vital signs are taken (see Chap. 20). and metabolism of food. Heat is lost through the skin,
Vital signs are very sensitive to alterations in physiol- the lungs, and the body’s waste products through the
ogy; therefore, nurses measure them at regular intervals processes of radiation, conduction, convection, and
(Box 12-1) or whenever they determine it is appropriate evaporation (Table 12-1).
to assess a client’s health status. This chapter describes The body’s shell temperature (warmth at the skin sur-
how to obtain each component of the vital signs and face) is usually lower than its core temperature (warmth
explains what findings indicate based on established in deeper sites within the body like the brain and heart).
norms. Core temperature is much more significant than shell tem-
perature because there is a narrow range within which
core temperature can fluctuate without resulting in neg-
ative outcomes.
BOX 12-1 ● Recommendations for
Measuring Vital Signs
Vital signs are taken Temperature Measurement
❙ On admission, when obtaining data base assessments
❙ According to written medical orders
❙ Once per day when a client is stable
Physicists studying thermokinetics, or heat in motion,
❙ At least every 4 hours when one or more vital signs is abnormal have developed various scales for measuring heat and
❙ Every 5 to 15 minutes when a client is unstable or at risk for rapid cold. Some examples include Kelvin (K), Rankine (R),
physiologic changes such as after surgery Fahrenheit (F), and centigrade (C) scales, all of which are
❙ Whenever a client’s condition appears to have changed
based on increments at which water freezes and boils.
❙ A second time, or more frequently, when there is a significant difference
The centigrade temperature scale is also known as Celsius.
from the previous measurement
❙ When a client is feeling unusual
Health care professionals commonly use the Fahrenheit
❙ Before, during, and after a blood transfusion and centigrade scales.
❙ Before administering medications that affect any of the vital signs and The Fahrenheit scale (scale that uses 32°F as the tem-
after to monitor the drug’s effect perature at which water freezes and 212°F as the point
at which it boils) generally is used in the United States to
TABLE 12-1 MECHANISMS OF HEAT TRANSFER

RADIATION CONVECTION EVAPORATION CONDUCTION
Definition The diffusion or dissem- The dissemination of The conversion of a liquid The transfer of heat to
ination of heat by heat by motion to a vapor another object during
electromagnetic between areas of direct contact
waves unequal density
Example The body gives off An oscillating fan blows Body fluid in the form The body transfers heat to
waves of heat from currents of cool air of perspiration and an ice pack, causing the
uncovered surfaces. across the surface of insensible loss is vapor- ice to melt.
a warm body. ized from the skin.
Illustration
measure and report body temperature. The centigrade The hypothalamus promotes heat production by increas-
scale (scale that uses 0°C as the temperature at which ing metabolism through secretion of thyroid hormone as
water freezes and 100°C as the point at which it boils) is well as epinephrine and norepinephrine from the adrenal
used more often in scientific research and in countries medulla.
that use the metric system. Nurses are required to use When functioning appropriately, the hypothalamus
both scales occasionally and to convert between the two maintains the core temperature set point (optimal body tem-
measurements (Box 12-2). perature) within 1°C by responding to slight changes in the
skin surface and blood temperatures. Other physiologic
responses accompany the temperature-regulating mecha-
Normal Body Temperature nisms of the hypothalamus, as shown in Figure 12-1.
Temperatures above 105.8°F (41°C) and below 93.2°F
In normal, healthy adults, shell temperature generally (34°C) indicate impairment of the hypothalamic regula-
ranges from 96.6° to 99.3°F or 35.8° to 37.4°C (Porth, tory center. According to Porth (2004), the chance of
2004). Core body temperature, according to Nicholl survival is diminished when body temperatures exceed
(2002), ranges from 97.5° to 100.4°F (36.4° to 37.3°C).
110°F (43.3°C) or fall below 84°F (28.8°C).
If a client’s temperature is above or below normal, the
nurse records and reports the temperature, implements
Factors Affecting Body Temperature
nursing and medical interventions for restoring normal
body temperature when appropriate, and reassesses the Various factors affect body temperature. Examples in-
client frequently. clude food intake, age, climate, gender, exercise and
activity, circadian rhythm, emotions, illness or injury,
Temperature Regulation and medications.
The temperature of poikilothermic animals, such as rep-
tiles, fluctuates widely depending on environmental tem- FOOD INTAKE. Food intake, or lack of it, affects thermo-
perature. Humans, on the other hand, are homeothermic; genesis (heat production). When a person consumes food,
that is, various structural and physiologic adaptations the body requires energy to digest, absorb, transport,
keep their body temperature within a narrow stable range metabolize, and store nutrients. The process is some-
regardless of environmental temperature. times described as the specific dynamic action of food or
In humans, the hypothalamus (a structure within the the thermic effect of food because it produces heat. Protein
brain that helps control various metabolic activities) acts foods have the greatest thermic effect. Thus, both the
as the center for temperature regulation. The anterior amount and type of food eaten affect body temperature.
hypothalamus promotes heat loss through vasodilation Dietary restrictions can contribute to decreased body
and sweating. The posterior hypothalamus promotes heat as a result of reduced processing of nutrients.
two functions: heat conservation and heat production. It
produces heat conservation in the following ways: AGE. Infants and older adults have difficulty maintain-
ing normal body temperature for several reasons. Both
1. Adjusting where blood circulates
2. Causing piloerection (the contraction of arrector pili
muscles in skin follicles), which stiffens body hairs
and gives the appearance of what commonly is
described as “goose flesh”
3. Promoting a shivering response
BOX 12-2 ● Temperature Conversion Formulas

35.8
To convert Fahrenheit to centigrade, use the formula:
(°F − 32)
°C = Mechanisms Mechanisms
1.8
for for
Example: Step 1: 98.6°F − 32 = 66.6 Heat Production Heat Loss
Step 2: 66.6 ÷ 1.8 = 37°C
To convert centigrade to Fahrenheit, use the formula:

°F = ( °C × 1.8 ) + 32
Example: Step 1: 15°C × 1.8 = 27

Step 2: 27 + 32 = 59°F
FIGURE 12-1 • The hypothalamus regulates body temperature.
have limited subcutaneous white adipocytes (fat cells that essary for muscle activity, the body adjusts its metabolic
provide heat insulation and cushioning of internal struc- rate through endocrine hormones released from the pitu-
tures). The ability of both young and old to shiver and itary, thyroid, and adrenal glands. In contrast, inactivity
perspire also may be inadequate, putting them at risk for and reduced metabolism or nutrient intake may lead to
abnormally low or high body temperatures. Another lower body temperature.
problem for both populations is an inability to indepen-
dently forestall or reverse heat loss or gain without the CIRCADIAN RHYTHM. Circadian rhythms are physiologic
assistance of a caretaker. changes, such as fluctuations in body temperature and
Newborns and young infants tend to experience tem- other vital signs, over 24-hour cycles. Body temperature
perature fluctuations because they have a three times fluctuates 0.5° to 2.0°F (0.28° to 1.1°C) during a 24-hour
greater surface area from which heat is lost (Nicholl, period. It tends to be lowest from midnight to dawn and
2002) and a metabolic rate (use of calories for sustaining highest in the late afternoon to early evening. People who
body functions) twice that of adults. Older adults are com- routinely work at night and sleep during the day have
promised further by progressively impaired circulation, temperature fluctuations that cycle in reverse.
which interferes with losing or retaining heat through the
dilation or constriction of blood vessels near the skin. EMOTIONS. Emotions affect metabolic rate by trigger-
ing hormonal changes through the sympathetic and
CLIMATE. Climate affects mechanisms for temperature parasympathetic pathways of the autonomic nervous
regulation. Heat and cold produce neurosensory stimu- system (see Chap. 5). People who tend to be consis-
lation of thermal receptors in the skin, which transmit tently anxious and nervous are likely to have slightly
information through the autonomic nervous system to increased body temperatures. Conversely, people who
the hypothalamus. Cool environmental temperatures are apathetic or depressed are prone to have slightly
result in vasoconstriction of surface blood vessels with lower body temperatures.
subsequent shunting of blood to vital organs. This phys-
iologic phenomenon helps to explain how brain cells are ILLNESS OR INJURY. Diseases, disorders, or injuries that
protected temporarily in cold-water drownings. affect the function of the hypothalamus or mechanisms
People who live in predominately cold climates have for heat production and loss alter body temperature,
more brown adipocytes (fat cells uniquely adapted for sometimes dramatically. Some examples include tissue
thermogenesis) (Austen, 1998). Thermogenesis from injury, infections and inflammatory disorders, fluid loss,
brown fat occurs when norepinephrine triggers lipolysis injury to the skin, impaired circulation, and head injury.
(breakdown of fat). Those who live in arctic regions are
highly cold adaptive because they have increased brown MEDICATIONS. Various medications affect body tempera-
adipocytes. They tend to have an overall 10% to 20% ture by increasing or decreasing metabolic rate and energy
higher metabolic rate compared with those who live in requirements. Drugs, such as aspirin, acetaminophen, and
geographic areas with less severe environmental temper- ibuprofen, directly lower body temperature by acting on
atures (Edwards, 1999). Conversely, those who live in the hypothalamus itself. In the absence of fever, however,
the tropics have a 10% to 20% lower metabolic rate than their use will not lower body temperature to subnormal
those in milder climates. levels. Stimulant drugs, like those containing dextroam-
phetamine (Dexedrine) or ephedrine, increase metabolic
GENDER. Body temperature increases slightly in women rate and body temperature.
of childbearing age during ovulation. This probably results
from hormonal changes affecting metabolism or tissue
injury and repair after release of an ovum (egg). The Stop • Think + Respond BOX 12-1
change in body temperature is so slight that most women Explain how infants and older adults are particularly
are unaware of it unless they are monitoring their tem- vulnerable to alterations in temperature regulation.
perature daily (to plan or avoid pregnancy).
EXERCISE AND ACTIVITY. Both exercise and activity involve Assessment Sites
muscle contraction. As muscle groups and tendons repeat-
edly stretch and recoil, the friction produces body heat. Body temperature can be assessed at various locations,
Shivering is another example of contractile thermogenesis. some of which are more practical than others. The most
Muscles also are the largest mass of metabolically active accurate locations for measuring core body temperature
tissue. This means that muscle activity generates addi- are the brain, heart, lower third of the esophagus, and
tional heat from chemical reactions during the muscle urinary bladder. Measuring the temperature in the brain
cells’ combustion of nutrients for cellular functions. To is currently prohibitive because of a lack of technology.
provide adequate calories that will give the energy nec- The temperature of blood circulating through the heart,
esophagus, or bladder is measured using a thermistor

catheter (heat-sensing device at the tip of an internally Probe tip
placed tube). The required skill for insertion and risks
associated with the use of thermistor catheters, however, Ear canal
restricts their use to clients with highly acute illness.
The most practical and convenient temperature assess-
ment sites are the ear (tympanic membrane), mouth,
rectum, and axilla. These areas are anatomically close 36.9
to superficial arteries containing warm blood, enclosed 37.3
areas where heat loss is minimal, or both. Of the four
36.6
sites, the ear (more specifically, the tympanic membrane) 34.5
is the peripheral site that most closely reflects core body
temperature.
Temperature measurements vary slightly depending Tympanic
on the assessment site (Table 12-2). To evaluate trends in membrane
body temperature, the nurse documents the assessment
site as O for oral, R for rectal, AX for axillary, and T for
tympanic membrane. He or she takes the temperature by
FIGURE 12-2 • Obtain the most accurate tympanic temperature by
the same route each time. aiming the probe toward the anterior inferior third of the ear canal.
The Ear
Research indicates that the temperature within the ear an oral thermometer in the rear sublingual pocket at the
near the tympanic membrane has the closest correla- base of the tongue (Fig. 12-3). Poor placement or prema-
tion to core temperature. This conclusion is based on two ture removal of the thermometer can result in inaccurate
anatomic facts: the tympanic membrane is just 1.4 inches measurements, deviating by as much as 1.5°F (0.9°C)
(3.8 cm) from the hypothalamus; blood from the internal from the actual temperature.
and external carotid arteries, the same vessels that supply The oral site is contraindicated for clients who are
the hypothalamus, also warms the tympanic membrane. uncooperative, very young, unconscious, shivering, prone
For these reasons, temperatures obtained at this site, if to seizures, or mouth breathers; those who have had oral
the thermometer is inserted correctly (Fig. 12-2), are con- surgery; and those who continue to talk during temper-
sidered more reliable than those obtained at the oral and ature assessment. To ensure accuracy, the nurse delays
axillary sites. They also correlate closely with those taken oral temperature assessment for at least 30 minutes after
at the rectal site. Also, because the tympanic membrane the client has been chewing gum, smoking a cigarette, or
is fairly deep within the head, warm or cool air temper- eating hot or cold food or beverages.
atures affect it less.
Oral Site
The oral site, or mouth, is convenient. It generally mea- 36.88 36.77
sures 0.8° to 1.0°F (0.5° to 0.6°C) below core tempera-
ture. The area under the tongue is in direct proximity to
the sublingual artery. As long as the client keeps the X X
mouth closed and breathes normally, the tissue remains
at a fairly consistent temperature. Valid measurement 36.88 36.77
also depends on accurate placement and maintenance of
36.66 36.66
EQUIVALENT THERMOMETER 36.33 36.22

TABLE 12-2 MEASUREMENTS ACCORDING 36.0
TO SITE 36.66 36.77
ASSESSMENT SITE FAHRENHEIT CENTIGRADE 36.0
Oral 98.6° 37°

Rectal equivalent 99.5° 37.5°
Axillary equivalent 97.5° 36.4° FIGURE 12-3 • Temperature measurements vary with the placement
Tympanic membrane 99.5° 37.5° of the oral thermometer. A thermometer placed at the rear sublingual
pockets provides the most accurate measurement.
Rectal Site requires that the thermometer remain at the assessment

site for a longer, steady time to obtain the actual temper-
A rectal temperature differs only about 0.2°F (0.1°C) from
ature. There is no significant difference in temperature
core temperature. Rapid fluctuations in temperature may
measurements obtained by the predictive versus the mon-
not be identified for as long as 1 hour, however, because
itor mode (Nicholl, 2002). The electronic unit senses
this area retains heat longer than other sites. In addition,
when the temperature ceases to change and emits a beep.
this site can be embarrassing and emotionally traumatic for
The audible signal alerts the nurse to remove the probe
alert clients. Furthermore, stool in the rectum, improper
and read the displayed measurement.
placement of the thermometer, and premature removal
affect the accuracy of rectal temperature assessment.
Infrared (Tympanic) Thermometers
Axillary Site Infrared tympanic thermometers are the newest type
of electronic equipment for assessing body temperature.
The axilla, or underarm, is an alternative site for assess-
ing body temperature. Temperature measurements from The device consists of a hand-held covered probe that is
this site are generally 1°F (0.6°C) lower than those inserted into the ear canal (Fig. 12-5). Its base-charging
obtained at the oral site and reflect shell rather than core unit is sometimes referred to as its cradle.
temperature (except in newborns). Because infants can The probe contains an infrared sensor that detects
be injured internally with thermometers and because the warmth radiating from the tympanic membrane
they lose heat through their skin at a greater rate than (eardrum) and converts the heat into a temperature mea-
other age groups, the axilla and the groin, areas where surement in 2 to 5 seconds. The potential for transferring
there is skin-to-skin contact, are preferred sites for tem- microorganisms from one client to another is reduced
perature assessment in this age group. because the probe cover is changed after each use and
The axillary site has several advantages for all age because the ear does not contain mucous membrane and
groups. It is readily accessible in most instances. It is safe. its accompanying secretions.
There is less potential for spreading microorganisms than Despite the advantages of tympanic thermometers,
with the oral and rectal sites, and it is less disturbing infrared thermometers can produce inaccurate measure-
psychologically than the rectal site. This route, how- ments in the following circumstances:
ever, requires the longest assessment time of 5 minutes • The ear canal is not straightened appropriately.
or longer depending on the electronic monitoring mode • The probe, which measures 6 to 8 mm, is too large for
being used (discussed later). Poor circulation, recent the ear canal (a problem with infants and small chil-
bathing, or rubbing the axillary area dry with a towel dren whose ear canals are 5 mm or smaller). The size
also affects the accuracy of the axillary site. difference alters the location where infrared light must
be precisely directed. Consequently use of a tympanic
thermometer is contraindicated for children younger
Thermometers than 2 years.
• The sensor is directed at the ear canal rather than
There are several types of clinical thermometers (instru- directly at the tympanic membrane.
ments used to measure body temperature): electronic, • There is impacted cerumen (ear wax), a common prob-
infrared, chemical, digital, and glass (Table 12-3). lem among older adults.
• There is fluid behind the tympanic membrane, a prob-
Electronic Thermometers lem that occurs with middle-ear infections.
An electronic thermometer (Fig. 12-4) uses a temperature- • The drawdown effect (cooling of the ear when it comes
sensitive probe covered with a disposable sheath and in contact with the probe) occurs.
attached by a coiled wire to a display unit. Electronic The first use of a tympanic thermometer after recharg-
thermometers are portable. They are recharged when
ing is not always as accurate as a second reading. Another
not in use.
criticism of tympanic temperature measurement is that
Electronic thermometers generally have two types of
currently there is no standard for actual ear or core
probes: one for oral or axillary use and another for rectal
temperatures. At present, tympanic thermometers use
use. Some models offer the option of providing the mea-
internally calculated offsets (predictive mathematical con-
surement in Fahrenheit or Centigrade.
versions) for oral and rectal temperatures. These offsets
Electronic thermometers operate in either a predic-
vary among manufacturers.
tive mode or monitor mode. If used in the predictive mode,
the thermometer takes multiple measurements that a
Glass Thermometers
computer chip processes in only a few seconds to deter-
mine what the temperature would be if the thermometer Electronic and infrared tympanic thermometers have
was left in place for several minutes. The monitor mode replaced glass mercury thermometers in health care
TABLE 12-3 TYPES OF CLINICAL THERMOMETERS

TYPE ADVANTAGES DISADVANTAGES
Electronic Faster than glass Expensive

Accurate Recharging necessary
No sterilization or disinfection needed Probe needs to be held by 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 (tympanic) Fastest Expensive
Convenient Battery recharging necessary
Closest approximation of core temperature Accuracy affected by improper placement and probe size
Least invasive Actual ear and core temperature ranges slightly
Accuracy unaffected by eating, drinking, or different from oral, rectal, and axillary sites
breathing Tip requires cleaning with a paper tissue or alcohol swab
Most sanitary Extreme hot or cold environmental temperatures
affecting electronics
No sterilization or disinfection required
Chemical Inexpensive Varying measurements at different body sites
Safe; nonbreakable depending 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
Memory displays last temperature thermometer of 95–102.2°F
Fast; records in 1 to 3 minutes Accuracy is +/− 0.4°F compared with glass
Audible signal during or after assessment thermometer at <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
Widely available 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 possible, if not
properly disposed of
agencies. Glass thermometers contain mercury and are the client has available. If a glass thermometer is the only
considered environmentally toxic and obsolete because option, the nurse teaches clients and their family mem-
safer alternatives are available and preferred. bers how to clean the glass thermometer. See Client and
The Mercury Reduction Act, passed in 2002 and Family Teaching 12-1.
amended in 2005, prohibits the sale or supply of mercury If a glass thermometer breaks, the mercury is dis-
fever thermometers to consumers, except by prescrip- posed following the actions discussed in Nursing Guide-
tion. It further requires manufacturers to provide clear lines 12-1.
instructions on handling mercury thermometers to avoid
breakage and proper cleanup in the event of breakage
Chemical Thermometers
(United States 109th Congress, 2002, 2005). Health care
institutions are making their facilities mercury free. Various chemical thermometers are available. One exam-
Nurses may be required to use a client’s glass ther- ple is a paper or plastic strip with chemically treated dots
mometer or teach a client to use one because that is all (Fig. 12-6). Temperature is determined by noting how
Cleaning Glass Thermometers

The nurse teaches the client or the family the
following:
• Don gloves if there is the potential for contact
with blood or stool (as with rectal assessment).
• Hold the thermometer at the tip of the stem.
Keep the bulb downward 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 potential breaking if dropped.
FIGURE 12-4 • Electronic thermometer. (Copyright B. Proud.) • Rinse the thermometer under cold running water.
• Dry the thermometer with a soft towel.
• Soak the thermometer in 70% to 90% isopropyl
many dots change color after the strip is held in the
alcohol or a 1:10 solution of household bleach
mouth. Chemical dot thermometers are discarded after
(1 part bleach to 10 parts water).
one use. They are used to assess the temperature of
• Rinse the thermometer after disinfecting it.
clients who require isolation precautions for infectious
• Store the thermometer in a clean, dry container.
diseases. Their use eliminates the need to clean a multi-
use electronic or infrared thermometer. Some physician’s
offices also use chemical dot thermometers because they
are disposable.
A second type of chemical thermometer is made of Disposing Heavy Metal Safely
a heat-sensitive tape or patch applied to the abdomen
❙ Don gloves.
or forehead (Fig. 12-7). The tape or patch changes color
according to body temperature. Heat-sensitive tapes ❙ Pick up shards of glass and place in a puncture-resistant
and patches can be reused several times before being container.
thrown away. ❙ Use an index card to pool the droplets of mercury.
❙ Collect the droplets with a syringe, pipette, adhesive tape, or wet
Digital Thermometers paper towel.
A plastic digital thermometer looks similar to a glass ther- ❙ Seal the mercury in a glass or plastic jar or sturdy plastic bag.
mometer (Fig. 12-8) and can be used at oral, axillary, and ❙ Affix a label identifying the contents as “mercury spill debris.”
rectal sites. It has a sensing tip at the end of the stem, an ❙ Deliver the mercury spill debris to the waste manager of the
on/off button, and a display area that lights up during use. health care institution or the county public health department
The battery used to operate the thermometer requires (Princeton University Environmental Health and Safety, 2004).
occasional replacement.
FIGURE 12-5 • Infrared tympanic thermometer. (Copyright B. Proud.) FIGURE 12-6 • Chemical thermometer.
FIGURE 12-7 • Disposable chemical thermometer with heat-sensitive

FIGURE 12-9 • An automated monitoring device. (Copyright B. Proud.)
liquid crystals. (Copyright B. Proud.)
money. Agencies have found that the use of automated

Digital thermometers are designed for multiple uses; monitors allows some potentially unstable clients to be
for this reason, they require cleaning after use. Digital cared for on a general medical-surgical unit rather than
thermometers are cleaned similarly to glass thermome- in the more expensive intensive care unit. To ensure
ters except that they are wiped rather than soaked with reliable data, the accuracy of automated devices is com-
isopropyl alcohol. Disposable plastic sheaths can be used pared with data measured with manual devices on a
to cover the probe with each use as an alternative sani- regular basis.
tary measure.
Continuous Monitoring Devices
Automated Monitoring Devices Continuous temperature monitoring devices are used
Some agencies use automated monitoring devices (equip- primarily in critical care areas. They measure body tem-
ment that allows for the simultaneous collection of mul- perature using internal thermistor probes within the
tiple data). They may measure the temperature, blood esophagus of anesthetized clients, inside the bladder, or
pressure, and pulse, as well as other information such as attached to a pulmonary artery catheter. These measure-
heart rhythm and pulse oximetry (Fig. 12-9). Some mod- ments generally are required when caring for clients with
els can store and display the trends in vital signs. extreme hypothermia or hyperthermia. Warming or cool-
Most automated monitors are portable and can be ing blankets usually are used at the same time (see Chap.
moved from room to room or remain at one client’s bed- 28). Temperature assessment aids in evaluating the effec-
side. Their chief advantage is that they save time and tiveness of these treatment devices.
Skill 12-1 describes how to assess body temperature
using electronic, infrared, and glass thermometers. Some
agencies also use automated and continuous monitoring
devices.

When caring for an older adult who has chronic disorders
but is currently stable, what type of thermometer and site
are best for temperature assessment? Explain your choice.
Elevated Body Temperature
A fever (body temperature that exceeds 99.3°F [37.4°C])

is a common indication of illness. Pyrexia (Greek word
for fire) is a term used to describe a warmer-than-normal
set point. A person with a fever is said to be febrile (con-
FIGURE 12-8 • A digital thermometer is a nonmercury alternative dition in which the temperature is elevated) as opposed
considered as accurate as a glass mercury thermometer. to afebrile (no fever).
The following are common signs and symptoms asso- VARIATIONS IN

ciated with a fever: TABLE 12-4
FEVER PATTERNS
• Pinkish, red (flushed) skin that is warm to the touch TYPE OF FEVER DESCRIPTION
• Restlessness or, in others, excessive sleepiness
Sustained fever Remains elevated with little fluctuation
• Irritability
• Poor appetite Remittent fever Fluctuates several degrees but never
reaches normal between fluctuations
• Glassy eyes and sensitivity to light
Intermittent fever Cycles frequently between periods of
• Increased perspiration
normal or subnormal temperatures
• Headache and spikes of fever
• Above-normal pulse and respiratory rates Relapsing fever Recurs after a brief but sustained
• Disorientation and confusion (when the temperature period during which temperature has
is high) been normal
• Convulsions in infants and children (when the tem-
perature is high)
• Fever blisters around the nose or lips in clients who
harbor the herpes simplex virus Common variations in fever patterns are described in
Table 12-4. Fevers also subside in different ways. If an
Hyperthermia (excessively high core temperature) de- elevated temperature suddenly drops to normal, it is
scribes a state in which the temperature exceeds 105.8°F referred to as a resolution by crisis. If descent is gradual,
(40.6°C). At this level, the person is at extremely high it is a resolution lysis.
risk for brain damage or death from complications asso-
ciated with increased metabolic demands. Nursing Management
Phases of a Fever A fever is considered an important body defense for
destroying infectious microorganisms. Therefore, as
A fever generally progresses through four distinct phases: long as a fever remains below 102°F (38.9°C) and the
1. Prodromal phase: The client has nonspecific symp- person does not have a chronic medical condition, fluids
toms just before the temperature rises. or rest may be all that is necessary.
2. Onset or invasion phase: Obvious mechanisms for Antipyretics (drugs that reduce fever), such as aspirin,
increasing body temperature, such as shivering, acetaminophen, or ibuprofen, are helpful when a temper-
develop. ature is 102° to 104°F (38.9° to 40°C). Physical cooling
3. Stationary phase: The fever is sustained. measures are used for temperatures between 104° and
4. Resolution or defervescence phase: Temperature 105.8°F (40° to 40.6°C). If the temperature is higher than
returns to normal (Fig. 12-10). 105.8°F (40.6°C) or if a high temperature is unchanged
FIGURE 12-10 • Phases of a fever and physiologic changes.

after a sufficient response time with conventional inter-

ventions, more aggressive treatment is warranted.
Nursing Care Plan 12-1 describes nursing actions used The Client With a Subnormal Temperature
for a client with a nursing diagnosis of hyperthermia. ❙ Raise the room temperature. Doing so warms the body surface.
NANDA (2005) defines hyperthermia as “body temper-
ature elevated above normal range.” If the fever is so ❙ Remove wet clothing. This measure reduces heat loss.
severe that it requires medical interventions, it is a col- ❙ Apply layers of dry clothing and loosely woven blankets. Layers
laborative problem. trap body heat next to the skin.
❙ Warm blankets and clothing in an oven or microwave if body
temperature is quite low. Heating raises the temperature of woven
Subnormal Body Temperature fabrics above ambient (room) temperature.
❙ Position client so that the arms are next to the chest and the legs
There are several ranges of hypothermia (core body tem- are tucked toward the abdomen. This position prevents heat loss.
perature less than 95°F [35°C]). A person is considered ❙ Cover the head with a cap or towel. Covering the head reduces
mildly hypothermic at temperatures of 95° to 93.2°F heat loss.
(35° to 34°C), moderately hypothermic at 93° to 86°F (33.8° ❙ Provide warm fluids. Fluids conduct heat to internal organs.
to 30°C), and severely hypothermic below 86°F (30°C).
Cold body temperatures are best measured with a tym-
❙ Massage the skin unless it has been frostbitten. Massage
produces mechanical friction, which produces warmth.
panic thermometer for two reasons. First, other clinical
thermometers do not have the capacity to measure tem- ❙ Apply bags filled with warm water between areas of skin folds,
peratures in hypothermic ranges. Second, the blood flow or place an electronic warming pad beneath the back and hips
(see Chap. 28), according to medical orders. These measures
in the mouth, rectum, or axilla generally is so reduced
transfer heat to the blood as it circulates through the skin.
that measurements taken from these sites are inaccurate.
The following are common signs and symptoms asso-
ciated with hypothermia:
• Shivering until body temperature is extremely low during the heart’s contraction. In most adults, the heart
• Pale, cool, and puffy skin contracts 60 to 100 times per minute at rest.
• Impaired muscle coordination
• Listlessness
• Slow pulse and respiratory rates Pulse Rate
• Irregular heart rhythm
• Decreased ability to think coherently and use good The pulse rate (number of peripheral pulsations palpated
judgment in 1 minute) is counted by compressing a superficial artery
• Diminished ability to feel pain or other sensations against an underlying bone with the tips of the fingers.
In some illnesses, such as hypothyroidism and starva-
tion, the client typically has a subnormal temperature. Rapid Pulse Rate
Therefore, the nurse must assess clients just as closely The pulse rate of adults is considered rapid if it exceeds
when body temperature falls below normal ranges as 100 beats per minute (bpm) at rest. Tachycardia (100 to
when it is elevated. 150 bpm) is a fast heart rate, but heart and pulse rates
Clients with severe hypothermia usually die. Never- can exceed 150 bpm. Rapid contraction, if sustained,
theless, clients have been known to live even with very tends to overwork the heart and may not oxygenate cells
low temperatures, as in near-drowning in cold water and adequately because the heart has such little time between
exposure in extremely cold environments. This phenom- contractions to fill with blood.
enon has led to the saying among paramedics and emer- The term palpitation (awareness of one’s own heart con-
gency department personnel that “a person isn’t dead traction without having to feel the pulse) can accompany
until he or she is warm and dead.” Various supportive tachycardia. Clients with a rapid pulse rate are monitored
measures are implemented when clients have subnormal closely, and the results are reported and recorded accord-
body temperatures. See Nursing Guidelines 12-2. ing to agency policy.
Slow Pulse Rate

PULSE The pulse rate of adults is considered slower than normal
if it falls below 60 bpm. Bradycardia (less than 60 bpm) is
Pulse,a wavelike sensation that can be palpated in a less common than tachycardia; it merits prompt reporting
peripheral artery, is produced by the movement of blood and continued monitoring.
Factors Affecting Pulse and Heart Rates cally slow heart rate. Caffeine, nicotine, cocaine, thyroid
replacement hormones, and adrenaline increase heart
Any factors that affect the rate of heart contraction
contractions and subsequently pulse rate.
also cause comparable effects in pulse rate. Because
one depends on the other, the pulse rate can never be
faster than the actual heart rate. Heart and pulse rates Pulse Rhythm
may vary depending on the following:
The pulse rhythm (pattern of the pulsations and the pauses
• Age. Some common rates are listed in Table 12-5.
between them) is normally regular. That is, the beats and
• Circadian rhythm. Rates tend to be lower in the morn-
the pauses occur similarly throughout the time the pulse
ing and increase later in the day.
is palpated.
• Gender. Men average approximately 60 to 65 bpm at rest;
An arrhythmia or dysrhythmia (irregular pattern of heart-
the average rate for women is about 7 or 8 bpm faster. beats) with a consequently irregular pulse rhythm is
• Body build. Tall, slender people usually have slower reported promptly. Some types indicate potentially life-
heart and pulse rates than short, stout people. threatening cardiac dysfunctions that may warrant more
• Exercise and activity. Rates increase with exercise and sophisticated monitoring and treatment. Details about
activity and decrease with rest. With regular aerobic dysrhythmias and their causes can be found in textbooks
exercise, however, a training effect occurs, in which that discuss cardiac disorders.
heart rate and consequently pulse rate become consis-
tently lower than average. This effect develops because
the heart muscle becomes efficient at supplying body Pulse Volume
cells with sufficient oxygenated blood with fewer beats.
Those who are physically fit exhibit slower pulse rates Pulse volume (quality of pulsations felt) usually is related
even during exercise. to the amount of blood pumped with each heartbeat, or
• Stress and emotions. Stimulation of the sympathetic the force of the heart’s contraction. A normal pulse is
nervous system and emotions such as anger, fear, and described as strong when it can be felt with mild pressure
excitement increase heart and pulse rates. Pain, which over the artery. A feeble, weak, or thready pulse describes
is stressful (especially when moderate to severe), can a pulse that is difficult to feel or, once felt, is obliterated
trigger faster rates. easily with slight pressure. A rapid, thready pulse is usu-
• Body temperature. For every degree of Fahrenheit ele- ally a serious sign and reported promptly. A bounding or
vation, the heart and pulse rates increase 10 bpm. A full pulse produces a pronounced pulsation that does not
1-degree increase in centigrade measurement causes a easily disappear with pressure.
15-bpm increase (Porth, 2004). With a fall in body Another way to describe the volume or quality of the
temperature, an opposite effect occurs. pulse is with corresponding numbers (Table 12-6). When
• Blood volume. Excessive blood loss causes the heart documenting pulse volume, the nurse should follow
agency policy about using descriptive terms or a num-
and pulse rates to increase. With decreased red blood
bering system.
cells or inadequate hemoglobin to distribute oxygen to
cells, the heart rate accelerates in an effort to keep cells
adequately supplied. Assessment Sites
• Drugs. Certain drugs can slow or speed the rate of heart
contraction. Digitalis preparations and sedatives typi- The arteries used for pulse assessment lie close to the
skin. Most, but not all, are named for the bone over which
they are located (Fig. 12-11). These pulse sites are collec-
NORMAL PULSE RATES PER tively called peripheral pulses because they are distant
TABLE 12-5 from the heart. Of all the peripheral pulses, the radial
MINUTE AT VARIOUS AGES
APPROXIMATE APPROXIMATE
artery, located on the inner (thumb) side of the wrist,
AGE RANGE AVERAGE is the site most often used for pulse assessment. Three
alternative assessment techniques can be used instead of
Newborn 120–160 140 or in addition to assessment of a peripheral pulse. These
1–12 months 80–140 120 techniques include counting the apical heart rate, obtain-
1–2 years 80–130 110 ing an apical–radial rate, and using a Doppler ultrasound
3–6 years 75–120 100 device over a peripheral artery.
7–12 years 75–110 95
Adolescence 60–100 80 Apical Heart Rate
Adulthood 60–100 80 The apical heart rate (number of ventricular contractions
per minute) is considered more accurate than the radial
TABLE 12-6 IDENTIFYING PULSE VOLUME

NUMBER DEFINITION DESCRIPTION
0 Absent pulse No pulsation is felt despite extreme pressure.

1+ Thready pulse Pulsation is not easily felt; slight pressure causes it to
disappear.
2+ Weak pulse Pulse is stronger than thready; light pressure causes it to
disappear.
3+ Normal pulse Pulsation is felt easily; moderate pressure causes it to
disappear.
4+ Bounding pulse Pulsation is strong and does not disappear with
moderate pressure.
pulse for two reasons. First, the sound of each heart- below the left nipple in line with the middle of the clav-
beat is obvious and distinct. Second, sometimes the heart icle (Fig. 12-12).
contraction is not strong enough to be felt at a periph- When assessing the apical heart rate by listening to the
eral pulse site. Counting the apical rate, however, is chest—which is generally the more accurate technique—
less convenient than counting a radial pulse. An apical the nurse listens for the “lub/dub” sound. The lub sound
heart rate generally is assessed when the peripheral is louder if the stethoscope has been correctly applied.
pulse is irregular or difficult to palpate because of a rapid These two sounds equal one pulsation at a peripheral
rate or thready quality or when it is necessary to obtain pulse site. The apical heart rate is counted for 1 full minute,
an actual heart rate. and the rhythm is also evaluated.
The apical heart rate is counted by listening at the
chest with a stethoscope or by feeling the pulsations Apical–Radial Rate
in the chest at an area called the point of maximum
impulse for 1 full minute. As the name suggests, the The apical–radial rate (number of sounds heard at the heart’s
heartbeats are best heard, or felt, at the apex, or lower apex and the rate of the radial pulse during the same
tip, of the heart. The apex in a healthy adult is slightly period) is counted by separate nurses at the same time
using one watch or clock (Fig. 12-13). The apical and
radial rates should be the same, but in some clients, they
are not. The pulse deficit (difference between the apical and
radial pulse rates) is noted. If a pulse deficit is significant—
and the rates have been counted accurately—the nurse
Temporal
Carotid
Apex of
heart Clavicle
Brachial
Radial
1
2
3
Femoral
4
Popliteal
5
Posterior
tibialis Apical
impulse
Dorsalis
pedis
FIGURE 12-12 • Assess the apical heart rate to the left of the sternum
FIGURE 12-11 • Peripheral pulse sites. at the interspace below the fifth rib in midline with the clavicle.
the rate, followed by the abbreviation D to indicate use

of a Doppler device.
Skill 12-2 describes how to assess the rate, rhythm,
and volume of the pulse at the radial artery.

If assessing the radial pulse is difficult or impossible, what
alternatives could be taken?
RESPIRATION
Respiration is the exchange of oxygen and carbon dioxide.

When it occurs between the alveolar and capillary mem-
FIGURE 12-13 • One nurse counts the radial pulse while the other branes, it is called external respiration. The exchange of
counts the apical rate. (Copyright B. Proud.) oxygen and carbon dioxide between the blood and body
cells is called internal or tissue respiration.
Ventilation (movement of air in and out of the chest)
reports the findings promptly and documents them in the involves inhalation or inspiration (breathing in) and exha-
client’s medical record. lation or expiration (breathing out). The medulla, which
is the respiratory center in the brain, controls ventila-
Doppler Ultrasound Device tion. The medulla is sensitive to the amount of carbon
A Doppler ultrasound device is an electronic instru- dioxide in the blood and adapts the rate of ventilations
ment that detects the movement of blood through periph- accordingly. Breathing can be voluntarily controlled to a
eral blood vessels and converts the movement to a sound. certain extent.
This instrument is most helpful when slight pressure
occludes pulsations or arterial blood flow is severely
compromised. Respiratory Rate
When the device is used, conductive gel is applied over
the arterial site, and the probe is moved at an angle over The respiratory rate (number of ventilations per minute)
the skin until a pulsating sound is heard (Fig.12-14). The varies considerably in healthy people, but normal ranges
pulsating sounds are counted, much like the palpated have been established (Table 12-7). Factors that influence
pulsations. The nurse documents the assessment site and pulse rate generally also affect respiratory rate. The faster
the pulse rate, the faster the respiratory rate, and vice
versa. The ratio of one respiration to approximately four
or five heartbeats is fairly consistent in healthy adults.
Rapid Respiratory Rates

Resting respiratory rates that exceed the standards for
a client’s age are considered abnormal. Tachypnea (rapid
TABLE 12-7
NORMAL RESPIRATORY RATES
AT VARIOUS AGES
AGE AVERAGE RANGE
Newborn 30–80
Early childhood 20–40
Late childhood 15–25
Adulthood
Men 14–18
FIGURE 12-14 • Using a Doppler ultrasound device. (Copyright B. Women 16–20
Proud.)
respiratory rate) often accompanies an elevated temper- nurse uses a stethoscope to listen to the sounds of air mov-
ature or diseases that affect the cardiac and respiratory ing through the chest. The technique and the characteris-
systems. tics of lung sounds are described in Chapter 13.
Skill 12-3 lists techniques to use when counting the
Slow Respiratory Rates respiratory rate.
Bradypnea (slower-than-normal respiratory rate at rest)
can result from medications—for instance, morphine
sulfate slows the respiratory rate. Slow respirations also
may be observed in clients with neurologic disorders or What nursing actions are appropriate if a client has an
experiencing hypothermia. abnormal respiratory rate?
Breathing Patterns and

BLOOD PRESSURE
Abnormal Characteristics
Various breathing patterns and abnormal characteris- Blood pressure is the force that the blood exerts within
tics may be identified when assessing respiratory rates. the arteries. Several physiologic variables create blood
Cheyne-Stokes respiration refers to a breathing pattern pressure:
in which the depth of respirations gradually increases, • Circulating blood volume averages 4.5 to 5.5 L in adult
followed by a gradual decrease, and then a period when
women and 5.0 to 6.0 L in adult men. Lower-than-
breathing stops briefly before resuming again. Cheyne-
normal volumes decrease blood pressure; excess vol-
Stokes respiration is a serious sign that may occur as death
umes increase it.
approaches.
• Contractility of the heart is influenced by the stretch
Hyperventilation (rapid or deep breathing or both) and
of cardiac muscle fibers. Based on Starling’s law of the
hypoventilation (diminished breathing) affect the volume
heart, the force of heart contraction is related to preload
of air entering and leaving the lungs. Changes in ventila-
(volume of blood that fills the heart and stretches the
tion may occur in clients with airway obstruction or pul-
heart muscle fibers during its resting phase). A common
monary or neuromuscular diseases.
analogy is to compare the effect of preload and contrac-
Dyspnea (difficult or labored breathing) is almost always
accompanied by a rapid respiratory rate as clients work tility with the snap of a rubber band stretched to vari-
to improve the efficiency of their breathing. Clients with ous lengths—the longer the rubber band is stretched,
dyspnea usually appear anxious and worried. The nos- the greater it snaps when released. Tissue damage that
trils flare (widen) as they fight to fill the lungs with air. scars the heart, such as after a heart attack, impairs
They may use the abdominal and neck muscles to assist stretching and reduces contractility. Regular aerobic
other muscles in breathing. When observing these clients, exercise increases the tone of the heart muscle, making
the nurse should note how much and what type of activ- it an efficient muscular pump.
ity brings on dyspnea. For example, walking to the bath- • Cardiac output (volume of blood ejected from the left
room may bring on dyspnea in a client but sitting in a ventricle per minute) is approximately 5 to 6 L (slightly
chair may not. more than a gallon) in adults at rest. It is estimated
Orthopnea (breathing facilitated by sitting up or stand- by multiplying the heart rate by the stroke volume
ing) occurs in clients with dyspnea who find it easier to (amount of blood that leaves the heart with each con-
breathe this way. The sitting or standing position causes traction). The average stroke volume in adults is 70 mL.
organs in the abdominal cavity to fall away from the With exercise, cardiac output can increase as much as
diaphragm with gravity. This gives more room for the five times the resting volume. Bradycardia can severely
lungs to expand within the chest cavity, allowing the per- reduce cardiac output and thus blood pressure.
son to take in more air with each breath. • Blood viscosity (thickness) creates a resisting force
Apnea (absence of breathing) is life threatening if it when the heart contracts. The resistance compromises
lasts more than 4 to 6 minutes. Prolonged apnea leads to stroke volume and cardiac output. Blood thickens when
brain damage or death. Brief periods of apnea lower oxy- there are more cells and proteins than water in plasma.
gen levels in the blood and can trigger serious abnormal Circulating viscous blood also tires the heart and weak-
cardiac rhythms (see Chap. 21 for more on sleep apnea). ens its ability to contract.
Terms such as stertorous breathing (noisy ventilation) • Peripheral resistance, referred to as afterload (force
and stridor (harsh, high-pitched sound heard on inspiration against which the heart pumps when ejecting blood),
when there is laryngeal obstruction) are used to describe increases when the valves of the heart and arterioles
sounds that accompany breathing. Infants and young chil- (small subdivisions of arteries) are narrowed or calci-
dren with croup often have stridor when breathing. The fied. Afterload is decreased when arteries dilate.
In healthy people, the arterial walls are elastic and

easily stretch and recoil to accommodate the changing
volume of circulating blood. Measuring the blood pres-
Systolic pressure
sure helps to assess the efficiency of the circulatory sys- (heart contracts)
tem. Blood pressure measurements reflect (1) the ability
of the arteries to stretch, (2) the volume of circulating 120
blood, and (3) the amount of resistance the heart must 200
overcome when it pumps blood.
60 240
40 280
Factors Affecting Blood Pressure
Besides the physiologic variables that create blood pres-

sure, other factors cause temporary or permanent alter- Diastolic pressure
ations: (heart at rest)
• Age. Blood pressure tends to rise with age as a result of

arteriosclerosis, a process in which arteries lose their Sphygmomanometer
elasticity and become more rigid, and atherosclerosis,
a process in which the arteries become narrowed with
fat deposits. The rate of these conditions depends on
FIGURE 12-15 • The pressure of blood in the arteries is higher during
heredity and lifestyle habits such as diet and exercise. systole when the heart contracts and lower during diastole when the
• Circadian rhythm. Blood pressure tends to be lowest heart muscle relaxes; hence, the terms systolic and diastolic pressure.
after midnight, begins rising at approximately 4 or
5 a.m., and peaks during late morning or early
afternoon. Currently blood pressure measurement is expressed
• Gender. Women tend to have lower blood pressure in millimeters of mercury (abbreviated mm Hg) because
than men of the same age. the mercury sphygmomanometer, an instrument for mea-
• Exercise and activity. Blood pressure rises during exer- suring blood pressure using a graduated column of mer-
cise and activity, when the heart pumps more blood. cury, has been the standard for use. Thus, a recording
Regular exercise, however, helps to maintain blood of 118/78 means the systolic blood pressure measured
pressure within normal levels. 118 mm Hg and the diastolic blood pressure measured
• Emotions and pain. Strong emotional experiences and 78 mm Hg. Because mercury within the sphygmomanom-
pain tend to increase blood pressure from sympathetic eter is a toxin that persists and accumulates within the
nervous system stimulation. environment and living species, mercury sphygmo-
• Miscellaneous factors. As a rule, a person has lower manometers have been eliminated. As a result, some pro-
blood pressure when lying down than when sitting or pose that the pressure measurements should be changed
standing, although the difference in most people is to something other than mm Hg. One possible alternative
insignificant. Blood pressure also seems to rise some- is to use the kilopascal (kPa), a measurement from the
what when the urinary bladder is full, when the legs are European Système International (SI) in which 1 mm Hg
crossed, or when the person is cold. Drugs that stimu- equals 0.133 kPa. Using this system, the equivalent of
a normal blood pressure of 118/78 mm Hg would be
late the heart such as nicotine, caffeine, and cocaine also
16/11 kPa when rounded to the nearest decimal point.
tend to constrict the arteries and raise blood pressure.
Currently a committee of experts from the National
Heart, Lung, and Blood Institute and American Heart
Association are investigating changes in blood pressure
Pressure Measurements equipment and standards to measure blood pressure
(Working Meeting on Blood Pressure Measurement,
When assessing blood pressure, nurses obtain both sys- 2002. Available at: http://www.nhlbi.nih.gov/health/
tolic and diastolic measurements. Systolic pressure (pres- prof/heart/hbp/bpmeasu.htm).
sure within the arterial system when the heart contracts) The pulse pressure (difference between systolic and
is higher than diastolic pressure (pressure within the arte- diastolic blood pressure measurements) is computed by
rial system when the heart relaxes and fills with blood). subtracting the smaller measurement from the larger.
Blood pressure measurement is expressed as a fraction. For example, when the blood pressure is 126/88 mm
The numerator is the systolic pressure, the pressure dur- Hg, the pulse pressure is 38. A pulse pressure between
ing systole, and the denominator is the diastolic pressure, 30 and 50 is considered normal, with 40 being a healthy
the pressure during diastole (Fig. 12-15). average.
Studies of healthy people show that blood pressure can Sphygmomanometer

fluctuate within a wide range and still be normal. Because
A sphygmomanometer may be portable or wall mounted.
individual differences can be considerable, analyzing the
usual ranges and patterns of blood pressure measure- It contains a gauge for measuring the pressure of a gas or
ments for each person is important. A rise or fall of 20 to liquid. Mercury manometers have always been consid-
30 mm Hg in usual pressure is significant, even if it is well ered the gold standard; however, health care agencies
within the generally accepted range for normal. have eliminated devices containing mercury. Now two
types of devices are available for measuring blood pres-
sure noninvasively: the aneroid and electronic oscillo-
Assessment Sites metric manometers (Fig. 12-16).
Blood pressure usually is assessed over the brachial artery ANEROID MANOMETER. An aneroid manometer, named
at the inner aspect of the elbow. It also is possible to use from the French word aneroide, which means “no liquid,”
the lower arm and radial artery. There are situations in measures pressure using a spring mechanism. Its gauge
which the nurse must use an alternative to brachial or features a needle that moves around a numbered dial. The
radial measurement: numbers correspond to the measurements obtained with
a mercury manometer. Before using an aneroid manome-
• When the client’s arms are missing ter, the needle on the gauge must be positioned at zero to
• When both of a client’s breasts have been removed
ensure an accurate measurement.
• When a client has had vascular surgery (such as that
which permits dialysis treatments for kidney failure)
ELECTRONIC OSCILLOMETRIC MANOMETER. An electronic
• When dressings or plaster or fiberglass casts obscure
oscillometric manometer is battery operated or uses power
the brachial and radial sites
from an electrical outlet. Unlike an aneroid manometer,
In these and other unusual circumstances, the blood pres- an electronic oscillometric manometer does not require
sure is measured over the popliteal artery behind the knee a stethoscope for auscultating sounds that correspond to
(see later sections, Alternative Assessment Techniques; pressure measurements. It measures blood pressure with
Measuring Thigh Blood Pressure). Documentation of the a transducer within the cuff. The transducer is a device
site is essential because measurements vary depending on that receives sound waves, in this case, from the flow of
the site used. blood within the artery. The device actually measures the
mean arterial pressure (MAP) and then electronically cal-
culates the systolic and diastolic pressure using a prepro-
Equipment for Measuring Blood Pressure grammed formula. The calculated pressures are visually
displayed. Models vary from those used in intensive care
Blood pressure most often is measured with a sphygmo- settings to others intended for home use.
manometer (a device for measuring blood pressure), an Aneroid and electronic monitors have advantages and
inflatable cuff, and a stethoscope. disadvantages (Table 12-8). Either can be used to assess
A B FIGURE 12-16 • Aneroid (A) and electronic oscillometric

manometer (B).
TABLE 12-8 COMPARISONS OF SPHYGMOMANOMETER EQUIPMENT

Aneroid Inexpensive Delicate

Easy to carry and store Periodic checking against a mercury sphygmomanometer necessary for
Ability to read gauge from any accuracy
position 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 accuracy.
Facilitation of BP measurement of Calibration check and readjustment recommended every 6 months.
newborns and infants in whom Manufacturer repair needed.
auscultation (listening with a
stethoscope) is difficult.
(Adapted from Blood pressure: Buying and caring for home equipment. American Heart Association, 1999.)
blood pressure, provided they are working properly and leading to a chest piece that may be a bell, diaphragm, or
are used correctly. both (Fig. 12-18). The eartips are generally rubber or
plastic. When the stethoscope is used, the eartips are posi-
Inflatable Cuff tioned downward and forward within the ears to produce
The cuff of a sphygmomanometer contains an inflat- the best sound perception. If various people are using
able bladder to which two tubes are attached. One is stethoscopes, they must clean the eartips with alcohol
connected to the manometer, which registers the pres- pads between uses. Personal stethoscopes also need peri-
sure. The other is attached to a bulb that is used to inflate odic cleaning to keep the eartips free of cerumen and dirt.
the bladder with air. A screw valve on the bulb allows the
nurse to fill and empty the bladder. As the air escapes,
80-100%
the pressure is measured.
Bladder
Cuffs come in various sizes. A common guide (Fig. length
12-17) is to use a cuff whose bladder width is at least
40% and whose length is 80% to 100% of midlimb cir-
cumference (Pickering et al., 2005). Note that it is not the 40%
Cuff Bladder
width and length of the cuff itself, but rather the inflatable
width
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-
Bladder
sure reading will be falsely high. At the working meet-
ing on blood pressure measurement under the auspices
of the National High Blood Pressure Education Pro-
gram, National Heart, Lung, and Blood Institute, and
American Heart Association in April 2002, it was noted
that the mean arm circumference of U.S. adults is increas-
ing because of the growing trend toward obesity. This
means that the standard adult blood pressure cuff no 40%
longer corresponds to a “standard adult” because more 80-100%
and more adults require a “large adult” cuff when the
blood pressure is measured. The nurse must select a cuff
with an appropriate bladder size for the body propor-
tions of each client.
Stethoscope
FIGURE 12-17 • To determine the appropriate size of blood pressure
A stethoscope (instrument that carries sound to the ears) cuff, the width of the bladder should be 40% of the midarm circumfer-
is composed of eartips, a brace and binaurals, and tubing ence, and the length should be at least 80%.
The bell, or cup-shaped chest piece, is used to detect

low-pitched sounds such as those produced in blood ves-
sels. The diaphragm, or disk-shaped chest piece, detects
high-pitched sounds such as those in the lungs, heart, or
abdomen. A cracked diaphragm must be replaced. When
the bell is used, care is taken to position it lightly over
the anatomic area because pressure flattens the skin and
creates the same effect as a diaphragm.
Measuring Blood Pressure
A The first time the blood pressure is measured, it is

assessed in each arm. The two blood pressure measure-
ments should not vary more than 5 to 10 mm Hg unless
pathology (disease) is present. Some agencies include
a blood pressure assessment of the client in lying, sit-
ting, and standing positions for the initial data base.
Several variables can result in inaccurate blood pres-
sure measurements (Table 12-9).
Korotkoff Sounds
Most blood pressure recordings are obtained indirectly.
That is, they are determined by applying a blood pressure
Bell side Diaphragm side
cuff, briefly occluding arterial blood flow, and listening
B for Korotkoff sounds (sounds that result from the vibra-
tions of blood within the arterial wall or changes in blood
FIGURE 12-18 • A stethoscope (A) and chest piece (B). flow). Blood pressure measurements are determined by
correlating the phases of Korotkoff sounds with the num-
The brace and binaurals generally are made of metal. bers on the sphygmomanometer. If Korotkoff sounds are
difficult to hear, they can be intensified in one of two ways:
They connect the eartips to the tubing and chest piece.
The brace prevents the tubing from kinking and distort- • Have the client elevate the arm before and during
ing the sound. Stethoscope tubing is rubber or plastic. cuff inflation then lower the arm after full inflation.
The best length for good sound conduction is about • Have the client open and close the fist after cuff
20 inches (50 cm). inflation.
TABLE 12-9 COMMON CAUSES OF BLOOD PRESSURE ASSESSMENT ERRORS

CAUSE EFFECT CORRECTION
Inaccurate manometer False high or low readings Recalibrate, repair, or replace gauge.
calibration
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 sound Remove arm from sleeve or have client don a gown.
perception
Tubing that leaks Rapid loss of pressure Replace or repair.
Improper positioning of Poor sound conduction Reposition and retake blood pressure.
eartips
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.
150 mm Hg 120 mm Hg 80 mm Hg 0 mm Hg tronic sphygmomanometer or other nonauscultatory

hybrid sphygmomanometers that are being developed
could eliminate number biases and provide more accu-
Phase I Phase II Phase III Phase IV Phase V
rate measurements (Working Meeting on Blood Pressure
Faint tapping Swishing Loud knocking Muffled Silence Measurement, 2002).
Directions for standard auscultatory blood pressure
FIGURE 12-19 • Characteristics of Korotkoff sounds. measurement are given in Skill 12-4.
Korotkoff sounds have five unique phases (Fig. 12-19).

Phase I begins with the first faint but clear tapping sound Alternative Assessment Techniques
that follows a period of silence as pressure is released
from the cuff. When the first sound occurs, it corresponds When Korotkoff sounds are difficult to hear in the usual
to the peak pressure in the arterial system during heart manner no matter how conscientious the effort to aug-
contraction, or the systolic pressure measurement. It is ment them, nurses assess blood pressure using alternative
recorded as the first number in the fraction. methods. They can measure blood pressure by palpation
The first sound, which is heard for at least two con- or by using a Doppler stethoscope. When blood pressure
secutive beats, may be missed if the cuff pressure is not requires frequent or prolonged assessment, an automated
pumped high enough initially. Palpating for the dis- blood pressure machine is necessary. When the brachial
appearance of a distal pulse when inflating the cuff helps or radial artery is inaccessible in both arms or assessing
to ensure that the cuff pressure is above arterial pressure. blood pressure at these sites is contraindicated, the thigh
Phase I sounds may disappear briefly before they be- is an optional alternative.
come reestablished, especially in older adults and clients
with high blood pressure or peripheral arterial disease. Palpating the Blood Pressure
An auscultatory gap (period during which sound disap-
When palpating the blood pressure, the nurse applies a
pears) can range as much as 40 mm Hg. Failure to identify
blood pressure cuff. Instead of using a stethoscope, how-
the first sound preceding an auscultatory gap results in an
ever, he or she positions the fingers over the artery while
inaccurate blood pressure assessment from undermea-
releasing the cuff pressure. The point at which the nurse
surement of the systolic pressure. Consequently many
feels the first pulsation corresponds to the systolic pres-
clients with hypertension may be unidentified and thus
sure. The diastolic pressure cannot be measured because
undiagnosed and untreated.
there is no perceptible change in the quality of pulsations
Phase II is characterized by a change from tapping
like there is in the sounds. When recording a blood pres-
sounds to swishing sounds. At this time, the diameter of
sure taken this way, it is important to indicate that pal-
the artery is widening, allowing more arterial blood flow.
pation was used.
Phase III is characterized by a change to loud and dis-
tinct sounds described as crisp knocking sounds. During
this phase, blood flows relatively freely through the artery Doppler Stethoscope
once more. A Doppler stethoscope (Fig. 12-20) helps to detect sounds
Phase IV sounds are muffled and have a blowing qual- created by the velocity of blood moving through a blood
ity. The sound change results from a loss in the transmis- vessel. The sounds of moving blood cells are reflected
sion of pressure from the deflating cuff to the artery. The toward the ultrasound receiver, producing a tone. The
point at which the sound becomes muffled is considered
the first diastolic pressure measurement. It generally is
preferred when documenting blood pressure measure-
ments in children.
Phase V is the point at which the last sound is heard,
or the second diastolic pressure measurement. This is
considered the best reflection of adult diastolic pressure
because phase IV is often 7 to 10 mm Hg higher than direct
diastolic pressure measurements. When recording adult
blood pressure measurements, the pressures at phase I
and phase V are used.
Studies have shown that some health care workers do
not record auscultated measurements accurately because
they have a number bias. In other words, they prefer
recording auscultated measurements in even numbers FIGURE 12-20 • A Doppler stethoscope is used when Korotkoff
or zero. Blood pressure measurements using an elec- sounds are difficult to hear.
nurse notes the pressure at which the sound occurs. The High Blood Pressure
onset of sound represents the peak pressure of arterial
Hypertension (high blood pressure) exists when the systolic
blood flow. A description of how the Doppler is used was
given earlier in this chapter. When documenting the pressure, diastolic pressure, or both are sustained above
pressure measurement, the nurse writes a D to indicate normal levels for the person’s age. For adults 18 years or
use of a Doppler. older, the Joint National Committee on Prevention, Detec-
tion, Evaluation, and Treatment of High Blood Pressure
Automatic Blood Pressure Monitoring (2003) considers a systolic pressure of 140 mm Hg or
greater and a diastolic pressure of 90 mm Hg or greater
An automatic electronic blood pressure monitoring device to be abnormally high (Table 12-10).
consists of a blood pressure cuff attached to a micro- An occasional elevation in blood pressure does not
processing unit. Such devices diagnose unusual fluctua- necessarily mean a person has hypertension. It does
tions in blood pressure that single or sporadic monitoring mean that the blood pressure should be monitored at
cannot identify. When used, the device records the client’s
various intervals depending on the significance of the
blood pressure every 10 to 30 minutes or as needed over
measurements (Table 12-11). Monitoring is especially
24 hours. It stores the data in the microprocessor’s mem-
important to determine whether the elevated blood
ory. Measurements are printed or transferred by hand to a
pressure is sustained or the result of white-coat hyper-
flow sheet for vital signs. Outpatients can wear a portable
tension (condition in which the blood pressure is ele-
model supported either at the shoulder or waist to help
vated when taken by a health care worker but normal
diagnose conditions in which blood pressure is altered.
at other times).
Measuring Thigh Blood Pressure Hypertensive blood pressure measurements often are
associated with the following:
The thigh is a structure that corresponds anatomically to
the upper arm. Nurses use this site for blood pressure • Anxiety
assessment when they cannot obtain readings in either • Obesity
of the client’s arms. The systolic measurement tends to • Vascular diseases
be 10 to 40 mm Hg higher than that obtained in the arms, • Stroke
but the diastolic measurement is similar (Rice, 1999). • Heart failure
Skill 12-5 describes the technique for obtaining a thigh • Kidney diseases
blood pressure measurement.
Low Blood Pressure
Stop • Think + Respond BOX 12-5 Hypotension (low blood pressure) is when blood pressure
What suggestions would you offer to a nurse who has measurements are below the normal systolic values for
difficulty hearing Korotkoff sounds when assessing a the person’s age. Having a consistently low pressure,
client’s blood pressure? 96/60 mm Hg for example, seems to cause no harm. In
fact, low blood pressure usually is associated with effi-
cient functioning of the heart and blood vessels. People
Abnormal Blood Pressure Measurements with low blood pressure, however, should continue to be
monitored to evaluate its significance. Low blood pres-
Blood pressures above or below normal ranges may indi- sure measurements may indicate shock, hemorrhage, or
cate significant health problems. side effects from drugs.
TABLE 12-10
CLASSIFICATION OF ADULT BLOOD
PRESSURE MEASUREMENTS
CATEGORY SYSTOLIC (MM HG) DIASTOLIC (MM HG)
Normal* <120 and <80

Prehypertension 120–139 or 80–89
Hypertension†
Stage 1 140–159 or 90–99
Stage 2 160 or higher or 100 or higher
*Normal blood pressure with respect to cardiovascular risk is below 120/80 mm Hg. However, unusually low
readings should be evaluated for clinical significance.
†Based on the average or two or more readings taken at each of two or more 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, 2003.)
TABLE 12-11
RECOMMENDATIONS FOR FOLLOW-UP BASED ON
INITIAL SET OF BLOOD PRESSURE MEASUREMENTS
INITIAL BLOOD
PRESSURE (MM HG)*
Systolic Diastolic FOLLOW-UP RECOMMENDED†
<120 <80 Recheck in 2 years.

120–139 80–89 Recheck in 1 year.‡
140–159 90–99 Confirm within 2 months.‡
160–179 100–109 Evaluate or refer to source of care within 1 month.
≥180 ≥110 Evaluate or refer to source of care immediately or within
1 week depending on clinical situation.
*If systolic and diastolic categories are different, follow recommendations for shorter follow-up (e.g., client with
160/86 mm Hg should be evaluated or referred to source of care within 1 month).
†Modify the scheduling of follow-up according to reliable information about past blood pressure measurements,
other cardiovascular risk factors, or target organ disease.

‡Provide advice about lifestyle modifications.
(From the seventh report of the Joint National Committee for the Detection, Evaluation, and Treatment of High
Blood Pressure, National Heart, Lung, and Blood Institute, National Institutes of Health, 2003).
Postural Hypotension GENERAL GERONTOLOGIC

Postural or orthostatic hypotension (sudden but temporary CONSIDERATIONS
drop in blood pressure when rising from a reclining posi- Older adults tend to have a lower “normal” or baseline temper-
tion) is most common in those with circulatory prob- ature; therefore, a temperature in the normal range may
lems, those who are dehydrated, and those who take actually be elevated for an older adult. An older person’s
diuretics or other drugs that lower blood pressure. A con- usual temperature should be assessed and documented to
enable accurate comparison when assessing for elevations.
sequence of a sudden drop in blood pressure is dizziness Nevertheless, with changes in an older adult’s thermoregula-
and fainting. Skill 12-6 describes assessment of postural tion system, temperature elevations may not accompany
hypotension for clients in high-risk categories or who infections.
become symptomatic during care. Some older adults have a delayed and diminished febrile
response to illnesses. Careful assessment is essential to iden-
tify temperature elevations or disease symptoms other than
increased temperature. Often a change in cognitive function,
DOCUMENTING VITAL SIGNS restlessness, or anxiety is an initial sign of illness.
Older adults are more susceptible to hypothermia and heat-
related conditions. Environmental factors, such as extreme
Once nurses have obtained vital sign measurements, heat and cold conditions and inadequately heated or cooled
they are documented in the medical record for analysis living environments, pose additional risk factors for develop-
of patterns and trends (Fig. 12-21). They also may be ing hypothermia and heat-related illnesses.
Older adults may experience elevated blood pressure readings in
entered as the data, along with any other subjective or
clinical settings (also known as white-coat hypertension). Self-
objective information, elsewhere in the client’s record monitoring devices or blood pressure monitors at community
such as in the narrative nursing notes. settings may promote comfort for the older adult, but these
monitors should be validated for accuracy.
Blood pressure is assessed in each arm when collecting baseline
assessment and documenting subsequent trends. Also, older
NURSING IMPLICATIONS adults need to have their blood pressure assessed while lying
and sitting to detect the possibility of postural hypotension.
Begin with assessing the blood pressure in a supine position;
Vital sign assessment is part of every client’s care and
deflate and leave the blood pressure cuff in place. Have the
forms the basis for identifying problems. Based on the older adult assume a sitting position and recheck the pres-
analysis of assessment data, the nurse may identify one sure. Again deflate and leave the cuff in place; assist the
or more of the following nursing diagnoses: client to stand and immediately check the pressure. Record
each reading from the same arm, observing for a drop upon
• Hyperthermia sitting or standing.
• Hypothermia Older adults are more susceptible to arrhythmias and to postural
• Ineffective Thermoregulation and postprandial hypotension (a drop in blood pressure of
20 mm Hg within 1 hour of eating a meal). If hypotension is
• Decreased Cardiac Output assessed in a client, plan for limited activities during the hour
• Risk for Injury following eating or for frequent smaller food consumption
• Ineffective Breathing Pattern throughout the day.
FIGURE 12-21 • Graphic recording of vital signs.

12 -1 N U R S I N G CAR E P L AN
The Client With a Fever
ASSESSMENT
Determine the following:
• Current temperature
• Contributing factors such as dehydration, illness, inability to perspire, exposure to warm environment or excessive layers
of clothing, prolonged physical activity, current drug history
• Trend in temperature measurements to determine if the fever is sustained, remittent, intermittent, or relapsing
• Additional assessment data such as if the client is flushed, restless, sleepy, confused, shivering, perspiring, sensitive to
light, has an accompanying headache or poor appetite
• Results of latest white blood cell count and thyroid hormone levels
• Exposure to others with similar symptoms
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° to 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
subsides. by 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; Antipyretics block the set point elevation in the
aspirin is contraindicated for children with fevers because hypothalamus.
it is associated with Reye’s syndrome.
Apply cool cloths or an ice bag to the forehead, behind the Cooling the skin lowers the temperature of blood by
neck, and between the axillary and inguinal skin folds. conduction as the warmer blood flows near the 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
30 minutes after administering an antipyretic. antipyretic helps to alter the set point in the
hypothalamus.
(continued)
The Client With a Fever
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 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.
Some older adults have a wide pulse pressure because of a rising 2. The best action a nurse can take when a client with a
systolic pressure exceeding the rate of diastolic elevation, and temperature of 103.6°F is shivering is to
they have a higher incidence of hypertension. 1. Offer the client a cup of hot soup.
The same criteria defining normal and abnormal (or high) blood 2. Cover the client with a light blanket.
pressure are used for younger and older adults.
3. Direct a fan in the client’s direction.
Manifestations of cardiovascular disease typically are more subtle
and variable in older adults, including variations in presenta-
4. Darken the room to provide rest.
tion for male and female older adults. 3. While assessing a client’s radial pulse, the nurse notes
Older adults generally have more profound responses to cardio- that it disappears with very slight pressure. The nurse is
vascular medications than younger adults. Subtle changes most correct in documenting that the pulse is
such as diminished appetite, nausea, or visual changes may 1. Normal
indicate a need for evaluation of cardiovascular medications.
2. Weak
3. Thready
CRITICAL THINKING E X E R C I S E S 4. Diminished
4. Before assessing an adult client’s blood pressure, the nurse
1. When visiting a friend with a fever, the only thermome-
is most correct in selecting a blood pressure cuff with a
ter available is glass mercury.
bladder width that is 40% and a bladder length that encir-
What suggestions for replacement would you offer when cles at least which percent of the client’s upper arm?
your friend feels better? 1. 40%
2. A neighbor with no medical experience asks how to tell 2. 60%
if her 4-year-old has a fever. 3. 80%
4. 100%
What advice would you give?
5. If the nurse detects that a client has symptoms associ-
3. An 80-year-old client explains that, as an economy ated with orthostatic hypotension, the best instruction
measure, she keeps her thermostat set at 65°F. What the nurse can offer the client is to
health information would be appropriate, considering 1. Limit consumption of fluids during the day.
this woman’s age? 2. Rise slowly from a lying or sitting position.
4. While participating in a community health assessment, 3. Remain on bedrest throughout care in the health
you discover a person with a blood pressure that mea- agency.
sures 190/110 mm Hg. What actions are appropriate 4. Ambulate about the health agency at least four
at this time? times a day.
1. Upon observing a nursing assistant taking a client’s vital
signs (oral temperature, pulse rate, respiratory rate, and
blood pressure) immediately after breakfast, the nurse
instructs the nursing assistant that it is best to
1. Obtain the client’s apical–radial heart rate.
2. Wait 15 minutes to assess the client’s pulse.
3. Assess the client’s temperature in 30 minutes.
4. Take the blood pressure with the client lying down.
Skill 12-1 • ASSESSING BODY TEMPERATURE
Assessment
Determine when and how frequently to monitor the Demonstrates accountability for making timely and
client’s temperature (see Box 12-1) and the type of appropriate assessments; ensures consistency in
thermometer previously used. technique for gathering data
Review previously recorded temperature measurements. Aids in identifying trends and analyzing significant
patterns
If using an oral electronic, digital, or glass

thermometer:
Observe the client’s ability to support a thermometer Shows consideration for accuracy because thermal energy
within the mouth and to breathe adequately through the is transferred from the oral cavity to the thermometer
nose with the mouth closed. probe; escape of heat invalidates the measurement
Read the client’s history for any reference to recent Shows consideration for safety and identifies possible
seizures or a seizure disorder. contraindication for oral site
Determine if the client consumed any hot or cold Shows consideration for accuracy because the temperature
substances or smoked a cigarette within the past in the oral cavity can be temporarily altered from
30 minutes. substances recently placed within the mouth.
Planning
Arrange to take the client’s temperature as near to the Ensures consistency and accuracy
scheduled routine as possible.
Gather supplies including a thermometer, watch, and Promotes efficiency, accuracy, and safety
probe 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 is
always appropriate after any client contact.)
Implementation
Introduce yourself to the client if you have not done so Demonstrates responsibility and accountability
during earlier contact.
Explain the procedure to the client. Reduces apprehension and promotes cooperation
Wash hands or perform hand antisepsis with an alcohol Reduces the spread of microorganisms
rub (see Chap. 10).
Electronic Thermometer
Remove the electronic unit from the charging base. Promotes portability
Select the oral or rectal probe depending on the intended Ensures appropriate use
site for assessment.
(continued)
ASSESSING BODY TEMPERATURE (Continued)
Insert the probe into a disposable cover until it locks into Protects the probe from contamination with secretions
place (Fig. A). containing microorganisms
Inserting the probe into a disposable cover. (Photo by Rick Brady.)
Oral method
Place the covered probe beneath the tongue to the right or Locates the probe near the sublingual artery to ensure
left of the frenulum (structure that attaches the correct location
underneath surface 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 it does not drift away from its
intended location; ensures valid data collection
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)
Maintaining the probe in position. (Photo by Rick Brady.)
Remove the probe and eject the probe cover into a lined Confines contaminated objects to an area for proper
receptacle (Fig. D). disposal without direct contact
Releasing the probe cover. (Photo by Rick Brady.)
Replace the probe in the storage holder within the Prevents damage to the probe attachment
electronic unit.
Rectal method
Provide privacy. Demonstrates respect for the client’s dignity
Lubricate approximately 1 inch (2.5 cm) of the rectal Promotes comfort and ease of insertion
probe cover.
Position the client on the side with the upper leg slightly Helps to locate the anus and facilitate probe insertion
flexed at the hip and knee (Sims’ position).
Instruct the client to breathe deeply. Relaxes the rectal sphincter and reduces discomfort
during insertion
(continued)
Insert the thermometer approximately 1.5 inches (3.8 cm)
in an adult, 1 inch (2.5 cm) in a child, and 0.5 inch
(1.25 cm) in an infant (Fig. E).
Rectal thermometer insertion.
Maintain the probe in position until an audible sound Signals when the sensed temperature remains constant
occurs.
Observe the numbers displayed on the electronic unit. Indicates temperature measurement
receptacle (see Fig. D). disposal without direct contact
electronic unit.
Wipe lubricant and any stool from around the client’s Demonstrates concern for the client’s hygiene and comfort
rectum.
Remove and discard gloves, if worn; wash hands or Reduces the transmission of microorganisms
perform hand antisepsis with an alcohol rub
(see Chap. 10).
Axillary method
Insert the thermometer into the center of the axilla and Confines the tip of the thermometer so that room air does
lower the client’s arm to enclose the thermometer not affect it
between the two folds of skin (Fig. F).
Placement for auxiliary temperature assessment.
F
(continued)
Hold the probe in place. Supports the probe so it does not drift away from its
intended location; ensures valid data collection
Maintain the probe in position until an audible sound Signals when the sensed temperature remains constant
occurs.
receptacle (see Fig. D). disposal without direct contact
electronic unit.
Return the electronic unit to its charging base. Facilitates reuse
Record 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 care plan
Infrared Tympanic Thermometer
Remove the thermometer component from its holding Facilitates insertion of the tympanic speculum (funnel-
cradle (Fig. G). shaped instrument used to widen and support an
opening in the body)
Tympanic thermometer and cradle. (Photo by Rick Brady.)
Inspect the tip of the thermometer for damage and the Promotes safety and hygiene
lens for cleanliness.
Replace a cracked or broken tip; clean the lens with a dry Ensures accurate data collection
wipe or lint-free swab moistened with a small amount
of isopropyl alcohol, and then wipe to remove the
alcohol film.
Wait 30 minutes 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 Maintains cleanliness of the tip
in place.
Press the mode button to select the choice of temperature Adjusts the tympanic measurement, norms for which
translation (conversion of tympanic temperature into an have not been established, into more common frames
oral, rectal, or core temperature). of reference. The rectal equivalent is recommended for
children younger than 3 years.
(continued)
Depress the mode button for several seconds to select Eliminates need to calculate conversion measurements
either Fahrenheit or centigrade. by hand
Hold the probe in your dominant hand. Improves motor skill and coordination
Position the client with the head turned 90°, exposing the Promotes proper probe placement; if the right hand is
ear with the hand holding the probe. holding the probe, the right 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 Seats the tip of the probe within the ear canal and
back-and-forth motion until it seals the ear canal. confines the radiated heat within the area of
the probe
Point the tip of the probe in an imaginary line between Positions the probe in direct alignment with the tympanic
the sideburn hair and the eyebrow on the opposite side membrane; if pointed elsewhere, the infrared sensor
of the face (Fig. H). detects the temperature of surrounding tissue rather
than membrane temperature
Placement of probe for accurate tympanic assessment. (Photo by Rick Brady.)
Press the button that activates the thermometer as soon as Initiates electronic sensing; for some models, this action
the probe is in position. must be done within 25 seconds of having removed
the thermometer from its holding cradle
Keep the probe within the ear until the thermometer Indicates that the procedure is complete
emits a sound or flashing light.
Repeat the procedure after waiting 2 minutes if this is the Ensures accuracy with a second assessment
first use of the tympanic thermometer since it was
recharged.
(continued)
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 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
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
Skill 12-2 • ASSESSING THE RADIAL PULSE
Assessment
client’s pulse (see Box 12-1). appropriate assessments
Review data collected in previous assessments of the pulse Aids in identifying trends and analyzing significant
or abnormalities in other vital signs. patterns
Read the client’s history for any reference to cardiac or Demonstrates an understanding of factors that may affect
vascular disorders. the 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 Ensures accurate timing when counting pulsations
available.
Plan to assess the client’s pulse after 5 minutes of Reflects the characteristics of the pulse at rest rather than
inactivity. 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 Demonstrates responsibility and accountability
earlier.
Raise the height of the bed. Reduces musculoskeletal strain
rub (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 Provides access to the radial artery and relaxes the arm
extended (Fig. A).
Locating the radial pulse.
A
(continued)
ASSESSING THE RADIAL PULSE (Continued)
Press the first and second fingertips toward the radius Ensures accuracy because the nurse may feel his or her
while feeling for a recurrent pulsation. own pulse if using the thumb; light palpation should not
obliterate the pulse.
Palpate the rhythm and volume of the pulse once it is Provides comprehensive assessment data
located.
Note the position of the second hand on the clock or Identifies the point at which the assessment begins
watch.
Count the number of pulsations for 15 or 30 seconds and Provides pulse rate data. A regular pulse rate should not
multiply the number by 4 or 2 respectively. If the pulse vary whether it is counted for a full minute or some
is irregular, count for a full minute. portion thereof, 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 Demonstrates responsibility for client care, safety, and
provides comfort, and lower the bed. comfort
Record assessed measurement on the graphic sheet or Provides documentation for future comparisons
the flow sheet or in the narrative nursing notes.
Verbally report rapid or slow pulse rates. Alerts others to monitor the client closely and to make
changes in the plan for care
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
Date and Time Radial pulse 88 bpm full and regular.
SIGNATURE/TITLE
Skill 12-3 • ASSESSING THE RESPIRATORY RATE
Assessment
client’s respiratory rate (see Box 12-1). appropriate assessments
Review the data collected in previous assessments of the Aids in identifying trends and analyzing significant
respiratory rate and other vital signs. patterns
Read the client’s history for any reference to respiratory, Demonstrates an understanding of factors that may affect
cardiac, or neurologic disorders. the respiratory rate
respiratory or neurologic effects.
Planning
Arrange to count the client’s respiratory rate as close to Ensures consistency and accuracy
the scheduled routine as possible.
Make sure a watch or wall clock with a second hand is Ensures accurate timing
available.
Plan to assess the client’s respiratory rate after a 5-minute Reflects the characteristics of respirations at rest rather
period of inactivity. than under the influence of activity
Implementation
Introduce yourself to the client, if you have not done so Demonstrates responsibility and accountability
previously.
rub (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 Discourages conscious control of breathing or talking
watched; it may help to count the respiratory rate while during assessment of the rate of breathing
appearing to 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
Restore the client to a therapeutic position or one that Demonstrates responsibility for client care, safety,
provides comfort, and lower the bed. and comfort
Record assessed measurement on the graphic sheet or flow Provides documentation for future comparisons
sheet, or in the narrative nursing notes.
Verbally report rapid or slow respiratory rates or any Alerts others to monitor the client closely and make
other unusual characteristics. changes in the plan for care
(continued)
ASSESSING THE RESPIRATORY RATE (Continued)
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/min at rest. Breathing is noiseless and effortless.
SIGNATURE/TITLE
Skill 12-4 • ASSESSING BLOOD PRESSURE
Assessment
client’s blood pressure (see Box 12-1). appropriate 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.
vascular disorders. the blood pressure
cardiovascular effects.
Planning
Gather the necessary supplies: blood pressure cuff, Promotes efficient time management. A recently
sphygmomanometer, and stethoscope. calibrated aneroid 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
(continued)
ASSESSING BLOOD PRESSURE (Continued)
Planning (Continued)
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 Avoids obtaining a higher-than-usual measurement from
used tobacco. arterial 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 Demonstrates responsibility and accountability
so earlier.
rub (see 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 Ensures collecting accurate data and facilitates locating
palm of the hand upward. the brachial artery
Expose the inner aspect of the elbow by removing clothing Facilitates application of the blood pressure cuff and
or loosely rolling up a sleeve. optimum sound perception
Center the cuff bladder so that the lower edge is about Places the cuff in the best position for occluding the blood
1 to 2 inches (2.5 to 5 cm) above the inner aspect of the flow through the brachial artery
elbow (Fig. A).
Applying the blood pressure cuff. (Copyright B. Proud.)
Wrap the cuff snugly and uniformly about the Ensures the application of even pressure during inflation
circumference of the arm.
Make sure the aneroid gauge can be clearly seen. Prevents errors when observing the gauge
(continued)
Palpate the brachial pulse (Fig. B). Determines the most accurate location for assessing and
hearing Korotkoff sounds
Palpating the brachial artery. (Copyright B. Proud.)
Tighten the screw valve on the bulb (Fig. C). Prevents loss of pumped air
Tightening the screw valve. (Copyright B. Proud.)
Compress the bulb until the pulsation within the Provides an estimation of systolic pressure
artery stops and note the measurement at that point.
Deflate the cuff and wait 15 to 30 seconds. Allows the return of normal blood flow
(continued)
Place the eartips of the stethoscope within the Ensures accurate assessment
ears and 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. (Copyright 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 Facilitates identifying phase I of Korotkoff sounds
above the point where the pulse previously disappeared
(Fig. E).
Pumping the bulb. (Copyright B. Proud.)
(continued)
Loosen the screw on the valve. Releases air from the cuff bladder
Control the release of air at a rate of approximately Ensures accurate assessment between perception of a
2 to 3 mm Hg per 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 Follows recommended standards for children or adults
when phase I, IV, or V is noted.
Release the air quickly when there has been silence for at Indicates phase V is complete
least 10 mm Hg.
Write down the blood pressure measurements. Ensures accurate documentation
Repeat the assessment after waiting at least 1 minute if Allows time for the arterial pressure to return to baseline
unsure of the pressure measurements. before another assessment
provides comfort, and lower the bed. comfort
rub (see Chap. 10).
Record assessed measurement on the graphic sheet or flow Provides documentation for future comparisons
sheet, or in the narrative nursing notes.
Verbally report elevated or low blood pressure Alerts others to monitor the client closely and make
measurements. 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
client’s blood pressure (see Box 12-1). appropriate assessments
Review the data collected in previous assessments. Aids in identifying trends and analyzing significant
patterns
Determine in which thigh previous assessments were made. Ensures consistency when evaluating data
vascular disorders. blood pressure
Planning
Gather the necessary supplies: thigh blood pressure cuff, Promotes efficient time management and ensures an
sphygmomanometer, stethoscope (Fig. A). accurate measurement when a wider and longer blood
pressure cuff is used
Application of blood pressure cuff to the thigh.
Plan to assess blood pressure after client has been Promotes conditions for obtaining accurate measurements.
reclining for at least 10 minutes.
Wait 30 minutes from the time the client has ingested Eliminates factors that contribute to constriction or
caffeine, used tobacco, consumed a heavy meal, dilation of blood vessels.
exercised vigorously, or taken a hot shower or bath.
Implementation
Introduce yourself to the client if you have not done Demonstrates responsibility and accountability
so earlier.
rub (see Chap. 10).
(continued)
OBTAINING A THIGH BLOOD PRESSURE (Continued)
Place the client in either the supine or 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
when the cuff is inflated but that remaining still will explanation for its necessity
facilitate accuracy.
Tighten the screw valve on the bulb. Prevents loss of air from the cuff bladder
Compress the bulb until the pulsation within the artery Provides an estimation of systolic pressure
stops and note the pressure measurement.
Place the eartips of the stethoscope within the ears Ensures accurate assessment
and position 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 Reduces sound distortion
linen.
above the point where the pulse previously
disappeared.
Control the release of air at a rate of approximately Ensures accurate assessment between perception of the
2 to 3 mm Hg per second. sound 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
least 10 mm Hg.
provides comfort. comfort
rub (see Chap. 10).
Record assessed measurements on the graphic sheet or the Provides documentation for future comparisons
flow sheet or in the narrative nursing notes.
Verbally report blood pressure measurements to the nurse Alerts others to monitor the client closely or to modify the
in charge. client’s plan of care
Evaluation
• Korotkoff sounds are heard clearly.
• Blood pressure is consistent with the client’s
condition.
(continued)
OBTAINING A THIGH BLOOD PRESSURE (Continued)
Document
• Date and time
• Systolic and diastolic pressure measurements.
• Assessment site
Date and Time BP 176/88 at popliteal artery of left thigh. States, “It hurts when the blood pressure cuff gets tight.”
SIGNATURE/TITLE
Skill 12-6 • ASSESSING FOR POSTURAL HYPOTENSION
Assessment
Determine when and how frequently to monitor client’s Demonstrates accountability for making timely and
blood pressure (see Box 12-1). appropriate assessments
Review the data collected in previous assessments. Aids in identifying trends and analyzing significant
patterns
Determine in which arm previous assessments were made. Ensures consistency when evaluating data
vascular disorders. the blood pressure
Planning
Gather the necessary supplies: blood pressure cuff, Promotes efficient time management
sphygmomanometer, 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 Ensures consistency
Plan to assess the blood pressure after client has been Promotes conditions for obtaining accurate baseline
reclining for at least 5 minutes. measurements for comparison
Wait 30 minutes from the time the client has ingested Eliminates factors that contribute to constriction or
caffeine, used tobacco, consumed a heavy meal, dilation of blood vessels
exercised vigorously, or taken a hot shower or bath.
(continued)
ASSESSING FOR POSTURAL HYPOTENSION (Continued)
Implementation
Introduce yourself to the client, if you have not done Demonstrates responsibility and accountability
so earlier.
rub (see 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 Ensures collecting accurate data and facilitates locating
palm of the hand upward. the brachial artery
Expose the inner aspect of the elbow by removing clothing Facilitates application of the blood pressure cuff and
or loosely rolling up a sleeve. optimum sound perception
Center the cuff bladder so that the lower edge is about Places the cuff in the best position for occluding blood
1 to 2 inches (2.5 to 5 cm) above the inner aspect of the flow through the brachial artery
elbow.
Wrap the cuff snugly and uniformly about the Ensures the application of even pressure during inflation
circumference of 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
Compress the bulb until the pulsation within the artery Provides an estimation of systolic pressure
stops and note the pressure measurement.
Place the eartips of the stethoscope within the ears and Ensures accurate assessment
position 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
above the measurement where the pulse previously
disappeared.
Control the release of air at a rate of approximately Ensures accurate assessment between perception of a
2 to 3 mm Hg per second. sound 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 recommended standards for adults or children
least 10 mm Hg.
Assist the client to stand or sit. Stimulates reflexes for maintaining blood flow to the
brain
(continued)
ASSESSING FOR POSTURAL HYPOTENSION (Continued)
Be prepared to steady or assist the client should he or she Promotes safety and reduces potential for injury
become dizzy or faint.
Repeat the blood pressure and pulse measurement 30 Provides data for comparison
seconds after the client assumes an upright position.
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 response (Carlson, 1999).
more, or the pulse rises 20 beats or more.
Restore the client to a therapeutic position or one that Demonstrates responsibility for client care, safety and
provides comfort. comfort
Instruct the client to rise slowly from sitting or lying Allows time for physiological adaptation in blood flow to
position if the data indicate the client experiences the brain
postural hypotension.
rub (see Chap. 10).
Record assessed measurements on the graphic or flow Provides documentation for future comparisons
sheet or in the narrative nursing notes.
Verbally report blood pressure measurements to the nurse Alerts others to monitor the client closely or to modify the
in charge. client’s 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
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 lightheaded.” Assisted to lay 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
13
Chapter
Physical
Assessment
LEARNING OBJECTIVES
● List four purposes of a physical assessment.
● Name four assessment techniques.
● List at least five items needed when performing a basic physical assessment.
● Discuss at least three criteria for an appropriate assessment environment.
● Identify at least five assessments that can be obtained during the initial survey of clients.
● State two reasons for draping clients.
● Differentiate a head-to-toe and a body systems approach to physical assessment.
● List six ways in which the body may be divided for organizing data collection.
● Identify two self-examinations that nurses should teach their adult clients.
THE first step in the nursing process is assessment, or gathering information. Physical
assessment (systematic examination of body structures) is one method for gathering
health data. This chapter describes how to perform a physical assessment from a gen-
eralist’s or beginning nurse’s point of view and identifies common assessment find-
ings. Students can learn advanced physical assessment skills through additional
WORDS TO KNOW education and experience or by consulting specialty texts.
accommodation
audiometry
auscultation
body systems approach
OVERVIEW OF PHYSICAL ASSESSMENT
capillary refill time
cerumen Health care practitioners use various techniques and equipment to perform phys-
consensual response
drape
ical assessment. Although settings for physical assessment vary, each environment
edema must facilitate accurate data collection and be conducive to the client’s privacy and
extraocular movements comfort.
head-to-toe approach
hearing acuity
inspection
Jaeger chart
Purposes
mental status assessment
palpation The overall goal of a physical assessment is to gather objective data about a client. To
percussion achieve this goal, nurses thoroughly examine clients on admission, briefly at the start
physical assessment of each shift, and any time a client’s condition changes. The purposes of assessment
Rinne test
smelling acuity
are as follows:
Snellen eye chart • To evaluate the client’s current physical condition
turgor
visual acuity
• To detect early signs of developing health problems
visual field examination • To establish a baseline for future comparisons
Weber test • To evaluate the client’s responses to medical and nursing interventions
229
A B
FIGURE 13-1 • (A) Inspection. (Copyright B. Proud.) ( B) Percussion. (Copyright Ken Kasper.)
Techniques change in the area being examined. If percussion is per-

formed correctly, the client experiences no discomfort.
The four basic physical assessment techniques are inspec- Pain could indicate a disease process or tissue injury.
tion, percussion, palpation, and auscultation.
Palpation
Inspection Palpationis lightly touching or applying pressure to the
Inspection (purposeful observation) is the most frequently body. Light palpation involves using the fingertips, back of
used assessment technique. It involves examining partic- the hand, or palm of the hand (Fig. 13-2A). It is best used
ular body parts, looking for specific normal and abnormal when feeling the surface of the skin, structures that lie just
characteristics (Fig. 13-1A).With advanced instruction, beneath the skin, pulsations from peripheral arteries, and
some nurses learn to use special instruments to inspect vibrations in the chest. Deep palpation is performed by
parts of the body, such as the interior of the eyes, that are depressing tissue approximately 1 inch (2.5 cm) with the
potentially inaccessible to ordinary vision and inspection forefingers of one or both hands (Fig. 13-2B).
techniques. Palpation provides information about the following:
• The size, shape, consistency, and mobility of normal
Percussion
tissue and unusual masses
Percussion, the least used assessment technique by nurses, • The symmetry or asymmetry of bilateral (both sides
is striking or tapping part of the client’s body with the of the body) structures such as the lobes of the thy-
fingertips to produce vibratory sounds (see Fig. 13-1B) roid gland
(Table 13-1). The quality of the sounds aids in determin- • Skin temperature and moisture
ing the location, size, and density of underlying structures. • Any tenderness
A sound different from expected suggests a pathologic • Unusual vibrations
TABLE 13-1 PERCUSSION SOUNDS

DESCRIPTIVE COMMON
SOUND INTENSITY TERM LOCATIONS
Muted Soft Flat Muscle, bone

Thud Soft to moderate Dull Liver, full bladder, 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
C H A P T E R 1 3 ● Physical Assessment 231
FIGURE 13-2 • Palpation tech-

niques. (A) Light palpation. (B) Deep
A B
palpation. (Copyright B. Proud.)
Auscultation Equipment
Auscultation (listening to body sounds) is used frequently,
The items generally needed for a basic physical assess-
most often to assess the heart, lungs, and abdomen. A
ment are listed in Box 13-1. More advanced practitioners
stethoscope is required to hear soft sounds (Fig. 13-3), but
use additional examination equipment.
in some cases, loud sounds, such as those associated with
intestinal hyperactivity, are audible with gross hearing
(i.e., listening without any instrumentation). Environment
Nurses must practice auscultation repeatedly on var-
ious healthy and ill people to gain proficiency with the Nurses assess clients in a special examination room or
equipment and experience in interpreting data. To en- at the bedside. Regardless of the assessment location,
sure the accuracy of findings, it is best to eliminate or the area should have easy access to a restroom; a door
reduce environmental noise as much as possible. or curtain that ensures privacy; adequate warmth for
client comfort; a padded, adjustable table or bed; suffi-
cient room for moving to either side of the client; adequate
lighting; facilities for hand hygiene; a clean counter or
surface for placing examination equipment; and a lined
receptacle for soiled articles.
BOX 13-1 ● 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
FIGURE 13-3 • Auscultation. (Copyright B. Proud.)

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 much general data during the first

contact with the client. At this time, the nurse appraises
the client’s overall condition. By observing and interact-
ing with the client before the actual physical examina-
tion, the nurse notes the following:
• Physical appearance in relation to clothing and hygiene
• Level of consciousness
• Body size
• Posture FIGURE 13-4 • Assessment of height and weight.
• Gait and coordinated movement (or lack of it)
• Use of ambulatory aids
powered electronic scales can weigh people who are 400
• Mood and emotional tone
to 500 lbs (181 to 227 kg) while protecting against a
The nurse also gathers some preliminary data, such as client’s fall or injury to the nurse. Several models store
vital signs (see Chap. 12), weight, and height, at this time. the client’s weight in memory, allowing it to be automat-
The nurse documents the client’s weight and height ically recalled until another client is weighed. Electronic
because they provide more reliable data than a subjective scales can be transported from storage to a client’s room
assessment of body size. The recorded measurements are when needed.
extremely important in assessing trends in future weight
loss or gain. For hospitalized clients, health care practi-
tioners also use weight and height to calculate dosages of Draping and Positioning
some drugs. In most cases, nurses weigh and measure
adult clients and older children using a standing scale Because assessment takes place while clients are naked
(Fig. 13-4). See Nursing Guidelines 13-1. (or wearing only a loose examination gown), they gen-
Nurses use an electronic bed or chair scale to weigh erally appreciate being covered with a drape (sheet of
medically unstable clients, clients who are extremely soft cloth or paper). A drape provides more modesty than
obese, and clients who cannot stand (Fig. 13-5). Battery- warmth.

Obtaining Weight and Height
❙ Check to see that the scale is calibrated at zero. Doing so ensures ❙ Move the lighter weight across the calibrations for individual pounds
accuracy. and ounces until the bar balances in the center of the scale. This
positioning correlates with the actual weight.
❙ Ask or assist the client to remove shoes and all but a minimum of
clothing. Doing so facilitates measuring body weight. ❙ Read the weight and write it down. Doing so ensures accurate
documentation.
❙ Place a paper towel on the scale before the client stands on it in bare
feet. This helps to reduce contact with microorganisms on equipment ❙ Raise the measuring bar well above the client’s head. This provides
that other people use. room for positioning the client without injury.
❙ Assist the client onto the scale. Doing so helps to prevent injury should ❙ Ask the client to stand straight and look forward. Doing so facilitates
the client become dizzy or unstable. measuring height.
❙ Position the heavier weight in a calibrated groove of the scale
❙ Lower the measuring bar until it lightly touches the top of the client’s
arm. Doing so provides a rough approximation of the gross head. This positioning correlates with actual height.
body weight. ❙ Note the height and write it down. This ensures accurate documentation.
Consequently, each nurse develops his or her own order

and sequence for examining clients or uses an assess-
ment form as a guide. Nurses should conduct the assess-
ment consistently each time to avoid omitting essential
information.
Head-to-Toe Approach
A head-to-toe approach means gathering data from the top
of the body to the feet. This has three advantages:
1. It helps to prevent overlooking some aspect of data
collection.
2. It reduces the number of position changes required
of the client.
FIGURE 13-5 • Bed-sling scale. (Copyright B. Proud.) 3. It generally takes less time because the nurse is not
constantly moving around the client in what may
appear to be a haphazard manner.
The examination usually begins with the client stand-
ing or sitting (Fig. 13-6). Some components of the phys- Body Systems Approach
ical assessment require the client to recline and turn from
side to side. Specific positions for special examinations A body systems approach means collecting data according
are described and illustrated in Chapters 14 and 23. to the functional systems of the body. It involves exam-
ining the structures in each system separately. For exam-
ple, the nurse assesses the skin, mucous membranes,
Selecting an Approach for Data Collection nails, and hair because they are all parts of the integu-
mentary system. When assessing the cardiovascular sys-
Once the client is draped and positioned, selection of a tem, the nurse palpates peripheral pulses, listens to heart
systematic, organized pattern facilitates further data sounds, and so on. One advantage of this method is that
collection. Two common approaches are the head-to- findings tend to be clustered, making problems more eas-
toe approach and the body systems approach. The objec- ily identifiable. Disadvantages are that the nurse examines
tive of both methods is to obtain the same basic data. the same areas of the body several times before complet-
ing 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.

You have been asked to assess two new clients. One
arrived by wheelchair and has been walking around the
nursing unit. The other was transported by ambulance, has
intravenous fluid infusing, and is receiving oxygen. Which
client would you assess first? Why? What differences might
you use in the physical assessment of each client?
DATA COLLECTION
When collecting data, the nurse may divide the body

into six general areas: head and neck, chest, extremities,
FIGURE 13-6 • Client is prepared for examination. (Copyright B. Proud.) abdomen, genitalia, and anus and rectum. The following
discussion identifies structures commonly assessed, spe-

cific techniques, and common findings.
Head and Neck
Head
The nurse begins at the client’s head by assessing men-
tal status and the symmetry and function of cranio-
facial structures (eyes, ears, nose, mouth). The nurse
also assesses the client’s skin, oral and nasal mucous
membranes, hair, and scalp.
MENTAL STATUS ASSESSMENT. A mental status assessment

(technique for determining the level of a client’s cog-
nitive functioning) provides information about a client’s
attention, concentration, memory, and ability to think
abstractly. For most clients, documenting that they are
FIGURE 13-7 • An ophthalmoscopic examination. (Copyright B. Proud.)
alert and oriented is all that is necessary. More objec-

tive assessment data are important, however, when car-
the eye. After gross inspection, the nurse assesses func-
ing for the following clients:
tions such as visual acuity, pupil size and response, and
• Previously unconscious clients ocular movements.
• Clients who were recently resuscitated Visual acuity (ability to see both far and near) is not
• Clients with periods of confusion assessed in every client. It is always appropriate, how-
• Clients with head injury ever, to ask if a client wears glasses or contact lenses, has
• Clients who took an overdose of drugs a false eye, or considers himself or herself blind.
• Clients with a history of chronic alcoholism To assess far vision grossly, the nurse asks the client
• Clients with psychiatric diagnoses to cover one eye at a time and from a distance of approx-
imately 20 feet count the number of fingers the nurse
EYES. When examining the head, one of the most obvi- raises. Clients can wear corrective lenses during this
ous assessments is the appearance of the eyes, which assessment. For close vision, the nurse asks literate clients
generally are of similar size and distance from the cen- to read newsprint from approximately 14 inches away.
ter of the face. Each iris is the same color, the sclerae A Snellen eye chart (tool for assessing far vision) is a
(plural of sclera) appear white, the corneas are clear, more objective technique (Fig. 13-8). Each line on the
and eyelashes are present along the margins of each eye. chart is printed in progressively smaller letters or symbols.
More advanced practitioners use an instrument called an The nurse asks the client to read the smallest line he or
ophthalmoscope (Fig. 13-7) to examine structures within she can see comfortably from a distance of 20 feet both
FIGURE 13-8 • Three examples of

Snellen eye charts. (Courtesy of Ken
Timby.)
Pupil gauge (mm) NURSING GUIDELINES 13-2

8 9
6 7 Assessing Pupillary Response
4 5
2 3
❙ Dim the lights in the examination area and instruct the client to stare
straight ahead. Doing so facilitates pupil dilation.
FIGURE 13-9 • Pupil size assessment guide. ❙ Bring a narrow beam of light, like that from a pen light or small
flashlight, from the temple toward the eye. This step provides a
direct stimulus for pupil constriction.
with and without any corrective lenses. The nurse then ❙ Observe the pupil of the stimulated eye as well as the unstimulated
compares the client’s vision against norms. pupil. The response should be the same. This assessment indicates
Normal vision is the ability to read printed letters status of brain function.
that most people can see at a distance of 20 feet without ❙ Repeat the assessment by directly stimulating the opposite eye.
prescription lenses. This number is written as a fraction Doing so provides comparative data.
(e.g., 20/20). If, at 20 feet from the chart, a person sees ❙ Ask the client to look at a finger or object approximately
only the first line—one that people with normal vision 4 inches (10 cm) from his or her face. This measure produces a
can see from 200 feet away—the client’s visual acuity is situation in which the pupils should get smaller.
recorded as 20/200. The nurse tests near vision using a ❙ Tell the client to look from the near object to another that is more
Jaeger chart, a visual assessment tool with small print. distant. This measure produces a situation in which the pupils
The size of each pupil is estimated in millimeters should get larger.
under normal light conditions (Fig. 13-9). Normal pupils
are round and equal in size. There is also a consensual
response (brisk, equal, and simultaneous constriction of
both pupils when one eye then the other is stimulated movement in one eye may indicate cranial nerve dam-
with light) (Fig. 13-10A). In addition, the nurse assesses age; irregular or uncoordinated movement may suggest
the pupils for accommodation (ability to constrict when other neurologic pathology.
looking at a near object and dilate when looking at an A visual field examination is assessment of peripheral
object in the distance) (see Fig. 13-10B). He or she docu- vision and continuity in the visual field. The nurse may
ments normal findings using the abbreviation PERRLA: perform a gross assessment or test using more sophis-
pupils equally round and react to light and accommoda- ticated ophthalmic equipment. For gross assessment,
tion. See Nursing Guidelines 13-2. the nurse stands directly in front of the client, and each
The nurse observes extraocular movements, which are person covers his or her eye. The nurse instructs the
eye movements controlled by several pairs of eye mus- client to look straight ahead and indicate when he or
cles. He or she asks the client to focus on and track the she sees a light or the nurse’s finger as the nurse brings
nurse’s finger or some other object as it moves in each of it from several sectors of the periphery toward the cen-
six positions (see Fig. 13-10C). During the assessment, ter. If the client’s and the nurse’s visual fields are normal,
both eyes should move in a coordinated manner. No they see the object at the same time. Certain eye and
A B C
FIGURE 13-10 • (A) Testing pupil response to light. (B) Testing accommodation. (C) Assessing extra-
ocular movements.
hear and discriminate sound) by performing a voice test

or the Weber or Rinne test. See Nursing Guidelines 13-3.
The Weber and Rinne tests help to determine hearing
impairment resulting from sensory nerve damage or dis-
orders that interfere with sound conduction through the
ear. To perform the Weber test (assessment technique for
determining equality or disparity of bone-conducted
sound), the nurse strikes a tuning fork on his or her palm
and places the vibrating stem in the center of the client’s
head (Fig. 13-13). He or she then asks the client if the
sound is audible equally in both ears. A positive response
indicates either a normal finding or that hearing in both
ears is equally diminished. Hearing the sound louder in
one ear is a sign of unequal hearing (hearing loss greater
in one ear).
A tuning fork is also necessary in the Rinne test (assess-
FIGURE 13-11 • Technique for straightening the ear canal of an adult
ment technique for comparing air versus bone conduc-
and child.
tion of sound). First, the nurse strikes the tuning fork and
then places the stem on the client’s mastoid area behind
neurologic disorders are associated with changes in the the ear (Fig. 13-14). This tests for bone conduction of
visual field. sound waves in the tested ear. The client reports when
the sound stops. The nurse then moves the tines of the
EARS. The nurse inspects and palpates the external ears. still-vibrating tuning fork near the ear canal and asks the
More advanced practitioners use an otoscope to examine client if he or she perceives sound. This tests air conduc-
the tympanic membrane, or eardrum. tion of sound in the tested ear. Both ears are assessed
The nurse performs a gross examination of the ear by separately. Normally sound is heard longer by air con-
observing the appearance of the ears. Both should be sim- duction. If the client does not continue to hear sound
ilar in size, shape, and location. He or she moves the skin when the tuning fork is beside the ear, it indicates a prob-
behind and in front of the ears as well as the underlying lem with the ear structures that collect and transmit sound
cartilage to determine whether there is any tenderness. through the ear.
The nurse shines a penlight or other light source within Audiometry, a sophisticated test of range of hearing,
each ear to illuminate the ear canal. For optimal visualiza- measures hearing acuity at various sound frequencies.
tion, the nurse straightens the curved ear canal as much An audiologist is a professional trained to test hearing
as possible. For children, this is done by pulling the ear with standardized instruments. Audiometric hearing
down and back; for an adult, the ear is pulled up and back tests measure exact pitch and volume deficits. They mea-
(Fig. 13-11). Cerumen (yellowish-brown, waxy secretion sure hearing in decibels (intensity of sound)—the greater
produced by glands within the ear) is a common finding. the intensity of sound, the more impaired the hearing
Any other drainage is abnormal, and the nurse describes (Table 13-2).
and reports its characteristics.
If the client relies on a hearing aid to amplify sound, the NOSE. The nurse inspects the nose and nasal passages by
nurse notes that information on the assessment form. The having the client assume a “sniffing” position. The septum
nurse may discover changes in hearing acuity (ability to (tissue that divides the nose in half) should be in midline,

Performing a Voice Test for Hearing Acuity
❙ Stand approximately 2 feet behind and to the side of the client. This ❙ Instruct the client to repeat the whispered word. This reveals the client’s
placement simulates the distance between most people during social ability to discriminate sound.
interaction and prevents the client from observing visual cues. ❙ Continue the same pattern using several more words; increase
❙ Instruct the client to cover the ear on the opposite side (Fig. 13-12). This the volume from a soft to medium to loud whisper or spoken
step facilitates sound conduction to the tested ear only. voice if the client’s response is inaccurate. Variations provide more
❙ Whisper a color, number, or name toward the uncovered ear. Doing so reliable data.
delivers a high-pitched sound, the most common type of hearing loss, ❙ Repeat the test on the opposite ear. Doing so provides separate
toward the tested ear. assessment findings for each ear.
FIGURE 13-12 • Voice test. (Copyright B. Proud.)
causing the nasal passages to be equal in size. Pressing at

the tip of the nose facilitates deeper inspection. Air should
move fairly quietly through the nose during breathing.
Normal nasal mucous membrane is pink, moist, and free
of obvious drainage. The nurse documents a deviated FIGURE 13-14 • For the Rinne test, the tuning fork base is placed first
septum, lesions, growths, flaring of the nostrils, or un- on the mastoid process (top), after which the prongs are moved to the
usual drainage. front of the external auditory canal (bottom). (Copyright B. Proud.)
Smelling acuity (ability to smell and identify odors) is
not commonly checked unless impairment is suspected.
MOUTH AND ORAL MUCOUS MEMBRANES. The lips sur-
To test smelling acuity:
round the mouth, which contains the tongue and teeth.
1. Have the client occlude one nostril and close his or The nurse inspects these structures by having the client
her eyes. open the mouth widely. The protruding tongue is nor-
2. Place substances with strong odors, such as lemon, mally in midline. The nurse documents any dentures,
vanilla extract, coffee, peppermint, or alcohol, one missing or malpositioned teeth, or a partial plate. Some
at a time beneath the patent (open) nostril. unusual breath odors are diagnostic. For example, the
3. Ask the client to inhale and identify the substance. odor of alcohol or acetone suggests additional health
problems.
Normal oral mucous membranes are pink, intact, and
kept moist by salivary glands located below the tongue.
When the client smiles, purses the lips as though prepar-
ing to whistle, or shows the teeth, the lips should look
the same.
The tongue contains many taste buds that detect partic-
ular taste characteristics (Fig. 13-15). Although assessing
taste is rarely done, it is facilitated by placing substances
TABLE 13-2 HEARING ACUITY LEVELS

HEARING LEVEL DECIBEL RANGE
Normal 0–25 dB
Mildly impaired 26–30 dB
Moderately impaired 31–55 dB
Moderately to severely impaired 56–70 dB
Severely impaired 71–90 dB
FIGURE 13-13 • The Weber test assesses sound conducted through Profoundly impaired 91 dB or greater
bone. (Copyright B. Proud.)
• A fissure is a crack in the skin especially in or near

mucous membranes.
• A scar is a mark left by the healing of a wound or lesion.
Other common skin lesions and their characteristics are
Facial nerve described in Table 13-4. Additional skin assessments are
described later as related to other body areas.
Glossopharyngeal Stop • Think + Respond BOX 13-2

nerve
A nurse has documented that a client has maculopapular
skin lesions over her body. Describe how these would
Bitter
appear.
Sour
Salt
Sweet HAIR. Assessment of the hair includes scalp hair, eye-
FIGURE 13-15 • Assessing taste. brows, and eyelashes. The nurse notes the color, texture,
and distribution (presence or absence in unusual loca-
tions for gender or age). He or she also inspects the hair
on the tongue and asking the client to identify them with for debris such as blood in a client with head trauma; nits
the eyes closed. To ensure valid results, the nurse instructs (eggs from a lice infestation); or scales from scalp lesions.
the client to sip water between assessments. As the physical assessment progresses, the nurse also
observes characteristics of body hair.
FACIAL SKIN. The nurse notes characteristics of the facial
skin while assessing the head. Although skin assess- SCALP. The nurse assesses the scalp by randomly separat-
ment begins here, it continues as the nurse examines ing the hair and inspecting the skin. He or she looks for
other body areas. Regardless of location, skin should be signs that the scalp is smooth, intact, and free of lesions.
smooth, unbroken, of uniform color consistent with the The nurse also palpates the skull for any unusual contour.
client’s ethnicity or race, warm, and resilient. It should
not be wet or dry. Diagnostic variations in skin color are Neck
listed in Table 13-3.
The neck supports the head in midline. The client should
While examining the skin, the nurse may detect one
be able to bend the head forward, backward, and to either
or more alterations in its integrity:
side as well as to rotate it 180 degrees. The trachea (wind-
• A wound is a break in the skin. pipe) should be in the center of the neck. Pulsations in the
• An ulcer is an open crater-like area. carotid arteries (see Chap. 12) are visible and easy to pal-
• An abrasion is an area that has been rubbed away by pate. There should be no unusual bulges or fullness in the
friction. neck. Some nurses lightly palpate the lymph nodes in the
• A laceration is a torn, jagged wound. neck area or assess for an enlarged thyroid gland.
TABLE 13-3 COMMON SKIN COLOR VARIATIONS

COLOR TERM POSSIBLE CAUSES
Pale, regardless Pallor Anemia, blood loss

of race
Red Erythema Superficial burns, local inflammation, carbon
monoxide poisoning
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
cells
Brown Tan Ethnic variation, sun exposure, pregnancy,
Addison’s disease
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 than Enlarged lymph node
papule
Cyst Encapsulated, round fluid-filled or solid mass Tissue growth

beneath the skin
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.
Chest and Spine deviations may be noted (Fig. 13-18). Lordosis is an exag-
gerated natural lumbar curve of the spine. Kyphosis is an
The chest is a cavity surrounded by the ribs and verte- increased thoracic curve. Scoliosis is a pronounced lateral
brae and houses the heart and lungs. The nurse observes curvature of the spine.
the chest’s shape and movement with breathing, notes the
curved appearance of the spine, and assesses skin turgor, Breasts
breasts, heart sounds, and lung sounds. Although abnormalities such as tumors occur in men,
Turgor (resiliency of the skin) is a combination of the
they are more common in women. Usually more advanced
elastic quality of the skin and the pressure exerted on practitioners examine the breasts, but because tumors are
it by fluid within. To assess skin turgor, the nurse grasps common and early diagnosis promotes a better prognosis,
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 assessment location because
the skin in other areas tends to loosen with age. When
the nurse releases the tissue, it should return immedi-
ately to its original position. Prolonged “tenting” indi-
cates dehydration.
Chest Shape and Movement

In normal adults, the lateral dimension of the chest is
approximately twice the anterior-posterior dimension. Inspiration
Various musculoskeletal abnormalities, cardiac or res-
piratory diseases, or trauma can cause changes in shape Expiration
(Fig. 13-16). With normal breathing, the chest expands
equally on both sides. To assess chest expansion, the
nurse places his or her thumbs side by side over the
client’s posterior vertebrae at about the level of the 10th
rib (Fig. 13-17). As the client inhales, the nurse notes
how far the thumbs separate; normally the distance is
1 to 2 inches (3 to 5 cm).
Spine
The spine, or vertebral column, appears in midline with FIGURE 13-17 • Palpation of thoracic excursion. In the posterior
gentle concave and convex curves when viewed from the approach, the nurse places the hands at the level of the 10th rib and
side. The shoulders are at equal height. Some common observes for equal movement as the client inhales.
the “lub” sound and is louder at the apex or mitral area

when using the diaphragm of a stethoscope. Although
the second heart sound, S2 or the “dub” sound, can be
heard in the mitral area, it is louder over the aortic area.
Sometimes there is tiny 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 stethoscope at point P or T on the chest.
A B C D ABNORMAL HEART SOUNDS. The nurse may hear two

FIGURE 13-18 • Variations in spinal curves: normal (A), scoliosis (B), additional sounds, S3 and S4, when auscultating the chest.
lordosis (C), and kyphosis (D). S3, which is normal in children but abnormal in most
adults, appears after S2. S3 sounds like “lub-dub-dub” or
the cadence of sounds in “Ken-tuck-y.” An S3 is much
all nurses are responsible for teaching women how to self- more pronounced than a split second sound. S4 is heard
examine their breasts (Client and Family Teaching 13-1). just before S1. It may sound like “lub-lub-dub” or the syl-
lables in “Ten-nes-see.”
Heart Sounds Identifying abnormal heart sounds—S3, S4, heart
murmurs, clicks, and rubs—is a skill that nurses master
When assessing the anterior chest, the nurse listens to the
after they become proficient at distinguishing S1 from
heart sounds, which presumably are caused by the closing
S2. A beginning nurse should consult with an experi-
of the atrial and ventricular valves. A beginning nurse
enced nurse or physician if there is any unusual charac-
may limit assessment to the apical area (see Chap. 12).
teristic in a client’s S1 and S2 heart sounds.
Experienced nurses expand their skills to auscultate at the
aortic, pulmonic, tricuspid, and mitral areas (Fig. 13-20).
Lung Sounds
NORMAL HEART SOUNDS. The two normal heart sounds Listening to the lungs is another skill that requires fre-
are S1 and S2. S1, the first heart sound, correlates with quent and repeated practice because some sounds are
Breast Self-Examination • Put a pillow or folded towel under the shoulder on

The nurse teaches the client as follows: the side where the first breast will be examined;
reverse the pillow before examining the second
• Examine the breasts monthly about 1 week after
breast.
the menstrual period or on a specific date post-
• Again, place the arm behind the head.
menopause.
• Begin the examination in the shower. • Press the flat surface of the fingers in small circular
• Use the right hand to examine the left breast and motions from the outer margin of the breast toward
the left hand to examine the right breast. the nipple, feeling for changes in any area of the
• Place the hand on the side that will be examined breast (Fig. 13-19).
behind the head. • Feel upward toward the axilla of each arm.
• Glide the flat portion of the fingers over all • Complete at least three revolutions about the breast.
aspects of each breast in a circular fashion. • Squeeze the nipple gently between the thumb and
• Determine if there are any lumps, hard knots, or index finger to determine if there is any clear or
thickened areas. bloody discharge.
• Next, stand in front of a mirror. • Repeat the examination on the opposite breast
• Look at both breasts with the arms relaxed at the and axilla.
side, with the hands pressing on the hips, and • Report any unusual findings or changes to a physician.
with the hands elevated above the head. • Breast self-examination is combined with a clinical
• Look for dimpling in the skin or retraction of examination and mammography to ensure early
either nipple. diagnosis and treatment of cancerous tumors
• Lie down for the remainder of the examination. (Table 13-5).
FIGURE 13-19 • Patterns for palpating the breast when performing breast self-examination.
normal and others are abnormal. See Nursing Guide- are created by air moving through secretions or nar-
lines 13-4. rowed airways. Adventitious sounds are divided into
four categories:
NORMAL LUNG SOUNDS. Normal lung sounds are created
• Crackles, formerly called rales, are intermittent, high-
by air moving in and out of passageways. The sounds
pitched, popping, and heard in distant areas of the
vary in pitch and duration in relation to the size and loca-
lungs, primarily during inspiration. They resemble
tion of the air passages (Fig. 13-22). There are four nor-
the sound of crisped rice cereal when milk is added.
mal lung sounds:
They are attributed to the opening of partially col-
• Tracheal sounds are loud and coarse. They are equal in lapsed alveoli (terminal air sacs) or the movement of
length during inspiration and expiration and are sep- air over minute amounts of fluid in the periphery of
arated by a brief pause. the lungs during deep inspiration.
• Bronchial sounds, heard over the upper sternum and • Gurgles, formerly called rhonchi, are low-pitched, con-
between the scapulae, are harsh and loud. They are tinuous, bubbling, and heard in larger airways. They
shorter on inspiration than expiration with a pause are more prominent during expiration. Some describe
between them. gurgles as sounding like wet snoring. Gurgles may clear
• Bronchovesicular sounds are heard on either side of with deep breathing or coughing.
the central chest or back. These medium-range sounds
of equal length during 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 addi-
tion to normal lung sounds. Most adventitious sounds
TABLE 13-5
BREAST EXAMINATION
GUIDELINES
TECHNIQUE AGE FREQUENCY
Self-examination ≥20 years Once per month

Clinical examination by 20–40 years Every 3 years
a nurse or physician >40 years Every year
Mammography 40 years First examination
>40 years Every year
FIGURE 13-20 • Locations for assessing heart sounds: M, mitral area;
(Source: American Cancer Society, 2006.) T, tricuspid area; P, pulmonic area; A, aortic area.

Assessing Lung Sounds
❙ Wash hands or perform hand antisepsis with an alcohol rub ❙ Listen for one complete ventilation (inspiration and expiration) at each
(see Chap. 10). These measures reduce the spread of infection. area auscultated. This method ensures hearing characteristics during
❙ Provide privacy. Doing so demonstrates concern for client modesty. each phase of ventilation.
❙ Raise the bed to a comfortable position for you. Doing so reduces strain ❙ If body hair causes noise, wet it or press harder with the chest piece.
on the musculoskeletal system. This technique reduces sound distortion.
❙ Assist the client to a sitting position, if possible. This position facilitates ❙ Move the diaphragm from side to side from the apices (top) to the bases
auscultating the anterior, posterior, and lateral aspects of the chest with (bottom) of the lungs (Fig. 13-21). This sequence facilitates comparison
minimal client exertion. of sounds.
❙ Remove or loosen the client’s upper clothing. Doing so aids in ❙ Auscultate the lateral and anterior chest in a similar fashion. Doing so
identifying anatomic landmarks. ensures a comprehensive assessment.
❙ Reduce or eliminate environmental noise such as suction motors and ❙ Ask the client to cough or breathe deeply if crackles or gurgles
oxygen equipment. Quiet conditions promote the accurate identification are audible. This method helps to clear the air passages and open
of lung sounds. the alveoli.
❙ Ask the client to refrain from talking. Talking interferes with ❙ Reapply clothing and lower the bed. Doing so restores comfort and
concentration and distorts lung sounds.
safety.
❙ Warm the diaphragm of the stethoscope in the palm of your hand.
Warmth reduces discomfort when the diaphragm is applied to the chest.
❙ Wash hands or perform hand antisepsis with an alcohol rub (see Chap. 10).
Doing so reduces the spread of microorganisms.
❙ Instruct the client to breathe in and out through an open mouth deeply
but slowly. This type of breathing reduces noise from air turbulence and ❙ Record assessment findings. Documented data can be used for future
prevents hyperventilation. comparisons.
❙ Apply the chest piece to the upper back, but avoid placement over the ❙ Repeat lung sound assessments according to agency policy or the
scapulae or ribs. This method facilitates hearing sounds in the upper client’s condition. Doing so demonstrates responsibility, accountability,
and lower lobes and reduces competing sounds from the heart. and good clinical judgment.
• Wheezes are whistling or squeaking sounds caused Whenever adventitious sounds are heard, the nurse also
by air moving through a narrowed passage. They can assesses the characteristics of any cough and the appear-
be heard anywhere in the chest during inspiration or ance of raised sputum.
expiration. Wheezes may be audible without a stetho-
scope. Coughing and deep breathing do not usually
alter a wheeze; in fact, if wheezing suddenly stops, it Stop • Think + Respond BOX 13-3
may mean that the air passage is totally occluded. What physical assessments are appropriate when a client
• Rubs are grating, leathery sounds caused by two dry is coughing frequently?
pleural surfaces moving over each other.
A B C
FIGURE 13-21 • Auscultation sequence: anterior (A); lateral (B); posterior (C).
FIGURE 13-22 • Locations of normal lung sounds. The symbols indi-

cate the ratio of time they may be heard during inspiration and expi-
ration, as well as the presence or absence of pauses between the two.
Extremities
The nurse notes the alignment, mobility, and strength
of the extremities and compares their size. He or she feels
the skin temperature, notes the characteristics of the
nails, times the capillary refill, palpates local peripheral
pulses (see Chap. 12), checks for edema, and may test the
perception of skin sensations. Advanced practitioners B
assess deep tendon reflexes with a reflex hammer.
FIGURE 13-23 • Assessing muscle strength of lower extremities.
Muscle Strength
The nurse assesses all four extremities separately to deter- Edema
mine muscle strength. He or she asks the client to grasp,
squeeze, and release the nurse’s fingers. As the nurse pulls Edema is excessive fluid within tissue and signifies abnor-
and pushes on the forearm and upper arm, he or she mal fluid distribution. Clients with cardiovascular, liver,
instructs the client to resist. To test strength in the lower and kidney dysfunction are prone to edema. Subtle signs
extremities, the nurse has the client push and pull against of edema include weight gain, tight rings, and patterns in
resistance (Fig. 13-23).
Fingernails and Toenails

Changes in the shape and thickness of the fingernails and
toenails are often signs of chronic cardiopulmonary disease
(Fig. 13-24) or fungal infections. The nurse documents any
unusual characteristics of the nails or surrounding tissues.
Capillary refill time (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: Diamond-
1. Observe the color in the nail bed. shaped
2. Depress the nail bed, displacing capillary blood. space
3. Release the pressure.
4. Note how many seconds it takes for the preassess-
ment color to reappear. Watching a clock would
interfere with an accurate assessment, so count,
“one-one thousand, two-one thousand, three-one FIGURE 13-24 • Technique for assessing clubbed fingernails. A
thousand” to estimate the time in seconds. diamond-shape space between the nails of the ring fingers is normal.
BOX 13-2 ● Criteria for Estimating Pitting Edema
1+ Pitting Edema 2+ Pitting Edema

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

❙ Deep pit (6 mm) ❙ Deep pit (8 mm)
❙ Remains several seconds after pressing ❙ Remains for a prolonged time after
❙ Skin swelling obvious pressing, possibly minutes
by general inspection 6 mm ❙ Frank swelling 8 mm
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
the skin after removing socks or shoes. To determine the

extent of any edema, the nurse presses a thumb or finger
into the tissue over a bone. If an indentation remains Assessing Sensory Skin Perception
(pitting edema), the nurse attempts to quantify its sever-
❙ Gather a cotton ball, a safety pin or other pointed object, a small
ity (Box 13-2).
container of warm water and one of ice water, and a tuning fork.
These materials provide for a variety of test resources.
Skin Sensation ❙ Instruct the client to shut both eyes. Doing so reduces the potential
During a comprehensive rather than a basic assessment, for gathering invalid data.
the nurse tests the client’s ability to differentiate between ❙ Explain that you will touch the skin with test objects at various places
light touch, warmth, cold, sharp, dull, and vibration. See and on both sides of the body and that you will ask the client to identify
Nursing Guidelines 13-5. the location and characteristics of the sensation. This information
identifies the test method and how the client is expected to respond.
❙ Touch the client with the test objects in a random pattern. A random
Abdomen pattern prevents the potential for correct guessing.
❙ Use both the pointed and curved ends of the safety pin to determine
Most gastrointestinal and accessory digestive organs if the client can discriminate between sharp and dull. Take care not
lie within the abdomen. The bladder, if distended, may to puncture the skin. Doing so prevents injury.
rise into the abdomen. ❙ Stroke the skin with the cotton ball; touch areas with the warm and
For assessment purposes, the abdomen is divided cold containers. These tests assess the client’s ability to identify fine
into four quadrants (Fig. 13-25). The abdomen is always touch and differences in temperature.
inspected and then auscultated—in that sequence—before ❙ Strike a tuning fork and place the stem against bony areas such as
using palpation or percussion techniques. Touching or the wrists and along the length of the shins. This tests the client’s
manipulating the abdomen can alter bowel sounds, pro- ability to sense vibration.
ducing invalid findings.

Assessing Bowel Sounds
❙ Have the client recline. This position provides access to the abdomen.
❙ Reduce noise. A quiet environment facilitates accurate assessment.
A B ❙ Warm the diaphragm of the stethoscope. Warmth promotes comfort.
❙ Place the diaphragm lightly in the lower right quadrant and listen
for clicks or gurgles. Move the chest piece over all four quadrants. If
no sounds are audible initially, listen for 2 to 5 minutes. This
C D sequence follows the anatomic areas of the upper to lower bowel.
❙ Document the frequency and character of the bowel sounds. Doing
so provides data for problem identification and future comparisons.
❙ Once you have finished auscultation, note the softness or firmness
of the abdomen and feel for palpable masses (Box 13-3).
During inspection, the nurse notes the condition of

the skin and the distribution and characteristics of pubic
hair (lice may infest pubic hair). A physician or nurse
FIGURE 13-25 • Four abdominal quadrants. (A) Right upper quadrant
with advanced skills examines females internally with
(RUQ). (B) Left upper quadrant (LUQ). (C) Right lower quadrant (RLQ).
(D) Left lower quadrant (LLQ). an instrument called a speculum (see Chap. 14); in men,
the prostate gland is palpated during a rectal examination.
The nurse observes if the male is circumcised and if
Bowel Sounds the scrotum appears to be of normal size. Whenever pos-
sible, he or she instructs male clients how to examine
Wavelike muscular contractions of the large and small
intestines that move fluid and intestinal contents toward their testicles. See Client and Family Teaching 13-2.
the rectum produce bowel sounds. The nurse routinely
assesses a client’s bowel sounds on admission and once
per shift. Anus and Rectum
Normal bowel sounds resemble clicks or gurgles and
occur 5 to 34 times a minute (Bickley, 2007). They are Unless a client has specific symptoms, the nurse inspects
more frequent after eating. Bowel sounds are described only the anus. If touching is required, gloves are necessary.
as hyperactive if they are frequent, hypoactive if they occur To examine the anus, the nurse positions the client on the
after long intervals of silence, and absent if no sound is side with the knees bent. He or she separates the client’s
heard for 2 to 5 minutes. Occasionally the nurse also
detects the sound of blood pulsating through the abdom-
inal aorta. See Nursing Guidelines 13-6. BOX 13-3 ● Characteristics of Palpated Masses
Abdominal Girth CHARACTERISTIC DESCRIPTION
If the abdomen appears unusually large, the nurse checks Mobility Fixed—does not move
its girth (circumference) daily by using a tape measure Mobile—can be moved with palpation
around the largest diameter. To ensure that he or she Shape Round—resembles a ball
always measures from the same location, the nurse makes Tubular—is elongated
guide marks on the skin with an indelible pen (Fig. 13-26). Ovoid—resembles an egg
Irregular—has no definite shape
Consistency Edematous—leaves indentation when palpated
Genitalia Nodular—feels bumpy to touch
Granular—feels gritty to touch
In most cases, the nurse only inspects the genitalia. If Spongy—feels soft to touch
Hard—feels firm to touch
contact with genital structures or secretions is required,
the nurse dons gloves. To eliminate the possibility of being Size Measured in centimeters (1 cm = approximately 1⁄2″)
falsely accused of sexual impropriety, it is a good practice Tenderness Amount of discomfort when palpated—none,
to ask someone of the client’s gender to be present when slight, moderate, or severe
the nurse touches the genitalia.
FIGURE 13-26 • Measuring abdominal girth.

A
FIGURE 13-27 • Testicular self-examination. (A) Horizontal palpation.

buttocks and inspects the external orifice (Fig. 13-28). (B) Vertical palpation. (C ) Palpation of spermatic cord.
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 • Readiness for Enhanced Knowledge
extend beyond the external sphincter muscle. There may • Ineffective Health Maintenance
be rectal fissures (cracks) if the client has a history of • Effective or Ineffective Therapeutic Regimen Man-
chronic constipation. Trauma also may be present if the agement
client has participated in anal intercourse. • Deficient Knowledge
• Noncompliance
• Health-Seeking Behaviors
NURSING IMPLICATIONS Nursing Care Plan 13-1 is an example of how the nursing
process is used when a client has the nursing diagnosis of
Health-Seeking Behaviors, defined by NANDA (2005) as
Assessment findings form the basis for identifying health
“active seeking (by a person in stable health) of ways to
problems. Often during a physical assessment, clients
alter personal health habits and/or the environment in
reveal situations that caused their health to fail, or they
order to move toward a higher level of health.”
indicate a desire for more health information. The fol-
lowing are some nursing diagnoses that may apply:
GENERAL GERONTOLOGIC
CONSIDERATIONS
As with all clients, the examiner explains why each procedure is
Testicular Self-Examination needed immediately before touching the older person. A brief
explanation promotes cooperation and lessens anxiety.
The nurse teaches the client as follows: The nurse shows consideration for alterations in hearing, vision,
• Examine the testes monthly at a time when the or movement before starting the examination. Before the
testicles are warm and positioned loosely within
the scrotum (e.g., 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
(Fig. 13-27).
• Check for any unusual lumps; cancerous lumps
are located most often on the upper and outer
sides of the testes.
• 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. FIGURE 13-28 • Inspection of the anus.
Health-Seeking Behaviors
ASSESSMENT
• Interact with the client to determine if he or she expresses a desire to seek a higher level of wellness or manifests a lack of
knowledge about health promotional activities.
• Other evidence that validates the nursing diagnosis of Health-Seeking Behaviors is that the client voices concerns about
his or her health status or a desire for improvement.
Nursing Diagnosis: Health-Seeking Behaviors 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 Effective health teaching builds on a foundation of
common STDs and how they are transmitted. knowledge that the client already has acquired.
Explore the client’s views concerning nonpermanent The client’s ability to incorporate new health behaviors
measures that men can implement to reduce the potential depends on his acceptance of and willingness to integrate
for pregnancy. such changes.
Provide pamphlets titled “Choices” and “Understanding Information from an authoritative resource provides
Safer Sex” from the Reproductive Control Clinic. These scientifically based information.
describe birth control measures and illustrate the
technique for applying a condom to prevent STDs.
Give the client a supply of free condoms from the An initial supply of condoms facilitates implementation of
Reproductive Control Clinic. new health behaviors until the client acquires his own
personal supply.
Review the following health information and illustrations
(A and B) in the pamphlets.
A B
(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.
(continued)
Health-Seeking Behaviors
• Reduce sexual partners to one noninfected, faithful Sex with a monogamous, disease-free partner reduces the
person. potential for acquiring an STD.
• Use a latex condom and apply nonoxynol-9 either over the A condom provides a barrier for sperm and
tip of the condom or as a vaginal application. microorganisms. 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
remove the condom-covered penis from the vagina before leaking sperm within the vagina, which can lead to
the penis becomes limp. pregnancy.
• Do not have sexual contact again unless you apply another For maximum effectiveness, condoms are recommended
condom. for 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.
Evaluation of Expected Outcome:

• The client reads the pamphlets provided.
• The client states, “Condoms are inconvenient, but they’re better than getting a disease. They’re also cheaper than babies.
I plan to use them from now on until I find the right life partner.”
physical assessment, the nurse may ask, “Is there anything 3. Appearance of respiratory secretions
you want me to know before we begin?” or “How can I make 4. Any self-treatment that the client is using
you as comfortable as possible during this examination?”
If limitations are identified, the nurse makes appropriate adjust- 2. The nurse is correct in explaining that the best technique
ments to the examination such as speaking into the ear with for palpating breast tissue during breast self-examination
the best hearing or modifying positions to reduce discomfort. (BSE) is in small circles or as spokes of a wheel from the
Physical limitations from chronic diseases (e.g., difficulty breath- 1. Nipple to the outer margins of the breast
ing, limited movement, weakness) may require modifying 2. Outer margins of the breast to the nipple
assessment techniques during the examination. 3. Sternum toward each axilla
Older women may not be able to tolerate the lithotomy position
4. Each axilla toward the sternum
for gynecologic examinations. The knee–chest position may
also need modification, extra time, or padding. 3. A nurse caring for a client with a head injury performs all
Willingness of the examiner to make modifications and allow the following assessments. Which one is most important
extra time promotes the client’s trust. at this time?
1. The nurse assesses the client’s lung sounds.
2. The nurse assesses the client’s skin integrity.
3. The nurse assesses the client’s urine characteristics.
1. A client reports that he has not had a bowel movement 4. The nurse assesses the client’s pupillary responses.
for 3 days, which is unusual for him. Discuss the physical 4. The best location for the nurse to auscultate an S1 heart
assessments important to perform at this time. sound is at the
2. Describe the characteristics of lung sounds normally 1. Fifth intercostal space in the left midclavicular line
heard at the midchest area below the nipple line. 2. Fourth intercostal space to the left of the sternum
3. Second intercostal space to the right of the sternum
4. Second intercostal space to the left of the sternum
5. Before using a Snellen chart to assess a client’s vision, the
1. Although all the following information is appropriate to nurse is most correct in explaining to the client that he or
gather when assessing a client with a cough, it is most she must
important to document the characteristics of the cough 1. Read words the size of newsprint
and the 2. Read letters from a distance of 20 feet
1. Client’s family history of respiratory disease 3. Look at a colored picture and identify an image
2. Current assessment of the client’s heart rate 4. Look at a screen and say when an object is seen
Skill 13-1 • PERFORMING A PHYSICAL ASSESSMENT
Assessment
Identify the client. Ensures that assessment is 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 Helps to focus attention during the assessment on
any current or recent signs and symptoms. particular structures and their functions
Planning
Give the client a specimen container, if a urine sample Takes advantage of an opportunity when the client’s
is needed. bladder contains urine
Have the client empty his or her bladder before Facilitates the examination and reduces discomfort
undressing.
Pull the curtain or close the door and give the client a Prepares the client for accurate assessment and ensures
drape or examination gown to put on after undressing. privacy
Gather assessment equipment and supplies (see Box 13-1 Promotes organization and efficient time management
for basic necessities).
Decide to examine the client using either a head-to-toe or Establishes the plan for assessment and ensures that
body systems approach. comprehensive data will be gathered
Implementation
Explain how the assessment will be conducted. Reduces anxiety
Explain that all information will be kept confidential Encourages the client to be honest and open in identifying
among those involved in the client’s care. health problems
Wash hands or perform hand antisepsis with an alcohol Provides reassurance that the nurse is clean and
rub (see Chap. 10), preferably in the client’s presence. conscientious 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 Facilitates examination of the upper body without
table. requiring the client to change positions
Modify the client’s position if the examination is being Demonstrates adaptability
conducted 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 Demonstrates concern for the client’s comfort
experiences 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 Shows responsibility for controlling the spread of
rub (see Chap. 10) once again. microorganisms
Review pertinent findings, both normal and abnormal, Demonstrates compliance with the client’s right to
without making medical interpretations. information
(continued)
PERFORMING A PHYSICAL ASSESSMENT (Continued)
Offer the client an opportunity to ask questions. Encourages active participation in learning and
decision making
Begin organizing assessment findings outside the Ensures privacy
examination 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 Shows consideration for the next person who uses the
to the examination room, and restock used supplies. examination 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 outcome of the interaction
Date and Time 67-year-old man transported from bed to examination room per wheelchair for physical assessment.
Can cooperate without distress. Refer to assessment form for examination findings.
SIGNATURE/TITLE
14
Chapter
Special
Examinations
and Tests
LEARNING OBJECTIVES
● Differentiate between an examination and a test.
● List 10 general nursing responsibilities related to assisting with special examinations and tests.
● Name five positions commonly used during tests or examinations.
● Explain what is involved in a pelvic examination and Pap test.
● List six commonly performed categories of tests or examinations.
WORDS TO KNOW ● Identify four word endings and their meanings that provide clues as to how tests or examinations
are performed.
cold spot ● Explain the following procedures: sigmoidoscopy, paracentesis, lumbar puncture, throat culture,
computed tomography and measurement of capillary blood glucose.
contrast medium ● Discuss at least three factors to consider when performing examinations and tests on older adults.
culture
diagnostic examination
dorsal recumbent position
echography
electrocardiography IN ADDITION TO obtaining a health history and performing a physical assessment, the
electroencephalography nurse gains assessment data by evaluating the results of special examinations and
electromyography tests. This chapter gives an overview of some common diagnostic examinations and
endoscopy tests and related nursing responsibilities. Tests involving the collection of urine
fluoroscopy
glucometer
and stool specimens are discussed in Chapters 30 and 31, respectively.
Gram staining
hot spot
knee–chest position
laboratory test EXAMINATIONS AND TEST
lithotomy position
lumbar puncture
magnetic resonance A diagnostic examination is a procedure that involves physical inspection of body struc-
imaging tures and evidence of their functions. It is facilitated by the use of technical equip-
modified standing position
ment and techniques, such as the following:
nuclear medicine
department • Radiography (x-rays)
Pap (Papanicolaou) test
• Endoscopy (optical scopes)
paracentesis
pelvic examination • Radionuclide imaging (radioactive chemicals)
positron emission • Ultrasonography (high-frequency sound waves)
tomography • Electrical graphic recordings
radiography
radionuclides By learning root words and suffixes (word endings), which are primarily of Latin and
roentgenography Greek origin, it is possible to decipher many unfamiliar names of diagnostic exami-
Sims’ position nations and tests (Table 14-1).
specimens
A laboratory test is a procedure that involves the examination of body fluids or
speculum
spinal tap specimens. It involves comparing the components of a collected specimen with
transducer normal findings. A diagnostic examination may or may not include the collection
ultrasonography of specimens.
252
C H A P T E R 1 4 ● Special Examinations and Tests 253
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
General Nursing Responsibilities must repeat, simplify, clarify, or expand the original
explanation.
When clients undergo diagnostic examinations and labo- There are no exact rules for clarifying explanations. In
ratory tests, nurses have specific responsibilities before, general, it is best to find out how much of the physician’s
during, and after the procedures (Box 14-1). explanation the client understands and use the client’s
questions as a guide for providing further information.
Preprocedural Care Nurses should follow the suggestions for teaching and pro-
viding emotional support given in Chapter 8.
Before a client agrees to a procedure, the nurse determines
whether the client understands its purpose and the activ- PREPARING CLIENTS. Some examinations and tests require
ities involved. Once he or she obtains the client’s consent, special preparation of the client such as withholding food
the nurse prepares the client, obtains equipment and sup- and fluids or modifying the diet. Because test preparation
plies, and readies the examination area. requirements vary among health care agencies, the nurse
refers to written protocols in the agency’s manual rather
CLARIFYING EXPLANATIONS. In some cases, a signed con- than relying on memory.
sent form is required before the performance of examina- Once he or she understands the specific require-
tions or tests. To be legally sound, consent must contain ments for a test, the nurse provides directions to the client,
three elements: capacity, comprehension, and voluntariness nursing staff, and other hospital departments, such as
(Box 14-2). the dietary department, involved in the test. Everyone
Although physicians are responsible for giving clients involved must cooperate to ensure test accuracy. The
sufficient information to obtain their informed consent, nurse reports any incorrect test preparations promptly
not all clients fully understand the information. Some because the procedure may need to be canceled and
are too anxious to process details, others feel too inse- rescheduled.
cure to ask questions, and still others express additional Because many tests and examinations are done on an
concerns after the physician has left. Often the nurse outpatient basis, the nurse must understand the client’s
BOX 14-2 ● Elements of Informed Consent

BOX 14-1 ● General Nursing Responsibilities
for Examinations and Tests
Capacity Indicates that the client has the ability to make a rational
❙ Determine the client’s understanding of the procedure. decision; if not, a spouse, parent, or legal guardian
❙ Witness the client’s signature on a consent form. must do so.
❙ Teach or follow test preparation requirements. Comprehension Indicates that the client understands the physician’s
❙ Obtain equipment and supplies. explanation of the risks, benefits, and alternatives
❙ Arrange the examination area. that are available.*
❙ Position and drape the client. Voluntariness Indicates that the client is acting on his or her own free
❙ Assist the examiner. will without coercion or threat of intimidation.
❙ Provide the client with physical and emotional support.
❙ Care for specimens. *Sedative drugs or the effects of anesthesia may temporarily affect
❙ Record and report appropriate information. capacity and comprehension.
responsibilities and instruct him or her accordingly. See

Client and Family Teaching 14-1.
Regardless of the type of examination or test, the nurse
helps the client to change into an examination gown,
applies an identification bracelet, takes vital signs, and
suggests that the client empty the bladder. The nurse
continues to monitor the condition of waiting clients
who can experience adverse effects from fatigue, delayed
food consumption, or medical symptoms.
OBTAINING EQUIPMENT AND SUPPLIES. If an examination

or test is performed at the bedside or in an examination
room on the nursing unit, the nurse obtains equipment
and supplies ahead of time. Nurses are relieved of this
responsibility if the examination or test is carried out in
other locations or when a special technician performs
the procedure.
Some items that nurses may need are in packaged kits
(such as a lumbar puncture kit) kept in a clean utility
room (Fig. 14-1) or obtained from a central supply depart- FIGURE 14-1 • Obtaining equipment from the supply room. (Copy-
right Sharon Gynup.)
14-1 • CLIENT AND FAMILY TEACHING ment (also called materials management in some health
care agencies). If using a packaged kit, the nurse checks
Preparation for Special Examinations or Tests
the list of contents to determine what, if any, additional
The nurse teaches the client who is not items are needed. Clean gloves, goggles, masks, and
hospitalized to gowns are required to prevent direct contact with blood
• Call (specify the number) if he or she does not or body secretions (see the section on standard precau-
clearly understand or cannot follow any test tions in Chap. 22).
preparation instructions.
• Refrain from eating or drinking anything for at ARRANGING THE EXAMINATION AREA. If the procedure is
least 8 hours before a test or examination that performed at the bedside, the nurse removes unnecessary
requires a fasting state. articles from the area and provides privacy. Many nursing
• Follow exactly as directed all dietary specifica- units contain an examination room that is clean, well lit,
tions for eating or omitting certain foods. and stocked with frequently used equipment. The nurse
• Check with the physician about taking or covers the examination table with a sheet or paper dis-
readjusting the time schedule for taking pre- pensed from a roll. A lined receptacle is nearby for disposal
scribed medications on the day of the test or of soiled items.
examination. The nurse arranges equipment and supplies for easy
• Bathe or shower as usual on the day of the test access by the examiner (Fig. 14-2). Sterile items remain
or examination. wrapped or covered until just before their use. Before
• Dress casually and in layers so that he or she the examiner arrives, nurses check instruments that
can remove or add items of clothing to maintain require electric power, batteries, or lights so that they
comfort in the test environment. can replace nonfunctioning equipment.
• Ask a friend or family member to provide
transportation to and from the site if there is Procedural Responsibilities
a potential for drowsiness, lingering pain, or
weakness after the procedure. During the examination or test, the nurse positions
• Arrive at least 30 minutes before the test is and drapes the client, provides the examiner with tech-
scheduled. nical assistance, and supports the client physically and
• Identify himself or herself at the information emotionally.
or appointment desk upon arrival.
• Bring information to verify insurance or POSITIONING AND DRAPING. Five positions are commonly
Medicare coverage. used, depending on the type of examination, condition
head. The nurse places a drape to cover the client’s back,

buttocks, and thighs. This position is very difficult for
most clients—especially older adults—to assume for any
length of time. Therefore, the nurse waits to place the
client in this position until just before the examina-
tion. Some examination tables have movable sections
that facilitate maintaining this position without much
client effort.
In the modified standing position, the client stands with
the upper half of the body leaning forward. It is used pri-
marily for examining the prostate gland in men. For com-
fort and safety, the draped client stands in front of the
examination table and leans forward from the waist.
ASSISTING THE EXAMINER. The nurse must be familiar

with the examination equipment and the order of its
use. He or she places instruments and equipment on the
side of the examiner’s dominant hand, if possible. If not,
the nurse anticipates what will be needed during the pro-
FIGURE 14-2 • The nurse arranges supplies and equipment in an cedure and hands the examiner one item at a time.
endoscopic examination room. (Copyright B. Proud.) If the skin and underlying tissue require local anes-
thesia, the nurse holds a container of the medication as the
physician withdraws some of its contents (Fig. 14-3). The
of the client, and preference of the examiner. They include nurse always carefully checks the drug name and con-
the dorsal recumbent position, Sims’ or left lateral posi- centration on the label. A second method for ensuring
tion, lithotomy position, knee–chest or genupectoral use of the correct drug is to hold the container so that the
position, and modified standing position (Table 14-2). examiner can read the label.
The dorsal recumbent position is a reclining position with If the nurse is responsible for performing the test or
the knees bent, hips rotated outward, and feet flat. It is examination, he or she cannot leave the client to obtain
commonly used for various examinations. The nurse uses equipment and supplies. If he or she needs assistance or
a bath blanket to drape the client and places examination additional equipment, the nurse summons help with a
paper or a disposable pad under the client’s buttocks to telephone or call light in the examination room.
absorb drainage.
The lithotomy position is a reclining position with the PROVIDING PHYSICAL AND EMOTIONAL SUPPORT.
feet in metal supports called stirrups. It is used to facili- Throughout any examination or test, the nurse contin-
tate gynecologic (female reproductive), urologic, and some- uously observes the client’s physical and emotional reac-
times rectal examinations. The nurse uses a drape to cover tions and responds accordingly. For example, comfort
the client’s exposed perineum and legs. measures are in order if the client is cold or in pain. Hold-
In the Sims’ position, the client lies on the left side with ing the client’s hand and offering words of encourage-
the chest leaning forward, the right knee bent toward the ment help the client to endure temporary discomfort.
head, the right arm forward, and the left arm extended The nurse communicates assessments of the client to
behind the body. Indications are similar to those for the the examiner, who may choose to shorten or modify the
lithotomy position. It is an alternative gynecologic or examination in some manner.
urologic position when a client cannot abduct the hips
(move the legs outward from midline) because of restricted Postprocedural Care
joint movement such as that caused by arthritis. This posi-
tion also provides access to the anus and rectum when After the completion of examinations and tests, the nurse
the client requires rectal administration of medication or attends to the client’s comfort and safety, cares for spec-
instillation of enema solution. imens, and records and reports pertinent data.
In the knee–chest position, also called a genupectoral
position, the client rests on the knees and chest. He or ATTENDING TO THE CLIENT. First, the nurse helps the
she turns the head, which is supported on a small pillow, client to a position of comfort. He or she rechecks vital
to one side. The nurse places a pillow under the client’s signs to verify that the client’s condition is stable. The
chest for added comfort. The arms are above the head nurse cleans any substances from the client that caused
or bent at the elbows so they rest alongside the client’s soiling. He or she offers hospitalized clients a clean gown
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

a special examination or test. General information includes

the following:
• Date and time
• Pertinent pre-examination assessments and preparation
• Type of test or examination
• Who performed the test or examination
• Where the test or examination was performed
• Response of client during the examination and
afterward
• Type of specimen obtained, if any
• Appearance, size, or volume of specimen
• Where the specimen was transported
In addition to the written account of the examination,
the nurse reports significant information to other nursing
team members. This may include that the examination has
FIGURE 14-3 • Holding local anesthetic with the label clearly visible been completed, the client’s reactions during and immedi-
to the physician. ately after the procedure, and any delayed reactions. When
the nursing team stays aware of current events and
changes in the client’s condition, they can revise and keep
or directs outpatients to dress in their own clothing. When current the plan of care.
it is safe to do so, the nurse escorts clients to their rooms
or to the discharge area and provides instructions for
follow-up care.
Common Diagnostic Examinations
Many types of diagnostic examinations are performed

CARING FOR SPECIMENS. Sometimes specimens (samples commonly to assess and evaluate clients. Some of the most
of tissue or body fluids) are collected during an examina- common are discussed in this section. Additional infor-
tion or test. To ensure their accurate analysis, the nurse mation can be found in laboratory and test manuals and
does the following: courses in which specific diseases are studied; beginning
• Collects the specimen in an appropriate container nurses also will gain experiences with these examinations
• Labels the specimen container with correct information in the clinical setting.
• Attaches the proper laboratory request form
• Ensures that the specimen does not decompose before Pelvic Examination
it can be examined A pelvic examination is the physical inspection of the vagina
• Delivers the specimen to the laboratory as soon as and cervix with palpation of the uterus and ovaries. A
possible physician, physician’s assistant, or nurse practitioner
Box 14-3 lists factors that often interfere with accurate usually performs it. He or she often collects a specimen
examinations or invalidate test results. of cervical secretions for a Pap (Papanicolaou) test. This test,
also called a Pap smear, screens for abnormal cervical cells,
the status of reproductive hormone activity, and normal
RECORDING AND REPORTING DATA. The nurse must doc-
or infectious microorganisms within the vagina or uterus
ument certain information whenever a client undergoes
(Table 14-3).
When a pelvic examination is being used to screen
for cervical cancer, recommendations from the American
Cancer Society, the United States Preventive Services Task
BOX 14-3 ● Common Factors That Invalidate
Examination or Test Results Force, and the American College of Obstetricians and
Gynecologists (ACOG) have slight variations. ACOG’s
❙ Incorrect diet preparation
latest (2003) recommendations are that women:
❙ Failure to remain fasting
❙ Insufficient bowel cleansing 1. Receive their first Pap test approximately 3 years
❙ Drug interactions
❙ Inadequate specimen volume
after the onset of vaginal intercourse, but no later
❙ Failure to deliver specimen in a timely manner than 21 years of age.
❙ Incorrect or missing test requisition 2. Have annual Pap tests thereafter until 30 years
of age.
ing to shed abnormal cells after a hysterectomy. As

TABLE 14-3 PAP TEST RESULTS an alternative, physicians may opt to perform a Pap
TEST COMPONENT INTERPRETATION test and a second test on women 30 years and older
to detect human papillomavirus (HPV DNA test). If
Cellular Examination both yield negative results, the client can be retested,
Class I Negative; no abnormal cells using the same two tests every 3 years; if one test is
Class II Unusual, but not cancerous positive, the client is screened more frequently.
Class III Suggestive of cancer, but not definite 4. At or beyond age 65, women should continue to
Class IV Strongly suggestive of cancer
Class V Definitely cancerous have gynecologic examinations, but the physician
determines the frequency of cervical cancer screen-
Hormonal Effects (on a 6-point scale)
ing on a case-by-case basis. When three prior Pap
1 Marked estrogen effect
2 Moderate estrogen effect
tests within the previous 10 years were normal
3 Slight estrogen effect or negative, screening guidelines may be relaxed
4 Absent estrogen effect because cervical cancer in women older than 70 years
5 Compatible with pregnancy is almost entirely confined to women who have not
6 Too bloody, inflamed, or scanty
been previously screened or who have deviated
to analyze
from screening guidelines in the previous 10 years.
Identifiable Microorganisms (on a 5-point scale)
1 Normal microorganisms
2 Scanty or absent microorganisms
RELATED NURSING RESPONSIBILITIES. Skill 14-1 identifies
3 Trichomonas vaginalis (protozoan the nursing responsibilities involved in assisting with a
organism) pelvic examination and collecting cervical secretions for
4 Candida (yeastlike fungus) a Pap test.
5 Other or mixed collection of
microorganisms
Radiography
(Adapted from Fischbach F. [2003]. A manual of laboratory and diagnostic tests
[7th ed.]. Philadelphia: Lippincott, Williams & Wilkins.)
Radiography or roentgenography (general term for proce-
dures that use roentgen rays, or x-rays) produces images
of body structures. The actual film image is technically
3. Be screened every 2 to 3 years at or after 30 years of called a roentgenogram but is commonly known as an
age when three prior consecutive tests were normal x-ray. Roentgen rays produce electromagnetic energy
or negative. More frequent screenings are advocated that passes through body structures, leaving an image
for women who have a history of risk factors for cer- of dense tissue on special film. Table 14-4 lists common
vical cancer, such as being HIV positive, immuno- radiographic examinations and indications for their use.
suppressed secondary to an organ transplantation, X-rays cannot be seen or felt, but cells absorb the
exposed to diethylstilbestrol (DES) as a fetus, or pre- energy. Repeated exposure to x-rays, even at small doses,
viously diagnosed with cervical cancer, or continu- or a single exposure to a high dose causes cell damage
TABLE 14-4 COMMON RADIOGRAPHIC EXAMINATIONS

EXAMINATION EXAMPLES OF INDICATIONS FOR USE
Chest x-ray (anterior, posterior, lateral views) Detects pneumonia, broken ribs, lung tumors
Upper gastrointestinal x-ray (upper GI or barium swallow) Aids in diagnosis of ulcers, gastrointestinal tumors, narrowing of the
esophagus
Lower gastrointestinal x-ray (lower GI or barium enema) Helps in diagnosis of polyps or tumors of the bowel, intestinal
obstruction, and structural changes within the intestine
Cholecystography (x-ray of the gallbladder and ducts) Facilitates determining the presence of gallstones and obstruction in
the flow of bile
Intravenous pyelography (IVP) Helps identify urinary malformations, tumors, stones, cysts, and
obstructions in the kidneys and ureters
Retrograde pyelography Same as for IVP, but the contrast medium is instilled through a urinary
catheter
Angiography (x-ray of blood vessels) Determines the location where and the extent to which blood vessels
have narrowed, or evaluates improvement after treatment
Myelography (x-ray of spinal canal) Detects spinal tumors, ruptured intervertebral disks, and bony changes
in the vertebrae
FIGURE 14-4 • Magnetic resonance imaging.
that can lead to cancerous cell changes. Consequently raphy that displays an image in real time. It is used to
practitioners tend to be cautious about the number of observe the movement of contrast media—for example,
x-ray studies that they request. X-rays are avoided dur- as it is being swallowed or injected. Computed tomography
ing pregnancy if at all possible because a developing (CT) scanning is a form of roentgenography that shows
fetus is at greater risk for cellular damage from x-rays. planes of tissue. This and other types of x-ray examina-
Magnetic resonance imaging (MRI) is a technique for pro- tions use contrast media. The CT contrast medium makes
ducing an image by using atoms subjected to a strong it possible to identify differences in tissue density when
electromagnetic field. This diagnostic alternative does obtaining x-ray images from various angles and levels in
not involve exposure to the type of radiation produced the body (Fig. 14-5).
with roentgenography (Fig. 14-4).
Some hospitals are offering open MRIs that eliminate RELATED NURSING RESPONSIBILITIES. For the client under-
being enclosed within a tube. Claustrophobic and anxious going radiographic examination, nursing responsibilities
clients prefer the open system, which also is ideal for pedi- include the following:
atric clients and clients weighing more than 500 pounds. • Assess vital signs before the examination to provide
Metal devices that are within the body prohibit perform- a baseline and to help to detect changes in the client’s
ing an MRI; metal objects on a client’s person must be condition during or after the procedure.
removed before an MRI (Box 14-4). • Remove any metal items such as a religious medal or
clothing that contains metal such as the hooks and eyes
CONTRAST MEDIUM. A contrast medium is a substance that on a bra. Metal produces a dense image that may be
adds density to a body organ or cavity, such as barium confused with a tissue abnormality.
sulfate or iodine. It makes hollow body areas appear more • Request a lead apron or collar to shield a fetus or vul-
distinct when imaged on x-ray film. Some people are sen- nerable body parts during x-rays (Fig. 14-6).
sitive to substances used in contrast media and have an
immediate allergic reaction to them.
Contrast media are administered orally or rectally or
injected intravenously. Fluoroscopy is a form of radiog-
BOX 14-4 ● Metal Devices That Prohibit an MRI
ON THE BODY
WITHIN THE BODY (MUST BE REMOVED)
Artificial joint Watch

Wound staples Jewelry
Implanted pacemaker Hearing aid
Artificial heart valve Hair clips or pins
Metallic pins, screws, plates Pocket knives
Implanted drug delivery device Keys
Metal intrauterine device Credit cards or bank cards
Aneurysm clips
Implanted cardiac defibrillator
Implanted brain stimulator
Tattooed eyeliner FIGURE 14-5 • Cross-sections of cranial CT scan. (Courtesy of Ken
Timby.)
BOX 14-5 ● Examples of Endoscopic Examinations
❙ Bronchoscopy—inspection of the bronchi

❙ Gastroscopy—inspection of the stomach
❙ Colonoscopy—inspection of the colon
❙ Esophagogastroduodenoscopy (EGD)—inspection of the esophagus, stom-
ach, and duodenum
❙ Laparoscopy—inspection of the abdominal cavity
❙ Cystoscopy—inspection of the urinary bladder
short-acting form of anesthesia, sometimes referred to

as conscious sedation. When conscious sedation is used,
clients may have no memory of having had the test even
though they communicate and interact with staff during
its performance.
FIGURE 14-6 • Lead thyroid collar, apron, and skirt. (Copyright Endoscopic examinations are being performed more
B. Proud.) frequently on an outpatient basis and in the physician’s
office. They are an economical alternative to invasive tests
and procedures that previously required surgery.
• If the radiographic study involves administration of a RELATED NURSING RESPONSIBILITIES. For the client under-
contrast medium, ask the client about allergies, espe- going endoscopy, nursing responsibilities include the
cially to seafood or iodine, or previous adverse reactions following:
during a diagnostic examination. A reaction can range
from mild nausea and vomiting to shock and death. • To prevent aspiration, withhold food and fluids or
• Know the location of emergency equipment and drugs advise the client to do so for at least 6 hours before any
in case there is an unexpected allergic reaction to con- procedure in which an endoscope is inserted into the
trast medium. upper airway or upper gastrointestinal tract.
• To avoid interference with subsequent visual imaging, • If conscious sedation is used, monitor the client’s
schedule procedures requiring iodine before those that vital signs, breathing, oxygen saturation (using pulse
use barium. oximetry; see Chap. 21), and cardiac rhythm. Have
• To promote urinary excretion, encourage the client oxygen and resuscitation equipment readily available.
to drink a large amount of fluid after an examination • If topical anesthesia is used to facilitate the passage of
involving iodine to promote its excretion. an endoscope into the airway or upper gastrointestinal
• Check on bowel elimination and stool characteristics tract, withhold food or fluids for at least 2 hours after the
for at least 2 days after administration of oral barium procedure and until swallow, cough, and gag reflexes
contrast medium. Barium retention can lead to consti- return.
pation and bowel obstruction. Report absence of bowel • Relieve the client’s sore throat with ice chips, fluids, or
elimination beyond 2 days. Administration of a pre- gargles when it is safe to do so.
scribed laxative is often necessary. • Confirm that bowel preparation using laxatives and
enemas has been completed before endoscopic proce-
Endoscopic Examinations dures of the lower intestine.
• Report difficulty in arousing a client or any sharp pain,
Endoscopy (visual examination of internal structures) is
fever, unusual bleeding, nausea, vomiting, or difficulty
performed using optical scopes. Endoscopes have lighted
with urination after any endoscopic examination.
mirror-lens systems attached to a tube and are quite flexi-
ble so that they can be advanced through curved structures. Skill 14-2 describes the nurse’s role when assisting
Endoscopic examinations are named primarily for the with a sigmoidoscopy.
structure being examined (Box 14-5). In addition to allow-
ing the examiner to inspect the appearance of a structure,
endoscopes also have attachments that permit various Stop • Think + Respond BOX 14-1
forms of treatment or the collection of specimens for Explain why it is important for clients to have a
microscopic analysis. Endoscopic examinations that pro- sigmoidoscopy.
duce discomfort or anxiety are performed under a light,
Radionuclide Imaging devices on submarines, a hand-held probe called a trans-

ducer projects sound through the body’s surface. The
Radionuclides are elements whose molecular structures
sound waves cause vibrations within body tissues, pro-
are altered to produce radiation. They are identified by
ducing images as the waves are reflected back toward the
a number followed by a chemical symbol, such as 131I
machine. The reflected sound waves are converted into
(radioactive iodine) and 99Tc (radioactive technetium). a visual image called an ultrasonogram, sonogram, or
When radionuclides are instilled in the body, usually by echogram, which can be viewed in real time on a monitor
the intravenous route, particular tissues or organs absorb and recorded for future analysis. Doppler ultrasound,
them. A scanning device that detects radiation creates an discussed in Chapter 12, is a variation of this type of
image of the size, shape, and concentration of the organ technology.
containing the radionuclide. The terms hot spot (area Ultrasound examinations are used to visualize breast,
where the radionuclide is intensely concentrated) and abdominal, and pelvic organs; male reproductive organs;
cold spot (area with little if any radionuclide concentration)
structures in the head and neck; the heart and valves;
refer to the amount of radiation that the tissue absorbs. and structures within the eyes. Air-filled structures such
Positron emission tomography (PET) combines the technol-
as the lungs or intestines and extremely dense tissue
ogy of radionuclide scanning with the layered analysis of
such as bones do not image well. This type of examina-
tomography.
tion is used in obstetrics to determine fetal size, more
Radionuclide imaging offers two advantages over stan-
than one fetus, and location of the placenta. The outline
dard radiography: it visualizes areas within organs and
of fetal anatomy in the late stages of pregnancy is some-
tissue that are not possible with standard x-rays, and it
times visible on ultrasound, alerting the client to the gen-
involves less exposure to radiation than with roentgenog-
der of the fetus. Because ultrasound examinations do not
raphy. Tests using radionuclides, however, are contra-
involve radiation or contrast media, they are extremely
indicated for women who are pregnant or breast-feeding:
safe diagnostic tools.
the energy released is harmful to the rapidly growing cells
of an infant or fetus.
RELATED NURSING RESPONSIBILITIES. For the client under-
going ultrasonography, nursing responsibilities include
RELATED NURSING RESPONSIBILITIES. For the client under-
the following:
going radionuclide imaging, nursing responsibilities
include the following: • For best visualization, schedule abdominal and pelvic
• Inquire about a woman’s menstrual and obstetric ultrasonography before any examinations that use
history. Notify the nuclear medicine department (unit barium.
responsible for radionuclide imaging) if the client • Instruct clients undergoing abdominal ultrasonography
is pregnant, could possibly be pregnant, or is breast- to drink five to six full glasses of fluid approximately
feeding. 1 to 2 hours before the test. To ensure a full bladder,
• Ask about the allergy history because iodine commonly they should not urinate until after the test is completed.
is used in radionuclide examinations. • Explain that acoustic gel is applied over the area where
• Assist the client with a gown, robe, and slippers. Make the transducer is placed.
sure the client has no internal metal devices or external
metal objects because these interfere with diagnostic Electrical Graphic Recordings
findings. Machines can record electrical impulses from structures
• Obtain an accurate weight because the dose of radio- such as the heart, brain, and skeletal muscles. These tests
nuclide is calculated according to weight. are identified by the prefix “electro-” as in electrocardiog-
• Inform the client that he or she will be radioactive for raphy (ECG or EKG; examination of the electrical activity
a brief period (usually less than 24 hours) but that body in the heart), electroencephalography (EEG; examination
fluids, such as urine, stool, and emesis, can be safely of the energy emitted by the brain), and electromyography
flushed away. (EMG; examination of the energy produced by stimulated
• Instruct premenopausal women to use effective birth muscles).
control for the short period during which radiation To detect electrical activity, wires called electrodes are
continues to be present. attached to the skin (or muscle in the case of an EMG).
They transmit electrical activity to a machine that con-
Ultrasonography verts it into a series of waveforms (Fig. 14-7). Except for
Ultrasonography (soft tissue examination that uses sound an awareness of the electrodes, the client undergoing an
waves in ranges beyond human hearing) is also known ECG or EEG usually does not experience any other sen-
as echography. During ultrasonography, which is similar sations. Occasionally there is slight discomfort during
to the echolocation used by bats, dolphins, and sonar an EMG.
• Explain that electrical current is applied to muscles dur-

V1 V2 ing an EMG but that the sensation is not usually painful.
V3
V4
Also, a muscle electrode is inserted with a small-gauge
V5 needle in 10 or more locations, but the experience is
V6
painless unless it touches a terminal nerve in the area.
Diagnostic Laboratory Tests

Nurses, laboratory personnel, and physicians collect spec-
imens such as blood, urine, stool, sputum, intestinal secre-
tions, spinal fluid, and drainage from wounds or infected
tissue. They repeat tests on collected specimens at intervals
to monitor the progress of clients. Students can refer to
laboratory manuals to learn the purpose of specific tests
and associated nursing responsibilities.
Several examples of specimen collection are discussed
in future chapters where they are more pertinent. Nurs-
ing responsibilities for assisting with a paracentesis and
a lumbar puncture, collecting a specimen for a throat
culture, and measuring capillary blood glucose follow.
FIGURE 14-7 • The nurse attaches electrodes to the patient’s chest Assisting With a Paracentesis
and limbs before an ECG.
A paracentesis is a procedure for withdrawing fluid from
the abdominal cavity. A physician always performs it with
the assistance of a nurse. A paracentesis is done most
RELATED NURSING RESPONSIBILITIES. For the client under- commonly to relieve abdominal pressure and to improve
going an ECG, nursing responsibilities include the breathing, which generally becomes labored when fluid
following: crowds the lungs. Sometimes paracentesis removes 1 liter
• Clean the skin and clip hair in the area where the elec- (approximately 1 quart) or more of fluid. The physician
may send a specimen of the fluid to the laboratory for
trode tabs will be placed to ensure adherence and reduce
microscopic examination. See Nursing Guidelines 14-1.
discomfort on removal.
• Attach the adhesive electrode tabs to the skin where
the electrode wires will be fastened.
Assisting With a Lumbar Puncture
• Avoid attaching the adhesive tabs over bones, scars, or The physician requires nursing assistance when perform-
breast tissue. ing a lumbar puncture or spinal tap. This procedure involves
inserting a needle between lumbar vertebrae in the spine
For the client undergoing an EEG, nursing responsibili-
but below the spinal cord itself. The physician advances
ties include the following: the tip of the needle until it is beneath the middle layer
• Instruct the client to shampoo the hair the evening of the membrane surrounding the spinal cord. He or she
before the procedure to facilitate firm attachment of the measures the spinal fluid pressure and then withdraws a
electrodes. He or she should shampoo the hair after the small amount of fluid.
test to remove adhesive from the scalp. This test is performed for various reasons. It is used to
• Withhold coffee, tea, and cola beverages for 8 hours diagnose conditions that raise the pressure within the
before the procedure. Consult with the physician about brain, such as brain or spinal cord tumors, or infections
withholding scheduled medications, especially those such as meningitis. Spinal fluid also is withdrawn before
that affect neurologic activity. instilling contrast medium for x-rays of the spinal column.
• If a sleep-deprived EEG is scheduled, instruct the client Finally the treatment of some conditions is to instill drugs
that he or she must stay awake after midnight before directly into the spinal fluid after withdrawal of a similar
the examination. amount. See Nursing Guidelines 14-2.
For the client undergoing an EMG, nursing responsibilities Collecting a Specimen for a Throat Culture
include the following:
A culture (incubation of microorganisms) is performed by
• Tell the client he or she will be instructed to contract collecting body fluid or substances suspected of contain-
and relax certain muscles during the examination. ing infectious microorganisms, growing the living micro-

Assisting With a Paracentesis
❙ Explain the procedure or clarify the physician’s explanation to the ❙ Offer the client support as an area of the abdomen is anesthetized
client. Explanations prepare the client for an unfamiliar experience then pierced with an instrument called a trocar and a hollow sheath
or promote a clearer understanding. called a cannula is inserted (Fig. 14-8). Empathetic concern helps to
❙ Ensure that the client has signed the consent form, if needed. A relieve anxiety.
consent form provides legal protection. ❙ Reassess the client periodically after cannula insertion; expect that
❙ Measure and record weight, blood pressure, and respiratory rate; blood pressure and respiratory rate may decrease. Assessment
measure abdominal girth at its widest point with a tape measure. indicates the client’s response.
These data serve as a basis for postprocedural comparisons. ❙ Place a Band-Aid or small dressing over the puncture site after
❙ Obtain a prepackaged paracentesis kit along with a vial of local withdrawal of the cannula. The dressing acts as a barrier to
anesthetic. Gathering supplies promotes efficient time management. microorganisms and absorbs drainage.
❙ Make sure that extra gloves, gown, mask, and goggles are available. ❙ Assist the client to a position of comfort. Doing so demonstrates
These items protect against contact with microorganisms, such as HIV, concern for the client’s welfare.
that may be in blood or other body fluids. ❙ Measure the volume of fluid withdrawn. This measurement contributes
❙ Encourage the client to empty the bladder just before the procedure. to accurate assessment of fluid volume.
An empty bladder prevents accidental puncture of the bladder. ❙ Label the specimen, if ordered, and send it to the laboratory with the
❙ Place the client in a sitting position. This position pools abdominal fluid in appropriate requisition form. Doing so facilitates appropriate analysis.
the lower areas of the abdomen and displaces the intestines posteriorly. ❙ Document pertinent information such as the appearance and
❙ Hold the container of local anesthetic so the physician can withdraw a volume of the fluid, client assessments, and disposition of the
sufficient amount. Doing so prevents contaminating the physician’s specimen. Such documentation adds essential data to the client’s
sterile gloves. medical record.
organisms in a nutritive substance, and examining their

characteristics 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
(commonly streptococcal bacteria), the nurse obtains a
specimen from the throat. An abbreviated test that takes
approximately 10 minutes is performed on throat speci-
mens in many doctors’ offices and student health clinics.
A rapid preliminary diagnosis is made so that appropriate
treatment can be initiated immediately. If the quick test
is not clearly negative and symptoms 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 staining (process of adding a dye to a microscopic
specimen) is named for the Danish physician who devel-
oped the technique. The Gram stain helps to 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-negative bacteria (Fischbach,
FIGURE 14-8 • The nurse offers support during an abdominal 2003). Streptococci are round, grow in chains, and are
paracentesis. gram positive.

Assisting With a Lumbar Puncture
❙ Explain the procedure or clarify the physician’s explanation to the client. ❙ Tell the client that it is not unusual to feel pressure or a shooting pain
Explanations prepare the client for an unfamiliar experience or down the leg. This information prepares the client for expected
promote a clearer understanding. sensations.
❙ Ensure that the client has signed the consent form, if needed. A ❙ Perform Queckenstedt’s test, if asked, by compressing each jugular
consent form provides legal protection. vein separately for approximately 10 seconds while pressure is
❙ Perform a basic neurologic examination including pupil size and being measured. Queckenstedt’s test helps demonstrate if there is
response and muscle strength and sensation in all four extremities. an obstruction in the circulation of spinal fluid. If so, the pressure
This information provides a baseline for future comparisons. remains unchanged, rises slightly, or takes longer than 20 seconds to
return to baseline.
❙ Encourage the client to empty the bladder. An empty bladder promotes
comfort during the procedure.
❙ Observe that the physician fills three separate numbered containers
with 5 to 10 mL in their appropriate sequence if laboratory analysis is
❙ Administer a sedative drug if ordered. Sedatives reduce anxiety. desired. In this way, if blood is present but in the least amount in the
❙ Obtain a prepackaged lumbar puncture kit along with a vial of local third container, its source is most likely trauma from the procedure
anesthetic. Gathering supplies promotes efficient time management. rather than central nervous system pathology.
❙ Make sure that extra gloves, gown, mask, and goggles are available. ❙ Place a Band-Aid or small dressing over the puncture site after the
These items offer protection from contact with microorganisms, such needle has been withdrawn. The dressing acts as a barrier to
as HIV, that may be present in blood or other body fluids. microorganisms and absorbs drainage.
❙ Place the client on his or her side with the knees and neck acutely flexed ❙ Position the client flat on the back or abdomen; instruct the client to
(Fig. 14-9) or in a sitting position, bent from the hips. These positions remain flat and roll from side to side for the next 6 to 12 hours.
separate the bony vertebrae. These measures reduce the potential for severe headache.
❙ Instruct the client that once the needle is inserted, he or she must avoid ❙ Reassess the client’s neurologic status. Check the puncture site for
movement. This measure prevents injury. bleeding or clear drainage. Comparative data help the nurse to
evaluate changes in the client’s condition.
❙ Hold the container of local anesthetic so the physician can withdraw a
sufficient amount. Doing so prevents contaminating the physician’s ❙ Offer oral fluids frequently. They restore the volume of spinal fluid.
sterile gloves. ❙ Label the specimens, if ordered, and send them to the laboratory with
❙ Stabilize the client’s position at the neck and knees. This reinforces the the appropriate requisition form. Doing so facilitates appropriate
need to remain motionless. analysis.
❙ Support the client emotionally as the needle is inserted and the ❙ Document pertinent information such as the appearance of the fluid,
skin is injected with local anesthesia. Empathetic concern helps to client assessments, and disposition of the specimen. Doing so adds
relieve anxiety. essential data to the client’s medical record.
When there is evidence of microbial growth and the

infectious microorganism is identified, the most appro-
priate treatment can be provided. A throat culture is
performed most often on young children, who are sus-
ceptible to complications from upper respiratory infections
and infection of the tonsils. Adults who tend to harbor
infectious microorganisms 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.
Measuring Capillary Blood Glucose

Glucose is the type of sugar in blood that results from eat-
ing carbohydrates. A certain amount is always present to
supply cells with a source of instant energy. The amount
of blood glucose in a morning fasting state is generally
70 to 99 mg/dL (milligrams per deciliter); it may rise to
FIGURE 14-9 • Positioning for lumbar puncture. (Copyright B. Proud.) 139 mg/dL within 2 to 4 hours of eating a meal (American

Collecting a Specimen for a Throat Culture
❙ Check with the physician about proceeding with the throat culture if ❙ Be prepared for the client’s gagging. Stroking the back of the throat
the client is taking antibiotics. Antibiotics affect test results. stimulates the gag reflex.
❙ Delay collecting a specimen if the client has recently used an antiseptic ❙ Remove the swab and discard the tongue blade in a lined receptacle.
gargle. Such gargle affects the test’s diagnostic value. This measure controls the spread of microorganisms.
❙ Explain the purpose of and technique for obtaining the culture. ❙ Spread the secretions on the swab across the glass slide. Doing so
Explanations help to reduce anxiety and promote cooperation. prepares a specimen for quick staining and microscopic examination.
❙ Collect supplies: sterile culture swab, glass slide, tongue blade, gloves, mask ❙ Replace the swab securely within the tube, taking care not to touch the
if the client is coughing, paper tissues, and an emesis basin if the client gags. outside of the container. This method avoids collecting unrelated
Doing so facilitates organization and efficient time management. microorganisms and provides containment for the collected specimen.
❙ Have the client sit where light is optimum. Light enhances inspection of ❙ Crush the packet in the bottom of the tube. Crushing releases nourishing
the throat anatomy. fluid to promote bacterial growth.
❙ Don gloves and a mask, if necessary. Their use reduces the potential for ❙ Remove gloves, discard them in a lined receptacle, and wash your
transferring microorganisms. hands or perform hand antisepsis with an alcohol rub (see Chap. 10).
❙ Loosen the cap on the tube in which the swab is located. Doing so These steps reduce transmission of microorganisms.
facilitates hand dexterity. ❙ Label the culture tube with the client’s name, the date and time, and the
❙ Tell the client to open the mouth wide, stick out the tongue, and tilt the source of the specimen. These steps provide laboratory personnel with
head back. This position promotes access to the back of the throat. essential information.
❙ Depress the middle of the tongue with a tongue blade in your nondominant ❙ Attend to staining and examination of the prepared glass slide, if appropriate.
hand (Fig. 14-10). Doing so opens the pathway for the swab. Doing so provides tentative identification of streptococcal bacteria.
❙ Rub and twist the tip of the swab around the tonsil areas and back of ❙ Deliver the sealed culture tube to the laboratory or refrigerate it if there
the throat without touching the lips, teeth, or tongue. Doing so transfers will be a delay of longer than 1 hour. These steps ensure that the
microorganisms from the inflamed tissue to the swab. microorganisms will grow when transferred to other culture media.
Diabetes Association, 2006). The body produces the hor- which can have life-threatening consequences. There-
mones glucagon and insulin that regulate glucose metabo- fore, many clients with diabetes measure their own cap-
lism and maintain normal blood glucose levels. illary blood glucose levels rather than having venous
People with diabetes have an impaired ability to pro- blood drawn for laboratory analysis.
duce insulin and have difficulty regulating blood glucose A glucometer is an instrument that measures the amount
levels. They control their disease with diet, exercise, and of glucose in capillary blood. It operates by assessing the
in some cases, medications. People with diabetes may amount of light reflected through a chemical test strip
experience low or high blood glucose levels, both of (Fig. 14-11). Based on the amount of measured glucose
A B
FIGURE 14-10 • Throat culture. (A) Depressing the tongue. (B) Obtaining a specimen.
unfamiliar. The following are some nursing diagnoses

B D that nurses may identify during preprocedural and post-
C procedural stages of examinations and tests:
A
• Anxiety
• Fear
E • Impaired Adjustment
• Decisional Conflict
• Health-Seeking Behaviors
• Powerlessness
• Spiritual Distress
F Nursing Care Plan 14-1 illustrates the nursing process as

it relates to the nursing diagnosis of Decisional Conflict,
defined in the NANDA taxonomy (2005) as “uncertainty
about the course of action to be taken when choice among
FIGURE 14-11 • Equipment used to perform capillary blood glucose
testing: glucometer (A), control solution (B), lancet (C), lancet holder (D),
competing actions involves risk, loss, or challenge to per-
test strip (E), container of test strips (F). (Copyright B. Proud.) sonal life values.”
in the blood, clients with diabetes adjust their intake of GENERAL GERONTOLOGIC
food or medication. CONSIDERATIONS
Because diabetes is so common, nurses frequently are
Some laboratory values change minimally or not at all with age.
called on to teach people who have been recently diagnosed
Parameters are often determined by using averaged statistics.
with this problem how to test their own blood glucose Failure to appreciate age-related differences in laboratory test
levels. Nurses measure blood glucose levels for clients results can lead to overdiagnoses or underdiagnoses and,
with diabetes who are hospitalized or being cared for in therefore, inappropriate treatment.
long-term care institutions. Many prescription and over-the-counter medications, as well as
There are several important points to remember about herbal therapies, may affect laboratory values. Therefore,
measuring blood glucose: nurses must take care to review and evaluate all medica-
tions and alternative therapies before any laboratory
1. Several types of glucometers are available. The procedures.
user must follow the manufacturer’s instructions Knowing the usual range of laboratory results for older adults
who have chronic conditions is important. A chronic disorder
for accurate use.
or its treatment can cause abnormal test findings that may be
2. The blood glucose level usually is measured about
normal or acceptable for older adults. It is also important to
30 minutes before eating and before bedtime to know the client’s previous results for the diagnostic test being
determine what are likely to be the lowest levels of done as a baseline for comparison.
glucose. This allows time for the client to increase or Older adults, especially those who are medically frail, may not be
decrease food consumption or, if insulin-dependent, able to tolerate the withholding of food or fluids for long peri-
to administer additional prescribed insulin (see ods before tests or examinations. Assessing urinary output,
blood pressure, and mental status provides data on how well
Chap. 34), referred to as coverage.
an older adult is tolerating a fasting state.
3. Measuring blood glucose involves a risk for contact When older adults must abstain from food or fluid before a test or
with blood. Because blood may contain infectious examination, administration of their prescribed medications
viruses, nurses always wear gloves when performing with a small amount of water may be allowed based on
this test. consultation with the physician.
Older adults are more susceptible to dehydration. The resulting
Researchers are working on developing noninvasive concentration of blood can cause false elevations of labora-
devices that will not require piercing the skin with a lancet, tory blood tests.
but such devices are not available at present. Some older adults become exhausted by preparations for gas-
Skill 14-3 presents the steps involved in using a Life- trointestinal examinations that require the use of laxatives
scan glucometer. and enemas. Laxative or enema use may also deplete elec-
trolyte balance, leading to weakness or dizziness. Providing
a bedside commode and hands-on assistance is helpful for
older adults, especially those with impaired mobility, when
NURSING IMPLICATIONS they are undergoing preparation for gastrointestinal
examinations.
Frail older adults fatigue easily; therefore, coordinate tests
Most clients who undergo special examinations and tests and examinations with diagnostic personnel to eliminate
have emotional needs from the stress of a potential diag- long periods of fasting or waiting in uncomfortable
nosis or the anxiety created by undergoing something environments.
The Client Undergoing Amniocentesis to Diagnose
a Possible Fetal Genetic Disorder
ASSESSMENT
Determine the following:
• Signs of distress such as restlessness, tachycardia, increased muscle tension, rapid respirations
• Values and beliefs about terminating a pregnancy
• Remarks indicating uncertainty about subsequent choices pending the outcome of the amniocentesis
• Feelings of anguish or ambivalence regarding the decision to either carry the fetus to term or abort it
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 decision 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.
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 Consulting others helps to clarify issues and decreases
organizations that provide information about the disorder feelings of helplessness.
that may affect the client’s child.
Encourage the client to discuss concerns with husband Sharing concerns with others helps the client to perceive
and other significant people. conflicts more realistically and facilitates implementation
of a subsequent plan.
Suggest that the client compose a written list of the Identifying the pros and cons of alternatives is the first
advantages and disadvantages to possible choices before step in 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.
Evaluation of Expected Outcome

Client makes a decision with support of husband to continue pregnancy carrying a fetus that
will have cystic fibrosis.
Older adults are likely to need additional clothing, slippers, and

extra covers to keep them warm in waiting rooms and exami-
nation areas. 1. Discuss how the procedure for a sigmoidoscopy or another
After a diagnostic examination, offer older adults food and fluid
test or examination may differ if performed on an out-
and a period of rest before they resume physically taxing
activities. Encourage fluids because older adults may have
patient basis rather than in a hospital.
diminished thirst sensation and not realize the need for fluid 2. How might diminished mentation (capacity to under-
replacement. stand), reduced strength and stamina, and pain affect the
When working with an older adult who is cognitively compro- performance of a diagnostic examination or test?
mised (e.g., dementia), instruct a family member or responsible
caregiver about test preparations. Include the caregiver or 3. How might a pelvic examination be different if the per-
family member in the procedure as much as possible. son being examined is a victim of rape?
3. Which of the following instructions is most appropriate if

a specimen for a Papanicolaou (Pap) test will be obtained
1. Which of the following indicates that a client needs more at the time of a pelvic examination?
teaching before a sigmoidoscopy? 1. Do not douche for several days before your appoint-
1. The client says he will receive an anesthetic before ment.
the examination. 2. Stop using any and all forms of contraception tem-
2. The client says he can eat a light meal the evening porarily.
before the examination. 3. Drink at least 1 quart of liquid 1 hour before your
3. The client says a flexible scope will be inserted into appointment.
his rectum. 4. Take a mild laxative the night before your sched-
4. The client says he may take his prescribed medica- uled appointment.
tions in the morning.
2. Which nursing action is essential before a chest roent-
genogram (x-ray) is done?
1. Make sure the client does not eat food.
2. Remove the client’s metal necklace.
3. Have the client swallow contrast dye.
4. Administer a dose of pain medication.
Skill 14-1 • ASSISTING WITH A PELVIC EXAMINATION
Assessment
Determine the identity of the client on whom the Prevents errors
examination will be performed.
Determine if a Pap test is needed. Indicates the need for additional equipment and supplies
Find out if the client has had a pelvic examination before. Provides a basis for teaching
Ask if the client is currently menstruating or has had Blood, mucus, and pus are three substances that obscure
intercourse within the last 48 hours. and distort cells, making it difficult to determine if they
are atypical and interfering with the microscopic
examination of collected specimens. The examiner may
wish to delay obtaining a specimen.
Inquire if the client has douched in the last 24 hours. Suggests a need to reschedule the Pap smear because an
adequate sample of cells and secretions may not be
available.
Ask the client’s age, date of the last menstrual period, Provides data to determine the possibility of pregnancy, to
number of pregnancies and live births, and description compare cellular specimens with hormonal activity, and
of symptoms such as bleeding or drainage, itching, to provide clues as to possible pathology and the need
or pain. for additional tests
Determine if and what type of birth control the client is Correlates the influence of prescribed hormones on
using, if she is premenopausal. For oral contraceptives, cellular specimens
identify the name of the drug and dosage.
Ask menopausal women if they are taking hormone Correlates the influence of prescribed hormones on
replacement, and the brand name and dosage. cellular 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 Tends to reduce anxiety
to ask questions.
Provide an examination gown and direct the client to Facilitates palpation of the uterus and ovaries
empty her bladder.
Place a speculum (a metal or a disposable plastic Promotes efficient time management. Metal specula
instrument for widening the vagina), gloves, (plural of speculum) are reused after sterilization. Select
examination light, lubricant, and the following an appropriate size according to the individual client.
materials for the Pap smear: long soft applicators 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).
(The liquid-based cytology [ThinPrep Pap Test], an
alternative technique of specimen preservation
approved by the 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 Identifies the location from which the specimens are
C for cervical, and the last with a V for vaginal. taken; endocervical means inside the cervix. The
cervix is the lower portion of the uterus, or womb.
(continued)
ASSISTING WITH A PELVIC EXAMINATION (Continued)
Equipment used for a pelvic examination.
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 Prevents lubricant used during palpation from interfering
cervical secretions for the Pap test before the examiner with microscopic examination of the specimens
proceeds to palpate the internal organs.
Implementation
Place the client’s legs in stirrups to facilitate a lithotomy Provides access to the vagina
position (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 Tends to reduce anxiety
strangers.
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 Illuminates the area, facilitating inspection
shoulder toward the vaginal opening.
Wet the speculum with warm water; if a Pap smear will Eases and provides comfort during insertion
not be obtained, apply water-soluble lubricant to the
speculum blades.
(continued)
Prepare the client to expect the momentary insertion of Tends to reduce anxiety and aids in relaxation
the speculum. Explain that she will hear a loud click as
it locks in place.
Hand the examiner a soft-tipped applicator, spatula, and Facilitates collection of secretions for the Pap smear
brush applicator in that order.
Hold the slide marked E so the examiner can roll or slide Deposits intact cells and secretions according to their
the specimen across the slide; follow a similar pattern as source; excessive manipulation of the cells while being
the second and third samples are collected from the obtained or applied to the slide can make normal cells
cervix and vagina (see Fig. C). look like atypical cells.
Transferring secretions to a glass slide.
Position the lined receptacle so the examiner can dispose Controls the spread of microorganisms
of the collection device and the speculum after use.
Place each slide in a chemical fixative solution or spray it Preserves the integrity of the specimens; delay in applying
with a similar chemical (see Fig. D). a fixative leads to air drying, enlargement of cells, and
loss of details in the nucleus—making it difficult to
determine if cells are atypical.
Preserving specimen.
If using the liquid-based cytology technique, immerse the Disperses the cells and breaks up blood, mucus, and
sampling device in the container of solution, cap it, and nondiagnostic debris
discard the tool.
Lubricate the gloved fingers of the examiner’s dominant Reduces friction; keeps the client informed of the progress
hand and prepare the client for an internal vaginal (and of the examination
in some cases rectal) examination.
Don gloves and clean the skin of lubricant when the Prevents the transmission of microorganisms; promotes
examination is completed; then remove the gloves. comfort and hygiene
Wash hands or perform hand antisepsis with an alcohol Reduces microorganisms on the hands
rub (see Chap. 10).
Lower both feet simultaneously from the stirrups and Reduces strain on abdominal and back muscles
assist the client to sit up.
Assist the client from the room after she has dressed. Maintains client safety
(continued)
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 litho-
tomy 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
Skill 14-2 • ASSISTING WITH A SIGMOIDOSCOPY
Assessment
Identify the client on whom the examination will be Prevents errors
performed.
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 Provides information about the purpose for performing
history of significant diseases. the procedure and an opportunity for reinforcing the
need for future regular sigmoidoscopic examinations
Ask for a description of the client’s dietary and fluid Indicates if the client complied with proper preparation
intake and bowel cleansing protocol and results. for the procedure
Assess the client’s vital signs and obtain other physical Provides a baseline for future comparisons
assessments according to agency policy, such as weight
or bowel sounds.
(continued)
ASSISTING WITH A SIGMOIDOSCOPY (Continued)
Assessment (Continued)
Ask for an allergy history and a list of medications being Influences drugs that may be prescribed and alerts staff to
taken. other medical problems
Planning
Direct the client to undress, don an examination gown, Facilitates the examination and gives the client an
and use the restroom. opportunity to empty the bowel and bladder again
Prepare for the examination by placing a sigmoidoscope Promotes efficient time management
(Fig. A), 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 Avoids delay, inconvenience, and discomfort once the
the suction equipment are operational. examination is in progress
Implementation
Help the client to assume a Sims’ position if a flexible Facilitates passage of the scope; an endoscopic table may
sigmoidoscope will be used or a knee–chest position if a be used in lieu of a self-maintained knee–chest position
rigid 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 Tends to reduce anxiety by keeping the client informed of
fingers, followed by the insertion of the sigmoidoscope. each step and the progress being made
Acknowledge any discomfort that the client may be Indicates that the nurse empathizes with the client’s
experiencing; explain that it should be short-lived. distress
Inform the client if, and before, suction is used, air is Prepares the client for unexpected sensations or
introduced, or a sample of tissue is obtained. temporary increase in discomfort
Open the specimen container, cover the specimen with Prevents loss and decomposition of the specimen
preservative, and recap the container.
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 Prevents the transmission of microorganisms; promotes
the examination is completed; remove the gloves. comfort and hygiene
(continued)
ASSISTING WITH A SIGMOIDOSCOPY (Continued)
Wash hands or perform hand antisepsis with an alcohol Reduces microorganisms
rub (see Chap. 10).
Assist the client from the room to an area where his or Maintains client safety and dignity
her clothing is located or provide a clean gown.
Explain that there may be slight abdominal discomfort until Provides anticipatory health teaching
the 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, Identifies significant data to report
the 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; Prepares the room for future use
restock supplies.
Complete laboratory requisition form, label specimen, and Facilitates microscopic examination
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 aller-
gies. 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 tak-
ing 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
Skill 14-3 • USING A GLUCOMETER
Assessment
Determine that a test using one or more control solutions Determines that the glucometer is functioning accurately;
has been performed on the glucometer since midnight complies with an agency’s policies for quality assurance
in a health agency. Identify the client on whom the and prevents errors
examination will be performed.
Find out if the client has ever had a blood glucose level Provides a basis for teaching
measured with a glucometer or if the client has any
questions.
Review previous blood glucose level and trends that may Helps evaluate the reliability of the assessed measurement
be obvious. when it is obtained
Check to see if 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 Determines if test strips are still appropriate for use.
the date has expired.
Discard unused test strips stored in a vial 4 months after Ensures accuracy.
they are opened.
Observe the code number on the container of test strips; Code numbers range from 1 to 16; if the numbers do not
compare it with the code number programmed into the match, the meter number is changed.
glucometer (Fig. A).
Comparing code number on test strip bottle to glucometer code number.

Inspect the client’s fingers and thumb for a nontraumatized Avoids secondary trauma
area; also inspect the earlobes, an acceptable alternative.
Planning
Test the machine’s calibration with a control strip or Verifies the machine’s accuracy
solution 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
30 minutes before a meal and at bedtime. detection of trends
Collect the necessary equipment and supplies: glucometer, Promotes efficient time management
lancets, lancet holder, test strips, and gloves.
(continued)
USING A GLUCOMETER (Continued)
Implementation
Ask the client to wash the hands with soap and warm Reduces microorganisms on the skin; warmth dilates the
water and towel dry. capillaries 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 Prepares the machine for testing the blood sample. The
reading, current test strip code, and the message machine retains the last glucose measurement in its
“Insert strip.” memory.
Place the notched end of one test strip into the holder Locates the strip in position for the application of blood
with the test spot up.
Assemble the lancet within the spring-loaded lancet Loads, holds the lancet in place, and prepares the lancet
holder (Fig. B). for a rapid thrust into the skin
Lancet insertion.
Don clean gloves after washing your hands or performing Provides a barrier against contact with blood
hand antisepsis with an alcohol rub (see Chap. 10).
Select a nontraumatized side of a client’s finger or thumb; Avoids puncturing an area with sensitive nerve endings
avoid the central pads (Fig. C).
Appropriate puncture sites.
Apply the lancet firmly to the side of the finger and press Thrusts the lancet into the skin
the release button.
Release lancet and holder. Opens a path for blood
Hold the finger or thumb so that a large hanging drop of Uses gravity to aid in collecting blood
blood forms.
(continued)
Touch the hanging drop of blood to the test spot on the Saturates the test spot to ensure accurate test results
strip, 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.
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 potential for a needlestick injury and
transmission of bloodborne infectious microorganisms.
Clean the window of the glucometer and the hole of the Keeps equipment free of debris that can impair light
test strip holder with a cotton swab or damp cloth to detection
remove dirt, blood, or lint at least once a week.
Remove gloves and immediately wash your hands or per- Reduces microorganisms
form hand antisepsis with an alcohol rub (see Chap. 10).
Remove equipment from the bedside if it does not belong Facilitates use of equipment that may be needed for other
to the client. clients
Store the test strips in a cool dry place at 37° to 85°F Prevents decomposition from heat and humidity
(1.7° to 30°C).
Record the glucose measurement in the client’s diabetic Documents essential data
record.
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 condi-
tion, previous trends, and concurrent treatment.
• Additional treatment is provided depending on
glucose measurement.
(continued)
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 per glucometer. 5 units of Humulin R insulin given subcutaneously as
coverage. SIGNATURE/TITLE
UNIT 4

for Chapters 10, 11, 12, 13, and 14
in parentheses.
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 physiological 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, laceration)
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 conservation and production. (cerebellum, hypothalamus, medulla)
Activity B: Mark each statement as either T (True) or F (False). Correct any false
statements.
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 2.5 cm with the forefingers of
one or both hands.
279
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.

1. Practices that decrease or eliminate infectious agents, their reservoirs, and their vehicles for transmission
2. Haven in which microbes survive, grow, and reproduce

3. Using atoms subjected to a strong electromagnetic field to produce an image
4. Hand-held probe used during ultrasonography to project sound through the body’s surface
5. Pronounced lateral curvature of the spine
6. Assessment technique frequently used to listen to body sounds
7. Rapid or deep breathing, or both, affecting the volume of air entering and leaving the lungs
8. 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 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 for-
ward, 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, hips rotated
outward, and feet flat.
U N I T 4 ● End of Unit Exercises for Chapters 10, 11, 12, 13, and 14 281
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

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?
Activity G: A surgical scrub extensively removes transient microorganisms from the

nails, hands, and forearms before an operative procedure. Write down in the boxes 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?

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 fever?
6. What is postural hypotension?
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?
5. Why 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 above steps?
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 drainage within the ear is considered normal?

6. A nurse is caring for a client who is to undergo 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?
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 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 assessment 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 leaving 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
4. A fever generally goes through four distinct phases. Arrange the phases in the order in which they occur.
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 receiving 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
UNIT 5
Assisting With
Basic Needs
15 Nutrition
16 Fluid and Chemical Balance
17 Hygiene
18 Comfort, Rest, and Sleep
19 Safety
20 Pain Management
21 Oxygenation
22 Infection Control
15
Chapter
Nutrition
LEARNING OBJECTIVES
WORDS TO KNOW
● Define nutrition and malnutrition.
anorexia ● List six components of basic nutrition.
anthropometric data ● List at least five factors that influence nutritional needs.
body-mass index ● Discuss the purpose and components of a food pyramid.
cachexia ● Describe three facts available on nutritional labels.
calorie ● Explain protein complementation.
carbohydrates ● Identify four objective assessments for determining a person’s nutritional status.
cellulose ● Discuss the purpose of a diet history.
complete proteins ● List five common problems that can be identified from a nutritional assessment.
diet history ● Plan nursing interventions for resolving problems caused or affected by nutrition.
dysphagia ● List seven common hospital diets.
emaciation ● Discuss four nursing responsibilities for meeting clients’ nutritional needs.
emesis ● Identify three facts the nurse must know about a client’s diet.
eructation ● Describe and demonstrate techniques for feeding clients.
essential amino acids ● Explain how to meet the nutritional needs of clients with visual impairment or dementia.
fat ● Discuss at least three unique aspects of nutrition that apply to older adults.
fat-soluble vitamins
flatus
food pyramid
incomplete proteins
kilocalorie HEALTHY people in general are becoming increasingly selective about the quantity
lipoproteins and quality of their daily food consumption. In a country of affluence, Americans
malnutrition are both undernourished and overnourished. According to the American Heart
megadoses Association and National Heart, Lung, and Blood Institute (Grundy et al., 2005),
metabolic rate
an estimated 50 million Americans, the equivalent of 26% of adults, meet the crite-
midarm circumference
minerals ria for metabolic syndrome, characterized by obesity, abdominal fat, hypertension,
nausea and elevated blood glucose (insulin resistance) and fat levels. The escalating inci-
nonessential amino acids dence of this syndrome indicates the critical need to control the epidemic of obesity
nutrition in the United States.
obesity
This chapter includes information about normal nutrition for promoting health.
projectile vomiting
protein It also provides suggestions that nurses may offer clients about what and how much
protein complementation to eat, the dangers of food fads and unsafe dieting, and techniques for managing the
regurgitation care of clients whose ability to eat, digest, absorb, or eliminate food is impaired.
retching
saturated fats
trans fats
unsaturated fats
vegans OVERVIEW OF NUTRITION
vegetarians
vitamins
vomiting
Eating is a basic need. It is the mechanism by which nutrients are obtained. An optimal
vomitus nutritional status provides (1) sufficient energy for daily activities, (2) maintenance and
water-soluble vitamins replacement of body cells and tissues, and (3) restoration of health following illness or
288
C H A P T E R 15 ● Nutrition 289
injury. Because the type and amount of nutrients con- burned in a laboratory then analyzed to quantify their
sumed affect health, it is important to understand basic energy value.
nutrition, or the process by which the body uses food. The energy, or heat equivalent, of food is measured in
Chronic, inadequate nutrition leads to malnutrition (a con- calories. A calorie (cal) (amount of heat that raises the
dition resulting from a lack of proper nutrients in the temperature of 1 gram of water 1°C) is one way to express
diet). Evidence of malnutrition is common among people the energy value of food. Sometimes the energy equivalent
living in poor, developing countries; however, it also of food is expressed in kilocalories (kcal) (1,000 calories, or
occurs among people living in countries known for their the amount of heat that raises the temperature of 1 kilo-
affluence like the United States. Examples of those in the gram of water 1°C).
United States at risk for an inadequate nutritional intake When proteins, carbohydrates, and fats are metab-
include the following: olized, they produce energy. Proteins yield 4 kcal/g,
carbohydrates yield 4 kcal/g, and fats yield 9 kcal/g.
• Older adults who are socially isolated or living on fixed
Alcohol yields 7 kcal/g but is not considered an essen-
incomes
tial nutrient.
• Homeless people
Although the number of calories a person needs
• Children of economically deprived parents
depends on age, body size, physical condition, and
• Pregnant teenagers
physical activity, healthy adults require an average of
• People with substance abuse problems such as alco-
2,000 calories/day (U.S. Department of Agriculture, 2005).
holism
Unless the caloric intake includes an appropriate mix
• Clients with eating disorders, such as anorexia nervosa
of proteins, carbohydrates, and fats, the person may be
and bulimia nervosa
marginally nourished or malnourished. In other words,
consuming 2,000 calories of chocolate, exclusive of any
other food, is not adequate to sustain a healthy state!
Human Nutritional Needs
Fortunately most foods contain a variety of nutrients,
vitamins, and minerals.
Increasing data support the connections between nutri-
tional status and health and well-being. Consequently
emphasis on improving nutrition to prevent and treat
Proteins
disease also is growing. All humans have basic nutritional Protein, a component of every living cell, is a nutrient
needs. Through scientific study, researchers have deter- composed of amino acids, or chemical compounds com-
mined standards for the recommended daily amounts of posed of nitrogen, carbon, hydrogen, and oxygen. Amino
the following: acids are responsible for building and repairing cells.
Twenty-two amino acids have been identified. Nine of
• Calories that provide the body with energy
these 22 are referred to as essential amino acids, which are
• Proteins, carbohydrates, and fats that supply calories
protein components that must come from food because
and are substances needed for growth and repair of body
the body cannot synthesize them. Nonessential amino
structures
acids are protein components manufactured within the
• Vitamins and minerals that do not supply calories but
body; however, this term is misleading. “Nonessential”
are essential for regulating and maintaining physiologic
refers to the fact that these amino acids are not depen-
processes necessary for health
dent on dietary intake, not that they are unnecessary
Water, also necessary for life, is discussed in Chapter 16. for health.
Although standards have been established for the types The body uses protein primarily to build, maintain,
and amounts of dietary components necessary to sustain and repair tissue. The body spares protein for energy
health, individual nutritional needs are influenced by and use as long as calories are available from carbohydrates
may require adjustment according to the following: and fats.
Dietary proteins come from animal and plant food
• Age sources. Good sources include milk, meat, fish, poultry,
• Weight and height
eggs, legumes (peas, beans, peanuts), nuts, and compo-
• Growth periods
nents of grains. Animal sources provide complete proteins
• Activity
(contain all the essential amino acids); plant sources
• Health status
contain incomplete proteins (contain only some essential
amino acids). Protein complementation (combining plant
Calories
sources of protein) helps a person to acquire all essential
Food is the source of energy for humans. Some nutrients amino acids from nonanimal sources (Fig. 15-1). Protein
produce more energy than others. By using a calorimeter, complementation is discussed later in relation to vege-
a device for measuring heat, the nutrients in food are tarian diets.
290 U N I T 5 ● Assisting With Basic Needs
Legumes Fats are a concentrated energy source, supplying more

Grains
Beans Peas than twice the calories per gram than either proteins or
Generally Breads
Peanuts complementary carbohydrates. Although fats are high in calories, they
Cereals
Lentils Tofu should not be eliminated from the diet. Fats provide energy
and are necessary for many chemical reactions in the body.
Generally Generally
complementary complementary
They are necessary for the absorption of some vitamins.
Also: Rice with Sesame Fats also add flavor to food, and because they leave the
Brazil nuts with Milk
Sesame with Milk
stomach slowly, they promote a feeling of having satisfied
Seeds Milk appetite and hunger.
Nuts Products The following food sources are rich in fat: beef and
pork; butter, margarine, and vegetable oils; egg yolk; whole
milk and cheese; peanut butter; salad dressings; avocados;
FIGURE 15-1 • Complementary protein guide for meatless meals.
chocolate; and nuts.
ROLE OF CHOLESTEROL. Cholesterol absorbs fatty acids

Carbohydrates and binds them to molecules of protein referred to as
lipoproteins (combination of fats and proteins). Lipo-
Carbohydrates are nutrients that contain molecules of proteins vary in their proportions of protein to cholesterol.
carbon, hydrogen, and oxygen and are found generally The more protein a molecule contains, the higher is its
in plant food sources. They are classified according to density. High-density lipoprotein (HDL) is referred to as
the number of sugar (saccharide) units they contain. “good cholesterol,” because the cholesterol is delivered to
Carbohydrates are subdivided into monosaccharides, di- the liver for removal. Low-density lipoprotein (LDL) is
saccharides, and polysaccharides (starches). called “bad cholesterol” because the cholesterol is deposited
Carbohydrates, the chief component of most diets, within the walls of arteries, which can eventually result
are the body’s primary source for quick energy. In addi- in cardiovascular disease.
tion to providing calories, carbohydrates contain cellulose
(undigestible fiber in the stems, skins, and leaves of fruits TYPES OF FATS. Saturated fats are lipids that contain as
and vegetables), which forms intestinal bulk. Fiber is much hydrogen as their molecular structure can hold
important for promoting bowel elimination. and are generally solid. Most saturated fats are in ani-
Sources of carbohydrates include cereals and grains mal sources such as the marbled fat in meat. Cholesterol
such as rice, wheat and wheat germ, oats, barley, corn and is almost exclusively present in foods of animal origin,
corn meal; fruits and vegetables; and sweeteners. Box 15-1 but the body also synthesizes cholesterol. Unsaturated fats
lists terms on food labels that identify ingredients that are missing some hydrogen. They are a healthier form
are, in essence, sugar. Foods containing sugar as a major of fats and are liquid at room temperature or congeal
ingredient tend to supply calories but few, if any, other slightly when refrigerated. Unsaturated fats are obtained
nutrients. from plant sources such as corn, safflower, olives, peanuts,
and soybeans. Trans fats are unsaturated fats that have
Fats been hydrogenated, a process in which hydrogen is added
Fats, nutrients that contain molecules composed of glycerol
to the fat. Hydrogenation changes the unsaturated fat
and fatty acids called glycerides, are known collectively to a saturated form that remains solid at room temper-
as lipids. Depending on the number of fatty acids that make ature. An example includes hydrogenation of vegetable
up a fat molecule, fats are referred to as monoglycerides, oil to create margarine or shortening. Hydrogenation
diglycerides, or triglycerides. reduces the rate at which a fat becomes rancid, thus
increasing the shelf life of food items that contain it
(e.g., cake mixes).
HEALTH RISKS RELATED TO FAT AND CHOLESTEROL. Gen-

BOX 15-1 ● Label Ingredients That Represent Sugar
erally, Americans eat more fats than people do in most
❙ Sucrose (table sugar) ❙ Honey other countries. The relationship between fat consump-
❙ Fructose ❙ Invert sugar tion and obesity to disorders such as metabolic syn-
❙ Glucose (dextrose) ❙ Lactose drome, heart disease, hypertension, diabetes, and some
❙ Brown sugar ❙ Maltose
cancers is well documented. In an effort to improve
❙ Corn sweetener ❙ Molasses
❙ Corn syrup ❙ Raw sugar national health, the Department of Health and Human
❙ Fruit juice concentrate ❙ Syrup Resources is continuing its initiative, Healthy People 2010:
National Health Promotion and Disease Prevention (1999).
TABLE 15-1 CARDIAC RISK ASSOCIATED WITH BLOOD FAT LEVELS

SUBSTANCE VALUE INTERPRETATION
Total cholesterol <200 mg/dL Desirable

200–239 mg/dL Borderline high
≥240 mg/dL High
Low-density lipoprotein (LDL) <100 mg/dL Optimal
100–129 mg/dL Near optimal
130–159 mg/dL Borderline high
160–189 mg/dL High
≥190 mg dL Very high
High-density lipoprotein (HDL) <40 mg/dL Low
40–59 mg/dL Acceptable
≥60 mg/dL Optimal
(Source: Adult Treatment Panel [ATPIII]. [2001]. Clinical guidelines for cholesterol testing and management.
The National Cholesterol Education Program, a division of the National Heart, Lung, Blood Institute.
[On-line]: http://www.mhbi.gov/guidelines/cholesterol/dskref.html.)
One goal the government advocates is for at least 50% trace minerals, their chief functions, and common dietary
of people 2 years and older to consume no more than sources.
30% of their daily calories from fat; of that, less than 10% As a national policy, specified amounts of certain min-
should be saturated fat. erals and vitamins are added to some processed foods.
Although the creation of trans fats has improved the For example, enriched flour and bread contain thiamine,
marketing of convenience foods, health-concerned agen- riboflavin, niacin, and iron to replace what is lost when
cies like the American Heart Association (AHA, 2006) the grain is milled into flour. Fortified foods have been
indicate that consumption of trans fats increases the enhanced with extra amounts of nutritional substances
risk for coronary heart disease. The U.S. Food and Drug present in the food naturally.
Administration (2003) now requires the listing of the
amount of trans fatty acid content on food labels. Vitamins
Health care providers use cholesterol and lipoprotein
Vitamins are chemical substances necessary in minute
levels to assess clients’ risks for cardiac and vascular
amounts for normal growth, maintenance of health, and
disease (Table 15-1). Cardiac risk also can be estimated
functioning of the body (Table 15-3). They were originally
by dividing the total serum cholesterol level, which should
named with letters; numbers were subsequently added to
be less than 200 mg/dL, by the HDL level. A result greater
some letters as more vitamins were identified. Chemical
than 5 suggests that a client has a potential for coronary
names are now replacing the letter-number system of
artery disease.
identification.
Water-soluble vitamins (B complex, C) are eliminated with
body fluids and so require daily replacement. Fat-soluble
Stop • Think + Respond BOX 15-1 vitamins (A, D, E, and K) are stored in the body as reserves
Which client has the lowest cardiac risk factor? for future needs.
• Client A: Total cholesterol level is 224 mg/dL; HDL level With the exception of vitamin K (menadione) and
is 38 mg/dL. biotin, the body does not manufacture vitamins. People
• Client B: Total cholesterol level is 198 mg/dL; HDL level can easily meet their vitamin requirements, however, by
is 35 mg/dL. eating a variety of foods. Cooking, processing, and not
• Client C: Total cholesterol level is 210 mg/dL; HDL level refrigerating can deplete the content of some vitamins in
is 55 mg/dL. food. Various commercially packaged foods such as mar-
garine, milk, and flour have been vitamin enriched or
fortified to promote health.
Generally, vitamin and mineral supplements are not
Minerals
necessary if a person eats a well-balanced diet. Con-
Minerals (noncaloric substances in food that are essential suming megadoses (amounts exceeding those considered
to all cells) help to regulate many of the body’s chemical adequate for health) of vitamins and minerals can be
processes such as blood clotting and conduction of nerve dangerous. Some athletes and people with terminal dis-
impulses. Table 15-2 lists some of the body’s major and eases choose to follow unconventional diets and take
TABLE 15-2 COMMON DIETARY MINERALS

COMMON DIETARY
MINERAL CHIEF FUNCTIONS SOURCES
Sodium Maintenance of water and electrolyte balance Table salt

Processed meat
Potassium Maintenance of electrolyte balance Bananas
Neuromuscular activity Oranges
Enzyme reactions Potatoes
Chloride Maintenance of fluid and electrolyte balance Table salt
Processed meat
Calcium Formation of teeth and bones Milk
Neuromuscular activity Milk products
Blood coagulation
Cell wall permeability
Phosphorus Buffering action Eggs
Formation of bones and teeth Meat
Milk
Iodine Regulation of body metabolism Seafood
Promotion of normal growth Iodized salt
Iron Component of hemoglobin Liver
Assistance in cellular oxidation Egg yolk
Meat
Magnesium Neuromuscular activity Whole grains
Activation of enzymes Milk
Formation of teeth and bones Meat
Zinc Constituent of enzymes and insulin Seafood
Liver
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 Promotion of vision, healthy hair and skin, and egg yolk, whole milk
cooking temperatures integrity of epithelial membranes Fish liver oil and liver
Prevention of xerophthalmia, a condition Green leafy and yellow fruits and
characterized by chronic conjunctivitis vegetables
B1 (Thiamine) Carbohydrate metabolism Fish
Not readily destroyed by Functioning of nervous system Lean meat and poultry
ordinary cooking temperatures Normal digestion Glandular organs
Prevention of beriberi, a condition characterized Milk
by neuritis Whole-grain cereals
Peas, beans, and peanuts
B2 (Riboflavin) Formation of certain enzymes Eggs
Not destroyed by heat except Normal growth Green leafy vegetables
in 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 Whole-grain cereals
by cutaneous, gastrointestinal, neurologic, and Peanuts
mental symptoms Yeast
Eggs
Liver (continued)
TABLE 15-3 VITAMINS (Continued)

VITAMIN CHIEF FUNCTIONS COMMON DIETARY SOURCES
B6 (Pyridoxine) Healthy gums and teeth Whole-grain cereals and wheat germ
Destroyed by heat, sunlight, Red blood cell formation Vegetables
and air 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 Green vegetables
by bleeding and abnormal bone and teeth Potatoes
formation
D (Calciferol) Absorption of calcium and phosphorus Fish liver oils, salmon, tuna
Relatively stable with Prevention of rickets, a condition characterized by Milk
refrigeration weak bones Egg yolk
Butter
Liver
Oysters
Formed in the skin by exposure to
sunlight
E (Alpha-tocopherol) Red blood cell formation Green leafy vegetables
Heat stable in absence Protection of essential fatty acids Wheat germ oil
of oxygen Important for normal reproduction in experimental Margarine
animals (i.e., rats) Brown rice
Pantothenic acid Metabolism Liver
Egg yolk
Milk
H (Biotin) Heat sensitive Enzyme activity Egg yolk
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
large doses of nutritional supplements. Athletes are moti- Nutritional Strategies

vated by a desire to alter their muscle mass, strength, and
endurance; people with terminal diseases seek attempts Healthy People 2010, a national effort to improve the
for cure. Although various deficiency diseases develop health of Americans, provides recommendations to
from inadequate nutrition, no conclusive evidence at enhance nutrition and general health (Box 15-2). Other
this time supports that consuming excessive nutrients, nutritional strategies include using the U.S. Department of
vitamins, or minerals is a safe substitute for healthy Agriculture’s MyPyramid, referring to labels about nutri-
eating or works as a singular established treatment for tion on processed and packaged foods, and understanding
disease. standard definitions for the terms used on food labels.
BOX 15-2 ● Proposed National Nutritional Objectives for 2010
❙ Reduce coronary heart disease deaths to no more than 100 per 100,000 people. ❙ Increase to at least 85% the proportion of people aged 18 and older who use
❙ Reverse the rise in cancer deaths to achieve a rate of no more than 130 per food labels to make nutritious food selections.
100,000 people. ❙ Achieve useful and informative nutrition labeling for virtually all processed foods
❙ Reduce overweight to a prevalence of no more than 20% among people aged 20 and at least 40% of ready-to-eat carry-away foods.
and older and no more than 15% among adolescents aged 12–19. ❙ Increase to at least 5,000 brand items the availability of processed food products
❙ Reduce growth retardation among low-income children aged 5 and younger to that are reduced in fat and saturated fat.
less than 10%. ❙ Increase to at least 90% the proportion of school lunch, breakfast, and child care
❙ Reduce dietary fat intake to an average of 30% of calories among people aged 2 food services with menus that are consistent with the nutrition principles in the
and older, and increase to at least 50% the number who consume less than 10% Dietary Guidelines for Americans.
of calories from saturated fat. ❙ Increase to at least 80% the receipt of home food services by people aged 65 and
❙ Increase complex carbohydrate and fiber-containing foods in diets of people older who have difficulty preparing their own meals or are otherwise in need of
aged 2 and older to an average of five or more daily servings for vegetables home-delivered meals.
(including legumes) and fruits, and to an average of six or more daily servings ❙ Increase to at least 75% the proportion of the nation’s schools that provide nutri-
for grain products. tion education from preschool to 12th grade, preferably as part of comprehensive
❙ Increase to at least 50% the proportion of overweight people aged 12 and older school health education.
who have adopted sound dietary practices combined with regular physical ❙ Increase to at least 50% the proportion of worksites with 50 or more employees
activity to attain an appropriate body weight. that offer nutrition education and/or weight-management programs for
❙ Increase calcium intake so at least 50% of people aged 11–24 and 50% of preg- employees.
nant and lactating women consume an average of three or more daily servings ❙ Increase to at least 75% the proportion of primary care providers who provide
of foods rich in calcium, and at least 75% of children aged 2–10 and 50% of nutrition assessment and counseling and/or referral to qualified nutritionists
people aged 25 and older consume an average of two or more servings daily. or dietitians.
❙ Decrease salt and sodium intake so at least 65% of home meal preparers prepare ❙ Reduce the prevalence of blood cholesterol levels of 240 mg/dL or greater to no
foods without adding salt, at least 80% of people avoid using salt at the table, more than 20% among adults.
and at least 40% of adults regularly purchase foods modified or lower in sodium. ❙ Increase to at least 50% the proportion of people with high blood pressure
❙ Reduce iron deficiency to less than 3% among children aged 1–4 and among whose blood pressure is under control.
women of child-bearing age. ❙ Reduce the mean serum cholesterol level among adults to no more than
❙ Increase to at least 75% the proportion of mothers who breast-feed their babies 200 mg/dL.
in the early postpartum period and to at least 50% the proportion who continue
breast-feeding until their infants are 5–6 months old. (Office of Disease Prevention and Health Promotion, U.S. Department of
❙ Increase to at least 75% the proportion of parents and caregivers who use Health and Human Services. The 1995 midcourse revisions of Healthy
feeding practices that prevent “baby bottle tooth decay.” People 2000 initiative. March 22, 1999.)
MyPyramid Nutritional Labeling

MyPyramid, developed in 2005 by the U.S. Department Nutritional information has appeared on food labels since
of Agriculture, replaces the previously used food pyramid. 1974. Today all packages of fresh meat and poultry must
MyPyramid is an improved tool for promoting a healthful provide printed disease prevention guidelines. There
daily intake of food (Fig. 15-2). Its advantage is that the have also been major changes in the way nutritional infor-
amounts from various food group categories can be indi- mation is provided on approximately 90% of processed
vidualized according to a person’s age, gender, and level and packaged food labels (Fig. 15-3). The labels identify
of activity (see http://www.mypyramid.gov). Following the amounts of each nutrient per serving, which is iden-
MyPyramid guidelines promotes the achievement of the tified in household measurements. To interpret the infor-
dietary recommendations set by the U.S. Department mation accurately, however, consumers must become
of Health and Human Services and the U.S. Depart- familiar with a variety of terms, such as daily value (DV).
ment of Agriculture’s Dietary Guidelines for Americans DVs are calculated in percentages based on standards
(http://www.health.gov/dietaryguidelines/dga2005/rec- set for total fat, saturated fat, cholesterol, sodium, carbo-
ommendations.htm). hydrate, and fiber in a 2,000-calorie diet. The standards
Children, adolescents, pregnant women, and breast- are as follows:
feeding mothers require more servings per day of certain
• Total fat: 65 g
food groups, particularly the milk group. Recommenda-
• Saturated fat: ≤20 g
tions for specific populations can be accessed at http://
• Cholesterol: 300 mg
www.healthierus.gov/dietaryguidelines.
• Sodium: <2,400 mg
• Total carbohydrate: 300 g
• Dietary fiber: 25 g
Using MyPyramid that has been individualized for a People consuming diets of more than or less than
2,000-calorie diet, how many servings of milk should the 2,000 calories must adjust the percentage of DVs. The
average person consume each day? required calculation may be difficult for the average con-
sumer. An expanded table showing the DV equivalents
FIGURE 15-2 • MyPyramid is color coded to show five groups of foods that should be consumed
each day. In this example, the number and amount of servings in each group are for a daily intake of
2,000 calories.
Nutrition Facts BOX 15-3 ● Regulations for Labeling Terms

Serving Size 1/2 of package (21g)
Servings Per Container 2
Calorie-free: <5 calories
Amount Per Serving Low calorie: ≤40 calories
Calories 70 Calories from Fat 20 Reduced calorie: at least 25% fewer calories than standard product
Light or “lite”: 1/3 fewer calories or 50% less fat than regular product
% Daily Value*
Fat-free: <0.5 g fat; example: skim milk
Total Fat 2.5g 4% Low fat: ≤3 g of fat; example: 1% milk
Saturated Fat 1.5g 6% Reduced fat: at least 25% less fat than regular product; example: 2% milk
Cholesterol Less than 5mg 1% Cholesterol-free: <2 mg cholesterol and ≤2 g saturated fat
Sodium 940mg 39% Low cholesterol: ≤20 mg cholesterol and ≤2 g saturated fat
Total Carbohydrate 12g 4% Sugar-free: <0.5 g sugar
Dietary Fiber 1g 6% Fruit drink/beverage: <100% fruit juice
Sugars 4g Imitation: new food that resembles a traditional food and contains less pro-
Protein 2g tein or less of any essential vitamin or mineral than the traditional food;
Vitamin A 0% • Vitamin C 0% example: imitation cheese
Calcium 6% • Iron 2%
* Percent Daily Values are based on 2,000
Figures per serving.
calorie diet. Your daily values may be higher (Food and drug Administration. Better life for special diets. Pub. #98-2291.
or lower depending on your calorie needs: Washington DC: FDA, 1998. www.fda/gov/fdac/foodlabel/special.html,
accessed 7/99.)
Calories: 2,000 2,500
Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Sodium Less than 2,400mg 2,400mg
Total carbohydrate 300g 375g
Dietary Fiber 25g 30g
• Time available for food preparation
Calories per gram:
Fat 9 • Carbohydrate 4 • Protein 4
• Number of people in the household
• Access to food markets
FIGURE 15-3 • Sample label with nutritional information. • Use of food for comfort, celebration, or symbolic reward
• Satisfaction or dissatisfaction with body weight
• Religious beliefs
for both a 2,000- and a 2,500-calorie diet appears on some, Vegetarianism

but not all, food labels. Because the requirements for
vitamins and minerals do not depend on calories, those Vegetarians are people who restrict their consumption
amounts are uniform to all consumers. of animal food sources, modifying their diets for reli-
Additional regulations affect food labels. For example, gious or personal reasons. Vegetarianism is practiced in
the federal Nutrition Labeling and Education Act requires
companies to comply with standard definitions if they
use health-related claims such as “low-fat” on their labels
(Box 15-3).
NUTRITIONAL PATTERNS
AND PRACTICE
Influences on Eating Habits
Most people learn their eating habits early in life. Cultural

(Fig. 15-4), economic, emotional, and social variables
influence the kinds of food a person consumes and his or
her eating habits. Some influential factors include the
following:
• Food preferences acquired during childhood
• Established patterns for meals
• Attitudes about nutrition
• Knowledge of nutrition FIGURE 15-4 • Cultural influences affect eating habits. (Copyright
• Income level Charles Gupton/Stock Boston.)
various forms. For example, vegans rely exclusively on

plant sources for protein. Semi-vegetarians exclude only
NUTRITIONAL STATUS ASSESSMENT
red meat.
Overall vegetarians have a lower incidence of col- Because eating is a basic need, nurses must identify any
orectal cancer and fewer problems with obesity and dis- current or potential client problems associated with nutri-
eases associated with a high-fat diet (American Dietetic tion. They obtain subjective information by asking clients
Association, 1997; American Heart Association, 2003). focused questions in a diet history. Nurses gather objec-
Nevertheless, a vegan diet, unless skillfully planned, can tive data using physical assessment techniques.
be inadequate in complete protein, calcium, riboflavin,
vitamins B12 and D, and iron. Thus, it is helpful to teach
vegans about protein complementation if they are un- Subjective Data
familiar with the practice. Protein complementation
involves combining two or more incomplete plant proteins A diet history is an assessment technique for obtaining
to provide all the essential amino acids present in animal facts about a client’s eating habits and factors that affect
protein sources (see Fig. 15-1). See Client and Family nutrition. The findings add to the data base of nutri-
Teaching 15-1 for more information. tional information. Common components in a diet history
• Level of appetite
• Weight loss or gain of 10 lbs in the past 6 months
15-1 • CLIENT AND FAMILY TEACHING • Number of meals the client eats per day
• Foods (in approximate household measurements) that
Vegetarian Diets
the client has eaten in the previous 24 hours
The nurse teaches the vegetarian client and his or • Time when the client generally eats meals
her family as follows: • Frequency with which the client eats meals alone
• Plan menus 1 day or week at a time. • Food likes, dislikes, allergies, intolerances, and cultural
• Eat a wide variety of foods. beliefs about food
• Use complementary plant proteins. • Amount of alcohol the client consumes daily or weekly
• Include dried fruit, molasses, and dried peas • Vitamin or mineral supplements the client takes
for iron. routinely
• Enhance absorption of iron by including a good • Any problems with eating, digestion, or elimination
source of vitamin C (e.g., orange juice) with • Special diets that have been medically prescribed or
each meal. self-imposed
• Use whole grains and enriched flour, rather • Use of over-the-counter drugs such as antacids or
than refined flour, to obtain riboflavin. laxatives
• Add brewer’s yeast, a source of B vitamins, to • Food supplements or restrictions and the reason for
the dough of baked goods. them
• Take a calcium supplement that supplies at • Desire to improve nutritional intake or to gain or lose
least 800 mg (preferably 1,200 mg) per day. weight
• Use soybean milk fortified with vitamin B12, or
consult a physician concerning replacement
Objective Data
therapy of at least 2 mcg/day.
• Select good sources of calcium such as broccoli,
The body is composed of water, fat, bone, and muscle.
collard and mustard greens, kale, and tofu.
The nurse uses physical assessments and laboratory data,
• Breast-feed infants, if possible. anthropometric data, and a person’s body measurements
• Consider taking cod liver oil as a source of to help to determine a client’s nutritional status.
vitamin D.
• Purchase meat analogs, products with the
taste and appearance of meat, poultry, or Anthropometric Data
fish, that are made from textured vegetable Anthropometric data are measurements pertaining to body
protein. Such analogs are available in health size and composition. The nurse obtains them by measur-
food stores. ing height and weight, calculating body-mass index, and
• Contact a Seventh-Day Adventist church, measuring midarm circumference and triceps skinfold
whose members practice vegetarianism, for thickness. Eating disorder clinics and fitness centers use
information on sources for meatless products more sophisticated tests such as bioelectrical impedance
and food preparation classes. analysis that calculate lean body mass, body fat, and total
body water based on changes in conduction of an applied BOX 15-4 ● Body-Mass Index Calculation
electrical current. and Interpretation
Obtaining the client’s height and weight generally
Calculation
provides sufficient anthropometric data unless a severe
1. Divide pounds by 2.2 = kilograms (kg).
nutritional problem is suspected or long-term therapy 2. Divide height in inches by 39.4 = meters (m).
is anticipated. An actual weight, rather than the client’s 3. Square the answer in step 2 by multiplying the number times itself.
estimate, is essential. The nurse uses a standing, chair, 4. Divide weight in kg by m2.
or bed scale depending on the client’s condition. He or INTERPRETATION BMI (KG/M2)
she records the date and time, the type of scale, and the
clothing the client wears. It is important to duplicate all Underweight <18.5
these factors when taking subsequent weights for com- Normal 18.5 to 24.9
parison. The nurse measures the client’s height with the Overweight 25.0 to 29.9
Obese 30.0 to 34.9
client wearing no shoes. A gross assessment tool using Severely Obese 35.0 to 39.9
weight and height is shown in Figure 15-5. Extremely Obese ≥40
Body-mass index (BMI) provides numeric data to com-
pare a person’s size in relation to established norms for
the adult population. It is calculated using height and
weight (Box 15-4). The measurement is based on the assumption that mus-
cle usually is located in anatomic areas such as the biceps.
When measuring midarm circumference,
• Use the nondominant arm.
Using the graph in Figure 15-5 and the formula in
Box 15-4, what is your analysis of a person who is 5 feet,
• Find the midpoint of the upper arm between the shoul-
7 inches and weighs 185 lbs? der and elbow.
• Mark the midarm location.
• Position the arm loosely at the client’s side.
• Encircle the arm with a tape measure at the marked
Midarm circumference helps to determine skeletal muscle
position.
mass. This technique, combined with other body mea- • Record the circumference in centimeters.
surements, helps to assess a client’s nutritional status.
The thickness of the skinfold at the triceps or sub-
BMI scapular areas is generally obtained to aid in estimating
Height* the amount of subcutaneous fat deposits (Fig. 15-6). The
18.5 25 30
6'6"
6'5"
6'4"
6'3"
6'2"
6'1"
HT
6'0"
EIG
5'11"
IGH
YW
5'10"
WE
LTH
5'9"
E
ES
ER
A
5'8"
OB
HE
OV
5'7"
5'6"
5'5"
5'4"
5'3"
5'2"
5'1"
5'0"
4'11"
4'10"
50 75 100 125 150 175 200 225 250 275
Pounds†
* Without shoes.
† Without clothes. The higher weights apply to people with more muscle and
bone, such as many men.
Source: Report of the Dietary Guidelines Advisory Committee on the Dietary
Guidelines for Americans, 2000, pages 3-4.
http://www.health.gov/dietaryguidelines
FIGURE 15-6 • Measuring triceps skinfold thickness with calipers.
FIGURE 15-5 • Tool for determining weight status. (Copyright B. Proud.)
skinfold thickness measurement relates to total body fat. hematocrit, and number of lymphocytes; serum albu-
To measure triceps skinfold thickness, min and transferrin levels that indicate protein status;
and cholesterol, triglyceride, and lipoprotein levels
• Use the same arm as for the midarm circumference that may reflect a need to adjust the amount of fat the
measurement. client eats.
• Grasp and pull the skin separate from the muscle at
the previously marked location.
• Place the calipers around the skinfold. MANAGEMENT OF PROBLEMS
• Record the measurement in millimeters. INTERFERING WITH NUTRITION
To calculate how much of the midarm circumference is
actual muscle (midarm muscle circumference), multiply Based on the assessment data, the nurse may identify one
the triceps skinfold measurement by 0.314. or more of the following nursing diagnoses:
To interpret the significance of the midarm circumfer-
ence measurement and triceps skinfold thickness, the • Imbalanced Nutrition: Less Than Body Requirements
nurse compares measurements with averages provided • Imbalanced Nutrition: More Than Body Requirements
in standardized charts (Table 15-4). Skinfold thickness • Deficient Knowledge: Nutrition
norms do not exist for adults older than 75 years. The • Self-Care Deficit: Feeding
circumference of the abdomen may be a more accurate • Impaired Swallowing
anthropometric measurement for older adults, but stan- • Risk for Aspiration
dardized norms have not been established.
If a nutritional problem is beyond the scope of indepen-
Physical Assessment dent nursing practice, the nurse consults with the physi-
cian. If the problem can be resolved through independent
In addition to anthropometric data, the nurse assesses nursing measures, the nurse may proceed by collaborating
the following in the client: with the dietitian, selecting appropriate nursing inter-
ventions, and continuing to monitor the client to evaluate
• General appearance the effectiveness of the nursing care plan.
• Integrity of the mouth
• Condition of the teeth
• Ability to chew and swallow Obesity
• Gag reflex
• Characteristics of skin and hair Obesity is a condition in which a person’s BMI equals or
• Joint flexibility exceeds 30 kg/m2 or the triceps skinfold measurement
• Hand strength exceeds 15 mm. Obesity indicates a need for healthy
• Attention and concentration weight-reduction measures. Research (Nicklas et al.,
2006; Racette et al., 2006; Vega et al., 2006) indicates
Laboratory Data that excess abdominal fat—a waist circumference more
Laboratory tests used in nutritional assessment include than 40 inches in men or 35 inches in women—is a great
a complete blood count (CBC), especially hemoglobin, health risk factor. An increased proportion of abdomi-
nal fat is associated with a higher incidence of heart
and vascular disease, hypertension, and diabetes mel-
TABLE 15-4
ANTHROPOMETRIC litus. Severely obese people are medically evaluated to
MEASUREMENTS FOR ADULTS determine whether there are physical etiologies for the
MEASUREMENT GENDER NORMAL RANGE* disorder or health risks associated with a weight-loss
program.
Midarm circumference Male 29.3–17.6 cm To lose 1 lb, the client must reduce his or her caloric
Female 28.5–17.1 cm
intake by 3,500 calories per week. Thus, decreasing one’s
Midarm muscle Male 25.3–15.2 cm
intake of food by 500 calories per day will produce a 1-lb
circumference Female 23.2–13.9 cm
weight loss per week. By omitting 1,000 calories per day,
Triceps skinfold Male 12.5–7.3 mm
Female 16.5–9.9 mm the person will lose 2 lbs per week. Generally a sustained
loss of 1 to 2 lb per week is a healthy goal. The nurse
* If measurements are below the lowest range for normal, nutritional advises clients trying to lose weight about healthy eating
support may be indicated. and the hazards of unsupervised weight-loss techniques
(Adapted from Jelliffe, D.B.[1986]. The assessment of the nutritional status of
the community. World Health Organization Monograph No. 53. Geneva; such as fasting, fad diets, or diet drugs. See Client and
World Health Organization.) Family Teaching 15-2.
Independent nursing interventions, including client

teaching, are appropriate for people who are approxi-
Promoting Weight Loss mately 10 lbs below their ideal body weight. To gain 1 lb,
The nurse teaches the client who needs to lose a person must consume 3,500 calories more than his or
weight and his or her family as follows: her metabolic needs per week. This is best done gradually.
• When using MyPyramid, follow the require-
ments for a 2,000-calorie diet.
• Limit the number of servings to the amounts Anorexia
that MyPyramid suggests:
• Grains—one slice of bread, 1 oz of cereal,
Anorexia (loss of appetite) is associated with multiple
or a half-cup of cooked pasta, rice, or cereal factors: illness, altered taste and smell, oral problems,
• Vegetables—1 cup of raw leafy vegetables,
and tension and depression. Simple anorexia is generally a
a half-cup of other raw or cooked vegetables, short-lived symptom that requires no medical or nursing
or three-fourths of a cup of vegetable juice intervention. Anorexia nervosa, a psychobiologic disorder,
• Fruits—one medium apple, banana, or
is associated with a 20% to 25% loss in previously stable
orange; a half-cup of chopped, cooked, or body weight. No matter what the etiology, the nurse never
canned fruit; or three-fourths of a cup of ignores that a client is not eating. If food is uneaten, the
fruit juice nurse assesses for physiologic, emotional, cultural, or social
• Dairy—1 cup of milk or yogurt, 1.5 oz of
etiologies that may be contributing factors. See Nursing
natural cheese, or 2 oz of processed cheese Guidelines 15-1.
• Meat—2 to 3 oz of cooked lean meat, poultry,
or fish. A half-cup of cooked dry beans,
one egg, 2 tablespoons of peanut butter, or Stop • Think + Respond BOX 15-4
one-third of a cup of nuts equals 1 oz of meat.
How can the nurse make food and its presentation
• Use fats, oils, and sugar sparingly. visually attractive to entice a client to eat?
• Eliminate junk food (contributes calories but
not much nutrition) and alcoholic beverages.
• Eat small but more frequent meals rather than
three large meals per day. Any nutrients not Nausea
used from large meals are stored as fat.
• Sit at the table to eat. Do not read or do other Nausea usually precedes vomiting and is produced when
tasks while eating; distraction often fools the gastrointestinal sensations, sensory data, and drug effects
brain into thinking that food has not been stimulate a portion of the medulla that contains the
consumed. vomiting center. Nausea may be associated with feeling
• Increase fiber in the diet from fresh fruits, faint or weak. Often, dizziness, perspiration, skin pallor,
vegetables, and whole grains. Fiber is not a rapid pulse rate, and a headache are present. The nurse
digested and may provide a full feeling without consults the physician when the measures presented in
large numbers of calories.
• Participate in some regular, active form of
exercise. Exercise raises the metabolic rate 15-3 • CLIENT AND FAMILY TEACHING
(speed at which the body uses calories) while
suppressing appetite. Information on activity Promoting Weight Gain
and exercise is located in Chapter 23. The nurse teaches the client who needs to gain
weight and his or her family as follows:
• Eat a variety of foods from MyPyramid, but
Emaciation increase the number of servings or serving sizes.
• Eat small amounts frequently.
Progressive or prolonged weight loss resulting in a BMI • Eat with others.
less than 16/m2 can have serious consequences. Emaciation • Snack on high-calorie but nutritious foods such
(excessive leanness) and cachexia (general wasting away as hard cheese, milkshakes, and nuts.
of body tissue) are consistent with severe malnourish- • Disguise extra calories by fortifying foods with
ment. States of severe malnourishment require collabo- powdered milk, gravies, or sauces.
ration with a physician, who will prescribe measures to • Garnish food with cubed or grated cheese,
ensure adequate nourishment such as gastric or enteral diced meat, nuts, or raisins.
tube feedings and parenteral nutrition (see Chap. 29). • Rest after eating.
NURSING GUIDELINES 15-1 NURSING GUIDELINES 15-2

Overcoming Simple Anorexia Relieving Nausea
❙ Cater to the client’s food preferences. The client will more likely ❙ Check to see if something as simple as an annoying odor or sight is
consume food he or she selects. contributing to nausea. Offensive sensory data can stimulate the
❙ Serve nutrient-dense foods (foods loaded with calories). They may vomiting center in the brain.
compensate for a low intake of food. ❙ Assist the client to take deep breaths. Distraction can overcome
❙ Offer small servings of food frequently. Eating small amounts nausea by directing conscious attention away from the unpleasant
frequently may result in a cumulative intake within acceptable sensation.
nutritional levels. ❙ Limit the client’s abrupt movements and activities. Movement may
❙ Ensure that the client is rested before meals. Lack of energy may shift gastrointestinal structures and their contents, intensifying
overpower the desire to eat. stimulation of the vomiting center.
❙ Provide an opportunity for oral hygiene before meals. Mouth care
❙ Limit the client’s intake of food and fluid temporarily until signs of
stimulates salivation and potentiates the pleasure from eating. nausea subside. Distention of the stomach is a common trigger of
the vomiting center.
❙ Help the client to a sitting position. Seeing food stimulates the
appetite center; sitting also promotes access to the food.
❙ Avoid making negative comments about food. Verbal comments
create visual images that may cause psychogenic stimulation of the
❙ Arrange for the client to eat with others. Because eating is a social vomiting center.
activity, the client may eat more when with a group.
❙ Serve food attractively. Visual presentation of food stimulates
appetite.
❙ Suggest adding spices and herbs to foods. Intensifying flavors and
aromas may stimulate a desire to eat; however, it may have the NURSING GUIDELINES 15-3
opposite effect as well. When experimenting, add new seasonings Managing the Care of a Vomiting Client
to small amounts of food.
❙ Serve foods at their appropriate temperature. The client may eat ❙ Temporarily limit the client’s food intake. Adding contents to an
more food if hot foods are hot and cold foods are cold. already upset stomach may prolong episodes of vomiting.
❙ Serve cool, bland foods to clients with mouth irritation. Hot or spicy ❙ Lean the client’s head forward over a container or the toilet. Tilting
foods intensify the irritation of oral structures. the chin toward the chest reduces the possibility that vomitus will
enter the lungs.
❙ Adjust light, sound, ventilation, and temperature to a comfortable level.
Minimizing sensory stimulation may reduce the urge to vomit.
Nursing Guidelines 15-2 are unsuccessful for overcoming ❙ Apply a cool washcloth to the client’s forehead or back of the neck.
nausea. Prescribed medications may be necessary. Increased perspiration and a clammy feeling to the skin may
Once nausea is relieved, assisting the client to resume accompany vomiting.
fluid intake and nourishment becomes a priority. The ❙ Help the client rinse the mouth, offer mouthwash, or provide mouth
nurse starts this process gradually, offering sips of clear care as soon as possible after vomiting. Gastric acid is harmful to
fluids first. If the client tolerates fluids, the nurse adds tooth enamel. Emesis usually produces an unpleasant aftertaste.
soft, bland foods in small amounts. ❙ Turn a vomiting client who is unconscious or weak onto the
abdomen or side. Gravity helps emesis to drain from the mouth
rather than remain in the throat, where the client could aspirate it
Vomiting into the lungs.
❙ Use a suction machine to clear vomitus from the mouth and throat
Vomiting (loss of stomach contents through the mouth) of a weak or unconscious client. Suctioning pulls fluid from the
commonly accompanies nausea. Emesis or vomitus (sub- oral cavity and airway, thus preventing choking and aspiration
stance that is vomited) is readily visible. Retching (act (see Chap. 36).
of vomiting without producing vomitus) may occur if ❙ Provide firm support with the hands or a pillow to the abdominal
the stomach is empty. Regurgitation (bringing stomach incision if the client has had abdominal surgery. An abdominal
contents to the throat and mouth without the effort of binder also may help to support the incision (see Chap. 28). Strong
vomiting) occurs commonly among infants after eating. muscle contractions may pull on stitches and increase pain and
Projectile vomiting (vomiting that occurs with great force) discomfort.
is associated with certain disease conditions such as ❙ Remove the container of emesis from the bedside as soon as
increased pressure in the brain or gastrointestinal bleeding. possible. Provide ventilation to remove any lingering odors. The
Nausea may be present, but it often is not. See Nursing appearance and odor of vomitus may stimulate more vomiting.
Guidelines 15-3.
The nurse describes the emesis in the client’s medical

record. If possible, he or she measures the amount of
MANAGEMENT OF CLIENT NUTRITION
emesis and records the volume. Documentation includes
the amount, color, appearance, and any unusual odor Common Hospital Diets
such as the odor of fecal material or alcohol. If the char-
acteristics of the emesis are unusual, the nurse saves a Some common hospital diets include the following:
specimen for the physician to examine. If there are any
• Regular or general: allows unrestricted food selections
doubts about whether to discard or save the emesis, it
• Light or convalescent: differs from regular diet in prepa-
is best to check with a more experienced nurse.
ration; typically omits fried, fatty, gas-forming, and raw
The nurse always consults the physician when vom-
foods and rich pastries
iting is prolonged. It may be necessary to administer pre-
• Soft: contains foods soft in texture; is usually low in
scribed medications for relief.
residue and readily digestible; contains few or no spices
or condiments; provides fewer fruits, vegetables, or
meats than a light diet
Stomach Gas • Mechanical soft: resembles a light diet but is used for
clients with chewing difficulties; provides cooked fruits
Gas in the stomach is primarily a result of swallowing air. and vegetables and ground meats
It becomes a problem only when it accumulates. Eructation • Full liquid: contains fruit and vegetable juices, creamed
(belching) is a discharge of gas from the stomach through or blended soups, milk, ices, ice cream, gelatin, junket,
the mouth. Flatus is gas formed in the intestine and released custards, and cooked cereals
from the rectum when eructation does not occur. Nurs- • Clear liquid: consists of water, clear broth, clear fruit
ing guidelines for relieving intestinal gas are discussed in juices, plain gelatin, tea, and coffee; may or may not
Chapter 31. See Nursing Guidelines 15-4. include carbonated beverages
• Special therapeutic: consists of foods prepared to meet
special needs, such as low in sodium, fat, or fiber
Most health care agencies have a dietitian who plans
NURSING GUIDELINES 15-4 the meals and a centralized food service that prepares
Preventing and Relieving Stomach Gas clients’ meals.
Nurses are generally responsible for ordering and can-
❙ Suggest that the client chew food with the mouth closed. celing diets for clients, serving and collecting meal trays,
Laughing and talking while eating increase the amount of helping clients to eat, and recording the percentage of
swallowed air.
food that clients eat. Nurses must know the type of diet
❙ Advise against using a straw. Each swallow of liquid also contains prescribed for each client, the purpose for the diet, and
the air in the straw. its characteristics. They take care to ensure that clients
❙ Advise against chewing gum and smoking cigarettes. Chewing receive the correct diet and that restricted foods are
gum increases salivation and results in swallowing both secretions withheld.
and air. The client actually may swallow a portion of inhaled
cigarette smoke.
❙ Limit or restrict foods that contain large volumes of air such as Meal Trays
soufflés, yeast breads, and carbonated beverages. Swallowing air
trapped within food and drinking beverages that contain dissolved Meals are usually served at the bedside, but some health
gas distend the stomach. care institutions have dining rooms or cafeterias for ambu-
❙ Recommend that when under stress, the client should avoid eating. latory clients. Clients in nursing homes generally eat
Emotions delay stomach emptying, which prevents the movement together in small groups unless they physically cannot.
of gas to the intestine. Nurses and dietary personnel work together to ensure
❙ Propose walking if uncomfortable. Activity helps gas to rise to its that clients receive food at mealtimes and that trays are
highest point in the stomach, making belching easier. collected afterward. The nursing responsibilities for serv-
❙ Consult with the physician about the use of medications that ing and removing trays are identified in Skill 15-1.
relieve gas accumulation. Instruct clients who purchase over-the-
counter drugs to follow label directions for their use. Simethicone
is an ingredient in several nonprescription antacids. Drugs Feeding Assistance
containing simethicone facilitate the elimination of gas by
reducing the surface tension of gas bubbles trapped in the Some clients need help with eating. Skill 15-2 provides sug-
gastrointestinal tract. gested actions for feeding clients who can bite, sip, chew,
and swallow but cannot cut food or use utensils for eating.
Suggestions for helping clients with dysphagia (difficulty • Prepare the food by opening cartons, cutting bite-size
swallowing), for helping clients who are blind or have both pieces, adding salt and pepper, buttering bread, and
eyes patched, and for promoting self-feeding in those with pouring coffee.
dementia (impairment of intellectual functioning) follow. • Use the analogy of a clock when describing where the
client may find food on the plate. For example, “The
Feeding the Client With Dysphagia potatoes are at 3 o’clock.”
Nurses use the following techniques when caring for • If the client needs to be fed, tell him or her what kind
clients who have difficulty chewing and swallowing food: of food you are offering with each mouthful.
• Devise a system by which the client can indicate when
• Always have equipment for oral and pharyngeal suc- he or she is ready for more food or drink, such as ask-
tioning at the bedside (see Chap. 36).
ing or raising a finger.
• Remain with the client throughout eating when there
• Do not rush the client; eating should be done at a
is a potential for aspiration.
leisurely pace.
• If the client has a tracheostomy tube or endotracheal
tube, make sure the cuff is inflated (see Chap. 36).
Assisting the Client With Dementia
• Place the client in a sitting position.
• Ensure that the client is rested and that you have his Dementia refers to the deterioration of previous intellec-
or her attention. tual capacity. It is a common problem among those with
• Give short, simple instructions to prompt the client to neurologic conditions such as Alzheimer’s disease. These
eat and swallow. clients often can retain their ability to carry out activities
• Limit distracting stimuli such as eating while watching of daily living, such as self-feeding, by maintaining atten-
television or in an area where activities are taking place. tion and concentration and repeating actions. Therefore,
• Request a full liquid or mechanically soft diet for the the following are useful nursing actions:
client who has missing teeth or has had recent oral
surgery. • Have the same staff person help the client, if possible,
• Provide small frequent meals if efforts to eat and swal- to develop a rapport with the client and promote con-
low tire the client. tinuity of care.
• Modify eating or feeding equipment to facilitate the • Be consistent with the time and place for eating.
client’s safety and independence. • Reduce or eliminate environmental distractions to pro-
• Determine that the client has swallowed one portion mote concentration on the task at hand.
of food before offering another. • Place the food tray close to the client, not the staff
• Encourage repeated swallowing attempts if there is person, to communicate visually and spatially that the
wet, gurgly vocalization, a sign that food is in the client is to eat the food.
esophagus and not the stomach. • Remove wrappers, containers, and food covers to reduce
confusion.
Nursing Care Plan 15-1 is an example of how the nurse
• Pour milk from the carton into a glass so it is easily
manages the care of a client who has a nursing diagno-
recognizable.
sis of Impaired Swallowing. This diagnostic category is
• Encourage the client’s participation by offering finger
defined in the NANDA taxonomy (2005) as “abnormal
foods and utensils to stimulate awareness and memory.
functioning of the swallowing mechanism associated
• Ensure that the client can see at least one other person
with deficits in oral, pharyngeal, or esophageal structure
who is also eating. This serves as a model for the desired
or function.”
behavior.
Feeding the Visually Impaired Client • Guide the hand with food to the client’s mouth.
• Reinforce a desired response by praising, touching, and
When caring for clients who are temporarily or perma- smiling at the client.
nently sightless, • Remain with the client. Do not begin feeding, leave, and
• Place a thick towel across the client’s chest and over then return because this interrupts the client’s atten-
the lap. tion and concentration.
• If the client can eat independently, consider using dishes
with rims or bowls to prevent spilling.
• Arrange as much as possible to have finger foods (foods GENERAL GERONTOLOGIC
that may be eaten with the hands) prepared for the CONSIDERATIONS
client.
Age-related changes are usually gradual; therefore, include evalu-
• Describe the food and indicate its location on the tray. ation of nutritional status in annual examinations or more
• Guide the client’s hand to reinforce the location of frequently if indicated by weight gain or loss of 10 lbs within
food and utensils. 6 months or 5 lbs within 1 month.
Impaired Swallowing
ASSESSMENT
• Note if there is coughing, choking, or drooling from the mouth when the client swallows saliva, liquids, or food.
• Look for asymmetry of the mouth.
• Ask the client to extend the tongue; observe if it deviates from a midline position.
• Determine if the oral mucous membranes are moist or dry.
• Check for the gag reflex by stimulating the posterior oral pharynx with a cotton-tipped swab.
• Inspect the mouth and buccal cavities for retained food, condition of the teeth, and evidence of tissue irritation,
swelling, or injury.
• Observe the client’s ability to understand and follow verbal instructions.
• Review the results of a fluoroscopic swallowing study as ordered by the physician.
Nursing Diagnosis: Impaired Swallowing related to left hemiparesis secondary to

cerebrovascular accident (stroke) as manifested 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 suction machine, suction catheter, and oxygen Equipment for suctioning the airway and improving oxy-
per mask at the bedside. genation may be necessary if the airway becomes obstructed.
Place the client in a sitting position. An upright position uses gravity to move food from
pharynx to 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 Dry and sticky foods are more difficult for a client to
foods such as crackers and sticky foods such as bananas. masticate and swallow.
Request semisolid foods with some texture such as Semisolids are easier to swallow than liquids and watery
oatmeal, poached eggs, and mashed potatoes. pureed 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 food. Smaller amounts of food are more easily swallowed; the
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 A chin-to-chest position closes the pathway to the trachea
swallow repeatedly without breathing in between. and 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, Raising the chin, clearing the throat, and breathing
clear the throat, and resume breathing. improve ventilation.
(continued)
Impaired Swallowing
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 hand-held 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 semi-sitting position for at The potential for aspiration is reduced once food leaves
least a half hour. the stomach.

• The client demonstrates techniques for clearing the mouth of food.
• The client swallows food completely.
• The client consumes sufficient calories to maintain weight.
Medical conditions, adverse medication effects, functional impair- Taking multiple medications increases the incidence of food–drug
ments, and psychosocial conditions (e.g., dementia, depression, interactions among older adults. Some medications also
social isolation) affect the nutritional status of older adults. cause constipation, diarrhea, loss of appetite, and other
Diminished senses of smell and taste, which may occur with problems that interfere with nutrition. Teaching regarding
normal aging, can interfere with appetite and intake. medication dosage should include the potential side effects as
Older adults often consume diets high in carbohydrates. Reasons well as recommended timing of administration in relation to
include changes in taste; changes in ability to prepare or food intake. Also, over-the-counter or herbal therapies can
obtain foods; or financial considerations of paying for medica- interfere with nutrient absorption.
tions, groceries, and living expenses on a fixed income. Oral infections, poorly fitting dentures, or vitamin deficiencies can
Older adults require fewer calories and, therefore, should be cause a painful or burning tongue, ulcers on the gums, or
taught to select nutrient-dense foods such as meat, fruits, other difficulties that interfere with eating.
vegetables, and dairy products or to combine plant-based Dysphagia among older adults often results from neurologic
proteins. MyPyramid can be accessed and used as a food conditions including stroke, esophageal disorders, or
guide according to age and activity level. increased pressure from abdominal disorders. Swallowing
Nutritional supplements should be evaluated. Protein-based liquid
studies may allow for appropriate teaching of strategies to
supplements will not provide the needed fiber and should not
promote swallowing effectiveness.
be relied on as the main source of protein.
Some older adults have difficulty obtaining and preparing nutri-
Older people may become more sedentary and should be taught
tious meals because of socioeconomic barriers such as low
the benefits of exercise within their ability. Decreased exercise
income and an inability to get to the grocery store. Addition-
may lead to decreased appetite. Sitting exercises may be indi-
ally, appropriate food storage (including food expiration dates,
cated if balance or functional abilities decline.
proper storage temperature, and access to cupboards if
Oral and dental problems are common in older adults and inter-
fere with adequate nutrition. Encourage older adults to get arthritic changes are present) should be evaluated.
dental care every 6 months and to practice good dental Psychosocial impairments such as dementia or depression
hygiene daily. Malfitting dentures may indicate weight change. interfere with food preparation, consumption, and enjoy-
Dry mouth (xerostomia), a common problem in older adults, often ment. An important initial sign of these changes may be
results from medications or the effects of disease. It interferes weight loss.
with chewing, swallowing, and enjoying meals. Encourage Homebound older adults may benefit from home-delivered
people with dry mouth to drink adequate noncaffeinated and meals. The nutrition of older adults who are isolated,
nonalcoholic beverages or to chew sugarless gum to promote depressed, or cognitively impaired may improve with partici-
salivation. pation in a group meal program. Home-delivered meals and
Older adults are likely to have chronic conditions such as arthritis group meal programs are widely available and are funded
and sensory impairments that affect their ability to meet their through the Older Americans Act. The National Eldercare
nutritional needs. Modifications such as plates with sides and Locator (800-667-1116) provides information.
large-handled utensils may help the older person maintain Refer low-income older adults to their local Agency on Aging for
self-care ability in feeding. assistance in obtaining food stamps.
3. Which of the following is the best evidence that a client

with anorexia as a result of cancer is responding to the
1. Describe appropriate nursing actions if a client eats none nutritional regimen developed by the nurse and dietitian?
or only some food served. 1. The client remains alert.
2. The client gains weight.
2. A client tells the nurse that she eats the following every
3. The client feels hungry.
day: cereal, milk, and banana for breakfast; a sandwich
4. The client is pain free.
made with processed meat, mayonnaise, and a soft drink
for lunch; a candy bar in the late afternoon; and meat, 4. When a client on a clear liquid diet asks for some nourish-
potatoes, a vegetable, and a glass of milk for supper. In ment, which of the following is appropriate for the nurse
the late evening, she snacks on potato chips. What rec- to provide?
ommendations would you make to improve this client’s 1. Milk
nutrition? 2. Pudding
3. Gelatin
4. Custard
5. The nurse is most correct in recommending which of
1. When caring for a client whose oral mucous membranes the following food sources of iron to a client with chronic
are irritated and sore, which of the following items is best anemia?
to withhold from the dietary tray? 1. Dairy products
1. Tomato soup 2. Citrus fruits
2. Lime gelatin 3. Red meat
3. Canned peaches 4. Yellow vegetables
4. Rice pudding
2. A nurse notes that a client coughs and chokes while eat-
ing. What initial nursing recommendation is best?
1. Have the dietary department send baby foods from
now on.
2. Tell the client to chew his or her food very thor-
oughly.
3. Advise the client to avoid drinking beverages with
meals.
4. Withhold milk and other dairy products in the future.
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 Ensures that eating does not affect therapeutic outcomes
have 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’ Reduces the potential for adverse reactions
food allergies or food intolerances.
Planning
Prepare clients so they are ready to eat at the designated Ensures food is served at its appropriate temperature
time.
Meet clients’ needs for comfort, hygiene, and elimination Promotes appetite and eating
before the meal arrives.
Help clients to a sitting position. Assists ambulatory clients to a comfortable position
Implementation
Wash hands before serving trays. Prevents transmission of microorganisms
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 Avoids dietary errors
client’s identification bracelet, or ask the client to
identify himself or herself by name.
Place the tray so it faces the client. 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 as necessary to open cartons and prepare Demonstrates consideration and facilitates independence
food.
Replace food that is objectionable or request special Demonstrates respect for unique needs
additional items from the dietary department.
Before leaving the room, check if the client has any further Reduces inconveniences during meal time
requests like adjustment of pillows or donning eyeglasses.
Make sure the signal cord is handy in case a need arises Provides a means for summoning assistance
later.
Check the client’s progress from time to time. Indicates a willingness to provide assistance
Remove the food tray when the client is finished eating. Restores order and cleanliness to the environment
Record the amount of fluid consumed from the dietary Ensures accurate fluid assessment
tray on the bedside flow sheet, if the client’s fluid intake
is being monitored.
Note the percentage of food that the client has eaten.* Ensures documentation of dietary intake according to
JCAHO using precise current 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
(continued)
SERVING AND REMOVING MEAL TRAYS (Continued)
Evaluation
• Client states that hunger is satisfied.
• Most food is consumed.
Document
• Type of diet and percentage of food consumed
SAMPLE DOCUMENTATION*
Date and Time Ate 100% of mechanical soft diet with need for assistance. SIGNATURE/TITLE
*Many agencies mandate nurses to record the percentage of consumed food on a flow sheet or checklist.
Nurses record other pertinent data within the medical record.
Skill 15-2 • FEEDING A CLIENT
Assessment
Compare the dietary information on the Kardex with the Ensures accuracy in therapeutic management
medical record.
Verify that food or fluids are not being temporarily Prevents delaying or having to cancel diagnostic tests
withheld.
Determine if the client’s fluid intake is being measured. Ensures accurate documentation of data
Assess the client to determine what or how much Aids in identifying specific problems and selecting nursing
assistance is necessary. interventions
Review the medical record to see how well and how much Helps to establish realistic goals and evaluate progress
the client has eaten during previous meals; note weight
trends.
Review the characteristics of the diet order. Helps to determine if 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 Identifies unmet physiologic needs
pain, nausea, fatigue.
Check the medication record for drugs that must be Facilitates optimal drug absorption and reduces drug side
administered before or with meals. effects
Planning
Set realistic goals for how much food the client will eat Establishes criteria for evaluating client responses
and how much the client will participate with self-
feeding.
Select appropriate nursing measures to promote client Helps resolve problems that, if ignored, may interfere with
comfort such as administering an analgesic. eating
(continued)
FEEDING A CLIENT (Continued)
Complete priority responsibilities for assigned clients. Allows a period of uninterrupted feeding
Provide oral hygiene and handwashing before serving the Controls transmission of microorganisms; promotes
tray. appetite and aesthetics
Prepare medications that must be given before or with Coordinates drug and nutritional therapy
meals, 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 Prevents transmission of microorganisms
rub (see Chap. 10) before preparing food.
Obtain or clean special utensils or containers that have Promotes independence and self-reliance
been 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 Promotes safety by facilitating swallowing
client to a chair (see Fig. A).
Feeding a client.
Check that you serve the correct diet and tray to the Indicates responsibility and accountability for therapeutic
correct client. management
Cover the client’s upper chest and lap with a napkin or Protects bedclothes and linen
towel.
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 Maintains or supports independence and self-care
abilities.
(continued)
FEEDING A CLIENT (Continued)
Avoid rushing. Communicates a relaxed atmosphere while eating
Collaborate with the client on which foods he or she Accommodates individual preferences
desires before loading a fork or spoon.
Provide manageable amounts of food with each bite. Prevents choking or airway obstruction
For a client with a stroke, direct the food toward the Places food in an area where there is feeling and muscle
nonparalyzed side of the mouth. control 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 Promotes an independent locus of control
food or 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 Documents essential assessment data
measured.
Remove the tray and make the client comfortable. It is A sitting position prevents the reflux of stomach contents
best for clients to remain sitting or semi-sitting for at into the esophagus and reduces the potential for
least 30 minutes after eating unless there is a medical aspiration.
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
16
Chapter
Fluid and
Chemical
Balance
WORDS TO KNOW
active transport electrochemical infiltration osmosis
air embolism neutrality infusion pump parenteral nutrition
anions electrolytes intake and output passive diffusion
cations emulsion intermittent peripheral parenteral
circulatory extracellular fluid venous access nutrition
overload facilitated diffusion device phlebitis
colloids filtration interstitial fluid ports
colloid solutions fluid imbalance intracellular fluid pulmonary embolus
colloidal osmotic hydrostatic pressure intravascular fluid third-spacing
pressure hypertonic solution intravenous fluids thrombus formation
crystalloid solutions hypervolemia ions total parenteral
dehydration hypoalbuminemia isotonic solution nutrition
drop factor hypotonic solution needleless systems venipuncture
edema hypovolemia nonelectrolytes volumetric controller
LEARNING OBJECTIVES
● Name four components of body fluid.
● List five physiologic transport mechanisms for distributing fluid and its constituents.
● Name 10 assessments that provide data about a client’s fluid status.
● Describe three methods for maintaining or restoring fluid volume.
● Describe four methods for reducing fluid volume.
● List six reasons for administering intravenous fluids.
● Differentiate between crystalloid and colloid solutions, and give examples of each.
● Explain the terms isotonic, hypotonic, and hypertonic when used in reference to
intravenous solutions.
● List four factors that affect the choice of tubing used to administer intravenous solutions.
● Name three techniques for infusing intravenous solutions.
● Discuss at least five criteria for selecting a vein when administering intravenous fluid.
● List seven complications associated with intravenous fluid administration.
● Discuss two purposes for inserting an intermittent venous access device.
● Identify three differences between administering blood and crystalloid solutions.
● Name at least five types of transfusion reactions.
● Explain the concept of parenteral nutrition.
BODY fluid is a mixture of water, chemicals called electrolytes and nonelectrolytes,

and blood cells. Water, the vehicle for transporting the chemicals, is the very essence
of life. Because water is not stored in any great reserve, daily replacement is the key
to maintaining survival. This chapter discusses the mechanisms for maintaining fluid
balance and restoring fluid volume and the components in body fluid.
311
BODY FLUID
Water
Depending on age and gender, the human body is approx-

imately 45% to 75% water. Body water normally is sup-
Cellular fluid
plied and replenished from three sources: drinking liquids, (about 50% of
consuming food, and metabolizing nutrients. Once the body weight)
water is absorbed, it is distributed among various locations, Interstitial fluid
called compartments, within the body. (about 15% of
body weight)
Fluid Compartments
Body fluid is located in two general compartments. Intra-

cellular fluid (fluid inside cells) represents the greatest pro- Plasma or
portion of water in the body. The remaining body fluid intravascular
fluid
is extracellular fluid (fluid outside cells). Extracellular fluid (about 5% of
is further subdivided into interstitial fluid (fluid in the tis- body weight)
sue space between and around cells) and intravascular fluid
(watery plasma, or serum, portion of blood) (Fig. 16-1).
The percentage of water in these compartments varies
according to age and gender (Table 16-1).
FIGURE 16-1 • Average distribution of body fluid.
Electrolytes
Electrolytes are measured in the serum of blood spec-
Electrolytesare chemical compounds, such as sodium and imens, and the amount is reported in milliequivalents
chloride, that are dissolved, absorbed, and distributed (mEq). When one or more cations or anions become
in body fluid and possess an electrical charge. They are excessive or deficient, an electrolyte imbalance occurs.
obtained from dietary sources of food and beverages. They Significant imbalances can lead to dangerous physio-
are essential for maintaining cellular, tissue, and organ logic problems. In many situations, electrolyte imbal-
functions. For example, electrolytes affect fluid balance ances accompany changes in fluid volumes.
and complex chemical activities such as muscle contrac-
tion and the formation of enzymes, acids, and bases (see
discussion of minerals in Chap. 15). Nonelectrolytes
Collectively, electrolytes are called ions (substances that
carry either a positive or negative electrical charge). Cations Nonelectrolytes are chemical compounds that remain
(electrolytes with a positive charge) and anions (electro- bound together when dissolved in a solution and do not
lytes with a negative charge) are present in equal amounts conduct electricity. The chemical end products of carbo-
overall, but their distribution varies in each body fluid hydrate, protein, and fat metabolism—namely glucose,
compartment (Table 16-2). For example, more potas- amino acids, and fatty acids—provide a continuous sup-
sium ions are inside cells than outside cells. ply of nonelectrolytes.
TABLE 16-1
PERCENTAGES OF BODY FLUID ACCORDING TO AGE
AND GENDER
FLUID ADULT ADULT
COMPARTMENT INFANTS MEN WOMEN ELDERLY
Intravascular 4% 4% 5% 5%
Interstitial 25% 11% 10% 15%
Intracellular 48% 45% 35% 25%
Total 77% 60% 50% 45%
C H A P T E R 16 ● Fluid and Chemical Balance 313
TABLE 16-2 MAJOR SERUM ELECTROLYTES

CHEMICAL PREDOMINANT
ELECTROLYTE SYMBOL CATION/ANION NORMAL SERUM LEVEL COMPARTMENT
Sodium Na Cation 135–148 mEq/L ECF

Potassium K Cation 3.5–5.0 mEq/L ICF
Chloride Cl Anion 90–110 mEq/L ECF
Phosphate PO4 Anion 1.7–2.6 mEq/L ICF
Calcium Ca Cation 2.1–2.6 mEq/L ICF
Magnesium Mg Cation 1.3–2.1 mEq/L ICF
Bicarbonate HCO3 Anion 22–26 mEq/L ICF
ECF, extracellular compartment; ICF, intracellular compartment.
In the absence of metabolic disease, a stable amount Fluid and Electrolyte

of nonelectrolytes circulate in body fluid as long as a Distribution Mechanisms
person consumes adequate nutrients. Deficiency states
occur when body fluid is lost or when the ability to eat Although fluid compartments are identified separately,
is compromised. water and the substances dissolved therein continuously
circulate throughout all areas of the body. Physiologic
transport mechanisms such as osmosis, filtration, passive
Blood diffusion, facilitated diffusion, and active transport gov-
ern the movement and relocation of water and substances
Blood consists of 3 liters of plasma, or fluid, and 2 liters within body fluid (Fig. 16-2).
of blood cells for a total circulating volume of 5 liters.
Blood cells include erythrocytes, or red blood cells;
Osmosis
leukocytes, or white blood cells; and platelets, also known
as thrombocytes. For every 500 red blood cells, there Osmosis helps to regulate the distribution of water by con-
are approximately 30 platelets and 1 white blood cell trolling the movement of fluid from one location to
(Fischbach, 2003). another. Under the influence of osmosis, water moves
Any disorder that alters the volume of body fluid, through a semipermeable membrane like those surround-
whether it is fluid retention or loss, also affects the ing body cells, capillary walls, and body organs and cavi-
plasma volume of blood. Examples include chronic ties, from an area where the fluid is more dilute to another
bleeding or hemorrhage, infection, chemicals or condi- area where the fluid is more concentrated (see Fig. 16-2A).
tions that destroy the blood cells once they have been Once the fluid is of equal concentration on both sides of the
produced, and disorders that affect the bone marrow’s membrane, the transfer of fluid between compartments
production of blood cells. Deficits in either fluid or cell does not change appreciably except volume for volume.
volume are treated by administering fluid, whole blood The presence and quantity of colloids on either side of
or packed cells, or individual blood components. the semipermeable membrane influence osmosis. Colloids
Arteriole Na
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.
are undissolved protein substances such as albumin and of higher concentration to one that is lower. Glucose is an
blood cells within body fluids that do not readily pass example of a substance distributed by facilitated diffusion.
through membranes. Their very presence produces col- Insulin is the carrier substance for glucose.
loidal osmotic pressure (force for attracting water) that
influences fluid volume in any given fluid location. Active Transport
Active transport,a process of chemical distribution that
Filtration requires an energy source, involves a substance called
Filtration regulates the movement of water and substances adenosine triphosphate (ATP) (see Fig. 16-2E). ATP pro-
from a compartment where the pressure is higher to one vides energy to drive dissolved chemicals against the con-
where the pressure is lower. It is another mechanism that centration gradient. In other words, it allows chemical
influences fluid distribution. The force of filtration is distribution from an area of low concentration to one that
referred to as hydrostatic pressure (pressure exerted against is higher—the opposite of passive diffusion.
a membrane). For example, because of contraction of the An example of active transport is the sodium-potassium
left ventricle, the fluid pressure is higher at the arterial end pump system on cellular membranes, which regulates the
of a capillary than at the venous end. Consequently, fluid movement of potassium from lower concentrations in the
and dissolved substances are forced into the interstitial extracellular fluid into cells where it is more highly con-
compartment at the capillary’s arterial end. Water is then centrated. It also moves sodium, which has a lower con-
reabsorbed from the interstitial fluid in comparable centration within the cells, to extracellular fluid where it
amounts at the venous end of the capillary because of col- is more abundant.
loidal osmotic pressure (see Fig. 16-2B). Filtration also
governs how the kidney excretes fluid and wastes and
Fluid Regulation
then selectively reabsorbs water and substances that need
to be conserved.
In healthy adults, fluid intake generally averages approx-
imately 2,500 mL per day, but it can range from 1,800 to
Passive Diffusion 3,000 mL per day with a similar volume of fluid loss
Passive diffusion is the physiologic process in which dis- (Table 16-3). Normal mechanisms for fluid loss are uri-
solved substances, such as electrolytes and gases, move nation, bowel elimination, perspiration, and breathing.
from an area of higher concentration to an area of lower Losses from the skin in areas other than where sweat
concentration through a semipermeable membrane (see glands are located and from the vapor in exhaled air are
Fig. 16-2C). It occurs without an expenditure of energy— referred to as insensible losses because they are, for prac-
hence the word passive. Passive diffusion facilitates electro- tical purposes, unnoticeable and unmeasurable.
chemical neutrality (identical balance of cations with anions) Under normal conditions, several mechanisms main-
in any given fluid compartment. Like osmosis, passive dif- tain a match between fluid intake and output. For exam-
fusion remains fairly static once equilibrium is achieved. ple, as body fluid becomes concentrated, the brain triggers
the sensation of thirst, which then stimulates the person
to drink. As fluid volume expands, the kidneys excrete
Facilitated Diffusion
a proportionate volume of water to maintain or restore
Facilitated diffusion is the process in which certain dissolved proper balance.
substances require the assistance of a carrier molecule to There are circumstances, however, in which oral intake
pass from one side of a semipermeable membrane to the or fluid losses are altered. Therefore, nurses assess clients
other (see Fig. 16-2D). It also regulates chemical balance. for signs of fluid deficit or excess, particularly in those
Facilitated diffusion distributes substances from an area prone to fluid imbalances (Box 16-1).
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
BOX 16-1 ● Conditions That Predispose

types of clients are placed automatically on I&O; gener-
to Fluid Imbalances ally, they include the following:
Fluid Deficit • Clients who have undergone surgery, until they are
❙ Starvation eating, drinking, and voiding in sufficient quantities
❙ Impaired swallowing
• Clients receiving intravenous (IV) fluids
❙ Vomiting
❙ Gastric suction
• Clients receiving tube feedings
❙ Diarrhea • Clients with some type of wound drainage or suction
❙ Laxative abuse equipment
❙ Potent diuretics • Clients with urinary catheters, until it can be deter-
❙ Hemorrhage
❙ Major burns
mined that output is adequate or they are voiding well
❙ Draining wounds after removal of the catheter
❙ Fever and sweating • Clients undergoing diuretic drug therapy
❙ Exercise and sweating
❙ Environmental heat and humidity In addition, many agencies allow nurses to indepen-
dently order I&O assessment for clients who have or are
Fluid Excess
❙ Kidney failure
at risk for a fluid imbalance problem. The nurse dis-
❙ Heart failure continues the nursing order when the assessment is no
❙ Rapid administration of intravenous fluid or blood longer indicated but consults with the physician if it has
❙ Administration of albumin
been medically ordered.
❙ Corticosteroid drug therapy
❙ Excessive intake of sodium
Each agency has a specific I&O form kept at the bed-
❙ Pregnancy side so that nurses can conveniently record the type of
❙ Premenstrual fluid retention fluid and amounts that are consumed throughout the day
(Fig. 16-3). The nurse subtotals the amounts at the end
of each shift or more frequently in critical care areas. He
or she documents the grand total in a designated area in
FLUID VOLUME ASSESSMENT the medical record—for example, on the graphics sheet
with other vital sign information.
Nurses assess fluid status using a combination of physi-

cal assessment (Table 16-4) and measurement of intake Fluid Intake
and output volumes.
Intake and output (I&O) is one tool to assess fluid status Fluid intake is the sum of all fluid volume that a client
by keeping a record of a client’s fluid intake and fluid loss consumes or is instilled into the client’s body, including
over a 24-hour period. Agencies often specify which the following:
TABLE 16-4 SIGNS OF FLUID IMBALANCE

ASSESSMENT FLUID DEFICIT FLUID EXCESS
Weight Weight loss ≥2 lbs/24 hr Weight gain ≥2 lbs/24 hr

Blood pressure Low High
Temperature Elevated Normal
Pulse Rapid, weak, thready Full, bounding
Respirations Rapid, shallow Moist, labored
Urine Scant, dark yellow Light yellow
Stool Dry, small volume Bulky
Skin Warm, flushed, dry Cool, pale, moist
Poor skin turgor Pitting edema
Mucous membranes Dry, sticky Moist
Eyes Sunken Swollen
Lungs Clear Crackles, gurgles
Breathing Effortless Dyspnea, orthopnea
Energy Weak Fatigues easily
Jugular neck veins Flat Distended
Cognition Reduced Reduced
Consciousness Sleepy Anxious
FIGURE 16-3 • Intake and output volumes are recorded throughout a 24-hour period and subtotaled
at the end of each 8-hour shift.
• All the liquids a client drinks • Fluid instillations such as those administered through
• The liquid equivalent of melted ice chips, which is half feeding tubes or tube irrigations
of the frozen volume
• Foods that are liquid by the time they are swallowed, Fluid volumes are recorded in milliliters (mL). The
such as gelatin, ice cream, and thin cooked cereal approximate equivalent for 1 ounce is 30 mL, a teaspoon
• Fluid infusions such as IV solutions is 5 mL, and a tablespoon is 15 mL. Packaged beverage
containers such as milk cartons usually indicate the spe-

cific fluid volume on the label. Hospitals and nursing
homes commonly identify the volume equivalents con-
tained in the cups, glasses, and bowls used to serve food
and beverages from the dietary department (Box 16-2).
If an equivalency chart is not available, the nurse uses
a calibrated container (Fig. 16-4) to measure specific
amounts; estimated volumes are considered inaccurate.

Use Box 16-2 to calculate the volume of fluid intake for
the following: a glass of orange juice, a half-pint carton of
milk, a bowl of tomato soup, a dish of lime gelatin, a cup
of coffee, a 100-mL infusion of IV antibiotic solution.
FIGURE 16-4 • Calibrated containers used to measure liquid volumes.
Fluid Output
gested actions for maintaining an I&O record are pro-
Fluid output is the sum of liquid eliminated from the vided in Skill 16-1.
body, including the following:
• Urine
• Emesis (vomitus) COMMON FLUID IMBALANCES
• Blood loss
• Diarrhea Fluid imbalance is a general term describing any of several
• Wound or tube drainage conditions in which the body’s water is not in the proper
• Aspirated irrigations volume or location within the body. It can be life threat-
In cases in which accurate assessment is critical to a ening. Common fluid imbalances include hypovolemia,
client’s treatment, the nurse weighs wet linens, pads, dia- hypervolemia, and third-spacing.
pers, or dressings and subtracts the weight of a similar
dry item. An estimate of fluid loss is based on the equiv-
alent: 1 pound (0.47 kg) = 1 pint (475 mL). 16-1 • CLIENT AND FAMILY TEACHING
Client cooperation is needed for accurate I&O records.
Therefore, the nurse informs clients whose I&O volumes Recording Intake and Output
are being recorded about the purpose and goals for fluid The nurse teaches the client or family as follows:
replacement or restrictions and the ways they can assist • Write down the amount or notify the nurse
in the procedure (Client and Family Teaching 16-1). Sug- whenever oral fluid is consumed.
• Use a common household measurement,
such as 1 glass or cup, to describe the volume
BOX 16-2 ● Volume Equivalents consumed, or refer to an equivalency chart.
for Common Containers • Do not let a staff person remove a dietary tray
CONTAINER VOLUME (ML) until the fluid amounts have been recorded.
• Do not empty a urinal or urinate directly into
Teaspoon 5 the toilet bowl.
Tablespoon 15
• Make sure that a measuring device is in the
Juice glass 120
Drinking glass 240 toilet bowl if the bathroom is used for voiding
Coffee cup 210 (Fig. 16-5).
Milk carton 240 • If a urinal needs to be emptied, call the nurse or
Water pitcher 900 empty its contents into a calibrated container.
Paper cup 180
• Use a container such as a bedpan or bedside
Soup bowl 200
Cereal bowl 120 commode if diarrhea occurs. Notify the nurse
Ice cream cup 120 to measure the contents before it is emptied.
Gelatin dish 90 • If vomiting occurs, use an emesis basin rather
than the toilet.
• Translocation of large volumes of intravascular fluid

to the interstitial compartment or to areas with only
potential spaces such as the peritoneal cavity, peri-
cardium, and pleural space
Fluid balance is restored by treating the cause of hypo-
volemia, increasing oral intake, administering IV fluid
replacements, controlling fluid losses, or a combination
of these measures. See Nursing Guidelines 16-1.
Hypervolemia
Hypervolemia means a higher-than-normal volume of

FIGURE 16-5 • Urine is collected in a calibrated container. (Copyright
water in the intravascular fluid compartment and is
B. Proud.)
another example of a fluid imbalance. Edema develops
when excess fluid is distributed to the interstitial space.
Hypovolemia When fluid accumulates in dependent areas of the body
(those influenced by gravity), the tissue pits (forms
Hypovolemia is a low volume in the extracellular fluid indentations) when compressed (see Chap. 13). Edema
compartments. If untreated, hypovolemia may result in does not usually occur unless there is a 3-liter excess in
dehydration (fluid deficit in both extracellular and intra-
cellular compartments). Mild dehydration is present
when there is a 3% to 5% loss of body weight; moderate NURSING GUIDELINES 16-1
dehydration is associated with a 6% to 10% loss of body Increasing Oral Intake
weight; and severe dehydration, a life-threatening emer-
gency, occurs with a loss of more than 9% to 15% of body ❙ Explain to the client the reasons for increasing consumption of oral
weight. In addition to weight loss, dehydration is evi- fluids. Knowledge facilitates client cooperation.
denced by decreased skin turgor (Fig. 16-6). ❙ Compile a list of the client’s preferences for beverages. Involving
Causes of fluid volume deficits include the following: the client facilitates individualized collaboration with the dietary
• Inadequate fluid intake department.
• Fluid loss in excess of fluid intake ❙ Obtain a variety of beverages on the client’s list. Catering to client
preferences promotes compliance.
❙ Develop a schedule for providing small portions of the total fluid
volume over a 24-hour period. Scheduling ensures that the final
goal is reached by meeting short-term goals.
❙ Plan to provide the bulk of the projected fluid intake at times when
the client is awake. Providing a higher proportion of fluid during
waking hours avoids disturbing sleep.
❙ Offer verbal recognition and frequent feedback, or design a method
for demonstrating the client’s progress—for example, a bar graph or
pie chart. Positive reinforcement encourages compliance and
maintains goal-directed efforts.
❙ Keep fluids handy at the bedside and place them in containers the
client can handle. Availability and convenience promote compliance.
❙ Vary the types of fluid, serving glass, or container frequently. Variety
reduces boredom and maintains interest in working toward the goal.
❙ Serve fluids in small containers and in small amounts. Small
portions avoid overwhelming the client.
❙ Ensure that fluids are at an appropriate temperature. Palatability
promotes pleasure and enjoyment.
❙ Include gelatin, popsicles, ice cream, and sherbet as alternatives to
liquid beverages (if allowed). Varying the liquid’s consistency and
FIGURE 16-6 • Assessing skin turgor. If the patient is dehydrated, the techniques for consumption offers an alternative to items that are
skin returns slowly (i.e., >30 seconds) to its original shape after being sipped from a glass.
pinched.

Restricting Oral Fluids
❙ Explain the purpose for the restrictions. Knowledge facilitates
client cooperation.
❙ Identify the total amount of fluid the client may consume,
using measurements with which the client is familiar. An
explanation helps the client to understand the extent of the
restrictions.
❙ Work out a plan for distributing the permitted volume over a
24-hour period with the client. Including the client in planning
promotes cooperation.
FIGURE 16-7 • Foot care is very important for the patient with edema.
The edema and reddened areas can easily break down.
❙ Ration the fluid so that the client can consume beverages between
meals as well as at mealtimes. Distributing opportunities to drink
fluid helps to minimize thirst.
body fluid. Hypervolemia can lead to circulatory overload ❙ Avoid sweet drinks and foods that are dry or salty. This reduces
(severely compromised heart function) if it remains thirst and the desire for fluid.
unresolved. ❙ Serve liquids at their proper temperature. This demonstrates
Control of edema is an important nursing priority concern for the client’s pleasure and enjoyment.
(Fig. 16-7). Fluid balance is restored by
❙ Offer ice chips as an occasional substitute for liquids. Ice chips
• Treating the disorder contributing to the increased appear to contain more liquid than they actually do, and holding
fluid volume. them within the mouth prolongs the time over which the fluid
• Restricting or limiting oral fluids. is consumed.
• Reducing salt consumption (Box 16-3). ❙ Provide water or other fluid in a plastic squeeze bottle or
• Discontinuing IV fluid infusions or reducing the infus- spray atomizer. These devices provide only a small volume
ing volume. of fluid.
• Administering drugs that promote urine elimination. ❙ Help the client with frequent oral hygiene. Oral hygiene relieves
• Using a combination of these interventions. thirst, moistens oral mucous membranes, and prevents drying and
chapping of lips.
❙ Allow the client to rinse his or her mouth with water but not
swallow it. Rinsing reduces thirst and keeps the mouth moist.
Third-Spacing
Third-spacing is the movement of intravascular fluid to ated commonly with disorders in which albumin levels
nonvascular fluid compartments, where it becomes are low. Causes of hypoalbuminemia (deficit of albumin in
trapped and useless. It generally is manifested by tissue the blood) include liver disease, chronic kidney disease,
swelling or fluid that accumulates in a body cavity such and disorders in which capillary and cellular permeabil-
as the peritoneum (Fig. 16-8). Third-spacing is associ- ity is altered such as burns and severe allergic reactions.
Depletion of fluid in the intravascular space may lead
to hypotension and shock; thus, fluid therapy becomes
BOX 16-3 ● Foods High in Salt (Sodium)
❙ Processed meats such as frankfurters and cold cuts

❙ Smoked fish
❙ Frozen egg substitutes
❙ Peanut butter Tympany (air)
❙ Dairy products, especially hard cheese
❙ Powdered cocoa or hot chocolate mixes
❙ Canned vegetables, especially sauerkraut
❙ Pickles
❙ Tomato and tomato–vegetable juice Dullness (fluid)
❙ Canned soup and bouillon
❙ Boxed casserole mixes
❙ Baking mixes
❙ Salted snack foods
❙ Seasonings such as catsup, gravy mixes, soy sauce, monosodium glutamate
(MSG), pickle relish, tartar sauce FIGURE 16-8 • Fluid accumulation within the peritoneal cavity. Dull-
ness on percussion indicates fluid, whereas tympany indicates air.
challenging. The priority is to restore the circulatory • Maintain or replace electrolytes.

volume by providing IV fluids, sometimes in large vol- • Administer water-soluble vitamins.
umes at rapid rates. Blood transfusions or the adminis- • Provide a source of calories.
tration of albumin by IV infusion also is used to restore • Administer drugs (see Chap. 35).
colloidal osmotic pressure and pull the trapped fluid • Replace blood and blood products.
back into the intravascular space. When this occurs,
clients who were previously hypovolemic can suddenly
become hypervolemic. The nurse closely monitors clients Types of Solutions
who receive albumin replacement for signs of circula-
tory overload. There are two types of IV solutions: crystalloid and col-
loid. Crystalloid solutions are made of water and other uni-
formly dissolved crystals such as salt and sugar. Colloid
solutions are made of water and molecules of suspended
INTRAVENOUS FLUID substances such as blood cells and blood products (such
ADMINISTRATION as albumin).
Policies and practices vary concerning how much respon- Crystalloid Solutions
sibility practical/vocational nurses assume with IV fluid Crystalloid solutions are classified as isotonic, hypotonic,
therapy. The discussion that follows is provided to meet and hypertonic (Table 16-5), depending on the concen-
the needs of those nurses who have been trained and have tration of dissolved substances in relation to plasma. The
demonstrated competencies for administering IV fluids. concentration of the solution influences the osmotic dis-
Intravenous (IV) fluids are solutions infused into a client’s
tribution of body fluid (Fig. 16-9).
vein to
• Maintain or restore fluid balance when oral replacement ISOTONIC SOLUTIONS. An isotonic solution contains the
is inadequate or impossible. same concentration of dissolved substances normally
TABLE 16-5 TYPES OF CRYSTALLOID INTRAVENOUS SOLUTIONS

SOLUTION COMPONENTS SPECIAL COMMENTS
Isotonic Solutions
0.9% saline, also called normal saline 0.9 g of sodium chloride/100 mL of water Amounts of sodium and chloride are
physiologically equal to those found
in plasma
5% dextrose and water, also called D5W 5 g of dextrose (glucose/sugar)/100 mL Isotonic when infused but the glucose
of water metabolizes quickly, leaving a solution
of dilute water
Ringer’s solution or lactated Ringer’s Water and a mixture of sodium, chloride, Electrolyte replacement in amounts simi-
calcium, potassium, bicarbonate, and in lar to those found in plasma. The lac-
some cases lactate tate, when present, helps maintain
acid–base balance.
Hypotonic Solutions
0.45% sodium chloride, also called 0.45 g of sodium chloride/100 mL of water Smaller ratio of sodium and chloride than
half-strength saline found in plasma, 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,
100 mL of water leaving a hypotonic salt solution
Hypertonic Solutions
10% dextrose in water, also called D10W 10 g of dextrose/100 mL of water Twice the concentration of glucose
as in plasma
3% saline 3 g of sodium chloride/100 mL of water Dehydration of cells and tissues from
the high concentration 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

Identify the net effect when the following IV solutions are
infused: 0.45% sodium chloride, Ringer’s solution, and
50% glucose.
A B C
FIGURE 16-9 • (A) Isotonic solutions. (B) Hypotonic solutions. (C) Hyper-
tonic solutions.
Colloid Solutions
Colloid solutions are used to replace circulating blood vol-
found in plasma. It generally is administered to maintain ume because the suspended molecules pull fluid from
fluid balance in clients who may not be able to eat or other compartments. Examples are blood, blood products,
drink for a short period. Because of its equal concentra- and solutions known as plasma expanders.
tion, an isotonic solution does not cause any appreciable
redistribution of body fluid. BLOOD. Whole blood and packed cells are probably the
most common colloid solutions. One unit of whole blood
HYPOTONIC SOLUTIONS. A hypotonic solution contains contains approximately 475 mL of blood cells and plasma
fewer dissolved substances than normally found in plus 60 to 70 mL of preservative and anticoagulant
plasma. It is administered to clients with fluid losses in (Smeltzer & Bare, 2006). Packed cells have most of the
excess of fluid intake, such as those who have diarrhea plasma removed and are preferred for clients who need
or vomiting. Because hypotonic solutions are dilute, the cellular replacement but do not need, or may be harmed
water in the solution passes through the semipermeable by, the administration of additional fluid.
membrane of blood cells, causing them to swell. This Most blood given to clients comes from public donors.
temporarily increases blood pressure as it expands the In some cases—for example, when a person anticipates
circulating volume. The water also passes through cap- the potential need for blood in the near future or when pro-
illary walls and becomes distributed within other body cedures are used to reclaim blood from wound drainage—
cells and the interstitial spaces. Hypotonic solutions, the client’s own blood may be reinfused (see Chap. 27).
therefore, are an effective way to rehydrate clients with
fluid deficits. BLOOD PRODUCTS. Several blood products are available
for clients who need specific substances but do not need
HYPERTONIC SOLUTIONS. A hypertonic solution is more all the fluid or cellular components in whole blood
concentrated than body fluid and draws cellular and (Table 16-6).
interstitial water into the intravascular compartment.
This causes cells and tissue spaces to shrink. Hyper- BLOOD SUBSTITUTES. Because some people, such as Jeho-
tonic solutions are not used very frequently except in vah’s Witnesses, object to receiving blood on religious
extreme cases when it is necessary to reduce cerebral grounds and because of the risks for blood-borne dis-
edema or to expand the circulatory volume rapidly. eases, such as hepatitis and AIDS, scientists have been
TABLE 16-6 TYPES OF BLOOD PRODUCTS

BLOOD PRODUCT DESCRIPTION PURPOSE FOR ADMINISTRATION
Platelets Disk-shaped cellular fragments Restores or improves the ability to

that promote coagulation control bleeding
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 increas-
ing colloidal osmotic pressure
Cryoprecipitate Mixture of clotting factors Treats blood clotting disorders
such as hemophilia
working on perfecting blood substitutes. A chemical nomical and virus-free substitutes for blood and blood
group called perfluorocarbons appears promising. Perflu- products when treating hypovolemic shock.
orocarbons have been tested and used on a limited basis
as artificial substitutes for human blood. The first of its
Preparation for Administration
kind, Fluosol DA, produced undesirable side effects: in
clinical trials, recipients had a diminished resistance to
Regardless of the prescribed solution, the nurse prepares
infection and an increased risk for bleeding. A second-
the solution for administration, performs a venipuncture,
generation blood substitute called Oxygent is in phase III
regulates the rate of administration, monitors the infu-
clinical trials in Europe and further phase III clinical trial
sion, and discontinues the administration when fluid bal-
in the United States. Alliance, the company that will mar-
ance is restored.
ket Oxygent, is currently collaborating with Johnson and
Johnson to acquire U.S. Food and Drug Administration Solution Selection
(FDA) approval (Perfluorocarbon Emulsions, 2005;
Winslow, 2006). The data in clinical trials show that in IV solutions are commonly stored in plastic bags contain-
smaller volumes, these new blood substitutes have avoided ing 1,000, 500, 250, 100, and 50 mL of solution. A few
the need to replace 1 to 2 units of blood (Spahn, 1999). solutions are stocked in glass containers. The physician
Other applications for perfluorocarbons are being specifies the type of solution, additional additives, the vol-
explored because they have a smaller molecular size than ume (in mL), and the duration of the infusion. To reduce
red blood cells. This unique characteristic permits oxygen- the potential for infection, IV solutions are replaced every
carrying molecules to pass through blood vessels that 24 hours even if the total volume has not been completely
have been narrowed as a result of blood clots. Therefore, instilled.
perfluorocarbons may be able to restore oxygen to tissues Before preparing the solution, the nurse inspects the
with impaired circulation such as the brain after a stroke container and determines that
or the heart after a heart attack. Scientists theorize that the • The solution is the one prescribed by the physician.
same effect could be used in the treatment of clients with • The solution is clear and transparent.
sickle cell crisis: pain could be relieved by oxygenating tis- • The expiration date has not elapsed.
sues in which sickled red blood cells have obstructed blood • No leaks are apparent.
flow. This same chemical could prolong the preservation • A separate label is attached, identifying the type and
of organs for transplantation and could improve the oxy- amount of other drugs added to the commercial solution.
genation of cancer cells, making them more vulnerable
to standard treatments. Tubing Selection
In addition to perfluorocarbons, other substances
All IV tubing consists of a spike for accessing the solu-
are being tested in the search for a safe, effective sub-
tion, a drip chamber for holding a small amount of fluid,
stitute for whole blood. For example, solutions con-
a length of plastic tubing with one or more ports for adding
taining just hemoglobin have been used successfully in
IV medications (see Chap. 35), and a roller or slide clamp
animals. Attempts are being made to recycle outdated
to regulate the rate of infusion (Fig. 16-10). The nurse then
red blood cells in donated blood by sealing them within
selects from several options:
a lipid capsule; this product is referred to as microencap-
sulated hemoglobin. With continued research, these sub- • Primary (long) or secondary (short) tubing
stances, such as PolyHeme and Hemosol, may improve • Vented or unvented tubing
the treatment of disorders that previously required blood • Microdrip (small drops) or macrodrip (large drops)
transfusions. Perfecting a blood substitute may reduce chamber
the need for human blood donors while decreasing the • Unfiltered or filtered tubing
risk for blood-borne viral diseases. • Needle or needleless access ports
PLASMA EXPANDERS. Various nonblood solutions are used PRIMARY VERSUS SECONDARY TUBING. Primary tubing is
to pull fluid into the vascular space. Two examples are approximately 110 inches (2.8 m) long; secondary tub-
dextran 40 (Rheomacrodex) and hetastarch (Hespan). ing is 37 inches (94 cm) long. These measurements vary
These two substances are polysaccharides—large, insol- among manufacturers. Primary tubing is used when the
uble complex carbohydrate molecules. When mixed with tubing must span the distance from a solution that hangs
water, they form colloidal solutions. Because the sus- several feet above the infusion site. Secondary tubing,
pended particles cannot move through semipermeable which is shorter, is used to administer smaller volumes
membranes when given intravenously, they attract water of solution into a port within the primary tubing.
from other fluid compartments. The desired outcome is
to increase the blood volume and raise the blood pres- VENTED VERSUS UNVENTED TUBING. Vented tubing
sure. Consequently, plasma expanders are used as eco- draws air into the container; unvented tubing does not
Spike Slide clamp
Connector
Drip chamber
Roller clamp
Injection port
FIGURE 16-10 • Basic intravenous tubing. (Courtesy of Abbott Laboratories, North Chicago, IL.)
(Fig. 16-11). The choice depends on the type of con- DROP SIZE. Drop size refers to the size of the opening
tainer in which the solution is packaged. Vented tubing is through which the fluid is delivered into the tubing. The
necessary for administering solutions packaged in rigid nurse determines whether it is more appropriate to use
glass containers; if unvented tubing is inserted into a glass macrodrip tubing, which produces large drops, or micro-
bottle, the solution will not leave the container. Plastic drip tubing, which produces very small drops. When a
bags of IV solutions do not need vented tubing because solution infuses at a fast rate, such as 125 mL/hr, it is
the container collapses as the fluid infuses. generally easier to count fewer, larger drops than many
smaller ones. When the solution must infuse very pre-
cisely or at a slow rate, smaller drops are preferred.
Microdrip tubing, regardless of manufacturer, deliv-
ers a standard volume of 60 drops/mL. Macrodrip tubing
manufacturers, however, have not been consistent in
designing the size of the opening. Therefore, the nurse
must read 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 grav-
ity (e.g., without an electronic infuser) and is discussed
later in this chapter.
FILTERS. An in-line filter (Fig. 16-12) removes air bub-

bles as well as undissolved drugs, bacteria, and large sub-
stances. 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 IV tubing were designed for
access with a needle. This method, however, contributes
to the estimated 600,000 to 800,000 needle-stick injuries
among health care workers each year (Josephson, 2004;
National Institute for Occupational Safety and Health,
2000). To reduce the incidence of work-related injuries
and the potential for infection with blood-borne pathogens,
FIGURE 16-11 • Unvented (left) and vented (right) tubing. (Copyright needleless systems (IV tubing that eliminates the need for
K. Timby.) access needles) are preferred.
Secondary IV tubing
Primary IV
tubing
Blunt tip
tubing
connector
Needleless
access port
Blunt tip
syringe
Needleless
access port
FIGURE 16-13 • Needleless systems allow resealable ports to be

punctured with a blunt tip syringe or secondary IV tubing connector.
Electronic Infusion Devices

FIGURE 16-12 • In-line filter. (Copyright K. Timby.)
The two general types of infusion devices are infusion
pumps and volumetric controllers. Both are programmed
With a needleless system, the nurse uses a blunt can- to deliver a preset volume per hour. They trigger audible
nula to pierce the resealable port each time it is necessary and visual alarms if the infusion is not progressing at the
to enter the tubing (Fig. 16-13; and see Chap. 35). A needle- rate intended. They also sound an alarm when the infu-
less access port can be pierced with a needle a limited num- sion container is nearly empty, air is detected within the
ber of times without altering its integrity, but a port that tubing, or an obstruction or resistance occurs in deliver-
requires a needle for access cannot be punctured with a ing the fluid.
blunt cannula.
INFUSION PUMPS. An infusion pump (infusion device
that uses pressure to infuse solutions) requires special
Infusion Techniques tubing that contains a device such as a cassette to create
sufficient pressure to push fluid into the vein (Fig. 16-14).
IV infusions are administered either by gravity alone or The machine adjusts the pressure according to the
with an infusion device, an electric or battery-operated resistance it meets. This can be a disadvantage because
machine that regulates and monitors the administration if the catheter or needle within the vein becomes dis-
of IV solutions. The use of an infusion device may affect placed, the pump continues to infuse fluid into the tissue
the type of tubing used. until the machine’s maximum preset pressure reaches
its limit.
Gravity Infusion
VOLUMETRIC CONTROLLERS. A volumetric controller (elec-
Generally, most basic types of tubing can be used for tronic infusion device that instills IV solutions by gravity)
infusing a solution by gravity. The height of the IV solu- mechanically compresses the tubing at a certain frequency
tion rather than the tubing is the most important factor to infuse the solution at a precise, preset rate. Volumetric
affecting gravity infusions. controllers may or may not require special tubing.
To overcome the pressure within the client’s vein, Some models allow the nurse to program the infusion
which is higher than atmospheric pressure, the solution of more than one simultaneous infusion of solutions.
is elevated at least 18 to 24 inches (45 to 60 cm) above the In some cases, when one container of fluid finishes
site of the infusion. The height of the solution affects the infusing, the controller automatically resumes infusing
rate of flow: the higher the solution, the faster the solu- another solution. The solution and tubing are prepared
tion infuses, and vice versa. before accessing the vein with a needle or catheter.
needed equipment, inspects and selects an appropriate

vein, and inserts the venipuncture device.
Venipuncture Devices
Several devices are used to access a vein: a butterfly needle,
an over-the-needle catheter (most common), or a through-
the-needle catheter (Fig. 16-15).
Venipuncture devices are available in various diameters
or gauges; the larger the gauge number, the smaller the
diameter. The diameter of the venipuncture device always
should be smaller than the vein into which it is inserted to
reduce the potential for occluding blood flow. An 18-, 20-,
or 22-gauge is the size most often used for adults.
In addition to a device for puncturing the vein, the
following items are needed: clean gloves; tourniquet;
antiseptic swabs to cleanse the skin; transparent dress-
ing to cover the puncture site; and adhesive tape to
secure the venipuncture device and tubing. The use of
antibiotic or antimicrobial ointment at the site varies;
the nurse follows agency policy. An armboard may be
needed to prevent the client from dislodging the venipunc-
ture device.
Vein Selection
The veins in the hand and forearm are used most com-
monly for inserting a venipuncture device (Fig. 16-16);
FIGURE 16-14 • Special tubing with a cassette is inserted into the
scalp veins are used for infants and small children. See
electronic infusion pump. (Copyright B. Proud.)
Nursing Guidelines 16-3.
Once the general site is selected, the nurse applies a
Skill 16-2 describes how to prepare an IV solution for tourniquet to select a specific vein (Fig. 16-17). Box 16-4
administration. identifies several techniques for promoting vein distention.
A blood pressure cuff can be substituted for a rubber
tourniquet. Whichever technique is used, the radial pulse
should be palpable to indicate that arterial blood flow is
Venipuncture
being maintained.
Venipuncture(accessing the venous system by piercing a
Venipuncture Device Insertion
vein with a needle) is a nursing responsibility when a
peripheral vein (one distant from the heart) is used. Skill 16-3 describes the technique for inserting an over-
When performing a venipuncture, the nurse assembles the-needle catheter within a vein.
Needle
Catheter
Needle tip Catheter
A B-1 C-1
Needle guard
Needle removed attached
Needle
Catheter
B-2 C-2
FIGURE 16-15 • Venipuncture devices. (A) Butterfly needle. (B-1) Over-the-needle catheter. (B-2) Needle
removed. (C-1) Through-the-needle catheter. (C-2) A needle guard covers the tip of the needle, which
remains outside the skin.
FIGURE 16-16 • Potential venipuncture sites.
Infusion Monitoring and Maintenance Regulating the Infusion Rate

The nurse is responsible for calculating, regulating, and
Once the venipuncture is performed and the solution is maintaining the rate of infusion according to the physi-
infusing, the nurse regulates the rate of infusion, assesses cian’s order. If an infusion device is used, the electronic
for complications, cares for the venipuncture site, and equipment is programmed in milliliters per hour. If the
replaces equipment as needed. solution is infused without an electronic infusion device

Selecting a Venipuncture Site
❙ Use veins on the nondominant side. This reduces the potential for ❙ Look for a large vein, if a large-gauge needle or catheter is necessary.
dislodging the device as a result of movement and use. Matching the needle and vein size prevents compromising circulation.
❙ Do not use foot and leg veins. Using foot and leg veins restricts mobility ❙ Avoid using veins on the inner surface of the wrist. This prevents pain
and increases the potential for blood clots. and discomfort.
❙ If possible, do not use a vein on the side of previous breast surgery or ❙ Look for a vein proximal to the current site or in the opposite hand or
in which vascular surgery has been performed for kidney dialysis. arm. This promotes healing and decreases the risk of fluid leaking from
Using such veins further compromises circulation and increases the the vein into the tissue.
potential for infection and poor healing. ❙ Feel and look for a fairly straight vein. It is easier to thread the device
❙ Choose a vein in a location unaffected by joint movement. A into a straight vein.
venipuncture device in such a location could become displaced ❙ Do not use a vein that appears inflamed or if the skin over the area
more easily. looks impaired in any way. Use of such a site creates additional trauma.
BOX 16-4 ● Techniques for Promoting

Vein Distention
❙ Apply a tourniquet or blood pressure cuff tightly around the arm.
❙ 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.
A Stop • Think + Respond BOX 16-3

Calculate the rate of infusion for the following two
medical orders:
1. Infuse 1,000 mL of 0.9% NaCl over 12 hours using an
electronic infusion device.
2. Infuse 500 mL of 5% dextrose and 0.45% NaCl in 8 hours
by gravity infusion; your tubing delivers 15 gtt/mL.
Assessing for Complications

Complications associated with the infusion of IV solu-
tions (Table 16-7) are circulatory overload (intravascular
volume that becomes excessive), infiltration (escape of IV
B fluid into the tissue), phlebitis (inflammation of a vein),
thrombus formation (stationary blood clot), pulmonary
embolus (blood clot that travels to the lung), infection
(growth of microorganisms at the site or within the blood
stream), and air embolism (bubble of air traveling within
the vascular system).
The minimum quantity of air that may be fatal to
humans is not known. Animal research indicates that
fatal volumes of air are much larger than the quantity pres-
ent in the entire length of infusion tubing. The average
infusion tubing holds about 5 mL of air, an amount not
ordinarily considered dangerous. Clients, however, are
C BOX 16-5 ● Formulas for Calculating Infusion Rates
FIGURE 16-17 • (A) To apply a tourniquet, the ends are pulled tightly When using an infusion device:
in opposite directions. (B) Then one end is tucked beneath the other. Total volume in mL
(C) This allows it to be released easily by pulling one of the free ends. = mL hr
Total hours
When infusing by gravity:
Total volume in mL
(i.e., by gravity), the rate is calculated in drops (gtt) per × drop factor* = gtt min
Total time in minutes
minute. Formulas for calculating infusion rates are pro-
Example:
vided in Box 16-5.
For gravity infusions, the nurse counts the number of 1, 000 mL
= 125 mL hr
8 hr
drops falling into the drip chamber per minute. By adjust-
ing the roller clamp, the number of drops is increased or 1, 000 mL
decreased until the infusion rate matches the calculated × 20 = 42 gtt min
480 min
rate. Thereafter, the nurse monitors the time strip on the
side of the container at hourly intervals to ensure that the * The macrodrip drop factor varies among manufacturers.
infusion is instilling at the prescribed rate.
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 venipuncture Restart the IV.
Discomfort 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 previously station- Stay with the client.
Shortness of breath ary blood clot to the lungs Call for help.
Anxiety Administer oxygen.
Rapid heart rate
Drop in blood pressure
Air embolism Same as pulmonary embolus Failure to purge air from the tubing Same as for pulmonary embolus,
but also place the client’s head
lower than the feet.
Position the client on left side.
often frightened when they see air in the tubing, and

nurses make every effort to remove air bubbles. See Nurs-
ing Guidelines 16-4. Removing Air Bubbles From IV Tubing
Caring for the Site ❙ Flush the line with IV solution before inserting the adaptor
into the venipuncture device. This action purges air from
Because the venipuncture is a type of wound, it is impor- the tubing.
tant to inspect the site routinely. The nurse documents
❙ Tighten the roller clamp if small bubbles are observed. This action
its appearance in the client’s record. A common practice
prevents continued forward movement of the air.
is to change the dressing over the venipuncture site every
24 to 72 hours, according to the agency’s infection con- ❙ Tap the tubing below the air bubbles (Fig. 16-18). Doing so
trol policy (see Chap. 28). promotes upward movement of the air above the fluid in the
drip chamber.
Replacing Equipment ❙ Milk the air in the direction of the drip chamber or filter, if one is
Solutions are replaced when they finish infusing or every incorporated within the tubing. Doing so pushes the air physically
24 hours, whichever occurs first (Skill 16-4). IV tubing is to an area where it can be trapped or released.
changed every 72 hours, depending on agency policy, with ❙ Wrap the tubing around a circular object, like a pencil, starting
some exceptions. Tubing used to instill parenteral nutri- below the trapped air. This moves the air toward the drip
tion is replaced daily. Tubing used to administer whole chamber where it can escape from the liquid into the empty
blood can be reused for a second unit if one unit is admin- air space.
istered immediately after the other. Whenever tubing is ❙ Insert the barrel of a syringe within a port below the air, and open
changed, it is more convenient to replace both the solution the roller clamp. This siphons fluid and air from the tubing as it
and the tubing at the same time. Skill 16-5 describes how passes by the bevel of the needle.
to replace just the tubing, which is generally more difficult.
device also is called a saline lock because the chamber is

filled and periodically flushed with sterile normal saline
to prevent blood from clotting at the tip of the catheter or
needle. Central venous catheters are usually kept patent
by flushing the device with heparinized saline. Intermit-
tent venous access devices are used when the client
• No longer needs continuous infusions of fluid.
• Needs intermittent administration of IV medication.
A B • May need emergency IV fluid or medications if his or
FIGURE 16-18 • Removing air bubbles. (A) Tapping the tubing may her condition deteriorates.
help air bubbles rise into the drip chamber. (B) Twisting the tubing
around a pencil or other object may displace air bubbles toward the These devices are replaced when the venipuncture site
drip chamber. is changed. Skill 16-7 describes how to insert an intermit-
tent venous access device and ensure its patency. The use
of a medication lock when administering IV drugs is dis-
cussed in Chapter 35.
Discontinuation of an Intravenous Infusion
IV infusions are discontinued when the solution has
infused and no more is scheduled to follow. Skill 16-6 is BLOOD ADMINISTRATION
a procedure for removing a venipuncture device when IV
infusions are no longer needed. When the client needs
occasional infusions of solutions or the administration of Blood is collected, stored, and checked for safety and
IV medications, the venipuncture is temporarily capped compatibility before it is administered as a transfusion.
but kept patent with the use of an intermittent venous
access device also known as a medication lock.
Blood Collection and Storage
Insertion of an Intermittent Blood donors are screened to ensure they are healthy
Venous Access Device and will not be endangered by the temporary loss in
blood volume. Refrigerated blood can be stored for 21
An intermittent venous access device (sealed chamber that to 35 days, after which it is discarded.
provides a means for administering IV medications or
solutions periodically; Fig. 16-19) is inserted into a veni-
puncture device. An intermittent peripheral venous access Blood Safety
Once collected, the donated blood is tested for syphilis,
hepatitis, and human immunodeficiency virus (HIV)
antibodies to exclude administering blood that may trans-
mit these blood-borne diseases. Blood that tests positive is
discarded. Unfortunately disease-carrying viruses may
remain undetected if the antibodies have not reached a
level high enough to be measured.
The U.S. Blood Safety Council, a division of the Depart-
ment of Health and Human Services, has made policies
regarding potential hepatitis C infection by blood transfu-
sions. All blood collection agencies must notify people
who received blood before 1987 if the donation came from
a donor who has tested positive for hepatitis C since 1990.
This policy is being implemented to promote early diagno-
sis and treatment of infected but asymptomatic transfu-
sion recipients.
In May 2001, the American Red Cross adopted a new
policy concerning blood donations to eliminate the poten-
FIGURE 16-19 • Intermittent venous access device. (Copyright B. tial transmission of neurologic infectious microorganisms
Proud.) known as prions. Prions cause various brain disorders,
one of which is bovine spongiform encephalopathy (mad

cow disease) detected in people who live in the United Stop • Think + Respond BOX 16-4
Kingdom. Because blood is one possible mode of transmit- Which blood type or types are compatible for clients who
ting prions from animals to humans and humans to are blood types B (Rh) positive and O (Rh) negative?
humans, there is a current policy to ban the collection of
blood from anyone who has lived in the United Kingdom
for a total of 3 months or longer since 1980, lived any- Blood Transfusion
where in Europe for a total of 6 months since 1980, or
received a blood transfusion in the United Kingdom (Cen- Before administering blood, the nurse obtains and doc-
ters for Disease Control and Prevention, 2001; Meckler & uments the client’s vital signs to provide a baseline
Ricks, 2001). for comparison should the client have a transfusion reac-
tion. Each client who receives blood has a color-coded
bracelet with identifying numbers that must correlate
Blood Compatibility with those on the unit of blood. IV medications are never
infused through tubing being used to administer blood.
There are several hundred differences among the pro- Blood transfusions require special equipment and mon-
teins in the blood of a donor and recipient. They can itoring for potential complications.
cause minor or major transfusion reactions. One of the
most dangerous differences involves the antigens, or pro- Blood Transfusion Equipment
tein structures, on membranes of red blood cells. Anti-
gens determine the characteristic blood group—A, B, There are certain standards for the gauge of the catheter
AB, and O—and Rh factor. Rh positive means the pro- or needle and the type of tubing used to transfuse blood.
tein is present; Rh negative means the protein is absent. CATHETER OR NEEDLE GAUGE. Because blood contains
Before donated blood is administered, the blood of the cells in addition to water, it generally is infused through a
potential recipient is typed and mixed, or cross-matched, 16- to 20-gauge—preferably an 18-gauge—catheter or nee-
with a sample of the stored blood to determine whether dle. Using a smaller gauge increases the potential for pro-
the two are compatible. To avoid an incompatibility reac- longing the infusion beyond 4 hours, and 4 hours is the
tion, it is best to administer the same blood group and Rh maximum safe period for administering one unit of blood.
factor. Exceptions are listed in Table 16-8.
Type O blood is considered the universal donor BLOOD TRANSFUSION TUBING. Blood is administered
because it lacks both A and B blood group markers through tubing referred to as a Y-set (Fig. 16-20). Two
on its cell membrane. Therefore, type O blood can be
given to anyone because it will not trigger an incom-
patibility reaction when given to recipients with other
blood types. Persons with type AB blood are referred
to as universal recipients because their red blood cells
have proteins compatible with types A, B, and O. Rh-
positive persons may receive Rh-positive or Rh-negative
blood because the latter does not contain the sensitizing
protein. Rh-negative persons, however, should never
receive Rh-positive blood.
TABLE 16-8
BLOOD GROUPS AND
COMPATIBLE TYPES
BLOOD PERCENTAGE OF COMPATIBLE
GROUPS POPULATION BLOOD TYPES
A 41% A and O
B 9% B and O
O 47% O
AB 3% AB, A, B, and O
Rh+ 85% whites Rh+ and Rh–
95% African Americans
Rh– 15% whites Rh– only
5% African Americans
FIGURE 16-20 • Blood transfusion tubing.
branches are at the top of the tubing; one is used to nurses monitor clients frequently during a transfusion
administer normal saline solution, the other to adminis- and instruct them to call for assistance if they feel any
ter blood. Normal saline (0.9% sodium chloride) is the unusual sensations (Table 16-9).
only solution used when administering blood because
other solutions 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 PARENTERAL NUTRITION
is administered before the blood is hung and follows
after the blood has been infused. It also is used during The term parenteral means “a route other than enteral
the infusion if the client has a transfusion reaction or intestinal.” Therefore, parenteral nutrition (nutrients
(Skill 16-8). such as protein, carbohydrate, fat, vitamins, minerals,
and trace elements, administered intravenously) is pro-
Transfusion Reactions vided by other than the oral route. Depending on the
Serious transfusion reactions generally occur within the concentration of these substances, parenteral nutrition
first 5 to 15 minutes of the infusion, so the nurse usually is administered through an IV catheter in a peripheral
remains with the client during this critical time. Because vein or through a catheter that terminates in a central
a transfusion reaction can occur at any time, however, vein near the heart.
TABLE 16-9 TRANSFUSION REACTIONS

TYPE OF REACTION SIGNS AND SYMPTOMS CAUSE(S) ACTION
Incompatibility Hypotension, rapid pulse rate, Mismatch between donor and Stop the infusion of blood.
difficulty breathing, back pain, recipient blood groups Infuse the 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 the Stop the blood infusion.
rapid pulse, muscle aches donated blood Start the saline.
Check vital signs.
Report findings.
Septic Fever, chills, hypotension Infusion of blood that contains Stop the infusion of blood.
microorganisms Start the saline.
Report findings.
Save the blood and tubing.
Allergic Rash, itching, flushing, stable Minor sensitivity to substances in Slow the rate of infusion.
vital signs 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 of Reduce the rate.
moist breath sounds, bounding infusion; inadequate cardiac or Elevate the head.
pulse kidney function Give oxygen.
Report findings.
Be prepared to give a diuretic.
Hypocalcemia Tingling of fingers, hypotension, Multiple blood transfusions con- Stop the blood infusion.
(low calcium) muscle cramps, convulsions taining anticalcium agents Start saline.
Report findings.
Be prepared to give antidote
(calcium chloride).
Peripheral Parenteral Nutrition
Peripheral parenteral nutrition (isotonic or hypotonic IV

nutrient solution instilled in a vein distant from the heart)
is not extremely concentrated and so can be infused
through peripheral veins. It provides temporary nutri-
tional support of approximately 2,000 to 2,500 calories
daily. It can meet a person’s metabolic needs when oral
intake is interrupted for 7 to 10 days, or it can be used as
a supplement during a transitional period as the client
begins to resume eating.
Total Parenteral Nutrition
Total parenteral nutrition (TPN; hypertonic solution of

nutrients designed to meet almost all caloric and nutri-
tional needs) is preferred for clients who are severely
malnourished or may not be able to consume food or liq-
uids for a long period. Box 16-6 lists clients who may
benefit from TPN.
Because TPN solutions are extremely concentrated,
they must be delivered to an area where they are diluted
in a fairly large volume of blood. This excludes periph-
eral veins. TPN solutions are infused through a catheter FIGURE 16-21 • Central venous catheter inserted into the subclavian
vein and threaded into the superior vena cava.
inserted into the subclavian or jugular vein; the tip ter-
minates in the superior vena cava. This type of a catheter
is referred to as a central venous catheter (Fig. 16-21).
Sometimes a peripherally inserted central catheter is used;
this long catheter is inserted in a peripheral arm vein, but
its tip terminates in the superior vena cava (Fig. 16-22).
Lipid Emulsions
An emulsion (mixture of two liquids, one of which is insol-

uble in the other) can be administered parenterally. The
combination allows a vehicle for administering lipids, or
fat, which is often missing from parenteral nutritional
solutions. A parenteral lipid emulsion is a mixture of
BOX 16-6 ● Candidates for Total

Parenteral Nutrition
❙ Clients who have not eaten for 5 days and are not likely to eat during Insertion site
the next week
❙ Clients who have had a 10% or more loss of body weight
❙ Clients exhibiting self-imposed starvation (anorexia nervosa)
❙ Clients with cancer of the esophagus or stomach
❙ Clients with postoperative gastrointestinal complications
❙ Clients with inflammatory bowel disease in an acute stage
❙ Clients with major trauma or burns
❙ Clients with liver and renal failure FIGURE 16-22 • Peripherally inserted central catheter with distal tip
in the superior vena cava.

Administering TPN
❙ Weigh the client daily. A record of the client’s weight assists with
monitoring his or her response to treatment.
❙ Use tubing that contains a filter. Filters absorb air and bacteria,
two potential complications associated with the use of central
venous catheters.
❙ Change TPN tubing daily. Doing so reduces the potential for infection.
❙ Tape all connections in the tubing and central catheter. Taping
prevents accidental separation and reduces the potential for an
air embolism.
❙ Clamp the central catheter and have the client bear down whenever
separating the tubing from its catheter connection. This action
prevents an air embolism.
FIGURE 16-23 • Administration of lipid emulsion. (Copyright B. Proud.)
❙ Use an infusion device to administer TPN solution. An infusion
device monitors and regulates precise fluid volumes.
❙ Infuse initial TPN solutions gradually (25 to 50 mL/hr). Gradual
administration allows time for physiologic adaptation. NURSING IMPLICATIONS
❙ Never increase the rate of infusion to make up for an uninfused
volume unless the physician has been consulted. Speeding up the Clients who have fluid, electrolyte, blood, and nutritional
infusion tends to increase blood glucose levels. imbalances are likely to have one or more of the follow-
❙ Monitor intake and especially urine output. High blood glucose ing nursing diagnoses:
levels can trigger diuresis (increased urine excretion), resulting in
output greater than intake. • Self-Care Deficit, Feeding
• Deficient Fluid Volume
❙ Monitor capillary blood glucose levels (see Chap. 14). Blood glucose
• Excess Fluid Volume
may not be adequately metabolized without the additional
administration of insulin.
• Risk for Impaired Oral Mucous Membrane
• Risk for Impaired Skin Integrity
❙ Wean the client from TPN gradually. Weaning prevents a sudden • Deficient Knowledge
drop in blood glucose levels.
Nursing Care Plan 16-1 illustrates the nursing pro-
cess as applied to a client with Deficient Fluid Volume.
The North American Nursing Diagnosis Association
(NANDA, 2005) defines this diagnostic category as
water and fats in the form of soybean or safflower oil, egg “decreased intravascular, interstitial and/or intracellular
yolk phospholipids, and glycerin. fluid.”
Lipid solutions, which look milky white (Fig. 16-23),
are given intermittently with TPN solutions. They provide
additional calories and promote adequate blood levels of GENERAL GERONTOLOGIC
fatty acids. Lipid solutions are administered peripherally CONSIDERATIONS
or in a port in the central catheter below the filter and Older adults are at risk for fluid and electrolyte imbalances if they
close to the vein. If the lipid solution is squeezed or mixed experience chronic conditions affecting the heart, kidneys, and
with TPN solutions in larger volumes than those moving intestinal absorption.
Diuretic medications, often prescribed for older adults with cardio-
through the catheter, the lipid molecules tend to “break”
vascular disorders, increase the risk for fluid and electrolyte
and separate in the solution. imbalances. Laxatives, enemas, antihistamines, or tricyclic anti-
The client receiving an administration of lipids may depressants may also alter fluid and electrolyte balance.
have an adverse reaction within 2 to 5 hours of the infu- Mobility limitations, cognitive impairments, and impaired ability
to perform activities of daily living can lead to fluid deficits in
sion (Dudek, 2006). Common manifestations include
older adults who cannot maintain adequate food and fluid
fever, flushing, sweating, dizziness, nausea, vomiting, intake independently.
headache, chest and back pain, dyspnea, and cyanosis. Infections, elevated temperature, or both may alter fluid balance.
Delayed reactions (up to 10 days later) are characterized Assessment of stool consistency is important because water is lost
through loose or very soft stools.
by enlargement of the liver and spleen accompanied by Older adults may need to be encouraged to drink fluids, even at
jaundice, reduced white blood cell and platelet counts, times when they do not feel thirsty, because age-related
elevated blood lipid levels, seizures, and shock. changes may diminish the sensation of thirst.
Deficient Fluid Volume
ASSESSMENT
• Monitor intake and output (I&O) each shift and total the sum every 24 hours.
• Assess for unusual loss of fluid via emesis, diarrhea, wound drainage, intestinal suction, blood loss, etc.
• Weigh the client consistently on the same scale, at the same time, in similar clothing and compare the findings.
• Note the color and odor of urine.
• Check vital signs every 4 hours while the client is awake.
• Assess skin turgor over sternum each shift.
• Note the color and warmth of the skin and degree of moisture of mucous membranes each shift.
• Ask the client to identify any thirst, weakness, or fatigue.
• Determine the client’s level of consciousness and evidence of confusion or disorientation.
• Review laboratory data such as specific gravity of urine, hematocrit, and electrolyte concentration.
Nursing Diagnosis: Deficient Fluid Volume related to inadequate oral fluid intake and
increased fluid loss as manifested by intake of 1,000 mL in previous 24 hours, urine output
of 750 mL in previous 24 hours, 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 hours (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 to facilitate the client’s cooperation in
and the process of recording the volume of fluid intake and reaching the goal.
output.
Place an I&O record form at the client’s bedside. Having a form for recording I&O promotes accurate
assessment.
Put a hat for collecting urine inside the bowl of the toilet; Placing a device for collecting voided urine helps to
explain its purpose to the client. prevent accidental flushing of urine that needs to be
measured.
Instruct the client to record fluids and amounts consumed Periodic recording facilitates accuracy.
and to remind nursing personnel to do likewise.
Ask the client to turn on the signal light after each use of Measuring urine output after each voiding and recording
the toilet or urinal. the 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 An oral fluid intake of 100 mL/hr for 16 hours will meet
fluid every hour over the next 16 hours (day and evening the minimum target of 1,500 mL.
shifts).
Offer oral fluid if the client awakens during the night, but Ensuring sleep is a priority as long as the goals for fluid
avoid disturbing the client if asleep and oral intake from intake are met.
previous shifts is adequate.
(continued)
Deficient Fluid Volume
Request a regular diet from dietary department that Sodium attracts water.
contains foods that are good sources of sodium such as
milk, cheese, bouillon, and ham.

• Total oral intake for 24 hours is 2,250 mL.
• Total urine output for 24 hours is 1,975 mL.
• Oral temperature is 98.2°F, pulse is 88 beats/min and strong, respirations are 18 breaths/min at rest,
and BP is 128/84 mm Hg in right arm while lying down.
• Weight remains at admission weight of 157 lbs.
• Urine is light yellow and free of strong odor.
• Oral mucous membranes are pink and moist.
• Skin is warm and elastic.
• The client is alert and oriented.
• The client is not thirsty, weak, or unusually fatigued.
Clients may consume more fluid if the nurse offers it, rather than Nurses need to monitor closely the response of older adults to IV
if the nurse asks the older adult if he or she would like a drink. infusions who may be unable to tolerate volumes that may be
Offering a small amount of liquid hourly throughout the day safely administered to younger adults.
will assist in keeping oral mucosa moist and providing hydra- Dehydration in older adults may be a consequence or indicator of
tion needs. Types of fluid and temperature preferences (which abuse or neglect.
may vary at different times of the day) should be determined.
Encourage older adults to drink noncaffeinated beverages
because of the diuretic effect of caffeine or to replace the vol-
ume of caffeinated beverages by consuming the same volume
of noncaffeinated fluids per day. 1. When calculating a client’s I&O, you find that she
To maintain adequate consumption of nutrients, it is best to offer has had a total 24-hour intake of 1,000 mL and output
fluids to older adults at times other than meals. Distending the
of 750 mL. What other assessment findings are you
stomach with liquids creates a sensation of satiety (fullness)
and reduces the consumption of food.
likely to observe?
Older adults may restrict their fluid intake under the mistaken 2. A client will be receiving a blood transfusion. The regis-
notion that this will reduce urinary incontinence. This practice tered nurse who hangs the unit of blood and initiates the
actually contributes to the problem by increasing bladder irri- administration of the blood asks you to assess the client
tability and increases the risks for urinary tract infection, pos-
during its infusion. What assessments are appropriate to
tural hypotension, falls, and injuries. Assessment for fluid and
electrolyte imbalances is important for any older adult who
monitor?
has a change in mental status.
When older adults must fast before certain procedures, empha-
size the need to increase oral fluid intake in the hours before NCLEX-STYLE REVIEW Q U E S T I O N S
beginning fluid restrictions to prevent dehydration.
1. When the nursing care plan indicates that a client is to be
Skin elasticity diminishes with aging as subcutaneous fat deposits
decrease. Therefore, assessment of skin turgor is more accu-
weighed regularly, which is most important to consider?
rate over the sternum. Additional indicators of dehydration in 1. When the client was weighed before
older adults include mental status changes; increases in pulse 2. When the client last took a drink of fluid
and respiration rates; decrease in blood pressure; dark, con- 3. How much the client has eaten so far today
centrated urine with a high specific gravity; dry mucous mem- 4. Whether the client feels like being weighed
branes; warm skin; furrowed tongue; low urine output;
hardened stools; and elevated hematocrit, hemoglobin, serum
2. The best evidence that a client understands dietary restric-
sodium, and blood urea nitrogen (BUN). tions for following a low-sodium diet is if the client says he
Daily weights at the same time of day, in the same clothing, and must avoid
on the same scale enable tracking of weight changes indica- 1. Soy sauce
tive of fluid volume fluctuations. 2. Lemon juice
3. Maple syrup 4. If all the following units of blood are available, which is
4. Onion powder the nurse correct to refuse for a client with type A, Rh-
3. When a client asks how a transfusion of packed red blood positive blood because it is incompatible for this client?
cells differs from the usual whole blood transfusion, the 1. A, Rh negative
nurse is most correct in explaining that a unit of packed red 2. O, Rh positive
blood cells 3. O, Rh negative
1. Has the same number of red blood cells in less fluid 4. AB, Rh positive
volume 5. During the first 15 minutes of infusing a unit of blood,
2. Contains more red blood cells in the same amount which of the following is most indicative that the client is
of fluid volume experiencing a transfusion reaction?
3. Is less likely to cause an allergic transfusion reaction 1. The client feels an urgent need to urinate.
4. Will stimulate the bone marrow to make more red 2. The client’s blood pressure becomes low.
blood cells 3. Localized swelling is at the infusion site.
4. The skin is pale at the site of the infusing blood.
Skill 16-1 • RECORDING INTAKE AND OUTPUT
Assessment
Check the Kardex or listen in report to determine if an Ensures compliance with the plan for care
assigned client is on I&O.
Verify during report how much IV fluid has been Indicates the credited volume for calculating fluid intake
accounted for from any currently infusing solution. at the end of the shift
Review the nursing care plan for any previously identified Promotes continuity of care
fluid problem and nursing orders for specific
interventions.
Review the client’s medical record and analyze trends in Aids in analyzing trends in fluid status
I&O, vital sign measurements, laboratory findings, and
weight records.
Perform a physical assessment to obtain data that reflect Provides current data
the client’s fluid status (see Table 16-4).
Inspect all tubings and drains to ensure they are patent Ensures that methods for instilling or removing fluids are
(open). functional
Notice if 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 Verifies if additional teaching is needed
measurements, 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 Facilitates measuring voided urine
has none and uses the toilet for urinary elimination.
Measure the amount of water in the client’s bedside carafe Provides a baseline for measuring fluid consumed in
at the beginning of the shift. addition to that served at regular meal times
Planning
Place the client on I&O or plan to measure I&O if the Demonstrates safe and appropriate nursing care
client is at high risk for fluid imbalance or the
assessment data suggest a problem.
Identify the goal for fluid intake or restriction. A Provides a target for client care
minimum of 1,000 mL in 8 hours 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 Facilitates client cooperation
be followed for measuring I&O.
Record the volume for all fluids consumed from the Contributes to accurate assessment records
dietary tray and other sources of oral liquids.
Make sure that all IV fluids or tube feedings are being Ensures compliance with medical therapy
administered at the prescribed rate.
(continued)
RECORDING INTAKE AND OUTPUT (Continued)
Ensure that the nurse who adds additional IV fluid Ensures accurate record keeping
containers also records the volume when the infusion is
complete or replaced.
Keep track of the fluid volumes used to irrigate drainage Ensures accurate record keeping
tubes or flush feeding tubes.
Measure and record the volume of voided urine. Although Ensures accurate record keeping and reduces the
urine is not considered a vehicle for the transmission of transmission of microorganisms
blood-borne microorganisms, gloves are worn as
standard precautions.
Measure and record the volume of urine collected in a Ensures accurate record keeping
catheter drainage bag near the end of the shift (Fig. A).
Urine drainage bag. (Copyright B. Proud.)
Wear gloves to measure liquid stool or other body fluids Prevents the transmission of microorganisms and provides
and record their measured amounts. assessment data
Wash hands or perform hand antisepsis with an alcohol Reduces the presence and potential transmission of
rub (see Chap. 10) after removing and disposing of microorganisms
the gloves.
Check the volume remaining in currently infusing IV Ensures accurate assessment data
fluids; subtract the remaining volume from the credit
provided at the beginning of the shift.
Total all fluid intake volumes and all fluid output Ensures accurate record keeping
volumes for the current 8-hour shift; record the
amounts.
Compare the data to determine if the intake and output Demonstrates concern for safe and appropriate care
are approximately the same and if the goals for fluid
intake or restrictions have been met.
Report major differences in I&O to the nurse in charge or Demonstrates concern for safe and appropriate care
the client’s physician.
(continued)
RECORDING INTAKE AND OUTPUT (Continued)
Review the plan of care and make revisions if the goals Demonstrates responsibility and accountability
have not been met or if additional nursing interventions
seem appropriate.
Report the I&O volumes, IV fluid credit amount, and any Demonstrates responsibility and accountability
other pertinent data to the nurse who will be assuming
responsibility 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
Skill 16-2 • PREPARING INTRAVENOUS SOLUTIONS
Assessment
Check the medical order for the type, volume, and Ensures accuracy and guides the selection of equipment
projected length of fluid therapy.
Determine if the solution is in a bag or bottle and if the Affects the selection of tubing
infusion will be administered by gravity or infusion
device.
Review the client’s medical record for information on the Determines need for filtered tubing
risk for infection.
Read the label on the solution at least three times. Helps prevent errors
(continued)
PREPARING INTRAVENOUS SOLUTIONS (Continued)
Planning
Mark a time strip and attach it to the side of the container Facilitates monitoring
(see Fig. A).
Marking a time strip. (Copyright B. Proud.)
Implementation
rub (see Chap. 10).
Select the appropriate tubing and stretch it once it has Straightens the tubing by removing bends and kinks
been removed from the package.
Tighten the roller clamp (see Fig. B). Aids in filling the drip chamber
Tightening the roller clamp. (Copyright B. Proud.)
Remove the cover from the access port. Provides access for inserting the spike
(continued)
Insert the spike by puncturing the seal on the container Provides an exit route for fluid
(see Fig. C).
Inserting the spike. (Copyright B. Proud.)
Hang the solution container from an IV pole or suspended Inverts the container
hook.
Squeeze the drip chamber, filling it no more than half full Leaves space to count the drops when regulating the rate
(see Fig. D). of infusion
Squeezing the drip chamber. (Copyright B. Proud.)
Release the roller clamp. Flushes air from the tubing

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 loss of fluid
(continued)
Attach a piece of tape or a label on the tubing giving the Provides a quick reference for determining when the
date, time, and your initials (see Fig. E). tubing needs to be changed
Take the solution and tubing to the client’s room. Facilitates administration
Attaching label on the tubing. (Copyright B. Proud.)
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
Skill 16-3 • STARTING AN INTRAVENOUS INFUSION
Assessment
Check the identity of the client. Prevents errors
Review the client’s medical record to determine if there Influences supplies that will be used and modifications in
are any allergies to iodine or tape. the procedure
Inspect and palpate several potential venipuncture sites Provides an alternative if the first attempt is unsuccessful
(see Fig. A).
Palpating veins. (Copyright 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 Promotes comfort and facilitates inspection of the arm
position.
Place an absorbent pad beneath the hand or arm. Prevents having to change bed linen if the site bleeds
Select a site most likely to facilitate the purpose for the Facilitates continuous fluid administration and minimizes
infusion and comply with the criteria for vein selection. potential 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 Provides local anesthesia to insertion site to minimize
cream. pain associated with a needle stick
Tear strips of tape, open the package with the Saves time and ensures that the venipuncture device is
venipuncture device, and place antiseptic ointment on not displaced once inserted. The application of
an opened Band-Aid or gauze square, based on the antimicrobial ointment is controversial and is
agency’s policy. dependent on agency policy.
Implementation
Wash hands or perform hand antisepsis with an alcohol Reduces the number of microorganisms.
rub (see Chap. 10).
Apply a tourniquet or a blood pressure cuff 2 to 4 inches Distends the vein
(5 to 10 cm) above the vein that will be used.
Use an antimicrobial solution such as Betadine and/or Reduces the potential for infection
alcohol to cleanse the skin, starting at the center of the
site outward 2 to 4 inches (see Fig. B).
(continued)
STARTING AN INTRAVENOUS INFUSION (Continued)
Swabbing the site. (Copyright B. Proud.)
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 to straighten the vein and prevents it from moving
tissues about 2 inches (5 cm) below the intended site of around underneath the skin
entry (see Fig. C).
Stabilizing the vein. (Copyright 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.
(continued)
Warn the client just before inserting the needle. Prepares the client for discomfort
Feel for a change in resistance and look for blood to Indicates the vein has been pierced
appear behind the needle.
Once blood is observed, advance the needle about 1⁄8 inch Positions the catheter tip within the inner wall of the vein
to 1⁄4 inch (see Fig. E).
Advancing the needle tip. (Copyright B. Proud.)
Withdraw the needle slightly so that the tip is within the Prevents puncturing the outside of the vein wall
catheter.
Slide the catheter into the vein until only the end of the Ensures full insertion of the catheter
infusion 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 Facilitates infusing the solution
tubing and insert it into the end of the venipuncture
device.
Release the roller clamp and begin infusing solution Clears blood from the venipuncture device before it
slowly. can clot
Remove gloves when there is no longer a potential for Facilitates handling tape
direct contact with blood.
Place a small amount of antiseptic ointment onto the site Reduces the potential for infection. However, the
or dressing. application of antimicrobial ointment is controversial.
Agency policy must be followed.
(continued)
Secure the catheter by criss-crossing a piece of tape from Prevents catheter displacement
beneath the tubing. Cover with a piece of transparent
tape (see Fig. F).
Stabilizing the catheter. (Copyright B. Proud.)
Cover the entire site with additional strips of tape, taking Prevents tension on the tubing that may cause
care to loop and secure the tubing (see Fig. G). displacement
Securing the tubing. (Copyright B. Proud.)
(continued)
Write the date, time, gauge of the catheter, and your Provides a quick reference for determining when the site
initials on the outer piece of tape. must be changed
Tighten or release the roller clamp to regulate the rate of Facilitates compliance with the medical order
fluid 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 #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 IV SOLUTION CONTAINERS
Assessment
Assess the volume that remains in the infusing container Helps to establish when the solution will need to be
and the rate at which it is infusing. replaced
Check the medication record or physician’s orders to Ensures compliance with the medical order
determine what solution is to follow the current
infusion.
Planning
Obtain the replacement solution well in advance of Ensures that the infusion will be uninterrupted
needing it.
Attach a time strip to the new container indicating the Avoids having to complete this responsibility later
date, your initials, and the hourly infusion volumes.
(continued)
CHANGING IV SOLUTION CONTAINERS (Continued)
Organize client care to change the container when the Demonstrates efficient time management
current infusion becomes low.
Implementation
Check the identity of the client. Prevents errors
rub (see Chap. 10).
Tighten the roller clamp slightly or slow the rate of Slows the rate of infusion so that the drip chamber
infusion on an infusion device. remains filled with solution
Remove the almost-empty solution container from the Facilitates separating the tubing from the container
suspension hook with the tubing still attached.
Invert the empty solution container and pull the Prevents minor loss of remaining solution
spike free.
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 Restores height to overcome venous pressure
IV standard or infusion device.
Inspect for the presence of air within the tubing; remove Reduces the potential for air embolism or an alarm from
it, if present. an infusion device detecting air
Readjust the roller clamp or reprogram the infusion device Demonstrates compliance with the medical order
to restore the prescribed rate of infusion.
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 administration 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
swelling or discomfort in the area of the infusing fluid. SIGNATURE/TITLE
Skill 16-5 • CHANGING IV 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 Determines the approximate time when the tubing must
tubing. be changed
Determine if the solution container will need to be Facilitates changing both the container and tubing at the
replaced before the time expires on the tubing. same time
Planning
Obtain appropriate replacement tubing and supplies for Ensures that equipment will be available and ready when
changing the dressing. needed
Attach a new label to the tubing indicating the date and Provides a quick reference for determining when the
time the tubing is changed and your initials. tubing must be changed again
Implementation
rub (see Chap. 10).
Tear strips of adhesive tape and dressing materials and Facilitates dexterity later in the procedure
place them in a convenient location.
Open the new package containing the tubing, stretch the Prepares the tubing for insertion into the solution
tubing, and tighten the roller clamp. container
Remove the solution container from the suspension hook Facilitates separating the tubing from the container
with the tubing still attached.
Invert the solution container and pull the spike free. Prevents minor loss of remaining solution
Secure the spike to the IV pole with a strip of previously Facilitates continued infusion
torn 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 Prevents accidental removal of the catheter or needle from
the tubing from it. the vein
Remove the cap from the end of the new tubing and Connects the venipuncture device to the tubing without
attach it to the end of the venipuncture device. contaminating the tip of the tubing
Continue to hold the venipuncture device with one hand Re-establishes the infusion
while releasing the roller clamp on the new tubing.
Replace the dressing on the venipuncture site, and secure Covers the site and keeps the tubing and venipuncture
the tubing. device from being pulled out
Readjust the rate of infusion. Complies with the medical order
(continued)
CHANGING IV TUBING (Continued)
Write the date, time, and your initials on the new Provides a quick reference for determining future nursing
dressing, and include the gauge of the venipuncture responsibilities for infection control
device and original 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 Demonstrates responsibility and accountability for
discontinue the infusion of IV fluid. carrying out medical orders
Check the client’s identity. Prevents errors
Planning
Assemble necessary equipment, which includes clean Promotes organization and efficient time management
gloves, sterile gauze, and tape.
Implementation
rub (see Chap. 10).
Clamp the tubing and remove the tape that holds the Facilitates removal without leaking fluid
dressing and venipuncture device in place.
(continued)
DISCONTINUING AN INTRAVENOUS INFUSION (Continued)
Don gloves. Prevents contact with blood
Press a gauze square gently over the site where the Helps to absorb blood
venipuncture device enters the skin.
Remove the catheter or needle by pulling it out without Prevents discomfort and injury to the vein
hesitation following the course of the vein.
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. (Copyright 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 Prevents accidental needle-stick injuries and transmission
if it is a needle. of blood-borne infectious microorganisms
Enclose a catheter used for venipuncture within a glove as Facilitates disposal and prevents contact with blood
they are removed and discarded within a lined waste
container.
Wash hands or perform hand antisepsis with an alcohol Removes transient microorganisms
rub (see Chap. 10) after glove disposal.
Encourage the client to flex and extend the arm or hand Helps the client to regain sensation and mobility
several times.
Record the amount of intravenous fluid that the client Contributes to an accurate record of fluid intake
received before discontinuing the infusion on the I&O
sheet.
Document the time the infusion was discontinued and the Demonstrates responsibility and accountability for the
condition of the venipuncture site. client’s care
(continued)
DISCONTINUING AN INTRAVENOUS INFUSION (Continued)
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. # 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
Skill 16-7 • INSERTING A MEDICATION LOCK
Assessment
Confirm that the physician has written an order to Demonstrates responsibility and accountability for
discontinue the continuous infusion of IV fluid and carrying out medical orders
insert a medication 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 if the infusion is instilling at the predetermined Indicates if the vein and catheter are patent (open)
rate.
Determine if 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 Promotes organization and efficient time management
medication lock, syringe containing 2 mL of sterile
normal saline (0.9% sodium chloride) or heparinized
saline (10 U per mL or 100 U per mL, depending on the
agency’s policy), alcohol swabs, gloves, and supplies for
changing or reinforcing the dressing over the site.
(continued)
INSERTING A MEDICATION LOCK (Continued)
Implementation
rub (see Chap. 10).
Fill the chamber of the medication lock with saline or Displaces air from the empty chamber
heparin solution.
Loosen the tape over the dressing to expose the Facilitates removing the tubing from the client
connection 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
lock. the lock
Don clean gloves. Provides a barrier from contact with blood
Tighten the roller clamp on the tubing and stop the Prevents leakage of fluid when the tubing is removed
infusion 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. (Copyright B. Proud.)
Remove the tip of the tubing from the venipuncture Seals the opening in the catheter or needle
device and insert the medication lock (see Fig. B).
Inserting the device. (Copyright B. Proud.)
(continued)
INSERTING A MEDICATION LOCK (Continued)
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 needle on the syringe or blunt Clears blood from the venipuncture device and lock before
needleless adapter and gradually instill 2 mL of saline or it can clot
heparin until the syringe is almost empty (see Fig. C).
Instilling saline or heparin solution. (Copyright B. Proud.)
Begin to remove the needle from the port as the last Continues the application of positive pressure (pushing
volume of solution is instilled; clamp or pinch the effect) rather than negative pressure (pulling effect)
tubing, or press over the venipuncture device before during the time the syringe is removed. Negative
removing a needleless adapter. pressure pulls blood into the catheter or needle tip,
which may cause an obstruction.
Retape or secure the dressing. Reduces the possibility that the lock and catheter may be
accidentally dislodged
Plan to flush the lock at least every 8 hours with 1 or 2 mL Ensures continued patency
of flush solution when it is not used or after each use.
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
Skill 16-8 • ADMINISTERING A BLOOD TRANSFUSION
Assessment
Determine if a special signed consent is required. Complies with legal responsibilities
Check the size of the current venipuncture device if an IV Indicates if another venipuncture must be performed
is infusing.
Review the medical record for results of type and cross- Indicates if blood is available in the blood bank
match.
Take temperature, pulse, respirations, and blood pressure Provides a baseline for comparison during the transfusion
within 30 minutes of obtaining blood.
Planning
Complete major nursing activities before starting the Avoids disturbing the client once the blood is being
infusion of saline unless the blood must be given administered
immediately.
Plan to perform a venipuncture or start the infusion of Prevents administering fluid unnecessarily
saline just before obtaining the blood.
Obtain necessary equipment including a 250-mL Complies with the standards of care for administering
container of normal saline (0.9% NaCl) and a Y-set. blood
Tighten the roller clamp on one branch of the Y-tubing Prepares the tubing for purging with saline
and the roller clamp below the filter.
Insert the unclamped branch of the Y-set into the Moistens the filter and fills the upper portion of the tubing
container of saline; squeeze the drip chamber until it with saline
and the filter are half full.
Release the lower clamp and flush air from the remaining Reduces the potential for infusing a bolus of air
section of tubing.
Implementation
Perform the venipuncture or connect the Y-set to the Provides access to the venous circulation and ensures that
present venipuncture device if it is a 16–20 gauge. blood 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 Prevents mistaken identity when releasing the matched
sure to take a form identifying the client. blood
Double-check the information on the blood bag with the Prevents releasing the wrong unit of blood or blood that is
cross-matched information on the lab slip with the not a compatible blood group and Rh factor
blood bank 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 Indicates deteriorated or tainted blood
appears 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 Avoids damaging intact cells
container, if the serum has separated from the cells.
(continued)
ADMINISTERING A BLOOD TRANSFUSION (Continued)
At the bedside, check the label on the blood bag with the Reduces the potential for administering incompatible
numbers on the client’s wristband with a second nurse; blood
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 Fills the tubing and filter with blood
and release the roller clamp on the blood branch.
Regulate the rate of infusion at no more than 50 mL/hr Establishes a slow rate of infusion so the nurse can
for the first 15 minutes (check the drop factor to monitor for and respond to signs of a transfusion
determine the rate in gtt/min). reaction
Increase the rate after the first 15 minutes to complete the Increases the rate of administration to infuse the unit
infusion in 2 to 4 hours if a second assessment of vital within a safe period
signs is 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 Flushes blood cells from the tubing
the 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 Prevents leaking when the IV is discontinued
looks reasonably clear of blood.
Don gloves. Provides a barrier from contact with blood
Loosen the tape covering the venipuncture site and Discontinues the infusion or restores previous fluid
remove the catheter, or remove the blood tubing and therapy
reconnect the previously infusing solution.
Apply a dressing or Band-Aid over the venipuncture site if Prevents infection
the IV is discontinued.
Dispose of the blood container and tubing according to Blood is a biohazard and requires special bagging to
agency policy. ensure that 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, or
• Reactions have been minimized by appropriate
interventions.
• Infusion is discontinued or previous orders are
resumed.
Document
• Venipuncture procedure, if initiated for the adminis-
tration of blood
• Preinfusion vital signs
• Names of nurses who checked armband and blood bag
container
(continued)
ADMINISTERING A BLOOD TRANSFUSION (Continued)
Document (Continued)
• 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 #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—98° (tympanic), P—90, R—22, BP 116/64 in R. arm while lying flat. One
unit of type O+ whole blood #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 evidence of transfusion reaction. T—98° (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 dis-
continued. SIGNATURE/TITLE
17
Chapter
Hygiene
LEARNING OBJECTIVES
● Define hygiene.
● Name five hygiene practices that most people perform regularly.
● Give two reasons why a partial bath is more appropriate than a daily bath for older adults.
● List at least three advantages of towel or bag baths.
● Name two situations in which shaving with a safety razor is contraindicated.
● Name three items recommended for oral hygiene.
● Identify two methods to prevent the chief hazard when providing oral hygiene to an
unconscious client.
● Describe two techniques for preventing damage to dentures during cleaning.
● Describe two methods for removing hair tangles.
● Name two types of clients for whom nail care is provided with extreme caution.
● Name four visual and hearing devices.
● List two alternatives for clients who cannot insert or care for their own contact lenses.
● Discuss four reasons for sound disturbances experienced by people who wear hearing aids.
● Describe an infrared listening device.
HYGIENE means those practices that promote health through personal cleanliness. Peo-
ple foster hygiene through activities such as bathing, performing oral care, cleaning
WORDS TO KNOW and maintaining fingernails and toenails, and shampooing and grooming hair.
Hygiene also applies to the care and maintenance of devices such as eyeglasses and
bag bath
hearing aids to ensure continued and proper function. Hygiene practices and needs
bed bath
bridge differ according to age, inherited characteristics of the skin and hair, cultural val-
caries ues, and state of health.
cuticles This chapter provides suggestions to nurses for carrying out hygiene practices
dentures when providing client care. Principles that refer to the client’s environment, such as
gingivitis
hygiene
bed-making skills, are discussed in Chapter 18.
integument
ophthalmologist
optometrist
oral hygiene THE INTEGUMENTARY SYSTEM
partial bath
perineal care
periodontal disease The word integument (covering) refers to the collective structures that cover the sur-
plaque face of the body and its openings. Most hygiene practices are based on maintaining
podiatrist
sordes
or restoring a healthy integumentary system, which includes the skin, mucous mem-
tartar branes, hair, and nails. Because the mouth, or oral cavity (which is lined with mucous
towel bath membrane), also contains teeth, this chapter also discusses this accessory structure.
358
C H A P T E R 17 ● Hygiene 359
Pore (opening of sweat gland)
FIGURE 17-1 • Cross-section of

the skin.
Skin • Maintain fluid and chemical balance.

• Provide sensory information such as pain, temperature,
The skin consists of the epidermis, dermis, and subcuta- touch, and pressure.
neous layer (Fig. 17-1). The epidermis, or outermost • Assist in converting precursors to vitamin D when
layer, contains dead skin cells that form a tough protein exposed to sunlight.
called keratin. Keratin protects the layers and structures
within the lower portions of the skin. The cells in the
epidermis are shed continuously and replaced from the Mucous Membranes
dermis, or true skin, which contains most of the secretory
glands (Table 17-1). The subcutaneous layer separates the The mucous membranes are continuous with the skin.
skin from skeletal muscles. It contains fat cells, blood ves-
They line body passages such as the digestive, respiratory,
sels, nerves, and the roots of hair follicles and glands.
urinary, and reproductive systems. Mucous membrane
Skin structures carry out the following functions:
also lines the conjunctiva of the eye. Goblet cells in the
• Protect inner body structures from injury and infection. mucous membranes secrete mucus, a slimy substance that
• Regulate body temperature. keeps the membranes soft and moist.
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
Hair
Each hair is a thread of keratin. Hair forms from cells
at the base of a single follicle. Although hair covers the
entire body, its amount, distribution, color, and texture
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 appear-
ance, hair basically helps to prevent heat loss. As heat
escapes from the skin, it becomes trapped in the air
between the hairs. The contraction of small arrector pili FIGURE 17-2 • External and cross-sectional views of a nail.
muscles around hair follicles, commonly described as
goose bumps, further maintains body heat.
Sebaceous glands in the hair follicles release sebum, smooth. The free margin ordinarily extends from the
an oily secretion that adds weight to the shafts of hair, end of each finger or toe, and the skin around the nails
causing them to flatten against the skull. Oily hair further is intact. Changes in the shape, color, texture, thickness,
attracts dust and debris. and integrity of the nails provide evidence of local injury
The texture, elasticity, and porosity of hair are inher- or infection and even systemic diseases (see Chap. 13).
ited characteristics influenced by the amount of keratin
and sebum produced. To alter the basic genetically inher-
ited structure, some people use chemicals to curl, relax, Teeth
or lubricate their hair.
Teeth, the enamel of which is a keratin structure, are
present beneath the gums at birth. The exposed portion
Nails of each tooth is referred to as the crown; the portion
within the gum is the root (Fig. 17-3).
Fingernails (Fig. 17-2) and toenails also are made of ker- The teeth begin to erupt at about 6 months of age and
atin, which in concentrated amounts gives them their continue to do so for 2 or 21⁄2 more years. As the jaw
tough texture. Fingernails and toenails provide some grows, the deciduous teeth (baby teeth) are replaced by
protection to the digits. Normal nails are thin, pink, and permanent teeth. Adults have 28 to 32 permanent teeth,
FIGURE 17-3 • Cross-section of a tooth. (From

Cohen B. [2004] Medical terminology: An illustrated
guide [4th ed.]. Philadelphia: Lippincott Williams
& Wilkins.)
depending on whether or not the third molars (wisdom oil, dirt, and microorganisms from the skin. Although
teeth) are present. restoring cleanliness is the primary objective, bathing
Healthy teeth are firmly fixed within the gums. Their has several other benefits:
alignment, which is related to jaw structure, generally is a
• Eliminating body odor
result of heredity. Although the teeth are white originally,
they become discolored from chronic consumption of cof- • Reducing the potential for infection
fee or tea, tobacco use, or certain drugs such as tetra- • Stimulating circulation
cycline antibiotics taken during childhood. • Providing a refreshed and relaxed feeling
The integrity of the teeth largely depends on the per- • Improving self-image
son’s oral hygiene practices, diet, and general health. In addition to bathing for hygiene purposes, other types
Saliva, which moistens food and begins its digestive of bathing serve different functions (Table 17-2). In gen-
processes, tends to keep the teeth clean and inhibits bac- eral, however, most bathing is done in a tub or shower,
terial growth. The accumulation of food debris, espe- at a sink, or at the bedside.
cially sugar, and plaque (substance composed of mucin
and other gritty substances in saliva) supports the growth
of mouth bacteria. The combination of sugar, plaque, and Stop • Think + Respond BOX 17-1
bacteria may eventually erode the tooth enamel, causing
How might a nurse respond to a client who believes that
caries (cavities).
daily bathing is unnecessary or even unhealthy?
Tartar (hardened plaque) is more difficult to remove and
may lead to gingivitis (inflammation of the gums). Pockets
of gum inflammation promote periodontal disease, a condi-
tion that results in the destruction of the tooth-supporting Tub Bath or Shower
structures and jawbone. If the safety risks are negligible and there are no con-
traindications, the nurse encourages clients to bathe inde-
pendently in a tub or shower (Skill 17-1). Most hospitals
HYGIENE PRACTICES
and nursing homes equip bathing facilities with various
rails and handles to promote client safety.
The integument contains many secretory glands that
produce odors and attract debris, and the teeth are prone Partial Bath
to decay if uncared for. Therefore, hygiene measures
are beneficial for maintaining personal cleanliness and A daily bath or shower is not always necessary—in fact,
healthy integumentary structures. Although hygiene for older adults, who perspire less than younger adults
practices vary widely, most Americans routinely per- and are prone to dry skin, frequent washing with soap
form bathing, shaving, brushing the teeth, shampooing, further depletes oil from the skin. Therefore, partial
and caring for nails. bathing sometimes is appropriate. A partial bath means
washing only those body areas subject to greatest soiling
or that are sources of body odor: generally the face, hands,
Bathing axillae, and perineal area. Partial bathing is done at a sink
or with a basin at the bedside.
Bathing is a hygiene practice in which a person uses a Sometimes the perineum, the area around the geni-
cleansing agent such as soap and water to remove sweat, tals and rectum, requires special or frequent cleansing
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
in addition to bathing. Perineal care (peri-care; techniques some aspects of bathing. Skill 17-3 explains how to give a
used to cleanse the perineum) is especially important bed bath. Also see Nursing Guidelines 17-1.
after a vaginal delivery or gynecologic or rectal surgery Some agencies use two variations of the traditional bed
so that the impaired skin remains as clean as possible. It bath—the towel bath and the bag bath—because they
is also appropriate whenever male or female clients have save time and expense. Box 17-1 lists their advantages.
bloody drainage, urine, or stool that collects in this area.
When providing perineal care, nurses must TOWEL BATH. With a towel bath, the nurse uses a single
large towel to cover and wash a client. It requires a towel
• Prevent direct contact between themselves and any
or bath sheet measuring 3 × 7.5 feet but no basin or soap.
secretions or excretions; this is generally accomplished
The nurse prefolds and moistens the towel or bath sheet
by wearing clean gloves (see Standard Precautions in
with approximately one-half gallon (2 L) of water heated
Chapter 22).
to 105° to 110°F (40° to 43°C) and 1 ounce (30 mL) of no-
• Cleanse so that they remove secretions and excretions
rinse liquid cleanser. He or she unfolds the towel so that
from less soiled to more soiled areas.
it covers the client (Fig. 17-4) and uses a separate section
These principles help to prevent the transfer of infectious to wipe each part of the body, beginning at the feet and
microorganisms to the nurse and to uncontaminated moving upward. The nurse folds the soiled areas of the
areas on or within the client (Skill 17-2). towel to the inside as he or she bathes each area and allows
the skin to air-dry for 2 to 3 seconds. After washing the
front of the body, the nurse positions the client on the side
Stop • Think + Respond BOX 17-2 and repeats the procedure. He or she unfolds the towel so
What suggestions can you make to promote the dignity that the clean surface covers the client. The nurse bathes
of clients who need nursing assistance with perineal care? the client’s back, then the buttocks. When the towel bath
is complete, the nurse changes the bed linen.
BAG BATH. A bag bath involves the use of a commer-

Bed Bath
cially packaged kit with 8 to 10 premoistened, disposable
Clients who cannot take a tub bath or shower indepen- cloths in a plastic bag or container and is another form
dently may be given any one of three types of baths: a bed, of a bed bath. The cloths contain a no-rinse surfactant
towel, or bag bath. During a bed bath (washing with a basin (a substance that reduces surface tension between the skin
of water at the bedside), the client may actively assist with and surface contaminants) and an emollient/humectant

Bathing Clients
❙ Ask the client if he or she uses special soap, lotion, or other hygiene ❙ Wash one part of the body at a time. Exposing only one part prevents
products. Determining the client’s preferences individualizes care. chilling.
❙ Wear gloves if there is any potential for direct contact with blood, ❙ Place a towel under the part of the body being washed. A towel absorbs
drainage, or other body fluid. Gloves reduce the potential for acquiring moisture.
an infection. ❙ Use firm but gentle strokes. Gentle strokes avoid friction that can
❙ Keep the client covered during the bath. Covering the client damage the skin.
demonstrates respect for modesty. ❙ Wash and dry well between folds of skin. Effective washing removes
❙ Wash cleaner areas of the body first and dirtier areas last. This reduces debris and microorganisms from areas where they are apt to breed.
the spread of microorganisms. ❙ Keep the washcloth wet, but not so wet that it drips. This demonstrates
❙ Encourage the client to participate at whatever level is appropriate. concern for the client’s comfort.
Participation promotes independence and self-esteem. ❙ Wash more soiled areas, such as the anus, last. Doing so prevents
transferring microorganisms to cleaner areas of the body.
❙ Monitor the client’s tolerance of activity. If activity becomes too
strenuous, it should be discontinued and resumed later. ❙ Remove all soap residue. This prevents drying the skin and possible itching.
❙ Inspect the body during washing for skin disorders (Table 17-3). ❙ Dry the skin after it has been rinsed. Drying the skin prevents chilling.
Bathing provides an excellent opportunity for physical assessment. ❙ Replace the water as it cools. Using warm water shows concern for the
❙ Communicate with the client and use the occasion to do informal health client’s comfort.
teaching. Talking demonstrates respect for the client as a person rather ❙ Apply an emollient lotion to the skin after bathing. A lotion restores
than an object being washed; teaching promotes health. lubrication to the skin.
TABLE 17-3 EXAMPLES OF INTEGUMENTARY DISORDERS

CONDITION DESCRIPTION CLIENT TEACHING
Acne Inflammation of sebaceous glands and hair Keep the face clean.
follicles 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
and itching irritating 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 than others in
family; launder personal bath items in hot
water and bleach.
Wash hands thoroughly before and after applying
medication to the skin.
Psoriasis Noninfectious chronic skin disorder that appears Follow medical regimen, which may be life-long.
as elevated silvery scales that shed over Be wary of advertised remedies that promise a
elbows, knees, trunk, and scalp. Acute episodes cure or quick relief, because they rarely do.
occur between periods of relief.
Pediculosis Brown crawling insects that move over the scalp Inspect the skin carefully; adult lice move quickly
(lice infestation) and skin and deposit yellowish-white eggs on from light.
hair shafts including pubic area. Skin bite Look for eggs (nits) on hairs 1⁄4″ to 1⁄20″ from the
causes itching. scalp or skin surface.
Do not share clothing, combs, brushes; lice are
spread by direct contact.
Use a pediculocide (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 genitalia Don clean clothes after bathing.
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 itch, become scaly, cracked, Wear clothing that promotes evaporation of
and sore perspiration.
Skin cancer Newly pigmented growth or change in existing See a physician for examination and possible
skin lesion, especially where skin is chronically biopsy.
exposed to sun Avoid direct sun exposure between 10 AM and 4 PM.
Recommend using a sun screen of SPF ≥15.
Wear a wide-brimmed hat.
Do not use artificial tanning facilities.
Fungal nail infection Thick, yellowed, rough-appearing toenails or Consult a physician about prescription drugs,
fingernails; can spread from one nail to others which are approximately 50% effective.
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
candidiasis appears as white patches or red medications.
spots on the tongue, gums, or throat. Vaginal Swish antifungal mouth rinses, retain the solution
candidiasis appears as a thick, cottage cheese– in the mouth as long as possible, and then
like discharge that causes itching and burning. swallow the rinse.
Avoid simple sugars and alcohol, because they
promote growth of yeast.
Eat yogurt that contains live Lactobacillus acidophilus
to restore a balance of helpful to harmful
microbes.
BOX 17-1 ● Advantages of Towel or Bag Baths BOX 17-2 ● Contraindications to Using a Safety Razor
❙ Reduce the potential for skin impairment because the nonrinsable cleanser Use of a safety razor is contraindicated for clients:
lubricates rather than dries the skin ❙ Receiving anticoagulants (drugs that interfere with clotting)
❙ Prevent the transmission of microorganisms that may be growing in wash basins ❙ Receiving thrombolytic agents (drugs that dissolve blood clots)
❙ Reduce the spread of microorganisms from one part of the body to another ❙ Taking high doses of aspirin
because separate cloths or regions of the towel are used ❙ With blood disorders such as hemophilia
❙ Preserve the integrity of the skin because friction is not used while drying the skin ❙ With liver disease who have impaired clotting
❙ Promote self-care among clients who may lack the strength or dexterity to ❙ With rashes or elevated or inflamed skin lesions on or near the face
wet, wring, and lather a washcloth ❙ Who are suicidal
❙ Save time compared to conventional bathing
❙ Promote comfort because the moist towel or cloths are used so quickly they
are warmer when applied
operated razor is used. When the client cannot shave, the

nurse assumes responsibility for this hygiene practice.
(a substance that attracts and traps moisture in the skin), See Nursing Guidelines 17-2.
but no soap. The nurse warms the container and its con-
tents in a microwave or warming unit or sets them in a
container of warm water before use. At the bedside, the Oral Hygiene
nurse uses a separate cloth to wash each part of the client’s
body. Rinsing is not required. Air-drying circumvents Oral hygiene consists of those practices used to clean the
the need for a towel. mouth, especially brushing and flossing the teeth. Den-
tures and bridges also require special cleaning and care.
Which method of bathing (shower, tub bath, bed/towel/
bag bath) is appropriate for (1) a 75-year-old woman NURSING GUIDELINES 17-2
with arthritis of the hips; (2) a 60-year-old man with Shaving Clients
frequent seizures; (3) a 65-year-old man who becomes
short of breath with exertion; and (4) a 72-year-old ❙ Prepare a basin of warm water, soap, face cloth, and towel. These
woman recovering from pneumonia? Explain the supplies are necessary for wetting, rinsing, and lathering the face (or
reasons for your answers. other area that requires shaving).
❙ Wash the skin with warm, soapy water. Washing removes oil,
which helps raise hair shafts.
Shaving ❙ Lather the skin with soap or shaving cream. Use of soap or shaving
cream reduces surface tension as the razor is pulled across the skin.
Shaving removes unwanted body hair. In the United ❙ Start at the upper areas of the face (or other area that requires
States, most men shave their face daily, and most women shaving) and work down (Fig. 17-5). This progression provides
shave their axillae and legs regularly. The nurse respects more control of the razor.
personal or cultural differences and asks each client about ❙ Pull the skin taut below the area to be shaved. This evens the level
his or her preferences before assuming otherwise. of the skin.
Shaving is accomplished with an electric or a safety ❙ Pull the razor in the direction of hair growth. Shaving with the hair
razor. In some circumstances, use of a safety razor is reduces the potential for irritation.
contraindicated (Box 17-2), and an electric or battery- ❙ Use short strokes. They provide more control of the razor.
❙ Rinse the razor after each stroke or as hair accumulates. Rinsing
keeps the cutting edge of the razor clean.
❙ Rinse the remaining soap or shaving cream from the skin. Rinsing
reduces the potential for drying the skin.
❙ Apply direct pressure to areas that bleed, or apply alum sulfate
(styptic pencil) at the site of bleeding. Pressure or alum helps to
promote clotting.
❙ Apply aftershave lotion, cologne, or cream to the shaved area if the
client desires it. The alcohol in lotion and cologne reduces and
retards microbial growth in the tiny abrasions caused by the razor;
cream restores oil to the skin.
FIGURE 17-4 • Giving a towel bath.
BOX 17-3 ● Advantages of Electric Toothbrushes
❙ Promote full 2 minutes of toothbrushing with 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
(Spindler, S. J. [1998]. Review of 3 electric toothbrushes. http://ourworld.

compuserve.com/homepages/Perio-Horizons/elbrush.htm; Brooke, J.
[2001]. More about power toothbrushes. http://dentistry.about.com/library/
weekly/aa030801.htm. Accessed April 2002.)
Most dentists recommend using a soft-bristled or elec-

tric toothbrush and toothpaste twice a day. For the advan-
tages of electric toothbrushes, see Box 17-3. Flossing
removes plaque and food debris from the surfaces of
FIGURE 17-5 • Shaving a client’s face. (Copyright B. Proud.) teeth 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;
Tooth Brushing and Flossing
unwaxed floss frays more quickly.
Clients who are alert and physically capable generally Although conscientious oral hygiene does not prevent
attend to their own oral hygiene. For clients confined dental problems completely, it reduces the incidence of
to bed, the nurse assembles the necessary items—a tooth- tooth and gum disease. Therefore, clients need to learn
brush, toothpaste, a glass of water, an emesis basin, how to maintain the structure and integrity of the nat-
and floss. ural teeth. See Client and Family Teaching 17-1.
Reducing Dental Disease and Injuries • If brushing is impossible, rinse the mouth with
The nurse teaches the client or family as follows: water after eating.
• Use a battery-operated oral irrigating device,
• Brush and floss the teeth as soon as possible
which uses pulsating jets of water to flush
after each meal, using the following techniques:
• Moisten the toothbrush and apply toothpaste.
debris from teeth, bridges, or braces.
• Hold a manual toothbrush at a 45-degree
• Eat fewer sweets such as soft drinks containing
angle to the teeth. sugar, candy, gum that contains fructose or
• Brush the front and back of all teeth from
another form of sugar, pastries, and sweet
gum line toward crown, using circular desserts.
motions (Fig. 17-6). • Eat more raw fruits and vegetables that natu-
• Brush back and forth over the chewing surfaces rally remove plaque and other food as they are
of the molars. chewed.
• Rinse the mouth periodically to flush loosened • Eat two or three servings of dairy products per
debris. day to provide calcium.
• Wrap an 18-inch length of floss around the • If antacids are used, select ones with calcium.
middle fingers of each hand. • Use frozen orange juice concentrate fortified
• Slide the floss between two teeth until it is with calcium.
next to the gum. • Do not use the teeth to open packages or
• Move the floss back and forth. containers.
• Repeat flossing with new sections of the floss • Use scissors rather than the teeth to cut thread.
until all the teeth have been flossed including • Do not chew ice cubes or crushed ice.
the outer surface of the last molar. • Avoid chewing unpopped or partially popped
• Use a tartar-control toothpaste or rinse containing kernels of popcorn.
fluoride. • Have dental check ups at least every 6 months.
Toothbrushing is the preferred technique for providing

oral hygiene to unconscious clients (Skill 17-4). Clients
who are not alert, however, are at risk for aspirating
(inhaling) saliva and liquid oral hygiene products into
their lungs. Aspirated liquids predispose clients to pneu-
monia. Therefore, the nurse uses special precautions to
avoid getting fluid in the client’s airway.
In addition to toothbrushing, the nurse moistens and
refreshes the client’s mouth with oral swabs. He or she
A uses various substances for oral hygiene depending on
the circumstances and assessment findings for each client
(Table 17-4).
Denture Care
Dentures (artificial teeth) substitute for a person’s lower
or upper set of teeth, or both. A bridge, a dental appliance
that replaces one or several teeth, is fixed permanently to
other natural teeth so that it cannot be removed, or it is
B
fastened with a clasp that allows it to be detached from
the mouth.
For clients who cannot remove their own dentures,
the nurse dons gloves and uses a dry gauze square or clean
face cloth to grasp and free the denture from the mouth
(Fig. 17-7). He or she cleans dentures and removable
bridges with a toothbrush, toothpaste, and cold or tepid
water. The nurse takes care to hold dentures over a plas-
tic basin or towel so they will not break if dropped.
Dentists recommend that dentures and bridges remain
C in place except during cleaning. Keeping dentures and
bridges out for long periods permits the gum lines to
change, affecting the fit. If a nurse removes a client’s
bridge or dentures during the night, he or she stores them
in a covered cup. Plain water is used most often to cover
dentures when they are not in the mouth, but some add
mouthwash or denture cleanser to the water.

Compare independent oral hygiene performed by a client
D and that administered by a nurse. How are they similar;
how are they different?
FIGURE 17-6 • (A) Brushing toward crown of teeth. (B) Brushing
chewing surfaces. (C) Preparing floss for use. (D) Using floss; about
11⁄4 inches of approximately 18 inches of wrapped floss is used at any
one time. Hair Care
Sometimes clients need assistance with grooming or

Oral Care for Unconscious Clients shampooing their hair.
Oral hygiene is not neglected because a client is uncon-
scious. In fact, because unconscious clients are not salivat- Hair Grooming
ing in response to seeing, smelling, and eating food, they
The following are recommendations for grooming clients’
need oral care even more frequently than conscious clients.
hair:
Sordes (dried crusts containing mucus, microorganisms,
and epithelial cells shed from the mucous membrane) are • Try to use a hairstyle the client prefers.
common on the lips and teeth of unconscious clients. • Brush the hair slowly and carefully to avoid damaging it.
TABLE 17-4 OPTIONAL SUBSTANCES FOR ORAL CARE

SUBSTANCE USE
Antiseptic mouthwash diluted with water Reduces bacterial growth in the mouth; freshens breath
Equal parts of baking soda and table salt in warm water, or Removes accumulated secretions
baking soda mixed with normal saline
One part of hydrogen peroxide to 10 parts of water Releases oxygen and loosens dry sticky particles; prolonged
use may damage tooth enamel
Milk of magnesia Reduces oral acidity; dissolves plaque, increases flow of saliva,
and soothes oral lesions
Lemon and glycerin swabs Increases salivation and refreshes the mouth; glycerin may
absorb water from the lips and cause them to become dry
and cracked if used for more than several days
Petroleum jelly Lubricates lips
• Brush the hair to increase circulation and distribution Shampooing

of sebum.
• Use a wide-toothed comb, starting at the ends of the Hair should be washed as often as necessary to keep it
hair rather than from the crown downward if the hair clean. A weekly shampoo is sufficient for most people, but
is matted or tangled. shampooing more or less often will not damage the hair.
• Apply a conditioner or alcohol to loosen tangles. Long-term health care facilities often employ beau-
• Use oil on the hair if it is dry. Many preparations are ticians and barbers, but if professional services are un-
available, but pure castor oil, olive oil, and mineral oil available, the nurse or delegated nursing staff member
are satisfactory. shampoos the client’s hair (Skill 17-5). Dry shampoos,
• Braid the hair to help prevent tangles. which are applied to the hair as a powder, aerosol spray,
• If hair loss occurs from cancer therapy or some other or foam, are available for occasional use. The nurse
disease or medical treatment, provide the client with a applies the cleaning agent to the hair, massages it thor-
turban or baseball cap. oughly to distribute, and brushes or towels it from the
• Avoid using hairpins or clips that may injure the scalp. hair afterward.
• Obtain the client’s or family’s permission before cut-
ting the hair if it is hopelessly tangled and cutting seems Nail Care
to be the only solution to provide adequate grooming.
Nail care involves keeping the fingernails and toenails
clean and trimmed. Clients who have diabetes, impaired
circulation, or thick nails are at risk for vascular compli-
cations secondary to trauma. The services of a podiatrist
(person with special training in caring for feet) often are
A B
FIGURE 17-7 • (A) Removing an upper denture. (B) Cleaning dentures.

indicated. It is best to check with the client’s physician tion and use. Therefore, the nurse cares for these devices
before cutting fingernails or toenails. at the same time that he or she provides other hygiene
If there are no contraindications, the nurse cares for measures.
the client’s nails as follows:
• Soak the hands or feet in warm water to soften the
keratin and loosen trapped debris. Eyeglasses
• Clean under the nails with a wooden orange stick or
other 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.
downward with a soft towel. Glass lenses are more apt to break if dropped. When not
• Use a hand-held electric rotary file made by Dremel or in use, eyeglasses are stored in a soft case or rested on
some other company or an emery board to reduce the the frame.
length of long fingernails or toenails. The nurse cleans glass and plastic lenses as follows:
• Avoid sharp or jagged points that may injure the adja- • Hold the eyeglasses by the nose or ear braces.
cent skin. • Run tepid water over both sides of the lenses (hot water
To keep the skin and nails soft and supple, the nurse damages plastic lenses).
applies lotion or an emollient cream after bathing and nail • Wash the lenses with soap or detergent.
care. If foot perspiration is a problem, he or she uses a pre- • Rinse with running tap water.
scribed antifungal, deodorant powder. Because impaired • Dry with a clean, soft cloth such as a handkerchief. Do
skin, especially on the feet, is often slow to heal and sus- not use paper tissues because some contain wood fibers,
ceptible to infection, the nurse reports any abnormal and pulp can scratch the lenses.
assessment findings immediately. To avoid injuring the Some prefer to use commercial glass cleaner, but this is
feet, clients should wear sturdy slippers or clean socks not necessary.
and supportive shoes.
Contact Lenses
VISUAL AND HEARING DEVICES
A contact lens is a small plastic disk placed directly on
Eyeglasses and hearing aids improve communication the cornea. Clients usually wear contact lenses in both
and socialization. Both represent a considerable financial eyes, but some clients who have had cataract surgery on
investment. If they become damaged or broken, the tem- one eye wear a single contact lens or a single contact
porary loss deprives clients of full sensory perception. lens and eyeglasses. The nurse should not assume that
Therefore, they should be well maintained and safely someone who wears eyeglasses does not use a contact lens,
stored when not in use. and vice versa.
Although eyeglasses and hearing aids are not body Several types of contact lenses are available: hard, soft,
structures, they are worn in close contact with the body or gas permeable (Fig. 17-8). All contact lenses, even dis-
for long periods. Consequently they tend to collect secre- posable types, need removal for cleaning, eye rest, and
tions, dirt, and debris that may interfere with their func- disinfection. People who are not conscientious about
A B
FIGURE 17-8 • Location and size of hard and soft
contact lenses. (A) Side view. (B) Front view.
following a routine for contact lens care risk infection, rates the hard lens from the cornea. If the blink method
eye abrasion, and permanent damage to the cornea. is unsuccessful, the nurse places an ophthalmic suction
When caring for a client who wears contact lenses, the cup on the lens and with gentle suction lifts the lens from
nurse asks the client to remove and to insert the lenses the eye. After removal, the nurse soaks the lenses in the
and to care for them according to his or her established storage container.
routine (Fig. 17-9). For clients who cannot do so, the
nurse may assist with the removal of the lenses or should
consult the client’s ophthalmologist (medical doctor who Artificial Eyes
treats eye disorders) or optometrist (person who prescribes
corrective lenses) about alternatives to promote adequate An artificial eye is a plastic shell that acts as a cosmetic
vision and safety. Some people, when ill, resume wear- replacement for the natural eye. There is no way to restore
ing eyeglasses temporarily, use a magnifying glass, or do vision once the natural eye is removed. The artificial eye
without any visual aid. and the socket into which it is placed need occasional
cleaning. If the client cannot care for the artificial eye, the
Contact Lens Removal nurse removes it by depressing the lower eyelid until the
Before removing contact lenses, the nurse obtains an lid margin is wide enough to allow the artificial eye to
appropriate storage container. Commercial containers slide free. The nurse irrigates the eye socket with water
are available. Because the lens prescriptions may differ or saline before reinserting the artificial eye.
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 Hearing Aids
contact lenses. The technique for removing soft contact
lenses is different than for hard contact lenses. There are four types of hearing aids:
To remove a soft contact lens, the nurse moves the lens
from the cornea to the sclera by sliding it into position • In-the-ear devices are small, self-contained aids that fit
with a clean, gloved finger. When repositioning the lens, in the outer ear.
he or she compresses the lid margins together toward the • Canal aids fit deep within the ear canal and are largely
lens. Compression bends the pliable lens, allowing air to concealed. Because of their small size, they may be dif-
enter beneath it. The air releases the lens from the surface ficult to remove and adjust.
of the eye. The nurse then gently grasps the loosened lens • Behind-the-ear devices consist of a microphone and
between thumb and forefinger for removal. Soft lenses dry amplifier worn behind the ear that delivers sound to
and crystallize if exposed to air, so the nurse immediately an internal receiver.
places them in a soaking solution in the storage container. • Body aid devices use electrical components enclosed
To remove a hard contact lens, the blink method is in a case carried somewhere on the body to deliver
the most common technique. The nurse positions and sound through a wire connected to an ear mold receiver
prepares the client similarly as for removing soft contact (Fig. 17-10).
lenses, leaving the lens in place on the cornea. He or she In-the-ear and behind-the-ear models are most com-
places the thumb and a finger on the center of the upper mon. Behind-the-ear models can be attached to an eye-
and lower lids. The nurse applies slight pressure to the glass frame. Use of body aids is most common for those
lids while instructing the client to blink, which sepa- with severe hearing loss or those who cannot care for a
small device. Hearing aids are powered by small mer-
cury or zinc batteries that need to be replaced after 100
to 200 hours of use.
Most clients insert and remove their own hearing aids,
but the nurse may need to assess and troubleshoot prob-
lems that develop (Table 17-5). Clients and their families
need to know how to maintain the hearing aid (Client
and Family Teaching 17-2).
Infrared Listening Devices
FIGURE 17-9 • Insertion of a contact lens by the client. (Copyright Infrared listening devices (IRLDs) resemble earphones
B. Proud.) attached to a hand-held receiver. They are an alternative
FIGURE 17-10 • Examples of hearing aids: in-the-ear (A), behind-

C the-ear (B), and one whose volume, pitch, and noise reduction can be
controlled by a hand-held remote control (C).
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, tip of a pin, or needle on a syringe.
Ear congestion from an upper respiratory Consult the physician about administering a
infection decongestant.
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 fully in the ear
that return sound to the Kinked receiver tubing Remove and untwist.
microphone Excessive volume Reduce volume control.
Hearing aid left on while removed from the ear Turn hearing aid off or replace it in the 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.
Older adults do not need to bathe as frequently as younger

17-2 • CLIENT AND FAMILY TEACHING adults because they have diminished perspiration and sebum
production.
Maintaining a Hearing Aid Older adults with limited range of motion in their joints from
The nurse teaches the client and family as follows: arthritis require assistance with hygiene. Long-handled bath
sponges or hand-held shower attachments help them to
• Keep a supply of extra batteries on hand. maintain independence.
• Avoid exposing the electrical components to If older adults are not rushed, chilled, or exposed, they are more
extreme heat, water, cleaning chemicals, or receptive to assistance with their personal hygiene.
hair spray. Nonskid strips on the floor of bathtubs and showers, along with
strategically placed handles and grab bars, help to reduce the
• Wipe the outer surface of a body aid or behind-
risk for falls in older adults when bathing. Grab bars should be
the-ear case occasionally. placed at arm level and within reach of the dominant arm.
• Turn the hearing aid off when not in use to A tub/shower seat is an important safety measure for older adults
prolong the life of the battery. who have mobility limitations or difficulty maintaining balance.
• Store the hearing aid in a safe place where it An elongated seat that extends outside the tub/shower may
allow older adults to sit on the chair, pivot, and slide along
will not fall or become lost.
the seat, finally bringing their legs into the tub/shower while
seated. This decreases the risk for slipping as they lift their feet
into the tub/shower. These seats also provide an area for older
adults to remain seated during most of the drying process, thus
to conventional hearing aids. An IRLD converts sound decreasing the risk for a fall secondary to bending over.
into infrared light and sends it through a wall- or ceiling- Older adults should use soap, which is extremely drying to the
mounted receiver to the person wearing the listening skin, sparingly. A mild, superfatted, nonperfumed soap such
as castile, Dove, Tone, or Basis may be preferable.
device. The light is converted back into an auditory
Bath oils can be added to a water basin when administering a
stimulus. People who need help hearing lectures, tele- bed bath to an older adult. Oils are not used in showers or
vision, or live performances are using IRLDs. Some geri- bathtubs, however, because they increase the risk for falls.
atric centers are installing IRLDs in rooms used for Avoid the use of skin care products containing alcohol or perfumes
social and recreational activities. because they tend to aggravate common dry skin conditions.
These agents also can cause allergic reactions. Over time,
One advantage of an IRLD over a conventional hear- lotions may be a medium for bacterial growth.
ing aid is that an IRLD reduces background noise, which The skin of older adults is more susceptible to tears and scratches.
is a common reason people give for not wearing their hear- Therefore, nails should be kept trimmed and smoothed.
ing aids. A disadvantage is that IRLDs cannot be used out- An emery board or nail file should be used to diminish risk
for injury. Special care should be taken with filing toenails
doors, in rooms that contain many windows, or in rooms
if circulation to the lower extremities is impaired, such as
that are brightly lit because infrared light jams the signal, with diabetes.
causing audio interference. When drying the skin of older adults, use gentle patting motions
rather than harsh, rubbing motions. Ensure that the areas
between toes are dry to prevent drying and resultant cracking.
Teach older adults and caregivers to check carefully the areas
NURSING IMPLICATIONS between the toes following each bath for breakdown, fungus,
or other infestations. Thorough inspection of the feet of older
adults is essential because feet may have ulcerations or other
Clients who require assistance with personal hygiene may lesions of which older adults are unaware.
have a variety of nursing diagnoses: Diminished ability to sense temperature changes may occur with
aging. The temperature of bath water should be checked with
• Self-Care Deficit, Bathing/Hygiene the wrist before immersing older adults in it.
• Self-Care Deficit, Dressing/Grooming Older adults who are cognitively impaired may be fearful of
• Activity Intolerance bathing, especially in a tub or shower.
Be aware of implications of terms used with older adults in relation
to their experienced history. For example, the term “we are
Nursing Care Plan 17-1 is for a client with a nursing diag- going to the showers” may promote fear in older adults who
recall WWII experiences.
nosis of Self-Care Deficit, Bathing/Hygiene, defined in the Increasing oral fluid intake or adding humidity to the air reduces
NANDA taxonomy (2005) as “impaired ability to per- the discomfort of dry skin experienced by older adults.
form or complete bathing/hygiene activities for oneself.” Modifying clothing by using Velcro closures, front zippers, elastic
waists, and oversized buttons and buttonholes facilitates an
older adult’s ability to dress and undress independently.
Prevent lower extremity skin and nail problems by encouraging
GENERAL GERONTOLOGIC older adults to purchase sturdy shoes and to replace or repair
CONSIDERATIONS them as they become worn.
Benign skin lesions such as seborrheic keratoses (tan to black
Poor hygiene and grooming in older adults are often signs of raised areas on the trunk) and senile lentigines (brown, flat
visual impairments, functional changes, dementia, depression, patches on the face, hands, and forearms) are common in
abuse, or neglect. older adults.
Self-Care Deficit: Bathing/Hygiene
ASSESSMENT
• Observe client’s motor skills, strength, and coordination to determine the extent to which he or she can perform hygiene skills.
• Determine if the client’s mental status is sufficient to follow directions, complete tasks required for hygiene, and ensure safety.
• Assess client’s level of endurance to accomplish hygiene activities such as changes in respiratory and heart rate, increased
blood pressure, pain, or fatigue when performing self-care.
Nursing Diagnosis: Self-Care Deficit: Bathing/Hygiene related to 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 suspension
applied to nondominant arm.
Expected Outcome: The client will receive assistance with bathing and oral hygiene on a
daily basis and prn.
Administer a daily bed bath at a convenient time for Scheduling hygiene according to the client’s preference
the client. and avoiding conflicts with other components of care and
treatment meets the client’s individualized needs and
avoids unnecessary interruptions.
Use castile soap that the client prefers, soft-bristled Demonstrates organization and respect for the client’s
toothbrush, and fluoride toothpaste. personal choices
Let the client use the arm in the cast to dry areas of the Facilitates participation in care and maintains self-esteem
skin that can be reached after the nurse has washed them.
Turn the client toward the arm in traction when bathing Avoids disturbing the alignment of the arm in traction
the client’s back and buttocks.
Apply client’s deodorant and body lotion located in Demonstrates respect for 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 Facilitates covering the arm suspended in traction
that fasten with snaps.
Help the client to perform oral hygiene by wrapping and Promotes self-care with modifications for using the
taping a washcloth around the handle of the toothbrush. toothbrush

• The client’s hygiene needs for bathing and oral care are completed.
• The client assists with hygiene needs to the extent possible.
• The client states, “I feel so much better about seeing my doctor and visitors after I’ve gotten cleaned up in the morning.”
Tooth loss is common in older adults as a result of periodontal

disease.
Older adults are more susceptible to impacted cerumen (ear 1. You have been assigned to two clients: a 75-year-old
wax), a common cause of hearing loss. Over-the-counter woman who is unconscious after a stroke and a 38-year-
eardrops such as Debrox are used to prevent and treat
old male mechanic being treated for an ulcer. How do
this condition. Irrigation of the ear with body-temperature
their hygiene needs differ?
tap water followed by instillation of a drying agent such
as 70% alcohol may be necessary to remove impacted 2. You are responsible for inspecting long-term care facili-
cerumen. ties such as nursing homes. What criteria should health
care agencies meet in relation to bath facilities and 2. When examining the skin of a client with psoriasis, the
hygiene policies to receive a positive evaluation? nurse is most likely to observe
1. Weeping skin lesions on the trunk of the body
2. Red skin patches covered with silvery scales
NCLEX-STYLE REVIEW Q U E S T I O N S 3. Fluid-filled blisters surrounded by crusts
1. When a health nurse visits the home of a family being 4. A red rash containing pus-filled lesions
treated for pediculosis (head lice), which of the following 3. When a client develops pruritus (itching skin), which nurs-
items should the nurse discourage? ing measure is best for relieving the client’s discomfort?
1. Pediculicide shampoo 1. Use a medicated bath with oatmeal or cornstarch.
2. Fine-toothed comb 2. Apply extra wool blankets to the bed for warmth.
3. Hair conditioner 3. Give frequent showers or tub baths.
4. Warm tap water 4. Rub the skin dry after bathing.
Skill 17-1 • PROVIDING A TUB BATH OR SHOWER
Assessment
Check the Kardex or nursing care plan for hygiene Ensures continuity of care
directives.
Assess the client’s level of consciousness, orientation, Provides data for evaluating the client’s ability to carry
strength, and mobility. out hygiene practices independently
Check for gauze dressings, plaster cast, or electrical or Maintains the client’s safety and ensures integrity of
battery-operated equipment; determine whether they treatment devices
can be protected with waterproof material or are safe if
they become wet.
Determine if and when any laboratory or diagnostic Aids in time management
procedures 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. (Copyright B. Proud.)
Planning
Clean the tub or shower if necessary. Reduces potential for spreading microorganisms
Consult with the client about a convenient time for Promotes client cooperation and participation in decision
tending to hygiene needs. making
Assemble supplies: floor mat, towels, face cloth, soap, Demonstrates organization and efficient time management
clean 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° to Demonstrates concern for the client’s safety and comfort
110°F (40° to 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 Ensures privacy
door.
(continued)
PROVIDING A TUB BATH OR SHOWER (Continued)
Help the client into the tub or shower if he or she needs Reduces the risk of falling
assistance 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
Have the client sit on a stool or seat in the tub or shower Ensures safety
if the client will have difficulty exiting the tub or may
become weak while bathing (Fig. B).
Shower chair. (Copyright 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 Shows respect for privacy yet concern for safety
and 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; Reduces spread of microorganisms and demonstrates
dispose of soiled linen in its designated location. concern 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
*Generally, nurses document routine hygiene measures on a checklist, but for teaching purposes an example of
narrative charting has been provided.
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
Wash hands or perform hand antisepsis with an alcohol Reduces spread of microorganisms
rub (see Chap. 10).
Gather gloves, soap, water, and clean cloths or antiseptic Provides a means of removing debris and microorganisms
wipes 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 Provides access to the perineum
with a bath blanket (Fig. A).
Positioning and draping the client. (Copyright B. Proud.)
Pull and fan-fold the top linen to the foot of the bed while Maintains client modesty and keeps upper linen clean and dry
the client holds the top of the blanket.
For a female client, place a disposable pad beneath the Helps to absorb liquid that may drip during cleansing
buttocks or place the client on a bedpan; for a male client,
place a disposable 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
Separate the folds of the labia and wash from the pubic Cleanses in a direction from less soiled to more soiled;
area toward the anus (Fig. B). Never go back over an prevents reintroducing microorganisms into previously
area that you already have cleaned. cleaned areas
(continued)
ADMINISTERING PERINEAL CARE (Continued)
Cleansing the labia.
Use a clean area of the cloth or a separate antiseptic wipe Avoids resoiling already clean areas
for each stroke.
Wash debris on the outside of a urinary catheter, if one Reduces the number and growth of microorganisms that
exists, especially where it is in contact with mucous may ascend to the bladder
membrane and genital tissue.
Squeeze the antiseptic solution container, if one is used, Ensures that solution will drain toward more soiled body
starting at the upper areas of the labia down toward areas; prevents reintroducing microorganisms into
the anus (Fig. C). previously cleaned areas
Rinsing the perineum.
(continued)
For males, grasp the penis; if the client is uncircumcised, Facilitates removing debris and secretions that may be
retract the foreskin. trapped beneath the fold of skin
Clean the tip of the penis using circular motions (Fig. D). Keeps the urethral opening clean
Never go back over an area that you already have cleaned.
Cleansing the glans penis.
Replace the foreskin. Prevents trauma

Wipe the shaft of the penis toward the scrotum (Fig. E). 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
microorganisms
Pat the skin dry with a towel. Removes excess moisture
(continued)
Turn the client to the side and wash from the perineum Cleans in a direction toward more soiled body areas
toward 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 Promotes cleanliness and reduces contact between the
menstruating or have other types of vaginal or rectal skin and moist drainage
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 Controls the spread of microorganisms
appropriate container.
Empty and rinse the bedpan. Controls the spread of microorganisms
Remove gloves and wash hands or perform hand Reduces the spread of microorganisms
antisepsis with an alcohol rub (see Chap. 10).
Attend to the client’s comfort and safety. Demonstrates concern for the client’s welfare
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 BATH
Assessment
Check the Kardex or nursing care plan for hygiene Ensures continuity of care
directives.
Inspect the skin for signs of dryness, drainage, or Provides data for determining whether a complete or
secretions. partial bath is appropriate
Planning
Consult with the client to determine a convenient time for Promotes client cooperation; allows client participation in
tending to hygiene needs. decision making
Assemble supplies: bath blanket, towels, face cloths, soap, Demonstrates organization and efficient time management
wash basin, clean pajamas or gown, clean bed linen,
other hygiene articles such as deodorant or
antiperspirant, and a razor for males.
Implementation
rub (see 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 Prepares the client for washing the anterior body surface
client 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 Keeps linen, which may be reused, clean
fan-fold 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° to 110°F (40° to 43°C) water; place Provides comfortably warm water for bathing within
the basin on the overbed table. easy access
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.
A
(continued)
GIVING A BED BATH (Continued)
Wipe each eye with a separate corner of the mitt from the Prevents getting soap in the eyes
nose toward the ear (Fig. B).
Wiping the eyes.
Lather the wet washcloth with soap and finish washing Removes oil, sweat, and microorganisms
the face.
Rinse the washcloth and remove soapy residue from the Prevents drying the skin
face, then dry well.
Bathe each of the client’s arms separately; the axillae may Cleanses soiled material and keeps the client from
be included now or when the chest is washed (Fig. C). becoming too chilled
Washing the arm.
Offer to apply deodorant or antiperspirant after washing Demonstrates respect for the client’s usual hygiene
the axillae. practices; 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.
D (continued)
GIVING A BED BATH (Continued)
Discard and replace the water in the basin; rinse the Eliminates debris, microorganisms, and soap residue and
washcloth 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, then the feet following Follows the principle of washing from cleaner to more
the steps described for the upper body (Fig. E). soiled areas
Washing a leg.
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 of the body
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. Reduces the potential for contact with lesions or drainage
Dry thoroughly. that 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
Date and Time Complete bed bath given. Client could wash face and genitals independently. Skin is intact. No dyspnea
noted during bath. SIGNATURE/TITLE
*Generally, nurses document routine hygiene measures on a checklist, but for teaching purposes an example of
narrative charting has been used.
Skill 17-4 • GIVING ORAL CARE TO UNCONSCIOUS CLIENTS
Assessment
Check the nursing care plan about the frequency of oral Maintains continuity of care
hygiene.
Inspect the client’s mouth. Helps to determine equipment and supplies needed
Look for oral hygiene supplies that may be at the client’s Controls costs
bedside already.
Planning
Arrange to brush the client’s teeth once per shift and to Promotes a schedule for removing plaque and
provide additional oral care at least every 2 hours if microorganisms and moistening and refreshing
necessary. 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 agencies may stock a toothbrushing device
connected directly to a suction catheter (Fig. A).
Using a toothbrushing device.
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 Prevents liquids from draining into the airway
lowered.
Place a towel beneath the head. Absorbs liquids
Connect a Yankeur suction tip or catheter to a portable or Promotes safety
wall-mounted suction source.
Spread toothpaste over a moistened toothbrush. Prepares the toothbrush for use
(continued)
GIVING ORAL CARE TO UNCONSCIOUS CLIENTS (Continued)
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 Serves as a safe substitute for the nurse’s fingers
mouth and separate the teeth (see Fig. A).
Brush all tooth surfaces with the toothbrush (Fig. B). Removes plaque and microorganisms
Brushing with tongue blade separating teeth.
Instill water and suction the mouth with a bulb syringe or Removes debris and reduces the potential for aspiration
Yankeur suction device (Fig. C).
Rinsing and suctioning.
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 Demonstrates concern for the client’s dignity and welfare
of comfort and safety.
Evaluation
• The teeth are clean.
• The oral mucosa is smooth, pink, moist, and intact.
• Safety is maintained.
(continued)
GIVING ORAL CARE TO UNCONSCIOUS CLIENTS (Continued)
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
*Generally, the nurse documents routine hygiene measures on a checklist, but for teaching purposes an
example of narrative charting has been used.
Skill 17-5 • SHAMPOOING HAIR
Assessment
Inspect the client for oily and limp hair or signs of Provides data to determine the need for shampooing and
accumulating secretions or lesions on the scalp. what supplies may be appropriate to use
Assess for respiratory symptoms, pain, or other conditions Aids in establishing priorities for care
that increase or contribute to activity intolerance.
Determine if and when medical treatments or tests are Ensures that hygiene measures will not interrupt
scheduled. therapeutic or 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 Involves the client in decision making
for shampooing.
Assemble equipment, which may include shampoo, Promotes organization and efficient time management
conditioner, hair oil treatment, towels, water pitcher,
and 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 Absorbs moisture
with towels; cover the client’s chest and shoulders
with a towel.
(continued)
SHAMPOOING HAIR (Continued)
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
Work the shampoo into a lather. Facilitates cleansing throughout the hair
Rinse the hair with water (Fig. A). Removes oil and shampoo from the hair
Shampooing the hair using a shampoo trough.
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 Facilitates hair care
direct contact with blood or secretions.
Comb, braid, or style the hair according to the client’s Promotes self-esteem
preference.
Clean and store shampooing supplies. Restores cleanliness and order to the client environment
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
18
Chapter
Comfort, Rest,
and Sleep
WORDS TO KNOW
apnea hypnotic nocturnal sleep apnea/hypopnea
bruxism hypopnea polysomnography syndrome
cataplexy hypoxia occupied bed sleep diary
circadian rhythm insomnia parasomnia sleep paralysis
climate control jet lag photoperiod sleep rituals
comfort massage phototherapy sleep–wake cycle disturbance
drug tolerance mattress overlay progressive somnabulism
environmental melatonin relaxation stimulants
psychologist microsleep relative humidity sundown syndrome
humidity multiple sleep rest sunrise syndrome
hypersomnia latency test restless legs thermoregulation
hypersomnolence narcolepsy syndrome tranquilizer
hypnogogic nocturnal sedative unoccupied bed
hallucinations enuresis sleep ventilation
LEARNING OBJECTIVES
● Differentiate among comfort, rest, and sleep.
● Describe four ways to modify the client environment to promote comfort, rest, and sleep.
● List four standard furnishings in each client room.
● State at least five functions of sleep.
● Describe the two phases of sleep and their differences.
● Describe the general trend in sleep requirements as a person ages.
● Name 10 factors that affect sleep.
● List four categories of drugs that affect sleep.
● Name four techniques for assessing sleep patterns.
● Describe four categories of sleep disorders.
● Discuss at least five techniques for promoting sleep.
● Name two nursing measures that promote relaxation.
● Discuss unique characteristics of sleep among older adults.
COMFORT (state in which a person is relieved of distress) facilitates rest (waking state char-
acterized by reduced activity and mental stimulation) and sleep (state of arousable
unconsciousness). One factor that contributes to comfort is a safe, clean, and attractive
environment.
This chapter addresses measures for ensuring that the setting for client care pro-
motes a sense of well-being. It includes measures for maintaining the order and clean-
liness of the client’s bed and room and describes nursing interventions that facilitate
rest and sleep.
387
Climate Control
THE CLIENT ENVIRONMENT
means mechanisms for maintaining tem-
Climate control
perature, humidity, and ventilation. It is a method of pro-
The term environment, as used here, refers to the room
moting physical comfort.
where the client receives nursing care and its furnishings.
In a broader sense, however, the health care facility’s TEMPERATURE AND HUMIDITY. Most clients are comfort-
location and design involve many other subtle elements able when the room temperature is 68° to 74°F (20° to
that influence the consumer’s overall impression of the 23°C). Newer buildings provide thermostats in each room
institution. so that the temperature can be adjusted to suit the client.
Most clients are unaware of the thought and consider- Humidity (amount of moisture in the air) and relative
ation that go into their surroundings. Accessible parking, humidity (ratio between the amount of moisture in the air
lighting inside and outside the physical plant, landscap- and the greatest amount of water vapor the air can hold at
ing, barriers that reduce traffic noise, and signage that a given temperature) affect comfort. At a relative humid-
helps clients to find their way around the building create ity of 60%, the air contains 60% of its potential water
a positive appeal among those in need of health care. capacity. A relative humidity of 30% to 60% is comfort-
able for most clients.
If the environmental temperature becomes greater
Client Rooms
than the skin temperature, evaporation is the only mech-
anism for regulating body temperature. Evaporation is
Client rooms resemble bedrooms but are no longer the
reduced when humidity levels rise because air that is
bare, white, sterile environments of a few decades ago.
almost or fully saturated with water cannot absorb addi-
Thanks to environmental psychologists (specialists who
tional moisture. Therefore, instead of evaporating, sweat
study how the environment affects behavior and well-
accumulates and drips from the skin. Many agencies are
being), client rooms are now brighter, more colorful, and
air-conditioned. Electric fans and dehumidifiers are not
tastefully decorated. The wall and floor treatments, light-
always an adequate substitute but may be used if air con-
ing, and mechanisms for maintaining climate control are
ditioners are not available. In buildings where the air is
practical and conducive to comfort.
dry, a humidifier or a cool mist machine can add moisture
Walls to the environment. Clients who have ineffective thermo-
regulation (ability to maintain stable body temperature)
Blue and colors with blue tints, such as mauve and light may feel hot or cold even when the temperature and
green, promote relaxation, so these color schemes are pre- humidity are optimal.
ferred within health care settings and client rooms. If they
are not used exclusively, they are integrated into wallpaper VENTILATION. At home, methods of ventilation (move-
trim and decorative accessories such as framed pictures. ment of air) include opening windows or using ceiling
The art often depicts country scenes and peaceful images. fans. In hospitals and nursing homes, however, open
windows are a fire and safety hazard, and ceiling fans
Floors spread infectious microorganisms. Consequently, venti-
Because noise interferes with comfort, the hallways and lation usually occurs through a system of air ducts that
work stations are carpeted in most agencies. The floors circulate air in and out of each client room.
in client rooms have tile or linoleum surfaces to facilitate Poorly ventilated rooms and buildings tend to smell
the cleaning of spills. badly. Removing soiled articles, emptying bedpans and
urinals, and opening privacy curtains and room doors
Lighting help to reduce odors. An alternative is to use an air fresh-
ener or deodorizer; generally, however, scented sprays
Adequate lighting, both natural and artificial, is impor- substitute one odor for another, and ill clients usually
tant to the comfort of clients and nursing personnel. find any strong smell disagreeable. Nurses should be con-
Newer buildings have large window areas, atriums, sky- scientious about their own body and oral hygiene, refrain
lights, and enclosed courtyards to facilitate exposure to from wearing overpowering perfume, and avoid smelling
sunlight as a technique for reducing stress. of cigarette smoke.
Bright artificial light facilitates nursing care but is not
conducive to client comfort. Therefore, most client rooms
have multiple lights in various locations with adjustable Room Furnishings
intensity. Dim light and darkness promote sleep; however,
injuries are more likely in dark and unfamiliar environ- Manufacturers of hospital furnishings attempt to design
ments. Therefore, client rooms have adjustable window equipment that is both attractive and practical (Fig. 18-1).
blinds and night lights near the floor. The bed and its components, mattress and pillow, chairs,
C H A P T E R 18 ● Comfort, Rest, and Sleep 389
Full or half side rails are attached to the bed frame.

There is controversy as to whether raised side rails are a
risk or benefit because some clients climb over them
rather than seek nursing assistance. Side rails are consid-
ered a form of physical restraint in long-term care facili-
ties, and their use must be justified (Omnibus Budget
Reconciliation Act of 1987; see Chap. 19).
Some beds have removable headboards (Fig. 18-2). This
facilitates resuscitation efforts if the client experiences res-
piratory or cardiac arrest. Removing the headboard gives
the code team responders better access for airway intuba-
tion. Placing the headboard under the client’s upper body
allows more effective cardiac compression than is possible
on a mattress.
MATTRESS. Many people equate the comfort of a bed

FIGURE 18-1 • Typical hospital room furnishings. (Copyright B. Proud.)
with the quality of the mattress. A good mattress adjusts
to the shape of the body while supporting it. A mattress
that is too soft alters the alignment of the spine, causing
overbed table, and bedside stand must be safe, durable, some people to awaken feeling sore from muscle and
and comfortable. joint strain.
Hospital mattresses generally consist of tough materi-
The Bed als that will withstand long-term use. Because mattresses
Hospital beds are adjustable—that is, the height and are washed but not sterilized between uses, they are cov-
position of the head and knees can be changed either ered with a waterproof coating that withstands cleaning
electronically or manually. Adjusting the bed promotes with strong antimicrobial solutions.
comfort, enables self-care, and facilitates a therapeutic Occasionally mattress overlays (layers of foam or other
position (see Chap. 23). Hospital beds usually remain in devices placed on top of the mattress; Fig. 18-3) are
their lowest position except when clients are receiving used to promote comfort or to keep the skin intact (see
nursing care or during a change of bed linens. Skill 18-1 Chap. 23). Box 18-1 lists clients for whom a mattress
describes how to make an unoccupied bed (changing linen overlay or therapeutic mattress of foam, gel, air, or water
when the bed is empty). is appropriate.
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. (Copyright B. Proud.)
able, absorbent pads are placed between the client and

the bottom sheet to avoid the need to change the entire
bed when linen becomes soiled. Skill 18-2 explains how
to make an occupied bed (changing linen while the client
remains in bed).

List situations when it would be appropriate to change
some linen when providing client care and other situa-
tions in which it is more appropriate to change all linen.
Privacy Curtain
A privacy curtain is a long fabric partition mounted from
the ceiling. It can be drawn completely around each
client’s bed. The privacy curtain preserves the client’s dig-
nity and modesty whenever it is necessary to examine or
FIGURE 18-3 • A waterproof mattress cover protects the mattress over-
lay. (Copyright B. Proud.)
expose him or her for care. It also is used to shield a client
from observation while using a urinal or bedpan.
PILLOWS. Pillows primarily are used for comfort, but Overbed Table
they also are used to elevate a part of the body, relieve An overbed table is a portable, flat platform positioned
swelling, promote breathing, or help to maintain a ther- over the client’s lap. The height of the table is adjustable
apeutic position (see Chap. 23). Pillows are stuffed with depending on whether the bed is in a high or low posi-
foam, kapok (a mass of silky fibers), or feathers. tion. The overbed table makes it convenient for the client
to eat while in bed and to perform personal hygiene or
BED LINEN. The linen used for most hospital beds includes other activities requiring a flat surface. Nurses also use
the following articles: the overbed table to hold equipment when providing
• Mattress pad client care. Most overbed tables have a concealed com-
• Bottom sheet that is sometimes fitted partment that may contain a mounted mirror and a place
• Optional draw sheet that is placed beneath the client’s for personal items (hairbrush, comb, cosmetic bag, razor,
hips or book).
• Top sheet
• Blanket, depending on the client’s preference Bedside Stand
• Spread
A bedside stand is actually a small cupboard. It usually
• Pillowcase
contains a drawer for personal items and two shelves. The
Some hospitals use printed sheets to provide a more home- upper shelf is used to store the client’s bath basin, soap
like atmosphere. dish, soap, and a kidney-shaped basin called an emesis
To control expenses, bed linen may not be changed basin. The lower shelf is used to store a bedpan, urinal,
every day, but any wet or soiled linen is changed as fre- and toilet paper. The elimination utensils are kept sepa-
quently as necessary. Sometimes folded sheets or dispos- rate from the hygiene supplies to reduce the transmission
of microorganisms. A carafe of water and a drinking con-
tainer are placed atop the bedside stand.
BOX 18-1 ● Client Criteria for Mattress Overlay
or Therapeutic Mattress Chairs
❙ Complete immobility Generally there is at least one chair per client in each
❙ Limited mobility room. Hospital chairs usually are straight-backed to facil-
❙ Impaired skin integrity itate good postural support. The best sitting position is
❙ Inadequate nutritional status
❙ Incontinence of stool, urine, or both
when the hips, knees, and ankles are all at 90° angles.
❙ Altered tactile perception There may be one upholstered chair in each client room.
❙ Compromised circulatory status Although upholstered chairs are more comfortable, some
clients find that rising from them is difficult.
Awake:
SLEEP AND REST low-voltage, fast
No matter how comfortable the physical environment or

how attractive and homelike the furnishings, failure to
promote rest and sleep may sabotage or prolong recuper-
ation. Although sleep requirements vary, alterations in Awake eyes closed:
sleep patterns can have serious physical and emotional alpha-waves, 8–12 cps
consequences.
Functions of Sleep
NREM:
In addition to promoting emotional well-being, sleep en- Stage 1:
hances various physiologic processes. Although the exact theta-waves, 3–7 cps
mechanisms are not totally understood, the restorative
functions of sleep can be inferred from the effects of sleep
deprivation (Box 18-2). Sleep is believed to play a role in
the following:
Stage 2:
• Reducing fatigue 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 REM:
eye movements are either subdued or energetic. low-voltage mixed frequency
Nonrapid eye movement sleep, which progresses sawtoothed waves
through four stages, is also called slow wave sleep because
during this phase electroencephalographic (EEG) waves
appear as progressively slower oscillations. The REM sawtooth
phase of sleep is referred to as paradoxical sleep because FIGURE 18-4 • Characteristic electroencephalogram waveforms by
the EEG waves appear similar to those produced during sleep stage. cps, Cycles per second. (From Craven, R. F., & Hirnle, C. J.
[2006]. Fundamentals of nursing: Human health and function [5th ed.].
Philadelphia: Lippincott Williams & Wilkins.)
BOX 18-2 ● Effects of Chronic Sleep Deprivation

periods of wakefulness (Fig. 18-4), but it is the deepest
❙ Reduced physical stamina stage of sleep. Thus, NREM sleep is characterized as quiet
❙ Altered comfort, such as headache and nausea sleep and REM sleep as active sleep.
❙ Impaired coordination, especially of fine motor skills
❙ Loss of muscle mass and weight
❙ Increased susceptibility to infection
❙ Slower wound healing Sleep Cycles
❙ Decreased pain tolerance
❙ Poor concentration
❙ Impaired judgment During sleep, people alternate through NREM and REM
❙ Unstable moods phases (Table 18-1). NREM sleep normally precedes REM
❙ Suspiciousness sleep, the phase during which most dreaming occurs.
Although the time spent in any one phase or stage varies
TABLE 18-1 CHARACTERISTICS OF SLEEP PHASES

SLEEP PHASE LENGTH FEATURES
NREM 50–90 minutes Deep, restful, dreamless sleep

Stage 1 A few minutes Light sleep, easily aroused
Gradual reduction in vital signs
Stage 2 10–20 minutes Deeper relaxation
Can be awakened with effort
Stage 3 15–30 minutes Early phase of deep sleep
Snoring
Relaxed muscle tone
Little or no physical movement
Difficult to arouse
Stage 4 15–30 minutes; shortens Deep sleep
toward morning Sleep-walking, sleep-talking, and bed-
wetting may occur
REM 20-minute average; Darting eye movements
lengthens toward Very difficult to awaken
morning 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 seconds
Absence of snoring
Muscle twitching
Gastric secretions increase
Men may have erections
according to age and other variables, most people cycle time spent in stages 3 and 4 of NREM decreases, while
between stages 2, 3, and 4 of NREM to REM phases four periods of REM sleep increase (Fig. 18-5). According to
to six times during the night. the National Sleep Foundation’s 2005 poll on Sleep in
America (http://www.sleepfoundation.org), older adults
sleep more on weeknights, but younger adults sleep more
Sleep Requirements on weekends. Older adults nap more than younger adults,
a fact that may be attributed to daytime inactivity or
Sleep requirements vary among different age groups. reduced mental stimulation.
The need for sleep decreases from birth to adulthood,
although individuals vary (Table 18-2). With age, the
Factors Affecting Sleep
Approximately 49% of adults surveyed rate their sleep

TABLE 18-2 SLEEP REQUIREMENTS
as good compared with 74% of older adults (National
PERCENTAGE Sleep Foundation, 2005). The latter finding is surprising
AGE TOTAL SLEEP TIME IN REM because older adults awaken more frequently during the
night for several reasons: pain; smaller bladder capacity,
Newborn 16–20 hours/day 50% which results in an increased need to urinate; dementia-
3 months–1 year 14–15 hours/day 35% related sleep problems; side effects from medications
Toddler 12 hours/night No data such as diuretics and antihypertensives; and diminished
plus 1 or 2 naps
production of neurochemicals, such as melatonin, that
Preschool 9–12 hours/night No data
promote sleep. Other factors not related to age also affect
5–6 years 11 hours/night 20%
the amount and quality of a person’s sleep (Table 18-3).
11 years 9 hours/night No data
Adolescent 7–9 hours/night 25%
Light
Adult 7–9 hours/night 20%–25%
Elderly 7–9 hours/night 13%–15% Daylight and darkness influence the sleep–wake cycle. Cir-
cadian rhythm (phenomena that cycle on a 24-hour basis) is
Younger Older
Awake
REM sleep
FIGURE 18-5 • The time spent in REM Deep sleep

and NREM sleep is different in younger
adults than in older adults. 11 p.m. to 6 a.m. 11 p.m. to 6 a.m.
a term derived from two Latin words: circa (about) and light, the pineal gland secretes melatonin (hormone that
dies (day). Thus, drowsiness and sleep correlate with the induces drowsiness and sleep); light triggers suppression
circadian rhythm of the setting sun and night. Wakeful- of melatonin secretion.
ness corresponds with sunrise and daylight.
Researchers (Rosenthal et al., 1984) have suggested Activity
that the cycles of wakefulness followed by sleep are
linked to a photosensitive system involving the eyes and Activity, especially exercise, increases fatigue and the
the pineal gland in the brain (Fig. 18-6). Without bright need for sleep. Activity appears to increase both REM and
NREM sleep, especially the deep sleep of NREM stage 4.
When physical activity occurs just before bedtime, how-
ever, it has a stimulating rather than relaxing effect.
TABLE 18-3 FACTORS AFFECTING SLEEP
Environment
SLEEP-PROMOTING SLEEP-SUPPRESSING
FACTORS FACTORS Most people sleep best in their usual environment: they
develop a preference for a particular pillow, mattress,
Darkness, dim light Sunlight, bright light
Consistent sleep schedule Inconsistent sleep schedule
Secretion of melatonin Suppression of melatonin
Familiar sleep environment Strange sleep environment
Optimal warmth and Cold, hot, stuffy room
ventilation
Performance of sleep rituals Disturbance of sleep rituals
Sedative, hypnotic drugs Stimulant drugs
Depression Depression, anxiety, worry
Relaxation Activity
Satiation Hunger, thirst
Proteins containing Protein-deficient diets
L-tryptophan
Excessive alcohol Metabolism of alcohol

consumption
Comfort Pain, nausea, full bladder
Quiet Noise
Effortless breathing Difficulty breathing FIGURE 18-6 • A photosensitive light system influences the sleep–
wake cycle.
and blankets. They also tend to adapt to the unique sounds Illness
of where they live such as traffic, trains, and the hum of
Stress, anxiety, and discomfort accompany almost any
appliance motors or furnaces.
illness, which can alter normal sleep patterns. In the hos-
In addition, sleep rituals (habitual activities performed
pital, other factors that contribute to sleep loss or fragmen-
before retiring) induce sleep. Examples include eating a
tation include being aroused by noise from equipment,
light snack, watching television, reading, and performing
awakened for nursing activities, and disturbed by unfa-
hygiene. Therefore, alterations in the environment or
miliar sounds such as loud talking, elevators, dietary
the activities performed before bedtime—such as occur
carts, and housekeeping equipment.
during vacation or in the hospital—negatively affect a
Several medical disorders involve symptoms that are
person’s ability to fall and remain asleep.
aggravated at night or can disturb sleep. For example,
ulcers tend to be more painful during the night because
Motivation hydrochloric acid increases during REM sleep. In fact,
When a person has no particular reason to stay awake, pain of any kind is more distressing when distractions
sleep generally occurs easily. But if the desire to remain are few. Conditions worsened by lying flat in bed, such
awake is strong, such as when a person wishes to partic- as some cardiac, respiratory, and musculoskeletal dis-
ipate in something interesting or important, the desire to orders, contribute to sleeplessness.
sleep can be overcome.
Drugs
Emotions and Moods Caffeine and alcohol, which have already been discussed,
Depressive disorders classically are associated with an are nonprescription drugs that affect sleep. Some pre-
inability to sleep or the tendency to sleep more than usual. scribed drugs also can promote or interfere with sleep.
Also, emotions such as anger, fear, anxiety, and dread Sedatives and tranquilizers (drugs that produce a relaxing
interfere with sleep. All are more than likely the result of and calming effect) promote rest, a precursor to sleep.
changes in the types and amounts of neurotransmitters Hypnotics are drugs that induce sleep. Stimulants (drugs
that affect the sleep–wake center in the brain. that excite structures in the brain) cause wakefulness
Sometimes sleeplessness is conditioned—that is, antic- (Table 18-4).
ipating sleeplessness, a characteristic pattern of some Some sedatives and hypnotics have a paradoxical
chronic insomniacs, actually reinforces it (a self-fulfilling effect when administered to older adults: they tend to
prophecy). The expectation that the onset of sleep will be produce restlessness and wakefulness instead of sleep.
difficult increases the person’s anxiety. The anxiety then Also, people who take sedative and hypnotic drugs for a
floods the brain with stimulating chemicals that interfere period tend to develop drug tolerance (diminished effect
with relaxation, a prerequisite for natural sleep. from the drug at its usual dosage range). Without realiz-
ing the danger, these people may increase the dose of the
drug or the frequency of its administration to achieve the
Food and Beverages same effect first experienced at a lower dose. Increasing
Hunger or thirst interferes with sleep. The consumption the dose or frequency has potentially life-threatening
of particular foods and beverages also may promote or consequences.
inhibit the ability to sleep. When sedatives, tranquilizers, and hypnotics are
Sleep is facilitated by a chemical known as abruptly discontinued, this causes a period of intense
L-tryptophan, found in protein foods such as milk and stimulation that interferes with sleep.
dairy products. The recommendation to drink warm milk Some drugs that increase the formation of urine, such
to induce sleep may have originally been an anecdotal as diuretics, may awaken those who take them with a
observation of its hypnotic (sleep-producing) effect. need to empty the bladder. For this reason, diuretics gen-
L-tryptophan is also present in poultry, fish, eggs, and, to erally are administered early in the morning so that the
some extent, plant sources of protein such as legumes. peak effect has diminished by bedtime.
Alcohol is a depressive drug that promotes sleep, but
it tends to reduce normal REM and deep-sleep stages of
NREM sleep. As alcohol is metabolized, stimulating chem-
icals that were blocked by the sedative effects of the alco-
SLEEP ASSESSMENT
hol surge forth from neurons, causing early awakening.
Beverages containing caffeine, a central nervous system Many people blame inadequate sleep for daytime fatigue,
stimulant, cause wakefulness. Caffeine is present in cof- or they underestimate the actual time they sleep. Nurses
fee, tea, chocolate, and most cola drinks. can obtain a more accurate sleep pattern assessment
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
through sleep questionnaires, sleep diaries, polysomno- he or she is asleep, describes daily activities during each
graphic evaluation, and a multiple latency sleep test. 15-minute waking period, completes a 24-hour log of
consumed food and beverages, and notes when he or she
takes any medications. These self-kept diaries generally
Questionnaires cover a 2-week period.
Although sleep diaries and questionnaires are inex-
Several questionnaires have been developed to help to pensive and simple to compile, they vary in accuracy and
identify sleep patterns. They are either designed to reliability (Libman et al., 2000). Therefore, sleep assess-
obtain specific information or are unstructured to give ments include other objective diagnostic techniques for
the person more freedom to respond. Nurses can gather gathering data to ensure accurate identification of sleep
data during interviews, or clients can answer the ques-
disorders and their etiologies.
tions independently in the form of a self-report.
Examples of questions for the client include the
following:
Nocturnal Polysomnography
• When you think about your sleep, what kinds of
impressions come to mind? Nocturnal polysomnography is a diagnostic assessment
• Does anything about your sleep bother you? technique in which a client is monitored for an entire
• Do you fall asleep at inappropriate times? night’s sleep to obtain physiologic data. It generally
• Do you wake feeling rested? takes place in a sleep disorder clinic, but it is now pos-
• How long does it take you to fall asleep? sible to conduct the study at the client’s home; a tech-
• Do you feel stiff and sore in the morning? nician monitors a computerized recording system up to
• Have you been told that you stop breathing while 60 feet away.
asleep? Dime-sized sensors attached to the head and body
• Do you fall sleep during physical activities? (Fig. 18-7) record the following:
• What do you do to help yourself sleep well?
• Brain waves
Examples of questions for members of the client’s house-
• Eye movements
hold include the following:
• Muscle tone
• Does the client snore or gasp for air when sleeping? • Limb movement
• Does the client kick or thrash around while sleeping? • Body position
• Does the client sleep-walk? • Nasal and oral airflow
• Chest and abdominal respiratory effort
• Snoring sounds
Sleep Diary • Oxygen level in the blood
A sleep diary is a daily account of sleeping and waking The diagnostic data are compared with the patterns
activities. The client or personnel compile the informa- and characteristics of normal sleep cycles to help to diag-
tion in a sleep disorder clinic. The client notes the times nose sleep disorders.
Sleep Disorders, 1998). Many of those affected do

not seek treatment. Most problems are short-lived,
but some sleep disorders are both chronic and serious.
The four categories of sleep disorders are insom-
nia, hypersomnia, sleep–wake cycle disturbance, and
parasomnia.
Insomnia
Insomnia means difficulty falling asleep, awakening fre-

quently 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.
According to the American Psychiatric Association
(2000), insomnia is considered a sleep disturbance if
it occurs over at least 1 month. Although chronic insom-
nia can be treated with hypnotic drugs, it is helpful to
start treatment with nonpharmacologic interventions.
Promoting Sleep
FIGURE 18-7 • Providers evaluate normal sleep patterns and sleep The nurse teaches the client or the family
disorders by collecting physiologic data. as follows:
• Resist napping during the day.
• Use the bed and bedroom just for sleeping.
Multiple Sleep Latency Test
• Perform sleep rituals.
• Go to bed and get up at approximately the same
A multiple sleep latency test (assessment of daytime sleepi-
ness) is another helpful study. The person undergoing time, even on weekends or days off.
this test is asked to take a daytime nap at 2-hour inter- • If you cannot get to sleep for more than 20 to
vals while attached to sensors similar to those used in 30 minutes, get out of bed and do something
polysomnography. The client is allowed to nap for about else such as reading.
20 minutes. The nap periods are repeated four or five • Try a bedtime relaxation tape that plays soothing
times throughout the day. music, sounds of nature, or a constant background
Clients who have certain sleep disorders causing day- sound (white noise).
time sleepiness have a short latency period—that is, they • Exercise regularly during the day but not late in
fall asleep in less than 5 minutes. Most well-rested per- the evening.
sons take an average of 15 minutes before they experi- • Avoid alcohol, nicotine, and caffeine.
ence the onset of daytime sleep. • Eat dairy products and other proteins daily.
Experiencing early REM sleep is also a pathologic find- • Modify the temperature and ventilation in the
ing that can be detected during a multiple sleep latency bedroom according to personal preferences.
test. A REM period normally does not occur for at least • Use earplugs or eyeshades to reduce environ-
1 hour and after cycling through the first four stages mental noise or light.
of NREM. Therefore, REM should not occur during a • Avoid using nonprescription or prescription
20-minute test nap. sleeping pills unless they have been recom-
mended by a physician. Hypnotics should be
used on a short-term basis only.
SLEEP DISORDERS • Try drinking chamomile tea, which some claim
improves sleep.
About 40 million Americans have some type of sleep • Follow label directions on any medications.
disorder; an additional 20 to 30 million have intermit- • If a diuretic drug is prescribed, take it early in
tent sleep-related problems (National Commission on the morning.
Hypersomnia The incidence of sleep apnea is highest among older

adults, especially obese men who snore. Methods to reduce
Hypersomnia is a sleep disorder characterized by feeling apneic episodes include sleeping in other than the supine
sleepy despite getting normal sleep. Two conditions of position, losing weight, and avoiding substances that
hypersomnia are narcolepsy and sleep apnea/hypopnea depress respirations such as alcohol or sleeping medica-
syndrome. tions. In severe cases, clients wear a special breathing
mask that keeps the alveoli inflated at all times. Surgery
Narcolepsy on the tonsils, uvula, pharynx, tongue, or epiglottis is
another treatment option when conservative measures
Narcolepsy is characterized by the sudden onset of day-
are ineffective.
time sleep, short NREM period before the first REM
phase, and pathologic manifestations of REM sleep. This
disabling condition should not to be confused with hyper-
somnolence, which is excessive sleeping for long periods, Sleep–Wake Cycle Disturbances
as in Washington Irving’s 1819 American folk story, Rip
Van Winkle. A sleep–wake cycle disturbance results from a sleep schedule
Although the diagnosis of narcolepsy generally requires that involves daytime sleeping and interferes with biologic
a multiple sleep latency test and polysomnography, its rhythms. Changes in the intensity of light trigger sleeping.
symptoms help to distinguish it from other conditions When exposure to light comes at an atypical time, the
that cause sleepiness. For example, the sleepiness of nar- sleep–wake cycle is desynchronized. Sleep–wake cycle
colepsy is accompanied by the following: disorders occur among shift workers, jet travelers, and
those diagnosed with seasonal affective disorder, a cycli-
• Sleep paralysis—the person cannot move for a few min-
cal mood disorder believed to be linked to diminished
utes just before falling asleep or awakening exposure to sunlight.
• Cataplexy—sudden loss of muscle tone triggered by an
emotional change such as laughing or anger Shift Work
• Hypnogogic hallucinations—dreamlike auditory or visual
experiences while dozing or falling asleep Those who work evening or night shifts or who switch
• Automatic behavior—performance of routine tasks from one shift to another are especially prone to un-
without full awareness or later memory of having synchronized sleep–wake cycles. The indoor lighting
done them to which most shift workers are exposed is not bright
enough to suppress melatonin; consequently, many shift
Many older adults experience a decrease in the sever- workers fight to stay awake. Some experience microsleep,
ity of narcoleptic symptoms after 60 years of age (National which is unintentional sleep lasting 20 to 30 seconds.
Institute of Neurologic Disorders and Stroke, 2006). If Statistics show that shift workers are more prone to
untreated, the client may become involved in a motor vehi- errors and accidents from sleepiness (Harrington,
cle crash or occupational accident. Prescribed stimulant 2001; National Institute for Occupational Safety and
drugs, such as methylphenidate (Ritalin) or ampheta- Health [NIOSH], 2004). Most people who work night
mine (Adderall), help to improve alertness. Antidepres- shifts never completely adapt to the reversal of day
sants reduce the symptoms associated with atypical and night activities, no matter how long the pattern is
REM sleep. established.
Sleep Apnea/Hypopnea Syndrome Jet Travel
Apnea (cessation of breathing) and hypopnea (hypoventi-
Jet travel causes a sudden change in the currently estab-
lation) are manifestations of a second form of hypersom- lished photoperiod (number of daylight hours) to which
nia, sleep apnea/hypopnea syndrome. In this disorder, the a person is accustomed. Consequently, travelers often
sleeper stops breathing or breathing slows for 10 seconds describe having jet lag, or emotional and physical changes
or longer, five or more times per hour (Justesen, 1999). experienced when arriving in a different time zone. Many
This is discussed further in Chapter 21. travelers have difficulty falling or staying asleep, but jet
During the apneic or hypopneic periods, ventilation lag is more transient than shift work. Some travelers re-
decreases and blood oxygenation drops. The accumu- establish normal sleep–wake cycles, but it takes at least
lation of carbon dioxide and the fall in oxygen cause 1 day for each time zone that is crossed when traveling
brief periods of awakening throughout the night. This east, slightly less when traveling west.
disturbs the normal transitions and periods of NREM
and REM sleep. Consequently, clients with sleep apnea/ Seasonal Affective Disorder
hypopnea syndrome feel tired after having slept, or worse,
their symptoms may cause a heart attack, stroke, or sud- Seasonal affective disorder is characterized by hypersom-
den death from hypoxia (decreased cellular oxygenation) nolence, lack of energy when awake, increased appetite
of the heart, brain, and other organs. accompanied by cravings for sweets, and weight gain.
The symptoms begin during darker winter months and failure, and peripheral nerve pathology, can mimic the
disappear as daylight hours increase in the spring. In manifestations of restless legs syndrome. Once these con-
some ways, the disorder resembles the hibernation pat- ditions are diagnostically eliminated, the condition is
terns in bears and other animals. confirmed with polysomnography.
Some suggest that seasonal affective disorder results Conservative treatment of the parasomnias includes
from excessive melatonin. To counteract the symptoms, safety measures for sleep-walkers (stair gates, security
phototherapy (technique for suppressing melatonin by locks on doors and windows), mouth devices for brux-
stimulating light receptors in the eye) is prescribed. The ism, lifestyle changes, nutritional support, and good sleep
artificial light used in phototherapy is at least 2000 to hygiene. In severe cases, drug therapy is used.
2500 lux, the equivalent of the bright light measured
on a sunny spring day. Clients use the lights for 2 to 6 hours
each day to simulate the number of daylight hours dur- NURSING IMPLICATIONS
ing sunnier months (Box 18-3). Phototherapy usually
relieves symptoms within 3 to 5 days, but symptoms tend
to recur in the same amount of time if a client abruptly After assessing client comfort and sleep patterns and the
discontinues phototherapy. accompanying symptoms, nurses identify one or more
nursing diagnoses that require interventions:
• Fatigue
Parasomnia • Impaired Bed Mobility
• Disturbed Sleep Pattern
Parasomnias are conditions associated with activities • Sleep Deprivation
that cause arousal or partial arousal, usually during • Relocation Stress Syndrome
transitions in NREM periods of sleep. They are not life- • Risk for Injury
threatening, but they disturb others in the household— • Impaired Gas Exchange
most significantly, the bed partner. Some examples of
parasomnias include the following: Nursing Care Plan 18-1 is an example of how the
nursing process has been used to develop a plan of care
• Somnambulism (sleep-walking) for a client with Disturbed Sleep Pattern, defined in the
• Nocturnal enuresis (bedwetting) NANDA taxonomy (2005) as a “change in the quantity
• Sleep-talking or quality of his or her rest pattern that causes discom-
• Nightmares and night terrors fort or interferes with desired lifestyle.”
• Bruxism (grinding of the teeth) Several sleep-promoting nursing measures, such as
• Restless legs syndrome (movement typically in the legs maintaining sleep rituals, reducing the intake of stimu-
[but occasionally in the arms or other body parts] to lating chemicals, promoting daytime exercise, and adher-
relieve disturbing skin sensations) ing to a regular schedule for retiring and awakening,
Restless legs syndrome, also known as nocturnal have already been discussed. Two additional beneficial
myoclonus, may be the most disabling parasomnia. The methods are assisting the client with progressive relax-
symptoms keep the person awake or prevent continuous ation exercises and providing a back massage.
sleep. Eventually, sleep deprivation affects the person’s
life, damaging work productivity and personal relation-
ships. Medical etiologies, such as iron deficiency, kidney Progressive Relaxation
is a therapeutic exercise in which a
Progressive relaxation
BOX 18-3 ● Components of Phototherapy person actively contracts then relaxes muscle groups to
break the worry–tension cycle that interferes with relax-
To relieve the symptoms of seasonal affective disorder, the client: ation. See Nursing Guidelines 18-1.
❙ Initiates a schedule of full-spectrum* light exposure beginning in October–
Clients can learn to perform progressive relaxation
November
❙ Removes eyeglasses or contact lenses that have ultraviolet filters
exercises independently using self-suggestion. Some clients
❙ Sits within 3 feet of the artificial light for approximately 2 hours soon after eventually omit the muscle contraction phase and go
awakening from sleep directly to progressive relaxation of muscle groups.
❙ Glances at the light periodically but may engage in other activities such as
reading or handiwork
❙ Repeats the exposure to light after sundown (to simulate extending the
daylight hours) up to a cumulative time of 3 to 6 hours a day
Back Massage
❙ Continues the pattern of light exposure until spring
Massage (stroking the skin) promotes two desired out-
* Full-spectrum light simulates the energy of bright natural sunlight. comes: it relaxes tense muscles and improves circula-
tion (Skill 18-3). Nurses perform massage using various

Facilitating Progressive Relaxation
❙ Select a room that is quiet, private, and dimly lit. Such a setting reduces ❙ Tell the client to tighten the muscles in an area of the body, such as the
stimulation of the arousal center in the brain, which responds to noise, foot, and hold the position for at least 5 seconds. Tightening a muscle
bright lights, and activity. depletes the level of stimulating neurotransmitters.
❙ Encourage the client to assume a comfortable position; this usually ❙ Direct the client to relax the tensed muscles and focus on the pleasant
involves lying down or sitting. Sitting or lying down provides external feeling. Focusing on the pleasant feeling directs the cortex’s attention to
support for the body, which facilitates muscle relaxation. the desired outcome and raises the client’s awareness.
❙ Advise the client to avoid talking and instead listen to the suggestions ❙ Proceed with sequence after sequence of muscle contraction followed
that will follow. Advising the client to take a passive role reduces by relaxation until all muscle groups in the body have been
performance anxiety (worry about appearing incompetent or foolish). exercised. Continued tensing and relaxation leads to higher
❙ Instruct the client to close the eyes and consciously focus on breathing. planes of relaxation.
Closing the eyes blocks visual stimuli; focusing on breathing helps to ❙ Continue suggesting throughout that the client focus on how relaxed or
turn the client’s attention away from distracting thoughts and feelings. weightless he or she feels. These verbal cues reinforce relaxation.
❙ Tell the client to inhale deeply through the nose and exhale slowly out ❙ Tell the client that as you reach zero after counting backward from 10,
the mouth. Repeat the activity several times. This breathing oxygenates he or she can begin to move. This provides a gradual end to the
the blood and brain and reduces the heart rate. relaxation period.
stroking techniques (Table 18-5). Stimulating strokes are Older adults have more difficulty falling asleep, awaken more
omitted if the purpose is to relax the client. readily, and spend less time in the deeper stages (including the
dream stage) of sleep. Consequently, they often feel tired,
complain of sleep problems, and spend more time in bed with-
out actually sleeping.
Stop • Think + Respond BOX 18-2 The older adult’s established pattern and circadian rhythms may
not correspond to schedules of institutional settings. Modifica-
Describe techniques for maximizing the positive effects of tions in established institutional routines may be needed to
a back massage. accommodate for individual differences.
Bright outdoor light or use of simulated outdoor lighting during
the afternoon may help to reset circadian rhythms. Some peo-
ple use melatonin (a hormone available for purchase in many
GENERAL GERONTOLOGIC health food stores) to promote sleep.
Using night lights rather than bright room lights is preferred if an
CONSIDERATIONS older adult arises during the night. Bright lights stimulate the
brain and interfere with efforts to resume sleep.
Older adults who move to institutional settings, such as nursing
The National Institute of Neurological Disorders and Stroke (2006)
homes or assisted living facilities, are usually more comfort-
recommends that sleep disorders in older adults be managed
able with their own bed furnishings and personal mementos without hypnotic medications, which tend to have paradoxical
and belongings. effects in older adults (i.e., a stimulating effect or mental
Older adults tend to prefer warmer room temperatures because of changes).
decreased subcutaneous fat deposits. Those with cognitive Although hypnotic medications may be effective initially, toler-
impairment, however, may feel that environmental tempera- ance usually develops sometimes within a few days; therefore,
tures are uncomfortably warm or cool, even when the temper- their use is not recommended for longer than 2 weeks. Hyp-
ature is comfortable for others. notic medications reduce REM sleep and may cause older
Insomnia and hypersomnia are often manifestations of depres- adults to have nightmares and other sleep cycle disturbances
sion among older adults. for several weeks after discontinuation.
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.
Identifying potential sources of sleep disturbances among older

BOX 18-4 ● Characteristics of Sundown Syndrome adults is important. Examples include discomfort, emotional or
medical conditions, uncomfortable environment, and the
❙ Alert and oriented during the day effects of caffeine, alcohol, or medications (see Table 18-4).
❙ Onset of disorientation as the sun sets Chronic conditions may interfere with sleep by causing pain, diffi-
❙ Disorganized thinking culty breathing, or frequent urination. Interventions to control
❙ Restlessness these conditions help improve sleep.
❙ Agitation Older adults may need evaluation for sleep apnea if morning
❙ Perseveration (ruminating over the same repetitive thought) headaches or frequent nighttime awakenings occur.
❙ Wandering Older adults with limited mobility may sleep better if they partici-
pate in chair or water exercises during the day, but not imme-
diately before bedtime.
Encourage older adults to use any of the following relaxation
Many hypnotic medications, particularly those with a very long techniques before bedtime: imagery, meditation, deep breath-
half-life such as flurazepam (Dalmane), tend to cause daytime ing, progressive relaxation, soothing music, body or foot mas-
drowsiness and increase the risk for falls. Examples of hyp- sage, chair rocking, reading nonstimulating materials, or
notics with shorter half-lives that are better tolerated by older watching nonstimulating television.
adults include triazolam (Halcion), temazepam (Restoril), zolpi- Short daytime naps and rest periods, usually less than 2 hours in
dem (Ambien), or zaleplon (Sonata). duration, can restore energy for an older adult without inter-
Some older adults with cognitive impairment develop sundown fering with nighttime sleep. However, 7 to 9 hours of sleep
syndrome (onset of disorientation as the sun sets) (Box 18-4). within a 24-hour period is the usual total amount of sleep
Others develop sunrise syndrome (early-morning confusion) required by older adults. Therefore, expectations for the
associated with inadequate sleep or the effects of sedative number of sleep hours during the night must be adjusted
and hypnotic medications. according to the amount of daytime sleep.
Family members, especially spouses, may experience sleep Boredom may be a cause of daytime napping. Working with
disturbances if an older adult snores, gets up during the older adults to determine meaningful diversions may actually
night, or wanders. help with nighttime sleep, when naps are diminished.
Disturbed Sleep Pattern
ASSESSMENT
• Ask the client to rate his or her quality of sleep using a numeric scale of 1 indicating severe disturbance to 10 indicating
satisfactory.
• Identify sleep aids including medications, alcohol, and sleep rituals and lifestyle practices that may interfere with sleep
such as excessive consumption of caffeine.
• Inquire about the client’s usual time for retiring and awakening without an alarm clock.
• Have the client keep a diary for several days of
• Bedtime
• Approximate time for onset of sleep
• Number of times awakened during sleep and reason for awakening
• Time of awakening in the morning
• Number and length of daytime naps
• Compare collected data with age-related norms.
• Seek information from sleep partner regarding symptoms of disorders manifested during sleep such as snoring interrupted
by a period of apnea, unusual movement, or sleep walking.
• Consult with the family regarding the client’s level of stress, emotional stability, attention, work endurance, incidence of
work-related or driving accidents.
Nursing Diagnosis: Disturbed Sleep Pattern 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 Retiring and arising at a consistent time helps to develop
0730 each morning regardless of the duration or quality of a sleep–wake pattern.
sleep.
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 The duration of a complete cycle of NREM and REM
blocks of sleep. sleep is approximately 70 to 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
times a day but no later than 1930. a person if performed close to bedtime.
(continued)
Disturbed Sleep Pattern
Provide milk, yogurt, vanilla pudding, custard, or some Dairy products are a good source of L-tryptophan, which
other dairy product at approximately 2030. promotes sleep.
Delay administering sleeping medication and give a back Massage promotes relaxation, which is a precursor to
massage at bedtime. sleep. Sleep medications can interfere with REM sleep and
may cause daytime drowsiness.

• The client was observed to fall asleep in 30 to 45 minutes.
• The client experienced uninterrupted sleep for 3 hours.
• The client’s total duration of sleep was 6 to 7 hours.
2. When making an unoccupied bed of a client who has

been incontinent of stool, which action is essential?
1. What items in the health care environment would you 1. The nurse discards all linen.
find important in supporting your comfort, rest, and sleep? 2. The nurse dons clean disposable gloves.
3. The nurse uses a fitted bottom sheet.
2. Discuss possible effects of suffering from or living with a
4. The nurse puts a blanket over the top sheet.
person who has a sleep disorder.
3. To help a client suffering from insomnia, which plan for
nursing care is best?
NCLEX-STYLE REVIEW Q U E S T I O N S 1. Administer a prescribed hypnotic drug each night.
2. Try to duplicate the client’s pattern of sleep rituals.
1. When observing an unlicensed nursing assistant make
3. Have the client exercise for 30 minutes at bedtime.
an occupied bed, which of the following actions indicates
4. Suggest the client go to bed earlier than the usual
a need for further learning?
time.
1. The assistant loosens all the linen under the client.
2. The assistant wears gloves to remove soiled linen.
3. The assistant keeps the bed in low position.
4. The assistant rolls the client to the far side of the bed.
Skill 18-1 • MAKING AN UNOCCUPIED BED
Assessment
Check the Kardex or nursing care plan to determine the Determines if the client can be out of bed during
client’s activity level. bedmaking
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 Reduces the potential for wetting or soiling the clean linen
have been met.
rub (see 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 Reduces transmission of microorganisms to clean supplies
seat or back of a chair (Fig. A).
Arranging clean bed linen. (Copyright B. Proud.)
Assist the client from the bed. Facilitates bedmaking
Implementation
Raise the bed to a high position and lower siderails. 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 Facilitates removal or retightening
the mattress.
(continued)
MAKING AN UNOCCUPIED BED (Continued)
Fold any linen that may be reused and place it on a clean Promotes efficiency and orderliness
surface.
Don gloves, if necessary, and roll linen that will be Gloves are a standard precaution to provide a barrier
replaced so that the soiled surface is enclosed (Fig. B). between 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. (Copyright B. Proud.)
Remove the soiled linen while holding it away from your Prevents transferring microorganisms to your uniform
uniform (Fig. C). and then to other clients
Avoiding contact with uniform. (Copyright B. Proud.)
(continued)
Place the soiled linen directly into a pillowcase, laundry Keeps the soiled linen from being further contaminated
hamper, 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. (Copyright B. Proud.)
Remove gloves and wash hands or perform hand Facilitates use of the hands
antisepsis 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 Reduces postural strain
fold 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 Prevents skin pressure and irritation
flush 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 fitted sheet taut. (Copyright B. Proud.)
E
(continued)
If the client is apt to soil the linen with urine or stool, fold Reduces the need to change all the bottom linen
a flat 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. Saves time by reducing the number of moves around the bed
Move 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 Secures and smooths the bottom linen
linen to position the top sheet.
Center the top sheet and unfold it to one side, leaving Provides a smooth edge next to the client’s neck
sufficient 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 Secures the top linen
excess 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. (Copyright B. Proud.)
(continued)
Smooth the top sheet (Fig. H)
Smoothing the top sheet. (Copyright B. Proud.)
Gather the pillowcase as you would hosiery and slip the Prevents contact between the pillow and your uniform
case over the pillow (Fig. I).
Covering the pillow. (Copyright B. Proud.)
Place the pillow at the head of the bed with the open end Presents a tidy view of the room from the hallway;
away from the door and the seam of the pillowcase prevents pressure on the skin around the head and neck
toward the headboard.
(continued)
Fan-fold or pie-fold the top linen toward the foot of the Facilitates returning to bed
bed (Fig. J).
Prefolding the linen. (Copyright 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
rub (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
• 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.
Absorbent pad placed over bottom sheet. SIGNATURE/TITLE
Skill 18-2 • MAKING AN OCCUPIED BED
Assessment
Check the Kardex or nursing care plan to confirm that the Demonstrates compliance with the care plan
client must remain in bed.
Assess the client’s level of consciousness, physical strength, Indicates a need for bedrest if abnormal findings are
breathing pattern, heart rate, and blood pressure. noted, 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 Avoids postural or muscular injury and ensures the
too weak or unable to cooperate. client’s comfort and safety
Planning
Plan to change the linen after the client’s hygiene needs Reduces the potential for wetting or soiling the clean linen
have been met.
rub (see 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 Reduces transmission of microorganisms to clean supplies
back of 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 Promotes efficiency and orderliness
on a clean surface.
Unfasten equipment attached to the bottom linen and Avoids breakage, spills, or loss of personal items
check for personal items.
Loosen the bed linen from where it has been tucked under Facilitates removal or retightening
the mattress.
Lower the rail on the side of the bed where you are standing Provides room for making the bed while ensuring the
and roll the client toward the opposite side rail. client’s safety
Roll the soiled bottom sheets as close to the client as Facilitates removal
possible.
Proceed to unfold and tuck the bottom sheet and drawsheet Remakes half of the bed with clean linen
on the vacant side of the bed, as described in Skill 18-1
(Fig A).
Fold the free edges of the sheet under the folded portion of Keeps the clean sheet from becoming soiled; facilitates
the soiled sheets. pulling the sheets from under the client
Raise the siderail and move to the opposite side of the bed. Prevents postural and muscular strain
Lower the siderail in your new position and help the Helps reposition the client on the clean side of the bed
client to roll over the mound of sheets.
(continued)
MAKING AN OCCUPIED BED (Continued)
Changing linen on half of the bed. (Copyright B. Proud.)
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 Keeps the soiled linen from becoming further contaminated
pouch that is off the floor.
Pull the clean bottom sheet until it is unfolded from Promotes client comfort
beneath the client (Fig. B).
Pulling clean linen through. (Copyright B. Proud.)
Miter or square the upper corner of the sheet; pull and Secures the clean sheets
tuck the 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.
(continued)
MAKING AN OCCUPIED BED (Continued)
Reposition the client according to the therapeutic regimen Demonstrates compliance with the care plan; shows
or comfort. concern for client comfort
Lower the height of the bed and raise the remaining Reduces the potential for injury
siderail if appropriate.
Dispose of the soiled linen in a laundry hamper outside Restores order to the room and ensures that the linen will
the room. be collected for laundering
rub (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 siderails raised. Bed in low position.
SIGNATURE/TITLE
Skill 18-3 • GIVING A BACK MASSAGE
Assessment
Observe if the client is still awake 30 minutes after Indicates a delay in the usual onset of sleep
retiring for sleep.
Determine if the client is experiencing pain, has a need for Eliminates all but psychophysiologic etiologies as the
bladder or bowel elimination, is hungry, is too warm or cause for sleeplessness
cold, or has any other physical or environmental
problem that may be easily overcome.
(continued)
GIVING A BACK MASSAGE (Continued)
Check the medical record to determine if the client has Demonstrates concern for the client’s safety and comfort
any condition 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 Demonstrates organization and efficient time management
or powder if the client’s skin is oily.
Use gloves if there are any open, draining lesions on the skin. Provides a barrier against bloodborne microorganisms
Reduce environmental stimuli such as bright lights and Decreases stimulation of the wake center in the brain
loud noise.
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 Reduces back strain
the waist.
rub (see Chap. 10); don gloves if appropriate.
Help the client to lie on the abdomen or side, and untie Provides access to the back
the 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 Warms the lotion
rub them together.
Place the entire surface of the hands on either side of the Uses effleurage to promote relaxation
lower spine and move them upward over the shoulders
and back again using long, continuous strokes. Repeat
the stroke pattern several times.
Apply firmer pressure with the upstroke and lighter Enhances relaxation by alternating pressure and rhythm
pressure during the downstroke.
Make smaller circular strokes up and down the length of Uses friction to improve blood flow and remove chemicals
the back with the thumbs. that accumulate in contracted muscles
Lift and gently compress tissue with the fingers, starting at Utilizes pétrissage to increase blood circulation
the base of the spine and ending at the neck and
shoulder areas.
Pull the skin in opposite directions in a kneading fashion Uses another pétrissage technique to reduce tension in
to lift and stretch it from the base of the spine to the muscles and improve circulation
shoulder 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.
Lightly cover the client and lower the bed. Extends the period of relaxation by reducing activity and
may induce NREM sleep
(continued)
Effleurage Effleurage
(example 1). (example 2).
Pétrissage
Pétrissage (example 2).
(example 1).
Frôlement
(continued)
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
19
Chapter
Safety
LEARNING OBJECTIVES
● Give an example of one common injury that predominates during each developmental stage
(infancy through older adulthood).
● Name six injuries that result from environmental hazards.
● Identify at least two methods for reducing latex sensitization.
● List four areas of responsibility incorporated into most fire plans.
● Describe the indications for using each class of fire extinguishers.
● Discuss five measures for preventing burns.
● Name three common causes of asphyxiation.
● Discuss two methods for preventing drowning.
● Explain why humans are susceptible to electrical shock.
● Discuss three methods for preventing electrical shock.
● Name at least six common substances associated with poisonings.
● Discuss four methods for preventing poisonings.
● Discuss the benefits and risks of using physical restraints.
● Explain the basis for enacting restraint legislation and JCAHO accreditation standards.
● Differentiate between a restraint and a restraint alternative.
● Give at least four criteria for applying a physical restraint.
● Describe two areas of concern during an accident.
● Explain why older adults are prone to falling.
SAFETY (measures that prevent accidents or unintentional injuries) is a major nursing

responsibility. The Joint Commission on Accreditation of Healthcare Organizations
( JCAHO) and the World Health Organization (WHO) consider safety a priority
when caring for clients. JCAHO has established National Patient Safety Goals (Box 19-1)
to reduce the incidence of injuries to those being cared for in health agencies. If the Cen-
WORDS TO KNOW ters for Disease Control and Prevention counted hospital errors as a cause of death, they
would rank as the sixth cause of death, ahead of diabetes, influenza, pneumonia, and
asphyxiation Alzheimer’s disease (Association of California Nurse Leaders, 2006). Such findings
drowning
electrical shock
validate the conclusion that receiving health care is an extreme risk to a person’s safety.
environmental hazards This chapter examines factors that place people at risk for injury, environmental haz-
fire plan ards in homes and health care facilities, and nursing measures that keep clients safe.
latex-safe environment
latex sensitivity
macroshock
microshock AGE-RELATED SAFETY FACTORS
National Patient Safety Goals
poisoning
No age group is immune to accidental injury. Distinct differences among age groups
restraint alternatives
restraints exist, however, because of varying levels of cognitive function and judgment, activity
safety and mobility, and degree of supervision as well as the design of and safety devices
thermal burn within physical surroundings.
415
BOX 19-1 ● Patient Safety Goals (2006-2007)*
JOINT COMMISSION ON ACCREDITATION

OF HEALTHCARE ORGANIZATIONS WORLD HEALTH ORGANIZATION CENTRE ON PATIENT SAFETY
Improve the accuracy of patient identification Prevent patient care handover errors
Improve the effectiveness of communication among caregivers Prevent wrong site/wrong procedure/wrong person surgical errors
Improve safety of using medications Prevent continuity of medication errors
Reduce the risk of health care–related infections Prevent high concentration drug errors
Accurately and completely reconcile medications across the continuum of care Promote effective hand hygiene practices
Reduce the risk for patient harm resulting from falls
Encourage patients’ active involvement in their own care as a patient safety strategy
Identify safety risks (including suicide) inherent in its patient population
* JCAHO safety goals as they apply to hospitals; additional goals may be more applicable to ambulatory care and office-based surgery centers, assisted living,
behavioral health care, home care, long-term care, and so on.
(Source: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_facts.htm.)
Infants and Toddlers thermal burns, asphyxiation, electrical shock, poison-

ing, and falls.
Infants rely on the safety consciousness of their adult care-
takers. They are especially vulnerable to injuries result-
ing from falling off changing tables or being unrestrained Latex Sensitization
in automobiles. Toddlers are naturally inquisitive and
more mobile than infants and fail to understand the dan- Increasing numbers of people are developing latex sen-
gers that accompany climbing. Consequently, they are sitivity (allergic response to the proteins in latex). Latex,
often the victims of accidental poisoning, falls down stairs natural rubber sap whose origin is a species of tree indige-
or from high chairs, burns, electrocution from exploring nous to Brazil, is a component of many household items,
outlets or manipulating electric cords, and drowning. such as balloons, envelope glue, erasers, and carpet back-
ing, as well as health care products. Health-related sensi-
tization is partly the result of repeated exposure to latex
School-Aged Children and Adolescents in medical gloves and other equipment (Box 19-2). Clients
predisposed to latex sensitivity include those with a his-
School-aged children are physically active, which makes tory of asthma and allergies to other substances, multiple
them prone to play-related injuries. Many adolescents suf- surgeries, and recurring medical procedures.
fer sports-related injuries because they participate in phys-
ically challenging activities—sometimes without adequate Types of Latex Reactions
protective equipment—before their musculoskeletal sys- Sensitization follows latex exposure via the skin, mucous
tems can withstand the stress. Adolescents also tend to be membranes, inhalation, ingestion, injection, or wound
impulsive and take risks as a result of peer pressure. management. The two forms of allergic reactions to latex
or the chemicals used in its manufacture are as follows:
• Contact dermatitis, a delayed localized skin reaction
Adults that occurs within 6 to 48 hours and lasts several days
• Immediate hypersensitivity, an instantaneous or fairly
Adults are at risk for injuries from ignoring safety issues, prompt systemic reaction manifested by swelling, itch-
fatigue, sensory changes, and effects of disease. The types ing, respiratory distress, hypotension, and death in
of injuries that young, middle-aged, and older adults incur severe cases.
depend on their social, developmental, and physical differ-
ences (Table 19-1). Sensitized people also can develop a cross-reaction to
fruits and vegetables such as avocados, bananas, almonds,
peaches, kiwi, tomatoes, and others because the molecu-
lar structure in latex and other plant substances is similar.
ENVIRONMENTAL HAZARDS
Safeguarding Clients and Personnel
Environmental hazards are potentially dangerous conditions One of the best techniques for preventing latex sensiti-
in the physical surroundings. Examples in the home zation and allergic reactions is to minimize or eliminate
and health care environment include latex sensitization, latex exposure. Health care agencies are providing per-
C H A P T E R 19 ● Safety 417
TABLE 19-1 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 amputations,
soft tissue and back injuries
Middle-aged adults Failure to use safety devices Physical trauma (see above)
Overexertion and fatigue Burns and asphyxiation related to nonfunctioning
Disregard for use of seat belts and car safety harnesses smoke, heat, and carbon monoxide detectors
Lack of expertise in performing home maintenance
or repairs
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
sonnel with more than one type of gloves (Table 19-2). tors are required to report injuries, serious illnesses,
If they use latex gloves, nurses also should avoid using or deaths from unsafe equipment to the U.S. Food and
oil-based hand creams or lotions and should wash their Drug Administration
hands thoroughly after removing gloves to reduce the • Referring sensitized clients to latex allergy support
transfer of latex proteins to others and objects in the envi- groups
ronment. Other measures to protect clients and person- • Recommending that latex-sensitive clients wear a
nel include the following: Medic-Alert bracelet at all times
• Advising latex-sensitive clients to notify their em-
• Obtaining an allergy history and a sensitivity to latex
ployer’s health officer about the allergy in case of a
in particular
future claim for worker’s compensation or a legal case
• Flagging the chart and room door and attaching an
concerning discrimination in the workplace
allergy-alert identification bracelet on latex-sensitive
clients
• Assigning clients with a latex allergy to a private room
or latex-safe environment (room stocked with latex-free Burns
equipment and wiped clean of glove powder)
• Stocking a latex-safe cart containing synthetic gloves A thermal burn is a skin injury caused by flames, hot liq-
and latex-free client care and resuscitation equipment uids, or steam and is the most common form of burn.
in the room of a client sensitive to latex Burns also result from contact with caustic chemicals such
• Communicating with personnel in other departments as lye, electric wires, or lightning.
so that they use nonlatex equipment and supplies dur-
ing diagnostic or treatment procedures Burn Prevention
• Reporting allergic events and their possible cause Because many adults become complacent about safety
promptly to the agency’s administration; administra- hazards, the nurse reviews burn-prevention measures
with clients being treated for thermal-related accidents.
BOX 19-2 ● Common Items Containing Latex Exits must be identified, lighted, and unlocked. Most
fire codes require that public buildings, including hospitals
Medical gloves Intravenous injection ports
Band-Aids Nondisposable sheet protectors
and nursing homes, have a functioning sprinkler system.
Bulb syringes Stethoscope tubing Sprinkler systems help control fires and limit structural
Medication vial stoppers Tourniquets damage.
Urinary catheters Elastic (Jobst) stockings
Condoms Mattress covers Fire Plans
Wound drains Dental bands
Endoscopes Blood pressure cuff and tubing To prevent or limit burn injuries in a health care setting,
all employees must know and follow the agency’s fire plan
TABLE 19-2 TYPES OF MEDICAL GLOVES

Latex
Powdered latex Inexpensive Release latex protein allergen into the air via powder
Elastic
Adequate barrier against bloodborne 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 Deposit 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 Similar strength of latex gloves Less durable and more likely to leak than latex
powder-free Cost approximately the same as powdered latex Recommend changing after 30 minutes to maintain
gloves barrier protection
Nitrile Better resistance to tears, punctures, and chemical Possible contact dermatitis from chemicals contained
disintegration than latex or vinyl gloves in nitrile
More expensive than latex or vinyl
Neoprene Fit, strength, and barrier protection similar to latex Contain potentially allergic chemicals
More expensive than nitrile gloves
Thermoplastic Strength and protection similar or superior to latex Free of latex or chemical allergens
elastomer Most expensive of all gloves
Burn Prevention • Buy clothing, especially sleepwear, made from nat-

The nurse teaches the client or family as follows: ural or flame-resistant fabrics.
• Never run if clothing is on fire; instead: stop, drop,
• Change the batteries in smoke, heat, and carbon
and roll.
monoxide detectors at least every year. • Do not overload electrical outlets or circuits.
• Equip the home with at least one fire extinguisher. • Set thermostats on hot water heaters to less than
• Develop an evacuation plan (and an alternate 120°F (48.8°C).
escape route) and a place for family members to • Keep cords to coffee pots, electric frying pans, or
meet after exiting a burning home or apartment. other small cooking appliances above the reach of
• Practice the evacuation plan periodically. young children.
• Keep all windows and doors barrier free. • Follow label directions about the use of gloves
• Identify the location of exits when staying in a when using chemicals.
hotel. • Flush chemicals with copious amounts of water if
• Dispose of rags that have been saturated with they come in contact with skin.
solvents. • Go inside if the weather is threatening or you see
• Keep items away from the pilot lights on the lightning.
furnace, water heater, or clothes dryer. • If you are inside a burning building,
• Avoid storing gasoline, kerosene, turpentine, or • Feel if the surface of a door is hot before opening it.
other solvents. • Close doors behind you.
• Go to public fireworks displays rather than ignit- • Crawl on the floor if the room is smoke-filled.
ing them at home. • Use stairs rather than elevators.
• Never smoke when sleepy or around oxygen • Never go back inside, regardless of whom or what
equipment. has been left there.
• Use safety matches rather than a lighter; children • Go to a neighbor’s home to call the fire department
are less capable of using matches. or 911 operator.
(procedure followed if there is a fire). Compliance with the • Return to the nursing unit when an alarm sounds; do
fire plan is a major component of the JCAHO inspection. not use the elevator.
Every accredited health care agency must demonstrate • Clear the halls of visitors and equipment.
and document that staff members have been trained in • Close the doors to client rooms and stairwells as well
the following five areas: as fire doors between adjacent units. Wait for further
• Specific roles and responsibilities at and away from the directions.
fire’s point of origin • Place moist towels or bath blankets at the threshold of
• Use of the fire alarm system doors if smoke is escaping.
• Roles in preparing for building evacuation • Use an appropriate fire extinguisher if necessary.
• Location and proper use of equipment for evacuation
RESCUE AND EVACUATION. The first priority is to rescue
or transporting clients to areas of refuge
clients in the immediate vicinity of the fire. Nurses lead
• Building compartmentalization procedures for con-
those who can walk to a safe area and close the room and
taining smoke and fire (Krozek & Scoggins, 1999)
fire doors after exiting. Nursing personnel evacuate those
To obtain JCAHO accreditation, staff members on each who cannot walk using a variety of techniques (Fig. 19-1).
shift also must participate in quarterly fire drills.
FIRE EXTINGUISHERS. There are four types of fire extin-
Fire Management guishers (Table 19-3). Each type is labeled. Nurses must
The National Fire Protection Association, whose Life know which type of extinguisher is appropriate for the
Safety Code is the basis for the JCAHO’s management burning substance and how to use it. See Nursing Guide-
standards, recommends using the acronym RACE to iden- lines 19-1.
tify the basic steps to take when managing a fire:
R—Rescue Asphyxiation
A—Alarm
C—Confine (the fire) Asphyxiation (inability to breathe) can result from airway
E—Extinguish obstruction (see Chap. 37), drowning, or inhalation of
Most health care agencies incorporate these concepts by noxious gases such as smoke or carbon monoxide.
including the following actions in their fire plans:
Smoke Inhalation
• Evacuate clients from the room with the fire.
• Inform the switchboard operator of the fire’s location. Smoke can be more deadly than fire. Almost all health care
He or she will alert personnel over the public address facilities have banned cigarette smoking; consequently,
system and notify the fire department. smoke inhalation now accounts for less than 8% of fires
FIGURE 19-1 • Evacuation of clients.

(A) Human crutches—rescuers secure a
weak but ambulatory client’s arm and waist.
(B) Seat carry—rescuers interlock arms
and carry a nonambulatory client. (C)
Body drag—rescuer drags an unconscious C
victim or one who cannot assist on a blan-
ket or sheet.
TABLE 19-3 TYPES OF FIRE EXTINGUISHERS

TYPE SYMBOL CONTENTS USE
Class A Water under pressure Burning paper, wood, cloth

A
Class B Carbon dioxide Fires caused by gasoline, oil, paint, grease, and
B other flammable liquids
Class C Dry chemicals Electrical fires

C
Class ABC (combination Graphite Fires of any kind
extinguisher) A B C
at these facilities (Fig. 19-2). Although the percentage substances commonly used to heat homes). When inhaled,
has been reduced, there is still a risk for fires from smok- CO binds with hemoglobin and interferes with the oxy-
ing; some attribute this to the fact that secretive smok- genation of cells. Without adequate ventilation, the con-
ers tend to discard smoldering cigarette butts quickly sequences can be lethal.
rather than risk being discovered. Home fires, on the Because CO can be present even without smoke, CO
other hand, often occur when smokers fall asleep with a detectors should be installed in all homes, and fire depart-
burning cigarette or when children play with matches or ment personnel should investigate alarms. Without detec-
lighters. tors, victims may be unaware of the presence of CO and
Many homes and apartment buildings are equipped may attribute their symptoms to the flu (Box 19-3). As
with smoke detectors. Some people dismantle their smoke their condition deteriorates, they become confused and
detector, however, when it begins to emit an audible lapse into a coma, followed by death.
alarm signaling low battery power, and they fail to If a person is suspected of being poisoned by carbon
replace the batteries. monoxide, initial treatment requires getting the victim
out of the present environment. If moving the person
Carbon Monoxide out of doors is impossible, rescuers should open win-
dows and doors to reduce the level of toxic gas and pro-
Carbon monoxide (CO), an odorless gas, is released dur-
ing the incomplete combustion of carbon products such
as fossil fuels (kerosene, natural gas, wood, and coal—
Unknown (6.4%)
Other heat, flame, Suspicious (9.8%)
spark (1.2%)
Heating (3.8%)
NURSING GUIDELINES 19-1 Equipment
Appliances (19.4%)
Using a Fire Extinguisher
(14.2%)
❙ Know the location of each type of fire extinguisher. Doing so
minimizes response time.
❙ Free the extinguisher from its enclosure. The extinguisher must be
removed for use.
Open
❙ Remove the pin that locks the handle. The pin must be removed for use. flame,
❙ Aim the nozzle near the edge, not the center, of the fire. The chemical ember,
torch
will contain the fire.
Cooking (7.8%)
❙ Move the nozzle from side to side. Doing so increases the equipment
effectiveness of fire control. (17.4%) Other (1.9%)
❙ Avoid skin contact with the contents of the fire extinguisher. The
chemicals in the extinguisher can cause injury.
Electrical (10.5%) Smoking material (7.6%)
❙ Return the extinguisher to the maintenance department. The FIGURE 19-2 • Fire statistics as collected by the National Fire Protec-
extinguisher will be replaced or refilled for future use. tion Association. (Source: Structure fires in facilities that care for the
sick. [2002]. Quincy, MA: National Fire Protection Association.)
BOX 19-3 ● Symptoms of Carbon Monoxide Poisoning
Nausea Confusion
Vomiting Shortness of breath
Headache Cherry-red skin color
Dizziness Loss of consciousness
Muscle weakness
mote the client’s ventilation of air. Once emergency

personnel arrive, they administer oxygen. In the case of
extremely high blood levels of carbon monoxide, the
victim may be treated with hyperbaric (high-pressure)
oxygen (see Chap. 21).
Drowning FIGURE 19-3 • Parents being taught cardiopulmonary resuscitation

as part of discharge planning. (Copyright B. Proud.)
Drowning is a condition in which fluid occupies the airway
and interferes with ventilation. It can occur in swimmers
and nonswimmers alike. Accidental drownings occur Electrical Shock
during water activities such as fishing, boating, swim-
ming, and water-skiing. Some incidents are linked to Electrical shock (discharge of electricity through the body)
alcohol abuse, which tends to interfere with judgment is a potential hazard wherever there are machines and
and promotes risk taking. Other victims overestimate equipment. The body is susceptible to electrical shock
their stamina. because it is composed of water and electrolytes, both of
Drownings also can occur at home or in health care which are good conductors of electricity. A conductor is
environments. Young children can drown if left momen- a substance that facilitates the flow of electrical current;
tarily in a bathtub or if they have access to a swimming an insulator is a substance that contains electrical cur-
pool. Swimming pools should be fenced and locked, and rents so they do not scatter. Electric cords are covered
children should never be left unattended in a bathtub with rubber or some other insulating substance.
Macroshock is a harmless distribution of low-amperage
or pool.
Although the potential for drowning in a health care electricity over a large area of the body. It feels like a slight
tingling. Microshock is low-voltage but high-amperage elec-
institution is statistically remote, it can happen. Therefore,
tricity. A person with intact skin usually does not feel
nurses never leave any helpless or cognitively impaired
microshock because intact skin offers resistance or acts
client, young or old, alone in a tub of water regardless
as a barrier between the electrical current and the water
of its depth. and electrolytes within. If the skin is wet or its integrity
Victims of cold-water drownings are more likely to be is impaired, however, the electrical current can be fatal,
resuscitated because the cold lowers their metabolism, especially if delivered directly to the heart.
conserving oxygen (see Chap. 12). Prevention, however, Use of grounded equipment reduces the potential
is far better: for electrical shock. A ground diverts leaking electrical
• Learn to swim. energy to the earth. Grounded equipment is identified
• Never swim alone. by the presence of a three-pronged plug.
• Wear an approved flotation device. In addition to using grounded equipment, other safety
measures to prevent electrical shock include the following:
• Do not drink alcohol when participating in water-
related sports. • Never use an adaptor to bypass a grounded outlet.
• Notify a law enforcement officer if boaters appear • Make sure all outlets and switches have cover plates.
unsafe. • Plug all machines used for client care into outlets within
12 feet of one another or within the same cluster of wall
Resuscitation outlets (Berger & Williams, 1999).
• Unplug machines if they are no longer necessary.
Cardiopulmonary resuscitation (CPR), if begun imme- • Discourage clients from resting electric hair dryers,
diately, may be lifesaving for a victim of asphyxiation curling irons, or razors on or near a sink that con-
or drowning. Current CPR certification is generally an tains water.
employment requirement for nurses. Many hospitals • Do not use a machine that has a frayed or cracked cord
teach new parents how to administer CPR (Fig. 19-3). or a plug with exposed wires.
• Grasp the plug, not the cord, to remove it.

• Do not use extension cords.
• Report macroshocks to the engineering department.
• Clean liquid spills as soon as possible.
• Stand clear of the client and bed during cardiac
defibrillation.
Poisoning FIGURE 19-4 • A toll-free number provides immediate access to an

expert at a poison center with answers to questions about poisons and
poisonings.
Poisoning is injury caused by the ingestion, inhalation, or
absorption of a toxic substance. Poisonings are more com-
mon in homes than in health care institutions, although Treatment
medication errors could be considered a form of poisoning
(see Chap. 32). Preventing medication errors is one of the Initial treatment for a victim of suspected poisoning
prime JCAHO goals for keeping people safe in health care involves maintaining breathing and cardiac function.
agencies. Medication safety is discussed in more depth in After that, rescuers attempt to identify what was ingested,
Unit 9, Medication Administration. Accidental poison- how much, and when. Definitive treatment depends on
ings usually occur among toddlers and commonly the substance, the client’s condition, and if the substance
involve substances located in bathrooms or kitchens is still in the stomach. For ingestions of commercial prod-
(Box 19-4). Many children treated for accidental poison- ucts containing multiple ingredients, the poison control
ing have a repeat episode. center is consulted. Otherwise, treatment follows the deci-
Health care facilities have fewer poisonings because sion tree in Figure 19-6.
they keep medications locked. By law, they must keep
chemicals such as liquid antiseptics, intended for external
use, separate from other drugs. Nevertheless medication Falls
errors (see Chap. 32), in which the wrong medication or
dose is administered or given to the wrong client, persist. Falls, more than any other injury discussed thus far, are
the most common accident experienced by older adults
Prevention and have the most serious consequences for this age
group. Between 2004 and 2005, almost 1.9 million adults
Curious children should be educated about poisons. The
older than 65 years experienced an unintentional fall;
American Association of Poison Control Centers pro-
more than 350,000 required hospitalization, and nearly
motes awareness for assistance with accidental poisoning
with a “poison help” logo (Fig. 19-4). The logo provides
a nationwide toll-free number that, when dialed, auto-
matically connects the caller to the closest poison control 19-2 • CLIENT AND FAMILY TEACHING
center. Nurses and pharmacists who are certified special-
Preventing Childhood Poisoning
ists in poison information answer emergency calls around
the clock. All nurses can teach parents and others how to The nurse teaches parents or caretakers as follows:
reduce the risk for poisoning in the home. See Client and • Install child-resistant latches on cupboard doors.
Family Teaching 19-2. Adults who have trouble remem- • Request childproof caps on all prescription
bering or who cannot administer their own medications medications.
safely can use containers prefilled by a responsible per- • Buy chemicals and nonprescription drugs with
son (Fig. 19-5). tamper-proof lids.
• Flush old medications down the toilet.
• Never transfer a toxic substance to a container
BOX 19-4 ● Common Substances Associated With usually used for food.
Childhood Poisonings • Do not refer to medications as “candy,” and do
Drugs: aspirin, acetaminophen, vitamins with iron, antidepressants, sedatives, not tell children they taste “yummy.”
tranquilizers, antacid tablets, diet pills, laxatives • Do not keep drugs in your purse.
Cleaning agents: bleach, toilet bowl or tank disks, detergents, drain cleaners • Remind grandparents or babysitters to “child-
Paint solvents: turpentine, kerosene, gasoline
proof” their homes.
Heavy metals: lead paint chips
Chemical products: glue, shoe polish, antifreeze, insecticides • Remove toxic houseplants from the home.
Cosmetics: hair dye, shampoo, nail polish remover • Keep the home well ventilated when using an
Plants: mistletoe berries, rhubarb leaves, foxglove, castor beans aerosol or another substance that leaves linger-
ing fumes in the air.
Although slippers are more comfortable, less expensive,

and less tiring to put on than shoes, they do not offer much
support or traction. 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 be prompt. Medications and altered health sta-
tus may cause temporary confusion and poor judgment.
Assessment
Determining which clients are at higher risk can prevent
some falls. Preventing falls is one of the National Patient
Safety Goals (see Box 19-1). Accredited hospitals and
long-term care agencies are implementing fall-reduction
programs and evaluating their effectiveness (Fig. 19-7).
FIGURE 19-5 • A pill organizer may help reduce the incidence of Most assessment tools identify risk factors to determine
medication overdoses. (Copyright B. Proud.) which clients need fall-prevention protocols.
15,000 died as a result of falls (National Center for Injury Prevention

Prevention and Control, 2005). Many who survive a fall Different fall-prevention approaches are used in the
suffer years of disability, impaired mobility, and pain. home and in health care facilities. Measures for prevent-
ing falls are modified based on the client’s circumstances.
Contributing Factors See Client and Family Teaching 19-3.
Older adults are more prone to falls for several reasons. Older adults should keep a list of emergency numbers
Many have age-related changes such as visual impair- posted by the phone. Those who live alone may want to
ments and disorders affecting gait, balance, and coordina- become part of a daily phone tree in which someone
tion. Some take medications that lower blood pressure, investigates if an older adult does not call in or answer
causing them to feel dizzy on rising. Others have urinary a call. Personal response services are also available in
urgency and rush to reach the toilet. Other social and which the subscriber wears a wireless, waterproof pen-
environmental factors also contribute. For example, older dant with a button that he or she can use to summon
adults often wear slippers to accommodate swollen feet. help in an emergency. Activating the button places a call
to the manufacturer’s emergency response center; once
connected, the user can carry on a two-way hands-free
POISON conversation. The center directs calls for assistance to
↓
predetermined people such as family, neighbors, the
Petroleum
Caustic physician, or emergency personnel. If the user cannot
Corrosive communicate, the center dispatches emergency person-
nel to the user’s location.
↓ ↓
Yes No
↓ ↓
Dilute with water or milk. Alert RESTRAINTS
↓
↓ ↓
Prevent vomiting.
Yes No In health care agencies, fall prevention measures may
↓
↓ ↓
Hydrate. include the use of physical and chemical restraints, which
Induce vomiting. Give antidote.
↓ are methods of restricting a person’s freedom of move-
or or
Treat symptoms. ment, physical activity, or normal access to his or her body
Lavage. Lavage.
↓ ↓ ( JCAHO, 2003). The use of restraints, however, is closely
regulated. Although the use of restraints is intended to
↓
↓
Give activated charcoal. prevent falls and other injuries, in many cases, their risks
↓ outweigh their benefits. Research indicates that restrained
Administer laxative. clients become increasingly confused; suffer chronic con-
FIGURE 19-6 • Decision tree for treating ingested poisons. stipation, incontinence, infections such as pneumonia,
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
Get-up-and-go (rising from chair) test:
Able to rise in a single movement 0
Pushes up, successful in one attempt +1 FIGURE 19-7 • Hendrich Fall Risk
Multiple attempts, but successful +3 Tool. (Original research in Hendrich,
Unable to rise without assistance +4 A., Nyhuis, A., Kippenbrock, T., & Soja,
M. E. [1995]. Hospital falls: Develop-
ment of a predictive model for clinical
FINAL RISK SCORE = * practice. Applied Nursing Research,
8[3], 129–139. Used with permission
* KEY: >5, High risk for falling of Ann Hendrich, MSN, RN, Methodist
Hospital, Indianapolis, IN.)
and pressure ulcers; and experience a progressive decline

in their ability to perform activities of daily living (Stone
Preventing Falls et al., 1999). Restrained clients are more likely to die dur-
The nurse teaches the client or the family as ing their hospital stay than those who are not restrained.
follows: It is unethical and a violation of JCAHO standards to
use physical or chemical restraints for disciplinary rea-
• Keep the environment well lit. sons or to compensate for limited personnel. Restraints
• Install and use handrails on stairs inside and must be the last intervention used after trying all other
outside the home.
measures to solve the problem. Nurses must take mea-
• Place a strip of light-colored adhesive tape on
sures to protect the restrained client’s health, safety, dig-
the edge of each stair for visibility.
nity, rights, and well-being.
• Remove scatter rugs.
• Keep extension cords next to the wall.
• Do not wax floors.
• Wear shoes or slippers with nonskid soles. Legislation
• Keep pathways clutter free.
• Wear short robes without cloth belts that may After research studies revealed the widespread use of
loosen and trip the client. physical restraints in long-term care facilities, federal leg-
• Use a cane or walker if prescribed. islation known as the Nursing Home Reform Law was
• Replace the tip on a cane as it wears down. incorporated in the Omnibus Budget Reconciliation Act
• Stay indoors when the weather is icy or snowy. (OBRA) in 1987 (Box 19-5). Compliance with the law
• Sit down when using public transportation, even has been mandatory since 1990.
if it means asking someone for his or her seat.
• Install and use grab bars in the shower and
near the toilet.
BOX 19-5 ● OBRA Legislation Addressing Restraints
• Place a nonskid mat or decals on the floor of
the tub or shower. The Omnibus Reconciliation Act (OBRA) of 1987 specifies that:
• Use soap-on-a-rope or a suspended container of The resident (patient) has the right to be free from any physical restraints
liquid soap to prevent slipping on a loose soap imposed or psychoactive drug administered for purposes of discipline or
bar. convenience, and not required to treat the resident’s (patient’s) medical
symptoms. . . . Restraints may only be imposed to ensure the physical safety
• Use a flashlight or nightlight when it is dark. of the resident or other residents and only upon the written order of a physi-
• Make sure that pets are not underfoot. cian that specifies the duration and the circumstances under which the
• Mop up spills immediately. restraints are to be used (except in emergency situations which must be
• Use long-handled tongs rather than climbing on addressed in the facility’s restraint policy).
a chair to reach high objects.
Accreditation Standards communicates with the client’s family regarding the need
for restraints and notes the time in the documentation.
The JCAHO followed the lead of OBRA legislation by When the assessment findings indicate that the client has
developing restraint and seclusion standards in 1991. improved, the nurse removes the restraint even if the
They continue to revise these standards, which differ order has not expired.
for nonpsychiatric and psychiatric institutions; the
most recent revision occurred in 2000. The standards
address three areas: agency restraint protocol, medical Restraint Alternatives
orders, and client monitoring and documentation of
nursing care. Agencies are being challenged to implement interven-
tions that protect clients from injury while ensuring
Restraint Protocol their freedom, mobility, and dignity. The intent of both
the OBRA legislation and JCAHO standards is to pro-
A protocol is a plan or set of steps to follow when imple- mote restraint alternatives (protective or adaptive devices
menting an intervention. During a JCAHO inspection, that promote client safety and postural support but that
the accrediting team examines an agency’s protocol for the client can release independently) and eventually
restraint use that the medical staff has approved. The restraint-free client care.
protocol must identify the criteria that justify the appli- Restraint alternatives are generally appropriate for
cation and discontinuation of restraints. Restraints are clients who tend to need repositioning to maintain their
considered appropriate when the risk for a person harm- body alignment or improve their independence and func-
ing himself/herself or staff is imminent. Nonphysical tional status. Some examples include seat inserts or grip-
interventions, such as reorienting a person to place and ping materials that prevent sliding, support pillows,
circumstances, or “time-out,” which involves removing seat belts or harnesses with front-releasing Velcro or
the client from the immediate environment to a quiet buckle closures, and commercial or homemade tilt wedges
room, is preferred. In the case of a client attempting to (Fig. 19-8). If the client is unaware of or cannot release
remove an endotracheal tube that facilitates mechanical the restraint alternative, it is considered a restraint.
ventilation, personnel must first attempt less restrictive Other supplementary measures also may reduce the
measures, such as having someone sit with the client. need for restraints. Personnel are encouraged to improve
gait training, provide physical exercise, reorient clients,
Medical Orders encourage assistive ambulatory devices such as walk-
A physician must write a restraint order, or a nurse must ers and hall rails, and use electronic seat and bed monitors
obtain one from a physician by telephone. If a physician that sound an alarm when clients get up without assis-
is unavailable, a registered nurse may initiate restraint use tance. Before considering the use of physical restraints, the
based on appropriate assessment of the client. A physician nurse observes and documents the client’s response to
must give a telephone order and perform a face-to-face other alternatives. When clients are in a wheelchair,
evaluation within 1 hour of restraint application. nurses must position them correctly (Table 19-4).
The order must specify the type of and reason for the
restraint. For nonpsychiatric clients, an order for use of
a restraint is time limited to no longer than 24 hours. For Use of Restraints
adult psychiatric clients, the time limit is 4 hours; for
pediatric psychiatric clients, the time limit is 2 hours When the use of restraints is justified, nurses and the
for those 9 to 17 years, and 1 hour for those younger than personnel they supervise must demonstrate continued
9 years. If need for restraint is ongoing, the physician competency in their safe application. Skill 19-1 explains
must reevaluate the client and write a new medical order. how to apply restraints and use them appropriately.
Monitoring and Documentation

The client’s chart must contain documented evidence
of frequent and regular nursing assessments of the
restrained client’s vital signs; circulation; skin condi-
tion or signs of injury; psychological status and comfort;
and readiness for discontinuing restraint. In addition,
the nurse must record nursing care concerning toileting,
nutrition, hydration, and range of motion while the
client is restrained. The documented care must reflect the
agency’s established protocol. The nurse also promptly FIGURE 19-8 • Examples of restraint alternatives.
TABLE 19-4 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 Tops of hips level in horizontal line Lumbar curve preserved
Thighs Knees 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 inches from knee
crease
Feet Great toes and fifth toes level in horizontal line Heel and forefoot positioned on footplate; ankle in neutral
position
Pang, J. (1994). Proper patient positioning in wheelchairs. Nursing Update, 5(1),2. With permission from J. T. Posey Co.,
Arcadia, CA.
• Avoids moving the client until doing so is safe.

Stop • Think + Respond BOX 19-1 • Reports the accident and assessment findings to the
List some methods for avoiding a lawsuit when restraints physician.
are necessary. • Completes an incident report as soon as the client is
stabilized (see Chap. 3).
NURSING IMPLICATIONS GENERAL GERONTOLOGIC

CONSIDERATIONS
Nurses must recognize safety hazards and identify clients Feelings of safety and security as one ages depend on perceived
at the greatest risk for injury. Once they gather and ana- familiarity and predictability of personal living space (Ebersole,
lyze the data, they may identify several nursing diagnoses. et al., 2004). The number of falls and the severity of injury
resulting from them increase as people become older. Falls
• Risk for Latex Allergy Response may result in major life-changing events, robbing the older
• Risk for Injury person of independence.
• Risk for Trauma Most falls among people 65 years or older occur at home. Com-
• Impaired Walking mon injuries include head injuries and wrist, spine, and hip
fractures. Hospitalizations involving falls are nearly twice as
• Disturbed Sensory Perception
long compared with those who do not fall. Approximately
• Acute Confusion 50% of clients hospitalized after falling are transferred to a
• Chronic Confusion nursing facility (Tideiksaar, 2002).
• Impaired Environmental Interpretation Syndrome Numerous factors may contribute to falls in the older person.
• Impaired Home Maintenance These factors may be classified as conditions (e.g., sedative and
psychoactive medication use, alcohol use, lower blood pres-
Nursing Care Plan 19-1 gives sample interventions sure, abnormalities of balance and gait, fear of falling, multiple
for a client with a nursing diagnosis of Risk for Injury, disorders, sensory deficits) or situations (e.g., environmental
defined in the NANDA taxonomy (2005) as a state in hazards, inadequate lighting, general clutter, assistive devices).
which a person is “at risk for harm because of a percep- Any of these factors may occur simultaneously, thus requiring
careful assessment for fall risks.
tual or physiologic deficit, a lack of awareness of hazards, Choice of shoes is important in reducing fall risk. Well-fitting
or maturational age.” shoes that enclose the heel and toe of the foot and have
Despite appropriate assessments and plans for pre- nonskid soles are recommended.
venting injuries, accidents still occur. When they do, Osteoporosis (loss of bone mass) increases the risk for fractures,
the nurse’s first concerns are the safety of the client especially in older women. Osteoporotic fractures may occur
with little or no trauma and even without a fall.
and the potential for allegations of malpractice. There-
“Fallphobia,” or an exaggerated fear of falling, may be a more per-
fore, if an accident occurs, the nurse takes the follow- vasive problem for the older person than actual falling. Fear of
ing actions: falling can significantly limit mobility, which may actually
increase the risk for falls.
• Checks the client’s condition immediately.
Older adults who have had a previous fall or have a history of
• Calls for help if the client is in danger. falling are more likely to fall again and often exhibit a char-
• Begins resuscitation measures if necessary. acteristic gait attributed more to being overly cautious than
• Comforts and reassures the client. a result of a prior injury.
Risk for Injury
ASSESSMENT
• Note evidence of altered mental status.
• Determine signs of impaired mobility, balance, and coordination.
• Take vital signs and document postural changes in blood pressure.
• Consult drug references for medications that cause sensory or motor effects or deficits.
• Check about the client’s use of an ambulatory aid such as crutches, canes, or a walker.
• Communicate with the client regarding self-assessment of functional status.
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 duration of care.
Assess BP lying and standing daily @ 0800. Determines effects of postural changes on BP regulation.
Keep the bed in low position. Facilitates safety when relocating from 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 client to a sitting position until dizziness passes Given time, baroreceptors for regulating BP can adjust to
before standing. accommodate for venous pooling.
Keep walker within reach at all times. Enhances the possibility that the client will use the
ambulatory aid.
Help to put on nonskid shoes or slippers and glasses for Footwear with traction and support and maximizing
ambulation. vision help reduce the risk for falling.

• Ambulation is delayed briefly until dizziness has passed.
• Client is assisted with nonskid slippers and glasses before ambulating.
• Client ambulates with assistance and use of walker.
• No falls occur.
Practical methods such as assessing risk factors for falls and Several different types of monitors, identification bracelets
teaching fall management should be initiated. Placing beds at (that include a phone number), and alerting/alarm devices are
low heights may diminish risks from falls. available for use with older adults at risk for wandering.
Older adults who are confused or otherwise cognitively impaired, Special environments may be designed, so that the hallways form
without an awareness of or appreciation for personal safety, a circle around the nursing stations, allowing the older adult to
may need precautions to prevent wandering. Helpful devices walk, yet remain in view of the nursing staff, rather than having
include placing a specially designed net with a stop sign exit doors placed at the ends of hallways.
across the exit doorway with Velcro, using bells over doors to Caregivers should be aware that early identification is necessary so
alert caregivers, or disguising an exit door by covering it with that proper precautions can be initiated. Daily documentation of
a curtain or wallpaper that blends in with the surrounding what a person is wearing is helpful should the client wander
environment. and need to be identified.
Caregivers taking care of cognitively impaired older people should The Alzheimer’s Association (1-800-272-3900) sponsors a pro-
be creative in ways to ensure safety and prevent wandering. gram called “Safe Return,” which facilitates the reporting and
return of people with cognitive impairments who become lost. 2. During the orientation of an unlicensed nursing assistant,
Local police departments may provide a service of digital pho- which of the nurse’s descriptions of a restraint alternative
tography of the older adult and coded identification bracelets. is most accurate?
The photos and identification code are maintained on police 1. It fastens behind the client.
department computers for identification of an adult found
2. It is made of cloth or nylon.
wandering. Clients with dementia may also be fitted with a
global positioning satellite (GPS) device to facilitate locating a
3. The client must be able to release the device.
missing person. 4. The client must give consent for its application.
Older adults with cognitive impairments need to be protected from 3. When providing health teaching to caregivers of older
accidental ingestion of toxic substances, such as medications adults, the nurse is most correct in identifying which of
and cleaning agents, in households and institutional settings. the following as the greatest safety issue?
Care providers should be taught to keep these items in secure,
1. Chemical poisoning
locked locations at all times.
2. Thermal burns
3. Electrical shock
CRITICAL THINKING E X E R C I S E S 4. Accidental falls
4. Which of the following nursing actions is best to imple-
1. When discharging an older adult to the care of a family
ment initially when discovering an alert person who has
member, what safety measures are appropriate to include
ingested too much prescribed medication?
in the discharge instructions?
1. Induce vomiting.
2. Without resorting to the use of restraints, how can you 2. Administer an antacid.
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.
NCLEX-STYLE REVIEW Q U E S T I O N S 5. If a nurse determines that a physical restraint is neces-
sary to maintain a client’s safety, which of the following
1. When examining an unconscious client, which assess- is essential?
ment finding is most indicative of carbon monoxide 1. Obtaining a medical order for its use
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. Smokey odor to clothing
4. Rapid, irregular pulse rate
Skill 19-1 • USING PHYSICAL RESTRAINTS
Assessment
Assess the client’s physical and mental status for signs Provides data for determining the need for physical
suggesting danger to self or others. restraints
Consult with staff and family on options other than Supports the principle of using less restrictive approaches
restraints. initially
Observe the client’s response to alternative measures. Determines the need to revise the current plan for care
Check the chart for a physician’s order for the use of Complies with JCAHO requirements
restraints.
Review the agency’s restraint policy or procedure if there Follows standards for care
is no current medical order.
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 Ensures safety
are in poor condition.
Planning
Obtain a current order for the use of physical restraints if Complies with JCAHO guidelines
they are necessary.
Choose a restraint compatible with the client’s size. Prevents injury
Approach the client slowly and calmly. Speak in a soft, Reduces agitation
controlled voice.
Use the client’s name and make eye contact. Helps secure the client’s attention
Explain why restraint is necessary. Promotes understanding and cooperation
Reassure the client that the restraints will be discontinued Indicates criteria for releasing restraints
when the possibility for harm no longer exists.
Plan to remove or loosen the restraints at time periods Demonstrates attention to basic physiologic and safety
established by agency policy to assess circulation, needs; supports the principle that restraints are not
provide joint mobility, give skin care, assist with applied longer than necessary
elimination, offer food and fluids, and evaluate
whether restraints are still needed.
Implementation
Place the client in a position of comfort with proper body Maintains functional position and reduces discomfort
alignment.
Protect any bony prominences or fragile skin that a Reduces or prevents injury
restraint may injure.
Upper Extremity Restraints

Apply mitts rather than wrist restraints, if possible. Maintains freedom to move elbows and shoulders
Use soft cloth restraints instead of stiff leather. Promotes skin integrity
Provide as much length as possible without allowing the Facilitates movement
client to 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
(continued)
USING PHYSICAL RESTRAINTS (Continued)
Netted hand mitt. (Copyright B. Proud.)
Soft wrist restraints are applied over padded bony prominences. Ensure
that two fingers can be inserted between the restraint and the wrist.
Apply belts snugly over the thighs with at least a Minimizes sliding up toward the ribs and compromising
45-degree angle between the belt and knees. breathing
With the lap strap at a 45-degree angle to the knees, the hips are held toward the back of
the chair.
(continued)
Apply vests with Velcro or zipper closures at the back; use Keeps fasteners out of reach; prevents strangulation
criss-crossing vests with front closures only on docile
clients.
Support the feet on footrests. Reduces pressure behind the knees and promotes blood
circulation
Tie restraints under the chair not behind the back. Prevents suffocation if the client should slide downward
Restraint ties are secured beneath the chair. (Copyright B. Proud.)
Use a quick-release knot when tying any type of restraint. Facilitates removal should the client’s safety become
compromised
Follow the sequence in steps A, B, and C to tie a quick-release knot.
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
(continued)
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 Prevents injury from slipping between or below half rails
while the client is restrained.
Apply side-rail covers or pad the rails with soft bath Reduces the potential for becoming caught or injured
blankets if the client is extremely restless. within the open spaces of the rails
Apply jacket restraints snugly enough to prevent harm but Ensures ventilation
not so tight as to constrict the chest and interfere with
breathing.
Secure the straps to the moveable part of the bed frame Prevents sliding and chest compression
not the side rails or stationary frame.
The restraint ties are secured to the moveable portion of the bed frame.
Monitor aggressive, agitated, or restless clients frequently. Promotes client safety
Evaluation
• Restraint(s) 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
(continued)
• 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 elimina-
tion 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 differen-
tiate 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
20
Chapter
Pain
Management
WORDS TO KNOW
acupressure gate-control theory pain tolerance
acupuncture hypnosis patient-controlled analgesia (PCA)
acute pain imagery perception
adjuvants intractable pain percutaneous electrical nerve
alternative medical therapy intraspinal analgesia stimulation (PENS)
analgesic loading dose placebo
biofeedback malingerer referred pain
bolus meditation relaxation
chronic pain modulation rhizotomy
controlled substances neuropathic pain somatic pain
cordotomy nociceptors suffering
cutaneous pain nonopioids transcutaneous electrical nerve
distraction opioids stimulation (TENS)
endogenous opioids pain transduction
equianalgesic dose pain management transmission
fifth vital sign pain threshold visceral pain
LEARNING OBJECTIVES
Give a general definition of pain.
● List four phases in the pain process.
● Explain the difference between pain perception, pain threshold, and pain tolerance.
● Describe the gate-control theory of pain transmission.
● Discuss how endogenous opioids reduce pain transmission.
● Name at least five types of pain.
● Give at least three characteristics that differentiate acute pain from chronic pain.
● List five components of a basic pain assessment.
● Name four common pain-intensity assessment tools that nurses use.
● Identify at least three occasions when it is essential to perform a pain assessment and
document assessment findings.
● Name four physiologic mechanisms for managing pain.
● Give three categories of drugs used alone or in combination to manage pain.
● Identify two surgical procedures used when other methods of pain management are ineffective.
● List at least five nondrug, nonsurgical methods for managing pain.
● Discuss the most common reason why clients request frequent administrations of
pain-relieving drugs.
● Define addiction.
● Discuss how addiction affects pain management.
● Define placebo and explain the basis for its positive effect.
434
C H A P T E R 20 ● Pain Management 435
PAIN is probably the major cause of physical distress toward the spinal cord. Transduction begins when injured
among clients. This chapter provides information about cells release chemicals such as substance P, prosta-
pain and techniques for pain relief. glandins, bradykinin, histamine, and glutamate. These
chemicals excite nociceptors (type of sensory nerve recep-
tors activated by noxious stimuli) located in the skin,
PAIN bones, joints, muscles, and internal organs (Fig. 20-2).
Pain is an unpleasant sensation usually associated with

Transmission
disease or injury. It causes physical discomfort and also is Transmission is the phase during which stimuli move from
accompanied by suffering, which is the emotional compo- the peripheral nervous system toward the brain. Transmis-
nent of pain. Because there is no effective method for val- sion occurs when peripheral nociceptors form synapses
idating or invalidating pain, Margo McCaffery (1998), a with neurons within the spinal cord that carry pain
nursing expert on pain, defines pain as being “whatever impulses and other sensory information such as pressure
the person says it is, and existing whenever the person and temperature changes via fast and slow nerve fibers.
says it does.” Understanding how pain is produced and A-delta fibers, which are large myelinated fibers, carry
perceived is essential to finding mechanisms for pain impulses rapidly at a rate of approximately 5 to 30 meters
relief. Extensive research is being conducted to discover per second (Porth, 2004). Impulses via the fast pain path-
more about pain transmission, types of pain, and the man- way result in sharp, acute initial sensations like those felt
agement of pain. when touching a hot iron. The result is that the person
withdraws from the pain-provoking stimulus. Following
the fast transmission, impulses from small unmyelinated
The Process of Pain fibers known as C-fibers carry impulses at a slower rate
of 0.5 to 2 meters a second. They are responsible for the
The process by which people experience pain occurs in
throbbing, aching, or burning sensation that persists
four phases: transduction, transmission, perception, and
after the immediate discomfort.
modulation (Fig. 20-1).
With the help of substance P, pain impulses move
to sequentially higher levels in the brain, such as the
Transduction
reticular activating system, thalamus, cerebral cortex,
Transduction refers to the conversion of chemical informa- and limbic system. Prostaglandin, a chemical released
tion at the cellular level into electrical impulses that move from injured cells, speeds the transmission. As the pain
Perception
3
Transduction
1 4 Modulation
Transmission 2
FIGURE 20-1 • The phases of pain.

level, past pain experiences, and overall emotional dispo-

sition (Mayo Clinic, 2006).
Modulation
Modulation is the last phase of pain impulse transmission
during which the brain interacts with the spinal nerves in
a downward fashion to subsequently alter the pain expe-
rience. At this point, the release of pain-inhibiting neuro-
chemicals reduces the painful sensation. Examples of such
neurochemicals include endogenous opioids (discussed
later in this chapter), gamma-aminobutyric acid (GABA),
and others.
Research is being conducted to develop new types of
pain-modulating drugs. Current efforts are being directed
at medications that (1) occupy cell receptors for neuro-
transmitters like acetylcholine and serotonin, (2) block
glutamate receptors and peptides (protein compounds)
like tachykinin-neurokinin and substance P, (3) reduce
cytokines (type of immune system protein) that trigger
pain by promoting inflammation, and other scientific
endeavors to discover new methods for relieving pain
without the unwanted side effects of current analgesics
(Pain—Hope Through Research, 2006).
Pain Theories
Several theories attempt to explain how pain is transmit-
FIGURE 20-2 • Pain transmission pathway. ted and reduced. No one theory is all encompassing.
A hypothesis for how the perception of pain is dimin-
ished involves endogenous opioids (naturally produced
impulses are transmitted, pain receptors become increas-
morphine-like chemicals). The endogenous opioids en-
ingly sensitized. This finding helps to explain the clinical
dorphins, dynorphins, and enkephalins reduce pain. Two
observation that established pain is more difficult to
neurotransmitters, serotonin and norepinephrine, stim-
suppress.
ulate their release (see Chap. 5). When endogenous opi-
When pain impulses reach the thalamus within the oids are released, they are thought to bind to sites on the
brain, two responses occur. First, the thalamus transmits nerve cell’s membrane that block the transmission of pain-
the message to the cortex, where the location and severity conducting neurotransmitters such as substance P and
of the injury are identified. Second, it notifies the nocicep- prostaglandins (Fig. 20-3).
tors that the message has been received and that contin-
ued transmission is no longer necessary. A malfunction in
this secondary process may be one reason why chronic Types of Pain
pain lingers.
Not all pain is exactly the same. Five types of pain have
Perception been described according to source (cutaneous, visceral,
Perception (conscious experience of discomfort) occurs or neuropathic) or duration (acute or chronic).
when the pain threshold (point at which sufficient pain-
Cutaneous Pain
transmitting stimuli reach the brain) is reached. Once
pain is perceived, structures within the brain determine Cutaneous pain, discomfort that originates at the skin level,
its intensity, attach meaningfulness to the event, and is a commonly experienced sensation resulting from some
provoke emotional responses. form of trauma. The depth of the trauma determines the
Pain thresholds tend to be the same among healthy type of sensation felt. Damage confined to the epidermis
people, but each person tolerates or bears the sensation of produces a burning sensation. At the dermis level, pain is
pain differently. Pain tolerance (amount of pain a person localized and superficial. Subcutaneous tissue injuries pro-
endures) is influenced by genetics; learned behaviors spe- duce an aching, throbbing pain. Somatic pain (discomfort
cific to gender, age, and culture (see Chap. 6); and other generated from deeper connective tissue) develops from
biopsychosocially unique factors such as current anxiety injury to structures such as muscles, tendons, and joints.
FIGURE 20-3 • Mechanism of pain transmission and interference.
Visceral Pain
(discomfort arising from internal organs) is
Visceral pain
associated with disease or injury. It is sometimes referred
or poorly localized. Referred pain (discomfort perceived in
a general area of the body, usually away from the site of
stimulation) is not experienced in the exact site where an
organ is located (Fig. 20-4). Other autonomic nervous
system symptoms such as nausea, vomiting, pallor, hypo-
tension, and sweating accompany visceral pain.
Neuropathic Pain
Neuropathic pain (pain with atypical characteristics) is also
called functional pain. This type of pain often is experi-
enced days, weeks, or even months after the source of the
pain has been treated and resolved (Copstead-Kirkhorn &
Banasik, 2005). This has led some to speculate that the
transduction circuitry is dysfunctional, allowing pain FIGURE 20-4 • Areas of referred pain.
stimuli to continue in the absence of injury or disease.

One example of neuropathic pain is phantom limb pain
or phantom limb sensation, in which a person with an Chronic Pain
amputated limb perceives that the limb still exists and The characteristics of chronic pain (discomfort that lasts
feels burning, itching, and deep pain in tissues that have longer than 6 months) are almost totally opposite from
been surgically removed. those of acute pain (Table 20-1). The longer pain exists, the
more far-reaching its effects on the sufferer (Box 20-1).
Acute Pain
Others begin to show negative reactions to the chronic
Acute pain (discomfort that has a short duration) lasts for pain sufferer, such as the following:
a few seconds to less than 6 months. It is associated with
tissue trauma, including surgery or some other recent • Saying they are tired of hearing about the pain
identifiable etiology. Although severe initially, acute pain • Ignoring the sufferer’s concerns and complaints
eases with healing and eventually disappears. The grad- • Getting angry
ual reduction in pain promotes coping with the discom- • Suggesting that the pain has a psychological basis
fort because there is a reinforcing belief that the pain will • Telling the person he or she is using the pain to manip-
disappear in time. Both acute and chronic pain result in ulate others for selfish purposes
physical and emotional distress and can be intermittent • Criticizing the person for using drugs “as a crutch”
(incorporating periods of relief), but that is where the • Suggesting that the person is addicted to pain medica-
similarities end. tion (American Chronic Pain Association, 2004)
TABLE 20-1
CHARACTERISTICS OF ACUTE BOX 20-1 ● Quality-of-Life Activities Affected
AND CHRONIC PAIN by Chronic Pain
ACUTE PAIN CHRONIC PAIN Exercising
Working around the house
Recent onset Remote onset Sleeping
Symptomatic of primary Uncharacteristic of primary Enjoying hobbies and leisure time
injury or disease injury or disease Socializing
Specific and localized Nonspecific and generalized Walking
Concentrating
Severity associated with Severity out of proportion to
Having sex
the acuity of the injury the stage of the injury or
Maintaining relationships with family and friends
or disease process disease
Working a full day at employment
Favorable response to Poor response to drug therapy Caring for children
drug therapy
Requires less and less Requires more and more
drug therapy drug therapy
Diminishes with healing Persists beyond healing stage
with which all accredited health care organizations must
Suffering is decreased Suffering is intensified
comply. Aspects incorporated in the JCAHO standards
Associated with sympathetic Absence of autonomic
nervous system responses nervous system responses;
such as hypertension, manifests depression and
• Everyone cared for in an accredited hospital, long-
tachycardia, restlessness, irritability
anxiety term care facility, home health care agency, outpatient
clinic, or managed care organization has the right to
assessment and management of pain.
• Pain is assessed using a tool appropriate for the person’s
age, developmental level, health condition, and cul-
PAIN ASSESSMENT STANDARDS tural identity. Refer to Table 20-2 for pain-related infor-
mation that is included in an initial comprehensive pain
The American Pain Society has proposed that pain assess- assessment.
ment is the fifth vital sign. In other words, the nurse checks • Pain is assessed regularly throughout health care
and documents the client’s pain every time he or she delivery.
assesses the client’s temperature, pulse, respirations, and • Pain is treated in the health care agency, or the client
blood pressure. In August 1999, the Joint Commission is referred elsewhere.
on Accreditation of Healthcare Organizations (JCAHO) • Health care workers are educated regarding pain assess-
established Pain Assessment and Management Standards ment and management.
TABLE 20-2 JCAHO COMPONENTS OF A COMPREHENSIVE PAIN ASSESSMENT*

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
*If clients have pain in more than one area, assessment data are collected for each.
TABLE 20-3 COMPONENTS OF PAIN ASSESSMENT

CHARACTERISTIC DESCRIPTION EXAMPLES
Onset Time or circumstances under which the pain became After eating, while shoveling snow, during the night
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 to 10
Location Anatomic site Chest, abdomen, jaw
Duration Time span of pain Continuous, intermittent, hours, weeks, months
• Clients and their families are educated about effective indicators of pain, such as moaning, crying, grimacing,
pain management as an important part of care. guarded position, increased vital signs, reduced social
• The client’s choices regarding pain management are interactions, irritability, difficulty concentrating, and
respected. changes in eating and sleeping. Autonomic nervous sys-
tem responses such as tachycardia, hypertension, dilated
To comply with established standards of care, the nurse
pupils, perspiration, pallor, rapid and shallow breathing,
assesses pain whenever he or she considers it appropriate
urinary retention, reduced bowel motility, and elevated
and routinely in the following circumstances:
blood glucose levels may be apparent. Clients with chronic
• When the client is admitted pain are not as likely to manifest autonomic nervous sys-
• Whenever the nurse takes vital signs tem responses.
• At least once per shift when pain is an actual or poten-
tial problem
• When the client is at rest and when involved in a nurs- PAIN INTENSITY ASSESSMENT TOOLS
ing activity
• After each potentially painful procedure or treatment
• Before implementing a pain-management intervention, There is no perfect way to determine whether pain exists
such as administering an analgesic (pain-relieving drug) and how severe it is. Because no machines or laboratory
and again 30 minutes later tests can measure pain, nurses are limited to the subjec-
tive information that only clients can provide.
Nurses generally use one of four simple assessment
PAIN ASSESSMENT DATA tools to quantify a client’s pain intensity: a numeric scale,
a word scale, a linear scale (Fig. 20-5), and a picture scale
(Fig. 20-6). Clients identify how their pain compares with
A basic or brief pain assessment includes the client’s the choices on the scale.
description of the onset, quality, intensity, location, and One scale is not better than another. A numeric scale is
duration of the pain (Table 20-3). Nurses also ask about the most commonly used tool when assessing adults. The
symptoms that accompany the pain and what, if any- Wong-Baker FACES scale is best for children or clients
thing, makes it better or worse. During an admission who are culturally diverse or mentally challenged. Chil-
assessment, the nurse also asks questions such as, dren as young as 3 years can use the FACES scale. Regard-
• What activities are you unable to do because of pain? less of the assessment tool used, many clients underrate or
• Do you ever take pain medication? If so, when? minimize their pain intensity.
• What are the names and dosages of pain medicine
you take?
• What nondrug methods, such as rest, do you use to BOX 20-2 ● Underassessed and Undertreated
relieve your pain? Pain Populations
• How does your pain change with self-treatment? ❙ Infants
• What are your preferences for managing your pain? ❙ Children younger than 7 years of age
• What pain level is an acceptable goal for you if total ❙ Culturally diverse clients
pain relief is not possible? ❙ Clients who are mentally challenged (retarded)
❙ Clients with dementia (diminished brain function)
When caring for clients, especially those who are often ❙ Clients who are hearing or speech impaired
underassessed and undertreated (Box 20-2), the nurse ❙ Clients who are psychologically disturbed
observes for behavioral signs that are common nonverbal
Pain intensity scales Treatment Biases
Simple Descriptive Pain Intensity Scale* According to McCaffery and Ferrell (1999), nurses some-
times delay pain-relieving measures because “. . . (they)
expect someone in severe pain to look as if he hurts.”
Neither behaviors nor physiologic data, however, are
No Mild Moderate Severe Very Worst irrefutable indicators of pain. Responses to pain and
pain pain pain pain severe possible coping techniques are learned, and clients may express
pain pain them in a variety of ways. If a client’s expressions of pain
are incongruent with the nurse’s expectations, pain
0 – 10 Numeric Pain Intensity Scale*
management may not be readily forthcoming. Conse-
quently, the client’s pain may be undertreated.
0 1 2 3 4 5 6 7 8 9 10 Pain Management Techniques

No Moderate Worst
pain pain possible Pain management (techniques for preventing, reducing, or
pain
relieving pain) is a major focus for quality improvement
Visual Analog Scale (VAS)**
programs in health care agencies. The American Pain
Society, working with the Agency for Health Care Policy
and Research (a division of the Department of Health
No Pain as bad and Human Services), has developed Standards for the
pain as it could Relief of Acute Pain and Cancer Pain (Box 20-3). The
possibly be objective of this collaborative effort is to improve how
pain is assessed and controlled. The original effort has
* If used as a graphic rating scale, a 10-cm baseline been expanded to include the assessment and treatment
is recommended.
** A 10-cm baseline is recommended for VAS scales.
of pain in all client populations (Dahl et al., 1998).
Most techniques for managing pain fall into one of
FIGURE 20-5 • Pain assessment tools: word scale (top), numeric scale
(middle), linear scale (bottom).
four general physiologic categories (Table 20-4).
Drug Therapy
PAIN MANAGEMENT Drug therapy, either alone or in combination with other
therapeutic measures, is the cornerstone of pain man-
Because of the wide variety of types of pain and effects on agement. The World Health Organization (1996, 2006b)
lifestyle and personal relationships, management of the
client’s pain is a priority. Despite the fact that the client
is the only reliable source for quantifying pain, nurses are
BOX 20-3 ● Standards for the Relief of Acute Pain
not consistent in responding to clients’ reports of pain
and Cancer Pain
because of personal biases.
Standard I
Acute pain and cancer pain are recognized and effectively treated.
Standard II
Information about analgesics is readily available.
Standard III
Patients are informed on admission, both orally and in writing, that effective pain
FIGURE 20-6 • Wong-Baker FACES Pain Rating Scale. Instructions: relief is an important part of their treatment, that their communication of unrelieved
Explain to the person that each face is for a person who feels happy pain is essential, and that health professionals will respond quickly to their reports
because he has no pain (hurt) or sad because he has some or a lot of of pain.
pain. Face 0 is very happy because he doesn’t hurt at all. Face 1 hurts
Standard IV
just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face
Explicit policies for use of advanced analgesic technologies are defined.
4 hurts a whole lot. Face 5 hurts as much as you can imagine, although
you don’t have to be crying to hurt this bad. Ask the person to choose Standard V
the face that best describes how he or she is feeling. Rating scale is rec- Adherence to standards is monitored by an interdisciplinary committee.
ommended for persons age 3 years and older. (From Wong, D. L.,
Hockenberry-Eaton, M., Wilson D., Winkelstein, M. L., Ahmann, E., & Reprinted with permission from American Pain Society. (1999). Principles
DiVito-Thomas, P. A. [1999]. Whaley & Wong’s nursing care of infants and of analgesic use in the treatment of acute pain and chronic cancer pain
children [6th ed., p. 1153]. St. Louis: Mosby. Copyrighted by Mosby- (4th ed.) Skokie, Il; Author.
Year Book, Inc. Reprinted by permission.)
TABLE 20-4 APPROACHES TO PAIN MANAGEMENT

APPROACH INTERVENTION EXAMPLES
Interrupting pain-transmitting Local anesthetics, anti-inflammatory drugs Procaine, lidocaine, aspirin, ibuprofen,
chemicals at the site of injury acetaminophen, naproxen,
indomethacin
Altering transmission at the Intraspinal anesthesia and analgesia, Epidural, caudal, rhizotomy, cordotomy,
spinal cord neurosurgery sympathectomy
Using gate-closing mechanisms Cutaneous stimuli Massage, acupuncture, acupressure,
heat, cold, therapeutic touch, electrical
stimulation
Blocking brain perception Narcotics, nondrug techniques Morphine, codeine, hypnosis, imagery,
distraction
recommends following a three-tiered drug approach Nonopioid Drugs

based on the pain intensity and the client’s response to
Nonopioid drugs are non-narcotics including aspi-
therapy (Fig. 20-7). The original target of the WHO’s
rin, acetaminophen (Tylenol), and nonsteroidal anti-
analgesic ladder was to address methods for relieving
pain from cancer. To date, no large statistical studies have inflammatory drugs (NSAIDs) such as ibuprofen (Motrin,
been conducted either to validate or refute the WHO’s Advil, Nuprin), ketoprofen (Orudis KT), and naproxen
recommendations for pain management and their belief sodium (Naprosyn, Aleve). These drugs relieve pain by
that, if followed, 80% to 90% will be free of pain. Never- altering neurotransmission peripherally at the site of
theless, 20 years later, the principles continue to be appli- injury.
cable for managing pain from cancer as well as other One of the newest categories of nonopioid drugs is
causes of pain (WHO, 2006a). the cyclooxygenase-2 (COX-2) inhibitors such as cele-
Using a tiered approach, physicians prescribe one or coxib (Celebrex). COX is an enzyme: COX-1 protects the
more of the following classes of drugs: nonopioids (non- gastrointestinal tract and urinary system, and COX-2
narcotic drugs), opioids (narcotic drugs), and adjuvants promotes the production of pain-transmitting and inflam-
(drugs that assist in accomplishing the desired effect of a matory chemicals such as prostaglandins. The inhibi-
primary drug). The choice of drug, its dose, and the tim- tion of COX-2 results in pain relief. COX-2 inhibitors are
ing of medication administration are critical in achieving superior to older NSAIDs, which suppress both COX-1
optimal pain relief. and COX-2 enzymes. Inhibiting COX-2 to a greater degree
than COX-1 causes fewer undesirable gastric side effects.
The U.S. Food and Drug Administration has withdrawn
several COX-2 inhibitors from prescription use because
Freedom from pain there have been cardiac-related deaths among some users.
Most nonopioids are very effective at relieving pain
caused by inflammation. The exception is acetaminophen,
Opioid for mod
which has limited anti-inflammatory activity; however,
Pain persisting erate to it is still an effective analgesic. The efficacy of COX-2
1
severe pain
or increasing inhibitors for relieving other types of pain, such as head-
+/- Nonopioid
+/- Adjuvant aches and body aches from influenza, is not established.
Except for COX-2 inhibitors, almost all the NSAIDs
Opioid for cause gastrointestinal irritation and bleeding, so they
mild to mo
+/- Nonop
+/- Adjuva
derate pa
ioid
nt
in
2 should be given with food.
Opioid Drugs
3
Nonopio
id When pain is no longer controlled with a nonopioid, the
+/- Adjuv nonopioid is combined with an opioid—for example,
ant
aspirin with codeine or acetaminophen with codeine or an
adjuvant drug, which is discussed later. Opioids (synthetic
narcotics) and opiate analgesics, narcotics containing
FIGURE 20-7 • World Health Organization (WHO) pain relief ladder. opium or its derivatives, are controlled substances (drugs
underprescribed even if clients can benefit from their

use. When they are used, treatment biases lead some
nurses to administer the lowest dosage of a prescribed
range or to delay administration until the maximum time
between dosages has elapsed. Consequently, many clients
experience inadequate pain management, which con-
tributes to long-term suffering and disability. In addition,
unrelieved pain can lead to pneumonia due to shallow
breathing, suppressed coughing, and reduced movement.
Psychological effects of unrelieved pain include anxiety,
depression, and despair, even to the point of suicide.
PATIENT-CONTROLLED ANALGESIA. Patient-controlled anal-

gesia (PCA) is an intervention that allows clients to self-
administer narcotic pain medication through use of an
infusion device (Fig. 20-8). PCA is used primarily to
relieve acute pain after surgery, but this technology is
finding its way into the home health arena where non-
hospitalized clients with cancer are using it.
PCA has several advantages to both clients and nurses:
• Pain relief is rapid because the drug is delivered intra-
venously.
FIGURE 20-8 • Patient-controlled analgesia. • Pain is kept within a constant tolerable level (Fig. 20-9).
• Less drug is actually used because small doses contin-
uously control the pain.
whose prescription and dispensing are regulated by fed- • Clients are spared the discomfort of repeated injections.
eral law because they have the potential for being abused). • Anxiety is reduced because the client does not wait for
Examples include the following: the nurse to prepare and administer an injection.
• Morphine sulfate • Side effects are reduced with smaller individual dosages
• Codeine sulfate and lower total dosages.
• Meperidine (Demerol) • Clients tend to ambulate and move more, reducing the
• Fentanyl (Duragesic, Sublimaze) potential for complications from immobility.
• Clients take an active role in their pain management.
Narcotics interfere with central pain perception (at the • The nurse is free to carry out other nursing respon-
brain) and generally are reserved for treating moderate
sibilities.
and severe pain. They are administered by the oral, rec-
tal, transdermal, or parenteral (injected) route. The nurse programs the infusion device so that the
Opioids and opiates cause sedation, nausea, consti- client can receive a bolus or loading dose (larger dose of
pation, and respiratory depression. Because of an exag- drug administered initially or when pain is exceptionally
gerated fear of causing addiction, narcotics tend to be intense) and additional lower doses at frequent intervals
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 intramuscular (IM)
analgesia (A) than with patient-controlled analgesia (PCA) (B). (Adapted from Hormer, M., Rosen, M., Vickers,
M. D. Eds. [1985]. Patient-controlled analgesia. St. Louis, CV Mosby.)
depending on the client’s level of discomfort (Skill 20-1). Botulinum Toxin Therapy
Once a dose is delivered, the client cannot administer
Botulinum toxin (Botox) is an agent made from the bac-
another dose for a specified amount of time; this period,
terium Clostridium botulinum, which is found in soil and
known as a lockout, prevents overdoses.
water. Of the seven types of neurotoxins it produces,
botulinum type A (BTX-A) has been approved to treat
Stop • Think + Respond BOX 20-1 painful musculoskeletal conditions and various types of
Discuss appropriate nursing actions when a client uses headaches.
the maximum doses of drug with a PCA infuser. When injected directly into a muscle, the toxin blocks
the action of acetylcholine. Under normal conditions,
acetylcholine, a neurotransmitter, causes skeletal muscle
INTRASPINAL ANALGESIA. Intraspinal analgesia is a method contraction when it is released at the synapses of motor
of relieving pain by instilling a narcotic or local anesthetic nerves. Blocking acetylcholine results in temporary paral-
through a catheter into the subarachnoid or epidural space ysis of the injected muscle. When muscles are paralyzed,
of the spinal cord. It is another technique for managing spasms and nociceptive transduction are inhibited, result-
pain. The intraspinal analgesic is administered several ing in pain relief. The effect is local and specific rather
times per day or as a continuous low-dose infusion. Intra- than systemic and lasts 2 to 6 months or more (Preboth,
spinal analgesia relieves pain while producing minimal 2002; Schwedt, 2005). Injections must be repeated to con-
systemic drug effects. In clients who need long-term anal- tinue the therapeutic effect. The duration of each injec-
gesia, the use of intraspinal analgesia diminishes the risk tion’s effect tends to become shorter over time. Clinical
for injuring the subcutaneous tissue with repeated injec- resistance may result from the development of neutraliz-
tions that may eventually lessen drug absorption. ing BTX-A antibodies.
Those who are candidates for botulinum toxin therapy
Adjuvant Drugs may experience local pain, bruising, or infection at the
injection site. The muscle weakness may be somewhat
Analgesic drugs are combined with a wide range of adju- disturbing to some; a few develop new patterns of pain.
vant drugs to improve pain control. The categories of Because this type of therapy has been approved only since
adjuvant drugs and examples of each are as follows: 1989 and increasingly used since 1997, the long-term risks
• Antidepressants: tricyclic antidepressants such as ami- and benefits are still being compiled.
triptyline (Elavil); selective serotonin reuptake inhib-
itors such as fluoxetine (Prozac) and paroxetine (Paxil)
• Anticonvulsants: carbamazepine (Tegretol), gabapentin Surgical Approaches
(Neurontin)
• N-methyl-d-aspartate (NMDA) receptor antagonists: Intractable pain(pain unresponsive to other methods of
dextromethorphan, ketamine (Ketalar) pain management) can be relieved with surgery. Rhizot-
• Nutritional supplements such as glucosamine omy and cordotomy are neurosurgical procedures that
provide pain relief.
Each category of adjuvant drugs acts by different mech- A rhizotomy is surgical sectioning of a nerve root close
anisms. The antidepressants may produce their analgesic- to the spinal cord. It prevents sensory impulses from
enhancing effect by increasing norepinephrine and entering the spinal cord and traveling to the brain. Gener-
serotonin levels, augmenting the release of endorphins. ally more than one nerve needs to be sectioned to achieve
Anticonvulsants are believed to inhibit the transmis- the desired result. Chemical rhizotomy, using alcohol or
sion of pain by regulating and potentiating the inhibitory phenol, and percutaneous rhizotomy, which uses radio-
neurotransmitter gamma-aminobutyric acid (GABA) (see frequency waves, are nonsurgical alternatives for destroy-
Chap. 5). NMDA drugs interfere with the function of ing nerve fibers. A cordotomy is surgical interruption of
nociceptive nerve fibers, perhaps blocking the release of pain pathways in the spinal cord. It is accomplished by
substance P, its nerve-sensitizing properties, and other cutting bundles of nerves. Although both procedures
inflammatory chemicals. Those who favor alternative med- interrupt the sensation of pain, they also inhibit the per-
ical therapy (treatment outside the mainstream of tradi- ception of pressure and temperature in the area supplied
tional medicine) contend that glucosamine slows the by the nerves. Consequently, there is a greater risk for
breakdown of joint cartilage and promotes its regener- secondary injury.
ation, relieving pain associated with joint diseases.
Adjuvant drugs are never used as a first-line treat-
ment for pain. When they are used as combination drug Nondrug and Nonsurgical Interventions
therapy, however, the dose of the primary drug can often
be decreased. With a lowered opioid dosage, for instance, Several additional interventions can be used to help man-
the client will have less sedation and fewer undesirable age pain. Some independent nursing measures include
side effects. education, imagery, distraction, relaxation techniques, and
applications of heat or cold. Other interventions, such as guided imagery and relaxation (discussed later) are also
transcutaneous electrical nerve stimulation, acupuncture available, but the subject matter and descriptions can
and acupressure, percutaneous electrical nerve stimula- become boring when played repeatedly. Some prefer to
tion, biofeedback, and hypnosis, require collaboration use taped sounds of nature, making it easy to conjure dif-
with people who have specialized training and expertise. ferent images each time.
The latter interventions are more likely to be used for Physiologically, the process of imagery produces an
clients with chronic pain or those in whom acute pain alteration in consciousness that allows the client to for-
management techniques have been unsuccessful or are get uncomfortable sensory experiences such as pain.
contraindicated. Some believe that imagery stimulates the visual portion
of the brain’s cortex, located in the right hemisphere,
Education where abstract concepts and creative activities occur
(Fig. 20-10). While the person is imaging, neurotrans-
Educating clients about pain and methods for pain man- mitters are released that calm the body physically and
agement supports the principle that clients who assume an promote emotional well-being.
active role in their treatment achieve positive outcomes
sooner than others. See Client and Family Teaching 20-1. Meditation
It may be unrealistic for clients to expect to be totally pain
free, but they should not have to endure severe pain. Meditation is concentrating on a word or idea that pro-
motes tranquility and is similar to imagery except the
Imagery subject matter tends to be more spiritual. Sometimes
meditation involves silent repetition of a word such as
Imagery means using the mind to visualize an experience
“love” or “peace,” a prayer, or a statement that reflects a
and sometimes is referred to as intentional daydreaming.
strong personal or religious belief. Those who use this
The person chooses images based on pleasant memories.
technique successfully tend to experience a relaxed state
In guided imagery, the nurse or another person suggests the
with lowered blood pressure and pulse rates.
image to use, such as a walk in the woods, and describes
the sensory experiences in great detail. Tape recordings for
Distraction
Distraction is the intentional diversion of attention to
20-1 • CLIENT AND FAMILY TEACHING switch the person’s focus from an unpleasant sensory
experience to one that is neutral or more pleasant. The
Pain and Its Management distraction occurs in the “here and now”: it is not imag-
The nurse teaches the client or family as follows: ined. Examples are talking with someone, watching tele-
• Ask the doctor what to expect from the disorder vision, participating in a hobby, and listening to music.
or its treatment. The mind can attend to only one stimulus at a time:
• Discuss pain-control methods that have worked while the person is occupied with the diversional activ-
well or not so well before. ity, the brain is blocked from perceiving painful stimuli.
• Talk with the doctor and nurses about any
concerns you have about pain medicine. Relaxation
• Identify any drug allergies you have. Relaxationis a technique for releasing muscle tension
• Inform the doctor and nurses about other and quieting the mind that helps to reduce pain, relieve
medicines you take, in case they may interact
with pain medications.
• Help the doctor and nurses measure your pain
on a pain scale by stating the number or word Right brain Left brain
that best describes the pain.
• Ask for or take pain-relieving drugs when pain
begins or before an activity that causes pain. Intuitive Logical
• Set a pain-control goal such as having no pain Abstract Concrete
worse than 4 on a scale of 0 to 10. Subjective Objective
• Inform the doctor and nurses if the pain med- Spontaneous Cautious
ication is not working. Fantasy-oriented Reality-based
Imaginative Rational
• Perform simple techniques such as abdominal
Visual Mathematical
breathing and jaw relaxation to increase comfort. Sensible
• Consult with the doctor or nurses about using Fanciful
cold or hot packs or other nondrug techniques FIGURE 20-10 • Right hemispheric functions are used during imagery
to enhance pain control. and meditation.
anxiety, and promote a sense of well-being. Consciously Transcutaneous Electrical Nerve Stimulation
relaxing breaks the circuit among neurons that are over-
Transcutaneous electrical nerve stimulation (TENS), a med-
loading the brain with distressing thoughts and painful
ically prescribed pain management technique that deliv-
stimuli. See Client and Family Teaching 20-2 for a pro-
ers bursts of electricity to the skin and underlying nerves,
cedure clients can learn for relaxation.
is an intervention implemented by nurses (Skill 20-2).
Heat and Cold The client perceives the electrical stimulus, generated by
a battery-powered stimulator, as a pleasant tapping, tin-
Applications of heat or cold (thermal therapy) are well- gling, vibrating, or buzzing sensation. TENS is used inter-
established techniques for relieving pain. In some loca- mittently for 15 to 30 minutes or longer whenever the
tions of practice, nurses must obtain permission from the client feels a need for it.
physician before using heat or cold. For some time, clients with chronic pain have used
Pain caused by an injury is best treated initially with TENS, but currently surgical clients also are using it.
cold applications (ice bag or chemical pack). The cold Reports of its effectiveness range from “useless” to
reduces localized swelling and decreases vasodilation, “fantastic.”
which carries pain-producing chemicals into the circu- No one is sure exactly how TENS works. Supposedly
lation. Many believe that cold applications relieve pain the transmission of electrical stimuli over larger myelin-
faster and sustain pain relief longer. Heat applications
ated nerves takes precedence over the transmission of
(hot water bottle, rice bag [cloth bag containing uncooked
pain-producing stimuli to the brain. Others believe TENS
rice that is heated in the microwave], or moist packs) are
stimulates the body to release endogenous opioids, and
placed over a painful area 24 to 48 hours after the injury.
still others suggest that its effectiveness is based on the
Thermal applications, whether hot or cold, are never
power of suggestion.
used longer than 20 minutes at any one time (see
TENS is a non-narcotic, noninvasive method and has
Chap. 28). The skin is always protected with an insu-
no toxic side effects. It is contraindicated in pregnant
lating layer such as a cloth or towel. The client should
never go to sleep while a hot or cold pack is in place, and women because its effect on the unborn fetus has not been
hot and cold applications are contraindicated in areas determined. Clients with cardiac pacemakers (especially
of the body where circulation or sensation is impaired. the demand type), clients prone to an irregular heartbeat,
Menthol (Icy Hot, Heet, Ben Gay) and capsaicin and clients with previous heart attacks are not candidates
(Zostrix), a compound found in red peppers, are chemi- for TENS.
cals sometimes applied topically. Both increase blood flow
in the area of application, creating a warm or cool feeling
that lasts for several hours. Stop • Think + Respond BOX 20-2
Give some reasons that a person may object to using a
TENS unit for pain management.
Relaxation
Acupuncture and Acupressure
The nurse teaches the client and family as follows:
Acupuncture is a pain management technique in which
• Assume a comfortable position, either sitting or
long, thin needles are inserted into the skin; acupressure is
lying down.
a technique that involves tissue compression rather than
• Close your eyes and clear your mind.
needles to reduce pain. Both are based on ancient tradi-
• Let the chair or bed effortlessly support your body.
tions of Chinese medicine and have been demonstrated to
• Become aware of how your body feels.
prevent or relieve pain. Their exact analgesic mechanisms,
• Take deep abdominal breaths.
however, are not completely understood. Some speculate
• Focus on the rhythm of your breathing.
that these techniques stimulate the body’s production of
• Relax with each breath in and out.
endogenous opioids or that the twisting and vibration of
• Tighten and then release muscles in sequential
the needles and the pressure applied are forms of cuta-
parts of your body such as the toes, feet, lower
neous stimuli that interfere with pain transmitting neuro-
legs, thighs, and buttocks. Progress toward the
chemicals. Acupuncture and acupressure are becoming
face and scalp.
more accepted as legitimate forms of pain therapy in the
• Visualize healing energy flowing from your feet
United States (National Institutes of Health, 1997).
through your head. Release your worries and
discomfort as it passes through.
Percutaneous Electrical Nerve Stimulation
• Let yourself sleep, if possible.
• At the end of the session, wake up or begin to One of the newest innovations in acute and chronic
move gradually. pain management is percutaneous electrical nerve stimulation
(PENS), a pain management technique involving a combi- demonstrates to the client how well he or she is accom-
nation of acupuncture needles and TENS. Acupuncture- plishing the goal. Eventually clients can learn to control
like needles are inserted within soft tissue, and an electrical their symptoms without the assistance of the equipment,
stimulus is conducted through the needles (Fig. 20-11). 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
30 minutes for a total of 3 weeks (White et al., 1999). The
enters a trancelike state resulting in an alteration in per-
technique has been successful in research trials on clients
ception and memory. During hypnosis, the suggestion is
with low back pain, pain caused by the spread of cancer
made that the person’s pain will be eliminated or that
to bones, shingles (acute herpes zoster viral infection),
and migraine headaches. the client will experience the sensation in a more pleas-
ant way.
Biofeedback Although self-hypnosis is possible, more often hypnosis
is induced with the help of a hypnotherapist. Hypno-
With biofeedback, a client learns to control or alter a phys- therapists receive special clinical training; their profes-
iologic phenomenon (e.g., pain, blood pressure, headache, sional organizations include the American Society of
heart rate and rhythm, seizures) as an adjunct to tradi- Clinical Hypnosis and the International Society for Med-
tional pain management. Initially the client is connected ical and Psychological Hypnosis.
to a physiologic sensing instrument such as a pulse oxime-
ter or an electromyography machine. The instrument pro-
duces a visual or audible signal that correlates with the
person’s heart rate, skin temperature, or muscle tension.
The client is encouraged to reduce or extinguish the sig-
nal using whatever mechanism he or she can—generally Nurses must increase their knowledge about pain, take
by physically relaxing. The feedback from the machine every client’s pain seriously, and implement measures
for treating pain effectively. Whenever a client’s pain is
not controlled to his or her satisfaction, the nurse pur-
sues better goal achievement by collaborating with pain
experts. See Nursing Guidelines 20-1.
Clients with pain are likely to have various nursing
diagnoses, including the following:
• Acute Pain
• Chronic Pain
• Anxiety
• Fear
• Ineffective Coping
• Deficient Knowledge: Pain Management
Nursing Care Plan 20-1 is an example of how a nurse
T12 can follow the steps in the nursing process when plan-
+ L1 – ning the care of a client with Acute Pain, a nursing diag-
– L2 +
L3 nosis defined in the NANDA taxonomy (2005) as “an
+ L4 –
L5 unpleasant sensory and emotional experience arising
– S1 + from actual or potential tissue damage or described in
S2
S3 terms of such damage (International Association for the
+ – Study of Pain); sudden or slow onset of any intensity from
mild to severe with an anticipated or predictable end and
a duration of less than 6 months.”
Addiction
FIGURE 20-11 • With PENS therapy, five pairs of electrical stimulat-

One of the leading factors interfering with adequate pain
ing leads (alternating positive and negative current) are connected to management is the fear of addiction. The American Pain
needles inserted in the lumbar and sacral regions of the spine. Society (2006) defines addiction as “a pattern of compul-

Managing Pain
❙ Never doubt the client’s description of pain or need for relief. Bias on ❙ When the client’s pain is continuous, administer analgesic drugs on a
the nurse’s part may lead to withholding prescribed medication or scheduled basis rather than irregularly. Giving the drugs regularly
undertreating the symptoms. controls pain when it is at a lower intensity.
❙ Follow the written medical orders for administering pain medications. ❙ Monitor for drug side effects such as respiratory depression,
This practice demonstrates compliance with nurse practice acts. decreased levels of consciousness, nausea, vomiting, and constipation.
❙ Administer pain-relieving drugs as soon as the need becomes evident. Careful monitoring demonstrates concern for the client’s safety
Prompt administration of drugs reduces the client’s suffering. and comfort.
❙ Consult the physician if the current drug therapy is not controlling the ❙ Consult the professional literature or experts on the equianalgesic
client’s pain. Consulting with the physician demonstrates client dose (oral dose that provides the same level of pain relief as a
advocacy. parenteral dose). This prevents undertreatment of pain because of
changes in drug absorption or drug metabolism.
❙ Collaborate with the physician to develop several pain-management
options involving combinations of drugs, alternative routes of ❙ Change the client’s position, elevate a swollen limb to reduce swelling,
administration, and different dosing schedules. Developing options loosen a tight dressing, and assist the client with bowel or bladder
individualizes pain management. elimination. These measures reduce factors that intensify the pain
experience.
❙ Support the formation of an interdisciplinary pain management team
(physicians, surgeons, nurses, pharmacists, anesthesiologists, physical ❙ Implement independent and prescribed nondrug interventions, such as
therapists, massage therapists, and so forth) who can be consulted on client teaching, imagery, meditation, distraction, and TENS, as
hard-to-manage pain problems. Such a group makes available the additional techniques for pain management. These techniques reduce
expertise of a variety of practitioners. mild to moderate pain when used alone or potentiate pain
management when combined with drug therapy.
❙ Administer pain medication before an activity that produces or
intensifies pain. This timing prevents pain, which is much easier ❙ Allow rest periods between activities. Exhaustion reduces the client’s
than treating it. ability to cope with pain.
sive drug use characterized by a continued craving for an GENERAL GERONTOLOGIC

opioid and the need to use the opioid for effects other CONSIDERATIONS
than pain relief.” Statistics indicate that the fear of addic-
tion is greater than the reality. Regardless of its source, pain is one of the most common com-
Nurses often assume that a client’s desire to experi- plaints of older people, who are more likely to have atypical
presentations of pain.
ence the drug’s pleasant effects motivates his or her desire Chronic illnesses and disease increase the risk for pain for older
for frequent doses of narcotics. What may be happening people. Multiple chronic conditions (e.g., peripheral vascular
is that the prescribed dose or frequency of administration disease, diabetic neuropathies, orthopedic problems, cancer)
is not controlling the pain, a phenomenon that occurs can contribute to the pain, as can acute illnesses or response
as clients develop drug tolerance. Nurses may under- to injuries or surgeries.
A baseline assessment of pain is needed to determine the older
treat the pain or may convince the physician to prescribe
person’s expressions for pain, expectations for pain control,
a placebo. and previous methods used effectively for various causes
of pain.
Fear and anxiety of potential pain may generate thoughts that
Placebos the pain will result in disability or forced dependency or that
pain will be of such great intensity that the ability to cope will
A placebo is an inactive substance sometimes prescribed be compromised.
Pain often goes underreported among older adults because
as a substitute for an analgesic drug. Placebos can relieve
of many factors. For example, the older person may believe
pain, especially when clients have confidence in their that pain is a normal part of aging, may be a punishment
health care providers. The trust a client has in the nurse for past actions, may result in a loss of independence, or
or physician probably has more to do with the efficacy of may indicate that death is near, or that nothing can be
placebos than any other factor. Consequently, it is wrong done about it.
to assume that a client whose pain is relieved with place- Data related to age-associated changes in pain perception,
sensitivity, and tolerance are conflicting. Therefore, it is a
bos is addicted or is a malingerer (someone who pretends
dangerous assumption to believe that older adults are less
to be sick or in pain). Using deception and withholding sensitive to pain stimuli. Older adults may experience
pain medication are considered unethical (American needless suffering or undertreatment as a result of this
Pain Society, 2005). assumption.
Acute Pain
ASSESSMENT
• Determine the source of the client’s pain, when it began, its intensity, location, characteristics, and related factors such as
what makes the pain better or worse.
• Ask how the client’s pain interferes with life such as diminishing the person’s ability to meet his or her own needs for
hygiene, eating, sleeping, activity, social interactions, emotional stability, concentration, etc.
• Identify at what level the client can tolerate pain.
• Measure the client’s vital signs.
• Note pain-related behaviors such as grimacing, crying, moaning, and assuming a guarded position.
• Perform a physical assessment, taking care to gently support and assist the client to turn as various structures are examined.
Use light palpation in areas that are tender. Show concern when assessment techniques increase the client’s pain. Postpone
nonpriority assessments until the client’s pain is reduced.
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 after implementing a pain management technique.
Assess the client’s pain and its characteristics at least Prompt interventions prevent or minimize pain.
every 2 hours while awake and 30 minutes after
implementing a pain management technique.
Modify or eliminate factors that contribute to pain such as Multiple stressors decrease tolerance of pain.
a full bladder, uncomfortable position, pain-aggravating
activity, excessively warm or cool environment, noise, and
social isolation.
Determine the client’s choice for pain relief techniques Doing so encourages and respects the client’s participation
from among those available. in decision making.
Administer prescribed analgesics or alternative pain Suffering contributes to the pain experience; eliminating
management techniques promptly. delays in nursing responses can reduce suffering.
Advocate on the client’s behalf for doses of prescribed JCAHO standards mandate nurses and other health care
analgesics or the addition of adjuvant drug therapy if pain workers to facilitate pain relief for all clients.
is not satisfactorily relieved.
Administer a prescribed analgesic before a procedure or Prophylactic interventions facilitate keeping pain within a
activity that is likely to result in pain or intensify pain that manageable level.
already 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 Suggesting that there are additional untried options reduces
the 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 Diverting attention to something other than pain reduces
muscles, watching television, putting a puzzle together, pain perception.
or talking to someone on the telephone.
(continued)
Acute Pain
Apply warm or cool compresses to a painful site. Flooding the brain with alternative sensory stimuli
interrupt impulses that transmit pain.
Gently massage a painful area or the same area on the Massage promotes the release of endorphins and
opposite side of the body (contralateral massage). enkephalins that moderate the sensation of pain.
Promote laughter by suggesting that the client relate a Laughter releases endorphins and enkephalins that
humorous story or watch a video or comedy program of promote a feeling of well-being.
his or her choice.

• The client reports that pain is gone or at a tolerable level.
• The client perceives the pain experience realistically and copes effectively.
• The client can participate in self-care activities without undue pain.
Older adults with cognitive impairment may not be able to com- cold packs may relieve pain and reduce inflammation and
plain of pain or discomfort. Changes in mental status or edema. They also must be used with caution.
behavior are primary manifestations of pain in people with The most appropriate route for individual medication adminis-
dementia. When assessing pain in older adults, attention tration must be determined. Older adults may experience
should be focused on how the pain or discomfort interferes physiologic changes such as decreased gastric acid production,
with activities of daily living and quality of life. decreased gastrointestinal motility, changes in body fat ratio,
Older adults with depression or cognitive impairment often focus and changes in organ function (e.g., decreased liver blood
their complaints on physical symptoms such as pain, discom- flow, decreased glomerular filtration rate). Medication may
fort, and fatigue. Astute assessment of behavior changes such be absorbed more slowly from the intramuscular route in
as increased pulse, respiration, restlessness, agitation, and older adults, resulting in delayed onset of action, prolonged
wandering may provide the only clues to pain in older adults duration, and altered absorption with potential for toxicity.
with cognitive or expressive changes. Dermal, oral, and sublingual routes may be more effective.
Individual characteristics, family, culture, and ethnicity influence The older person will have increased sensitivity to narcotics.
tolerance and expression of pain. Initial dosing should be at lower levels (begin with half of
The personal experience of pain of the health care provider or the recommended dose) and titrated to the most effective
caregiver may influence his or her response to the older per- dose. “Start low, go slow” is a rule of thumb for analgesic
son’s expression of pain. Additionally, how well the older adult administration.
is known to the provider or caregiver may affect the response Older adults may become very confused if narcotic analgesics are
of the caregiver to the complaint of pain. administered. Demerol is not excreted as readily in the older
Older adults with depression, chronic conditions, or high levels of person and should be used cautiously as a method for pain
stress usually have diminished pain tolerance because they control. Demerol use in older persons may lead to seizures,
have less energy to cope with pain. confusion, or psychotic behavior. Morphine and codeine may
Older adults may endure pain for several reasons. They may be used, but safety precautions for assessing respirations and
not want to be perceived as a nuisance or a complainer, fall risk are necessary.
may believe that pain is expected with aging or indicates Although the administration of low doses of antidepressants, anti-
weakness, may fear tests or becoming addicted to pain convulsants, or stimulants may enhance the effectiveness of
medication, or may believe that they are suffering from a analgesics for older adults, these agents also increase the risk
serious illness. for adverse effects and drug interactions.
Pain control for the older person presents a challenge to health Acetaminophen, salicylates, and nonsteroidal anti-inflammatory
care providers. The least invasive, yet effective, method of drugs (NSAIDs) may be hepatoxic and increase clotting time.
pain control should be determined. Older adults may describe vascular pain as a “burning” sensation.
Adverse effects of analgesics, even over-the-counter products, Unrelenting pain, such as that associated with cancer, can lead to
often are more pronounced in older adults. Common sleep deprivation, poor nutrition, diminished social interaction,
adverse effects include confusion, disorientation, gastritis, feelings of helplessness, and suicide.
constipation, urinary retention, blurred vision, and gastro-
intestinal bleeding.
Topical application of heat may help relieve pain from inflamma- CRITICAL THINKING E X E R C I S E
tion (e.g., musculoskeletal). Assessment of cognitive level and
safety education for burn prevention are imperative. Topical 1. Describe factors that can intensify pain.
3. A nurse can expect that acute pain may have which of

the following effects on the client’s vital signs?
1. When a nurse observes that a client with upper abdom- 1. The temperature may be elevated.
inal pain is curled in a fetal position and rocking back 2. The pulse rate may be rapid.
and forth, which action would help most to further assess 3. The respiratory rate may be slow.
the client’s pain? 4. The blood pressure may fall.
1. Determine whether the client can stop moving. 4. Which of the following is the best action for a hospice
2. Ask the client to rate the pain from 0 to 10. nurse to take to provide maximum pain relief when caring
3. Observe if the client is perspiring heavily. for a client with terminal cancer?
4. Give the client a prescribed pain-relieving drug. 1. Give analgesic medication whenever the client
2. The most accurate explanation the nurse can give a requests it.
client with an amputated arm who says, “I know my arm 2. Administer pain medication every 3 hours as
is not there, but I feel it throbbing,” is that the client is prescribed.
experiencing 3. Ask the physician to prescribe a high dose of pain
1. Referred pain medication.
2. Phantom pain 4. Give pain medication when the client’s pain is
3. Visceral pain severe.
4. Cutaneous pain
Skill 20-1 • PREPARING A PATIENT-CONTROLLED ANALGESIA (PCA) INFUSER
Assessment
Check the written medical order for the use of a PCA Provides data for programming the infusion device
infusion 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
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) Avoids incompatibility reactions
solution is compatible with the prescribed analgesic.
Planning
Obtain the following equipment: infuser, PCA tubing, Promotes organization and efficient time management
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
rub (see Chap. 10).
Attach the PCA tubing to the assembled syringe (Fig. A). Provides a pathway for delivering the medication
Connecting tubing. (Copyright B. Proud.)
Open the cover or door of the infuser and load the syringe Stabilizes the syringe within the infuser
into its cradle (Fig. B).
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
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
(continued)
PREPARING A PATIENT-CONTROLLED ANALGESIA (PCA) INFUSER (Continued)
Program the infuser according to the individual dose and Prevents overdosing
lockout period.
Loading the syringe within the PCA machine. (Copyright B. Proud.)
Setting the loading dose. (Copyright B. Proud.)
Close the security door and lock it with a key (Fig. D). Prevents tampering
Instruct the client to press and release the control button Educates the client on how to operate the equipment
each time pain relief is needed (Fig. E).
Explain that a bell will sound when the infuser delivers Provides sensory reinforcement that the machine is
medication. 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)
Locking the infuser within the PCA machine. (Copyright B. Proud.)
Explaining the use of the PCA infuser. (Copyright B. Proud.)
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
(continued)
• Loading dose
• Individual dose and time schedule
• Reassessments of pain
• Total volume self-administered per shift
Date and Time 30 mL syringe of saline c– 30 mg of morphine sulfate inserted within PCA pump. Describes pain
around abdominal incision as continuous and stabbing. Rates the pain at a level of 7 on a scale of
0 to 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. Instructed and observed to self-administer a subsequent dose.
SIGNATURE/TITLE
OPERATING A TRANSCUTANEOUS ELECTRICAL NERVE

Skill 20-2 • STIMULATION (TENS) UNIT
Assessment
Check the written medical order for providing the client Demonstrates collaboration with the medical management
with a TENS unit. of client care
Ask the physician or physical therapist about the best Optimizes pain management by individualizing electrode
location for electrode placement. Some possible placement
variations are as follows:
• 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 if there are any Demonstrates concern for client safety
conditions for which the use of a TENS unit is
contraindicated.
Check the client’s wristband. Prevents errors and ensures proper client identification
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 Promotes organization and efficient time management
electrodes (Fig. A).
Explain the equipment and how it functions. Reduces anxiety and promotes independence
Establish a goal with the client for the level of pain Aids in evaluating the effectiveness of the intervention
management desired.
(continued)
OPERATING A TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

UNIT (Continued)
TENS unit.
Implementation
rub (see 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) Completes the circuitry from the electrodes to the battery-
on the TENS unit, much like a headset connects with operated power unit
a radio.
Turn the amplitude (intensity) knob on to the lowest Helps acquaint the client with the sensation that the
setting and assess if the client can feel a tingling, TENS unit produces
buzzing, or vibrating sensation.
(continued)

UNIT (Continued)
Gradually increase the intensity to the point at which the Adjusts intensity according to the client’s response—a
client experiences a mild or moderately pleasant high intensity does not always provide the most pain
sensation (Fig. C). 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
upward; a rate of 80 to 125 pulses per second is a comfort and tolerance
conventional setting.
Set the pulse width (the duration of each pulsation); Provides wider and deeper stimulation as the pulse width
a pulse width of 60 to 100 microseconds usually is increases
used for acute pain, but 220 to 250 microseconds at
higher amplitudes may be necessary for chronic or
intense pain.
Turn the unit off when a sufficient level of pain relief Tests whether or not the TENS unit may be sufficient for
occurs and turn it back on when pain reappears. intermittent rather than continuous use
Turn the unit off and remove the cord from the outlet Reduces hazards from potential contact of electrical
jacks before bathing the client. equipment with water
Remove the electrode patches periodically to inspect the Aids in skin assessment
skin; reapply electrodes if they become loose.
Slightly change the position of the electrodes if skin Promotes skin integrity
irritation 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.
(continued)

UNIT (Continued)
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
21
Chapter
Oxygenation
LEARNING OBJECTIVES
● Explain the difference between ventilation and respiration.
WORDS TO KNOW ● Differentiate between external and internal respiration.
● Name two methods for assessing the oxygenation status of clients at the bedside.
apnea ● List at least five signs of inadequate oxygenation.
arterial blood gas ● Name two nursing interventions that can be used to improve ventilation and oxygenation.
CPAP mask ● Identify four items that may be needed when providing oxygen therapy.
diaphragmatic breathing ● Name four sources for supplemental oxygen.
expiration ● List five common oxygen delivery devices.
face tent ● Discuss two hazards related to the administration of oxygen.
flowmeter ● Describe two additional therapeutic techniques that relate to oxygenation.
Fowler’s position ● Discuss at least two facts concerning oxygenation that affect the care of older adults.
fraction of inspired oxygen
humidifier
hyperbaric oxygen therapy
hypercarbia
hypoxemia OXYGEN, which measures approximately 21% in the Earth’s atmosphere, is essential
hypoxia for sustaining life. Each cell of the human body uses oxygen to metabolize nutrients
incentive spirometry and produce energy. Without oxygen, cell death occurs rapidly.
inspiration This chapter describes the anatomic and physiologic aspects of breathing, tech-
liquid oxygen unit
niques for assessing and monitoring oxygenation, types of equipment used in oxygen
nasal cannula
nasal catheter therapy, and skills needed to maintain respiratory function. Techniques for airway
non-rebreather mask management, such as suctioning and other methods for maintaining a patent airway,
orthopneic position are presented in Chapter 36.
oxygen analyzer
oxygen concentrator
oxygen tent
oxygen therapy ANATOMY AND PHYSIOLOGY OF BREATHING
oxygen toxicity
partial rebreather mask
pulse oximetry The elasticity of lung tissue allows the lungs to stretch and fill with air during inspi-
pursed-lip breathing ration (breathing in) and return to a resting position after expiration (breathing out).
respiration Ventilation (movement of air in and out of the lungs) facilitates respiration (exchange
simple mask of oxygen and carbon dioxide). External respiration takes place at the most distal
stent
point in the airway between the alveolar–capillary membranes (Fig. 21-1). Internal
surfactant
tension pneumothorax respiration occurs at the cellular level by means of hemoglobin and body cells. For
tidaling people without disease, increased blood levels of carbon dioxide and hydrogen ions
T-piece trigger the stimulus to breathe, both chemically and neurologically.
tracheostomy collar Ventilation results from pressure changes within the thoracic cavity produced by
transtracheal catheter the contraction and relaxation of respiratory muscles (Fig. 21-2). During inspiration,
ventilation
Venturi mask
the dome-shaped diaphragm contracts and moves downward in the thorax. The inter-
water-seal chest tube costal muscles move the chest outward by elevating the ribs and sternum. This com-
drainage bination expands the thoracic cavity. Expansion creates more chest space, causing
458
C H A P T E R 2 1 ● Oxygenation 459
Nose - mouth During expiration, the respiratory muscles relax, the

Airways of thoracic cavity decreases, the stretched elastic lung tis-
respiratory sue recoils, intrathoracic pressure increases as a result
tree (ventilation)
of the compressed pulmonary space, and air moves out of
Air blown out Air pulled in the respiratory tract. A person can forcibly exhale addi-
tional air by contracting abdominal muscles such as the
rectus abdominis, transverse abdominis, and external and
internal obliques.
Alveoli
External respiration (gas exchange ASSESSING OXYGENATION

O2 between air in alveoli and blood in
O2 pulmonary capillaries)
Tissue cells
Internal The nurse can determine the quality of a client’s oxy-
respiration
genation by collecting physical assessment data, moni-
CO2 (gas exchange
Blood in
O2
between tissue toring arterial blood gases, and using pulse oximetry. A
pulmonary capillaries Blood flow cells and blood combination of these helps to identify signs of hypoxemia
O2 in systemic
CO2 capillaries)
(insufficient oxygen within arterial blood) and hypoxia
Blood in (inadequate oxygen at the cellular level).
systemic capillaries
FIGURE 21-1 • External and internal respiration. Physical Assessment
The nurse physically assesses oxygenation by monitor-

the pressure within the lungs to fall below that in the ing the client’s respiratory rate, observing the breathing
atmosphere. Because air flows from an area of higher pattern and effort, checking chest symmetry, and auscul-
pressure to one of lower pressure, air is pulled in through tating lung sounds (see Chap. 13). Additional assessments
the nose, filling the lungs. When there is an acute need for include recording the heart rate and blood pressure, deter-
oxygen, additional muscles known as accessory muscles mining the client’s level of consciousness, and observ-
of respiration (the pectoralis minor and sternocleidomas- ing the color of the skin, mucous membranes, lips, and
toid) contract to assist with even greater chest expansion. nailbeds (Box 21-1).
Air
Air
Sternocleidomastoid
Intercostals Intercostals
Pectoralis
minor
0
20 4
0
1
0
0
20 4
0
1
0
Diaphragm Diaphragm
Abdominal
muscles
A B
FIGURE 21-2 • Ventilation and thoracic pressure changes. (A) Inspiration. (B) Expiration.
BOX 21-1 ● Common Signs of Inadequate

in performing arterial punctures may obtain the specimen.
Oxygenation See Nursing Guidelines 21-1.
❙ Decreased energy
❙ Restlessness
❙ Rapid, shallow breathing Pulse Oximetry
❙ Rapid heart rate
❙ Sitting up to breathe Pulse oximetry is a noninvasive, transcutaneous technique
❙ Nasal flaring for periodically or continuously monitoring the oxygen
❙ Use of accessory muscles
saturation of blood (Skill 21-1). A pulse oximeter is com-
❙ Hypertension
❙ Sleepiness, confusion, stupor, coma posed of a sensor and a microprocessor. Red and infrared
❙ Cyanosis of the skin (mucous membranes in dark-skinned patients), lips, and light are emitted from one side of a spring-tension or ad-
nailbeds hesive sensor that is attached to a finger, toe, earlobe, or
bridge of the nose. The opposite side of the sensor detects
the amount of light absorbed by hemoglobin. The micro-
processor then computes the information and displays it
Arterial Blood Gases on a machine at the bedside. The measurement of oxygen
saturation when obtained by pulse oximetry is abbrevi-
An arterial blood gas assessment (ABG) is a laboratory test ated and recorded as SpO2 to distinguish it from the SaO2
using arterial blood to assess oxygenation, ventilation, and measurement obtained from arterial blood.
acid–base balance. It measures the partial pressure of oxy- Based on the oxygen–hemoglobin dissociation curve
gen dissolved in plasma (PaO2), the percentage of hemo- (Fig. 21-4), it is possible to infer the PaO2 from the
globin saturated with oxygen (SaO2), the partial pressure pulse oximetry measurement. The normal SpO2 is 95%
of carbon dioxide in plasma (PaCO2), the pH of blood, and to 100%. A sustained level of less than 90% is cause for
the level of bicarbonate (HCO3) ions (Table 21-1). Arte- concern. If the SpO2 remains low, the client needs oxygen
rial blood is preferred for sampling because arteries have therapy. Various factors, however, affect the accuracy
greater oxygen content than veins and are responsible for of the displayed information (Table 21-2). Trouble-
carrying oxygen to all cells. Initial and subsequent ABGs shooting the equipment, performing current physical
are ordered to assess the client in acute respiratory distress assessments, and obtaining an ABG help to confirm the
or to evaluate the progress of a client receiving medical significance of the displayed findings.
treatment.
In most situations, a laboratory technician and the
nurse collaboratively collect arterial blood. The nurse noti- Stop • Think + Respond BOX 21-1
fies the laboratory of the need for the blood test, records What actions are appropriate if a client appears to be
pertinent assessments on the laboratory request form and hypoxemic, but the pulse oximeter indicates a normal
in the client’s chart, prepares the client, assists the labo- SpO2? What action(s) are appropriate if the opposite
ratory technician who obtains the specimen, and imple- occurs—that is, the client appears normal but the pulse
ments measures for preventing complications after the oximeter reading gives you cause for concern?
arterial puncture. In emergencies, a nurse who is trained
TABLE 21-1 VALUES FOR ARTERIAL BLOOD GASES

INDICATION OF
COMPONENT NORMAL RANGE ABNORMAL FINDINGS ABNORMAL FINDINGS
pH 7.35–7.45 <7.35 Acidosis

>7.45 Alkalosis
PaO2 80–100 mm Hg 60–80 mm Hg Mild hypoxemia
40–60 mm Hg Moderate hypoxemia
<40 mm Hg Severe hypoxemia
>100 mm Hg Hyperoxygenation
PaCO2 35–45 mm Hg <35 mm Hg Hyperventilation
>45 mm Hg Hypoventilation
SaO2 95%–100% <95% Hypoventilation
Anemia
HCO3 22–26 mEq <22 or >26 mEq Compensation for
acid–base imbalance

Assisting with an ABG
❙ Perform the Allen test before the arterial puncture by doing the following: ❙ Comfort the client during the puncture. An arterial puncture tends to be
• Flex the client’s elbow and elevate the forearm where the arterial painful unless a local anesthetic is used.
puncture will be made. ❙ After obtaining the specimen, expel all air bubbles from it. Doing
• Compress the radial and ulnar arteries simultaneously (Fig. 21-3A).
so ensures that the only gas in the specimen is that contained in
• Instruct the client to open and close the fist until the palm of the hand
the blood.
appears blanched.
• Release pressure from the ulnar artery while maintaining pressure on ❙ Rotate the collected specimen. Rotation mixes the blood with the
the radial artery (Fig. 21.3B). anticoagulant in the specimen tube, ensuring that the blood sample
• Observe whether the skin flushes or remains blanched. will not clot before it can be examined.
• Release pressure on the radial artery. ❙ Place the specimen on ice immediately. Blood cells deteriorate outside
The Allen test determines if the hand has an adequate ulnar arterial blood the body, causing changes in the oxygen content of the sample.
supply should the radial artery become damaged or occluded. The radial Cooling the sample slows cellular metabolism and ensures more
artery should not be punctured if the Allen test shows absent or poor accurate test results.
collateral arterial blood flow as evidenced by continued blanching after
❙ Apply direct manual pressure to the arterial puncture site for 5 to
pressure on the ulnar artery has been released. Alternative sites include the
10 minutes. Arterial blood flows under higher pressure than venous
brachial, femoral, or dorsalis pedis arteries.
blood. Therefore, prolonged manual pressure is necessary to control
❙ Keep the client at rest for at least 30 minutes before obtaining the bleeding.
specimen unless the procedure is an emergency. Because an ABG
reflects the client’s status at the moment of blood sampling, activity can
❙ Cover the puncture site with a pressure dressing composed of
transiently lower oxygen levels in the blood and lead to an incorrect several 4 inch × 4 inch gauze squares and tape. Tight mechanical
interpretation of the test results. compression provides continued pressure to reduce the potential for
arterial bleeding.
❙ Record the client’s current temperature, respiratory rate, and level of
activity if other than resting. Increased metabolism and activity affect ❙ Assess the puncture site periodically for bleeding or formation of a
cellular oxygen demands. Therefore, the data help in interpreting the hematoma (collection of trapped blood) beneath the skin. Periodic
results of laboratory findings. inspection aids in early identification of arterial bleeding, which can
lead to substantial blood loss and discomfort.
❙ Record the amount of oxygen the client is receiving at the time of the
test (either room air or prescribed amount) and ventilator settings. This ❙ Report the laboratory findings to the prescribing physician as soon
information helps to determine if oxygen therapy is necessary or aids in as they are available. Collaboration with the physician assists in
evaluating its current effectiveness. making changes in the treatment plan to improve the client’s
❙ Hyperextend the wrist over a rolled towel. Hyperextension brings the condition.
radial artery nearer the skin surface to facilitate penetration.
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 released.
100 Positioning
90
Unless contraindicated by their condition, clients with
80 hypoxia are placed in high Fowler’s position (an upright
70 seated position; see Chap. 23). This position eases breath-
SpO2 - Percent saturation
ing by allowing the abdominal organs to descend away

60 from the diaphragm. As a result, the lungs have the poten-
50 tial to fill with a greater volume of air.
As an alternative, clients who find breathing difficult
40 may benefit from a variation of Fowler’s position called
30 the orthopneic position. This is a seated position with the
arms supported on pillows or the arm rests of a chair,
20
and the client leans forward over the bedside table or a
10 chair back (Fig. 21-5) The orthopneic position allows
room for maximum vertical and lateral chest expansion
0
0 10 20 30 40 50 60 70 80 90 100 110120 130 140 and provides comfort while resting or sleeping.
PaO2 - Pressure of oxygen (mm Hg)
FIGURE 21-4 • Draw a line from the SpO2 in the left column across
the graph to the point at which it intersects the curve. Use the numeric Breathing Techniques
scale at the bottom to calculate the PaO2. In this example, with an SpO2
of 95%, the PaO2 is approximately 98 mm Hg. Breathing techniques such as deep breathing with or with-
out an incentive spirometer, pursed-lip breathing, and
diaphragmatic breathing help clients to breathe more
efficiently.
PROMOTING OXYGENATION Deep Breathing

Deep breathing is a technique for maximizing ventilation.
Many factors affect ventilation and subsequently respi- Taking in a large volume of air fills alveoli to a greater
ration (Table 21-3). Positioning and teaching breathing capacity, thus improving gas exchange.
techniques are two nursing interventions frequently Deep breathing is therapeutic for clients who tend to
used to promote oxygenation. Adhesive nasal strips can breathe shallowly, such as those who are inactive or in
be used to improve oxygenation by reducing airway resis- pain. To encourage deep breathing, the client learns to
tance and improving ventilation. take in as much air as possible, hold the breath briefly,
TABLE 21-2
FACTORS THAT INTERFERE WITH ACCURATE
PULSE OXIMETRY
FACTOR CAUSE REMEDY
Movement of the sensor Tremor Relocate sensor to another site.

Restlessness Replace sensor or tape in place.
Loss of adhesion
Poor circulation at the Peripheral vascular disease Change the sensor location
sensor site Edema or type of sensor.
Tourniquet effect from Loosen or change sensor location.
taped sensor Discontinue use temporarily.
Vasoconstrictive drug effects
Barrier to light Nail polish Remove polish.
Thick toenails Relocate sensor.
Acrylic nails Remove nail.
Extraneous light Direct sunlight Cover sensor with a towel.
Treatment lights
Hemoglobin saturation Carbon monoxide poisoning Discontinue use temporarily.
with other substances
TABLE 21-3 FACTORS AFFECTING OXYGENATION

FACT NURSING IMPLICATION
Adequate respiration depends on a minimum of 21% oxygen Know that clients with cardiopulmonary disorders require more
in the environment and normal function of the cardio- than 21% oxygen to maintain adequate oxygenation of
pulmonary system. blood and cells.
Breathing can be voluntarily controlled. Assist clients who are hyperventilating to slow the rate of
breathing; teach clients to perform pursed-lip breathing to
exhale more completely.
Clients with chronic lung diseases are stimulated to breathe Remember that giving high percentages of oxygen can depress
by low blood levels of oxygen, called the hypoxic drive to breathing in clients with chronic lung disease. No more than
breathe. 2–3 L oxygen is safe unless the client is mechanically
ventilated.
Smoking causes increased amounts of inhaled carbon monox- Keep in mind that clients who smoke have a greater potential
ide that compete and bond more easily than oxygen to the for compromised gas exchange and acquiring chronic
hemoglobin. pulmonary and cardiac diseases.
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, that can help smokers stop.
Pregnant women who smoke have a risk for low-birth-weight Promote smoking cessation for pregnant women who are
infants because low blood oxygenation affects fetal metabo- addicted to nicotine.
lism and growth.
Pulmonary secretions within the airway and fluid within the Encourage coughing, deep breathing, turning, and ambulating
interstitial space between the alveoli and capillaries interfere to 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
compromised by any condition that compresses the the diaphragm.
diaphragm, such as obesity, intestinal gas, pregnancy, and an Encourage weight loss, expulsion of gas via ambulation and
enlarged liver. bowel elimination, and assist with removing abdominal fluid
by paracentesis (see Chap. 14) to improve breathing.
Activity and emotional stress increase the metabolic need for Provide rest periods and teach stress reduction techniques
greater amounts of oxygen. such as 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
flank surgical incisions decreases the incentive to breathe the incision with a pillow and administer drugs that relieve
deeply and cough forcefully. pain to facilitate ventilation.
FIGURE 21-5 • (A) Orthopneic position. (B) Alternative orthopneic position.

and exhale slowly. In some cases it is helpful to use an

incentive spirometer; however, deep breathing alone, if
performed effectively, is sufficiently beneficial. Using an Incentive Spirometer
INCENTIVE SPIROMETRY. Incentive spirometry, a technique
for deep breathing using a calibrated device, encourages • Sit upright unless contraindicated.
clients to reach a goal-directed volume of inspired air. • Identify the mark indicating the goal for
Although spirometers are constructed in different ways, inhalation.
all are marked in at least 100-mL increments and include • Exhale normally.
some visual cue, such as elevation of lightweight balls, • Insert the mouthpiece, sealing it between the lips.
to show how much air the client has inhaled (Fig. 21-6). • Inhale slowly and deeply until the predetermined
The calibrated measurement also helps the nurse to eval- volume has been reached.
uate the effectiveness of the client’s breathing efforts. See • Hold the breath for 3 to 6 seconds.
Client and Family Teaching 21-1. • Remove the mouthpiece and exhale normally.
• Relax and breathe normally before the next
Pursed-Lip Breathing breath with the spirometer.
Pursed-lip breathing is a form of controlled ventilation in • Repeat the exercise 10 to 20 times per hour
which the client consciously prolongs the expiration phase while awake or as prescribed by the physician.
of breathing. This is another technique for improving gas
exchange, which, if done correctly, helps clients to elim-
inate more than the usual amount of carbon dioxide from Expiration should be two to three times longer than
the lungs. Pursed-lip breathing and diaphragmatic breath- inspiration. Not all clients can achieve this goal ini-
ing are especially helpful for clients who have chronic lung tially, but with practice the length of expiration can
diseases, such as emphysema, which are characterized by increase.
chronic hypoxemia and hypercarbia (excessive levels of
carbon dioxide in the blood). The client performs pursed- Diaphragmatic Breathing
lip breathing as follows:
Diaphragmatic breathing is breathing that promotes the
• Inhale slowly through the nose while counting to three. use of the diaphragm rather than the upper chest mus-
• Purse the lips as though to whistle. cles. It is used to increase the volume of air exchanged
• Contract the abdominal muscles. during inspiration and expiration. With practice, dia-
• Exhale through pursed lips for a count of six or more. phragmatic breathing reduces respiratory effort and
relieves rapid, ineffective breathing. See Client and
Family Teaching 21-2.
Diaphragmatic Breathing
• 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 to 10 minutes.
FIGURE 21-6 • During deep inhalation, a ball rises in an incentive • Progress to doing diaphragmatic breathing
spirometer. (Courtesy of Swedish Hospital Medical Center.) while upright and active.
Nasal Strips
Adhesive nasal strips, available for commercial purchase,
are used to reduce airflow resistance by widening the
breathing passageways of the nose. Increasing the nasal
diameter promotes easier breathing. Common users of
nasal strips are people with ineffective breathing as well
as athletes, whose oxygen requirements increase dur-
ing sustained exercise. Another use for nasal strips is to
reduce or eliminate snoring.
OXYGEN THERAPY
When positioning and breathing techniques are inade-

quate for keeping the blood adequately saturated with
oxygen, oxygen therapy is necessary. Oxygen therapy is
an intervention for administering more oxygen than is
present in the atmosphere to prevent or relieve hypox-
emia. It requires an oxygen source, a flowmeter, in some
cases an oxygen analyzer or humidifier, and an oxygen
FIGURE 21-7 • Portable oxygen tank.
delivery device.
Liquid Oxygen Unit
A liquid oxygen unit is a device that converts cooled liq-
Oxygen Sources uid oxygen to a gas by passing it through heated coils
(Fig. 21-8). Ambulatory clients at home primarily use
Oxygen is supplied from any one of four sources: wall
these small, lightweight, portable units because they allow
outlet, portable tank, liquid oxygen unit, or oxygen
greater mobility inside and outside the house. Each unit
concentrator.
holds approximately 4 to 8 hours’ worth of oxygen. Poten-
tial problems include that liquid oxygen is more expen-
Wall Outlet
sive, the unit may leak during warm weather, and frozen
Most modern health care facilities supply oxygen through moisture may occlude the outlet.
a wall outlet in the client’s room. The outlet is connected
to a large central reservoir filled with oxygen on a rou-
tine basis.
Portable Tanks
When oxygen is not piped into individual rooms or if
the client needs to leave the room temporarily, oxygen
is provided in portable tanks resembling steel cylinders
(Fig. 21-7) that hold various volumes under extreme pres-
sure. A large tank of oxygen contains 2,000 lbs of pressure
per square inch. Therefore, tanks are delivered with a pro-
tective cap to prevent accidental force against the tank
outlet. Any accidental force applied to a partially opened
outlet could cause the tank to take off like a rocket, with
disastrous results. Therefore, oxygen tanks are trans-
ported and stored while strapped to a wheeled carrier.
Before oxygen is administered from a portable tank,
the tank is “cracked,” a technique for clearing the outlet
of dust and debris. Cracking is done by turning the tank
valve slightly to allow a brief release of pressurized oxy-
gen. The force causes a loud hissing noise, which may be
frightening. Therefore, it is best to crack the tank away
from the client’s bedside. FIGURE 21-8 • Liquid oxygen unit.
Compressor
20
Filter psi
Zeolite
cannisters
Air O2
entry
Oxygen
Concentrator N2
FIGURE 21-9 • A portable oxygen con-

centrator extracts nitrogen and concen-
trates oxygen to enable clients who
require oxygen therapy to travel about
or maintain their lifestyle without the
need for multiple tanks of oxygen.
Oxygen Concentrator Flowmeter

An oxygen concentrator is a machine that collects and con- The flow of oxygen is measured in liters per minute
centrates oxygen from room air and stores it for client use. (L/min). A flowmeter is a gauge used to regulate the amount
To do so, the concentrator uses a substance called zeolite of oxygen delivered to the client and is attached to the oxy-
within two absorbing chambers. The machine compresses gen source (Fig. 21-10). To adjust the rate of flow, the
atmospheric air and diverts it into a chamber containing nurse turns the dial until the indicator is directly beside
zeolite. The zeolite absorbs nitrogen from the air, leav- the prescribed amount.
ing nearly pure oxygen, which is stored in the second The physician prescribes the concentration of oxygen,
chamber. When the nitrogen-absorbing chamber becomes also called the fraction of inspired oxygen (FIO2; the portion
saturated, the machine releases nitrogen back into the
atmosphere, and the process repeats itself, providing a
constant supply of oxygen (Fig. 21-9).
An oxygen concentrator eliminates the need for a Control dial
central reservoir of piped oxygen or the use of bulky
tanks that must be constantly replaced. This type of oxy-
gen source is used in home health care and long-term Wall outlet
care facilities primarily because of its convenience and
economy.
LITERS OF OXYGEN PER MIN @ 70° F & 760 mmHG
15
Although it is more economical than oxygen supplied
in portable tanks, the device increases the client’s electric
bill. Other disadvantages are that it generates heat from its 10
motor and that it produces an unpleasant odor or taste if
the filter is not cleaned weekly. Also, it is best that clients Flowmeter
have a secondary source of oxygen available in case of a 5
power failure.
0 Flow indicator bead
Equipment Used in Oxygen Administration
In addition to an oxygen source, other pieces of equipment

used during the administration of oxygen are a flowmeter, FIGURE 21-10 • Flowmeter attached to a wall outlet for oxygen
oxygen analyzer, and humidifier. administration.
of oxygen in relation to total inspired gas), as a percent- Control dial

age or as a decimal (e.g., 40% or 0.40). The prescription 15
Flowmeter
is based on the client’s condition. The Joint Commission 10
on Accreditation of Healthcare Organizations ( JCAHO) 5
Flow indicator bead

recommends that oxygen be prescribed as a percentage 0
rather than in L/min because, depending on the oxygen

delivery device, L/min may provide different percentages
of oxygen.
Connector to flowmeter
Oxygen Analyzer Tubing to patient
An oxygen analyzer is a device that measures the per-
centage of delivered oxygen to determine whether the
client is receiving the amount prescribed by the physi-
cian (Fig. 21-11). The nurse or respiratory therapist
Humidification bottle
first checks the percentage of oxygen in the room air
with the analyzer. If there is a normal mixture of oxy-
Sterile distilled water
gen and other gases in the environment, the analyzer
indicates 0.21 (21%). When the analyzer is positioned
near or within the device used to deliver oxygen, the
reading should register at the prescribed amount (greater
than 0.21). If there is a discrepancy, the nurse adjusts the FIGURE 21-12 • Oxygen humidifier attached to a flowmeter.
flowmeter to reach the desired amount. Oxygen analyzers

are used most often when caring for newborns in isolettes,
children in croup tents, and clients who are mechani- apist or nurse checks the water level daily and refills the
cally ventilated. bottle as needed.
Humidifier Stop • Think + Respond BOX 21-2

A humidifier is a device that produces small water droplets Explain the difference between a flowmeter and an
and may be used during oxygen administration because oxygen analyzer.
oxygen is drying to the mucous membranes. In most cases,
oxygen is humidified only when more than 4 L/min is
administered for an extended period. When humidifi- Common Delivery Devices
cation is desired, a bottle is filled with distilled water and
attached to the flowmeter (Fig. 21-12). A respiratory ther- Common oxygen delivery devices include a nasal can-
nula, masks, face tent, tracheostomy collar, or T-piece
(Table 21-4) The device prescribed depends on the client’s
oxygenation status, physical condition, and amount of oxy-
gen needed. Skill 21-2 describes how to administer oxygen
by common delivery methods.
Nasal Cannula
A nasal cannula is a hollow tube with 1⁄2-inch prongs placed
into the client’s nostrils. It is held in place by wrapping
the tubing around the ears and adjusting the fit beneath
the chin. It provides a means of administering low con-
centrations of oxygen. Therefore, it is ideal for clients
who are not extremely hypoxic or who have chronic lung
diseases. High percentages of oxygen are contraindicated
for clients with chronic lung disease because they have
adapted to excessive levels of retained carbon dioxide and
low blood oxygen levels stimulate their drive to breathe.
Consequently, if clients with chronic lung disease receive
more than 2 to 3 liters of oxygen over a sustained period,
FIGURE 21-11 • Oxygen analyzer. (Copyright B. Proud.) their respiratory rate slows or even stops.
TABLE 21-4 COMPARISON OF OXYGEN DELIVERY DEVICES

COMMON RANGE
DEVICE OF ADMINISTRATION ADVANTAGES DISADVANTAGES
Nasal cannula 2–6 L/min Is easy to apply; promotes Dries nasal mucosa at higher flows
FIO2 24%–40%* comfort May irritate the skin at cheeks and behind ears
Does not interfere with eating or Is less effective in some patients who tend to
talking mouth breathe
Is less likely to create feeling of Does not facilitate administering high FIO2 to
suffocation hypoxic patients
Nasal prongs
Adjustable
bead
Masks
Simple 5–8 L/min Provides higher concentrations Requires humidification
FIO2 35%–50%* than possible with a cannula Interferes with eating and talking
Is effective for mouth breathers Can cause anxiety among those who are
or patients with nasal disorders claustrophobic
Creates a risk for rebreathing CO2 retained
within mask
Adjustable
nose
conformer
Air vents
Adjustable
straps
Oxygen
(continued)
TABLE 21-4 COMPARISON OF OXYGEN DELIVERY DEVICES (Continued)

COMMON RANGE
Partial rebreather 6–10 L/min Increases the amount of oxygen Requires a minimum of 6 L/min
FIO2 35%–60%* with lower flows Creates a risk for suffocation
Requires monitoring to verify that reservoir
bag remains inflated at all times
2/3
Exhaled
air
1/3
Exhaled
air
Reservoir bag
Non-rebreather 6–10 L/min Delivers highest FIO2 possible See partial rebreather mask
FIO2 60%–90%* with a mask Creates a risk for oxygen toxicity
One-way flaps
All exhaled air
Oxygen
Reservoir bag
(continued)

COMMON RANGE
Venturi 4–8 L/min Delivers FIO2 precisely Permits condensation to form in tubing, which
FIO2 24%–40%* diminishes the flow of oxygen
Elastic head strap
Vent holes
Oxygen
Face tent 8–12 L/min Provides a comfortable fit Interferes with eating
FIO2 30%–55%* Is useful for patients with facial May result in inconsistent FIO2, depending on
trauma and burns environmental loss
Facilitates humidification
(continued)

COMMON RANGE
Tracheostomy collar 4–10 L/min Facilitates humidifying and Allows water vapor to collect in tubing, which
FIO2 24%–100%* 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%* high humidity Allows humidity to collect and moisten gauze
dressing
T-piece
Tracheostomy
tube
Oxygen
* Source: American Association for Respiratory Care (AARC).
Masks ports. An elastic strap holds it in place. The simple mask,

like other types of masks, allows the administration of
Oxygen can be delivered using a simple mask, a partial
higher levels of oxygen than are possible with a cannula.
rebreather mask, a non-rebreather mask, or a Venturi
A simple mask is sometimes substituted for a cannula
mask.
when a client has nasal trauma or breathes through the
SIMPLE MASK. A simple mask fits over the nose and mouth mouth. When a simple mask is used, oxygen is delivered
and allows atmospheric air to enter and exit through side at no less than 5 L/min.
The efficiency of any mask is affected by how well it open and loose around the face, clients are less likely to
fits the face. Without a good seal, the oxygen leaks from feel claustrophobic. An added advantage is that a face
the mask, thus diminishing its concentration. Other prob- mask can be used for clients with facial trauma or burns.
lems are associated with masks as well. All oxygen masks A disadvantage is that the amount of oxygen clients actu-
interfere with eating and make verbal communication dif- ally receive may be inconsistent with what is prescribed,
ficult to understand. Also, some clients become anxious because of environmental losses.
when their nose and mouth are covered because it creates
a feeling of being suffocated. Skin care also becomes a pri- Tracheostomy Collar
ority because masks create pressure and trap moisture.
A tracheostomy collar delivers oxygen near an artificial
PARTIAL REBREATHER MASK. A partial rebreather mask is opening in the neck. It is applied over a tracheostomy, an
an oxygen delivery device through which a client inhales opening into the trachea through which a client breathes
a mixture of atmospheric air, oxygen from its source, and (see Chap. 36). Because it bypasses the warming and
oxygen contained within a reservoir bag. It provides a moisturizing functions of the nose, a tracheostomy collar
means for recycling oxygen and venting all the carbon provides a means for both oxygenation and humidifica-
dioxide during expiration from the mask. During expiration. The moisture that collects, however, tends to satu-
tion, the first third of exhaled air enters the reservoir bag. rate the gauze dressing around the tracheostomy, making
The portion of exhaled air in the reservoir bag contains it necessary to change it frequently.
a high proportion of oxygen because it comes directly
from the upper airways; the gas in this area has not been T-Piece
involved in gas exchange at the alveolar level. Once the A T-piece fits securely onto a tracheostomy tube or endo-
reservoir bag is filled, the remainder of exhaled air is tracheal tube. It is similar to a tracheostomy collar but is
forced from the mask through small ports. With a simple attached directly to the artificial airway. Although the
mask, some carbon dioxide always remains within the gauze around the tracheostomy usually remains dry, the
mask and is reinhaled. moisture that collects within the tubing tends to con-
dense and may enter the airway during position changes
NON-REBREATHER MASK. A non-rebreather mask is an oxy- if it is not drained periodically. Another disadvantage is
gen delivery device in which all the exhaled air leaves the that the weight of the T-piece, or its manipulation, may
mask rather than partially entering the reservoir bag. It pull on the tracheostomy tube, causing the client to cough
is designed to deliver an FIO2 of 90% to 100%. This type or experience discomfort.
of mask contains one-way valves that allow only oxygen
from its source, as well as the oxygen in the reservoir
bag, to be inhaled. No air from the atmosphere is inhaled. Additional Delivery Devices
All the air that is exhaled is vented from the mask. None
enters the reservoir bag. Obviously, clients for whom non- Other methods for delivering oxygen are used less com-
rebreather masks are used are those who require high con- monly. Occasionally, oxygen is delivered by means of a
centrations of oxygen. They are usually critically ill and nasal catheter, oxygen tent, transtracheal catheter, or con-
may eventually need mechanical ventilation. tinuous positive airway pressure (CPAP) mask.
Humidification is not used when a mask with a reser-
voir bag is used, despite the high concentrations of oxy- Nasal Catheter
gen. Also, clients with partial and non-rebreather masks
are monitored closely to ensure that the reservoir bag A nasal catheter is a tube for delivering oxygen that is
remains partially inflated at all times. inserted through the nose into the posterior nasal phar-
ynx (Fig. 21-13). It is used for clients who tend to breathe
VENTURI MASK. A Venturi mask mixes a precise amount of through the mouth or experience claustrophobia when a
oxygen and atmospheric air. Sometimes called a Venti mask covers their face. The catheter tends to irritate the
mask, this mask has a large ringed tube extending from it. nasopharynx; therefore, some clients find it uncomfort-
Adapters within the tube, which are color-coded or regu- able. If a catheter is prescribed, the nurse secures it to the
lated by a dial system, permit only specific amounts of nose to avoid displacement and cleans the nostril with a
room air to mix with the oxygen. This feature ensures that cotton applicator regularly to remove dried mucus.
the Venturi mask delivers the exact amount of prescribed
oxygen. Unlike masks with reservoir bags, humidification Oxygen Tent
can be added when a Venturi mask is used.
An oxygen tent is a clear plastic enclosure that provides
cooled, humidified oxygen. It is most likely to be used in
Face Tent
the care of active toddlers. Children this age are less likely
A face tent provides oxygen to the nose and mouth with- to keep a mask or cannula in place but may require oxy-
out the discomfort of a mask. Because the face tent is genation and humidification for respiratory conditions
apnea is dangerous because falling oxygen saturation lev-

els may precipitate cardiac arrest and death.
Catheter
Uvula in place Transtracheal Oxygen
Some clients who require long-term oxygen therapy may
prefer its administration through a transtracheal catheter
(hollow tube inserted within the trachea to deliver oxy-
gen; Fig. 21-15). This device is less noticeable than a nasal
cannula. The client is adequately oxygenated with lower
flows, decreasing the costs of replenishing the oxygen
source.
Before transtracheal oxygen is used, a stent (tube that
keeps a channel open) is inserted into a surgically created
opening and remains there until the wound heals. There-
FIGURE 21-13 • Nasal catheter placement. after, 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 several times a day. During cleaning, clients
such as croup or bronchitis. A face hood may be used for administer oxygen with a nasal cannula.
less-active infants.
Oxygen concentrations are difficult to control when
an oxygen tent is used. Therefore when caring for a child Stop • Think + Respond BOX 21-3
in an oxygen tent, the edges of the tent must be tucked What evidence indicates a client is well oxygenated?
securely beneath the mattress; limit opening the zippered
access ports so that oxygen does not escape too freely.
Oxygen levels must be monitored with an analyzer. Oxygen Hazards
CPAP Mask Regardless of which device is used, oxygen administration

involves potential hazards: first and foremost, oxygen’s
A CPAP mask maintains positive pressure within the air- capacity to support fires; and second, the potential for oxy-
way throughout the respiratory cycle (Fig. 21-14). It keeps gen toxicity.
the alveoli partially inflated even during expiration. The
face mask is attached to a portable ventilator.
Clients generally wear this type of mask at night to
maintain oxygenation when they experience sleep apnea
(periods during which they stop breathing). The residual
oxygen within the alveoli continues to diffuse into the
blood during apneic episodes that may last 10 or more sec-
onds and be as frequent as 10 to 15 times an hour. Sleep
Inlet valve
Head strap
Oxygen tubing
Positive-
pressure
valve Adjustable
inflation valve
FIGURE 21-14 • CPAP mask. FIGURE 21-15 • Transtracheal oxygen administration.

Fire Potential BOX 21-2 ● Signs and Symptoms of Oxygen Toxicity

Oxygen itself does not burn, but it does support combus-
❙ Nonproductive cough ❙ Fatigue
tion; in other words, it contributes to the burning process. ❙ Substernal chest pain ❙ Headache
Therefore, it is necessary to control all possible sources ❙ Nasal stuffiness ❙ Sore throat
of open flames or ungrounded electricity. See Nursing ❙ Nausea and vomiting ❙ Hypoventilation
Guidelines 21-2.
Oxygen Toxicity
Oxygen toxicity means lung damage that develops when oxy- restore negative intrapleural pressure and reinflate the
gen concentrations of more than 50% are administered lung. Clients who require water-seal drainage have one
for longer than 48 to 72 hours. The exact mechanism by or two chest tubes connected to the drainage system.
which hyperoxygenation damages the lungs is not def- Several companies provide equipment for water-seal
initely known. One theory is that it reduces surfactant, drainage. All these products consist of a three-chamber
which is a lipoprotein produced by cells in the alveoli that system (Fig. 21-16):
promotes elasticity of the lungs and enhances gas diffusion. • One chamber collects blood or acts as an exit route for
Once oxygen toxicity develops, it is difficult to re-
pleural air.
verse. Unfortunately, early symptoms are quite subtle
• A second compartment holds water that prevents atmo-
(Box 21-2). The best prevention is to administer the low-
spheric air from reentering the pleural space (hence
est FIO2 possible for the shortest amount of time.
the term “water seal”).
• A third chamber, if used, facilitates the use of suction,
which may speed the evacuation of blood or air.
RELATED OXYGENATION
TECHNIQUES One of the most important principles when caring for
clients with water-seal drainage is that the chest tube must
never be separated from the drainage system unless it is
Two additional techniques relate to oxygenation: a water- clamped. Even then, the tube is clamped for only a brief
seal chest tube drainage system and hyperbaric oxygen time. Additional nursing responsibilities are included in
therapy. Skill 21-3.
Water-Seal Chest Tube Drainage

is a technique for evacuat-
Water-seal chest tube drainage Discuss how a collapsed lung affects oxygenation.
ing air or blood from the pleural cavity, which helps to

Attached to Attached to
Administering Oxygen Safely chest tube suction
Atmospheric
❙ Post “Oxygen in Use” signs wherever oxygen is stored or in use. air
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. 20 cm
❙ Inspect electrical equipment for frayed wires or loose connections. Chamber B

Chamber A (water seal)
Inspection helps to prevent sparks or an uncontrolled pathway for
(collection)
electricity.
❙ Avoid using petroleum products, aerosol products (such as hair Chamber C
spray), and products containing acetone (such as nail polish remover) (suction
where oxygen is used. This measure prevents ignition of flammable control)
substances.
❙ Secure portable oxygen cylinders to rigid stands. Doing so prevents
the tank from rupturing. 2 cm
FIGURE 21-16 • Three-chambered water-seal drainage system.
Hyperbaric Oxygen Therapy nursing process applies to a client with the nursing diag-
nosis of Ineffective Breathing Pattern. This diagnostic
Hyperbaric oxygen therapy (HBOT) consists of the deliv- category is defined in the NANDA taxonomy (2005) as
ery of 100% oxygen at three times the normal atmo- “inspiration and/or expiration that does not provide ade-
spheric pressure within an airtight chamber (Fig. 21-17). quate ventilation.” Interventions need to be adapted for
Treatments, which last approximately 90 minutes, are older clients, who have unique age-related changes and
repeated over days, weeks, or months of therapy. Pro- special teaching needs.
viding pressurized oxygen increases the oxygenation
of blood plasma from a normal level of 80 to 100 mm Hg
to more than 2,000 mm Hg (Bailey et al., 2004; Leifer, GENERAL GERONTOLOGIC
2001). Providing clients with brief periods of breathing CONSIDERATIONS
room air helps to prevent oxygen toxicity.
Reduced gas exchange and efficiency in ventilation are the major
HBOT helps to regenerate new tissue at a faster age-related changes in the respiratory system.
rate; thus, its most popular use is for promoting wound Age-related structural changes affecting the respiratory system
healing. It also is used to treat carbon monoxide poi- in older adults include the following: respiratory muscles
soning, gangrene associated with diabetes or other con- become weaker and the chest wall becomes stiffer as
ditions of vascular insufficiency, decompression sickness a result of calcification of the intercostal cartilage, kypho-
scoliosis, and arthritic changes to costovertebral joints;
experienced by deep-sea divers, anaerobic infections the ribs and vertebrae lose calcium; the lungs become
(especially in burn clients), and several other medical smaller and less elastic; alveoli enlarge; and alveolar walls
conditions. become thinner.
Functional changes to the respiratory system include diminished
coughing and gag reflexes, increased use of accessory muscles
for breathing, diminished efficiency of gas exchange in the
NURSING IMPLICATIONS lungs, and increased mouth breathing and snoring.
Some changes in lung volumes occur, resulting in a slight
decrease in overall efficiency and increased energy expendi-
Nurses assess the oxygenation status of clients on a ture by older adults. Older adults experience no change in
day-by-day and shift-by-shift basis. Therefore it is not the volume of air in the lungs after maximal inhalation
unusual to identify any one or several of the following (known as total lung capacity) as a result of using accessory
nursing diagnoses among clients experiencing hypox- muscles to breathe.
Weakness may lead to diminished strength for airway clearance.
emia or hypoxia:
Careful assessment of older adults who demonstrate restless-
• Ineffective Breathing Pattern ness or confusion is imperative to differentiate accurately
signs of inadequate oxygenation from signs of early delirium
• Impaired Gas Exchange
or dementia.
• Anxiety Older adults who smoke or are inactive, debilitated, or chronically
• Risk for Injury (related to oxygen hazards) ill are at a higher risk for respiratory infections and compro-
mised respiratory function.
Abnormal assessment findings often lead to collaboration Older adults who smoke need counseling about smoking cessa-
with the physician and the prescription for oxygen ther- tion and information about resources and techniques to assist
apy. Nursing Care Plan 21-1 is one example of how the with smoking cessation.
Unless contraindicated, older adults need encouragement to
maintain a liberal fluid intake (to keep mucous membranes
moist) and to engage in regular exercise (to maintain optimal
respiratory function).
Older adults who have lost weight and subcutaneous fat in their
cheeks may not receive the prescribed amounts of oxygen by
mask because of an inadequate facial seal.
Older adults who require home oxygen need encouragement to
continue socializing with others outside the home to prevent
feelings of isolation and depression.
The skin behind the ears of older adults should be assessed for
breakdown if oxygen administration equipment is secured by
tubing or elastic.
Advise older adults to receive annual influenza immunizations and
a pneumonia immunization after 65 years of age or earlier if
there is a history of chronic illness. Current guidelines recom-
mend a booster dose for older adults who received their initial
FIGURE 21-17 • Hyperbaric oxygen chamber. pneumonia immunization 5 or more years ago.
Ineffective Breathing Pattern
ASSESSMENT
• Determine the client’s respiratory rate and effort.
• Check the radial or apical pulse rate.
• Measure the client’s blood pressure.
• Note the client’s level of consciousness and mental status.
• Assess for the evidence of a cough and its characteristics.
• Observe the use of accessory thoracic and abdominal muscles for breathing.
• Observe the client’s chest contour.
• Inspect the skin, oral mucous membranes, and nailbeds for signs of cyanosis.
• Palpate the client’s abdomen for evidence of distention that could crowd the diaphragm.
• Note the client’s body position, which may or may not facilitate breathing.
• Measure the client’s SpO2 with a pulse oximeter.
• Review the results of arterial blood gas measurements.
• Auscultate anterior, posterior, and lateral lung sounds.
• Ask the client to describe his or her current status of oxygenation.
• Perform a pain assessment.
• Inquire as to the client’s medical history of respiratory disorders or other conditions that can affect ventilation.
• Identify the client’s smoking history.
• Review the client’s current medication history for drugs that can impair oxygenation.
Nursing Diagnosis: Ineffective Breathing Pattern related to 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 use of accessory muscles
to breathe; frequent productive cough; history of smoking 1 to 2 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 Pursed-lip breathing decreases respiratory rate, increases
breathing and practice same at least bid. tidal volume, decreases arterial CO2, increases arterial
oxygen, and improves exercise performance (Truesdell,
2000).
(continued)
Ineffective Breathing Pattern
Provide a minimum of 2,000 mL of oral fluid per 24 hours. Adequate hydration liquifies respiratory secretions and
facilitates expectoration. Expectoration of sputum clears
the airway and promotes ventilation.
Ensure a daily dietary intake of approximately 2,000 to The work of breathing creates additional caloric demands
2,500 calories. for energy.
Administer oxygen per nasal cannula at 2 L/min as Supplemental oxygen relieves hypoxemia. Administering
prescribed by the physician if SpO2 falls below 90% and is 2 to 3 L/minute prevents suppressing the hypoxic drive to
sustained there. breathe experienced by clients with chronic respiratory
diseases.
Explore nicotine cessation therapy with transdermal skin Transdermal nicotine skin patches reduce symptoms
patches. associated with nicotine withdrawal. The dose of nicotine
can be reduced gradually to promote nicotine cessation.
Evaluation of Expected Outcomes:

• Respiratory rate decreases from 34 to 26 when placed in high Fowler’s position.
• SpO2 increases from 86% to 90% with 2 L of oxygen per minute.
• The client demonstrates and performs pursed-lip breathing.
• The client consumes three cans of supplemental liquid nourishment, each of which has 350 calories, three times a day to
facilitate reaching minimum caloric goal of 2,000 calories.
• Fluid intake for 24 hours is between 1,800 to 2,200 mL
• Client expectorates copious volume of sputum.
3. When administering oxygen with a partial rebreather

mask, which of the following observations is most impor-
1. What levels of oxygen saturation and pulse rates are tant to report to the respiratory therapy department?
cause for nursing concern and indicate a need for further 1. Moisture accumulates inside the mask.
assessment? 2. The reservoir bag collapses during inspiration.
3. The mask covers the mouth and nose.
2. Discuss some differences between oxygen therapy in a
4. The strap around the head is snug.
health care setting and that in a home environment.
4. Which of the following flow rates is most appropriate for
a client with emphysema, a chronic lung disease?
NCLEX-STYLE REVIEW Q U E S T I O N S 1. 2 L/min
2. 5 L/min
1. When a client returns from surgery, which sign is an
3. 8 L/min
early indication that the client’s oxygenation status is
4. 10 L/min
compromised?
1. The client’s dressing is bloody. 5. When the nurse monitors the water-seal chamber of a
2. The client becomes restless. commercial chest tube drainage system that is draining
3. The client’s heart rate is irregular. by gravity, which finding suggests that the system is func-
4. The client indicates he is thirsty. tioning appropriately?
1. The fluid rises and falls with respirations.
2. If a client is adequately oxygenated, the pulse oximeter
2. The fluid level is lower than when first filled.
attached to her finger should measure oxygen saturation
3. The fluid bubbles continuously.
in the range of
4. The fluid looks frothy white.
1. 80 to 100 mm Hg
2. 95 to 100 mm Hg
3. 80% to 100%
4. 95% to 100%
Skill 21-1 • USING A PULSE OXIMETER
Assessment
Assess potential sensor sites for quality of circulation, Determines where sensor is best applied. The finger is the
edema, tremor, restlessness, nail polish, or artificial preferred site, followed by the toe, earlobe, and bridge
nails. of the nose. Aids in controlling possible factors that
might invalidate monitored findings
Review the medical history for data indicating vascular or Suggests the potential for unreliable data. There must be
other pathology, such as anemia or carbon monoxide adequate circulation, red blood cells, and oxygenated
inhalation. 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
oximetry. learning takes place when it is individualized
Planning
Explain the procedure to the client. Reduces anxiety and promotes cooperation and a sense of
security for coping with unfamiliar situations
Obtain equipment. Promotes organization and efficient time management,
preventing wasted motion and repeating actions
Implementation
Wash hands or perform hand antisepsis with an alcohol Reduces the transmission of microorganisms; soap, water,
rub (see Chap. 10). and friction remove surface microorganisms
Position the sensor so that the light emission is directly Ensures accurate monitoring; proper light and sensor
opposite the sensor. alignment ensure accurate measurement of red and
infrared light absorption by hemoglobin
Attach the sensor cable to the machine. Connects the sensor with the microprocessor to ensure
proper function
Observe the numeric display, audible sound, and Indicates the equipment is functioning
waveform on the machine.
Microprocessor
Oxygen saturation
Pulse rate OXYG

EN SAT
URATI xxxx
ON xxxx
xxxx
xxxx
PULSE xxxx
RATE xxxx
xxxx
xxxx
xxxx
xxxx
Oximetry equipment and monitor data.

Sensor
Infrared light
(continued)
USING A PULSE OXIMETER (Continued)
Set the alarms for saturation level and pulse rate Programs the machine to alert the nurse to check the client.
according to 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 pressure greater than 32 mm Hg leads to tissue hypoxia
sensor every 2 hours. and cellular necrosis.
Evaluation
• SpO2 measurements remain within 95% to 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
Date and Time SpO2 remains constant at 95% to 98% with pulse rate that ranges between 80 to 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 Ensures compliance with the plan for medical treatment,
device, liter flow or prescribed percentage, and whether because oxygen therapy is medically prescribed (except
the oxygen is to be administered continuously or only in emergencies)
as needed.
Note whether a wall outlet is available or if another type Promotes organization and efficient time management
of oxygen source must be obtained.
Determine how much the client understands about Indicates the need for and type of teaching that must be done
oxygen therapy.
Planning
Obtain equipment, which usually includes a flowmeter, Promotes organization and efficient time management
delivery device, and in some cases a humidifier.
Contact the respiratory therapy department for Follows interdepartmental guidelines; ensures nursing
equipment, if that is agency policy. collaboration with various paraprofessionals to provide
client care
“Crack” the portable oxygen tank if that is the type of Prevents alarming the client
oxygen source being used.
Explain the procedure to the client. Decreases anxiety and promotes cooperation
Eliminate safety hazards that may support a fire or Demonstrates concern for safety because open flames,
explosion. electrical sparks, smoking, and petroleum products are
contraindicated when oxygen is in use
Implementation
rub (see 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. (Copyright B. Proud.)
A
(continued)
ADMINISTERING OXYGEN (Continued)
Fill a humidifier bottle with distilled water to the Provides moisture because oxygen dries mucous
appropriate level if administering 4 or more L/min. membranes. The 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. (Copyright B. Proud.)
Insert the appropriate color-coded valve or dial the Regulates the FIO2
prescribed percentage if a Venturi mask is being used.
Attach the distal end of the tubing from the oxygen Provides a pathway for oxygen from its source to the client
delivery device to the flowmeter or humidifier bottle
(Fig. C).
Attaching tubing from the delivery device. (Copyright B. Proud.)
Turn on the oxygen by adjusting the flowmeter to the Fills the delivery device with oxygen-rich air
prescribed volume.
Note that bubbles appear in the humidifier bottle, if one is Indicates that oxygen is being released
used, or that air is felt at the proximal end of the
delivery device.
(continued)
ADMINISTERING OXYGEN (Continued)
Make sure that if a reservoir bag is used, it is partially Prevents asphyxiation and promotes high oxygenation. A
filled and remains that way throughout oxygen therapy. reservoir 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, Maintains intact skin and mucous membranes; reduces
and nasal hygiene at least every 4 to 8 hours. the growth of microorganisms
Reassess the client’s oxygenation status every 2 to 4 hours. Indicates how well the client is responding to oxygen
therapy
Notify the physician if the client manifests signs of Demonstrates concern for the client’s safety and well-being
hypoxemia or hypoxia despite oxygen therapy.
Evaluation
• Respiratory rate is 12 to 24 breaths per minute 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 min. 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 Indicates whether to expect air, bloody drainage, or both;
condition that necessitated inserting a chest tube. any 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 Helps direct assessment; the usual sites for chest tubes
tubes (Fig. A). are at the 2nd intercostal space in the midclavicular
line and in the 5th to 8th intercostal spaces in the
midaxillary line
Air Determining whether the physician has inserted one or two chest tubes.
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 Provides guidelines for carrying out medical treatment;
drainage is being collected by gravity or with the mechanical suction is used when there is a large air leak
addition of suction. or potential for a large accumulation of drainage
Planning
Arrange to perform a physical assessment of the client and Establishes a baseline and early opportunity for
equipment as soon as possible after receiving report. troubleshooting abnormal findings
Locate a roll of tape and 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 Reduces anxiety and promotes cooperation
for the interaction.
Wash hands or perform hand antisepsis with an alcohol Reduces the transmission of microorganisms;
rub (see Chap. 10). conscientious handwashing is one of the most effective
methods for preventing infection.
Check to see that a pair of hemostats (instruments for Facilitates checking for air leaks in the tubing or clamping
clamping) is at the bedside. the chest tube in the event the drainage system must
be replaced to prevent the re-entry of atmospheric air
within the pleural space, thus promoting lung expansion
(continued)
MAINTAINING A WATER-SEAL CHEST TUBE DRAINAGE SYSTEM (Continued)
Turn off the suction regulator, if one is used, before Eliminates noise that may interfere with chest
assessing the client. auscultation
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 re-expansion
Inspect the dressing for signs that it has become loose or Indicates a need for changing the dressing
saturated with drainage.
Palpate the skin around the chest tube insertion site to Indicates subcutaneous air leak and internal displacement
feel and listen for air crackling in the tissues (Fig. B). of the drainage tube
Palpating the skin around the chest tube inser-

tion site to feel and listen for air crackling in
the tissues. (Copyright B. Proud.)
Inspect all connections to determine that they are taped Indicates appropriate care has been performed and
and secure. ensures that the drainage system will not become
accidentally separated
Reinforce connections where the tape may be loose. Prevents accidental separation
Check that all tubing is unkinked and hangs freely into Ensures evacuation of air and bloody drainage because
the drainage system. fluid cannot drain upward against gravity; neither air
nor fluid can pass through a physical obstruction
Observe the fluid level in the water-seal chamber to see if Maintains the water seal, preventing the passage of
it is at the 2-cm level (Fig. C). atmospheric air into the pleural space
Add sterile distilled water to the 2-cm mark if the fluid is Maintains the water seal
below standard.
Note if the water is tidaling (the rise and fall of water in Indicates that the tubing is unobstructed and the lung has
the water-seal chamber that coincides with not completely inflated; intrathoracic pressure changes
respiration)(Fig. D). during breathing cause fluid to rise and fall
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.
(continued)
If constant bubbling is observed, clamp hemostats at the Provides a means for determining the location of an air
chest and within a few inches away; observe if the leak within the tubing because gas escapes through the
bubbling stops; continue releasing and reapplying the path of least resistance
hemostats toward the drainage system until the
bubbling stops.
20 cm 20 cm
(suction
control)
Noting water levels.
2 cm
(water
seal)
Chest
drainage
20 cm
Watching for tidaling—movement of water up

and down in the water-seal chamber.
2 cm
(water-seal
chamber)
Apply tape around the tube above where the last clamp Seals the origin of the air leak
was applied when the bubbling stopped.
Note if the water level in the suction chamber is at 20 cm Determines appropriate water level for suction because
and replace the evaporative loss (Fig. E). the depth of water in the suction chamber determines
the amount of negative pressure—not the pressure
setting on the suction source (usual depth is 20 cm)
(continued)
MAINTAINGING A WATER-SEAL CHEST TUBE DRAINAGE SYSTEM (Continued)
Add sterile distilled water to the 20-cm mark in the Maintains the standard amount for suction
suction control chamber if it has evaporated.
Regulate the suction so that it produces gentle bubbling. Prevents rapid evaporation and unnecessary noise
Observe the nature and amount of drainage in the Provides comparative data; more than 100 mL/hr or
collection chamber. bright-red drainage is reported immediately
Keep the drainage system below chest level. Maintains gravity flow of drainage
Adding water to the suction control chamber.
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 Creates extremely high negative intrapleural pressure;
the tubing to move stationary clots, only if necessary. milking is never done routinely
Encourage coughing and deep breathing at least every Promotes lung re-expansion because the mechanics of
2 hours while awake. breathing and forceful coughing help evacuate air
and fluid
Instruct the client to move about in bed, ambulate while Prevents hazards of immobility and maintains joint
carrying the drainage system, and exercise the shoulder flexibility with no danger to the client while the tube to
on the side of the drainage tube(s). the suction source is 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
Insert a separated chest tube within sterile water until it Provides a temporary water seal to prevent the entrance of
can be reattached and secured to the drainage system. atmospheric air, which can recollapse the lung
Prevent air from entering the tube insertion site by Reduces the amount of lung collapse
covering it with a gloved hand or woven fabric, if the
tube is accidentally pulled out.
(continued)
Mark the drainage level on the collection chamber at the Provides data about fluid loss without the risk of
end of each shift (Fig. F). recollapsing the lung; never empty the drainage
container
20 cm
Marking drainage level.
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
22
Chapter
Infection
Control
LEARNING OBJECTIVES
● Explain the meaning of infectious diseases.
● Differentiate between infection and colonization.
● List five stages in the course of an infectious disease.
● Define infection control measures.
● Name two major techniques for infection control.
● Discuss situations in which nurses use standard precautions and transmission-based precautions.
● Describe the rationale for using airborne, droplet, and contact precautions.
● Explain the purpose of personal protective equipment.
● Discuss the rationale for removing personal protective equipment in a specific sequence after
caring for a client with an infection.
● Explain how nurses perform double-bagging.
● List two psychological problems common among clients with infectious diseases.
● Provide at least three teaching suggestions for preventing infections.
● Discuss one unique characteristic of older adults in relation to infectious diseases.
INFECTIOUS DISEASES (diseases spread from one person to another) are also called contagious
or communicable diseases and community-acquired infections. They were once the lead-
ing 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, gonorrhea, and
some forms of wound and respiratory infections have developed drug-resistant strains
(see Chap. 10). Add to that the current public health problem with AIDS, an infectious
WORDS TO KNOW disease spread by HIV in blood and some body fluids (Box 22-1), severe acute respira-
tory syndrome (SARS), and the potential for bird flu, and it is clear that humans have
airborne precautions not won the war against pathogens.
colonization This chapter discusses precautions that confine the reservoir of infectious agents
contact precautions
double bagging
and block their transmission from one host to another. To understand the concepts of
droplet precautions infection control, it is important to understand the chain of infection (see Chap. 10)
hyperendemic infections and the course of an infection.
infection
infection control precautions
infectious diseases INFECTION
N95 respirator
personal protective
equipment Infection is a condition that results when microorganisms cause injury to a host. Infec-
Powered Air Purifying
tion differs from colonization, a condition in which microorganisms are present, but the
Respirator
standard precautions host does not manifest any signs or symptoms of infection. Regardless of whether the
transmission-based host is infected or colonized, the host can transmit pathogens and infectious diseases
precautions to others.
488
C H A P T E R 22 ● Infection Control 489
BOX 22-1 ● Facts and Myths About the Transmission INFECTION CONTROL PRECAUTIONS
of HIV
Facts
HIV is transmitted by
Infection control precautionsare physical measures designed
❙ Having unprotected vaginal, anal, or oral sexual contact with an infected to curtail the spread of infectious diseases. They are essen-
person tial when caring for clients. Infection control precautions
❙ Sharing needles or syringes with an infected person
require knowledge of the mechanisms by which an infec-
❙ Acquiring a needle-stick injury with the blood of an infected person
tious disease is transmitted and the methods that will inter-
(see Chap. 34)
❙ Receiving transfusions of infected blood or blood products fere with the chain of infection. The Centers for Disease
❙ Being born to or breast-fed by an HIV-infected mother Control and Prevention (1996, 2005) have established
❙ Having contact with the blood of an infected person through unsterilized guidelines for two major categories of infection control
equipment for ear-piercing, tattooing, acupuncture, dental procedures, precautions: standard precautions and transmission-based
safety razors, or toothbrushes
❙ Contacting blood of an infected person through an open cut or splashes precautions.
into the mucous membranes such as the eyes or inside of the nose
Myths
HIV is not transmitted by
❙ Donating blood
Standard Precautions
❙ Being bitten by insects
❙ Sharing cups and eating utensils Standard precautions are measures for reducing the risk
❙ Inhaling droplets from sneezes or coughs for microorganism transmission from both recognized and
❙ Hugging, touching, or closed-mouth kissing an infected person unrecognized sources of infection. Health care personnel
❙ Sharing telephones or computer keyboards
❙ Going to any public place with people infected with HIV
follow standard precautions when caring for all clients,
❙ Using public drinking fountains or toilet seats regardless of diagnosis or infection status (Box 22-2).
This precautionary system combines methods previously
Centers for Disease Control and Prevention, Divisions of HIV/AIDS known as universal precautions and body substance iso-
Prevention, The human immunodeficiency virus and its transmission. lation. The use of standard precautions reduces the poten-
Rockville, MD: CDC National AIDS Clearing House. http://www.cdc.gov/
nchstp/hiv_aids/pubs/facts/transmis.htm, last updated December 2002, tial for transmitting blood-borne pathogens and those
accessed 6/03; Ten things everyone should know about HIV. from moist body substances (feces, urine, sputum, saliva,
http:/aids.about.com/cs/aidsfactsheets/tp/tenhiv.htm; accessed 6/03.
wound drainage, and other body fluids). Health care per-
sonnel follow standard precautions whenever there is
the potential for contact with the following:
• Blood
Infections progress through distinct stages (Table 22-1).
• All body fluids except sweat, regardless of whether or
The characteristics and length of each stage may differ
not they contain visible blood
depending on the infectious agent. For example, the incu-
• Nonintact skin
bation period for the common cold is approximately 2 to
• Mucous membranes
4 days before symptoms appear, but it may take months
or years before a person infected with HIV demonstrates A sign that alerts health care workers may be posted
symptoms of AIDS. in various areas of the health care agency (Fig. 22-1).
TABLE 22-1 COURSE OF INFECTIOUS DISEASES

STAGE CHARACTERISTIC
Incubation period Infectious agent reproduces, but there are no recognizable symptoms.
The infectious agent may, however, exit the host at this time and
infect others.
Prodromal stage Initial symptoms appear, which may be vague and nonspecific. They
may include mild fever, headache, and loss of usual energy.
Acute stage Symptoms become severe and specific to the tissue or organ that is
affected. For example, tuberculosis is manifested by respiratory
symptoms.
Convalescent stage The symptoms subside as the host overcomes the infectious agent.
Resolution The pathogen is destroyed. Health improves or is restored.
BOX 22-2 ● Standard Precautions
Handwashing Environmental Control

❙ Wash hands after touching blood, body fluids, secretions, excretions, and con- ❙ Ensure that procedures for routine cleaning and disinfection of environmental
taminated items, whether or not gloves are worn. surfaces, beds, bedrails, bedside equipment, and other frequently touched
❙ Wash hands immediately after gloves are removed, between patient contacts, surfaces are carried out.
and when otherwise indicated; wash between tasks and procedures on the same
Linen
patient to prevent cross-contamination of different body sites. ❙ Handle, transport, and process soiled linen in such a way as to prevent exposure
❙ Use plain (non-antimicrobial) soap for routine handwashing.
❙ Use an antimicrobial agent or a waterless antiseptic agent to control outbreaks or
to oneself, others, and the environment.
hyperendemic infections (highly infectious in all age groups) Occupational Health and Blood-borne Pathogens
❙ Prevent injuries when using needles, scalpels, and other sharp devices
Gloves ❙ Never recap used needles
❙ Wear clean, nonsterile gloves when touching blood, body fluids, secretions,
❙ Use either a one-handed “scoop” method or mechanical device for covering
excretions, and contaminated items.
a needle.
❙ Change gloves between tasks on the same patient after contact with material that
❙ Place all disposable sharp items in a puncture-resistant container as close to
may contain a high concentration of microorganisms.
the location of use as possible; transport reusable syringes and needles in a
❙ Remove gloves and wash hands immediately before caring for another patient.
puncture-resistant container for reprocessing.
Mask, Eye Protection, Face Shield ❙ Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative
❙ Wear a mask and eye protection, or face shield to protect the eyes, nose, and to mouth-to-mouth resuscitation methods in areas where the need for resuscitation
mouth when there is a likelihood that splashes or sprays of blood, body fluids, is predictable.
secretions, or excretions will occur. Patient Placement
❙ Place a patient who contaminates the environment, who does not—or cannot be
Gown
❙ Wear a clean, nonsterile gown when there is a likelihood that splashes or sprays expected to—assist in maintaining appropriate hygiene or environmental control
of blood, body fluids, secretions, or excretions will occur. in a private room.
❙ Remove a soiled gown promptly and wash hands. ❙ Consult with an infection control professional concerning alternatives if a private
room is not available.
Patient-Care Equipment
❙ Handle equipment soiled with blood, body fluids, secretions, and excretions so as
(Adapted from: Centers for Disease Control and Prevention (1996). Standard
to prevent the transfer of microorganisms to oneself, others, or the environment. Precautions, Excerpted from Guideline for Isolation Precautions in Hospitals.
❙ Ensure that soiled reusable equipment is cleaned before another subsequent use. Available at: http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html.
❙ Discard soiled single-use equipment properly. Modified 2005; accessed January 2007.)
Transmission-Based Precautions epidemiologically important pathogens (Centers for Dis-

ease Control and Prevention, 1996). They are also called
Transmission-based precautions are measures for controlling isolation precautions. The three types of transmission-
the spread of infectious agents from clients known to be based precautions are airborne precautions, droplet pre-
or suspected of being infected with highly transmissible or cautions, and contact precautions (Table 22-2). These
FIGURE 22-1 • Sign that identifies

Standard Precautions.
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 tuberculosis

with a similarly infected Keep door closed; confine client to room. Measles (rubeola)
client Wear a mask for trapping airborne pathogens,
Negative air pressure* such as N95 respirator or Powered Air Purify-
Six to 12 air changes per ing Respirator in the case of tuberculosis.
hour Place a mask on the client if transport is
Discharge of room air to required.
environment or filtered
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 feet ing on agency policy but always when within Meningococcal meningitis
between other clients 3 feet of the client.
and visitors Place a mask on the client if transport is required.
Contact Private room or in a room Follow standard precautions. Gastrointestinal, respiratory, skin,
with similarly infected Don gloves before entering the room. or wound infections that are
client or consult with Change gloves during client care after contact drug-resistant
an infection control with infective material that contains high Gas gangrene
professional if the concentrations of microorganisms. Acute diarrhea
above options are Remove gloves before leaving the room. Acute viral conjunctivitis
not available. 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, sphygmo-
manometer, and other assessment tools
exclusively for the infected client; clean and
disinfect them before use for another client.
*Negative air pressure pulls air from the hall into the room when the door is opened, as opposed to positive air pressure,
which pulls room air into the hall.
Centers for Disease Control and Prevention. (1996). Guideline for isolation precautions in hospitals.
http://www.cdc.gov/ncidod/dhqp/gl_isolation.html modified 2005; accessed January 2007.
three types replace the earlier categories of strict isolation, Transmission-based precautions are required for var-
contact isolation, respiratory isolation, tuberculosis (AFB) ious lengths of time, depending on the nature of the
isolation, enteric precautions, and drainage/secretion pre- infecting microorganisms. Personnel discontinue some
cautions. Health care personnel base the decision to use precautions, with the exception of standard precautions,
one or a combination of precautions on the mechanism of when culture findings are negative, when a wound or
transmission of the pathogen. They use one or more cat- lesion stops draining, or after the initiation of effective
egories of transmission-based precautions concurrently therapy. Sometimes personnel employ them throughout
when diseases have multiple routes of transmission. a client’s treatment.
Airborne Precautions Contact Precautions

Airborne precautions are measures that reduce the risk Contact precautions are measures used to block the transmis-
for transmitting airborne infectious agents. They block sion of pathogens by direct or indirect contact. This is the
pathogens 5 microns or smaller that are present in the final category of transmission-based precautions. Direct
residue of evaporated droplets that remain suspended contact involves skin-to-skin contact with an infected
in the air, as well as those attached to dust particles. or colonized person. Indirect contact occurs by touching
Tuberculosis (TB) is an example of a disease transmit- a contaminated intermediate object in the client’s environ-
ted in the air. Caregivers must wear a specific type of mask ment. Additional precautions are necessary if the microor-
when caring for clients with TB. An N95 respirator, which ganism is antibiotic resistant.
is individually fitted for each caregiver, can filter particles Some infectious diseases like chickenpox (varicella),
1 micron (smaller than a millimeter) with an efficiency smallpox (variola), and SARS require both airborne and
of 95% or more, provided the device fits the face snugly contact precautions.
(Fig. 22-2A). A Powered Air Purifying Respirator (PAPR)
is an alternative if a caregiver has not been fitted for an
N95 respirator or has facial hair or a facial deformity that
prevents a tight seal with an N95 respirator (Fig. 22-2B). Stop • Think + Respond BOX 22-1
A PAPR blows atmospheric air through belt-mounted air-
Which type of transmission precautions do health care
purifying canisters to the facepiece through a flexible tube. personnel follow when caring for clients with the follow-
A PAPR can also be used when rescuing victims exposed ing medical diagnoses: (1) pulmonary tuberculosis,
to hazardous chemicals or bioterrorist substances. (2) streptococcal pneumonia, (3) an infected wound,
(4) acute diarrhea, and (5) meningococcal meningitis?
Droplet Precautions
Droplet precautions are measures that block pathogens
within moist droplets larger than 5 microns. They are
used to reduce pathogen transmission from close contact
(usually 3 feet or less) between an infected person or a
INFECTION CONTROL MEASURES
person who is a carrier of a droplet-spread microorganism
and others. Microorganisms carried on droplets com- Infection control measures involve the use of personal
monly exit the body during coughing, sneezing, talking, protective equipment (garments that block the transfer of
and procedures such as airway suctioning (see Chap. 36) pathogens from one person, place, or object to oneself
and bronchoscopy. Airborne precautions are not used or others) and techniques that serve as barriers to trans-
because droplets do not remain suspended in the air. mission (Fig. 22-3). Depending on the type of precau-
FIGURE 22-2 • (A) N95 respirator must fit tightly

around the mouth and nose with straps that attach it
to the head. A secure seal is evidenced by a slight
bulging on exhalation and slight collapse upon inhala-
tion. (B) Powered Air Purifying Respirator uses a blower
to remove contaminated air through a filter and sup-
A B plies purified air to a facepiece.
Client Environment
The client environment includes the room designated
Infectious client
T for the care of a client with an infectious disease and the
R equipment and supplies essential to controlling transmis-
A sion of the pathogens.
N
S Blood
M Infection Control Room
I
S Except when using standard precautions, most health
Noninfected S care agencies assign infectious or potentially infectious
clients Body substances
I clients to private rooms. Infection control personnel can
and O
personnel offer alternatives if a private room is not available (see
N
Table 22-2). They keep the door to the room closed to
B Air
control air currents and the circulation of dust particles.
A The room has a private bathroom so that personnel
R can flush contaminated liquids and biodegradable solids.
R A sink is also located in the room for handwashing.
I
E Droplets Staff members post an instruction card stating that
R isolation precautions are required on the door or nearby
S at eye level (Fig. 22-4). Nurses are responsible for teach-
ing visitors how to comply with the infection control
Linen, equipment, supplies measures.
In accord with the principles of medical asepsis, house-
FIGURE 22-3 • Blocking sources of infectious disease transmission.
keeping personnel clean the infectious client’s room last
to avoid transferring organisms on the wet mop to other
client areas. They deposit the mop head, if not disposable,
tions used, nurses implement all or some of the follow- with the soiled linen and wipe the mop handle with a dis-
ing measures: infectant. They flush solutions used for cleaning down
• Locating a client and equipping a room so as to confine the toilet.
pathogens to one area
• Using personal protective equipment such as cover Equipment and Supplies
gowns, face shields or goggles, cloth or paper masks The infection control room contains the same equipment
or respirators (see Chap. 10), and gloves to prevent and supplies as any other hospital room, with a few mod-
spreading microorganisms through direct and indirect ifications. Equipment that personnel would ordinarily
contact use for several noninfected clients, such as a stethoscope
• Disposing of contaminated linen, equipment, and sup- and sphygmomanometer, remains in the client’s room
plies in such a way that nurses do not transfer pathogens whenever possible. This prevents the need to clean and
to others disinfect the items each time they are removed.
• Using infection control measures to prevent pathogens For the same reason, disposable thermometers are pre-
from spreading when transporting laboratory speci- ferred. Personnel disinfect electronic or tympanic ther-
mens or clients mometers to make them safe for the next client. Items
FIGURE 22-4 • Door instructional

card.
FIGURE 22-7 • An anteroom outside the infection control room.

FIGURE 22-5 • Containing soiled laundry. (Copyright B. Proud.) (Copyright B. Proud.)
such as a container for soiled laundry (Fig. 22-5), lined with blood and body fluids; when they are removed after
waste containers, and liquid soap dispensers are also direct care of the infectious client, they reduce the possibil-
placed in the room. ity of transmitting pathogens from the client, the client’s
environment, or contaminated objects. Many types of
cover gowns exist, but all have the following common
Personal Protective Equipment characteristics:
• They open in the back to reduce inadvertent contact
Infection control measures involve the use of one or more
with the client and objects.
items for personal protection. Personal protective equip-
• They have close-fitting wristbands to help avoid con-
ment, also called barrier garments (Fig. 22-6), includes
taminating the forearms.
gowns, masks, respirators, goggles or face shields, and
• They fasten at the neck and waist to keep the gown
gloves (see Chap. 10). These items are located just outside
the client’s room or in an anteroom (Fig. 22-7). securely closed, thus covering all the wearer’s clothing.
Nurses wear a cover gown only once, then discard it.
Cover Gowns They place discarded cloth gowns in the client’s laundry
Cover gowns are worn for two reasons: they prevent con- hamper, remove them with the soiled linen, and wash
tamination of clothing and protect the skin from contact them before using them again. Disposable paper gowns
are placed in a waste container and incinerated.
Face-Protection Devices
Depending on the mode of transmission of the pathogen,
health care personnel wear a mask or respirator (see
Chap. 10), goggles, or a face shield. They always apply
these items before entering the client’s room.
Gloves
Gloves are required when an infectious disease is trans-
mitted by direct contact or contact with blood and body
substances. Health care personnel always don gloves
before or immediately on entering the client’s room. After
one use, they discard them.
Gloves are not a total and complete barrier to microorgan-
isms. They are easily punctured and can leak; the poten-
tial for leakage increases with the stress of use.
Wearing gloves does not replace the need for hand
FIGURE 22-6 • Donning personal protective equipment helps prevent antisepsis (see Chap. 10) after removal. Hands can be
the transmission of infectious microorganisms. (Copyright B. Proud.) contaminated during glove removal, and microorgan-
isms that were present on the hands before gloving grow

and multiply rapidly in the warm, moist environment
beneath the gloves.

What personal protective items would you expect to wear
when managing the care of a client with a draining
wound abscess?
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 FIGURE 22-9 • Waste container used for infectious waste. (Copyright
B. Proud.)
surfaces. Nurses remove the garments that are most con-
taminated first, preserving the clean uniform underneath
(Fig. 22-8).
Nurses can modify the technique to accommodate the end of each shift or more often if their contents accu-
the removal of any combination of equipment. The most mulate (Fig. 22-9). To avoid spreading pathogens, some
important nursing action is to perform thorough hand- items are double-bagged.
washing before leaving the client’s room and before Double-bagging is an infection control measure in which
touching any other client, personnel, environmental sur- one bag of contaminated items, such as trash or laundry, is
face, or client care items. placed within another. This measure requires two people.
One person bags the items and deposits the bag in a sec-
ond bag held by another person outside the client’s room.
Disposing of Contaminated Linen,
The person holding the second bag prevents contamina-
Equipment, and Supplies
tion by manipulating the bag underneath a folded cuff
Receptacles in the client’s room are used to collect con- (Fig. 22-10).
taminated items. Soiled waste containers are emptied at The Centers for Disease Control and Prevention (1996,
2005) have relaxed their recommendation concerning
double-bagging. Their revised position is that one bag is
adequate if the bag is sturdy and the articles are placed in
the bag without contaminating the outside of the bag.
Otherwise, double-bagging is used.
FIGURE 22-8 • Removing and disposing the most contaminated

garments first. (Copyright B. Proud.) FIGURE 22-10 • Double-bagging technique.
Discarding Biodegradable Trash aware that the client has an infectious disease. This
facilitates the expeditious care of the client and avoids
Biodegradable trash is refuse that will decompose natu- unnecessary waiting in areas with other clients.
rally into less complex compounds. It includes items such When the client returns, the nurse deposits the soiled
as unconsumed beverages, paper tissues, the contents of linen in the linen hamper in the client’s room, touching
drainage collectors, urine, and stool. All these items can only the outside surface of the protective covers. Some
be flushed down the toilet in the client’s room. Chemicals agencies also spray or wash the transport vehicle with
and filtration methods in sewage treatment centers are disinfectant before reuse.
sufficient for destroying pathogens in human wastes.
Nurses place bulkier items in a lined trash container
and remove them from the room by single- or double- PSYCHOLOGICAL IMPLICATIONS
bagging. They wrap moist items such as soiled dressings so
that during their containment, flying or crawling insects
Although infection control measures are necessary, they
cannot transfer pathogens. Eventually the bag and its con-
often leave clients feeling shunned or abandoned. Clients
tents are destroyed by incineration, or they are autoclaved.
with infectious diseases continue to need human contact
Autoclaved items can be safely disposed of in landfills.
and interaction, both of which are often minimal because
of the elaborate precautions taken on entering and leaving
Removing Reusable Items the room. Fearful family and friends may avoid visiting,
and clients are restricted from leaving their rooms. Mea-
To reduce the need for disinfection of reusable items, sures are needed to relieve the client’s feelings of isolation
disposable equipment and supplies such as plastic bed- by providing social interaction and sensory stimulation.
pans, basins, eating utensils, and paper plates and cups
are used as much as possible. If reusable items are nec-
essary for care, they are cleaned with an antimicrobial Promoting Social Interaction
disinfectant, bagged, and sterilized using heat or chemi-
cals (see Chap. 10). When transmission-based precautions are in effect, it is
important to plan frequent contact with the client. Nurses
encourage visitors to come as often as the agency’s poli-
Delivering Laboratory Specimens cies and the client’s condition permit. They use every
opportunity to emphasize that as long as visitors follow
Specimens are delivered to the laboratory in sealed con- the infection control precautions, they are not likely to
tainers in a plastic biohazard bag. When the testing is acquire the disease.
complete, most specimens are flushed, incinerated, or
sterilized.
Combating Sensory Deprivation
Transporting Clients Sensory deprivation results when a person experiences

insufficient sensory stimulation or is exposed to sensory
Clients with infectious diseases may need to be trans- stimulation that is continuous and monotonous. The goal
ported to other areas such as the x-ray department. Dur- is to provide a variety of sensory experiences at intervals.
ing transport, nurses use methods to prevent the spread See Nursing Guidelines 22-1.
of pathogens either directly or indirectly from the client.
For example, to prevent the exit of pathogens from the
client onto transport equipment, nurses line the sur- NURSING IMPLICATIONS
face of the wheelchair or stretcher with a clean sheet
or bath blanket to protect the surface from direct client
Caring for clients with infectious diseases involves meet-
contact. They use a second sheet or blanket to cover as
ing both their physical and emotional needs. Some fre-
much of the client’s body as possible during transport.
quently identified nursing diagnoses include the following:
The client wears a mask or particulate air filter respi-
rator if the pathogen is transmitted by the airborne or • Risk for Infection
droplet route. Any hospital personnel having direct con- • Ineffective Protection
tact with the client use personal protective equipment • Risk for Infection Transmission (not currently on the
similar to that used in client care. NANDA list)
Interdepartmental coordination is important. The • Impaired Social Interaction
department to which the client is transported is made • Social Isolation
NURSING GUIDELINES 22-1 22-1 • CLIENT AND FAMILY TEACHING

Providing Sensory Stimulation Preventing Infections
❙ Move the bed to various places in the room, or periodically The nurse teaches the client and family as follows:
rearrange the furnishings in the room. Such a change provides a • Bathe daily and perform other forms of personal
new perspective for the client. hygiene such as oral care.
❙ Position the client so he or she can look out the window. Having • Keep the home environment clean and
something different to look at reduces boredom. uncluttered.
❙ Encourage the client to use the telephone. Telephone calls allow • Use diluted household bleach (1:10 or 1:100) as
social interaction. a disinfectant.
❙ Communicate using the intercom system if entering the room is • Obtain appropriate adult immunizations (tetanus
inconvenient. This shows that the nurse is paying attention to vaccine at 10-year intervals, influenza vaccine
the client. yearly). A pneumococcal pneumonia immuniza-
tion lasts a lifetime or revaccination is required
❙ Converse with the client about current world events. Conversation
stimulates the client’s thought processes. every 5 years for extremely high-risk people.
• Investigate necessary vaccines, water purifi-
❙ Help the client to select television or radio programs. Watching
cation techniques, and foods to avoid when
television or listening to the radio engages the client’s attention.
traveling outside the United States.
❙ Change the location of equipment that produces monotonous sounds. • Practice a healthy lifestyle such as eating the
Changing the location will vary the volume or pitch of the noise. recommended number of servings from
❙ Encourage the client to be active, within the confines of the room. MyPyramid (see Chap. 15).
Activity provides a means of stimulation. • Perform frequent handwashing, especially
❙ Encourage activities that the client can do independently such as before eating, after contact with nasal secre-
reading, working crossword puzzles, playing solitaire, and putting tions, and after using the toilet.
picture puzzles together. Such activities are diverting. • Use disposable tissues rather than a cloth
❙ Offer a wide choice of foods with different flavors, temperatures, handkerchief for nasal and oral secretions.
and textures. Eating a variety of foods stimulates oral and olfactory • Avoid sharing personal care items such as
sensations. washcloths and towels, razors, and cups.
❙ Use touch appropriately by giving a backrub or changing the client’s • Stay home from work or school when ill rather
position. Touch produces tactile stimulation. than exposing others to infectious pathogens.
• Take over the task of cooking if the family
member who usually cooks is ill.
• Keep food refrigerated until use.
• Risk for Loneliness • Cook food thoroughly.
• Deficient Diversional Activity • Avoid crowds and public places during out-
• Powerlessness breaks of influenza.
• Fear • Follow infection control instructions when vis-
Nursing Care Plan 22-1 demonstrates how nurses apply iting hospitalized family members and friends.
the nursing process when caring for a client with the nurs- • Comply with drug therapy when prescribed.
ing diagnosis of Risk for Infection Transmission. The
North American Nursing Diagnosis Association has not
currently approved this diagnostic category, but Carpenito- diminished immune system functioning and inadequate
nutrition and fluid intake.
Moyet (2006, p. 239) defines it as “the state in which an
Symptoms of infections tend to be subtler among older adults.
individual is at risk for transferring an opportunistic or Because older adults tend to have a lower “normal” or baseline
pathogenic agent to others.” temperature, a temperature in the normal range may actually
Nurses also play a pivotal role by teaching measures to be elevated for an older adult.
prevent infection. See Client and Family Teaching 22-1. Infections are more likely to have a rapid course and life-threatening
consequences once they become established. Common manifes-
tations of infections in older adults include changes in behavior
and mental status.
GENERAL GERONTOLOGIC Thinning, drying, and decreases in vascular supply to the skin
CONSIDERATIONS predispose the older person to skin infections. Maintaining
intact skin is an excellent first-line defense against acquiring
Conscientious handwashing and standard precautions are nosocomial infections.
necessary basic nursing interventions when caring for all People with chronic conditions who may be debilitated or people
clients, but they are especially important with older adults. older than 75 years are at increased risk for infections, partic-
Older clients are more susceptible to infections caused by ularly those infections that are resistant to antibiotics.
Risk for Infection Transmission
ASSESSMENT
• Monitor laboratory test findings for evidence of infection such as an elevated white blood cell count or the results of a
culture indicating the growth of a pathogen.
• Check the client’s temperature regularly and note if there is a persistent elevation.
• Inspect the skin, mucous membranes, wounds, sputum, urine, and stool for signs of purulent or unusual drainage.
• Listen for abnormal lung sounds, especially if the client has a cough.
• Inspect the area around invasive devices such as an intravenous catheter, wound drain, abdominal feeding tube, etc.
• Ask if the client has a decreased appetite, lost weight, or felt weak and tired.
• Inquire about recent travel in a country or area where there has been an incidence of infectious disease or contact with
others who have been ill lately.
• Ask about the client’s immunization history.
• Read the results of a current skin test for tuberculosis or refer to a person who is certified to do so.
Nursing Diagnosis: Risk for Infection Transmission related to airborne spread of

pathogen causing tuberculosis (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 Airborne transmission precautions are the specified
culture is negative; follow standard precautions infection control measures for preventing the spread of
throughout length of stay. tuberculosis to susceptible individuals. Nurses implement
standard precautions during the care of all clients.
Once sputum specimens are free of infectious
microorganisms, the client will no longer require airborne
transmission precautions.
Post infection control measures on the room door, but do Posting instructions on the client’s door informs
not identify the name of the disease. personnel, family, and friend how to protect themselves
from contact with organisms that can cause the infectious
disease. Privacy 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 the nose and mouth with a paper A paper tissue collects moist respiratory secretions and
tissue when coughing, sneezing, or laughing, and dispose decreases airborne transmission. Paper is disposable and is
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
infectious organism that causes tuberculosis when a client
. is compliant with drug therapy.
Explain the purpose of combination drug therapy and the An informed and knowledgeable client promotes
need to continue uninterrupted administration to avoid compliance.
treatment failure and development of drug-resistant strain.
(continued)
Risk for Infection Transmission
Direct client to provide a sputum specimen at the public Continued monitoring of the client’s sputum provides a
health department within 2 to 3 weeks following means for evaluating if the client is noninfectious and
discharge. responding to treatment.
Recommend TB skin testing for close family members or Tuberculosis is usually spread among those who have
friends. close contact 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 used a paper tissue when coughing, sneezing, and talking.
• The client took all prescribed medications.
• The client’s family and friends followed posted infection control instructions.
• The client’s wife and children have received TB skin tests with negative results.
• The client verbalized how to self-administer his medications and the importance for remaining compliant.
• The client identified the date for a follow-up appointment with the Public Health Department for a repeat of sputum analysis.
Many long-term care residents, older hospitalized clients, and Older adults, family caregivers/members in close contact with older
health care personnel are colonized with antibiotic-resistant people, and all personnel in health care settings should obtain
bacteria, possibly with few or no symptoms. annual immunizations against influenza. Those 65 years and
Pneumonia, influenza, urinary tract and skin infections, and TB older and younger people with chronic diseases should receive
are common in older people, especially residents of long-term an initial dose of the pneumococcal vaccine.
care facilities. Most cases of TB occur in people older than Visitors with respiratory infections need to wear a mask or avoid
65 years and living in long-term care facilities (Ebersole et al., contact with older adults in their home or long-term care set-
2005). The incidence of TB in community-living older adults tings until their symptoms have subsided. In addition to the
is twice that of the general population (Miller, 2003). All mask, frequent thorough handwashing can help prevent
long-term care facilities are required to test each resident transfer of organisms.
on admission and each new employee for TB. Health care workers who are ill should take sick leave rather than
In many long-term care facilities and other institutional settings, expose susceptible clients to infectious organisms.
the limited number of private rooms and sinks for handwash- Older adults with cognitive impairment need more assistance with
ing increases the risk for the transmission of pathogens complying with infection control measures.
among residents.
Infections are often transmitted to vulnerable older adults through
equipment reservoirs such as indwelling urinary catheters, CRITICAL THINKING E X E R C I S E S
humidifiers, and oxygen equipment or through incisional sites
such as those for intravenous tubing, parenteral nutrition, or 1. Give some reasons why controlling the spread of infec-
tube feedings. Use of proper aseptic techniques is essential to tious diseases is difficult among children cared for in day
prevent the introduction of microorganisms. Daily assessment care centers.
for any signs of infection is imperative.
2. Discuss some reasons why new cases of AIDS occur
Prevention of urinary tract infections is best accomplished by
prompt attention to perineal hygiene (see Chap. 17). In
despite the fact that its mode of transmission is known.
women, thorough cleansing should always be done from the
urinary area toward the rectal area to prevent organisms in
stool from entering the bladder. Additionally, thorough hand- NCLEX-STYLE REVIEW Q U E S T I O N S
washing by the client, caregiver, or both is necessary. 1. When a nurse empties the secretions from a wound suc-
Indwelling catheters should be avoided, if at all possible, because
tion container, which of the following infection control
older adults have increased susceptibility to urinary tract
infections. Bladder training is much more desirable. When
measures is most important?
indwelling catheters are absolutely necessary, they require 1. Wear a mask.
meticulous daily care, and the tubing should never be placed 2. Wear a gown.
higher than the person’s bladder to prevent any backflow of 3. Wear goggles.
urine into the bladder. 4. Wear gloves.
2. When exiting the room of a client being cared for with 4. Other than obtaining an immunization against influenza,
contact precautions, the first step in removing personal what is the best advice the nurse can give to high-risk
protection items is to people to avoid acquiring this infection?
1. Take off the mask or particulate air respirator. 1. “Consume adequate vitamin C.”
2. Unfasten the front waist tie of the gown. 2. “Avoid going to crowded places.”
3. Unfasten the neck closure of the gown. 3. “Dress warmly in cold weather.”
4. Discard the gloves in a waste receptacle. 4. “Reduce daily stress and anxiety.”
3. The best advice the nurse can give to someone who is
allergic to latex yet must wear gloves for standard pre-
cautions is
1. “Rinse the latex gloves with running tap water
before donning them.”
2. “Apply a petroleum ointment to both hands before
donning latex gloves.”
3. “Eliminate wearing gloves, but wash both hands
vigorously with alcohol afterward.”
4. “Wear two pairs of vinyl gloves when there is a
potential for contact with blood or body fluid.”
Skill 22-1 • REMOVING PERSONAL PROTECTIVE EQUIPMENT
Assessment
Determine which type of infection control precautions are Indicates if garments must be removed and discarded
being used. within the room
Note if there is sufficient soap and paper towels, a laundry Provides a means for washing and confining soiled
hamper, and a lined waste receptacle within the room. garments
Planning
Make sure that all direct care of the client has been Avoids having to don barrier garments a second time
completed.
Implementation
Untie the waist closure if it is fastened at the front of the Provides hand protection while touching a part of the
cover gown before removing gloves. gown that is considered grossly contaminated
Remove gloves and discard them in a lined waste Confines grossly contaminated items
container.
Wash hands or perform an alcohol-based handrub (see Removes microorganisms
Chap. 10).
Remove mask (see Chap. 10) and other disposable face- Confines contaminated items
protection items and discard them in the waste
container.
Untie or unfasten the neck closure of the cover gown. Prevents contaminating the back of the uniform and the
hands
Remove the gown, but avoid touching the front, by either Prevents gross contamination of the hands
inserting your fingers at the shoulder or sliding a finger
under the cuff and pulling the sleeve down (Fig. A).
Removing a cover gown. (Copyright B. Proud.)
Fold the soiled side of the gown to the inside while Prevents contamination of the hands and uniform
holding it away from your uniform.
(continued)
REMOVING PERSONAL PROTECTIVE EQUIPMENT (Continued)
Roll up the gown and discard it in the waste container, if Confines contaminated garments
it is constructed of paper. If the gown is made of cloth,
discard it in the laundry hamper in the room.
Wash hands or perform an alcohol-based handrub. Removes microorganisms that may have been
inadvertently transferred during mask 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 Confines contaminated material
client’s room.
Leave the room, taking care not to touch anything. Prevents recontamination
Go directly to the utility room and perform hand Removes microorganisms; it is always safer to overdo
antisepsis one final time. than underdo any practice that controls the spread of
pathogens
Evaluation
• Appropriate personal protective equipment was
worn.
• Garments were removed with the least contamination
possible.
• Handwashing 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
UNIT 5
for Chapters 15, 16, 17, 18,
19, 20, 21, and 22
in parentheses.
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 neutral or more pleasant. (Distraction, Imagery, Meditation)
503
statements.
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.
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
U N I T 5 ● End of Unit Exercises for Chapters 15, 16, 17, 18, 19, 20, 21, and 22 505
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 com-
pounds containing nitrogen, carbon, hydrogen, and
oxygen)
4. Fats D. Nutrients that include sugars and starches
2. Match the types of fire extinguisher 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 based on the

criteria given below.
Crystalloid Solution Colloid Solution
Definition
Effects
Examples
2. Differentiate between acute and chronic pain based on the criteria given below.
Acute Pain Chronic Pain
Duration
Cause
Site of pain
Relief of pain
3. Differentiate between inspiration and expiration based on the criteria given below.
Inspiration Expiration
Definition
Process
Additional muscles involved

1.
a. Identify the figure.

b. 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 of pain.
1. Perception
2. Transmission
3. Modulation
4. Transduction
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.
1. Hold the breath for 3 to 6 seconds.
2. Sit upright unless contraindicated.
3. Insert the mouthpiece, sealing it between the lips.
4. Exhale normally.
5. Relax and breathe normally before the next breath with the spirometer.
6. Identify the mark indicating the goal for inhalation.
7. Remove the mouthpiece and exhale normally.
8. 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?
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. Why should the nurse administer analgesic drugs on a scheduled basis rather than whenever pain occurs?
8. Why is it important to use a humidifier when administering 4 or more liters of oxygen?
9. What is the purpose for implementing contact precautions during client care?
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?
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 likely to be offered to 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?
Activity K: Think over the following questions. Discuss them with your instructor
or peers.
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 disorientation, 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 complaining of 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?
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 pregnancy?
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 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 poison-
ing. 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 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 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.
6. A nurse is caring for a client recovering from tuberculosis. What infection control interventions should the nurse
follow? Select all that apply.
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 eat 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 intake of food with a moderately high salt content.
UNIT 6
Assisting the
Inactive Client
23 Body Mechanics, Positioning, and Moving
24 Therapeutic Exercise
25 Mechanical Immobilization
26 Ambulatory Aids
23 Body
Chapter
Mechanics,
Positioning,
and Moving
LEARNING OBJECTIVES
● Identify characteristics of good posture in a standing, sitting, or lying position.
● Describe three principles of correct body mechanics.
● Explain the purpose of ergonomics.
● Give at least two examples of ergonomic recommendations in the workplace.
● Describe at least 10 signs or symptoms associated with the disuse syndrome.
● Describe six common client positions.
● Explain the purpose of five different positioning devices used for safety and comfort.
● Name one advantage for each of three different pressure-relieving devices.
● Discuss four types of transfer devices.
● Give at least five general guidelines that apply to transferring clients.
INACTIVITY leads to deterioration of health. Multiple complications can occur among

WORDS TO KNOW people with limited activity and movement (Table 23-1). The consequences of
inactivity are collectively referred to as disuse syndrome (signs and symptoms that
alignment result from inactivity). Nursing care activities such as positioning and moving
anatomic position
balance
clients reduce the potential for disuse syndrome. Nurses can become injured, how-
base of support ever, if they fail to use good posture and body mechanics while performing these
bed board activities.
body mechanics This chapter describes how to position and move clients to prevent complications
center of gravity
associated with inactivity. It also discusses methods for protecting nurses from work-
contractures
disuse syndrome related injuries. Basic terms are defined in Table 23-2.
energy
ergonomics
foot drop
Fowler’s position MAINTAINING GOOD POSTURE
functional mobility
functional position
gravity Posture (position of the body, or the way in which it is held) affects a person’s appear-
lateral oblique position ance, stamina, and ability to use the musculoskeletal system efficiently. Good posture,
lateral position
whether in a standing, sitting, or lying position, distributes gravity through the center
line of gravity
muscle spasms of the body over a wide base of support (Fig. 23-1). Good posture is important for both
neutral position clients and nurses.
posture When a person performs work while using poor posture, muscle spasms (sudden,
prone position forceful, involuntary muscle contractions) often result. They occur more often when
repetitive strain injuries
shearing muscles are strained and forced to work beyond their capacity.
Sims’ position
supine position
transfer
516
C H A P T E R 23 ● Body Mechanics, Positioning, and Moving 517
TABLE 23-1 DANGERS OF INACTIVITY

SYSTEMS EFFECTS
Muscular Weakness
Decreased tone/strength
Decreased size (atrophy)
Skeletal Poor posture
Contractures
Foot drop
Cardiovascular Impaired circulation
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)
Constipation
Fecal impaction
Integumentary Pressure sores FIGURE 23-1 • Good posture helps to align gravity through the center
Endocrine Decreased metabolic rate of the body. A wide stance provides a stable base for support.
Decreased hormonal secretions
Central nervous Sleep pattern disturbances
Psychosocial changes
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 person 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 alignment with the pads of the fingers.
518 U N I T 6 ● Assisting the Inactive Client
Standing
To maintain good posture in a standing position

(Fig. 23-2):
• Keep the feet parallel, at right angles to the lower legs,

and about 4 to 8 inches (10 to 20 cm) apart.
• Distribute weight equally on both feet to provide a
broad base of support.
• Bend the knees slightly to avoid straining the joints.
• Maintain the hips at an even level.
• Pull in the buttocks and hold the abdomen up and in
to keep the spine properly aligned. This position sup-
ports the abdominal organs and reduces strain on both
back and abdominal muscles.
• Hold the chest up and slightly forward and extend or
stretch the waist to give internal organs more space and
maintain good alignment of the spine.
A B
• Keep the shoulders even and centered above the hips.
• Hold the head erect with the face forward and the chin FIGURE 23-3 • (A) Correct sitting posture. (B) Incorrect sitting posture.
(Courtesy of Lowren West, New York, NY.)
slightly tucked.
Sitting knee free from the edge of the chair to avoid interfering
with distal circulation.
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 Lying Down
Good posture in a lying position looks the same as in

a standing 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 compression of the arms or legs under
the body. The trunk is straight, and the hips are level.
A B
B
FIGURE 23-4 • (A) Correct lying posture. (B) Incorrect lying posture.
FIGURE 23-2 • (A) Good standing posture. (B) Poor standing posture. (Courtesy of Lowren West, New York, NY.)
The legs are parallel to each other with the feet at right The other component is applying and implementing
angles to the leg. ergonomics (specialty field of engineering science devoted
to promoting comfort, performance, and health in the
workplace). Ergonomics is used to improve the design of
BODY MECHANICS the work environment and equipment. The National
Institute for Occupational Safety and Health (NIOSH), a
division of the Centers for Disease Control and Preven-
The use of proper body mechanics (efficient use of the tion, requires employers to comply with many ergonomic
musculoskeletal system) increases muscle effectiveness, recommendations. Examples include the following:
reduces fatigue, and helps to avoid repetitive strain injuries
(disorders that result from cumulative trauma to muscu- • Use assistive devices to lift or transport heavy items
loskeletal structures). Basic principles of body mechan- or clients.
ics are important regardless of a person’s occupation or • Use alternative equipment for tasks that require repet-
daily activities, but body mechanics alone will not nec- itive motions—for instance, headsets or automatic
essarily reduce musculoskeletal injuries. See Nursing staplers.
Guidelines 23-1. • Position equipment no more than 20 to 30 degrees
away—about an arm’s length—to avoid reaching or
twisting the trunk or neck.
ERGONOMICS • Use a chair with good back support. A chair should be
high enough so the user can place his or her feet firmly
on the floor. There should be room for two fingers
Using proper body mechanics is one component of pre- between the edge of the seat and the back of the knees.
serving the integrity of the body, but body mechanics Arm rests should allow a relaxed shoulder position.
alone will not necessarily reduce musculoskeletal injuries. • Keep the elbows flexed no more than 100° to 110°, or
use wrist rests to keep the wrists in neutral position
when working at a computer.
• Work under nonglare lighting.
Health care workers, particularly nurses, are vulnerable
Using Good Body Mechanics to ergonomic hazards in the workplace as a direct conse-
quence of (1) lifting heavy loads (i.e., clients), (2) reaching
❙ Use the longest and strongest muscles of the arms and legs. Use
and lifting with loads far from the body, (3) twisting while
of these muscles provides the greatest strength and potential for
performing work.
lifting, (4) unexpected changes in load demand during the
lift, (5) reaching low or high to begin a lift, and (6) moving
❙ When lifting a heavy load, center it over the feet. Such positioning
or carrying a load a significant distance (Nelson, 2003).
creates a base of support.
The American Nurses Association (ANA) estimates that
❙ Hold objects close to the body. Doing so increases balance. in 2000, more than 33% of all nursing personnel experi-
❙ Bend the knees. Bending the knees prepares the spine to accept the enced work-related musculoskeletal disorders; 52% had
weight of the load. chronic low back pain; 20% transferred to a different unit
❙ Contract the abdominal muscles and make a long midriff. Doing so because of ongoing symptoms; 38% found it necessary to
protects the muscles of the abdomen and pelvis and prevents strain take a leave of absence; and 12% left nursing permanently
and injury to the abdominal wall. because of back pain (http://www.nursingworld.org/
❙ Push, pull, or roll objects whenever possible rather than lifting them. handlewithcare). Because of the pervasiveness of the
Lifting requires more effort. problem and its direct link to a shortage of employed
❙ Use body weight as a lever to assist with pushing or pulling an nurses, the ANA has taken an initiative to reduce injuries
object. This reduces muscle strain. to nurses (and their clients) by recommending a “no lift
❙ Keep feet apart for a broad base of support. This stance lowers the policy,” known as the Handle With Care Campaign, in the
center of gravity, which promotes stability. workplace. The campaign is an effort to reduce injuries
❙ Bend the knees and keep the back straight when lifting an object, through the use of assistive equipment and devices. Using
rather than bending over from the waist with straight knees. This assistive devices has many advantages (Box 23-1).
stance makes best use of the longest and strongest body muscles Health care agencies have already begun to implement
and improves balance by keeping the weight of the object close to the ANA guidelines. In 2006, Congress introduced a bill
the center of gravity. calling for a federal amendment to the Occupational Safety
❙ Avoid twisting and stretching muscles during work. Twisting can strain and Health Act (OSHA) to establish requirements for safer
muscles because the line of gravity is outside the body’s base of support. handling of clients in the United States. Some aspects of the
❙ Rest between periods of exertion. Resting promotes work endurance. proposed legislation address methods to reduce risks asso-
ciated with moving clients and evaluating alternatives or
BOX 23-1 ● 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

campaign. Available at: http://www.nursingworld.org/handlewithcare.)
FIGURE 23-5 • These nurses are using the Phil-e-slide Patient Han-
dling System to transfer a client. (Photo courtesy of ErgoSafe Products,
restricting manual lifting to emergency, life-threatening, LLC. St. Louis, MO).
or exceptional circumstances (Anderson, 2006). Volun-
tary changes in nursing practice, however, should not be
delayed while waiting for a change in the law. Common Positions
Nurses commonly use six body positions when caring for
bedridden clients: supine, lateral, lateral oblique, prone,
POSITIONING CLIENTS Sims’, and Fowler’s.
Good posture and body mechanics and ergonomically

Supine Position
designed assistive devices are necessary when inactive In the supine position, the person lies on the back
clients require positioning and moving. An inactive client’s (Fig. 23-6A). There are two primary concerns associated
position is changed to relieve pressure on bony areas of the with the supine position: prolonged pressure, espe-
body, promote functional mobility (alignment that maintains cially at the end of the spine, leads to skin breakdown;
the potential for movement and ambulation), and provide and gravity, combined with pressure on the toes from
for therapeutic needs. General principles for positioning bed linen, creates a potential for foot drop (permanent
are as follows: dysfunctional position caused by shortening of the calf
muscles and lengthening of the opposing muscles on the
• Change the inactive client’s position at least every anterior leg; Fig. 23-7). Foot drop hinders ambulation
2 hours. because it interferes with a person’s ability to place the
• Enlist the assistance of at least one other caregiver. heel on the floor. The supine position, however, is rec-
• Raise the bed to the height of the caregiver’s elbow. ommended as a way to reduce the incidence of sudden
• Remove pillows and positioning devices. infant death syndrome among newborns (National Insti-
• Unfasten drainage tubes from the bed linen. tute of Child Health and Human Development, 2006).
• Use a low-friction fabric or gel-filled plastic sheet, roller
sheet with handles, or a repositioning sling to slide, Lateral Position
rather than to drag or to lift, the client while turning or
transferring from bed to a stretcher (Fig. 23-5). With the lateral position (side-lying position; see Fig. 23-6B),
• Turn the client as a complete unit to avoid twisting the foot drop is of less concern because gravity does not pull
spine. down the feet as happens when clients are supine. Never-
• Place the client in good alignment with joints slightly theless, unless the upper shoulder and arm are supported,
flexed. they may rotate forward and interfere with breathing.
• Replace pillows and positioning devices.
• Support limbs in a functional position.
Lateral Oblique Position
• Use elevation to relieve swelling or promote comfort. In the lateral oblique position (a variation of the side-lying
• Provide skin care after repositioning. position), the client lies on the side with the top leg placed
B
A
E
High Fowler’s—
Mid Fowler’s— 60°–90° angle
45° angle
Low Fowler’s—
30° angle
C F
FIGURE 23-6 • (A) Supine position. (B) Lateral position. (C) Lateral oblique position. (D) Prone position.
(E) Sims’ position. (F) Fowler’s position.
in 30 degrees of hip flexion and 35 degrees of knee flexion drainage from bronchioles, stretches the trunk and extrem-
(see Fig. 23-6C). The calf of the top leg is placed behind the ities, and keeps the hips in an extended position. The
midline of the body on a support such as a pillow. The prone position improves arterial oxygenation in critically
back is supported, and the bottom leg is in neutral posi- ill clients with adult respiratory distress syndrome and
tion. This position produces less pressure on the hip than others who are mechanically ventilated (Viellard-Baron
a strictly lateral position and reduces the potential for et al., 2005). The prone position poses a nursing challenge
skin breakdown. for assessing and communicating with clients, however,
and it is uncomfortable for clients with recent abdominal
Prone Position surgery or back pain.
The prone position (one in which the client lies on the
abdomen; see Fig. 23-6D) is an alternative position for Sims’ Position
the person with skin breakdown from pressure ulcers In Sims’ position (semi-prone position), the client lies on
(see Chap. 28). The prone position also provides good the left side with the right knee drawn up toward the
chest (see Fig. 23-6E). The left arm is positioned along
the client’s back, and the chest and abdomen are allowed
to lean forward. Sims’ position also is used for examina-
tion of and procedures involving the rectum and vagina
(see Chap. 14).
Fowler’s Position
Fowler’s position(semi-sitting position) makes it easier for
the client to eat, talk, and look around. Three variations
FIGURE 23-7 • Foot drop. are common (see Fig. 23-6F). 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.
Fowler’s position is especially helpful for clients with
dyspnea because it causes the abdominal organs to drop
away from the diaphragm. Relieving pressure on the dia- FIGURE 23-9 • In the Trendelenburg position, the head is lower than
phragm allows the exchange of a greater volume of air. the feet.
Sitting for a prolonged period, however, decreases blood
flow to tissues in the coccyx area and increases the risk
for pressure ulcers in that area. Mattress
A comfortable, supportive mattress is firm but flexible
enough to permit good body alignment. A nonsupport-
Stop • Think + Respond BOX 23-1 ive mattress promotes an unnatural curvature of the
spine.
Give one advantage and one disadvantage for the
supine, lateral and lateral oblique, prone, Sims’, and
Fowler’s positions. Bed Board
A bed board (rigid structure placed under a mattress) pro-
vides additional skeletal support. Bed boards usually are
made of plywood or some other firm material. The size
Positioning Devices varies with the situation. If sections of the bed (the head
and foot) can be raised, the board must be divided into
Many devices are available to help maintain good body hinged sections. For home use, full bed boards can be
alignment in bed and prevent discomfort or pressure. Any purchased or made from sheets of plywood.
position, no matter how comfortable or anatomically cor-
rect, must be changed frequently. Pillows
Adjustable Bed Pillows are used to support and elevate a body part. Small
pillows, such as contour pillows, triangular wedges, and
The adjustable bed (see Chap. 18) can be raised or low- bolsters, are ideal for supporting and elevating the head,
ered and allows the position of the head and knees to be extremities, and shoulders. For home use, oversized pil-
changed. The high position facilitates the performance of lows are useful for elevating the upper part of the body
nursing care. Raising the head of the bed helps the client if an adjustable bed is not available.
to look around without twisting and bending. It also pro-
motes drainage of the upper lobes of the lungs and pre- Roller Sheet
pares the client for eventually standing and walking. The
low position enables an independent client to get in and A roller sheet (also known as a slider sheet) that extends
out of bed safely (Fig. 23-8). Placing a bed in slight Trend- from the upper back to midthighs is a helpful position-
elenburg position may help keep the client from sliding ing device. Some are designed with handles on either
down toward the foot of the bed (Fig. 23-9). side. When made of substances that reduce friction, the
roller sheets diminish the work of turning a client and
avoid the potential for skin injuries. They are used to
slide and roll, rather than to lift, the client. They help
to move up clients in bed from a supine position in the
center of the bed to the side of the bed, to turn clients
to a lateral position, or to transfer from bed to a stretcher.
A mechanical lift, which is discussed later, or a reposi-
tioning sling is recommended when major reposition-
ing is required. The roller sheet is placed close to the
sides of the client’s body during repositioning. Work-
ing as a team, nurses use the roller sheet to change the
client to an alternate position while avoiding any stoop-
FIGURE 23-8 • Grasping the mattress and pushing down with the ing, reaching, or twisting. The sheet is removed after
other hand is an independent technique for sitting on the edge of the being used or kept dry and free of wrinkles to prevent
bed in preparation for ambulating. skin breakdown.
Turning and Moving Clients NURSING GUIDELINES 23-2
In some cases the client may be fully capable of assisting Using a Trochanter Roll
with turning or moving. The amount of client assistance ❙ Fold a sheet lengthwise in half or in thirds and place it under the
depends on factors such as size, weight, mental status, and client’s hips. The sheet will anchor the body in correct position.
strength. If all criteria suggest that the nurse and client can
accomplish the task at hand, the nurse enlists the client’s
❙ Place a rolled-up bath blanket or two bath towels under each end of
cooperation by explaining the plan and how the client the sheet that extends on either side of the client. This provides
support to the trochanters.
can help. Assistive devices and additional caregivers are
needed when turning or moving a client who cannot ❙ Roll the sheet around the blanket so that the end of the roll is
change from one position to another independently or underneath. This action prevents unrolling.
who needs help doing so. Good turning and moving skills ❙ Secure the rolls next to each hip and thigh. The rolls prevent external
are important to prevent injury to the nurse and the client. rotation of the hip.
Skill 23-1 describes the process of repositioning and mov- ❙ Permit the leg to rest against the trochanter roll. This position allows
ing clients. normal alignment of the hips, preventing internal or external rotation.
Trochanter Rolls
Trochanter rolls (Fig. 23-10) prevent the legs from turn- (Fig. 23-12). Some commercial foot boards have supports
ing outward. The trochanters are the bony protrusions at that prevent outward rotation of the foot and lower leg.
the head of the femur near the hip. Placing a positioning If the client is short and cannot reach a foot board, a
device at the trochanters helps to prevent the leg from foot splint is used. A foot splint allows more variety in
rotating outward. See Nursing Guidelines 23-2.
body positioning while maintaining the foot in a func-
tional position. Some nurses have clients wear ankle-
Hand Rolls
high tennis shoes while in bed to prevent foot drop. They
Hand rolls (Fig. 23-11) are devices that preserve the remove the shoes regularly and give proper foot care.
client’s functional ability to grasp and pick up objects. If a foot splint or foot board is not available, the nurse
Hand rolls prevent contractures (permanently shortened can use a pillow and large sheet. He or she rolls the pillow
muscles that resist stretching) of the fingers. They keep in the sheet and twists the ends of the sheet before tuck-
the thumb positioned slightly away from the hand and ing it under the foot of the mattress. A pillow support does
at a moderate angle to the fingers. The fingers are kept not provide the firmness of a board or splint, and the nurse
in a slightly neutral position rather than a tight fist. A replaces it as soon as possible with a sturdier device.
rolled-up washcloth or a ball can be used as an alterna-
tive to commercial hand rolls. Hand rolls are removed
regularly to facilitate movement and exercise.
Foot Boards, Boots, and Foot Splints In addition to the usual hospital bed, what else will you
obtain to facilitate moving and repositioning a client who
Foot boards, boots, and splints are devices that prevent is weak and cannot assist with positioning and turning?
foot drop by keeping the feet in a functional position
FIGURE 23-10 • Placement of trochanter rolls. FIGURE 23-11 • Hand roll. (Copyright B. Proud.)
FIGURE 23-12 • Protective boots to avoid foot drop.

Trapeze Side Rails

A trapeze is a triangular piece of metal hung by a chain
over the head of the bed (Fig. 23-13). The client grasps Side rails (Fig. 23-14) are a valuable device to aid clients
the trapeze to lift the body and move about in bed. Unless in changing their position and moving about while in bed.
arm movement or lifting is undesirable, a trapeze is an With side rails in place, the client can safely turn from side
excellent device for helping a bedridden client to increase to side and sit up in bed. These activities help clients to
his or her activity. maintain or regain muscle strength and joint flexibility.
Mattress Overlays
PROTECTIVE DEVICES
Mattress overlays are accessory items made of foam or
containing gel, air, or water that nurses place over a stan-
Items such as side rails, mattress overlays, cradles, and
dard hospital mattress. Nurses use mattress overlays to
specialty beds protect inactive clients from harm or
reduce pressure and restore skin integrity (see Chap. 28).
complications.
Foam and Gel Mattresses
Several types of foam mattresses, made of latex or poly-
ethylene, are available. Foam acts like a layer of subcuta-
FIGURE 23-13 • Using a trapeze to facilitate movement. FIGURE 23-14 • Using side rails to change position.
neous tissue because it conforms to the client’s body and over bony prominences. This repetitive process promotes
acts like a cushion. Consequently, it redistributes pres- blood flow and keeps the tissue supplied with oxygen.
sure over a greater area, reducing the compressive effect The tubing connecting the mattress to its motor-driven
on skin and tissue. Foam also contains channels and cells compressor must not become kinked. The noise may dis-
filled with air that allow for evaporation of moisture and turb some clients.
escape of heat.
Some foam mattresses are convoluted or made with a Water Mattress
series of elevations and depressions, resembling an egg
A water mattress supports the body and equalizes the
crate (see Chap. 18) or waffle. The density of the foam
pressure per square inch over its surface. The pressure-
and the manner in which the foam is formed determine
relieving effect is maintained regardless of any shift
the degree of pressure reduction.
in the client’s position. Many claim that sleeping on a
Egg-crate foam mattresses provide minimal pressure re-
duction and are recommended for comfort only. Thicker, waterbed produces a feeling of tranquility, which may
waffle-shaped foam mattresses offer greater pressure re- provide beneficial emotional effects. Water mattresses
duction; nurses can use them to prevent skin breakdown. are heavy; therefore, the floor and the bed frame must
Gel is an alternative substance used to fill cushions and be able to support the weight. Puncturing leads to damage.
mattresses. It differs from foam in that it suspends and Filling and emptying, although done infrequently, are
supports the body part. Nurses place gel and foam cush- time-consuming.
ions in wheelchairs to prevent the “hammock effect”—
the posterior and lateral compression that occurs when
sitting in a slinglike seat. Cradle
Static Air Mattress A cradle is a metal frame secured to or placed on top of

the mattress. It forms a shell over the client’s lower legs
A static air pressure mattress is filled with a fixed volume to keep bed linen off the feet or legs. A cradle is often
of air. It is similar in appearance to those used for recre- used for clients with burns, painful joint disease, and
ational purposes. It suspends the client on a buoyant sur- fractures of the leg.
face, distributing the pressure on the underlying tissue.
If the mattress becomes underinflated, however, it loses
its effectiveness as a pressure-relieving device. Because Specialty Beds
plastic is nonabsorbent, air mattresses permit less evap-
oration of moisture than foam. Also, sharp objects can Specialty beds such as low–air-loss beds, air-fluidized
damage the integrity of the mattress. beds, oscillating support beds, and circular beds offer more
functions than standard hospital beds. Like mattress
Alternating Air Mattress overlays, they are used to relieve pressure and to prevent
An alternating air mattress (Fig. 23-15) is similar to a other problems associated with inactivity and immobility
static one with one exception: every other channel inflates (Table 23-3).
as the next one deflates. The process is then reversed. The
wavelike redistribution of air cyclically relieves pressure Low–Air-Loss Bed
A low–air-loss bed (Fig. 23-16) contains inflated air sacs
within the mattress. It maintains capillary pressure well
below that which can interfere with blood flow. Regard-
less of changes in body position, the mattress selectively
responds by redistributing the air to maintain low pres-
sure to all skin areas.
Air-Fluidized Bed
An air-fluidized bed (Fig. 23-17) contains a collection of
tiny beads within a mattress cover. The beads are blown
upward on warm air. When suspended, the dry beads
take on the characteristics of fluid, allowing the client to
float on the lifted beads. Excretions and secretions drain
away from the body and through the beads, thereby pre-
venting skin irritation and maceration from moisture.
FIGURE 23-15 • Alternating air mattress. (First Step Plus. Courtesy of The pressure-relieving effects of this type of bed have been
KCI Therapeutic Services, San Antonio, TX.) shown to speed the healing of severely impaired tissue.
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.
Spencegel pad
Static air, alternating air, TENDER Cloud At some risk for skin breakdown, or
or 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
Tilt and Turn skin breakdown
Paragon 9000 Combination of the following:
Low–air-loss bed KinAir Impaired skin
FLEXICAIR Continued existence of risk factors for further skin breakdown
Mediscus 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
An air-fluidized bed is better used for a client who is the head, arms, and legs prevent sliding and skin shearing
likely to remain in bed for long periods. Fluid balance (force exerted against the surface and layers of the skin
may become a problem because of the accelerated evapo- as tissues slide in opposite but parallel directions). Com-
ration caused by the warm, blowing air. Puncturing or partments within the bed are removed temporarily to
tearing the mattress is also a potential problem. facilitate assessment and care of the posterior body.
Oscillating Support Bed Circular Bed

An oscillating bed (Fig. 23-18) slowly and continuously A circular bed supports the client on a 6- or 7-foot ante-
rocks the client from side to side in a 124-degree arc. rior or posterior platform suspended across the diameter
Oscillation relieves skin pressure and helps to mobilize of the frame (Fig. 23-19). This type of bed allows the
respiratory secretions. Foam-covered supports applied to client to remain passively immobilized during a position
change. The bed has the capacity to rotate the client, who
is sandwiched between the anterior and posterior frames,
in a 180-degree arc. Turning permits access to the client
for nursing care. Clients learn how to operate the bed to
make minor adjustments in their position. This promotes
a sense of control among otherwise dependent clients.
TRANSFERRING CLIENTS
Transfer (moving a client from place to place) refers to

moving a client from 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
personnel with an assistive device is a passive transfer.
Transfer aids are assistive devices that help clients move
FIGURE 23-16 • Low–air-loss bed. (Courtesy of Hill-Rom Company, Inc.) laterally. Several devices are available to help transfer
FIGURE 23-17 • Air-fluidized bed.
clients. Some examples of transfer aids are transfer han- handrail to support the client’s weight while exiting and
dles, transfer belts, transfer boards, and mechanical or returning to bed. A transfer handle is not considered a
electrical lifts. Transfer devices are especially helpful restrictive device like side rails because the client is free
for decreasing the potential for injury to caregivers and to move around. It promotes activity and mobility for
clients or for times when caring for clients who fear falling many who are physically challenged.
or lack confidence in the ability of personnel to transfer
them safely and comfortably.
Transfer Belt
Transfer Handle A transfer belt is a padded device secured around the
client’s waist. Its handles provide a means of gripping
Some clients with disabilities find that a transfer handle and supporting the client. This device is designed for
helps them to remain active and independent (Fig. 23-20). clients who can bear weight and help with the transfer
A transfer handle fits between the mattress and bed frame but are unsteady. It also may be used as a walking belt to
or box spring and serves as a combination grab bar and provide safety and security while assisting a client with
ambulation (see Chap. 26).
FIGURE 23-18 • Oscillating bed. (Courtesy of Kinetic Concepts, Inc.,

San Antonio, TX.) FIGURE 23-19 • Circular bed.
FIGURE 23-20 • A transfer handle.
Transfer Boards
A transfer board serves as a supportive bridge between FIGURE 23-22 • A hydraulic mechanical lift is used to raise and
two surfaces such as the bed and a wheelchair, bed and transfer an obese or helpless client to some other location and return
stretcher, wheelchair and car seat, or wheelchair and toi- the client to bed.
let. 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 under- Mechanical Lift
neath side. Transfer boards are positioned in such a way
A mechanical lift (Fig. 23-22) helps to move heavy clients
that the client’s buttocks or body can slide across what
or those with limited ability to assist from the bed to a
would otherwise be an open space or a gap in height
chair, toilet, or tub, and back again. Both electric and
between two surfaces (Fig. 23-21). Some clients with hydraulic models are available with a lifting capacity of
strong arm and upper body muscles can use a transfer 350 to 600 lbs. Using a mechanical lift enables a caregiver
board independently. For clients who need assistance, to raise and lower clients secured in a canvas sling and
the nurse uses a transfer belt in conjunction with a trans- move them around on a wheeled frame. The wheels are
fer board. Full-body transfer boards also are available for locked when a stationary position is desired such as when
moving supine clients to a stretcher or x-ray table. A low- lowering a client into place. Standing assist lifts are an
friction roller sheet may be used in conjunction with a alternative for use when clients have some ability to bear
transfer board. weight (Fig. 23-23).
It is best to use assistive devices when they are needed,
observe the guidelines in Nursing Guidelines 23-3, and
use the recommendations in Skill 23-2 when transfer-
ring clients.

List the various devices for transferring clients in a
sequence from the one that requires the least work on the
part of the nurse to the one that may require the most.
During the initial and subsequent client assessments,

FIGURE 23-21 • A transfer board used to move a client from the bed the nurse determines the client’s level of dependence
to a stretcher. on nursing assistance. One scale for quantifying the
BOX 23-2 ● Levels of Functional Status
0 = Completely independent
1 = Requires use of assistive device
2 = Needs minimal help
3 = Needs assistance and/or some supervision
4 = Needs total supervision
5 = Needs total assistance or unable to assist (Carpenito, 2002)
• Risk for Perioperative-Positioning Injury

• Impaired Transfer Ability
• Impaired Bed Mobility
Nursing Care Plan 23-1 illustrates how nurses apply the
steps in the nursing process when caring for a client
with the nursing diagnosis of Risk for Disuse Syndrome.
The NANDA taxonomy (2005) describes this diagnos-
FIGURE 23-23 • A standing lift supports a client who can bear some
tic category as a state in which a person is “at risk for
body weight. It also facilitates lowering the client to a sitting position
on a chair or toilet. deterioration of body systems as the result of prescribed
or unavoidable musculoskeletal inactivity.”
While providing nursing care, there may be oppor-
client’s status is shown in Box 23-2. The nurse selects tunities to teach clients and their caregivers about tech-
positioning, transfer, and protective devices according niques that promote activity or reduce the potential for
to whether the client is independent or requires partial complications from inactivity. See Client and Family
or total assistance. Teaching 23-1.
Various nursing diagnoses may apply to inactive clients:
• Impaired Physical Mobility
• Risk for Injury 23-1 • CLIENT AND FAMILY TEACHING
• Risk for Disuse Syndrome
Promoting Activity and Mobility
NURSING GUIDELINES 23-3 • Balance periods of activity with periods of rest.
• Become aware of the dangers of inactivity.
Assisting with Client Transfer • Allow adequate time for performing activities.
❙ Be realistic about how much you can safely lift. Not exceeding one’s • Join a club that involves social activities.
capabilities demonstrates good judgment. • Develop hobbies or recreational interests.
• Become a volunteer at the hospital, your church,
❙ Always practice good body mechanics. They reduce the potential
for injury. or a municipal group.
• Join a local group—a coffee club, needlework
❙ Put on braces and other supportive devices before getting a client
group, football friends, or bingo or card players.
out of bed. Doing so maximizes time management.
• Remove objects that might pose safety hazards,
❙ Have the client wear shoes or nonskid slippers. Appropriate such as throw rugs or electrical cords. Make
footwear provides support and prevents foot injuries.
sure chair legs are not in the way. Promptly
❙ Plan to transfer clients across the shortest distance. A short transfer mop up any water spilled on the floor.
reduces the potential for injury. • Rent or purchase hospital equipment from a
❙ Make sure that the client’s stronger leg, if there is one, is nearest the medical supply company.
chair to which the client is transferring. This action ensures safety. • Investigate the loan of equipment for homebound
❙ Stand on the side of the bed to which the client will be moving. This terminal clients from national organizations
position helps the nurse assist the client. such as the American Cancer Society.
❙ Explain to the client what will be done, step by step, and solicit the • Ask about community services that encourage
client’s help as much as possible. These actions inform the client, independent living, such as homemaker services,
encourage self-help, and reduce the workload. trained dogs, Meals on Wheels, social services,
and church organizations.
Risk for Disuse Syndrome
ASSESSMENT
• Assess the client’s independent movement and activity status.
• Inspect the integrity of the skin.
• Inquire as to the client’s bowel elimination pattern and characteristics of stool.
• Observe the client’s depth of respirations and ability to raise pulmonary secretions.
• Check skin color, capillary refill of nailbeds, and urinary output for evidence of circulatory perfusion.
• Palpate distal peripheral pulses for rate and quality.
• Check Homans’ sign.
• Determine if there is a potential for infection of any type such as an indwelling urinary or venous catheter, artificial
airway, wound, etc.
• Observe if the client has sufficient muscle strength and coordination to protect himself or herself from a potential injury.
• Assess if there is any impairment of vision, hearing, tactile sensation.
• Note the client’s mental status for signs of dementia, depression, or apathy.
Nursing Diagnosis: Risk for Disuse Syndrome (A syndrome diagnosis contains its etiology
in the diagnosis; a “related to . . .” is not applicable [Carpenito-Moyet, L. J., 2006, p. 14])
Expected Outcome: The client will have no evidence of complications associated with
disuse as evidenced by intact skin/tissue 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 1500 mL/day
throughout length of care.
Reposition the client every 2 hours around the clock. Position changes relieve pressure and maintain sufficient
capillary circulation to ensure cellular and tissue integrity.
Provide clean, dry, and wrinkle-free bedding at all times. Clean dry linen prevents maceration of skin from
prolonged contact with moisture. Keeping the linen
wrinkle-free prevents compromised circulation from
increased pressure per square inch (psi) of skin.
Use and check incontinence pads on bed every 2 hours; Incontinence pads wick moisture away from the client and
change 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 bedside commode every 4 hours Transferring from bed to a commode promotes use of the
when 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.
(continued)
Risk for Disuse Syndrome
Apply a footboard to the bed or foot splints to both legs. These devices prevent foot drop and help to ensure the
potential for normal ambulation.
Encourage active exercise with a bed trapeze and Activity reduces the potential for complications associated
participation in activities of daily living such as assisting with disuse.
with bathing, 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
satisfaction 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 client has full range of motion in all joints.
• The client’s lungs are clear to auscultation anteriorly, posteriorly, and laterally.
• The pedal pulses are present and strong bilaterally.
• Homans’ sign is negative bilaterally when the feet are dorsiflexed.
• Capillary refill in nailbeds of great toes is 2 to 3 seconds.
• The client has a daily bowel movement without straining.
• The client’s urine is clear yellow with a daily volume between 2000 and 2200 mL.
• No foot drop or external rotation of hips and legs is noted when footboard and trochanter rolls are in use.
GENERAL GERONTOLOGIC Elevated toilet seats with handrails may be helpful to allow older
people to use arm muscles, rather than leg muscles, to assist
CONSIDERATIONS with sitting and rising.
Older adults may fear falling and thus limit their mobility.
By the seventh or eighth decade of life, muscle strength,
Handrails may be strategically placed to promote confidence
endurance, and coordination decline. Older adults need to
in ambulation. In addition, placement of chairs near a frequent
maintain as much mobility as possible to prevent disability.
Older adults require extra time and assistance during positioning, pathway in the home or institution allow for a “rest stop,” thus
transferring, and ambulating. They may need modifications to increasing confidence in ambulation.
positions because of limitations from pain or joint degeneration. Bone demineralization increases the risk for fractures in older
Allow a few minutes for an older person’s position changes, adults (see Chap. 25). Falls, fractures, and degenerative bone
such as from supine to sitting or standing, to allow for compen- diseases have serious economic effects on older adults. The
satory changes in blood pressure, thus preventing orthostatic risk for social isolation also increases as mobility is limited.
hypotension. Teach the client to wait until any dizziness has Older adults with cognitive impairment may have difficulty fol-
resolved before moving, thus decreasing the risk for falls. lowing directions regarding positioning and transferring.
An older person may be taught to use appropriate body mechan- Instructions should be given using clear, simple words to
ics, such as sitting in a chair to lift an object directly in front of make one request at a time. Demonstrations are very help-
it. Emphasize that lifting of objects should be done only from ful in conveying the message if word recall is diminished.
directly in front to prevent pulling of lateral back muscles or Photographs of the desired action may also be used.
vertebral disk compression. During times of bed rest, perform passive range-of-motion
Skeletal changes such as kyphosis, lordosis, or scoliosis change exercises or encourage active range-of-motion exercises if
the older person’s center of gravity. Also, pressure on cervical the older person can do them. These exercises can minimize
vertebrae from kyphotic changes while lying supine may be the effects of immobility, such as muscle atrophy, bone
minimized by using a small towel roll or neck roll pillow. demineralization, and constipation.
3. Before turning a postoperative client from a supine

to a lateral position, which nursing instruction is most
1. You observe a coworker using incorrect body mechanics appropriate?
while giving care to a client. How would you approach 1. “Hold your breath as you are turning.”
this coworker? What suggestions would you give? 2. “Bend your far knee over the other.”
3. “Curl up in a ball before I help you turn.”
2. List nursing activities that predispose to work-related
4. “Let me roll you as if you were a log.”
injuries. How can the nurse reduce risk for injury during
each? 4. After a client undergoes surgery, the nurse uses a tro-
chanter roll to prevent the hips from a position of:
1. Adduction
NCLEX-STYLE REVIEW Q U E S T I O N S 2. Abduction
1. The nurse who assists with a diagnostic examination 3. Flexion
involving the lower gastrointestinal tract, such as a sig- 4. Rotation
moidoscopy, is most correct in placing the client in a 5. Which of the following is most helpful for facilitating a
1. Lithotomy position 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
2. Which of the following body positions is best for the nurse 4. Lower side rails
to use to promote drainage from an abdominal wound?
1. Lithotomy position
2. Fowler’s position
3. Supine position
4. Trendelenburg position
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 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 Reduces interference during repositioning
as trochanter rolls.
Raise the bed to elbow height, which is a suitable working Prevents back strain by maintaining the center of gravity
height.
Secure two or three additional caregivers, positioning and Ensures safety
moving devices (e.g., 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).
Lower the side rail and have the client slide to one side of Provides room when turning
the bed.
Raise the side rail. Ensures safety
Move to the other side of the bed and lower the side rail Facilitates assistance and ease in working
on that side.
Flex the client’s far knee over the near one with the arms Aids in turning and protects the client’s arms
across the chest.
Spread your feet, flex your knees, and place one foot Provides a broad base of support
behind the other.
Place one hand on the client’s shoulder and one on the hip Facilitates turning
on the far side.
Roll the client toward you (Fig. A). Reduces effort
Replace pillows behind the back and between the legs and Aids in maintaining position and provides comfort
under the upper arm (Fig. B).
Raise the side rails and lower the height of the bed. Ensures safety
(continued)
TURNING AND MOVING A CLIENT (Continued)
Directing the client to turn.
Supporting arms and legs with pillows.
For a Prone Position

Begin as described earlier for the lateral position. Follows same principles
Have the client turn his or her head opposite to the Prevents pressure on the face and arms during and after
direction for rolling and leave the arms extended at repositioning
each side (Fig. C).
Shift your hands from the posterior of the shoulder and Controls the speed with which the client is repositioned
hip to the anterior as the client rolls independently onto
his or her abdomen (Fig. D).
Center the client in bed. Prevents pressure on arms
(continued)
Preparing for prone positioning.
Bracing the client during turning.
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 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
(continued)
Raise the bed to elbow height. Reduces back strain
Place a roller/slider sheet beneath the buttocks, if one is Promotes gliding and reduces friction
not already present, to facilitate movement if needed.
Instruct the client to grasp a trapeze and bend both knees Aids in assisting by using the stronger muscles of the arms
while keeping the feet flat on the bed. and legs
Ask the client to pull on the trapeze and push down with Creates momentum to facilitate moving
his or her feet, causing the legs to straighten. Repeat
again if necessary.
Rearrange pillows and remove the roller sheet unless it Restores comfort
will be needed again in the near future.
Place the client in a slight Trendelenburg position if Gravity keeps the client from sliding downward.
sliding 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 Facilitates gliding the client rather than lifting
and buttocks.
Stand facing each other on opposite sides of the bed Aids in coordinating movement between nurses
between 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 A palms-up grip provides more strength by keeping
in contact with the bed sheet. the elbows 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
momentum to facilitate sliding
Slide the client up on reaching a previously agreed signal, Promotes coordination of effort
such as the count of three.
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 Gravity keeps the client from sliding downward.
sliding downward is a persistent problem.
Wash hands or use an alcohol-based hand rub when Reduces the transmission of microorganisms
(continued)
Evaluation
• Movement is achieved.
• Client is comfortable.
• Pressure is relieved.
• Joints and limbs are supported.
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 Complies with the plan for care
for activity level.
Assess the client’s strength and mobility, as well as his or Determines the need for additional personnel or a
her mental and emotional status. mechanical lifting device
Planning
Consult with the client on the preferred time for getting Helps client participate in decision making
out of bed.
Locate a straight-backed chair, wheelchair, or stretcher to Facilitates efficient time management
which the client will be transferred.
Arrange the chair or stretcher next to or close to the bed Ensures safety
on the 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
(continued)
TRANSFERRING CLIENTS (Continued)
Implementation
From Bed to Chair
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 Provides easy access
side; raise the footrests if the client is using a wheelchair.
Apply a transfer belt or other assistive device, if needed Reduces the risk for falling
(Fig. A).
Applying a transfer belt.
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.
B
(continued)
Rock the client to a standing position at an agreed signal Provides momentum and reduces the need to lift the client
while 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 Places the client in close proximity with the chair
the back of the legs.
Instruct the client to grasp the arms of the chair while Promotes safety
you stabilize his or her knees and lower the client into
the chair (Fig. C).
Support the feet on the footrests. Facilitates good posture
Backing into wheelchair.
Using a Transfer Board

Remove an arm from the wheelchair. Reduces the transmission of microorganisms
Slide the client to the edge of the bed. Reduces interference with transfer
Angle the transfer board from the client’s buttocks and Maintains shortest distance for transfer
hips down toward the seat of the chair.
Position the transfer board beneath the client. Places the board where there is maximum weight
Support and brace the client’s knee with your knees while Supports upper body
maintaining proper body mechanics.
Slide the client down the transfer board into the seat of Prevents injury
the chair at an agreed-on signal (Fig. D).
Wash hands or perform an alcohol-based hand rub if Reduces the need to lift client
(continued)
Using a transfer board. (Copyright B. Proud.)
Using a Mechanical Lift

Wash hands or perform an alcohol-based hand rub if Reduces the transmission of microorganisms
Raise the bed to a height that places the client near the Reduces the risk for back injury
nurse’s 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 Positions the sling where it will support the greatest mass
to midthigh (Fig. E). of the client
Applying the lift’s sling.
Move the lift device on the same side of the bed as Facilitates safety when the client and equipment are
the chair or stretcher to which the client will be within close proximity
transferred.
Position the boom on the lift over the client’s torso. Enables attachment of lifting chains to the canvas sling
Lock the wheels on the lift. Stabilizes the lift in place
(continued)
Attach the hooks on the lifting chain or straps to the holes Connects the lift to the client
in the canvas sling (Fig. F).
Positioning the lift and 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 Aids in assessing whether the client is properly and safely
above the mattress (Fig. G). within the sling
Raising the client.
Unlock the wheels on the lift and move the lifted client Relocates the client to the desired location
directly 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 suspended position
Remove the lifting chains, but leave the canvas sling in Facilitates returning the client to bed
place beneath the client.
Wash hands or perform an alcohol-based hand rub if Reduces the transmission of microorganisms
(continued)
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. Tran-
sient pain rated at 1 on a scale of 0 to 10 experienced in left hip during transfer. Declined offer for
pain medication. Up in chair approximately 1 hr. SIGNATURE/TITLE
24
Chapter
Therapeutic
Exercise
LEARNING OBJECTIVES
● List at least five benefits of regular exercise.
● Define fitness.
● Identify seven factors that interfere with fitness.
● Name at least two methods of fitness testing.
● Describe how to calculate a person’s target heart rate.
● Define metabolic energy equivalent.
● Differentiate fitness exercise from therapeutic exercise.
● Differentiate isotonic exercise from isometric exercise.
● Give at least one example of isotonic and isometric exercises.
● Differentiate between active exercise and passive exercise.
● Discuss how and why range-of-motion exercises are performed.
● Provide at least two suggestions for helping older adults become or stay physically active.
EXERCISE (purposeful physical activity) is beneficial to people of all age groups (Box 24-1),
and the health risks of a sedentary lifestyle are well documented. This chapter addresses
WORDS TO KNOW techniques for improving health and maintaining or restoring muscle and joint func-
tion by promoting exercise. Because exercise must be individualized, nurses are respon-
active exercise
sible for assessing each person’s fitness level before initiating an exercise program with
aerobic exercise
ambulatory a client.
electrocardiogram
ankylosis
body composition
cardiac ischemia
FITNESS ASSESSMENT
continuous passive motion
machine
Fitnessmeans capacity to exercise. Factors such as a sedentary lifestyle, health prob-
exercise
fitness lems, compromised muscle and skeletal function, obesity, advanced age, smoking, and
fitness exercise high blood pressure can impair a client’s fitness and stamina. They could even result
isometric exercise in injury during exercise. Therefore, before a client begins an exercise program, assess-
isotonic exercise ment of his or her fitness level is necessary. Some assessment techniques include mea-
maximum heart rate
suring body composition, evaluating trends in vital signs, and performing fitness tests.
metabolic energy equivalent
passive exercise
range-of-motion exercises
recovery index Body Composition
step test
stress electrocardiogram Body composition is the amount of body tissue that is lean versus the amount that is fat.
submaximal fitness test
target heart rate
Determining factors include anthropometric measurements such as height, weight,
therapeutic exercise body-mass index, skinfold thickness, and midarm muscle circumference (see Chap. 13).
walk-a-mile test Inactivity without reduced food intake tends to promote obesity. Overweight or obese
543
BOX 24-1 ● 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
people are less fit than their leaner counterparts and need
to proceed gradually when initiating an exercise program.
Vital Signs FIGURE 24-1 • Stress electrocardiogram.
Vital signs—temperature, pulse rate, respiratory rate,

and blood pressure—reflect a person’s physical status rhythm, cardiac ischemia (impaired blood flow to the heart),
(see Chap. 12). Elevated pulse rate, respiratory rate, and elevated blood pressure, or exhaustion.
blood pressure while resting are signs that the person
may have life-threatening cardiovascular symptoms dur- Ambulatory Electrocardiogram
ing exercise. After a period of modified exercise, vital An ambulatory electrocardiogram is a continuous record-
signs may decrease, thus reducing the potential for heart- ing of heart rate and rhythm during normal activity. It
related complications. requires the client to wear a device called a Holter moni-
tor for 24 hours. This less taxing version of a stress elec-
trocardiogram is used when the person has had prior
Fitness Tests cardiac-related symptoms, such as chest pain, or has major
health risks that contraindicate a stress electrocardiogram.
Fitness tests provide an objective measure of a person’s Ambulatory electrocardiography helps to assess the
current fitness level and potential for safe exercise. They heart’s response to normal activity rather than activity
also help to establish safe parameters for the level and imposed during a stress electrocardiogram. It also helps
duration of exercise. Two methods of fitness testing are to evaluate how a person is responding to cardiac reha-
a stress electrocardiogram and an ambulatory electrocar- bilitation and medical therapy.
diogram. Another is a submaximal fitness test, which is an The Holter monitor, which is connected to chest
exercise test that does not stress a person to exhaustion. leads, is attached to a belt or shoulder strap or carried in
Examples of submaximal fitness tests include a step test a pocket (Fig. 24-2). During ambulatory electrocardiog-
and a walk-a-mile test. Because submaximal tests are less raphy, the client should not shower or swim; a sponge
demanding, the validity of their results is less reliable bath is permitted as long as the monitor does not get wet.
than results obtained through electrocardiogram testing. The client also should avoid magnets, metal detectors,
electric blankets, and high-voltage areas that may cause
Stress Electrocardiogram artifacts on the recordings that interfere with an accu-
A stress electrocardiogram tests electrical conduction through rate interpretation of the test results.
the heart during maximal activity and is performed in The client keeps a diary of the time and type of activ-
an acute care facility or outpatient clinic (Fig. 24-1). The ities performed, when he or she took medications, and
client first walks slowly on a flat treadmill. As the test pro- when he or she experienced symptoms, if any. After the
gresses, the speed and incline of the treadmill increase. test period, the client returns the monitor, then a com-
The examiner notes the client’s heart rate and rhythm, puter and the physician check the electrically recorded
blood pressure, breathing, and symptoms such as dizzi- information. The physician compares the client’s diary
ness and chest pain. A pulse oximeter (see Chap. 21) is with the electrocardiogram. The assessment results help
used to measure peripheral oxygenation. The examiner to determine whether oxygenation to the heart muscle
stops the test if the client develops an abnormal heart was temporarily impaired during an activity or if an
C H A P T E R 24 ● Therapeutic Exercise 545
ECG electrodes
Lead wires
Holter monitor
FIGURE 24-2 • Ambulatory electro-

cardiography.
abnormal heart rhythm developed. Either finding indi- ery compares with the pretest pulse rate. The more sim-
cates that exercise should begin at a very low intensity ilar the pretest and post-test pulse rates, the more fit is
and for a short duration. the person.
The step test must be used with caution. Personnel
Step Test certified in cardiopulmonary resuscitation and use of an
automatic cardiac defibrillator (see Chap. 37) should be
A step test is a submaximal fitness test involving a timed
available to assist if there is an adverse cardiac event.
stepping activity. Several variations include the Harvard
Step Test, the Queens College Step Test, and the Chester
Step Test. A person undergoing this type of fitness analy- Walk-a-Mile Test
sis steps up and down on a platform of a prescribed The walk-a-mile test, devised by the American College of
height (20 inches for men, 16 inches for women) for 3 to Sports Medicine (2005), measures the time it takes a per-
5 minutes at a rate of at least 76 steps per minute. A step son to walk 1 mile. The person is instructed to walk 1 mile
up or down is considered one step. The time is shortened on a flat surface as fast as possible. The examiner calcu-
when the client no longer can sustain the prescribed rate lates the time from start to finish and interprets results
or develops discomfort. The examiner uses a metronome using the guidelines in Table 24-2.
and a stopwatch to keep track of the rate and the time.
Examiners calculate the client’s recovery index (guide
for determining a person’s fitness level) by taking a
TABLE 24-1
CARDIOVASCULAR ENDURANCE
30-second pulse rate 1, 2, and 3 minutes after the test
FITNESS LEVELS
and using the following formula:
SCORE FITNESS CLASSIFICATION
Recovery index =
(100 × test duration in seconds) ≥90 Excellent
2 × total of three 30-second 89–80 Good
pulse assessmeents. 79–65 Average
64–56 Below average
The examiner compares results with standardized fit- ≤55 Poor
ness levels (Table 24-1). A fit person has a smaller
decline in heart rate at each assessment. Another fitness From http://www.mhhe.com/hper/health/personalhealth/labs/cardiovascular/
indicator is how close the pulse rate at the end of recov- lab3-6.html (accessed 8/20/99) © 1998 McGraw-Hill Companies.
EVALUATION CRITERIA FOR

TABLE 24-2 TABLE 24-3 LEVELS OF PHYSICAL ACTIVITY
THE WALK-A-MILE TEST
PERFORMANCE PERFORMANCE FITNESS METABOLIC ENERGY
TIME FOR MEN TIME FOR WOMEN LEVEL EQUIVALENT (MET) EXAMPLES OF ACTIVITIES
≥17.5 minutes ≥16.5 minutes Needs work 1 MET Sewing

≤15 minutes ≤14 minutes Average Watching television
Dressing
≤11.75 minutes ≤10.25 minutes Good
1–2 METs Walking 1 mph on level ground
Bowling
2–3 METs Golfing with a cart
Mowing lawn with a power mower
EXERCISE PRESCRIPTIONS 3–4 METs Playing badminton (doubles)
Raking leaves
The prescription for an exercise program involves deter- 4–5 METs Slow swimming
mining the person’s target heart rate and the metabolic Lifting 50 lbs
energy equivalents (METs) of particular activities based 5–6 METs Square dancing
Shoveling snow
on the person’s fitness level.
6–7 METs Water skiing
Moving heavy furniture
7–8 METs Playing basketball
Target Heart Rate Playing noncompetitive handball
8–9 METs Cross-country skiing
Target heart rate means the goal for heart rate during exer- Playing contact football
cise. It is determined by first calculating the person’s ≥10 METs Running 6 mph or faster
maximum heart rate (highest limit for heart rate during
exercise). Maximum heart rate is calculated by subtract-
ing a person’s age from 220. Thus, a 20-year-old has a max-
imum heart rate of 200 beats per minute (bpm), whereas Fitness Exercise
a 50-year-old has a maximum heart rate of 170 bpm. The
target heart rate is 60% to 90% of the maximum heart Fitness exercise means physical activity performed by
rate (American College of Sports Medicine, 2003). Begin- healthy adults. Fitness exercise develops and maintains
ners should not exceed 60%, intermediates can exercise cardiorespiratory function, muscular strength, and en-
at 70% to 75%, and competitive athletes can tolerate durance (Fig. 24-3). The two categories of fitness exercise
80% to 90% of their maximum heart rate. are isotonic and isometric.
Exercising at the target rate for 15 minutes (excluding Isotonic exercise is activity that involves movement
the warm-up and cool-down periods) three or more times and work. The prime example is aerobic exercise, which
per week strengthens the heart muscle and promotes the involves rhythmically moving all parts of the body at a
use of fat reserves for energy. Exercising beyond the tar- moderate to slow speed without hindering the ability to
get heart rate reduces endurance by increasing fatigue. breathe. In other words, the person can talk comfortably
if the exercise is within his or her level of fitness. To pro-
mote cardiorespiratory conditioning and increase lean
Metabolic Energy Equivalent
Because fitness levels vary, exercises also are prescribed
according to their metabolic energy equivalent (measure of
energy and oxygen consumption during exercise; MET).
This is the prescribed amount that a person’s cardiovas-
cular system can safely support. Low to vigorous physi-
cal activities and their approximate METs are listed in
Table 24-3.
TYPES OF EXERCISE
Exercise is performed to promote fitness or to achieve

therapeutic outcomes. The two major types of exercise
are fitness exercise and therapeutic exercise. FIGURE 24-3 • Stationary cycling.
muscle mass, a person should perform isotonic exercise squeezing a soft ball, finger-climbing the vertical surface
at his or her target heart rate. of a wall, and swinging a rope attached to a doorknob.
Isometric exercise consists of stationary exercises gener- Active therapeutic exercise often is limited to a partic-
ally performed against a resistive force. Examples include ular part of the body that is in a weakened condition. It
body building, weight lifting, and less intense activities is assumed that clients will use their unaffected muscle
such as simply contracting and relaxing muscle groups groups while performing activities of daily living such as
while sitting or standing. Isometric exercises increase bathing and dressing.
muscle mass, strength, and tone and define muscle groups.
Although they improve blood circulation, they do not pro- Passive Exercise
mote cardiorespiratory function. In fact, strenuous iso- is therapeutic activity that the client per-
Passive exercise
metric exercises elevate blood pressure temporarily. See forms with assistance and is provided when a client can-
Client and Family Teaching 24-1. not move one or more parts of the body. For example, for
clients who are comatose or paralyzed from a stroke or
spinal injury, nurses perform exercises that maintain
Therapeutic Exercise muscle tone and flexible joints. One form of frequently
provided passive therapeutic exercise is range-of-motion
Therapeutic exercise is activity performed by people with exercise. Another form is delivered with a continuous
health risks or being treated for an existing health problem. passive motion machine.
Clients perform therapeutic exercise to prevent health-
RANGE-OF-MOTION EXERCISES. Range-of-motion (ROM)
related complications or to restore lost functions (see Per-
are therapeutic activities that move the joints.
exercises
forming Leg Exercises in Chap. 27 and Strengthening They are performed for the following reasons:
Pelvic Floor Muscles in Chap. 30). Therapeutic exercise
may be isotonic or isometric; isotonic exercises are per- • To assess joint flexibility before initiating an exercise
formed actively or passively. program
• To maintain joint mobility and flexibility in inactive
Active Exercise clients
• To prevent ankylosis (permanent loss of joint movement)
Active exerciseis therapeutic activity that the client per- • To stretch joints before performing more strenuous
forms independently after proper instruction. For exam- activities
ple, clients who have undergone a mastectomy learn to • To evaluate the client’s response to a therapeutic exer-
exercise the arm on the surgical side by combing their hair, cise program
A Safe Exercise Program • Wear reflective clothing after dark.

The nurse teaches the client or family as follows: • Walk or jog against traffic; cycle in the same direc-
tion as traffic.
• Seek a pre-exercise fitness evaluation from a
• Eat complex carbohydrates (pasta, rice, cooked
health care provider or a certified sports trainer.
• Determine the target heart rate according to cereal) rather than fasting or eating simple sugars
fitness level. (cookies, chocolate, sweetened drinks) before
• Determine the appropriate level of METs. exercising.
• Choose a form of exercise that seems pleasurable • Avoid drinking alcohol, which dilates the blood ves-
and involves as many muscle groups as possible. sels, promotes heat loss, and interferes with good
• Plan at least 20-minute exercise periods at a con- judgment.
venient time 3 to 5 days each week (American • Warm up for 5 minutes by stretching muscle groups
College of Sports Medicine, 2003). or doing light calisthenics.
• Build up to 30 minutes or more of moderate- • Measure the heart rate two or three times while
intensity physical activity on most (preferably all) exercising.
days of the week (Thompson et al., 2003). • Slow down if the heart rate exceeds the pre-established
• Exercise with a partner for safety and motivation. target.
• Avoid exercising in extreme weather conditions • Try to sustain the target heart rate for at least 12 to
(high humidity, smog). 15 minutes.
• Dress in layers according to the temperature • Never stop exercising abruptly.
and weather conditions. • Cool down for at least 5 minutes in a manner
• Wear supportive shoes. similar to the warmup.
TABLE 24-4 JOINT POSITIONS

POSITION DESCRIPTION
Flexion Bending so as to decrease the angle between two adjoining bones

Extension Straightening so as to increase the angle between two adjoining bones
up to 180 degrees
Hyperextension Increasing the angle between two adjoining bones more than
180 degrees
Abduction Moving away from the midline
Adduction Moving toward the midline
Rotation Turning from side to side as in an arc
External rotation Turning outward, away from the midline of the body
Internal rotation Turning inward, toward the midline of the body
Circumduction Forming a circle
Pronation Turning downward
Supination Turning upward
Plantar flexion Bending toward the sole of the foot
Dorsiflexion Bending the foot toward the dorsum or anterior side
Inversion Turning the sole of the foot toward the midline
Eversion Turning the sole of the foot away from the midline
During ROM exercises, the client moves or is assisted

to move unused joints in the positions that the joint nor-
mally permits (Table 24-4). Whenever possible, the client Performing Range-of-Motion Exercises
actively exercises as many joints as possible while the
❙ Use good body mechanics (see Chap. 23). Doing so conserves
nurse assists with those that are compromised. See Nurs-
energy and avoids muscle strain and injury.
ing Guidelines 24-1.
Nurses perform ROM exercises whenever they care ❙ Remove pillows and other positioning devices. Such items can
for inactive clients (Skill 24-1). interfere with the exercises.
❙ Position the client to facilitate movement of the joint through all its
usual positions. This positioning makes it easier to perform a
Stop • Think + Respond BOX 24-1 comprehensive exercise program.
Why would a nurse promote active ROM exercises in the

❙ Follow a systematic, repetitive pattern—such as beginning at the
upper body for a client who is paralyzed below the waist head and moving down. A routine prevents overlooking a joint.
after a motor vehicle collision? ❙ Perform similar movements with each extremity. Doing so exercises
the joints bilaterally.
❙ Support the joint being exercised. Support reduces discomfort.
CONTINUOUS PASSIVE MOTION MACHINE. A continuous pas- ❙ Move each joint until there is resistance but not pain. This method
sive motion machine is an electrical device used as a supple- exercises each joint to its point of limitation.
ment or substitute for manual ROM exercise (Fig. 24-4). ❙ Watch for nonverbal communication. Nonverbal signs may indicate
Machine-assisted ROM sometimes is preferred during the client’s response.
the rehabilitation of clients who have experienced burns ❙ Avoid exercising a painful joint. Doing so can contribute to injury.
or have had knee or hip replacement surgery because
the machine precisely controls the degree of joint move- ❙ Stop if spasticity develops, as manifested by a sudden, continuous
ment and can increase it in specific increments through- muscle contraction. Taking a break gives muscles time to relax and
recover.
out recovery.
In addition to restoring and increasing joint ROM, the ❙ Apply gentle pressure to the muscle or move the spastic limb more
movement created by the machine prevents the pooling slowly. These actions relieve spasticity.
of venous blood, thus decreasing the risk for blood clots. ❙ Expect the client’s respiratory and heart rates to increase during
Also, it accelerates wound healing because the synovial exercise but to return to a resting rate later. This is a normal
fluid circulates around the joint. cardiopulmonary response to activity.
Most machines produce 0 to 110 degrees of motion ❙ Teach the family to perform ROM exercises. A regular exercise
2 to 10 times per minute. Initially, the nurse sets the program improves the potential for regaining function.
machine at very low speeds and degrees of movement—
joint flexion according to the physician’s exercise pre-

scription (Skill 24-2).

List the assessment findings that indicate a positive response
to the use of a continuous passive motion machine.
FIGURE 24-4 • Continuous passive motion machine.
Few people exercise sufficiently to promote optimal health.

it is common to begin with 5 or 10 degrees of flexion With this in mind, the Department of Health and Human
cycling twice a minute at least six times a day. The nurse Services has established goals and strategies for improving
increases the settings each day as the client’s tolerance the health of U.S. citizens (Table 24-5). Nurses can set an
builds. The nurse positions the client’s extremity in the example for others in the community by improving their
machine and programs the speed and the degree of desired own physical fitness and encouraging others to do so.
TABLE 24-5 HEALTHY PEOPLE 2010, NATIONAL PHYSICAL ACTIVITY AND FITNESS OBJECTIVES*
OBJECTIVE PERCENT IN 2000 TARGET FOR 2010
Reduce the proportion of adults who engage in no leisure-time physical activity. 40% 20%
Increase the proportion of adults who engage regularly (preferably daily) in 15% 30%
moderate physical activity for at least 30 minutes.
Increase the proportion of adults who engage in vigorous physical activity that 23% 30%
promotes the development and maintenance of cardiorespiratory fitness 3 or
more days per week.
Increase the proportion of adults who perform physical activities that enhance 18% 30%
and maintain strength and endurance.
Increase the proportion of adults who perform physical activities that enhance 30% 43%
and maintain flexibility.
Increase the proportion of adolescents who engage in moderate physical activity 27% 35%
for at least 30 minutes on 5 or more days per week.
Increase the proportion of adolescents who engage in vigorous physical activity 65% 85%
that promotes cardiorespiratory fitness for 20 or more minutes 3 or more days
per week.
Increase the proportion of U.S. public and private schools that require daily 17% (middle school) 25%
physical education for all students. 2% (high school) 5%
Increase the proportion of adolescents who participate in daily school physical 29% 50%
education.
Increase the proportion of adolescents who spend at least 50% of school physical 38% 50%
education time being physically active.
Increase the proportion of adolescents who view television 2 or fewer hours on 57% 75%
school days.
Increase the proportion of U.S. public and private schools that provide access to Under development
their physical activity spaces and facilities for all people outside normal school
hours (i.e., before and after the school day, on weekends, and during summer
and other vacations).
Increase the proportion of work sites employing 50 or more people that offer 22% 36%
employee-sponsored physical activity and fitness programs.
Increase the proportion of trips of 1 mile or less made by walking among adults 17% 25%
18 years or older.
Increase the proportion of trips of 5 miles or less by bicycling among adults 0.6% 2%
18 years or older.
*Adapted from United States Department of Health and Human Services. Healthy People 2010. Washington DC, U.S. Public
Health Service. http://www.healthypeople.gov/Document/HTML/Volume2/22Physical.htm (accessed 7/2003).
For people with medical disorders, nurses may iden- avoid depleting fluid volume. Water is the preferred drink for
tify one or more of the following nursing diagnoses that fluid replacement.
Encourage older adults to join organizations and social clubs that
are treated with activity or an exercise regimen:
promote activities for senior citizens such as the American
• Impaired Physical Mobility Association of Retired Persons (AARP) and programs spon-
• Risk for Disuse Syndrome sored by local offices on aging. Socialization through participa-
tion affects both the physical and psychosocial well-being of
• Unilateral Neglect older adults.
• Risk for Delayed Surgical Recovery Encourage families and caregivers of older adults with cognitive
• Activity Intolerance impairment to help their older relatives participate in physical
activities such as walking and ball throwing. If the older per-
Nursing Care Plan 24-1 illustrates how a nurse can son has difficulty with balance, exercises may be done while
incorporate exercise into the care of a client with a stroke sitting or lying. Active ROM exercises should be scheduled
using the nursing diagnosis of Unilateral Neglect. The daily and may be divided into short sessions. If the older adult
NANDA taxonomy (2005) defines this diagnosis as “lack cannot participate actively in an exercise program, the care-
of awareness and attention to one side of the body.” givers can perform passive ROM exercises, at least daily, to
prevent muscle atrophy and disuse syndrome.
Many shopping malls permit, and even encourage, people to
walk through the mall before stores open for business.
GENERAL GERONTOLOGIC Swimming or exercising in water puts less stress on joints and is
CONSIDERATIONS beneficial for older adults.
Many physically challenging sports, such as bowling, golfing,
Older adults, especially those who are disabled, need to balance walking in marathons, and weight lifting, have competition
periods of physical activity with periods of rest. Shortness of categories for older adults.
breath or increased heart rate indicates that the level of activ- Precautions, such as wearing safe shoes with nonskid soles, are
ity is beyond the client’s tolerance. necessary to prevent falls when older adults exercise. Compli-
Older adults need to eliminate their intake of caffeinated and cations from falls contribute to morbidity and mortality among
alcoholic beverages before and during physical activity to older people.
Unilateral Neglect
ASSESSMENT
• Observe the client’s bilateral movement or unilateral lack of movement.
• Note if the client uses both sides of the body in an integrated and coordinated manner.
• Determine if the client omits, ignores, or favors activities or objects consistently on one side.
• Check the client’s vision and sensation bilaterally.
Nursing Diagnosis: Unilateral Neglect related to lack of awareness of objects in L. visual

field secondary to stroke as manifested by lack of attention to food on left side of plate and
tray, inability to see objects placed on left side, combing only right side of hair, no response
to touch or pain stimuli on left side, and inability to differentiate between warm or cold on
the left.
Expected Outcome: The client will identify own body parts on the left side, attend to their
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
unaffected side.
Place items for safety, such as the signal cord, and those for The neurologic deficit predisposes the client to ignore
self-care, such as a glass of water, on the client’s right side. objects on the affected side.
(continued)
Unilateral Neglect
Suggest that the client turn the head from side to side for a Directing the client to scan the environment uses the
panoramic view of the environment visual 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
field each shift; then relocate objects to the left side and develop awareness skills.
encourage the client to turn the head and identify where
they are located.
Have the client locate and touch the left arm and other Attending to the affected side helps to retrain the client’s
body structures on the left side. brain to recognize and integrate parts of the self.
Add one self-care task at a time such as bathing the Practice and repetition facilitate progress in reaching
affected arm, inserting the arm into a gown or shirt, and goals.
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 right side of the client to facilitate awareness.
• The client locates and identifies one of three objects such as pen, watch, and banana after looking at them in the right
visual field and then in the left.
• The client states “That’s my arm and leg” when instructed to look to the left side of his or her body.
• The client touches and moves the affected left arm with the right arm.
• The client performs range-of-motion exercises with assistance from the nurse for affected extremities.
• The client continues to practice bathing and exercise.
3. The nursing explanation that best describes the primary

purpose of a continuous passive motion machine is that
1. List at least five excuses people give for not exercising it is used to
and offer counterarguments for each. 1. Strengthen leg muscles
2. A client with paralysis of the lower extremities is depressed 2. Relieve foot swelling
and questions the purpose for performing passive ROM 3. Reduce surgical pain
exercises on the lower body. Assuming paralysis is per- 4. Restore joint function
manent and the client will never walk again, how would 4. When documenting the client’s progress while using a
you respond? continuous passive motion machine, it is essential that
the charting indicate the degree of joint flexion, the num-
ber of cycles per minute, and the
1. Condition of the sutures around the incision
1. If a client performs isometric exercises of the quadriceps 2. Time the client used the machine
muscles correctly, the nurse will observe the client 3. Characteristics of drainage from the wound
1. Move the toes toward and away from the head. 4. Presence and quality of arterial pulses
2. Contract and relax the muscles of the thigh. 5. When a client asks of what use a stress electrocardio-
3. Lift the lower leg up and down from the bed. gram (ECG) will be, the most accurate answer the nurse
4. Bend the knee and pull the lower leg upward. can give is that it
2. When the nursing team develops a plan of care for a 1. Shows how the client’s heart performs during
client with a stroke, which area of nursing management exercise
is most important to the client’s rehabilitation? 2. Determines the client’s potential target heart rate
1. Regulating bowel and bladder elimination 3. Verifies how much the client needs to improve
2. Dealing with problems of disturbed body image fitness
3. Preventing contractures and joint deformities 4. Can predict if the client will have a heart attack
4. Facilitating positive outcomes from grieving soon
Skill 24-1 • PERFORMING RANGE-OF-MOTION (ROM) EXERCISES
Assessment
Review the medical record and nursing plan for care. Determines whether activity problems have been
identified and measures for treating any
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 Determines the type and amount of health teaching
inactivity and purposes for exercise. needed
Planning
Explain the procedure for performing ROM. Reduces anxiety and promotes cooperation
Consult with the client on when ROM exercises may be Shows respect for independent decision making
best performed.
Suggest performing ROM 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 Increases exercise benefits
exercise period.
Implementation
Wash your hands or perform an alcohol-based handrub Reduces the potential for transferring microorganisms
(see 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 Avoids exposing the client
or shorts.
Begin at the head. Facilitates organization
Support the client’s neck and bring the chin toward the Flexes and hyperextends the neck (Fig. A)
chest and then as far back in the opposite position as
possible.
Neck hyperextension. Neck flexion.
(continued)
PERFORMING RANGE-OF-MOTION (ROM) EXERCISES (Continued)
Place a hand on either side of the head and move the neck Rotates the neck (Fig. B)
from side to side.
Neck rotation.
Turn the head in a circular fashion. Puts the head and neck through circumduction (Fig. C)
Support the elbow and wrist while moving the Flexes, extends, then hyperextends the shoulder (Fig. D)
straightened arm above the head and behind the body.
C D
Circumduction of the neck. Flexion and extension of the shoulder.
(continued)
Move the straightened arm away from the body and then Abducts and adducts the shoulder (Fig. E)
toward the midline.
Abduction and adduction of the shoulder.
Bend the elbow and move the arm so that the palm is Produces internal and external rotation of the shoulder
upward and then downward. (Fig. F)
Internal and external rotation of the shoulder.
Move the arm in a full circle. Circumducts the shoulder (Fig. G)
Circumduction of the shoulder.
(continued)
Place the arm at the client’s side and bend the forearm Flexes and extends the elbow (Fig. H)
toward the shoulder, and then straighten it again.
Flexion and extension of the elbow.
Bend the wrist forward and then backward. Moves the wrist from flexion to extension and then
hyperextension (Fig. I)
Twist the wrist to the right and then left. Rotates the wrist joint (Fig. J)
I
J
Flexion and extension of the wrist.
Rotation of the wrist.
(continued)
Bend the thumb side of the hand way from the wrist and Provides adduction and then abduction of the wrist
then in the opposite direction. (Fig. K)
Abduction and adduction of the wrist.
Turn the palm downward and then upward. Pronates and supinates the wrist (Fig. L)
Pronation and supination of the wrist.
(continued)
Open and close the fingers as though making a fist. Extends and flexes fingers (Fig. M)
Flexion and extension of the fingers.
Bend the thumb toward the center of the palm and then Flexes and extends the thumb (Fig. N)
back to its original position.
Spread the fingers and thumb as widely as possible and Abducts and adducts the fingers and thumb (Fig. O)
then bring them back together again.
N O
Flexion and extension of the thumb. Abduction and adduction of the fingers and thumb.
Bring the straightened leg forward of and backward from Flexes, extends, and hyperextends the hip (Fig. P)
the body.
Flexion and extension of the hip.
(continued)
Move the straightened leg away from the body and back Abducts and then adducts the hip (Fig. Q)
beyond 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.
Turn the leg in a circle. Circumducts the hip (Fig. S)
Circumduction of the hip.
(continued)
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 Causes dorsiflexion and plantar flexion (Fig. U)
ankle.
Dorsiflexion and plantar flexion of the foot.
Bend the sole of the foot toward the midline and then Inverts and everts the ankle (Fig. V)
away from midline.
Inversion and eversion of the ankle.
V
(continued)
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 R. side of body. Joints
on L. side passively exercised through full ranges. No resistance or pain experienced.
SIGNATURE/TITLE
Skill 24-2 • USING A CONTINUOUS PASSIVE MOTION (CPM) MACHINE
Assessment
Review the medical record and nursing care plan for the Determines the exercise prescription for the client
amount 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
especially if this is the first time it is being used. provide
Assess the quality of peripheral pulses, capillary refill, Provides a baseline of data for future comparisons
edema, temperature, sensation, and mobility of the
affected extremity.
(continued)
USING A CONTINUOUS PASSIVE MOTION (CPM) MACHINE (Continued)
Compare assessment findings with the unaffected Provides comparative data
extremity.
Determine the client’s need for pain-relieving medication Controls pain before it intensifies with exercise
before use of the CPM machine.
Planning
Develop a schedule with the client for using the machine Involves the client in decision making
as appropriate.
Instruct the client on techniques for muscle relaxation and Empowers the client with techniques for controlling pain
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 Prepares the machine for supporting the leg
or soft flannel cloth to the horizontal bars to form a
cradle (sling) for the calf.
Wash hands or perform an alcohol-based handrub (see Reduces the transmission of microorganisms
Chap. 10).
Don gloves and empty any wound drainage containers; Prevents leakage during exercise, when drainage is likely
change or reinforce the dressing (see Chap. 28). to increase
Implementation
Explain the purpose, application, and use of the CPM Reduces anxiety and promotes cooperation
machine.
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 Prepares the client for exercise
foot 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 Positions the knee correctly
knob and goniometer, a device for measuring ROM.
Use Velcro or canvas straps to secure the leg within the Supports and stabilizes leg
fabric cradle of the machine.
Adjust the machine to a lower-than-prescribed rate and Provides gradual progression to prescribed parameters
degree of flexion.
Turn on the machine and observe the client’s response. Indicates level of tolerance
(continued)
USING A CONTINUOUS PASSIVE MOTION (CPM) MACHINE (Continued)
Readjust the alignment of the leg or position of the Demonstrates concern for the client’s well-being
machine for optimal comfort.
Increase the degree of flexion and cycles per minute Facilitates adaptation
gradually until the prescribed levels are reached.
Turn off the machine with the leg in an extended position Facilitates lifting the leg from the machine
at the end of the prescribed period of exercise.
Release the straps and support the joints beneath the knee Reduces discomfort
and ankle while lifting the leg.
Remove the machine from the bed; encourage active Potentiates effects from CPM
range-of-motion exercises and isometric exercises.
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 sec. Pedal pulses
present and strong bilaterally. CPM machine used for 15 minutes with ROM at 30° of 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
25
Chapter
Mechanical
Immobilization
LEARNING OBJECTIVES
● List at least three purposes of mechanical immobilization.
● Name four types of splints.
● Discuss why slings and braces are used.
● Explain the purpose of a cast.
● Name three types of casts.
● Describe at least five nursing actions that are appropriate when caring for clients with casts.
● Discuss how casts are removed.
● Explain what traction implies.
● List three types of traction.
● Name seven principles that apply to maintaining effective traction.
● Describe the purpose for an external fixator.
● Identify the rationale for performing pin site care.
SOME clients are inactive and physically immobile as a result of an overall debilitat-
ing condition. For others, mobility impairment results from trauma or its treatment.
Such is the case for clients with orthoses, which are orthopedic devices that support
or align a body part and prevent or correct deformities. Examples of orthoses include
WORDS TO KNOW splints, immobilizers, and braces. Other clients have limited mobility when use of
bivalved cast slings, casts, traction, and external fixators is necessary. Caring for clients who are
body cast mechanically immobilized with orthopedic devices requires specialized nursing skills
braces described in this chapter.
cast
cervical collar
cylinder cast
external fixator PURPOSES OF MECHANICAL IMMOBILIZATION
functional braces
immobilizers
inflatable splints Most clients who require mechanical immobilization have suffered trauma to the
manual traction
molded splints
musculoskeletal system. Such injuries are painful and heal less rapidly than injuries
orthoses to the skin or soft tissue. They require a period of inactivity to allow new cells to
pin site restore integrity to the damaged structures.
prophylactic braces Mechanical immobilization of a body part accomplishes the following:
rehabilitative braces
skeletal traction • Relieves pain and muscle spasm
skin traction • Supports and aligns skeletal injuries
sling • Restricts movement while injuries heal
spica cast
splint
• Maintains a functional position until healing is complete
traction • Allows activity while restricting movement of an injured area
traction splints • Prevents further structural damage and deformity
563
MECHANICAL IMMOBILIZING DEVICES NURSING GUIDELINES 25-1

Applying an Emergency Splint
Use of various immobilizing devices can achieve therapeu-
❙ Avoid changing the position of the injured part even if it appears
tic benefits. Examples of such devices include splints,
grossly deformed. Keeping the part in place prevents additional
slings, braces, casts, and traction. injuries.
❙ Leave a high-top shoe or a ski boot in place if the injury involves an
Splints ankle. The shoe or boot limits movement and reduces pain and
swelling.
Some conditions are treated with a splint, which is a device ❙ Cover any open wounds with clean material. Such a covering
that immobilizes and protects an injured body part. Splints absorbs blood and prevents dirt and additional pathogens from
are used before or instead of casts or traction. entering.
❙ Select a rigid splinting material such as a flat board, broom handle,
Emergency Splints or rolled-up newspaper. Rigid material provides support while
restricting movement.
Splints often are applied as a first-aid measure for sus-
pected sprains or fractures (Fig. 25-1). See Nursing Guide- ❙ Pad bony prominences with soft material. Padding cushions
lines 25-1. pressure and prevents friction on the skin.
❙ Apply the splinting device so that it spans the injured area from the
Commercial Splints joint above to the joint below the injury. Such placement
immobilizes the injured tissue.
Commercial splints are more effective than improvised
splints. They are available in various designs depending on ❙ Use an uninjured area of the body adjacent to the injured part as a
the injury. Examples include inflatable splints, traction splint, if no other sturdy material is available. The uninjured part
can serve as a substitute for an external splint.
splints, immobilizers, molded splints, and cervical collars.
Inflatable and traction splints are intended for short-term ❙ Use wide tape or wide strips of fabric to confine the injured part to
use: they usually are applied just after the injury and are the splint. Securing the body part prevents displacement and
removed shortly after more thorough assessment of the reduces the risk for compromising circulation.
injury. Immobilizers and molded splints are used for longer ❙ Loosen the splint or the material used to attach it if the fingers or
periods. toes are pale, blue, or cold. Loosening the splint facilitates
circulation.
INFLATABLE SPLINTS. Inflatable splints, also called pneu- ❙ Elevate the immobilized part, if possible, so the lowest point is
matic splints, are immobilizing devices that become rigid higher than the heart. Elevation reduces swelling and enhances
when filled with air (Fig. 25-2). In addition to limiting venous return to the heart.
motion, they control bleeding and swelling. The injured ❙ Keep the client warm and safe. Shock is a risk.
body part is inserted into the deflated splint. When air is ❙ Seek assistance in transporting the client to a health care agency.
infused, the splint molds to the contour of the injured The client requires more sophisticated treatment.
part, preventing movement. The splint is filled with air
to the point at which it can be indented 1⁄2 inch (1.3 cm)
with the fingertips. The injury should be examined and
treated within 30 to 45 minutes after application of the as easy to apply as inflatable splints. One example is a
splint; otherwise, circulation may be affected. Thomas splint, which requires special training for its appli-
cation to prevent additional injuries (Fig. 25-3).
TRACTION SPLINTS. Traction splints are metal devices that
immobilize and pull on contracted muscles. They are not IMMOBILIZERS. Immobilizers are commercial splints made
from cloth and foam and held in place by adjustable Velcro
straps (Fig. 25-4). As the name implies, immobilizers limit
FIGURE 25-1 • Emergency first aid splinting immobilizes the injured

leg to the uninjured leg with a make-shift splint, such as a board, broom
handle, or golf club. Neckties, belts, or scarves keep the splint in place. FIGURE 25-2 • An inflatable splint.
C H A P T E R 25 ● Mechanical Immobilization 565
FIGURE 25-5 • Molded splint.
injuries and other trauma that results in a neck sprain or

strain (Fig. 25-6). Neck strain sometimes is referred to as
FIGURE 25-3 • (A) Thomas splint. (B) Thomas splint applied to the whiplash or a whiplash injury. The incidence of whiplash
lower extremity. injuries has decreased primarily for two reasons: improved
athletic protective equipment and use of shoulder har-
nesses and neck supports in automobiles.
motion in the area of a painful but healing injury such as
the neck and knee. They are removed for brief periods
during hygiene and dressing.
MOLDED SPLINTS. Molded splints are orthotic devices made

of rigid materials and used for chronic injuries or dis-
eases. They may be appropriate for clients with repetitive
motion disorders such as carpal tunnel syndrome. They
provide prolonged support and limit movement to pre- A
vent further injury and pain. (Fig. 25-5). They maintain
the body part in a functional position to prevent contrac-
tures and muscle atrophy during immobility.
CERVICAL COLLARS. A cervical collar is a foam or rigid splint

placed around the neck. It is used to treat athletic neck
FIGURE 25-4 • Leg immobilizer. FIGURE 25-6 • (A) Foam cervical collar. ( B) Rigid cervical collar.
When the neck injury—which is generally more pain- vical spine and peripheral nerve roots. If neuromuscular
ful the day after trauma—is mild or moderate, a foam col- function is intact, the client can do the following:
lar, covered with stockinette (a stretchable cotton fabric),
• Elevate both shoulders
is used. When the client wears it, it reminds him or her
• Flex and extend the elbows and wrists
to limit neck and head movements. For more serious
• Generate a strong hand grip
injuries, a rigid splint made from polyurethane is used to
• Spread the fingers
control neck motion and support the head, reducing its
• Touch the thumb to the little finger on each hand
load-bearing force on the cervical spine.
To determine proper collar size, the nurse measures the The nurse documents and communicates to the physi-
neck circumference and the distance between shoulder cian any difference in strength or movement on one side
and chin (Fig. 25-7). He or she compares measurements or the other.
with the size guide suggested by the collar manufacturer.
For example, a person with a neck size of 15 to 20 inches
and a shoulder-to-chin height of 3 inches probably would Slings
require a regular adult size. Adult sizes also come in short,
tall, and extra-tall. Pediatric collars also are available. A sling is a cloth device used to elevate, cradle, and support
When applying a cervical collar, the head is placed in parts of the body. Slings are applied commonly to the arm
neutral position (see Chap. 23). The front of the collar is (Fig. 25-8), leg, or pelvis after immobilization and exami-
positioned well beneath the chin and slid upward until the nation of the injury. Many ambulatory clients use the
chin is well supported. The opening of the collar is cen- commercial type of arm sling; a triangular piece of muslin
tered at the back of the neck. Straps made of Velcro or cloth occasionally may be used to fashion a sling. To be
other materials are used to secure the collar in the desired effective, slings require proper application (Skill 25-1).
position. When applied appropriately, the client can
breathe and swallow effortlessly while wearing the collar.
Clients wear cervical collars almost continuously, even Stop • Think + Respond BOX 25-1
while sleeping, for 10 days to 2 weeks. They remove them List the advantages and disadvantages of using a com-
to do gentle range-of-motion neck exercises (see Chap. 24). mercially made canvas sling and a triangular cloth sling.
The sooner a client performs exercise (within his or her
pain tolerance), the faster revascularization and recovery
occur. Prolonged dependence on the collar for comfort can Braces
lead to permanent stiffness in the neck. Braces are custom-made or custom-fitted devices designed
During recovery, the nurse assesses the client’s neuro- to support weakened structures. The three categories of
muscular status by having the client perform movements braces are (1) prophylactic braces (those used to prevent
that correlate with muscular functions controlled by cer- or reduce the severity of a joint injury), (2) rehabilitative
Neck
circumference
Chin to shoulder
FIGURE 25-7 • Vertical and circumferential measurements for cervi-

cal collar size. FIGURE 25-8 • A sling used for arm suspension. (Copyright B. Proud.)
The purpose of the cast is to immobilize the injured

structure. Casts usually are applied to fractured (bro-
ken) bones. They are formed using either wetted rolls
of plaster of Paris or premoistened rolls of fiberglass
(Table 25-1).
Types of Casts
There are basically three types of casts: cylinder, body,
and spica. Cylinder and body casts may be bivalved.
CYLINDER CAST. A cylinder cast encircles an arm or leg and

leaves the toes or fingers exposed. The cast extends from
the joints above and below the affected bone. This pre-
vents movement, thereby maintaining correct alignment
during healing. As healing progresses, the cast may be
trimmed or shortened.
FIGURE 25-9 • A rehabilitative brace that ensures appropriate control

BODY CAST. A body cast is a larger form of a cylinder cast
of knee motion following an operative procedure.
and encircles the trunk of the body instead of an extrem-
ity. It generally extends from the nipple line to the hips.
For some clients with spinal problems, the body cast ex-
braces (those that allow protected motion of an injured
tends from the back of the head and chin areas to the
joint that has been treated operatively; Fig. 25-9), and
(3) functional braces (those that provide stability for an hips, with modifications for exposing the arms.
unstable joint).
Because clients generally wear braces during active BIVALVED CAST. The physician may create a bivalved cast
periods, braces are made of sturdy materials such as metal (one that is cut in two pieces lengthwise) from either a
and leather. Leg braces may be incorporated into a shoe. body or cylinder cast. Creating a front and a back for a
Some back braces are made of cloth with metal staves, or body cast facilitates bathing and skin care. If the physician
strips, sewn within the fabric of the brace. An improperly approves, the anterior half of the shell is removed tem-
applied or ill-fitting brace can cause discomfort, deformity, porarily for hygiene; the client lies prone in the anterior
and skin ulcerations from friction or prolonged pressure. shell during removal of the posterior half. A bivalved cast
on an extremity (Fig. 25-10) is created when
Casts • Swelling compresses tissue and interferes with

circulation.
A cast is a rigid mold placed around an injured body part • The client is being weaned from the cast.
after it has been restored to correct anatomic alignment. • A sharp x-ray is needed.
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
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
Dries in 5–15 minutes by excessive swelling
Allows immediate weight bearing Macerates skin if padding becomes wet
Durable Cast edges may be sharp and cause skin abrasions
Unaffected by water
FIGURE 25-10 • (A) A bivalved cast. (B) The two halves are rejoined. FIGURE 25-11 • Hip spica cast. (Timby, B. K., Smith, N. [2007].
Introductory medical-surgical nursing [9th ed., p. 1191]. Philadelphia:
Lippincott Williams & Wilkins.)
• Painful joints need to be immobilized temporarily in a

client with arthritis. the cast is referred to as a shoulder spica; one applied to
the lower extremities is called a hip spica (Fig. 25-11).
SPICA CAST. A spica cast encircles one or both arms or legs Spica casts, especially those on the lower extremities, are
and the chest or trunk. It generally is strengthened with heavy, hot, and frustrating because they severely restrict
a reinforcement bar. When applied to the upper body, movement and activity.

Basic Cast Care
❙ Leave a freshly applied cast uncovered until it is dry. Doing so facilitates ❙ Apply ice packs to the cast at the level of injury or where surgery has
assessment and drying. been performed (Fig. 25-16). Ice packs reduce swelling and help to
❙ Assess circulation frequently in exposed fingers or toes (Fig. 25-12). control bleeding.
The condition of the fingers or toes provides comparative data for ❙ Avoid getting the cast wet. If the cast becomes wet, dry it using a blow
identifying neurovascular complications. dryer set on a cool setting. Dampness under the cast can lead to skin
❙ Monitor the mobility of the fingers (Fig. 25-13) or toes. Mobility status breakdown. A cool setting reduces the risk for burn injury.
provides data about neuromuscular function. ❙ Caution clients not to insert objects (e.g., straws, combs, utensils) within the
❙ Assess sensation frequently in exposed fingers or toes (Fig. 25-14). cast. Such objects could impair the skin if they fell inside the cast.
Sensation indicates intact neurologic function. ❙ Advise clients not to write or draw on a fiberglass cast. Fiberglass casts
❙ Elevate the cast on pillows or another support. Elevation helps to reduce are porous.
swelling and pain. ❙ Circle areas where blood has seeped through the cast; note the time on the
❙ Swab fiberglass resin from the skin with alcohol or acetone. Alcohol cast. Such actions help in evaluating the significance of blood loss.
and acetone are chemical solvents. ❙ Report significant abnormal findings promptly, especially pain that
❙ Encourage the client to exercise fingers or toes frequently. Exercise helps progressively worsens. Prompt reporting ensures that complications
to decrease swelling, prevent stiffness, and increase circulation. are treated early.
❙ Ensure that the edges of the cast are padded. Inspect the skin around ❙ Ambulate clients as soon as possible or have them exercise in bed.
the edges of the cast frequently (Fig. 25-15). Such padding reduces the Movement prevents complications from immobility.
risk for skin irritation and breakdown.
FIGURE 25-12 • Assessing capillary refill. (Copyright B. Proud.) FIGURE 25-14 • Assessing sensation in exposed fingers. (Copyright
B. Proud.)
When applied to a lower extremity, the cast is trimmed

in the anal and genital areas to allow elimination of urine
and stool. Clients with a hip spica cannot sit during elim- Stop • Think + Respond BOX 25-2
ination, so the nurse protects the cast from soiling using Discuss discharge teaching for a client who has had a
plastic wrap and positions the client on a small bedpan cast applied.
known as a fracture pan (see Chap 30).
Cast Application
Cast application generally requires more than one per- Cast Removal
son. The nurse prepares the client, assembles the cast In most cases, casts are removed when they need to be
supplies, and helps the physician during cast application changed and reapplied or when the injury has healed suf-
(Skill 25-2). A light-cured fiberglass cast requires expo- ficiently that the cast is no longer necessary. A cast is
sure to ultraviolet light to harden. removed prematurely if complications develop.
Most casts are removed with an electric cast cutter, an
Basic Cast Care instrument that looks like a circular saw (Fig. 25-17).
Some clients need extended care after surgery that has The cast cutter is noisy and may frighten clients. There
included application of a cast. The nurse is responsible for is a natural expectation that an instrument sharp enough
caring for the cast and making appropriate assessments to to cut a cast is sharp enough to cut skin and tissue.
prevent complications. See Nursing Guidelines 25-2. Proper use of an electric cast cutter, however, leaves the
skin intact.
When the cast is removed, the unexercised muscle is
usually smaller and weaker. The joints may have a limited
FIGURE 25-15 • Soft edges of cast minimize risk for skin irritation.
FIGURE 25-13 • Checking mobility. (Copyright B. Proud.) (Copyright B. Proud.)
Traction
Traction is a pulling effect exerted on a part of the skele-
tal system. It is a treatment measure for musculoskeletal
trauma and disorders. Traction is used to accomplish the
following:
• Reduce muscle spasms
• Realign bones
• Relieve pain
• Prevent deformities
The pull of the traction generally is offset by the coun-
terpull from the client’s own body weight. Except for trac-
FIGURE 25-16 • Applying ice pack to minimize pain. (Copyright tion exerted with the hands, application of traction
B. Proud.) involves the use of weights connected to the client through
a system of ropes, pulleys, slings, and other equipment.
range of motion. The skin usually appears pale and waxy Types of Traction
and may contain scales or patches of dead skin. The skin The three basic types of traction are manual, skin, and
is washed as usual with soapy warm water, but the semi- skeletal. The categories reflect the manner in which trac-
attached areas of skin are left in place; they are not tion is applied.
forcibly removed. Applying lotion to the skin adds mois-
ture and tends to prevent the rough skin edges from MANUAL TRACTION. Manual traction means pulling on the
catching on clothing. Eventually the dead skin fragments body using a person’s hands and muscular strength (Fig.
will slough free. 25-18). It most often is used briefly to realign a broken
A B
FIGURE 25-17 • Cast removal. (A) The cast is bivalved with an electric cast cutter. (B) The cast is split.
(C) The padding is manually cut.
bone. It also is used to replace a dislocated bone into its

original position within a joint.
SKIN TRACTION. Skin traction means a pulling effect on the

skeletal system by applying devices, such as a pelvic belt
and a cervical halter, to the skin (Fig. 25-19). Other names
for commonly applied forms of skin traction are Buck’s
traction and Russell’s traction (Fig. 25-20).
SKELETAL TRACTION. Skeletal traction means pull exerted

directly on the skeletal system by attaching wires, pins, or
tongs into or through a bone (Fig. 25-21). Skeletal traction
FIGURE 25-18 • Manual traction. is applied continuously for an extended period.
A B
FIGURE 25-19 • (A) Pelvic belt. (B) Cervical halter.
A B
FIGURE 25-20 • (A) Buck’s traction. (B) Russell’s traction.

A B FIGURE 25-21 • The application of skele-

tal traction. (A) A pin transects the bone.
(B) Traction is applied.
Traction Care
Regardless of the type of traction used, its effectiveness
depends on the application of certain principles during
Clients with immobilizing devices such as casts and
the client’s care (Box 25-1). See Nursing Guidelines 25-3.
traction may have one or more of the following nursing
diagnoses:
External Fixators • Acute Pain
• Impaired Physical Mobility
An external fixator is a metal device inserted into and • Risk for Disuse Syndrome
through one or more broken bones to stabilize fragments • Risk for Peripheral Neurovascular Dysfunction
during healing (Fig. 25-22). Although the external fixator • Impaired Bed Mobility
immobilizes the area of injury, the client is encouraged to • Risk for Impaired Skin Integrity
be active and mobile (see Chap. 26 for information about • Risk for Ineffective Tissue Perfusion
ambulatory aids). • Self-Care Deficit: Bathing/Hygiene
During recovery, the nurse provides care for the pin site
(location where pins, wires, or tongs enter or exit the Nursing Care Plan 25-1 describes the nursing process as
skin). In conjunction with an external fixator and skele- it applies to a client with a nursing diagnosis of Risk for
tal traction, pin site care is essential to prevent infection. Peripheral Neurovascular Dysfunction, defined in the
Insertion of pins impairs skin integrity and provides a port NANDA taxonomy (2005, p. 140) as a state in which a
of entry for pathogens. Caring for a pin site is described in client is “at risk for disruption in circulation, sensation,
Skill 25-3. or motion of an extremity.”
Stop • Think + Respond BOX 25-3 GENERAL GERONTOLOGIC

A culture from a specimen taken at a pin site reveals that CONSIDERATIONS
the pin site is infected with Staphylococcus aureus. Hip fractures are common in older adults, especially post-
What nursing actions are required for contact precautions menopausal women not treated for osteoporosis. The fracture
to control transmission of the pathogen? (Use informa- may result from weakness of the bone and lead to a fall. Or a
tion in Chap. 22 as a resource or to review.) fall may cause the fracture of a weakened bone.
With aging, bones become brittle and weak, resulting in longer
healing time for fractures. Joints become stiffer because of
decreased synovial fluid.
Encourage older adults who have poor appetites or inadequate
BOX 25-1 ● Principles for Maintaining oral intake to drink liquid supplements that are high in nutri-
Effective Traction ents several times a day. Registered dietitians often are helpful
in planning adequate nutritional intake.
❙ Traction must produce a pulling effect on the body. To promote healing of a musculoskeletal injury, encourage older
❙ Countertraction (counterpull) must be maintained. adults to consume a diet rich in protein, calcium, and zinc. Teach
❙ The pull of traction and the counterpull must be in exactly opposite clients who are lactose intolerant to use milk or calcium substi-
directions. tutes. Vitamin D may be included in the calcium preparation.
❙ Splints and slings must be suspended without interference. Encourage sun exposure (10 to 30 minutes/day) for vitamin D
❙ Ropes must move freely through each pulley. absorption and weight-bearing exercises daily if the older
❙ The prescribed amount of weight must be applied. person can tolerate these activities.
❙ The weights must hang free. Although musculoskeletal injuries are quite painful, caution is nec-
essary when administering narcotic analgesics to older adults.

Caring for Clients in Traction
❙ Inspect the mechanical equipment used to apply traction. Inspection
determines the status of the equipment.
❙ Provide a trapeze and an overbed frame if not present. They
facilitate mobility and self-care.
❙ Position the client so that the body is in an opposite line with the
pull of traction. This is one of the principles for maintaining
effective traction.
❙ Avoid tucking top sheets, blankets, or bedspreads beneath the
mattress. Bed clothes tucked under the mattress will interfere with
the pull produced by traction equipment.
❙ Keep the traction applied continuously unless there are medical
orders to the contrary. Continuous traction fosters achievement
of desired outcomes.
❙ Keep the weights from resting on the floor. Keeping the weights
above the floor maintains effective traction.
❙ Ask the physician to replace fraying ropes or those with knots that
interfere with movement through pulleys. Intact equipment
maintains effective traction.
❙ Limit the client’s positions to those indicated in the medical orders
or standards for care. Positions that alter the pull and counterpull
of traction interfere with therapy.
❙ Bathe the backs of clients who must remain in a supine or other
back-lying position by depressing the mattress enough to insert
a hand. This action facilitates skin care and hygiene.
❙ Make the bed by applying sheets from the bottom toward the top,
rather than side to side. Making the bed in this way maintains the
client in alignment with the traction.
❙ Use a pressure-relieving device (see Chaps. 23 and 28) and FIGURE 25-22 • An external fixator. Metal rods exert traction between
conscientious skin care if the client is confined to bed for a two sets of skeletal pins.
prolonged time. Proper care prevents skin breakdown.
❙ Do not use a pillow if the client’s head or neck is in traction unless
Although these medications are effective in relieving pain,
medical orders indicate otherwise. Using a pillow could disturb the
older adults are more susceptible to developing adverse
pull and counterpull. effects such as constipation, mental changes, and depressed
❙ Use a small bedpan, called a fracture pan, if elevating the hips alters respirations. If narcotic analgesics are necessary, a lower dose
the line of pull. Keeping the hips in the proper position maintains may be effective, or the time between doses may be length-
the effectiveness of traction. ened if the absorption or metabolism of the drug is prolonged.
Because of diminished tactile sensation, older people may be
❙ Encourage isometric, isotonic, and active range-of-motion exercises. unaware of skin pressure from a splint, cast, traction, or other
Exercise maintains the tone, strength, and flexibility of the mechanical device. Check the skin of an older person daily for
musculoskeletal system. redness or other signs of pressure (reddened area does not
resolve in 30 minutes of pressure relief). If the older person
❙ Cleanse the skin around skeletal insertion sites using soap and cannot change positions, the caregiver is responsible for
water or an antimicrobial agent. Cleansing reduces the risk ensuring that pressure is relieved from any body area at least
for infection. every 2 hours.
❙ Cover the tips of protruding metal pins or other sharp traction When an indwelling catheter is used at the time of orthopedic
devices with corks or other protective material. Covering these items surgery, the catheter should be removed as soon as possible
after the surgery. Older people are likely to develop inconti-
prevents accidental injury.
nence or urinary tract infections when indwelling catheters are
❙ Insert padding within slings if they tend to wrinkle. Padding helps used, especially for long periods. Interventions (such as blad-
to cushion and distribute pressure, prevents interference with der training schedules) should be initiated to help the older
circulation, and reduces the risk for skin breakdown. person maintain or regain continence. Appropriate technique
for rolling a person with a fracture must be used when placing
❙ Provide diversional activities as often as possible. Activities relieve a fracture-style bedpan.
boredom and sensory deprivation. Some fractures, particularly of the upper extremities, are treated
nonsurgically with immobilization. Occupational and physical
Risk for Peripheral Neurovascular Dysfunction
ASSESSMENT
• Monitor peripheral circulation:
• Check for the presence and quality of peripheral pulses in affected and unaffected extremities.
• Feel the temperature of exposed toes or fingers and compare findings with the opposite extremity.
• Compress the nailbeds and determine the time for the color to return following blanching.
• Observe for swelling in the affected extremity in comparison to the unaffected extremity.
• Look at the skin color and compare differences in the extremities.
• Assess the client’s neurologic status in both extremities:
• Ask the client to move the toes or fingers in the extremities.
• Touch the client’s extremities with objects that are sharp, dull, warm, or cold to determine if the client can
differentiate the stimuli without actually seeing the source of stimulation.
• Quantify the client’s level of pain, its location, characteristics, and whether it decreases or increases with usual
pain-relieving measures.
Nursing Diagnosis: Risk for Peripheral Neurovascular Dysfunction related to tissue

swelling and compression of blood vessels 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).
Elevate the casted left leg so that toes are higher than the Use of gravity facilitates venous return of blood from
client’s heart. distal areas to the heart.
Have client exercise toes of left foot in cast every Contraction of skeletal muscles compresses capillaries and
15 minutes 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 Lack of improvement or escalation of signs suggesting
pain, and mobility of toes in affected extremity every neurovascular impairment indicate a medical emergency.
30 minutes.
Report worsening of symptoms to the charge nurse and Failure to report and implement additional interventions
physician immediately. can 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 and regular in unaffected foot despite elevation of casted leg
on three pillows, the client performs active exercises with toes every 15 minutes. Ice bag is applied to cast over lateral ankle.
• Client rates pain at 10 after receiving Demerol 75 mg IM.
• The nurse notifies the doctor, who gives orders to obtain cast cutter for bivalving cast.
• Capillary refill is 2 seconds in toes on both feet. Pedal pulses are palpable and equal bilaterally. The client moves and detects
sensation equally bilaterally and rates pain at 5 after cast is bivalved.
• Affected leg remains elevated with ice bag applied. Client does exercises as directed.
therapists are helpful in assisting older adults to regain func- 2. A nurse is accurate in stating that an advantage of fiber-
tion and range of motion following any period of immobiliza- glass casts is that they are generally
tion to prevent decrease or permanent loss of function. 1. Less expensive
Every effort must be made to prepare the older person to become
2. More lightweight
mobile as soon as possible to prevent pressure ulcers and
other life-threatening complications (i.e., pneumonia).
3. More flexible
As adults live longer, many are dealing with the pain and loss of 4. Less restrictive
function associated with arthritis. Advances in joint replacement 3. Which of the following techniques is best for assessing
or reconstructive surgeries allow the older person more choices circulation in the casted extremity of a client with a long
for treatment options than those in previous years. These inter-
leg plaster cast?
ventions may involve rehabilitation with various types of
mechanical devices in the home or rehabilitation setting. 1. Ask the client if the cast feels exceptionally heavy.
2. Feel the cast to determine whether it is unusually
cold.
CRITICAL THINKING E X E R C I S E S 3. Depress the nailbed and time the return of color.
4. See if there is room to insert a finger within the cast.
1. Although slings are applied most often to support injured
extremities, discuss possible reasons for applying a sling 4. Which finding is most suggestive that a client in skeletal
on an arm paralyzed by a stroke. traction has an infection at the pin site?
2. Discuss the differences and similarities between caring 1. There is serous drainage at the pin site.
for clients with casts and caring for clients in traction. 2. There is bloody drainage at the pin site.
3. There is mucoid drainage at the pin site.
3. Discuss ways to provide diversion for clients with a cast
4. There is purulent drainage at the pin site.
or in traction who are confined to bed while their injuries
heal. 5. While providing nursing care for a client in Buck’s skin
traction, which of the following indicates a need for
immediate action?
NCLEX-STYLE REVIEW Q U E S T I O N S 1. The traction weights are hanging above the floor.
1. When the physician wraps the arm of a client with rolls 2. The leg is in line with the pull of the traction.
of wet plaster, it is most appropriate for the nurse to sup- 3. The client’s foot is touching the end of the bed.
port the wet cast 4. The rope is in the groove of the traction pulley.
1. On a soft mattress
2. On a firm surface
3. With the tips of the fingers
4. With the palms of the hands
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 Provides baseline objective data for future comparisons
time, and 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 or arm feel and Provides baseline subjective data for future comparisons
to rate any pain on a scale of 0 to 10.
Determine if the client has 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
(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 Facilitates circulation
elbow has been injured.
Canvas Sling
Slip the flexed arm into the canvas sling so that the elbow Encloses the forearm and wrist
fits flush with the corner of the sling (Fig. A).
Positioning a commercial arm sling.
Bring the strap around the opposing shoulder and fasten it Provides the means for support
to the sling (Fig. B).
Pad and tighten the strap sufficiently (Fig. C). Reduces friction and pressure to preserve skin integrity.
Keep the elbow flexed and the wrist elevated (Fig. D). Promotes circulation
(continued)
APPLYING AN ARM SLING (Continued)
Placing the strap around the neck.
Placing padding between the strap and neck.
Sling in place.
(continued)
Triangular Sling
Place the longer side of the sling from the shoulder Positions the sling where length is needed
opposite the injured arm to the waist.
Position the apex or point of the triangle under the elbow Facilitates making a hammock for the arm
(Fig. E).
Positioning a triangular sling.
Bring the point at the waist up to join the point at the Encloses the injured arm
neck and 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 Keeps the elbow enclosed
may be necessary (Fig. F).
Completed sling.
Inspect the condition of the skin at the neck and the Provides comparative data
circulation, mobility, and sensation of the fingers at
least once per shift.
(continued)
Pad the skin at the neck with soft gauze or towel material Reduces pressure and friction
if the skin becomes irritated.
Tell the client to report any changes in sensation, Indicates developing complications
especially pain with limited movement or pressure.
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 sec 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 medical treatment
Assess the appearance of the skin that the cast will cover; Provides a baseline of data for future comparisons
also check circulation, mobility, and sensation.
Ask the client to describe the location, type, and intensity Determines if the client needs analgesic medication
of any pain.
Determine what the client understands about the Indicates the type of health teaching needed
application of a cast.
Check with the physician as to whether a plaster of Paris Facilitates assembling appropriate supplies
or fiberglass cast will be applied.
(continued)
ASSISTING WITH A CAST APPLICATION (Continued)
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 Avoids having to cut and destroy clothing
cast once it is applied.
Provide a gown or drape. Preserves dignity and protects clothing
Assemble materials, which may include stockinette, felt Facilitates organization and efficient time management
padding, cotton batting, rolls of cast material, gloves,
and aprons.
Anticipate that if the cast is being applied to a lower Shows awareness of discharge planning
extremity, the client will need crutches and instructions
on their use (see Chap. 26).
Have an arm sling available if applying the cast to an Shows awareness of discharge planning
upper extremity.
Implementation
Explain how the cast will be applied. If using plaster of Paris, Reduces anxiety and promotes cooperation
be sure to tell the client that it will feel warm as it dries.
(see Chap. 10).
Wash the client’s skin with soap and water and dry well. Removes dirt, body oil, and some microorganisms
Cover the skin with protective padding as directed. Protects the skin from direct contact with the cast material
and provides a fabric cushion that protects the skin
If applying a plaster cast, open rolls and strips of plaster Prepares the cast material for application
gauze 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 Reduces the risk of rapidly drying and becoming unfit
time. for use
Support the extremity while the physician wraps the cast Facilitates going around the injured area; ensures proper
material around the arm or leg. For a fiberglass cast, alignment because fiberglass is harder to mold
hold the extremity in this position until the cast is dry
(approximately 15 minutes).
Help to fold back the edges of the stockinette at each end of Forms a smooth, soft edge at the margins of the cast,
the cast just before the final layer of cast material is applied. which may protect the skin from becoming irritated.
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 Prevents clogging of plumbing
plaster trap 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.
(continued)
ASSISTING WITH A CAST APPLICATION (Continued)
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 sec. 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 supported 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
Skill 25-3 • PROVIDING PIN SITE CARE
Assessment
Check the medical orders or standards for care regarding Demonstrates collaboration with medical treatment
the frequency of pin site care and the preferred
cleansing agent.
Review the medical record for trends in the client’s Uses data that reflect indications of infection
temperature, white blood cell count, reports of pain,
and frequency for treating pain.
Inspect the area around the pin insertion site for redness, Provides data for current and future comparisons
swelling, 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 Adds to the client’s understanding
client.
Assemble gloves, prescribed cleansing agent (usually Contributes to organization and efficient time
hydrogen peroxide or povidone–iodine), and sterile management
cotton-tipped applicators. Sometimes presaturated
swabs are available.
Place the bed at a comfortable height. Prevents back strain
(continued)
PROVIDING PIN SITE CARE (Continued)
Implementation
Wash your hands or perform an alcohol-based handrub Removes transient microorganisms and reduces the
(see Chap. 10). transmission of pathogens
Don gloves; clean gloves can be used to hold the stick end Prevents skin contact with blood or body fluid
of the applicator.
Open the package containing cotton-tipped applicators Avoids contaminating the point of contact between the
without touching the applicator tips. applicator tip and the client’s skin
Pour enough cleansing agent to saturate the dry Prepares applicators for use while maintaining sterility of
applicators while holding them over a basin or the applicator tip.
wastebasket.
Cleanse the skin at the pin site moving outward in a Prevents moving microorganisms toward the area of open
circular manner (Fig. A). skin.
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 Aids in determining the identity of pathogenic micro-
obtaining a wound culture if purulent drainage (that organisms and the need to institute infection-control
which contains pus) is present. measures such as 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; Demonstrates principles of medical asepsis (see Chap. 10)
remove gloves; and wash hands or perform an alcohol-
based handrub.
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.
(continued)
PROVIDING PIN SITE CARE (Continued)
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
26
Chapter
Ambulatory
Aids
LEARNING OBJECTIVES
● Name four activities that prepare clients for ambulation.
● Give two examples of isometric exercises that tone and strengthen lower extremities.
● Identify one technique for building upper arm strength.
● Explain the reason for dangling clients or using a tilt table.
● Name two devices used to assist clients with ambulation.
● Give three examples of ambulatory aids.
● Identify the most stable type of ambulatory aid.
● Describe three characteristics of appropriately fitted crutches.
● Name four types of crutch-walking gaits.
● Explain the purpose of a temporary prosthetic limb.
● Discuss two criteria that must be met before constructing a permanent prosthetic limb.
● Name four components of above-the-knee and below-the-knee prosthetic limbs.
● Describe how a prosthetic limb is applied.
● Discuss age-related changes that affect the gait and ambulation of older adults.
CLIENTS 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.
PREPARING FOR AMBULATION

WORDS TO KNOW
axillary crutches Debilitated clients (those who are frail or weak from prolonged inactivity) require phy-
cane sical conditioning before they can ambulate again. Some techniques for increasing mus-
crutches
cular strength and the ability to bear weight include performing isometric exercises
crutch palsy
dangling with the lower limbs, performing isotonic exercises with the upper arms, dangling at
forearm crutches the bedside, and using a device called a tilt table.
gluteal setting
parallel bars
platform crutches
prosthetic limb Isometric Exercises
prosthetist
quadriceps setting Isometric exercises (see Chap. 24) are used to promote muscle tone and strength. Tone
strength means the ability of muscles to respond when stimulated; strength means the power to
tilt table
tone
perform. Both tone and strength are inherent in maintaining mobility. Frequent con-
walker traction of muscle fibers retains or improves muscle tone and strength. Active people
walking belt maintain these two qualities through everyday activities, but inactive people and those
584
C H A P T E R 26 ● Ambulatory Aids 585
who have been immobilized in casts or traction may re-

quire focused periods of exercise to re-establish their pre-
vious ability to walk.
Quadriceps setting and gluteal setting exercises are
two types of isometric exercises that promote tone and
strength in weight-bearing muscles. Both types are easily
performed in bed or in a chair. They are initiated long
before the anticipated time when ambulation will start.
Most clients can perform these exercises independently
once they have been instructed. See Client and Family
Teaching 26-1.
FIGURE 26-1 • Modified hand push-ups are performed by extend-
Quadriceps Setting ing the elbows and flexing the wrists to lift the buttocks slightly off the
mattress.
Quadriceps setting is isometric exercise in which the client
alternately tenses and relaxes the quadriceps muscles. This
squeezing a ball or spring grip, and performing modified
type of exercise is sometimes referred to as “quad setting.”
hand push-ups in bed (Fig. 26-1).
The quadriceps muscles (rectus femoris, vastus inter-
Clients perform modified push-ups (exercises in which
medius, vastus medialis, and vastus lateralis) cover the
front and side of the thigh. Together they aid in extending clients support their upper body on the arms) several
the leg. Exercising the quadriceps muscles, therefore, ways, depending on age and condition. While sitting in
enables clients to stand and support their body weight. bed, a client may lift the hips off the bed by pushing down
on the mattress with the hands. If the mattress is soft, the
Gluteal Setting nurse places a block or books on the bed under the client’s
hands. If a sturdy armchair is available, the client can
is contraction and relaxation of the gluteal
Gluteal setting raise his or her body from the seat while pushing on the
muscles (gluteus maximus, gluteus medius, and gluteus arm rests.
minimus) to strengthen and tone them. As a group, the If the client can lie on the abdomen, he or she performs
muscles in the buttocks aid in extending, abducting, and push-ups in the following sequence:
rotating the leg—functions that are essential to walking.
1. Flex the elbows.
2. Place the hands, palms down, at approximately
Upper Arm Strengthening shoulder level.
3. Straighten the elbows to lift the head and chest off
Clients who will use a walker, cane, or crutches need upper the bed.
arm strength. An exercise regimen to strengthen the upper
arms typically includes flexion and extension of the arms For effectiveness, clients must perform push-ups three or
and wrists, raising and lowering weights with the hands, four times a day.
Dangling
Quadriceps and Gluteal Setting Exercises Dangling (sitting on the edge of the bed; Fig. 26-2) helps to
normalize blood pressure, which may drop when the client
rises from a reclining position (see the section on postural
• Tighten (contract) the quadriceps muscles by hypotension in Chap. 12). See Nursing Guidelines 26-1.
flattening the backs of the knees into the mat-
tress. If that is not possible, place a rolled towel
under the knee or heel before attempting to Using a Tilt Table
tighten the quadriceps muscles.
• Check to see that the kneecaps move upward. A tilt table is a device that raises the client from a supine
This is an indication that the client is perform- to standing position (Fig. 26-3). It helps clients adjust to
ing the exercise correctly. being upright and bearing weight on their feet. Although
• Hold the contracted position for a count of five. the tilt table usually is located in the physical therapy
• Relax and repeat two or three times each hour. department, nurses often prepare the client for this type
• Tighten (contract) the gluteal muscles by of preambulation therapy and communicate with the ther-
pinching the cheeks of the buttocks together. apists about the client’s response.
• Hold the contracted position for a count of five. Just before using a tilt table, the nurse applies elastic
• Relax and repeat two or three times each hour. stockings (see the section on antiembolism stockings in
FIGURE 26-2 • Dangling. (Copyright B. Proud.) FIGURE 26-3 • Tilt table.
Chap. 27). These stockings help to compress vein walls, entire table is then tilted in increments of 15 to 30 degrees
thus preventing pooling of blood in the extremities, which until the client is in a vertical position. If symptoms such
may trigger fainting. as dizziness and hypotension develop, the table is lowered
After being transferred from the bed or stretcher to the or returned to the horizontal position.
horizontal tilt table, the client is strapped securely to pre-
vent a fall. The feet are positioned against the foot rest. The
ASSISTIVE DEVICES

Some clients still need assistance to ambulate indepen-
Assisting Clients to Dangle dently even after performing strengthening exercises.
Two devices used to provide support and assistance with
❙ Perform dangling before ambulating whenever a client has been walking are parallel bars and a walking belt.
inactive for an extended period. Performing dangling before Clients use parallel bars (double row of stationary bars)
ambulating demonstrates concern for the client’s safety.
as handrails to gain practice in ambulating. Sometimes a
❙ Place the client in a Fowler’s position for a few minutes. This tilt table is positioned just in front of the parallel bars so
position maintains safety should the client become dizzy or faint. that the client can progress from being upright to actu-
❙ Lower the height of the bed. With a lowered bed, the client can use ally walking again (Fig. 26-4).
the floor for support. A walking belt is applied around the client’s waist. If the
❙ Provide a footstool if the client’s feet do not reach the floor. client loses balance, the nurse can support him or her and
A footstool is an alternative for supporting the feet. prevent injuries. When assisting a client to ambulate, the
nurse walks alongside the client, holding the walking belt
❙ Fold back the top linen. Linen can interfere with movement.
or the client’s own belt and supporting the client’s arm
❙ Provide the client with a robe and slippers. Doing so maintains (Fig. 26-5).
warmth and shows respect for the client’s modesty. While ambulating, the nurse observes the client for
❙ Help the client pivot a quarter of a turn to swing the legs over the pallor, weakness, or dizziness. If fainting seems likely,
side and sit on the edge of the bed. This position helps the client the nurse supports the client by sliding an arm under the
adjust to the sitting position. axilla and placing a foot to the side, forming a wide base
❙ Stay with the client until he or she no longer feels dizzy or light- of support. With the client’s weight braced, the nurse bal-
headed. The nurse can provide immediate assistance. ances the client on a hip until help arrives or slides the
client down the length of the nurse’s leg to the floor.
FIGURE 26-4 • Parallel bars.
wood or aluminum. Aluminum canes are more common.

AMBULATORY AIDS Canes have rubber tips to reduce the potential for slipping.
Clients may use different types of canes depending on
Three aids are used to help with ambulation: canes, walk- their physical deficits. A T-handle cane has a handgrip
ers, and crutches. with a slightly bent shaft, offering the user more stabil-
ity. A quad cane has four supports at the base and pro-
vides even more stability than the other types (Fig. 26-6).
Canes A cane must be the right height for the client. The
cane’s handle should be parallel with the client’s hip,
A client who has weakness on one side of the body uses providing elbow flexion of approximately 30 degrees. Re-
a cane, which is a hand-held ambulation device made of moving a portion of the lower end can shorten wooden
FIGURE 26-6 • A quad cane. Note that the handle is parallel to the
FIGURE 26-5 • Using a walking belt. client’s hip. (Copyright B. Proud.)
canes. Depressing metal buttons in the telescoping shaft

can shorten or lengthen aluminum canes. See Client and
Family Teaching 26-2.
When clients are beginning to use a cane, the nurse
assists by applying a walking belt and standing toward
the back of the client’s stronger side.
Walkers
Clients who require considerable support and assistance

with balance use a walker, the most stable form of ambu-
latory aid. Examples of clients who commonly use walk-
ers are those beginning to ambulate after prolonged bed
rest or after hip surgery.
Standard walkers are constructed of curved aluminum
bars that form a three-sided enclosure with four legs for
support. Some have front wheels (Fig. 26-7) or a seat.
Other adaptations are made for clients who have compro-
mised use of one or both arms or those who must use
stairs. The height of a walker as well as a cane is adjusted.
Using a Cane
The nurse teaches the client and family as follows: FIGURE 26-7 • Using a walker with wheels.
• Place the cane on the stronger side of the body.
• Stand upright with the cane 4 to 6 inches (10 to
15 cm) to the side of the toes. Nurses instruct clients who use a walker to
• Move the cane forward at the same time as the • Stand within the walker.
weaker extremity. • Hold on to the walker at the padded handgrips.
• Take the next step with the stronger extremity. • Pick up the walker and advance it 6 to 8 inches (15 to
• When using stairs 20 cm).
• Use a stair rail rather than the cane when • Take a step forward.
going up or down stairs, if possible. • Support the body weight on the handgrips when mov-
• Take each step up with the stronger leg fol- ing the weaker leg (for clients with partial or non–
lowed by the weaker one. Reverse the pattern weight-bearing on one leg).
for descending the stairs.
When the client with a walker wants to sit down, the
• If there is no stair rail, advance the cane
technique is similar to that with a cane, with one excep-
just before rising or descending with the
tion. When the legs are at the front of the chair seat, the
weaker leg.
client grips an arm rest with one arm while placing the
• When sitting
other hand on the walker and using the stronger leg for
• Back up to the chair until the seat is against
support. The client releases the grip on the walker while
the back of the legs.
using the free hand to grasp the opposite arm rest and
• Rest the cane close by. lower himself or herself into the chair. To rise, the client
• Grip the arm rests with both hands. moves to the edge of the chair and repositions the walker.
• Sit down. After pushing up on the arm rests with both arms until
• When getting up from a chair the body weight is centered, the client uses one hand then
• Grip the arm rests while holding the cane in the other to grasp the walker.
the stronger hand.
• Advance the stronger leg.
• Lean forward. Crutches
• Push with both arms against the arm rests.
• Stand until balanced and any symptoms of Crutches, an ambulatory aid generally used in pairs, are con-
dizziness pass. structed of wood or aluminum. Because the use of crutches
requires a great deal of upper arm strength and balance, weight-bearing), two-point gait, and swing-through gait
older adults or weak clients do not commonly use them. (Table 26-1). The word point refers to the sum of the
The three basic types of crutches are axillary, forearm, crutches and legs used when performing the gait. Nurses
and platform (Fig. 26-8). Axillary crutches (standard type are responsible for assisting clients who are learning to
of crutches) have a bar that fits beneath the axilla; this is walk with crutches (Skill 26-2).
the most familiar type. Clients who need brief, tempo-
rary assistance with ambulation are likely to use axillary
crutches. Forearm crutches (crutches that have an arm cuff Stop • Think + Respond BOX 26-1
but no axillary bar) include Lofstrand and Canadian What negative consequences can occur when a client
crutches. Forearm crutches generally are used by experi- uses ambulatory aids?
enced clients who need permanent assistance with walk-
ing. Platform crutches (crutches that support the forearm)
are used by clients who cannot bear weight with their
hands and wrists. Many clients with arthritis use them.
Sometimes a client uses one axillary crutch and one plat- PROSTHETIC LIMBS
form crutch—for example, when one arm is broken.
Once the type of ambulatory aid is medically prescribed,
Some clients with leg amputations ambulate using a pros-
the client is measured (Skill 26-1).
thetic limb (substitute for an arm or leg) without the assis-
tance of crutches or other ambulatory aids. The design of
Crutch-Walking Gaits a prosthetic limb varies depending on whether the lower
extremity is amputated at the foot (Syme’s amputation),
The term gait refers to one’s manner of walking. A crutch- below-the-knee (BK amputation), or above-the-knee
walking gait is the walking pattern used when ambulat- (AK amputation), or whether the entire leg and a portion
ing with crutches; clients use some of the same gaits with of the hip (hemipelvectomy) are removed.
walkers or canes.
The four types of crutch-walking gaits are four-point
gait, three-point gait (non–weight-bearing or partial Temporary Prosthetic Limb
In many cases, clients return from surgery with an imme-

diate postoperative prosthesis (IPOP), which is a temporary
artificial 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. 26-9). A belt with garters
keeps the temporary prosthesis in place. The belt is loos-
ened 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 ambulation and promotes an intact
body image immediately after surgery. It also helps to con-
trol stump swelling.
The nurse is responsible for ensuring that the incision
heals and that no complications, such as joint contrac-
tures or infection, develop. Complications delay rehabil-
itation. Contractures interfere with limb and prosthetic
alignment, which ultimately affects the client’s ability
to walk.
Permanent Prosthetic Components
Construction of a permanent prosthesis is delayed for

several weeks or months until the wound heals and the
A B C
stump size is relatively stable. The permanent prosthesis
FIGURE 26-8 • Three types of crutches: axillary (A), forearm (B), and is custom-made to conform to the stump and to meet the
platform (C). client’s needs.
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, but One crutch and opposite foot
clients have more moved in unison, followed
strength, coordination, by the remaining pair
and balance
Three-point non– One amputated, injured, Both crutches move forward

weight-bearing or disabled extremity followed by the weight-
(fractured leg or severe bearing leg
ankle sprain)
Three-point partial Amputee learning to use Both crutches are advanced

weight-bearing prosthesis, minor injury with weaker leg; stronger
to one leg, or previous leg is placed parallel to
injury showing signs of weaker leg
healing
Swing-through Injury or disorder affecting Both crutches are moved for-

one or both legs, such ward; one or both legs are
as a paralyzed client advanced beyond the
with leg braces or an crutches.
amputee before being
fitted with a prosthesis
Permanent prostheses for BK amputees include a Many clients wear one or more socks over the stump as
socket, a shank, and an ankle/foot system (Fig. 26-10). a layer between the skin and the socket. Stump socks,
AK prostheses also include a knee system to replace the made of wool or cotton, come in a variety of thicknesses
knee joint. to accommodate slight changes in stump size. Tube socks
The socket, a molded cone, holds the stump and enables are not an appropriate substitute. Despite the expense,
the amputee to move the prosthesis. It is held in place by stump socks must be replaced whenever holes develop or
suction or by a leather belt, also referred to as a sling. they become worn: a darned stump sock can cause skin
There are two basic types of ankle/foot systems: those

that have one or more moving artificial joints (articulated
systems) and those that do not. Although articulated sys-
tems allow more motion, the nonarticulated type has a
cushion in the heel that permits compression during walk-
ing. The client wears a sock and shoe on the prosthetic
foot. The client can vary his or her shoes, but all should be
of similar height to ensure alignment of the prosthesis and
a near-normal gait pattern.
Client Care
Nurses are responsible for managing the care of the stump

and ensuring maintenance of the prosthesis (Skill 26-3).
Ambulation With a Lower Limb Prosthesis

FIGURE 26-9 • Many amputees receive prostheses soon after surgery
and begin learning to use them with the support of the rehabilitation Ambulation with a lower limb prosthesis requires strength
team. 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
breakdown as a result of friction within the socket. learn to stand erect and look ahead when walking. They
Some amputees also wear a nylon sheath beneath the keep the feet close together and take each step without hik-
stump sock to wick perspiration from the skin toward the ing the hip unnaturally to swing the artificial limb forward.
sock and reduce friction on the skin. If using a cane, the client holds it in the hand opposite the
For AK amputees, the prosthetic knee system allows prosthetic limb. When going up or down stairs, curbs, or
flexion and extension to accommodate sitting and a nat- hills, the client moves the unaffected leg first, followed by
ural gait while walking. The knee system connects the the one with the prosthesis.
socket to the shank of the prosthesis. Amputees who wish to participate in strenuous acti-
The shank usually is shaped like a natural lower leg. vities such as snow skiing can use a sturdier modified
It transfers the body weight to the walking surface. The prosthesis.
shank is painted to resemble the client’s skin color.

Give some reasons why amputees may abandon rehabil-
itation and the use of a prosthesis; discuss how clients can
Socket
overcome these impediments.
Knee
system
Many nursing diagnoses are possible for clients who need
to use an ambulatory aid. Applicable nursing diagnoses
Shank • Impaired Physical Mobility
• Risk for Disuse Syndrome
• Unilateral Neglect
• Risk for Trauma
Foot-ankle • Risk for Peripheral Neurovascular Dysfunction
system • Risk for Activity Intolerance
FIGURE 26-10 • Components of a permanent prosthetic limb; a pros- Nursing Care Plan 26-1 demonstrates how the nurse
thesis for a BK amputation does not contain a knee system. would devise a care plan for a client with the nursing
Impaired Physical Mobility
ASSESSMENT
• Assess motor strength and range of motion in both lower extremities.
• Observe the client’s ability to turn himself or herself, rise from a lying or sitting position, and move from one location to
another.
• Watch the client walk, noting whether the client has a stable or unstable gait.
• Ask if the client uses any type of ambulatory assistive device like crutches, cane, or walker.
• Inspect the client’s lower extremities to determine if the client wears a lower limb prosthesis or mechanical brace.
• Review the client’s health history for disorders that affect or impair mobility such as a previous stroke, joint disease like
arthritis, or neurologic deficits that affect balance and coordination such as Parkinson’s disease.
• Gather information about the client’s current use of prescription and nonprescription medications and research possible
actions or side effects that can cause sedation, dizziness, and physical instability.
Nursing Diagnosis: Impaired Physical Mobility related to restricted positioning, limited

weight bearing, pain, and fear of ambulating 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 feet 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
and perform quad-setting exercises of both lower flexibility and muscle tone.
extremities while awake.
Instruct and supervise the client to dorsiflex, plantar flex, Active exercise and range of motion promote joint
and perform quad-setting exercises of both lower flexibility and muscle tone.
extremities 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 use of patient-controlled analgesia (PCA) pump Relieving pain facilitates the client’s comfort and
at frequent intervals to control pain. cooperation in performing rehabilitative exercise and
mobility.
Transfer from bed to standing position at the bedside, Preventing hip flexion helps to maintain the placement of
following these directions: the hip prosthesis until healing is complete.
• Slide affected L. 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 to avoid
leaning forward and praise efforts at moving.
• Lower unaffected R. foot to floor and help with lowering
affected L. foot, keeping knees apart.
• Dangle at bedside for approximately 5 minutes.
(continued)
Impaired Physical Mobility
• Apply walking safety belt around waist.
• Brace feet and pull forward on belt.
• Stand at bedside, putting only partial weight on L. leg.
• Reverse actions for returning to bed.

• Client maintains postoperative positions as ordered by physician.
• Abduction wedge is in place while client is in bed.
• Client performs active isotonic and isometric (quad-setting) exercises.
• Use of PCA pump reduces pain to a level that facilitates exercise.
• Client can transfer from bed and stand at bedside following procedure outlined in written plan of care.
• Client alternates full weight bearing on R. leg with partial weight bearing on L. in preparation for ambulation in physical
therapy department.
diagnosis of Impaired Physical Mobility, defined in the A walking or gait belt is an important safety device that can be
NANDA taxonomy (2005, p. 118) as a “limitation in used to assist the older person with transferring, even if the
client is not ambulatory. The older client should balance on
independent, purposeful physical movement of the body the stronger extremity while being assisted to transfer. The
or of one or more extremities.” This diagnosis can be used gait belt provides another means for client support, but the
for clients who are completely independent; those who client should never be forced to walk if unable.
require help from another person for assistance, super- A home evaluation by a physical or occupational therapist is help-
ful in assessing and recommending adaptations and devices
vision, or teaching; those who require help from another
to improve safety, mobility, and independent function. The
person for assistance and a device; or those who are older adult’s health insurance plan may cover this service.
totally dependent (NANDA, 2005). A home safety evaluation is recommended before discharging an
older person who will be using a mobility device. If necessary,
obtain permission to make the home safe by removing scatter
rugs or replacing them with secure mats. Ensure that lighting is
GENERAL GERONTOLOGIC adequate and that no electric cords are in passageways. Furni-
CONSIDERATIONS ture may have to be rearranged and railings or grab bars
added to bathrooms and outside entrances.
Self-perception of general health and well-being is often linked If an older person has mobility concerns, assess their ability to get
to the ability to maintain functional mobility. Functional on and off toilet seats.
ability involves both mobility and making adaptations to An elevated toilet seat and grab bars may be needed to improve the
compensate for changes occurring with aging or disease individual’s ability to transfer and to maintain independence.
processes. Older people may need encouragement and The use of an assistive device for mobility may cause depression
support to integrate adaptations into their activities of daily in the older person. Assessment of the older person’s percep-
tion of assistive devices and the impact on the individual’s self-
living, while maintaining their self-concept and body image.
concept is necessary. Assistive devices may contribute to a
Maintaining independence is important to the older person.
negative self-image (e.g., I can no longer function as I always
Mobility facilitates staying active and independent.
did; I must be getting old; What will others think of me?) Nega-
Limited or unsteady mobility may be a problem for some older
tive thoughts associated with assistive devices may cause the
adults as a result of age-related postural changes. Limited or older person to be reluctant to use the assistive device. If the
unsteady mobility may lead to the development of a swaying caregiver reinforces that the assistive device is a means of
or shuffling gait. As a person ages, he or she may develop maintaining as much independence as possible, the client may
flexion of the spine, which can alter the center of gravity and have greater acceptance. Matter-of-fact discussion of the bene-
may result in an increase in falls. fits (safety, independence, and adaptation to the current situa-
If a client appears to have an unusual gait, assess the feet for tion) can help modify the client’s negative perceptions.
corns, calluses, bunions, and ingrown or very long toenails. If Older adults who have difficulty going up and down stairs may
any of these conditions are found, a podiatry referral may be consider rearranging their homes so all necessary furnishings
indicated. Vascular changes may lead to numbness and a are on one level. A bedside commode decreases the number
decreased sensory ability to perceive contact with the ground, of trips up and down stairs if the bathroom is not on the same
which can also change a person’s gait. level as the bedroom or living area.
A ramp with a hand rail helps older adults to enter and leave their 2. When the nurse observes a client with arthritis using a
residence more conveniently and safely when they are using cane, which finding indicates that the client needs more
an ambulatory aid. instruction about its use?
Older adults sometimes use a “step-stop” pattern when using an
1. The client’s cane tip is covered with a rubber cap.
ambulatory aid; that is, they take one step, then stop, and
repeat again. If that is the case, encourage a smooth, progres-
2. The client wears athletic shoes with nonskid soles.
sive cadence. 3. The client uses the cane on his painful side.
Some older adults develop the habit of picking up and carrying a 4. The client holds his head up and looks straight
walker rather than having it make contact with the floor. In ahead.
these situations, the person may benefit from another type
3. After a client undergoes a total hip replacement, it is
of walker such as a walker with wheels or a three-wheeled
walker. A physical therapist can assess the situation and
essential for the nurse to maintain the operative hip in a
recommend an appropriate walker. position of
Rubber tips and handgrips on ambulatory aids should be kept 1. Adduction
clean and replaced when they are worn. Worn or dirty tips 2. Abduction
and handgrips contribute to falls and unsafe mobility. 3. Flexion
4. Rotation
CRITICAL THINKING E X E R C I S E S 4. Which activity is best to plan immediately after surgery

for strengthening the muscles of a client before ambulat-
1. Compare the differences in using two types of ambula- ing with crutches?
tory aids, such as crutches and a walker. 1. Standing at the side of the bed
2. Discuss stereotypes of people who use ambulatory aids. 2. Balancing between parallel bars
3. Lifting herself with the trapeze
4. Transferring from bed to a chair
NCLEX-STYLE REVIEW Q U E S T I O N S 5. Which of the following observations is most indicative
1. The best evidence that a client is performing a three-point that the crutches a client is using need further adjustment?
partial weight-bearing gait is that the client advances the 1. The client stands straight without bending forward.
walker and his operative leg while putting most of his 2. The elbows are slightly flexed when standing in
weight on the place.
1. Hand grips of the walker 3. The top bars of the crutches fit snugly into the
2. Back legs of the walker axillae.
3. Toes of his operative leg 4. The wrists are hyperextended when grasping the
4. Heel of his unoperative leg handgrips.
Skill 26-1 • MEASURING FOR CRUTCHES, CANES, AND WALKERS
Assessment
Check the medical orders. Collaborates nursing activities with 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 Complies with agency procedures; clients in health care
measuring and dispensing ambulatory aids. agencies sometimes are referred to personnel in the
physical therapy department.
Determine the strength of the client’s arm and leg Indicates the client’s potential for weight bearing;
muscles. weakness suggests a need to measure the client in bed
or for further collaboration 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 handrub Reduces the transmission of microorganisms
(see Chap. 10).
Assist the client with donning socks and walking shoes, if Aids in more accurate measurement that accommodates
the client can stand for the measurement. added height of the heel
Implementation
Axillary Crutches
Assist the client who can support his or her body weight to Positions the client in a posture for actual use of crutches
a standing position at the bedside with supportive shoes.
Measure from the anterior skinfold of the axilla to approxi- Approximates the length required for appropriate use
mately 4 to 8 inches (10 to 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)
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 Accommodates for the added height of the heel
axilla to heel and add 2 inches (5 cm) or subtract
16 inches (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 Ensures the potential for extending the elbow and
flexion and 15 degrees of wrist hyperextension when supporting body weight
client grasps the handgrips standing upright (Fig. C).
30 flexion
15 hyperextension
Appropriate position for handgrips.
(continued)
Lengthen or shorten axillary crutches by removing wing Customizes the length of the crutches according to the
nuts and replacing metal screws in the appropriate client’s height
hole in the stem of the crutch. Adjust handgrips in the
same way (Fig. D).
Adjusting length of an axillary crutch. (Copyright B. Proud.)
Forearm Crutches
Stand the client in shoes with the elbows flexed so the Simulates appropriate posture when using forearm
crease of the wrist is at the hip. crutches
Measure the forearm from 3 inches below the elbow, then Adjusts total length to accommodate for elbow and wrist
add the distance between the wrist and floor (Fig. E). flexion
30 flexion
Hip A
joint
Measuring forearm crutches. Total length C = sum of A (3 inches below elbow to wrist) + B (wrist to floor).
Hip
joint
C
Adjust the length of the forearm crutches by telescoping Customizes the final fit
them up or down.
(continued)
Canes
Have the client stand erect in shoes that he or she wears Incorporates the height of the client’s shoes
most often for ambulating
Instruct the client to avoid leaning forward or elevating Ensures accurate measurement
the 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 Customizes the final height of the cane
flexion 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 (weakened forearm, wrist, and hand muscles
from nerve impairment secondary to pressure on the
brachial plexus of nerves in the axilla) from incor-
rectly fitted crutches or poor posture.
• There is 30 degrees of elbow flexion and slight hyper-
extension 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″ (132.5 cm) based on length
from axillary fold to heel (51″) while in a supine position and the addition of 2″.
SIGNATURE/TITLE
Skill 26-2 • ASSISTING WITH CRUTCH-WALKING
Assessment
Review the medical orders for the type of activity and Reflects the implementation of the medical treatment
crutch-walking gait.
Read any previous nursing documentation regarding the Provides evaluative data and indicates need to simulate or
client’s efforts at crutch-walking. modify nursing interventions
Wash hands or perform an alcohol-based handrub Reduces the transmission of microorganisms
(see 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 if there is any muscle or joint pain or Provides subjective data concerning the effects of crutch-
tingling or numbness in the fingers. walking and possible nerve irritation
Inspect the conditions of the axillary pads and rubber Demonstrates concern for safety
crutch tips.
Planning
Consult with the client about the preferred time for Shows respect for individual decision making
ambulation.
Assist the client to don clothes or a robe and supportive Demonstrates concern for modesty and safety
shoes or slippers with nonskid soles.
Apply a walking belt if the client is weak or inexperienced Demonstrates concern for safety
in the use of crutches.
Clear a pathway where the client will ambulate. Demonstrates concern for safety
Review the technique for performing the prescribed Reinforces prior learning
crutch-walking gait.
Implementation
Help the client to a standing position. Prepares the client for ambulation
Offer the crutches and observe that they are placed 4 to Forms a triangle for good balance
8 inches (10 to 20 cm) to the side of the feet (Fig. A).
Remind the client to stand straight with the shoulders Reduces muscle strain
relaxed.
Position yourself to the side and slightly behind the client Facilitates assistance without causing interference
on the weaker side (Fig. B).
Take hold of the walking belt. Helps steady or support the client
Instruct the client to advance the crutches, lean forward, Promotes walking
put 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 Demonstrates concern for the client’s well-being
fatigue or intolerance to the activity.
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 Frees the opposite hand
same side as the weaker leg (Fig. C).
(continued)
ASSISTING WITH CRUTCH-WALKING (Continued)
A B
A tripod of support.
Positioning for assistance. (Copyright B. Proud.)
While using the handgrips on the crutches for support, Reduces the potential for falling
have the client grasp one arm rest with the free hand.
Sitting down.
When balanced, tell the client to lower himself or herself Facilitates sitting
into 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
(continued)
Instruct the client to hold the crutches upright on the Positions crutches for support
weaker side, balancing them with one hand.
Tell the client to position the weaker leg forward of the Helps to distribute weight over the stronger leg
body and the stronger leg toward the base of the chair.
Tell the client to push on the handgrips and arm rest, 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 Balances needed support
body, if possible.
Have the client transfer both crutches to the hand Frees one hand for grasping the handrail for support
opposite the handrail.
Tell the client to push down on the handrail and step up Uses the stronger muscles for bearing weight
with 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 Enables safe descent
weaker leg is advanced first with the support of the
crutches or handrail; 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.
(continued)
Document
• Distance ambulated
• Gait used
Date and Time Ambulated length of hospital corridor (approx. 100 feet) 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
Skill 26-3 • APPLYING A LEG PROSTHESIS
Assessment
Wash hands or perform an alcohol-based handrub Reduces the transmission of microorganisms.
(see Chap. 10).
Inspect the stump for evidence of bleeding, wound Detects complications that delay healing and
drainage, skin abrasions, blisters, and edema. rehabilitation or 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 Indicates changes in stump size and the need to add or
within the socket. decrease the numbers or thickness of stump socks
Examine the joint connections in the prosthetic limb. Determines if lubrication or prosthetic maintenance is
necessary; concerns about the mechanical features of
the prosthesis or its fit are referred to a prosthetist
(person who constructs prostheses) immediately.
Inspect the shoe on the prosthetic limb for signs of wear Establishes whether heels or the entire shoe need to be
or moisture. replaced or dried.
Planning
Cleanse the skin on the stump each evening, not in the Allows sufficient time for the skin to be moisture-free
morning.
Rinse the soap from the stump and dry it well. Avoids skin impairment and irritation
Encourage the client to lie supine or prone periodically Promotes venous circulation, reduces stump edema, and
during the day. avoids 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
(continued)
APPLYING A LEG PROSTHESIS (Continued)
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 Promotes cleanliness and comfort
change 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, Maintains shape and integrity
and stretch it lengthwise before air drying; never
remove water by twisting the sheath.
Advise the client with a new prosthesis to wear it for Prevents overexertion and impaired skin integrity
short periods initially and then increase the wearing
time each day.
Implementation
Cover the prosthetic foot with the stocking and shoe of Coordinates apparel and helps to conceal the appearance
choice. of the prosthetic limb
Apply the nylon sheath, if used, and the appropriate Promotes comfort and fit of the stump within the
number or ply of stump socks. prosthesis
Place a nylon stocking over the stump sock, allowing a Helps to slide the stump within the socket
long portion of the toe to extend from the base of the
stump (Fig. A).
Stand and position the prosthetic limb next to the residual Facilitates application
limb.
Pull the toe of the nylon stocking through the valve at the Locates the stump well within the lower area of the socket
base of the socket (Fig. B).
A B
A nylon stocking covers the stump sock. 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 Expels air and creates a vacuum that keeps the prosthesis
completely removed. attached to the stump
Replace the plug within the valve opening. Ensures retention of vacuum suction
Fasten all slings if other than a suction-socket type of Secures the prosthesis to the stump
prosthesis is used.
(continued)
APPLYING A LEG PROSTHESIS (Continued)
Evaluation
• Stump size is unchanged.
• Skin is intact.
• Circulation is adequate based on similar skin color in
the stump and 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 appli-
cation 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 minutes without loss of balance or other difficulties.
SIGNATURE/TITLE
UNIT 6

for Chapters 23, 24, 25, and 26
Activity A: Fill in the blanks by choosing the correct word from the options given in
parentheses.
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)
statements.
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.
605

1. Amputation at 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
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 based on the criteria given below.
Plaster of Paris Fiberglass
Application
Cost
Durability
Weight
Weight bearing
Effect of water
UNIT 6 ● End of Unit Exercises for Chapters 23, 24, 25, and 26 607
2. Differentiate between active exercise and passive exercise based on the criteria given below.
Active Exercise Passive Exercise
Definition
Uses
Examples

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?
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 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?
3. A nurse is preparing to transfer an elderly client from 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 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 to move around.
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 in bed?
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 to begin accepting the amputation and 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?

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 a 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 nailbeds 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? Select all that apply.
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.
UNIT 7
The Surgical Client

27 Perioperative Care
28 Wound Care
29 Gastrointestinal Intubation
27
Chapter
Perioperative
Care
LEARNING OBJECTIVES
● Define perioperative care.
● Identify the three phases of perioperative care.
● Differentiate inpatient from outpatient surgery.
● List at least four advantages of laser surgery.
● Discuss two methods for donating blood before surgery.
● Identify four major activities that nurses perform for all clients immediately before surgery.
● Name three topics to address in preoperative teaching.
● Explain the purpose of antiembolism stockings.
● Name three methods for removing hair when preparing the skin for surgery.
● List at least five items that are verified on the preoperative checklist.
● Name three parts of the surgical department used during the intraoperative period.
WORDS TO KNOW ● Describe the focus of nursing care during the immediate postoperative period.
● Give four examples of common postoperative complications.
anesthesiologist ● Discuss the purpose of a pneumatic compression device.
anesthetist ● Describe at least two items of information included in discharge instructions for postsurgical clients.
antiembolism stockings ● Discuss at least two ways in which the surgical care of older adults differs from that of other
atelectasis age groups.
autologous transfusion
conscious sedation
depilatory agent
directed donors
discharge instructions PERIOPERATIVE CARE (care that clients receive before, during, and after surgery) is
emboli unique. The current trend is to facilitate as short a perioperative period as possible.
forced coughing This trend is driven by efforts to control health care costs by facilitating the client’s
informed consent recovery in the comfort and support of his or her home environment. This chapter
inpatient surgery
discusses the general responsibilities nurses assume when caring for clients during
intraoperative period
microabrasions the preoperative, intraoperative, and postoperative periods of perioperative care.
outpatient surgery
perioperative care
plume
pneumatic compression
PREOPERATIVE PERIOD
device
pneumonia
The preoperative period starts when clients, or their families in an emergency, learn
postanesthesia care unit
postoperative care that surgery is necessary and ends when clients are transported to the operating
postoperative period room. This period can be short or long; one major factor affecting its length is the
preoperative checklist urgency with which the surgery must be performed (Table 27-1).
preoperative period
receiving room
reversal drugs Inpatient Surgery
substituted judgment
surgical waiting area
thrombophlebitis Surgery is performed for various reasons (Table 27-2). Inpatient surgery is the term
thrombus used for procedures performed on a client who is admitted to the hospital, expected
614
C H A P T E R 27 ● Perioperative Care 615
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
to remain at least overnight, and in need of nursing care are free-standing, privately owned facilities not affiliated
for more than 1 day after surgery. All except the sickest with a hospital. The client remains in the outpatient sur-
of clients usually are admitted the morning of the sched- gical suite for a brief time and is discharged by midafter-
uled surgery. noon or early evening when (1) the client is awake and
Many people who have inpatient surgery undergo alert, (2) vital signs are stable, (3) pain and nausea are con-
prior laboratory and diagnostic tests. Some have met trolled, (4) oral fluids are retained, (5) the client voids a
with an anesthesiologist (physician who administers chem- sufficient quantity of urine, and (6) the client has received
ical agents that temporarily eliminate sensation and discharge instructions. If a complication develops, the
pain; Table 27-3) or an anesthetist (nurse specialist who client is transferred and admitted to a hospital unit.
administers anesthesia under the direction of a physi-
cian). Most clients will have received preoperative Laser Surgery
instructions from either the surgeon’s office nurse or a
hospital nurse. Outpatient surgical procedures have increased dramat-
ically since the early 1980s as a result of advances in
surgical techniques and methods of anesthesia, pro-
Outpatient Surgery spective reimbursement, managed care, and changes
in Medicare and Medicaid provisions (Smeltzer & Bare,
Outpatient surgery, also called ambulatory surgery and same- 2006). Another factor contributing to the increase in
day surgery, is the term used for operative procedures outpatient procedures is advances in laser surgery. The
performed on clients who return home the same day. It acronym LASER stands for light amplification by the
generally is reserved for clients in an optimal state of health stimulated emission of radiation. Lasers convert a solid,
whose recovery is expected to be uneventful. Advan- gas, or liquid into light. When focused, the energy from
tages and disadvantages of outpatient surgery are listed the light is converted to heat, causing vaporization of tis-
in Table 27-4. sue and coagulation of blood vessels. Examples include the
Outpatient surgical units are located in either a hospi- carbon dioxide laser, argon laser, ruby laser, and yttrium-
tal or a separate building that the hospital owns. Others aluminum-garnet (YAG) laser.
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; usually involves Exploration of abdomen for
exploration of a body cavity or use of scopes inserted through unexplained pain
small incisions Exploratory laparoscopy
Curative Removal or replacement of defective tissue to restore function Cholecystectomy
Total hip replacement
Palliative Relief of symptoms or enhancement of function without cure Resection of a tumor to relieve
pressure and pain
Cosmetic Correction of defects, improvement of appearance, or change to Rhinoplasty
a physical feature Cleft lip repair
Mammoplasty
616 U N I T 7 ● The Surgical Client
TABLE 27-3 TYPES OF ANESTHESIA

TYPE DESCRIPTION
General Anesthesia Eliminates all sensation and consciousness of or memory for the
event
Inhalants Includes gas or volatile liquids
Injectables Are given intravenously
Regional Anesthesia Blocks sensation in an area, but consciousness is unaffected
Spinal (includes epidural) Eliminates sensation in lower extremities, lower abdomen, pelvis
Local Blocks sensation in a circumscribed area of skin and subcuta-
neous tissue
Topical Inhibits sensation in epithelial tissues such as skin and mucous
membranes where directly applied
Laser surgery is used as an alternative to many previ- mability. Surgical instruments are coated black to avoid
ously conventional surgical techniques such as reattach- absorbing scattered light that causes them to heat. Some-
ing the retina, removing skin tattoos, and revascularizing times even the client’s teeth are covered with plastic or a
ischemic heart muscle (instead of coronary artery by- rubber mouth guard to shield metal fillings. For the same
pass graft surgery). Laser surgery offers the following reason, no jewelry is allowed.
advantages: When a laser is used, it releases plume (substance com-
posed of vaporized tissue, carbon dioxide, and water) that
• Cost effectiveness
may contain intact cells. Plume is accompanied by smoke,
• Reduced need for general anesthesia
an offensive odor, and (for some) burning and itching
• Smaller incisions
eyes. The latter effects are not hazardous and usually can
• Minimal blood loss
be reduced with the use of smoke evacuators. The greater
• Reduced swelling
concern involves the consequences of inhaling plume.
• Less pain
Airborne cells in the inhaled plume may contain viruses,
• Decreased incidence of wound infections
possibly including HIV. Although no cases of HIV trans-
• Reduced scarring
mission through lasers have been documented, high-
• Less time recuperating
efficiency respirator masks (see Chap. 22) are better
Laser technology requires unique safety precautions than conventional surgical masks for reducing the risk
such as eye, fire, heat, and vapor protection. Depending on for infection transmission.
the type of laser used, everyone—including the client—
wears goggles. In some cases, prescription glasses with
side shields are allowed, but not contact lenses. Informed Consent
Because lasers produce heat, fire and electrical safety
are paramount. Volatile substances such as alcohol and Regardless of whether surgery is performed conven-
acetone are not used around lasers because of their flam- tionally or with a laser, clients commonly are fearful
TABLE 27-4 ADVANTAGES AND DISADVANTAGES OF OUTPATIENT SURGERY

ADVANTAGES DISADVANTAGES
Lowers the surgical costs because of the reduced use of Reduces the time for establishing a nurse–client relationship
hospital services
Reduces the time spent away from home, school, or place Requires intensive preoperative teaching in a short amount of time
of employment
Interferes less with the client’s usual daily routine Reduces the opportunity for reinforcement of teaching and for
answering questions
Provides the potential for more rest and sleep before and Allows for fewer delays in assessing and preparing a client once he
after surgery or she arrives for surgery
Allows more opportunity for family contact and support Requires that care of the client after discharge be carried out by
unskilled people
and anxious. They often have many questions and pre- someone with durable power of attorney for the client’s
conceived ideas about what surgery involves. Health health care must sign the consent form. If an adult client
care providers may answer some of these questions. is under the influence of a mind-altering drug such as a
Nevertheless, the physician is responsible for providing narcotic or is alcohol intoxicated, obtaining consent must
information that meets the criteria for informed consent be delayed until the drug has been metabolized. In a life-
(permission a client gives after an explanation of the threatening emergency, a court may waive the need to
risks, benefits, and alternatives; see Chap. 14). A signed obtain written or verbal consent from a client who requires
form, witnessed by a nurse, is evidence that consent has immediate surgery on the basis of substituted judgment; that
been obtained (Fig. 27-1). is, the court believes that if the client had the capacity to
If an adult client is confused, unconscious, or mentally consent, he or she would have done so. Refer to Chapter 14
incompetent, the client’s spouse, nearest blood relative, or for the elements that constitute informed consent.
FIGURE 27-1 • Surgical consent form.

If the client is younger than 18 years, a parent or legal the client. Doing so would rule them out as future organ
guardian must sign the consent form. In an emergency, or tissue donors for the client because antigens in the
health care personnel make every effort to obtain consent transfused blood would sensitize the recipient, increasing
by telephone, telegram, or fax. Adolescents younger than the risk for organ or tissue rejection. Also, a male sexual
18 years, living independently, and supporting themselves partner of a woman in her reproductive years should not
are regarded as emancipated minors and may sign their be a directed donor to avoid possible antibody reactions
own consent forms. against a fetus in any future pregnancy.
Each nurse must be familiar with agency policies Most authorities believe that receiving blood from
and state laws regarding surgical consent forms. Clients directed donors is no safer than receiving blood from
must sign the consent form before receiving any pre- public donors. Although predonation of blood is common
operative sedatives. When the client or designated per- in the United States, the criteria for autologous and
son has signed the permit, an adult witness also signs it directed donors (Table 27-5) vary among regions and
to indicate that the client or designee signed voluntarily. hospitals. Because directed donors must meet the same
This witness usually is a member of the health care team requirements as public donors, if the intended recipient
or an employee in the admissions department. The nurse does not use the blood, it is released into the public pool
is responsible for ensuring that all necessary parties have and can be given to someone else.
signed the consent form and that it is in the client’s chart
before the client goes to the operating room.
Immediate Preoperative Care
Preoperative Blood Donation Although some presurgical activities take place weeks in
advance, others cannot be performed until just before
The low risk for acquiring HIV from a blood transfusion surgery. During the immediate preoperative period—the
sometimes is discussed during the preoperative period. few hours before the procedure—several major tasks must
Although publicly donated blood is tested for several be completed: conducting a nursing assessment, provid-
pathogens, the potential for acquiring a blood-borne dis- ing preoperative teaching, performing methods of phys-
ease still exists. Therefore, some clients undergoing sur- ical preparation, administering medications, assisting
gery donate their own blood preoperatively. Predonated with psychosocial preparation, and completing the sur-
blood is held on reserve in the event that the client needs gical checklist.
a blood transfusion during or after surgery. Receiving
one’s own blood is called an autologous transfusion (self-
Nursing Assessment
donated blood). Autologous transfusions also are pre-
pared by salvaging blood lost during or immediately after Nurses share with physicians the responsibility for assess-
surgery. The salvaged blood is suctioned, cleaned, and filing preoperative clients. The assessment varies depending
tered from drainage collection devices. on the urgency of the surgery and if the client is admitted
Clients who do not meet the time or health require- the same day of surgery or earlier. Although assessment of
ments for self-donation may select directed donors (blood the surgical client always is necessary, the particular cir-
donors chosen from among the client’s relatives and cumstances dictate the extent of the process. There may
friends). The client’s siblings should not donate blood for not be time to perform a detailed assessment.
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 safe range Meet all the criteria of a public donor
Be free of infection at time of donation Have the same blood type as the potential recipient or one that
Meet the blood collection center’s minimum weight requirement is 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 to 5 days; once per Donate 20 to 3 days before the anticipated use
week is preferred Be free from bloodborne 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
When surgery is not an emergency, the nurse per- • Extremes of age

forms a thorough history and physical examination. He • Dehydration
or she assesses the client’s understanding of the surgical • Malnutrition
procedure, postoperative expectations, and ability to par- • Obesity
ticipate in recovery. The nurse also considers cultural • Smoking
needs, specifically as they relate to beliefs about surgery, • Diabetes
personal privacy, and presence of family members dur- • Cardiopulmonary disease
ing the preoperative and postoperative phases. The nurse • Drug and alcohol abuse
may question the client regarding strong culturally influ- • Bleeding tendencies
enced feelings about disposal of body parts and blood • Low hemoglobin and red cells
transfusions. • Pregnancy
On admission, the nurse reviews preoperative instruc-
Some problems, such as an unexplained elevation in tem-
tions, such as diet and fluid restrictions, bowel and skin
perature, abnormal laboratory data, current infectious
preparations, and the withholding or self-administration of
disease, or significant deviations in vital signs, are cause
medications, to ensure that the client has followed them.
for postponing or canceling the surgery (Table 27-6).
If the client has not carried out a specific portion of the
instructions, the nurse immediately notifies the surgeon.
Preoperative Teaching
The nurse identifies the client’s potential risks for
complications during or after the surgery. Certain sur- Preoperative teaching varies with the type of surgery
gical risk factors increase the likelihood of perioperative and length of hospitalization. Preoperatively, clients are
complications: alert and free from pain or in less pain at this time,
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,
mechanisms and infection
Elderly—Multiple organ degeneration and slowed Decreased metabolism and excretion of anesthetics and pain medica-
regulatory mechanisms tions, 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, wound infections
Obese—Stressed cardiovascular system, decreased Atelectasis, pneumonia, blood clots, delayed wound healing, wound
circulation, decreased pulmonary function infection, delayed metabolism and excretion of anesthetics and
pain medication
Substance Abuse
Altered respiratory function, nutritional status, or liver Atelectasis, pneumonia, altered effectiveness of anesthetics and pain
function medications, drug interactions, drug withdrawal
Medical Problems
Immune—Allergies and immunosuppression secondary to Adverse reactions to medications, blood transfusions, or latex; infection
corticosteroid therapy, transplants, chemotherapy,
or diseases such as AIDS
Respiratory—Acute and chronic respiratory problems and Atelectasis, bronchopneumonia, respiratory failure
history of tobacco use
Cardiovascular—Hypertension, coronary artery disease, Hypotension, hypertension, fluid overload, congestive heart failure,
peripheral vascular disease shock, dysrhythmias, myocardial infarction, stroke, blood clots
Hepatic—Liver dysfunction Delayed drug metabolism leading to drug toxicity, disrupted clotting
mechanisms leading to excessive bleeding or hemorrhage, confu-
sion, increased risk for infection
Renal—Kidney disease, chronic renal insufficiency, renal Fluid and electrolyte imbalances, congestive heart failure, dysrhythmias,
failure delayed excretion of drugs leading to drug toxicity
Endocrine—Diabetes Hypoglycemia, hyperglycemia, hypokalemia, infection, delayed
wound healing
which facilitates their participation. Knowledge of what

to expect on the part of clients and family can enhance
recovery from surgery. Performing Forced Coughing
The following are examples of information to include The nurse teaches the client and family as follows:
in preoperative teaching:
• Sit upright.
• Preoperative medications—when they are given and • Take a slow, deep breath through the nose.
their effects • Make the lower abdomen rise as much as possible.
• Postoperative pain control • Lean slightly forward.
• Explanation and description of the postanesthesia • Exhale slowly through the mouth.
recovery room or postsurgical area • Pull the abdomen inward.
• Discussion of the frequency of assessing vital signs • Repeat but this time, cough three times in a
and use of monitoring equipment row while exhaling.
The nurse also explains and demonstrates how to per-
form deep breathing, coughing, and leg exercises.
clients. Forced coughing is most appropriate for clients
DEEP BREATHING. Deep breathing, a form of controlled who have diminished or moist lung sounds or who raise
ventilation that opens and fills small air passages in the thick sputum. Nevertheless, all clients need to be pre-
lungs (see Chap. 21), is especially advantageous for clients pared for the possibility of having to perform this tech-
who receive general anesthesia or who breathe shallowly nique and receive instructions about it. See Client and
after surgery because of pain. Deep breathing reduces the Family Teaching 27-1.
postoperative risk for respiratory complications such as Coughing is painful for clients with abdominal or chest
atelectasis (airless, collapsed lung areas) and pneumonia incisions. Administering pain medication approximately
(lung infection), both of which can lead to hypoxemia. 30 minutes before coughing or splinting the incision dur-
The nurse practices deep breathing with clients before ing coughing can reduce discomfort. Methods of splint-
they undergo surgery (Fig. 27-2). Deep breathing involves ing include pressing on the incision with both hands,
inhaling deeply using the abdominal muscles, holding the pressing on a pillow placed over the incision, or wrap-
breath for several seconds, and exhaling slowly. Pursing ping a bath blanket around the client (Fig. 27-3).
the lips may extend the period of exhalation. Incentive
spirometers (see Chap. 21) also are used to promote deep LEG EXERCISES. Leg exercises help to promote circulation
breathing. and reduce the risk for forming a thrombus (stationary
blood clot) in the veins. Blood clots form when venous
COUGHING. Thickened respiratory secretions often ac- circulation is sluggish and when the fluid component of
company impaired ventilation. Coughing is a natural blood is reduced. Surgical clients are predisposed to both.
method for clearing secretions from the airways. Deep Surgical clients have reduced circulatory volume because
breathing alone is sometimes sufficient to produce a nat- of preoperative restriction of food and fluids and blood
ural cough. Forced coughing (coughing that is purposely loss during surgery. Also, blood tends to pool in the lower
produced) may not be necessary for all postoperative extremities because of the stationary position during
surgery and clients’ reluctance to move afterward. With
the use of leg exercises, efforts to reduce circulatory com-
FIGURE 27-3 • Teaching the client to splint the incision and to cough.
FIGURE 27-2 • Teaching deep breathing. (Copyright B. Proud.) (Copyright Ken Kasper.)
plications begin as soon as the client recovers from anes-

thesia. See Client and Family Teaching 27-2.
Antiembolism stockings are knee-high or thigh-high elas-
tic stockings. They are sometimes called thromboembolic
disorder (TED) hose. Antiembolism stockings help to pre-
vent thrombi and emboli (mobile blood clots) by compress-
ing superficial veins and capillaries, redirecting more blood
to larger and deeper veins, where it flows more effectively
toward the heart. Intermittent pneumatic compression
devices (discussed later in this chapter) are used for the
same purpose but are applied postoperatively.
Antiembolism stockings must fit the client properly
and must be applied correctly (Skill 27-1). Stockings that
become dirty are laundered, during which time a second
pair is used. If washed by hand, the stockings are laid flat
to dry to prevent loss of their elasticity.

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
surgical facility, the nurse may perform some physical
preparation that includes skin preparation, attention to
elimination, restriction of food and fluids, care of valuables, A
donning of surgical attire, and disposition of prostheses.
SKIN PREPARATION. Skin preparation involves removing

hair and cleansing the skin because hair and skin are
reservoirs for microorganisms (Skill 27-2). The goal is to
decrease transient and resident bacteria without compro-
mising skin integrity. Reducing bacteria helps to prevent
postoperative wound infections.
B
FIGURE 27-4 • Components of leg exercises. (A) Exercising the lower

27-2 • CLIENT AND FAMILY TEACHING legs. (B) Exercising the feet.
Performing Leg Exercises

The nurse teaches the client and family as follows: For planned surgery, the client may be asked to cleanse
• Sit with the head slightly raised. the particular area with soap for several days before
• Bend one knee. Raise and hold the leg above surgery. Hair usually is not removed before surgery
the mattress for a few seconds (Fig. 27-4). unless it is likely to interfere with the incision. Shaving
• Straighten the raised leg. causes microabrasions (tiny cuts that provide an entrance
• Lower the leg back to the bed gradually. for microorganisms). For this reason, many institutions
• Do the same with the other leg. use electric clippers for hair removal unless otherwise
• Rest both legs on the bed. specified by the surgeon.
• Point the toes toward the mattress and then Some authorities believe that simply washing the skin
toward the head. and hair is sufficient to prevent infections. Although the
• Move both feet in clockwise and then counter- research is limited to statistically small numbers of clients,
clockwise circles. infection rates among clients whose hair is clean do not
• Repeat the exercises five times at least every differ significantly from those whose body hair is removed
2 hours while awake. ( Joanna Briggs Institute, 2003).
eyeglasses and contact lenses, which the nurse places in

Stop • Think + Respond BOX 27-2 a safe location or gives to a family member.
Correlate the potential for transmitting an infection using
a razor for presurgical skin preparation with the chain of SURGICAL ATTIRE. Usually, clients wear a hospital gown
infection discussed in Chapter 10. and surgical cap to the operating room. The physician may
order thigh-high or knee-high antiembolism stockings or
order the client’s legs wrapped in elastic roller bandages
(see Chap. 28) before surgery to prevent venous stasis.
ELIMINATION. The nurse may need to insert an indwelling Hair ornaments are removed to avoid injury with
urinary catheter (see Chap. 30) preoperatively for some equipment used to administer oxygen and inhalant anes-
surgeries, particularly of the lower abdomen. A distended thetics. Makeup and nail polish are omitted to facilitate
bladder increases the risks for bladder trauma and diffi- assessing oxygenation. If a client has acrylic nails, one
culty in performing the procedure. The catheter keeps usually is removed to attach a pulse oximeter, which mea-
the bladder empty during surgery. If a catheter is not sures oxygen saturation (see Chap. 21).
inserted, the nurse instructs the client to urinate imme-
diately before receiving preoperative medication. DENTURES AND PROSTHESES. Depending on agency policy
Enemas or a laxative may be ordered to clean the lower and the preference of the anesthesiologist or surgeon,
bowel (see Chap. 31) if the client is having abdominal or the client removes full or partial dentures. Doing so
pelvic surgery. A clean bowel allows for improved visual- prevents the dentures from causing airway obstruction
ization of the surgical site and prevents trauma to the intes- during administration of a general anesthetic. Some anes-
tine or accidental contamination of the abdominal cavity thesiologists prefer that well-fitting dentures remain in
with feces. A cleansing enema or laxative is prescribed the place to preserve facial contours, but that information
evening before surgery and may be repeated the morning must be communicated and well documented. When
of surgery. If bowel surgery is scheduled, antibiotics may dentures are removed, they are placed in a denture con-
be prescribed to destroy intestinal microorganisms. tainer and stored at the client’s bedside or with the client’s
belongings. Other prostheses, such as artificial limbs,
FOOD AND FLUIDS. The physician gives specific instruc- also are removed unless otherwise ordered.
tions about how long to restrict food and fluids pre-
operatively. Fasting from food and water from midnight Preoperative Medications
onward before surgery is common, but the basis for the The anesthesiologist frequently orders preoperative par-
practice is now questionable. Fasting is used to reduce the enteral medications. Common preoperative medications
potential for aspirating (inhaling) stomach contents while include one or more of the following:
a client is anesthetized. However, aspiration is uncommon
• Anticholinergics, such as glycopyrrolate (Robinul), de-
today with standard practices used by those administering
crease respiratory secretions, dry mucous membranes,
general anesthesia. Consequently, the American Society and prevent vagal nerve stimulation during endotra-
of Anesthesiology (Warner et al.,1999) recommends that cheal intubation.
healthy preoperative clients can consume clear liquids • Antianxiety drugs, such as lorazepam (Ativan), reduce
2 hours before elective surgery, have a light breakfast preoperative anxiety, cause slight sedation, slow motor
6 hours before a surgical procedure, and eat a heavier activity, and promote the induction of anesthesia.
meal 8 hours beforehand (Crenshaw & Winslow, 2002; • Histamine-2 receptor antagonists, such as cimetidine
Warner et al., 1999). Despite these newer recommenda- (Tagamet), decrease gastric acidity and volume.
tions, old practices persist. The nurse, therefore, encour- • Narcotics, such as meperidine (Demerol), decrease the
ages clients to maintain good nutrition and hydration amount of anesthesia needed and sedate the client.
before the restricted time to promote nutrients, such as • Sedatives, such as midazolam (Versed), promote sleep
protein and ascorbic acid (vitamin C), needed for healing. or conscious sedation and decrease anxiety.
• Antibiotics, such as kanamycin (Kantrex), destroy
VALUABLES. The nurse instructs the client preoperatively enteric microorganisms.
to leave valuables at home. If the client forgets or does not
follow this instruction, he or she must entrust valuables Before administering preoperative medications, the nurse
to a family member. Otherwise health care agency per- checks the client’s identification bracelet (see Chaps. 32
sonnel itemize them, place them in an envelope, and lock and 34), asks about drug allergies, obtains vital signs, asks
the client to void, and ensures that the surgical consent
them in a designated area. The client signs a receipt, and
form has been signed.
the nurse notes the items’ whereabouts in the client’s
medical record.
Psychosocial Preparation
If the client is reluctant to remove a wedding band, the
nurse may slip gauze under the ring and then loop the Preparing the client emotionally and spiritually is as
gauze around the finger and wrist or apply adhesive tape important as doing so physically. Psychosocial prepa-
around a plain wedding band. The client also removes ration should begin as soon as the client is aware that
surgery is necessary. Anxiety and fear, if extreme, can • The surgical consent form has been signed and wit-
affect a client’s condition during and after surgery. Anx- nessed.
ious clients have a poor response to surgery and are prone • All laboratory test results have been returned and
to complications (Mitchell, 2003). Many clients are fear- reported if abnormal.
ful because they know little or nothing about what will • The client is wearing an identification bracelet.
happen before, during, and after surgery. Careful listening • Allergies have been identified.
and explaining by the nurse about what will happen and • The client has had nothing by mouth (NPO, nil per os)
what to expect can help to allay some of these fears and since midnight or the number of hours prescribed.
anxieties. The nurse also must assess methods the client • Skin preparation has been completed.
uses for coping. Religious faith is a source of strength for • Vital signs have been assessed and recorded.
many clients; therefore, nurses facilitate contact with a • Nail polish, glasses, contact lenses, and hairpins have
client’s clergyperson or the hospital chaplain, if requested. been removed.
• Jewelry has been removed or the wedding ring has
Preoperative Checklist been secured.
• Dentures have been removed.
A preoperative checklist is a form that identifies the status
• The client is wearing only a hospital gown and hair
of essential presurgical activities and is completed before
cover.
surgery. The nurse verifies the following:
• The client has urinated.
• The history and physical examination have been • Location of IV site, type of intravenous solution, and
documented. rate of infusion are identified.
• The name of the procedure on the surgical consent • The prescribed preoperative medication has been given
form matches that scheduled in the operating room. (Fig. 27-5).
FIGURE 27-5 • Preoperative checklist.

BOX 27-1 ● Universal Protocol for Preventing

Wrong Site, Wrong Procedure,
Wrong Person Surgery
Preoperative Verification Process
❙ Purpose: To ensure that all of the relevant documents and studies are avail-
able before the start of the procedure; that they have been reviewed; and that
they are consistent with each other, with the patient’s expectations, and with
the team’s understanding of the intended patient, procedure, site, and, as
applicable, any implants. Missing information or discrepancies must be
addressed before starting the procedure.
❙ Process: An ongoing process of information gathering and verification, begin-
ning with the determination to do the procedure, continuing through all set-
tings and interventions involved in the preoperative preparation of the patient,
up to and including the “time out” just before the start of the procedure.
Marking the Operative Site
❙ Purpose: To identify unambiguously the intended site of incision or insertion.
❙ Process: For procedures involving right/left distinction, multiple structures FIGURE 27-6 • Receiving room being prepared for incoming client.
(such as fingers and toes), or multiple levels (as in spinal procedures), the (Copyright B. Proud.)
intended site must be marked such that the mark will be visible after the
patient has been prepped and draped.
the receiving room rather than before leaving the nursing
“Time Out” Immediately Before Starting the Procedure unit. This practice coordinates the client’s sedation more
❙ Purpose: To conduct a final verification of the correct patient, procedure, site
closely with the actual time of surgery.
and, as applicable, implants.
❙ Process: Active communication among all members of the surgical/procedure
Skin preparation may be delayed until this time as well.
team, consistently initiated by a designated member of the team, conducted There is a direct relationship between the time the skin
in a “fail-safe” mode; i.e., the procedure is not started until any questions or preparation is performed and the rate of microbial pro-
concerns are resolved. liferation, especially when it has involved shaving with
a razor ( Joanna Briggs Institute, 2003; Odom-Forren,
(From Joint Commission International Center for Patient Safety [2003].
Available at: http://www.jcipatientsafety.org. Accessed July 14, 2005.)
2006). Microbes tend to grow vigorously in the plasma-
rich environment of abraded skin.
The nurse is responsible for completing and signing the Operating Room
checklist. Operating room personnel review it when they
arrive to transport the client. Surgery may be delayed if Eventually clients are taken to the operating room, where
the checklist is incomplete. their care and safety are in the hands of a team of experts
Emphasis has increased relative to ensuring that the including physicians and nurses.
right client has the proper procedure on the correct side
(if that applies). See Box 27-1 for the protocol developed
by the Joint Commission on Accreditation of Healthcare Anesthesia
Organizations (2003) to prevent errors in these categories.
Various types of anesthesia cause partial or complete loss
of sensation with or without loss of consciousness. They
INTRAOPERATIVE PERIOD include general, regional, and local anesthesia.
General Anesthesia
The intraoperative period (time during which the client
undergoes surgery) takes place in the operating suite. It General anesthesia acts on the central nervous system
involves transportation to a receiving room then to the to produce loss of sensation, reflexes, and consciousness.
operating room where anesthesia is administered and the General anesthetics commonly are administered via
procedure is performed. The family is directed to a surgi- inhaled and intravenous routes.
cal waiting area during this time. Throughout the duration of and recovery from anesthe-
sia, the client is monitored closely for effective breathing
and oxygenation; effective circulatory status, including
Receiving Room blood pressure and pulse within normal ranges; effective
temperature regulation; and adequate fluid balance. Dur-
The receiving room (Fig. 27-6) is a place in the surgery ing weaning from the anesthetic at the end of surgery, the
department where clients are observed until the operating client’s consciousness will be elevated sufficiently for him
room and surgical team are ready. In some hospitals, pre- or her to follow commands and breathe independently.
operative medication is administered when clients reach The recovery period can be brief or long. Many effects of
general anesthesia take some time for the client to elimi- how the client’s surgery is progressing. Many agencies
nate completely. Usually, clients do not remember much provide food and beverages, public telephones, television,
about the initial recovery period. and magazines in this area. Often the surgeon comes here
immediately after the procedure to contact the family.
Regional Anesthesia The family and surgeon generally go to a private room
Regional anesthesia interferes with the conduction of where the surgeon discusses the client’s status and the
sensory and motor nerve impulses to a specific area of procedure so as to ensure confidentiality.
the body. The client experiences loss of sensation and
decreased mobility to the specific anesthetized area. He
or she does not lose consciousness. Depending on the POSTOPERATIVE PERIOD
surgery, the client may receive a sedative to promote
relaxation and comfort during the procedure. Types of The postoperative period begins after the operative proce-
regional anesthesia include local and spinal anesthesia dure is completed and the client is transported to an area
and epidural and peripheral nerve blocks. to recover from the anesthesia and ends when the client
The major advantage of regional anesthesia is the is discharged. The postanesthesia care unit (PACU), also
decreased risk for respiratory, cardiac, and gastrointesti- known as the postanesthesia reacting (PAR) room or
nal complications. Team members must monitor the the recovery room, is the area in the surgical department
client for signs of allergic reactions, changes in vital signs, where clients are intensively monitored (Fig. 27-7).
and toxic reactions. In addition, they must protect the Nurses in the PACU ensure the safe recovery of surgi-
anesthetized area while sensation is absent because the cal clients from anesthesia. During this time, nurses on
client is at risk for injury. the general unit prepare for the client’s return.
The focus of postoperative care (nursing care after
Conscious Sedation surgery) is different during the immediate postopera-
Conscious sedation refers to a state in which clients are tive period than it is later, when clients are more stable.
sedated, a state of relaxation and emotional comfort, but
not unconscious. They are free of pain, fear, and anxiety
and can tolerate unpleasant diagnostic and short thera- Immediate Postoperative Care
peutic surgical procedures, such as endoscopies or bone
marrow aspiration, while maintaining independent car- The immediate postoperative period refers to the first
diorespiratory function. They can respond verbally and 24 hours after surgery. During this time, nurses monitor
physically. the client for complications as he or she recovers from
The intravenous route is used to administer medica- anesthesia. Once the client is stable, a nurse prepares a
tions that create conscious sedation. If other routes are room for the client’s return, and assessments of the client
used, the client must have venous access for treatment continue to prevent or minimize potential complications.
of possible adverse effects such as hypoxemia and cen-
tral 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.
Reversal drugs, medications that counteract the effects of
those used for conscious sedation, must be readily avail-
able in case the client becomes overly sedated. Two exam-
ples of reversal drugs are naloxone (Narcan), which is
the antagonist for opiates like morphine, and flumazenil
(Romazicon), which reverses antianxiety drugs like mida-
zolam (Versed). Clients are discharged shortly after the
procedure in which conscious sedation is used.
Surgical Waiting Area
The surgical waiting area is the room where family and

friends await information about the client. It is staffed by
volunteers who provide comfort, support, and news about FIGURE 27-7 • Postanesthesia care unit. (Copyright B. Proud.)
Initial Postoperative Assessments Food and Oral Fluids

The circulating surgical nurse or anesthesiologist reports Food and oral fluids are withheld until surgical clients
pertinent information regarding the surgery and the are awake and free of nausea and vomiting, and bowel
client’s condition to the nurse in the PACU. Once the care sounds are active. Postoperative clients usually progress
of the client is transitioned to the recovery room nurse, from a clear liquid diet to a surgical soft diet unless com-
the PACU nurse’s major responsibilities are to ensure a plications develop. Nurses monitor fluid intake and out-
patent airway; help to maintain adequate circulation; pre- put to ensure that clients are adequately hydrated.
vent or assist with the management of shock; maintain
proper positions and function of drains, tubes, and intra- Venous Circulation
venous infusions; and detect evidence of any complica-
Surgical clients ambulate with assistance as soon as pos-
tions. The nurse systematically checks the following:
sible to reduce the potential for pulmonary and vascular
• Level of consciousness complications. After some surgical procedures, however,
• Vital signs antiembolism stockings, leg exercises, ambulation, and
• Effectiveness of respirations elevation of the lower extremities may not be enough to
• Presence or need for supplemental oxygen reduce swelling of the lower extremities and the poten-
• Condition of the wound and dressing tial for thrombus formation.
• Location of drains and drainage characteristics For clients who have the potential for impaired circu-
• Location, type, and rate of intravenous fluid lation in one or both extremities, a pneumatic compression
• Level of pain and need for analgesia device (machine that promotes circulation of venous blood
• Presence of a urinary catheter and urine volume and relocation of excess fluid into the lymphatic vessels)
may be medically prescribed. Various companies make
Preparing the Room pneumatic compression devices, but they all consist of an
extremity sleeve with tubes that connect to an electrical
When the client is in the PACU, the nursing team who
air pump (Fig. 27-8). The device compresses the sleeved
will continue caring for the recovering client is alerted.
extremity either intermittently or sequentially from distal
They prepare the room for the next stage of care by getting
to proximal areas. Most devices cycle on for a few seconds
the client’s bed and the environment ready.
and then cycle off for a longer period. Depending on the
The nurses fold the top bed linen toward the foot or
manufacturer, pumps may cycle one to four times per
side of the bed. They place the bed in high position to
minute. The nurse is responsible for applying this device
facilitate transferring the client from the stretcher. Often
(Skill 27-3).
they keep additional blankets ready for use because some
Other measures to prevent thrombi include drinking
clients feel cold after being quiet and inactive.
plenty of fluids, avoiding long periods of sitting, keep-
Additionally, nurses assemble bedside supplies and
ing the legs uncrossed (especially at the knees), ambu-
equipment that facilitate caring for the client. Potentially
lating, and changing position frequently.
useful items include oxygen equipment (see Chap. 21),
a pole or electronic infusion device for continuing the
administration of intravenous fluids (see Chap. 16), an
emesis basin if the client vomits, paper tissues, and a Stop • Think + Respond BOX 27-3
device for collecting and measuring urine (see Chap. 30). Compare the use of TED hose with a pneumatic compres-
Suction canisters may be necessary for clients who have sion device; list advantages and disadvantages for each.
gastric tubes (see Chap. 29).
Monitoring for Complications Wound Management

Postoperative clients are at risk for many complications
Nurses assess the condition of the wound and the charac-
(Table 27-7), some of which are more likely soon after
teristics of drainage at least once each shift. They reinforce
surgery. Frequent focused assessments of the client and
or change dressings if they become loose or saturated.
equipment facilitate a safe postoperative recovery. See
Eventually sutures or staples are removed (see Chap. 28).
Most hospitalized clients are discharged within 3 to 5 days
of surgery to continue their recuperation at home.
Continuing Postoperative Care Discharge Instructions
After surgery, the client needs to resume eating and to The nurse provides discharge instructions (directions for
demonstrate adequate elimination, circulation, and wound managing self-care and medical follow-up) before the
healing. client leaves. Common areas to address when discharging
TABLE 27-7 POSTOPERATIVE COMPLICATIONS

COMPLICATION DESCRIPTION TREATMENT
Airway occlusion Obstruction of throat Tilt head and lift chin.

Insert an artificial airway.
Hemorrhage Severe, rapid blood loss Control bleeding.
Administer intravenous fluid.
Replace blood.
Shock Inadequate blood flow Place client in modified Trendelenburg position.
Modified Trendelenburg Position.
Replace fluids.
Administer oxygen.
Give emergency drugs.
Pulmonary embolus Obstruction of circulation through the Give oxygen.
lung as a result of a wedged blood Administer anticoagulant drugs.
clot that began as a thrombus
Hypoxemia Inadequate oxygenation of blood Give oxygen.
Adynamic ileus Lack of bowel motility Treat 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 Cleanse with antimicrobial agents.
beneath the incision Open and drain incision.
Administer antibiotics.
Dehiscence Separation of incision Reinforce wound edges.
Apply a binder.
Evisceration Protrusion of abdominal organs Cover with wet dressing.
through separated wound Reapproximate wound.
clients who have undergone surgery include the fol-

lowing:
• How to care for the incision site
Surgical clients offer unique nursing care problems.
• Signs of complications to report
Applicable nursing diagnoses include the following:
• What drugs to use to relieve pain
• How to self-administer prescribed drugs • Deficient Knowledge
• When presurgical activity can be resumed • Fear
• If and how much weight can be lifted
• Acute Pain
• Which foods to consume or avoid
• Impaired Skin Integrity
• When and where to return for a medical appointment
• Risk for Infection
The nurse should give information verbally and in writ- • Risk for Deficient Fluid Volume
ten form. • Ineffective Breathing Pattern

Providing Postoperative Care
❙ Obtain a summary report from a PACU nurse. This report provides ❙ Check the incisional area and the dressing for drainage. Findings
current assessment data concerning the client’s progress. provide data concerning the status of the wound and blood loss.
❙ Check the postoperative medical orders on the chart. The medical orders ❙ Inspect all tubes, insertion sites, and connections. For optimal outcomes,
provide instructions for individualized care. the equipment must function properly.
❙ Assist PACU personnel to transfer the client to bed. The client should be ❙ Check the type of intravenous fluid, rate of administration, and volume
observed continuously at this time. that remains. Findings provide data regarding fluid therapy.
❙ Observe the client’s respiratory pattern and auscultate the lungs. ❙ Monitor urination; report failure to void within 8 hours of surgery.
Maintaining breathing is a priority for care. Failure to void indicates urinary retention.
❙ Check oxygen saturation using a pulse oximeter if the client seems hypoxic ❙ Auscultate bowel sounds. Findings provide data concerning bowel
(see Chap. 21). An oximeter indicates the quality of internal respiration. motility.
❙ Administer oxygen if the oxygen saturation is less than 90% or if ❙ Assess the client’s level of pain, its location, and characteristics. Pain
prescribed by the physician. Oxygen administration increases oxygen indicates the need for analgesia.
available for binding with hemoglobin and for becoming dissolved in
the plasma.
❙ Administer analgesic drugs according to prescribed medical orders, if
doing so is safe. Analgesic drugs relieve pain.
❙ Note the client’s level of consciousness and response to stimulation.
Findings indicate the client’s neurologic status. ❙ Remind the client to perform leg exercises or apply antiembolism
stockings. Leg exercises and antiembolism stockings promote
❙ Orient the client and instruct him or her to take several deep breaths,
circulation.
as taught preoperatively. Deep breathing improves ventilation and
gas exchange. ❙ Use a side-lying position if the client is lethargic or unresponsive. This
position prevents airway obstruction by the tongue and aspiration of
❙ Check vital signs. Findings provide data for assessing the client’s current
emesis if vomiting occurs.
general condition.
❙ Raise the side rails unless providing direct care. Keeping the side rails
❙ Repeat vital sign assessments at least every 15 minutes until they are
up ensures safety.
stable; then follow agency policy and retake them every hour to every
4 hours depending on the client’s condition or medical orders. Repeat ❙ Fasten the signal device within the client’s reach. The signal device is a
assessment of vital signs provides comparative data. way for the client to communicate and obtain assistance.
• Ineffective Airway Clearance (2005, p.18) as “confusion in (the) mental picture of one’s
• Risk for Impaired Gas Exchange physical self.” This diagnosis is especially pertinent to
• Disturbed Body Image clients who have had their appearance altered as a result
• Risk for Ineffective Therapeutic Regimen Management of surgery.
Nursing Care Plan 27-1 shows how the nurse can use
the nursing process to identify and resolve a diagnosis of
Disturbed Body Image, defined in the NANDA taxonomy GENERAL GERONTOLOGIC
CONSIDERATIONS
Chronic health concerns may be present in older adults and
may increase the complexity of both the preoperative and
postoperative periods.
According to the Agency for Healthcare Research and Quality
(2003), clients 65 years and older account for one of every
three hospital admissions. The mean length of stay for this
age group is 1.7 days longer than for people younger than
65 years.
Older adults who rely on eyeglasses or hearing aids may experi-
ence sensory deprivation if these aids are removed before
surgery or other procedures. Removal may interfere with
communication or contribute to confusion and altered
mental status.
Older adults also are likely to be self-conscious when dentures are
removed before surgery. Collaboration with operating room
personnel regarding the removal of dentures, eyeglasses, and
hearing aids is helpful to ensure their use as much or as long
FIGURE 27-8 • Pneumatic compression device. as possible.
Disturbed Body Image
ASSESSMENT
• Observe the client’s reaction to his or her body changes.
• Note if the client refuses to touch or look at the body part that has been altered.
• Scrutinize the client’s involvement, or lack of it, in learning techniques for self-care or rehabilitation.
• Observe if the client seeks others to manage care for which he or she is capable.
• Watch the quality and quantity of the client’s social interactions or avoidance of others.
• Listen for self-depreciating remarks or hostility toward others.
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 feet 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
midafternoon, and early evening without performing communicates interest and acceptance of the client as a
direct care. worthwhile person.
During interaction, sit within 3 feet of the client. Sitting closely provides evidence that closeness is not a
problem.
Acknowledge verbally that the ostomy and resulting Verbalizing what the client is implying nonverbally and
change in elimination are difficult to accept. actively demonstrating shows empathy.
Offer to contact another person with an ostomy through Interacting with another person who is coping well with a
the United Ostomy Association. similar change can help the client to share feelings and
acquire a different perspective from an objective role
model.
Offer 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
avoid facial expressions that may communicate disgust or expressions during communication.
repulsion.
Use terminology such as “your stoma,” and avoid any Using inappropriate terms trivializes the significance of
depersonalized or slang names for the changed body part. the issue with which the client is coping.

• Client moved away to provide more distance during close interaction.
• Client looked at stoma while skin care and changing of appliance were demonstrated.
• Client read booklet provided by the United Ostomy Association.
• Client agreed to meet with the enterostomal therapist.
The period of fluid restriction before surgery may be shortened friends, options relative to extended or skilled nursing care
for older adults to reduce their risk for dehydration and should be explored and discussed. Options for skilled nursing
hypotension. Vital signs, weight, and sternal skin turgor or rehabilitation services may be available for home settings.
should be assessed before fluid restriction to serve as a
baseline for comparison.
The older person should be educated about taking usual medica- CRITICAL THINKING E X E R C I S E S
tions before surgical procedures and about resuming usual or
new medications after surgery. 1. A nurse assesses a postoperative client and obtains the
Many older adults are on anticoagulation therapy—including self- following data: blood pressure 102/64, pulse rate 90, res-
therapy with low-dose aspirin—and may need to have this pirations 32 and shallow, responds when shaken, expe-
addressed as a preoperative consideration. Evaluate the older riencing nausea. What finding is most serious at this time,
person’s use of aspirin and medications containing salicylates. and what nursing actions are appropriate?
Ibuprofen (Advil) and naproxen (Aleve) may also increase the
risk for gastrointestinal side effects such as bleeding. Assess- 2. A preoperative client who is Native American wants you to
ment of alternative therapies, such as herbs (e.g., ginkgo, attach a dream catcher, a circular object with a woven web,
ginseng), is necessary because these therapies may increase to the IV pole. What is an appropriate way to respond to
the risk for bleeding postoperatively. the client’s request?
The cardiac status of older adults is monitored carefully after
surgery because they may not be able to tolerate or eliminate
intravenous fluids given at standard rates. Similarly, rates of NCLEX-STYLE REVIEW Q U E S T I O N S
intravenous fluids may need to be adjusted for older adults,
especially if their renal or cardiac status is compromised. 1. Preoperative skin preparation is best performed
Muscle atrophy occurs in older adults who have been on bed rest 1. The night before surgery
even for 1 or 2 days. Range of motion and muscle tone can be 2. After the morning shower
maintained through routine active or passive range-of-motion 3. Before preoperative sedation
exercises. 4. In the operating room area
Wound healing in older adults may occur more slowly because of
age-related skin changes and impaired circulation and oxy-
2. From whom is it most appropriate to obtain consent to
genation. Poor hydration and nutrition further interfere with perform surgery on an adolescent with a fractured tibia?
wound healing. A registered dietitian can recommend nutri- 1. The client himself or herself
tional interventions such as albumin, zinc, and vitamin C to 2. The client’s physician
improve wound healing. 3. The client’s minister
If older adults develop postoperative infections, the manifestations 4. The client’s parent
are likely to be subtle or delayed. Older adults are likely to
have lower “normal” temperature. Therefore, it is imperative to
3. If a client who will undergo surgery is wearing a ring,
document the client’s usual baseline temperature so deviations which action is most correct?
can be assessed. A change in mental status may be an early 1. Put the ring in the bedside stand.
indicator of infection. 2. Leave the ring on the client’s finger.
If an indwelling catheter is inserted before surgery, it is best to 3. Give the ring to the security guard.
remove it as soon as possible after surgery to prevent inconti- 4. Lock the ring with his valuables.
nence and urinary tract infections. Prompt attention to bladder
4. After giving a preoperative medication containing a nar-
schedule is indicated to ensure adequate voiding amounts and
timing, especially if a bedpan will be required during a period cotic, the most important nursing action is to
of ambulatory restrictions. 1. Raise the side rails.
A thorough assessment of the client’s support system must be done 2. Help the client to the toilet.
well before discharge. It should include the ability of the support 3. Provide oral hygiene.
system to provide assistance once the client is discharged. 4. Teach leg exercises.
Support people should be included in discharge teaching, with
5. When the nurse assesses a client postoperatively, which
plenty of time to provide any return demonstration of learning
regarding the needs of the older adult. Additionally, the home’s assessment is most indicative of shock?
environment should be assessed before discharge for safety 1. Bounding pulse
issues (e.g., use of scatter rugs, lighting, rails, grab bars). 2. Slow respirations
If the older person cannot manage his or her postoperative care 3. Low blood pressure
independently or with the assistance of supportive family or 4. High body temperature
Skill 27-1 • APPLYING ANTIEMBOLISM STOCKINGS
Assessment
Review the medical orders and nursing plan for care. Directs client care
Wash your hands or perform an alcohol-based handrub Reduces the transmission of microorganisms.
(see Chap. 10).
Check Homans’ sign by dorsiflexing the foot and noting if Indicates the possibility of thrombophlebitis (inflammation
the client experiences pain in the calf. Report a positive of a vein as a result of a thrombus)
finding.
Measure the client’s leg from the flat of the heel to the Determines the length needed for knee-high or thigh-high
bend of 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 Determines the type and amount of health teaching
of elastic stockings. needed
Check the fit of stockings that the client is currently Identifies the potential complications from tight, loose, or
wearing. wrinkled stockings
Planning
Obtain the correct size of stockings before surgery or as Facilitates early preventive treatment
soon as possible after they are ordered.
Plan to remove the stockings for 20 minutes once each Allows for assessment and hygiene
shift 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
stockings if the client has been sitting or standing for blood in the lower extremities
some 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 stocking inside out, tucking heel inside. (Copyright B. Proud.)
(continued)
APPLYING ANTIEMBOLISM STOCKINGS (Continued)
Insert the toes and pull the stocking upward a few inches Reduces bunching and bulkiness
until it covers the foot (Fig. B).
Easing foot section over toe and heel. (Copyright B. Proud.)
Gather the remaining length of stocking and pull it Eases application and avoids forming wrinkles
upward a few inches at a time (Fig. C).
Pulling stocking upward over rest of leg. (Copyright 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 nailbeds within 3 seconds of compression. Skin over legs is smooth
and intact. Homans’ sign is negative. TED hose applied after bathing.
SIGNATURE/TITLE
Skill 27-2 • PERFORMING PRESURGICAL SKIN PREPARATION
Assessment
Consult the preoperative medical orders or a guide for Indicates the location and extent of skin preparation
surgical skin preparation (Fig. A). according to the planned surgical procedure
A
Guide for surgical skin preparation.
(see Chap. 10).
Assess the condition of the skin, looking especially for Indicates areas that may bleed if irritated or provide a
skin lesions. reservoir of microorganisms
Explore how much the client understands about the Helps to identify the extent and level of health teaching
purpose and extent of skin preparation. needed
Planning
Arrange to perform the skin preparation shortly before Reduces the time during which microorganisms will
the client is scheduled for surgery. recolonize 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 a skin preparation kit, towels, bath blanket, gloves, Provides essential supplies
hair removal items, if ordered, and source of water.
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
(continued)
PERFORMING PRESURGICAL SKIN PREPARATION (Continued)
Protect the bed with towels or an absorbent pad. Collects moisture
Use electric hair clippers to remove hair from the Prevents microabrasions
designated area.
If policy permits, use a depilatory agent (chemical that Removes hair where clippers or razors may be ineffective
removes hair) around bony prominences like the
knuckles or ankle.
Lather the designated skin area with soap or other Loosens dirt, debris, and microorganisms
antimicrobial agent (Fig. B).
Cleaning the designated skin area.
Use a safety razor to remove hair, if that is agency policy, Removes hair and epidermis; stretches skin to produce a
by pulling the skin taut and moving the razor in the flatter surface; increases effectiveness; cleans the blade
direction of hair growth. Rinse the razor periodically.
Rinse the lather and loose hair from the skin. Removes debris
Relather and scrub the skin from the center of the Follows principles of medical asepsis (see Chap. 10).
designated area outward toward the margins.
Remove the soap, following a similar pattern. Follows principles of medical asepsis
Dry the skin. Eliminates moisture
Discard the razor, if one was used, in a biohazard Reduces the potential for injury and transmission of
container. blood-borne viruses
Deposit the wet towels and bath blanket in a laundry Restores comfort and orderliness
hamper.
Place the used supplies in a waste receptacle. Confines sources of infectious disease transmission
Remove gloves and wash hands. Reduces the transmission of microorganisms
Evaluation
• Skin has been prepared according to policy and
medical orders.
• Skin remains essentially intact.
(continued)
PERFORMING PRESURGICAL SKIN PREPARATION (Continued)
Document
• Technique used
• Area prepared
Date and Time Skin areas for laparotomy procedure cleansed with Betadine and shaved. Skin is intact. No evidence of
bleeding. SIGNATURE/TITLE
Skill 27-3 • APPLYING A PNEUMATIC COMPRESSION DEVICE
Assessment
Review the medical orders and nursing plan for care. Directs client care
Determine whether the device will be applied to one or Gives direction for gathering assessment data and
both extremities. applying the device
Wash your hands or perform an alcohol-based handrub Reduces the potential for the transmission of
(see Chap. 10). microorganisms
Assess the circulation of the toes and integrity of the skin. Provides a baseline of data for future comparison
Check Homans’ sign (see Skill 27-1) and report if it is Indicates a possible thrombophlebitis; if positive, it is a
positive. contraindication for use of a pneumatic compression
device
Measure the calf circumference and assess for pitting Provides a baseline of data for future comparisons
edema in 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 Determines the type and amount of health teaching
of a pneumatic compression device. needed
Planning
Obtain the extremity sleeves, electric air pump, and Facilitates expeditious implementation of the medical
accompanying air tubes. order
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 Promotes independence yet ensures that the client can call
reach, including the signal device. for assistance
Help the client to a position of comfort such as a supine or Fosters rest and relaxation
low Fowler’s position.
(continued)
APPLYING A PNEUMATIC COMPRESSION DEVICE (Continued)
Implementation
Wrap the extremity sleeve snugly around the calf (Fig. A). Positions the sleeve where compression is desired
Applying the extremity sleeve. (Copyright B. Proud.)
Secure the sleeve once it encircles the leg; most are Ensures that the sleeve will remain in the applied position
secured with Velcro.
Secure the air pump to the bottom of the bed or a stable Protects the device from damage and prevents injury to
surface. staff or visitors
Attach the air tubes to the ports that extend from the Provides a channel through which air is delivered to the
sleeve and to the adapter within the air pump (Fig. B). extremity sleeve
Attaching air tubes so that arrows align. (Copyright 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
(most medical orders range from 35 to 55 mm Hg, with pressure to promote venous circulation
a common average of 40 mm Hg).
Turn the power switch on and observe that the function Indicates that the machine is operational
lights illuminate during compression and turn off
between compressions. (continued)
APPLYING A PNEUMATIC COMPRESSION DEVICE (Continued)
Assess the client’s circulatory status and comfort every 2 Focuses assessment on signs that indicate adverse effects
to 4 hours throughout the therapeutic treatment, which
is continuous for some clients.
Remove the extremity sleeve before ambulation or other Allows freedom of movement from the tether of the air
out-of-bed activities. tubes and pump
Discontinue the compressions if serious impairment of Helps to avoid serious complications
circulation and sensation, tingling, numbness, or leg
pain occurs.
Remove the extremity sleeve and assess calf size and Provides comparative data with which to evaluate the
circulation to distal areas of the extremity at least once therapeutic response
per day.
Apply elastic stockings and reinforce the need to perform Promotes venous circulation
leg exercises every hour when the machine is not in use.
Place equipment in a safe area where it is available for the Demonstrates regard for safety and efficient time
next use. management
Evaluation
• Calf size is reduced or does not increase in diameter.
• Homans’ sign is negative.
• Skin in lower extremity is intact, warm, and appropri-
ate color for ethnicity.
• Capillary refill is less than 2 to 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 R. calf measures 18″ (45 cm). L. calf is 20″ (50 cm). Toes are warm. Blood returns to nailbeds within
3 seconds of compression. Skin over legs is pink, warm, and intact. Homans’ sign is negative bilater-
ally. Pneumatic compression device applied to calves of both legs and set at a pressure of 40 mmHg.
SIGNATURE/TITLE
Date and Time Pneumatic compression device removed after 2 hrs. of use to facilitate bathing and reapplied at
40 mmHg. SIGNATURE/TITLE
28
Chapter
Wound Care
LEARNING OBJECTIVES
WORDS TO KNOW
aquathermia pad
bandage ● Define the term wound.
binder ● Name three phases of wound repair.
capillary action ● Identify five signs and symptoms classically associated with the inflammatory response.
closed wound ● Discuss the purpose of phagocytosis, including the two types of cells involved.
collagen ● Name three ways in which the integrity of a wound is restored.
compresses ● Explain first-, second-, and third-intention healing.
débridement ● Name two types of wounds.
dehiscence ● State at least three purposes for using a dressing.
douche ● Explain the rationale for keeping wounds moist.
drains ● Describe two types of drains, including the purpose of each.
dressing ● Name the two major methods for securing surgical wounds together until they heal.
evisceration ● Explain three reasons for using a bandage or binder.
first-intention healing ● Discuss the purpose for using one type of binder.
granulation tissue ● Give examples of four methods used to remove nonliving tissue from a wound.
hydrotherapy ● List three commonly irrigated structures.
inflammation ● State two uses each for applying heat and for applying cold.
irrigation ● Identify at least four methods for applying heat and cold.
leukocytes ● List at least five risk factors for developing pressure ulcers.
leukocytosis ● Discuss three techniques for preventing pressure ulcers.
macrophages
Montgomery straps
necrotic tissue
open wound
pack BODY tissues have a remarkable ability to recover when injured. This chapter dis-
phagocytosis
cusses several types of tissue injury, including those caused by surgical incisions and
pressure ulcer
proliferation prolonged pressure. It also addresses nursing interventions to support the healing
purulent drainage process and actions to prevent tissue injury.
regeneration
remodeling
resolution
scar formation
second-intention healing
sepsis
WOUNDS
serous drainage
shearing force
A wound (damaged skin or soft tissue) results from trauma (general term referring to
sitz bath
skin tear injury). Examples of tissue trauma include cuts, blows, poor circulation, strong chem-
soak icals, and excessive heat or cold. Such trauma produces two basic types of wounds:
staples open and closed (Table 28-1).
sutures An open wound is one in which the surface of the skin or mucous membrane is no
therapeutic baths
third-intention healing
longer intact. It may be caused accidentally or intentionally, as when a surgeon incises
trauma the tissue. In a closed wound, there is no opening in the skin or mucous membrane.
wound Closed wounds occur more often from blunt trauma or pressure.
638
C H A P T E R 28 ● Wound Care 639
TABLE 28-1 TYPES OF WOUNDS

WOUND TYPES DESCRIPTION
Open Wounds
Incision A clean separation of skin and tissue with smooth, even edges
Laceration A separation of skin and tissue in which the edges are torn and irregular
Abrasion A wound in which the surface layers of skin are scraped away
Avulsion Stripping away of large areas of skin and underlying tissue, leaving
cartilage and bone exposed
Ulceration A shallow crater in which skin or mucous membrane is missing
Puncture An opening of skin, underlying tissue, or mucous membrane caused
by a narrow, sharp, pointed object
Closed Wounds
Contusion Injury to soft tissue underlying the skin from the force of contact with a
hard object, sometimes called a bruise
Neutrophils and monocytes, specific kinds of white

WOUND REPAIR blood cells, are primarily responsible for phagocytosis,
which is a process by which these cells consume pathogens,
Regardless of the type of wound, the body immediately coagulated blood, and cellular debris. Collectively, neutro-
attempts to repair the injury and heal the wound. The phils and monocytes clean the injured area and prepare the
process of wound repair proceeds in three sequential site for wound healing.
phases: inflammation, proliferation, and remodeling.
Tissue injury
Inflammation
Cellular response
Inflammation, the physiologic defense immediately after tis-
sue injury, lasts approximately 2 to 5 days. Its purposes are
to (1) limit the local damage, (2) remove injured cells and Increased membrane permeability
debris, and (3) prepare the wound for healing. Inflamma-
tion progresses through several stages (Fig. 28-1). Swelling
During the first stage, local changes occur. Immedi-
ately following an injury, blood vessels constrict to con-
Reduced local circulation
trol blood loss and confine the damage. Shortly thereafter,
the blood vessels dilate to deliver platelets that form a
loose clot. The membranes of the damaged cells become
more permeable, causing release of plasma and chemical Vascular response Chemical response
substances that transmit a sensation of discomfort. The
local response produces the characteristic signs and symp- Dilation, redness, Pain
toms of inflammation: swelling, redness, warmth, pain, and and warmth
decreased function.
A second wave of defense follows the local changes
when leukocytes and macrophages (types of white blood Decreased function
cells) migrate to the site of injury, and the body produces
more and more white blood cells to take their place. Leuko- Leukocytosis
cytosis (increased production of white blood cells) is con-
firmed and monitored by counting the number and type of
Phagocytosis
white blood cells in a sample of the client’s blood. The lab-
oratory test is called a white blood cell count and differen-
tial. Increased white blood cells, particularly neutrophils Wound repair
and monocytes, suggest an inflammatory and, in some FIGURE 28-1 • The inflammatory response. The words in red are the
cases, infectious process. five classic signs and symptoms of inflammation.
Proliferation
Proliferation (period during which new cells fill and seal a

wound) occurs from 2 days to 3 weeks after the inflamma-
tory phase. It is characterized by the appearance of granu-
lation tissue (combination of new blood vessels, fibroblasts,
and epithelial cells), which is bright pink to red because of
the extensive projections of capillaries in the area.
Granulation tissue grows from the wound margin
toward the center. It is fragile and easily disrupted by A
physical or chemical means. As more and more fibroblasts
produce collagen (a tough and inelastic protein substance),
the adhesive strength of the wound increases. Toward the
end of the proliferative phase, the new blood vessels degen-
erate, causing the previously pink color to regress.
Generally, the integrity of skin and damaged tissue is
restored by (1) resolution (process by which damaged cells
recover and re-establish their normal function), (2) regen-
eration (cell duplication), or (3) scar formation (replacement
of damaged cells with fibrous scar tissue). Fibrous scar tis-
sue acts as a nonfunctioning patch. The extent of scar tis-
sue that forms depends on the magnitude of tissue damage
and the manner of wound healing (discussed later in this B
chapter).
Remodeling
Remodeling (period during which the wound undergoes

changes and maturation) follows the proliferative phase
and may last 6 months to 2 years (Porth, 2004). During
this time, the wound contracts, and the scar shrinks.
WOUND HEALING
C
FIGURE 28-2 • (A) First-intention healing. (B) Second-intention healing.
Several factors affect wound healing: (C ) Third-intention healing.
• Type of wound injury
• Expanse or depth of wound
plex reparative process. Because the margins of the
• Quality of circulation
wound are not in direct contact, the granulation tissue
• Amount of wound debris
needs additional time to extend across the expanse
• Presence of infection
of the wound. Generally, a conspicuous scar results.
• Status of the client’s health
Healing by second intention is prolonged when the
The speed of wound repair and the extent of scar tis- wound contains body fluid or other wound debris.
sue that forms depend on whether the wound heals by Wound care must be performed cautiously to avoid dis-
first, second, or third intention (Fig. 28-2). rupting the granulation tissue and retarding the healing
First-intention healing, also called healing by primary process.
intention, is a reparative process in which the wound With third-intention healing, the wound edges are widely
edges are directly next to each other. Because the space separated and are later brought together with some type
between the wound is so narrow, only a small amount of of closure material. This reparative process results in a
scar tissue forms. Most surgical wounds that are closely broad, deep scar. Generally, wounds that heal by third
approximated heal by first intention (Fig. 28-3). intention are deep and likely to contain extensive drainage
In second-intention healing, the wound edges are widely and tissue debris. To speed healing, they may contain
separated, leading to a more time-consuming and com- drainage devices or be packed with absorbent gauze.
removal of sutures or staples; unusual strain on the inci-

sion from severe coughing, sneezing, vomiting, dry heaves,
or hiccupping; weak tissue or muscular support secondary
to obesity; distention of the abdomen from accumulated
intestinal gas; or compromised tissue integrity from previ-
ous surgical procedures in the same area.
The client may describe that something has “given
way.” Pinkish drainage may appear suddenly on the dress-
ing. If wound disruption is suspected, the nurse positions
the client to put the least strain on the operated area. If
evisceration occurs, the nurse places sterile dressings
moistened with normal saline over the protruding organs
and tissues. For any wound disruption, the nurse notifies
the physician immediately. The nurse must be alert for
signs and symptoms of impaired blood flow such as
swelling, localized pallor or mottled appearance, and cool-
FIGURE 28-3 • Example of first-intention wound healing.
ness of the tissue in the area around the wound.
WOUND HEALING COMPLICATIONS Stop • Think + Respond BOX 28-1

Discuss the signs and symptoms a person would exhibit if
The key to wound healing is adequate blood flow to the a wound were infected.
injured tissue. Factors that may interfere include compro-
mised circulation; infection; and purulent, bloody, or
serous fluid accumulation that prevent skin and tissue
approximation. In addition, excessive tension or pulling WOUND MANAGEMENT
on wound edges contributes to wound disruption and
delays healing. One or several of these factors may be sec-
ondary to poor nutrition, impaired inflammatory or Wound management involves techniques that promote
immune responses secondary to drugs like corticosteroids, wound healing. Surgical wounds result from incising
and obesity (see discussion of surgical risks in Chap. 27). tissue with a laser (see Chap. 27) or an instrument called
The nurse assesses the wound to determine whether it is a scalpel. The primary goal of surgical or open wound
intact or shows evidence of unusual swelling, redness, management is to reapproximate the tissue to restore its
warmth, drainage, and increasing discomfort. integrity.
Two potential surgical wound complications include A pressure ulcer is a wound caused by prolonged capil-
dehiscence (separation of wound edges) and evisceration lary compression that is sufficient to impair circulation to
(wound separation with protrusion of organs) (Fig. 28-4). the skin and underlying tissue. The primary goal in man-
These complications are most likely within 7 to 10 days aging pressure ulcers is prevention. Once a pressure ulcer
after surgery. They may be caused by insufficient dietary forms, however, the nurse implements measures to reduce
intake of protein and sources of vitamin C; premature its size and to restore skin and tissue integrity.
FIGURE 28-4 • (A) Wound dehiscence (B) Wound

A B
evisceration.
Wound management involves changing dressings, car-

ing for drains, removing sutures or staples when directed
by the surgeon, applying bandages and binders, and admin-
istering irrigations.
Dressings
A dressing (cover over a wound) serves one or more A

purposes:
• Keeping the wound clean
• Absorbing drainage
• Controlling bleeding
• Protecting the wound from further injury
• Holding medication in place
• Maintaining a moist environment
Types and sizes of dressings differ depending on their
purpose. The most common wound coverings are gauze,
transparent, and hydrocolloid dressings.
Gauze Dressings B
Gauze dressings are made of woven cloth fibers. Their FIGURE 28-5 • (A) The adhesive outer edge of Montgomery straps
highly absorbent nature makes them ideal for covering are applied to either side of a wound. (B) The inner edges of Mont-
fresh wounds that are likely to bleed or wounds that exude gomery straps are tied to hold a dressing over a wound. They prevent
skin breakdown and wound disruption from repeated tape removal
drainage. Unfortunately, gauze dressings obscure the when checking or changing a dressing.
wound and interfere with wound assessment. Unless oint-
ment is used on the wound or the gauze is lubricated with
an ointment such as petroleum, granulation tissue may
28-7). They keep wounds moist. Moist wounds heal more
adhere to the gauze fibers and disrupt the wound when
quickly because new cells grow more rapidly in a wet
removed.
environment. If the hydrocolloid dressing remains intact,
Gauze dressings usually are secured with tape. If gauze
it can be left in place for up to 1 week. Its occlusive nature
dressings need frequent changing, Montgomery straps (strips
also repels other body substances such as urine or stool.
of tape with eyelets) may be used (Fig. 28-5). Another
For proper use, a hydrocolloid dressing must be sized gen-
method may be necessary if the client is allergic to tape
erously, allowing at least a 1-inch margin of healthy skin
(see the discussion of bandages and binders later in this
around the wound.
chapter).
Transparent Dressings
Transparent dressings such as Op-Site are clear wound
coverings. One of their chief advantages is that they allow
the nurse to assess a wound without removing the dress-
ing. In addition, they are less bulky than gauze dressings
and do not require tape because they consist of a single
sheet of adhesive material (Fig. 28-6). They commonly
are used to cover peripheral and central intravenous
insertion sites. Transparent dressings are not absorbent,
so if wound drainage accumulates, they tend to loosen.
Once a dressing is no longer intact, many of its original
purposes are defeated.
Hydrocolloid Dressings
Hydrocolloid dressings such as DuoDerm are self-adhesive,
opaque, air- and water-occlusive wound coverings (Fig. FIGURE 28-6 • Transparent dressing. (Copyright B. Proud.)
FIGURE 28-7 • A hydrocolloid dressing absorbs drainage into its matrix.
Dressing Changes
Health care professionals change dressings when a wound
requires assessment or care and when the dressing be-
comes loose or saturated with drainage. In some cases, the
physician may choose to assume total responsibility for
FIGURE 28-8 • An open drain is pulled from the wound, and the
changing the dressing—at least for the initial dressing excess portion is cut. A drain sponge is placed around the drain, and
change. Nurses commonly reinforce dressings (apply addi- the wound is covered with a gauze dressing.
tional absorbent layers), however, when dressings become
moist. Reinforcing a dressing prevents wicking micro-
organisms toward the wound (see Chap. 10). wound. To shorten a drain, the nurse pulls it from the
Because most surgical wounds are covered with gauze wound for the specified length. He or she then reposi-
dressings, this example is used when describing the tech- tions the safety pin or clip near the wound to prevent
nique for changing a dressing in Skill 28-1. When using the drain from sliding back internally within the wound
dressings made of materials other than gauze, nurses can (Fig. 28-8).
modify the technique by following the manufacturer’s
directions. Closed Drains
Closed drains are tubes that terminate in a receptacle.
Drains Some examples of closed drainage systems are a Hemovac
and Jackson-Pratt (JP) drain (Fig. 28-9). Closed drains are
Drains are tubes that provide a means for removing blood more efficient than open drains because they pull fluid by
and drainage from a wound. They promote wound heal- creating a vacuum or negative pressure. This is done by
ing by removing fluid and cellular debris. Although some opening the vent on the receptacle, squeezing the drainage
drains are placed directly within a wound, the current collection chamber, then capping the vent.
trend is to insert them so that they exit from a separate
location beside the wound. This approach keeps the
wound margins approximated and avoids a direct entry
site for pathogens. The physician may choose to use an
open or closed drain.
Open Drains
Open drains are flat, flexible tubes that provide a path-
way for drainage toward the dressing. Draining occurs
passively by gravity and capillary action (movement of a
liquid at the point of contact with a solid, which in this
case is the gauze dressing). Sometimes a safety pin or
long clip is attached to the drain as it extends from the
wound. This prevents the drain from slipping within
the tissue. As the drainage decreases, the physician may
instruct the nurse to shorten the drain, enabling heal-
ing to take place from inside toward the outside of the FIGURE 28-9 • Jackson-Pratt (closed) drain. (Copyright B. Proud.)
When caring for a wound with a drain, the nurse cleans Bandages and Binders
the insertion site in a circular manner. After cleansing, he
or she places a precut drain sponge or gauze, which is open A bandage is a strip or roll of cloth wrapped around a body
to its center, around the base of the drain. An open drain part. One example is an Ace bandage. A binder is a type of
may require additional layers of gauze because the drainage bandage generally applied to a particular body part such
does not collect in a receptacle. 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:
Sutures and Staples
• Holding dressings in place, especially when tape can-
Sutures, knotted ties that hold an incision together, gen- not be used or the dressing is extremely large
erally are constructed from silk or synthetic materials • Supporting the area around a wound or injury to reduce
such as nylon. Staples (wide metal clips) perform a pain
similar function. Staples do not encircle a wound • Limiting movement in the wound area to promote
like sutures; instead, they form a bridge that holds the healing
two wound margins together. Staples are advantageous
because they do not compress the tissue should the Roller Bandage Application
wound swell. Most bandages are prepared in rolls of varying widths.
Sutures and staples are left in place until the wound The nurse holds the end in one hand while passing the
has healed sufficiently to prevent reopening. Depending roll around the part being bandaged.
on the location of the incision, this may be a few days to Nurses follow several principles when applying a
as long as 2 weeks. roller bandage:
The physician may direct the nurse to remove sutures
and staples (Fig. 28-10), sometimes half on one day and • Elevate and support the limb.
the other half on another day. Adhesive Steri-Strips, also • Wrap from a distal to proximal direction.
known as butterflies because of their winged appearance, • Avoid gaps between each turn of the bandage.
• Exert equal, but not excessive, tension with each turn.
can hold a weak incision together temporarily. Some-
• Keep the bandage free of wrinkles.
times Steri-Strips are used instead of sutures or staples to
• Secure the end of the roller bandage with metal clips.
close superficial lacerations.
• Check the color and sensation of exposed fingers or
toes often.
• Remove the bandage for hygiene and replace at least
twice a day.
Six basic techniques are used to wrap a roller bandage
(Fig. 28-11): circular turn, spiral turn, spiral-reverse turn,
figure-of-eight turn, spica turn, and recurrent turn.
A circular turn is used to anchor and secure a bandage
where it starts and ends. It simply involves holding the
free end of the rolled material in one hand and wrapping
A
it around the area, bringing it back to the starting point.
A spiral turn partly overlaps a previous turn. The
amount of overlapping varies from one half to three
fourths of the width of the bandage. Spiral turns are used
when wrapping cylindrical parts of the body such as the
arms and legs.
A spiral-reverse turn is a modification of a spiral turn.
The roll is reversed or turned downward halfway through
the turn.
A figure-of-eight turn is best when bandaging a joint
such as the elbow or knee. This pattern is made by mak-
ing oblique turns that alternately ascend and descend,
simulating the number eight.
B
A spica turn is a variation of the figure-of-eight pat-
FIGURE 28-10 • (A) Technique for suture removal. (B) Technique for tern. It differs in that the wrap includes a portion of the
staple removal. trunk or chest (see spica cast, Chap. 25).
E
FIGURE 28-11 • (A) Circular and spiral turn. (B) Spiral-reverse turn. (C) Figure-of-eight turn. (D) Spica turn.
(E) Recurrent turn.
A recurrent turn is made by passing the roll back and uefy wound debris. A dressing is used to keep the enzyme
forth over the tip of a body part. Once several recurrent in contact with the wound and to help absorb the
turns are made, the bandage is anchored by completing drainage. This form of débridement is appropriate for
the application with another basic turn such as the figure- uninfected wounds or for clients who cannot tolerate
of-eight turn. A recurrent turn is especially beneficial sharp débridement.
when wrapping the stump of an amputated limb or the
head. Autolytic Débridement
Autolytic débridement, or self-dissolution, is a painless,
Binder Application
natural physiologic process that allows the body’s enzymes
Binders are not used as commonly as bandages; more con- to soften, liquefy, and release devitalized tissue. It is
venient commercial devices have largely replaced binders. used when a wound is small and free of infection. The
For example, brassieres frequently are used instead of main disadvantage to autolysis is the prolonged time it
breast binders. Sometimes after rectal or vaginal surgery, takes to achieve desired results. To accelerate autoly-
nurses apply a T-binder, which, as the name implies, sis, an occlusive or semiocclusive dressing keeps the
looks like the letter T (Fig. 28-12). T-binders are used to wound moist. Because removal of tissue debris is slow,
secure a dressing to the anus or perineum or within the the nurse monitors the client closely for signs of wound
groin. To apply a T-binder, the nurse fastens the cross- infection.
bar of the T around the waist. Then he or she passes the
single or double tails between the client’s legs and pins Mechanical Débridement
the tails to the belt. Adhesive sanitary napkins worn
inside underwear briefs are an alternative to a T-binder Mechanical débridement involves physical removal of
for stabilizing absorbent materials. debris from a deep wound. One technique is the applica-
tion of wet-to-dry dressings. The wound is packed with
moist gauze, which is removed approximately 4 to
Débridement 6 hours later when the gauze is dry. Dead tissue adheres
to the meshwork of the gauze and is removed when the
Most wounds heal rapidly with conventional care. Nev- dressing is changed. Recently, the use of wet-to-dry
ertheless, some wounds require débridement (removal of dressings for débridement has come under questioning.
dead tissue) to promote healing. The four methods for Some disadvantages include (1) impeded healing from
débriding a wound are sharp, enzymatic, autolytic, and local tissue cooling, (2) disruption of angiogenesis (forma-
mechanical. tion of new blood vessels), and (3) increased risk for infec-
tion from frequent dressing changes (Armstrong, 2004).
Sharp Débridement It has also been described as being nonselective, trauma-
tic, painful, costly, and time consuming (Dolynchuk
Sharp débridement is the removal of necrotic tissue (non-
et al., 2000). Many now believe that sharp débridement
living tissue) from the healthy areas of a wound with
is the preferred method for facilitating healing by second
sterile scissors, forceps, or other instruments. This method
intention.
is preferred if the wound is infected because it helps the
Another approach to mechanical removal of wound
wound to heal quickly and well. The procedure is done
at the bedside or in the operating room if the wound is debris is hydrotherapy (therapeutic use of water), in which
extensive. Sharp débridement is painful, and the wound the body part with the wound is submerged in a
may bleed afterward. whirlpool tank. The agitation of the water, which con-
tains an antiseptic, softens the dead tissue. Loose debris
Enzymatic Débridement that remains attached is removed afterward by sharp
débridement.
Enzymatic débridement involves the use of topically A third method for mechanically removing wound
applied chemical substances that break down and liq- debris is irrigation (technique for flushing debris). An irri-
gation is used when caring for a wound and also when
cleaning an area of the body such as the eye, ear, and
vagina.

List an advantage and disadvantage of methods used for
A B wound débridement.
FIGURE 28-12 • (A) Single T-binder. (B) Double T-binder.
WOUND IRRIGATION. Wound irrigation (Skill 28-2) gen-

erally is carried out just before applying a new dressing.
This technique is best used when granulation tissue has
formed. Surface debris should be removed gently with-
out disturbing the healthy proliferating cells.
EYE IRRIGATION. An eye irrigation flushes a toxic chemi-

cal from one or both eyes or displaces dried mucus or other
drainage that accumulates from inflamed or infected eye
structures. See Nursing Guidelines 28-1.
EAR IRRIGATION. An ear irrigation removes debris from

the ear. An ear irrigation is contraindicated if the tym-
panic membrane (eardrum) is perforated. Performing a FIGURE 28-13 • Eye irrigation. (Copyright B. Proud.)
gross inspection 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 sometimes necessary to treat an infection. See Client and
become even more tightly fixed. Solid objects may require Family Teaching 28-1.
removal with an instrument.
If an ear irrigation is not contraindicated, it is performed
much like an eye irrigation except that the nurse directs the Heat and Cold Applications
solution toward the roof of the auditory canal (Fig. 28-14).
Also the nurse takes care to avoid occluding the ear canal Heat and cold have various therapeutic uses (Box 28-1),
with the tip of the syringe because the pressure of the and each can be used in several ways. Examples include
trapped solution could rupture the eardrum. After the irri- an ice bag, collar, chemical pack, compress, and aquather-
gation, the nurse places a cotton ball loosely within the ear mia pad. Heat also is applied with soaks, moist packs,
to absorb drainage but not to obstruct its flow. and therapeutic baths.
The terms hot and cold are subject to wide interpre-
VAGINAL IRRIGATION. A vaginal irrigation, also known tation. Table 28-2 correlates common terms with tem-
as a douche (procedure for cleansing the vaginal canal), is perature ranges. Because exposing the skin to extremes of

Eye Irrigation
❙ Assemble supplies: bulb syringe, irrigating solution, gauze squares, ❙ Wipe a moistened gauze square from the nasal corner of the eye toward
gloves and other standard precaution apparel, absorbent pads, and the temple; use additional gauze squares, one at a time, as needed. This
at least one towel. Assembling equipment ahead of time ensures removes gross debris.
organization and efficient time management. ❙ Separate the eyelids widely with the fingers of one hand. This action
❙ Warm the solution to approximately body temperature by placing the widens the exposed surface area.
container in warm water except when administering emergency first ❙ Direct the solution onto the conjunctiva, holding the syringe or irrigating
aid. A warm solution is more comfortable for the client. device about 1 inch (2.5 cm) above the eye (Fig. 28-13). Holding the
❙ Position the client with the head tilted slightly toward the side. This syringe away from the eye prevents injury to the cornea.
position facilitates drainage. ❙ Instruct the client to blink periodically. Blinking distributes solution
❙ Place absorbent material in the area of the shoulder. Use of under the eyelid and around the eye.
absorbent material prevents saturating the client’s gown and ❙ Continue irrigating until debris is removed. This accomplishes the
bed linen. desired result.
❙ Give the client an emesis basin to hold beneath the cheek. The basin ❙ Dry the client’s face and replace wet gown or linen. These actions
can be used to collect the irrigating solution. promote client comfort.
❙ Wash hands or use an alcohol-based handrub and don gloves. ❙ Dispose of soiled materials and gloves; wash hands. These measures
Hand hygiene and glove use reduce the transmission of reduce the transmission of microorganisms.
microorganisms. ❙ Record assessment data, specifics of the procedure, and outcome.
❙ Open and prepare supplies. This enables the nurse to perform the Documentation records performance of the nursing intervention and
irrigation efficiently. the client’s response.
A B
FIGURE 28-14 • (A) and (B) Ear irrigation.
temperature can result in injuries, the nurse assesses the

temperature of the application and frequently monitors the
condition of the skin. Direct contact between the skin
28-1 • CLIENT AND FAMILY TEACHING and the heating or cooling device is avoided. Hot and cold
applications are used cautiously in children younger than
Douching 2 years, older adults, clients with diabetes, and clients who
The nurse teaches the client or family as follows: are comatose or neurologically impaired.
• Do not douche routinely because douching
removes microbes, called Döderlein bacilli, that Ice Bag and Ice Collar
help to prevent vaginal infections. Ice bags and ice collars are containers for holding crushed
• Do not douche 24 to 48 hours before a Pap test ice or small ice cubes (Fig. 28-15). Ice collars usually are
(see Chap. 14). Douching may wash away applied after tonsil removal. Ice bags are applied to any
diagnostic cells. small injury in the process of swelling. Although ice bags
• Consult a physician about symptoms such as are available commercially, they can also be improvised.
itching, burning, or drainage rather than A rubber or plastic glove, a plastic bag with a zipper clo-
attempting self-diagnosis. sure, or a bag of small frozen vegetables, such as peas, can
• Find out from the physician if sexual partners be used. Client instruction minimizes the risk for injury.
also need to be treated with medications to See Client and Family Teaching 28-2.
avoid reinfection.
• Buy douching equipment from a drugstore; pre- Chemical Packs
filled disposable containers are available.
• Warm the solution to a comfortable temperature Commercial cold packs are struck or crushed to activate
(no more than 110°F [43.3°C]). the chemicals inside, causing them to become cool. Most
• Clamp the tubing (on reusable equipment) and first-aid kits generally include this type of cold pack.
fill the reservoir bag. Commercial cold packs can be used only once. Gel packs,
• Undress and lie down in the bathtub. designed for cold or hot application, are reusable. They
• Suspend the douche bag (if used) about 18 to are stored in the freezer until needed or heated in a
24 inches (45 to 60 cm) above the hips. microwave.
• Insert the lubricated tip of the nozzle or the pre-
filled container downward and backward within
the vagina about the distance of a tampon.
• Unclamp the tubing and rotate the nozzle as the BOX 28-1 ● Common Uses for Heat
fluid is instilled. and Cold Applications
• Contract the perineal muscles as though trying USES FOR HEAT USES FOR COLD
to stop urinating, then relax the muscles.
❙ Provides warmth ❙ Reduces fevers
Repeat the exercise four or five times while ❙ Promotes circulation ❙ Prevents swelling
douching. ❙ Speeds healing ❙ Controls bleeding
• Sit up to facilitate drainage or shower afterward. ❙ Relieves muscle spasm ❙ Relieves pain
• Use a sanitary napkin or perineal pad to absorb ❙ Reduces pain ❙ Numbs sensation
residual drainage.
TABLE 28-2
TEMPERATURE RANGES FOR 28-2 • CLIENT AND FAMILY TEACHING
APPLICATIONS OF HEAT
AND COLD Using an Ice Bag
LEVEL OF HEAT OR COLD TEMPERATURE RANGE The nurse teaches the client or family as follows:
• Test the ice bag for leaks.
Very hot 40.5°C to 46.1°C (105°F–115°F)
Hot 36.6°C to 40.5°C (98°F–105°F)
• Fill it one-half to two-thirds full of crushed ice
Warm and neutral 33.8°C to 36.6°C (93°F–98°F) or small cubes so it can be molded easily to the
Tepid 26.6°C to 33.8°C (80°F–93°F) injured area.
Cool 18.3°C to 26.6°C (65°F–80°F) • Eliminate as much air from the bag as possible.
Cold 10°C to 18.3°C (50°F–65°F) • Pour water over the ice to provide slight melt-
Very cold Below 10°C (below 50°F)
ing. This tends to smooth the sharp edges from
frozen ice crystals.
• Cover the ice bag with a layer of cloth before
placing it on the body.
Compresses • Leave the ice bag in place no more than 20 to
Compresses (moist, warm or cool cloths) are applied to the
30 minutes. Allow the skin and tissue to recover
for at least 30 minutes before reapplying.
skin. Before applying the compress, the nurse soaks it in
• If the skin becomes mottled or numb, remove
tap water or medicated solution at the appropriate tem-
the ice bag—it is too cold.
perature and then wrings out excess moisture. To main-
tain the moisture and temperature, a piece of plastic or
plastic wrap is used to cover the compress and the area is
secured in a towel. As the compress material cools or specified setting. As with other forms of hot and cold ther-
warms outside the range of the intended temperature, apeutic devices, the nurse assesses the skin frequently
the nurse removes it and reapplies if necessary. and removes the device periodically.
If the skin is not intact, as in the case of a draining Before placing the client on the aquathermia pad or
wound, nurses wear gloves when applying a compress. wrapping it around a body part, the nurse covers the pad
They use aseptic surgical technique when applying com- to help prevent thermal skin damage. A roller bandage
presses to an open wound. may help hold the pad in place. The nurse positions the
electrical unit slightly higher than the client to promote
gravity circulation of the fluid.
Aquathermia Pad Larger styles are used to warm clients who are hypo-
An aquathermia pad (electrical heating or cooling device) thermic or to cool those with heat stroke. Because these
is sometimes called a K-pad. It resembles a mat but con- clients have dangerously altered body temperatures, the
tains hollow channels through which heated or cooled nurse must monitor vital signs continuously.
distilled water circulates (Fig. 28-16). An aquathermia
pad is used alone or as a cover over a compress. A ther- Soaks and Moist Packs
mostat is used to keep the temperature of the water at the A soak is a technique in which a body part is submerged
in fluid to provide warmth or apply a medicated solution.
A pack (commercial device for applying moist heat) also
can be used. Moist heat is more comforting and therapeu-
tic than dry heat.
FIGURE 28-15 • Ice bag filled with crushed ice. (Copyright B. Proud.) FIGURE 28-16 • Aquathermia pad (K-pad). (Copyright B. Proud.)
A soak usually lasts 15 to 20 minutes. The nurse keeps

the temperature of the fluid as constant as possible, which Stop • Think + Respond BOX 28-3
requires frequent emptying and refilling of the basin. The What assessment findings suggest that a sitz bath is
newly added water should not be too hot; overly hot water providing a therapeutic effect?
causes discomfort or tissue damage.
Packs differ from soaks in two major ways: the dura-
tion of the application is usually longer, and the initial
application of heat is generally more intense. Packs usu- PRESSURE ULCERS
ally are applied at temperatures as warm as the client can
tolerate. Because of the potential for causing burns, a pack
Pressure ulcers or sores, also referred to as decubitus ulcers,
never is used on a client who is unresponsive or paralyzed
most often appear over bony prominences of the sacrum,
and cannot perceive temperatures. The nurse must make
hips, and heels. They also can develop in other locations
frequent assessments and remove the pack if there is any
such as the elbows, shoulder blades, back of the head,
likelihood of a thermal injury.
and places where pressure is unrelieved because of infre-
quent movement (Fig. 28-17). The tissue in these areas
Therapeutic Baths
is particularly vulnerable because body fat, which acts as
Therapeutic baths (those performed for other than hygiene a pressure-absorbing cushion, is minimal. Consequently,
purposes) help to reduce a high fever or apply med- the tissue is compressed between the bony mass and a
icated substances to the skin to treat skin disorders or rigid surface such as a chair seat or bed mattress. If the
discomfort. Examples are baths to which sodium bicar- compression reduces the pressure in local capillaries to
bonate (baking soda), cornstarch, or oatmeal paste are less than 32 mm Hg for 1 to 2 hours without intermittent
added. relief, the cells die from lack of oxygen and nutrition.
The most common type of therapeutic bath is a sitz
bath (soak of the perianal area). Sitz baths reduce swelling
and inflammation and promote healing of wounds after Stages of Pressure Ulcers
a hemorrhoidectomy (surgical removal of engorged veins
inside and outside the anal sphincter) or an episiotomy Pressure ulcers are grouped into four stages according to
(incision that facilitates vaginal birth). Some health the extent of tissue injury (Fig. 28-18). Care and healing
care agencies have special tubs for administering sitz depend on the stage of injury. Without aggressive nurs-
baths, but most provide clients with disposable equipment ing care, early-stage pressure ulcers can easily progress
(Skill 28-3). to much more serious ones.
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 28-17 • Locations where pressure ulcers commonly form. (A) Supine position. (B) Side-lying
position. (C) Sitting position.
Epidermis
Dermis
Subcutaneous
Muscle
A B C D
Bone
FIGURE 28-18 • Pressure sore stages. (A) Stage I. (B) Stage II. (C) Stage III. (D) Stage IV.
Stage I is characterized by intact but reddened skin. The which pressure ulcers are likely to form. See Nursing
hallmark of cellular damage is skin that remains red and Guidelines 28-2.
fails to resume its normal color when pressure is relieved.
A stage II pressure ulcer is red and accompanied
by blistering or a skin tear (shallow break in the skin). NURSING IMPLICATIONS
Impairment of the skin may lead to colonization and
infection of the wound. Clients with a surgical wound, pressure ulcer, or other
A stage III pressure ulcer has a shallow skin crater that type of tissue injury are likely to have one or more of the
extends to the subcutaneous tissue. It may be accompa- following nursing diagnoses:
nied by serous drainage (leaking plasma) or purulent drainage
(white or greenish fluid) caused by a wound infection. • Acute Pain
The area is relatively painless despite the severity of • Impaired Skin Integrity
the ulcer. • Ineffective Tissue Perfusion
Stage IV pressure ulcers are life threatening. The tissue • Impaired Tissue Integrity
is deeply ulcerated, exposing muscle and bone (Fig. 28-19). • Risk for Infection
The dead or infected tissue may produce a foul odor. The Nursing Care Plan 28-1 shows how nurses use the nurs-
infection easily spreads throughout the body, causing ing process to care for a client with Impaired Tissue
sepsis (potentially fatal systemic infection).
Integrity, defined in the 2005 NANDA taxonomy as “dam-
age to mucous membrane, corneal, integumentary, or sub-
cutaneous tissue.”
Prevention of Pressure Ulcers
The first step in prevention is to identify clients with risk GENERAL GERONTOLOGIC
factors for pressure ulcers (Box 28-2). The second step is
to implement measures that reduce conditions under
CONSIDERATIONS
Wound healing is delayed in older adults. Regeneration of
healthy skin takes twice as long for an 80-year-old as it does
for a 30-year-old.
Granulation Age-related changes that affect wound healing include dimin-
tissue Epithelial edge ished collagen and blood supply and decreased quality of
elastin. Long-term exposure to ultraviolet rays from the sun
compounds these age-related changes.
Age-related changes (i.e., thinning dermal layer of skin, decreased
subcutaneous tissue) result in increased susceptibility to pres-
sure ulcers and shear-type injuries in older adults. Because of
the decreased blood supply to the skin, an older adult may
need position changes every 60 to 90 minutes, rather than
BOX 28-2 ● Risk Factors for Developing

Pressure Ulcers
❙ Inactivity ❙ Incontinence
Necrotic ❙ Immobility ❙ Vascular disease
tissue ❙ Malnutrition ❙ Localized edema
❙ Emaciation ❙ Dehydration
❙ Diaphoresis ❙ Sedation
FIGURE 28-19 • Example of stage IV pressure sore.

Preventing Pressure Ulcers
❙ Change the bedridden client’s position frequently. Remind a client who ❙ Keep the skin clean and dry especially when clients cannot control their
is sitting in a chair to stand and move hourly or at least to shift his or bladder or bowel function. Cleansing removes substances that
her weight every 15 minutes while sitting. Changing positions relieves chemically injure the skin.
pressure and restores circulation. ❙ Use a moisturizing skin cleanser rather than soap, if possible. A
❙ Lift rather than drag the client during repositioning. Dragging causes nonsoap cleanser maintains skin hydration and avoids altering the
friction, which abrades the skin and damages underlying blood skin’s natural acidity, which protects it from bacterial colonization.
vessels. ❙ Rinse and dry the skin well. Cleansing then drying removes chemical
❙ Avoid using plastic-covered pillows when positioning clients. Plastic residues and surface moisture.
prevents evaporation of perspiration because it is nonporous. It also ❙ Use pressure-relieving devices such as special beds or mattresses
raises skin temperature, further contributing to the growth of
(see Chap. 23). These special devices maintain capillary blood flow by
microorganisms.
reducing pressure.
❙ Use positioning devices such as pillows to keep two parts of the body ❙ Pad body areas such as the heels, ankles, and elbows, which are
from direct contact with each other. Such devices absorb perspiration,
vulnerable to friction and pressure (Fig. 28-20). Padding prevents
reduce localized heat, and avoid compression of tissue between two
friction and adds a cushioning layer over the bony prominence.
body parts.
❙ Use seat cushions such as a commercial gel-filled pad when clients sit
❙ Use the lateral oblique position (see Chap. 23) rather than the
for extended periods. These cushions distribute pressure over a wider
conventional lateral position for side-lying. The lateral oblique position
more effectively reduces the potential for pressure on vulnerable bony area, relieving direct pressure on the coccyx.
prominences. ❙ Keep the head of the bed elevated no more than 30 degrees.°. Sliding
❙ Massage bony prominences only if the skin blanches with pressure down in bed can produce shearing force (effect that moves layers of
relief. Massage improves circulation to normal tissue but causes further tissue in opposite directions).
damage to areas where pressure ulcers—even those that are stage I— ❙ Provide a balanced diet and adequate fluid intake. Adequate nutrition
are already established. maintains and restores cells and keeps tissues hydrated.
every 120 minutes. Take special care when moving older The risk for thermal skin injury is increased in older adults with
adults to avoid friction on the skin. impaired tactile sensation or sensory nerve damage because
Diminished immune response from reduced T-lymphocyte cells of complications from diabetes or other illnesses. Older adults
predisposes older adults to wound infections. who have problems with the ability to sense temperatures
Signs of inflammation may be subtle in older adults (see Chap. 22). need to take special precautions such as using a thermometer
Diabetes or other conditions that may interfere with circulation to ensure that the bath water is less than 100°F (38°C) to avoid
increase the older adult’s susceptibility to delayed wound burns or injury.
healing and wound infections. Although many other factors are influential, adherence to a med-
ical treatment regimen may be difficult for older adults on
fixed incomes. Cultural factors or health beliefs may conflict
with suggestions for care from the health care provider. Ask-
ing the client “What do you believe caused this wound?” and
“What do you believe will help this wound to heal?” may pro-
vide invaluable information to use in mutual goal-setting for
wound healing and for planning realistic interventions that
correspond to the client’s health beliefs and behaviors.
Factors such as depression, poor appetite, cognitive impairments,
and physical or economic barriers that interfere with adequate
nutrition in older adults may impair wound healing. Attempts
must be made to address these factors by using registered dieti-
tians, who can suggest appropriate nutritional interventions,
and by making referrals to community resources such as home-
delivered meals or homemaker/home health aide services.
Absorbent undergarments may contribute to skin breakdown
because they may not allow for air circulation. Urine or feces
next to the skin will cause damage and possible skin break-
down. Therefore, any incontinent older adult must be checked
every 2 hours to prevent skin damage.
If urinary incontinence interferes significantly with wound healing,
an indwelling catheter may be necessary. It should be
removed as soon as feasible, however, and efforts must be
made to restore continence. Fecal incontinence also interferes
FIGURE 28-20 • Heel and ankle protection. (continued on p. 654)
Impaired Tissue Integrity
ASSESSMENT
• Inspect the skin especially over bony prominences.
• Look for skin redness that does not blanch with relief of pressure, evidence of skin tears, or ulceration.
• Observe the client’s ability to move and reposition himself or herself independently.
• Assess the status of the client’s hydration and nutrition.
• Determine if the client is incontinent or feverish or has other contributing factors to skin and tissue breakdown such as
conditions accompanied by edema, those that require the application of devices such as a cast or traction, or treatments
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 coccyx and stage I over bilateral heels and
elbows.
Expected Outcome: The tissue integrity in the area of the coccygeal pressure sore will be
restored as evidenced by the development 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 Frequent repositioning maintains capillary pressure above
bed can be obtained. 32 mm Hg to facilitate oxygenation of tissue.
Avoid the supine and Fowler’s positions as much as These positions increase the potential for shear forces and
possible. 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,
Film. breathable film that is impervious to liquids and potential
irritants and protects against skin abrasion and friction.
Until results of wound culture are obtained, care for the
open coccygeal wound as follows:
• Mix antimicrobial solution with water and cleanse wound. An antimicrobial reduces the transient and resident micro-
• Rinse with normal saline. organisms that can increase the extent and severity of the
pressure sore and delay healing. Packing the wound with
• Pack the wound loosely with a continuous strip of gauze moist gauze is a form of mechanical débridement that
moistened with normal saline. removes devitalized tissue and promotes granulation of
• Cover with an abdominal (ABD) pad. 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.
• Clean, dry, and cover wound with transparent dressing A transparent dressing creates a moist environment that
(Op-Site) and leave in place for 5 days. accelerates the healing process. Accumulation of fluid
• If drainage collects, pierce Op-Site and aspirate fluid from beneath the dressing increases the potential for loosening
underneath. Seal opened area with a small reinforcement the wound cover. Aspiration of fluid through the dressing
of Op-Site over punctured area. reduces fluid volume. Sealing the puncture area restores
the occlusive nature of the dressing without the need to
replace it.
(continued)
Impaired Tissue Integrity
Measure open pressure sore every 3 days (8/18, 8/21, etc.) Regular assessment of the wound helps to determine the
during day shift. need to continue or revise the plan for wound care.

• Pressure ulcer in area of coccyx measures 2 inches × 3 inches × 1⁄2 inch on 8/18 with 1⁄16 inch of granulation tissue around
the circumference of the wound.
• Heels and elbows no longer appear red.
with wound healing; if at all possible, caregivers should check 2. When the nurse changes a client’s dressing, which nursing
the incontinent older adult every 60 to 90 minutes. action is correct?
Older adults with diminished mobility require aggressive skin care 1. The nurse removes the soiled dressing with sterile
to prevent pressure ulcers. The elbows, heels, coccyx, shoulder gloves.
blades, and hips are especially vulnerable, as are the creases 2. The nurse frees the tape by pulling it away from
above the ears, if oxygen tubing is in use. Special precautions
the incision.
include heel and elbow protectors, pressure-relief pads and
mattresses, and a strict routine of changing the client’s position
3. The nurse encloses the soiled dressing within a
at least every 2 hours or more frequently if the person’s skin latex glove.
becomes reddened in a shorter period. Assessment of at-risk 4. The nurse cleans the wound in circles toward the
pressure point areas should be done before the 2-hour period. incision.
Specific wound care products have been developed for use on dif- 3. When a nurse empties the drainage in a Jackson-Pratt
ferent types of wounds. Assessment should be thorough to
reservoir, which nursing action is essential for re-establish-
determine the type of wound (e.g., pressure, vascular, surgical,
burn). Use of evidence for best results of various products
ing the negative pressure within this drainage device?
should be determined in planning for use of skin barriers or 1. The nurse compresses the bulb reservoir and closes
wound treatments. the vent.
2. The nurse opens the vent, allowing the bulb to fill
with air.
CRITICAL THINKING E X E R C I S E S 3. The nurse fills the bulb reservoir with sterile normal
saline.
1. Describe the wound care appropriate for a client with a 4. The nurse secures the bulb reservoir to the skin
stage I pressure ulcer, one with an abdominal incision, near the wound.
and one with a peripheral intravenous infusion site.
4. When a client asks why the nurse is applying wet-to-dry
2. A 75-year-old client is admitted from a nursing home to dressings over a skin ulcer, the best explanation is that
have surgery to repair a fractured hip. Discuss the factors these dressings help to
that may threaten this client’s wound healing. 1. Prevent wound infections.
2. Remove dead cells and debris.
3. Absorb blood and drainage.
NCLEX-STYLE REVIEW Q U E S T I O N S 4. Protect the skin from injury.
1. Which of the following body positions will promote wound 5. The best evidence that a wound ulcer is healing is that
drainage from an abdominal incision with an open drain? the size becomes smaller and
1. Lithotomy 1. There is more drainage.
2. Fowler’s 2. There is less discomfort.
3. Recumbent 3. The cavity appears pink.
4. Trendelenburg 4. The wound margins are white.
Skill 28-1 • CHANGING A GAUZE DRESSING
Assessment
Inspect the current dressing for drainage, integrity, and Provides assessments indicating a need to change the
type of dressing supplies used. dressing and supplies that may be needed
Check the medical orders for a directive to change the Shows collaboration with the prescribed medical treatment
dressing.
Determine if the client has allergies to tape or Helps to determine dressing supplies to use
antimicrobial 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 Empowers the client to participate in decision making
change if there is no immediate need for it.
Give pain medication, if needed, 15 to 30 minutes before Allows time for medication absorption and effectiveness
the dressing change.
Gather the necessary supplies, which are likely to include Facilitates organization and efficient time management
a 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 handrub (see Reduces the transmission of microorganisms
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 Facilitates removal without separating the healing wound
toward the wound (Fig. A).
Loosen the tape. (Copyright B. Proud.)
(continued)
CHANGING A GAUZE DRESSING (Continued)
Don at least one glove and lift the dressing from the Provides a barrier against contact with blood and body
wound (Fig. B). substances
Remove the dressing.
Moisten the gauze with sterile normal saline, if it adheres Prevents disrupting granulation tissue
to the wound.
Discard the soiled dressing in a paper bag or other Confines sources of pathogens
receptacle along with the glove(s) (Fig. C).
Dispose of the dressing.
Wash your hands again or repeat the alcohol-based Removes transient microorganisms
handrub.
Tear several long strips of tape and fold the ends over, Facilitates handling tape later when wearing gloves and
forming tabs (Fig D). eases tape removal during the next dressing change
Apply the dressing.
(continued)
Open sterile supplies using the inside wrapper of one of Ensures aseptic technique
the 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 Supports principles of medical asepsis
microorganisms back to a cleaned area (Fig. E).
E
Wound cleansing techniques.
Use a single swab or 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.
(continued)
Secure the dressing with tape in the opposite direction of Prevents loosening with activity; holds the dressing in
the incision or across a joint. Place a strip of tape at each place without exposing the wound or incision.
end of the dressing and in the middle if needed (Fig. G).
Position the tape.
Remove and discard gloves. Confines sources of microorganisms

Rewash hands or repeat the alcohol-based handrub. 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 Shows collaboration with the prescribed medical
wound. treatment
Determine how much the client understands about the Indicates the level of health teaching needed
procedure.
(continued)
IRRIGATING A WOUND (Continued)
Planning
Plan to irrigate the wound at the same time that the Makes efficient use of time
dressing requires changing.
Gather the equipment required, which is likely to include a Facilitates organization
container of solution, basin, 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 Follows infection control guidelines when there is a potential
as goggles or face shield and cover apron or gown. for being splashed with blood or body substances
Implementation
Chap. 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 handrub. Reduces the transmission of microorganisms
Position the client to facilitate filling the wound cavity Ensures contact between the solution and the inner area
with solution. of the wound
Pad the bed with absorbent material and place an emesis Reduces the potential for saturating the bed linen
basin adjacent to and below the wound.
Open and prepare supplies following 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
substances
Fill the syringe with solution and instill it into the wound Dilutes and loosens debris
without touching the wound directly (Fig. A).
Hold the emesis basin close to the client’s body to catch Collects and contains irrigating solution
the solution as it drains from the wound (Fig. B).
B
Instill the irrigant. Position the client to drain the irrigant.
(continued)
IRRIGATING A WOUND (Continued)
Repeat the process until the draining solution seems clear. Indicates evacuation of debris
Tilt the client toward the basin. Drains remaining solution from the wound
Dry the skin. Facilitates applying a dressing
Dispose of the drained solution, soiled equipment, and Reduces the potential for transmitting microorganisms
linen.
Remove gloves, wash hands, and prepare to change the Provides for absorption of residual solution and coverage
dressing. of 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″. Approxi-
mately 300 mL of sterile NSS instilled within wound. Drained solution is cloudy with particles of
debris. SIGNATURE/TITLE
Skill 28-3 • PROVIDING A SITZ BATH
Assessment
Check the medical orders for a directive to administer a Shows collaboration with the prescribed medical
sitz bath. treatment
Determine how much the client understands about the Indicates the level of health teaching needed
procedure.
Assess the condition of the rectal or perineal wound and Provides baseline data for future comparisons; indicates if
the client’s level of pain. pain medication is needed
(continued)
PROVIDING A SITZ BATH (Continued)
Planning
Explain the procedure. Relieves anxiety and promotes cooperation
Ask if the client prefers the sitz bath before or after Involves the client in the decision-making process
routine hygiene.
Obtain disposable equipment unless specially installed Facilitates organization and efficient time management
tubs are available.
Assemble other supplies such as a bath blanket and Prepares for maintaining warmth and provides a means
towels. 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 Allows submerging the rectum and perineum
(Fig. A).
Position the sitz bath basin.
Implementation
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 Demonstrates concern for safety
bath will be administered.
Shut the door to the bathroom or tub room. Provides privacy
Clamp the tubing attached to the water bag. Prevents loss of fluid
(continued)
Fill the container with warm water, no hotter than 110°F Provides comfort without 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
(continued)
Cover the client’s shoulders with a bath blanket if the Promotes comfort
client feels chilled.
Instruct the client on how to signal for assistance. Ensures safety
Leave the client alone, but recheck frequently to add more Provides sustained application of warm water
warm water to the reservoir bag.
Help the client pat the skin dry after soaking for 20 to Restores comfort
30 minutes.
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 Supports principles of medical asepsis and infection
bath area. control
Replace the sitz bath equipment in the client’s bedside Reduces costs by reusing disposable equipment
cabinet or leave it in the client’s private bathroom.
Evaluation
• Sitz bath is administered according to policy or
standards of care.
• Safety is maintained.
• Client reports symptoms relieved.
Document
• Procedure
• Assessment data
Date and Time Sitz bath provided over 30 minutes. Client states, “I always feel so good after this treatment.” Per-
ineum is slightly swollen. Margins of episiotomy are approximated. Continues to have moderate
bloody vaginal drainage. SIGNATURE/TITLE
29
Chapter
Gastro-
intestinal
Intubation
LEARNING OBJECTIVES
● Define intubation.
● List six reasons for gastrointestinal intubation.
● Identify four general types of gastrointestinal tubes.
● Name at least four assessments that are necessary before inserting a tube nasally.
● Explain the purpose of and how to obtain a NEX measurement.
● Describe three techniques for checking distal placement in the stomach.
● Discuss three ways that nasointestinal feeding tubes or their insertion differ from their gastric
counterparts.
● Name two common problems associated with transabdominal tubes.
● Define enteral nutrition.
● Name four schedules for administering tube feedings.
WORDS TO KNOW ● Explain the purpose for assessing gastric residual.
● Name five nursing activities involved in managing the care of clients who are being tube-fed.
bolus feeding ● List four items of information to include in the written instructions for clients administering
continuous feeding their own tube feedings.
cyclic feeding ● Name two nursing responsibilities for assisting with the insertion of a tungsten-weighted
decompression intestinal decompression tube.
dumping syndrome
enteral nutrition
gastric reflux
gastric residual
gastrostomy tube (G-tube) CLIENTS, especially those undergoing abdominal or gastrointestinal (GI) surgery, may
gavage require some type of tube placed within their stomach or intestine. Use of a gastric or
intermittent feeding intestinal tube reduces or eliminates problems associated with surgery or conditions
intestinal decompression affecting the GI tract such as impaired peristalsis, vomiting, or gas accumulation.
intubation
Tubes also can nourish clients who cannot eat. This chapter discusses the multiple
jejunostomy tube (J-tube)
lavage uses for gastric and intestinal tubes and the nursing guidelines and skills for manag-
lumen ing associated client care.
nasogastric intubation
nasogastric tube
nasointestinal intubation
nasointestinal tubes
INTUBATION
NEX measurement
orogastric intubation Intubation generally means the placement of a tube into a body structure; in this chap-
orogastric tube
ostomy
ter, it refers specifically to insertion of a tube into the stomach or intestine by way of
percutaneous endoscopic the mouth or nose. Orogastric intubation (insertion of a tube through the mouth into the
gastrostomy (PEG) tube stomach), nasogastric intubation (insertion of a tube through the nose into the stomach;
percutaneous endoscopic Fig. 29-1), and nasointestinal intubation (insertion of a tube through the nose to the intes-
jejunostomy (PEJ) tube tine) are performed to remove gas or fluids or to administer liquid nourishment.
stylet
sump tubes
A tube also may be inserted within an ostomy (surgically created opening). A pre-
tamponade fix identifies the anatomic site of the ostomy; for instance, a gastrostomy is an artificial
transabdominal tubes opening into the stomach.
664
C H A P T E R 29 ● Gastrointestinal Intubation 665
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
A nasogastric tube (tube placed through the nose and
advanced to the stomach) is smaller in diameter than an
orogastric tube but larger and shorter than a nasointesti-
nal tube. Some nasogastric tubes have more than one
lumen (channel) within the tube.
A Levin tube is a commonly used, single-lumen gastric
tube with multiple uses, one of which is decompression.
Gastric sump tubes (double-lumen tubes) are used almost
exclusively to remove fluid and gas from the stomach
(Fig. 29-2). The second lumen serves as a vent. The use
of sump tubes decreases the possibility that the stomach
FIGURE 29-1 • Nasogastric intubation pathway. wall will adhere to and obstruct the drainage openings
when suction is applied.
Because nasogastric tubes remain in place for several
Gastric or intestinal tubes are used for a variety of rea- days or more, many clients complain of nose and throat
sons, including the following: discomfort. If the tube’s diameter is too large or pressure
from the tube is prolonged, tissue irritation or breakdown
• Performing a gavage (providing nourishment) may occur. Furthermore, gastric tubes tend to dilate the
• Administering oral medications that the client cannot esophageal sphincter, a circular muscle between the
swallow esophagus and stomach. The stretched opening may con-
• Obtaining a sample of secretions for diagnostic testing tribute to gastric reflux (reverse flow of gastric contents),
• Performing a lavage (removing substances from the especially when the tube is used to administer liquid for-
stomach, typically poisons) mula. If gastric reflux occurs, the liquid could enter the
• Promoting decompression (removing gas and liquid airway and interfere with respiratory function.
contents from the stomach or bowel)
• Controlling gastric bleeding, a process called compres-
sion or tamponade (pressure) Nasointestinal Tubes
Nasointestinal tubes(tubes inserted through the nose for
TYPES OF TUBES distal placement below the stomach) are longer than their
gastric counterparts. The added length permits them to be
Although all gastric and intestinal tubes have a proximal placed in the small bowel. They are used to provide nour-
and distal end, their size, construction, and composition ishment (feeding tubes) or to remove gas and liquid con-
vary according to their use (Table 29-1). The outside tents from the small intestine (decompression tubes).
diameter of most tubes is measured using the French
scale, indicated by a number followed by the letter “F.” Feeding Tubes
Each number on the French scale equals approximately Nasointestinal tubes used for nutrition, such as a Keofeed
0.33 mm. The larger the number, the larger the diameter tube, are usually small in diameter and made of a flexible
of the tube. substance such as polyurethane or silicone. Their narrow
Tubes can be identified according to the location of width and soft composition allow them to remain in the
their insertion (mouth, nose, or abdomen) or the loca- same nostril for 4 weeks or longer. In addition, they
tion of their distal end (stomach [gastric] or intestinal). reduce the potential for gastric reflux because they deliver
liquid nutrition beyond the stomach.
Narrow tubes are not problem free. They tend to curl
Orogastric Tubes during insertion because they are so flexible. Therefore,
some are supplied with a stylet (metal guidewire) that
An orogastric tube (tube inserted at the mouth into the helps to straighten and support them during insertion.
stomach), such as an Ewald tube, is used in an emergency Almost all have a weighted tip that helps them to descend
to remove toxic substances that have been ingested. The past the stomach. Checking the placement of the distal
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 inches (107–127 cm) long
Diagnostics • Multiple drain openings
Salem sump Decompression • Same diameter as Levin
• Double lumen
• Pig-tail vent
• 48 inches (122 cm) long
• Marked at increments to indicate depth of insertion
• Radiopaque
Sengstaken-Blakemore Compression • Usual diameter: 20 F
Drainage • 36 inches (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
• 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
• Double lumen
• Tungsten-weighted tip
• Graduated marks every 10 inches (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
end is more difficult; these tubes also become obstructed intestinal decompression (removal of gas and intestinal con-
more easily. tents) also may be used. A tube used for intestinal decom-
Despite the problems associated with maintenance, pression has a double lumen and a weighted tip (Fig. 29-3).
small-diameter tubes are preferred for their comfort. One lumen is used to suction the intestinal contents; the
They are ideal for providing a continuous infusion of other acts as a vent to reduce suction-induced trauma to
nourishment. intestinal tissue. The weighted tip and peristalsis, if pres-
ent, propel the tube beyond the stomach and into the intes-
tine. The progress of the radiopaque tip through the GI
Intestinal Decompression Tubes
tract is monitored by x-ray.
Although surgery is often the most common intervention At one time, intestinal tubes, such as the Cantor
when a client has a partial or complete bowel obstruction, and Miller-Abbott tubes, were weighted with mercury.
FIGURE 29-2 • Vented nasogastric (Salem sump) tube with

a one-way valve. (Copyright B. Proud.)
Because of mercury’s hazards to both the client and envi- Transabdominal tubes are used instead of nasogastric
ronment, however, mercury-weighted tubes are not used or nasointestinal tubes when clients require an alter-
today. Instead, intestinal tubes, like the Maxter tube (see native to oral feeding for more than 1 month.
Table 29-1), are now weighted with tungsten.
NASOGASTRIC TUBE MANAGEMENT

Transabdominal Tubes
Transabdominal tubes (tubes placed through the abdominal Usually nurses insert nasogastric tubes. Additional nurs-
wall) provide access to various parts of the GI tract. Two ing responsibilities include keeping the tube patent (or
examples are a gastrostomy tube or G-tube (transabdominal unobstructed), implementing the prescribed use, and
tube located within the stomach) and a jejunostomy tube or removing the tube when it has accomplished its thera-
J-tube (transabdominal tube that leads to the jejunum of peutic purpose.
the small intestine).
A gastrostomy tube is placed surgically or with the
use of an endoscope. A surgically inserted G-tube resem- Insertion
bles a long rubber catheter sutured to the abdomen. A per-
cutaneous endoscopic gastrostomy (PEG) tube (transabdominal
Inserting a nasogastric tube involves preparing the client,
tube inserted under endoscopic guidance) is anchored conducting preintubation assessments, and placing the
with internal and external crossbars called bumpers tube.
(Fig. 29-4A). A percutaneous endoscopic jejunostomy (PEJ)
tube (tube that is passed through a PEG tube into the
Client Preparation
jejunum) is small in diameter so it can be inserted Most clients are anxious about having to swallow a tube.
through the larger PEG tube (see Fig. 29-4B). Suggesting that the diameter of the tube is smaller than
most pieces of food may foster a positive outcome. Explain-
ing the procedure and giving instructions on how the
A
client can assist while the tube is being passed may fur-
ther reduce anxiety. One of the most important ways to
support clients is to provide them with some means of
B control. The nurse can establish with the client a signal,
such as the client raising the hand, to indicate that the
client needs a pause during the tube’s passage.
Preintubation Assessment
Before insertion, the nurse conducts a focused assessment
D C
that includes the client’s
FIGURE 29-3 • Intestinal decompression tube, including suction
lumen (A), vent lumen (B), openings for suction (C), and radiopaque • Level of consciousness
tungsten tip (D). • Weight
A B
FIGURE 29-4 • Transabdominal tubes. (A) Percutaneous endoscopic gastrostomy (PEG) tube. (B) Percu-
taneous endoscopic jejunostomy (PEJ) tube. (Courtesy of IVAC Corporation, San Diego, CA.)
• Bowel sounds tube reaches the xiphoid process, indicating the depth
• Abdominal distention required to reach the stomach.
• Integrity of nasal and oral mucosa
• Ability to swallow, cough, and gag Tube Placement
• Any nausea and vomiting
When inserting a nasogastric tube, the nurse’s primary
Assessment findings serve as a baseline for future com- concerns are to cause as little discomfort as possible, to
parisons and may suggest a need to modify the procedure preserve the integrity of the nasal tissue, and to locate the
or equipment used. One main goal of the assessment is to tube within the stomach, not in the respiratory passages.
determine which nostril is best to use when inserting the Once the tube is at its final mark, the nurse must ver-
tube and the length to which the tube will be inserted. ify the location within the stomach. The physical assess-
NASAL INSPECTION. After the client clears nasal debris by
blowing into a paper tissue, the nurse inspects each nostril
for size, shape, and patency. The client should exhale while
each nostril in turn is occluded. The presence of nasal
polyps (small growths of tissue), a deviated septum (nasal
cartilage deflected from the midline of the nose), or a nar-
row nasal passage excludes a nostril for tube insertion.
TUBE MEASUREMENT. Some tubes are already marked to

indicate the approximate length at which the distal tip
will be located within the stomach. These markings, how-
ever, may not correlate exactly with the client’s anatomy.
Therefore, before inserting a tube, the nurse obtains the
client’s NEX measurement (length from nose to earlobe to
the xiphoid process [tip of the sternum]; Fig. 29-5) and
marks the tube appropriately.
The first mark on the tube is made at the measured dis-
tance from the nose to the earlobe. It indicates the dis-
tance to the nasal pharynx, a location that places the tip
at the back of the throat but above where the gag reflex is
stimulated. A second mark is made at the point where the FIGURE 29-5 • Obtaining the NEX measurement.
pH
1
2
pH 3
7 4
5
9 6
10
11
FIGURE 29-6 • Aspirating gastric fluid. FIGURE 29-7 • Checking pH.
ment methods that nurses use to determine the distal Once the nurse has confirmed stomach placement
location of a nasogastric tube are as follows: (using two methods is best), he or she secures the tube to
avoid upward or downward migration (Fig. 29-8). The
• Aspirating fluid: If aspirated fluid appears clear, tube is then ready to use for its intended purpose. The
brownish-yellow, or green, the nurse can presume that steps to follow when inserting a nasogastric tube are out-
its source is the stomach (Fig. 29-6). lined in Skill 29-1.
• Auscultating the abdomen: The nurse instills 10 mL
or more of air while listening with a stethoscope over
the abdomen. If a swooshing sound is heard, the nurse
can infer that the cause was air entering the stomach.
Belching often indicates that the tip is still in the
esophagus.
• Testing the pH of aspirated liquid: The first two tech-
niques provide only presumptive signs that the tube is
in the stomach; testing pH confirms acidic gastric con-
tents. Other than obtaining an abdominal x-ray, the
pH test is the most accurate technique for checking
tube placement. See Nursing Guidelines 29-1.
A
Assessing the pH of Aspirated Fluid
❙ Wash hands or perform an alcohol-based handrub (see Chap. 10).
Hand hygiene reduces the transmission of microorganisms.
❙ Don gloves. They provide a physical barrier between the nurse’s
hands and body fluids.
❙ Aspirate a small volume of fluid from the tube with a clean syringe.
Doing so ensures valid test results.
❙ Drop a sample of gastric fluid onto an indicator strip. This step
initiates a chemical reaction on contact and saturation.
❙ Compare the color on the test strip with the color guide on the
container of reagent strips (Fig. 29-7). The color of the test strip
changes according to the hydrogen ion concentration of the liquid.
B
Stomach fluid usually has a pH of 1 to 3—very acid on the pH scale.
If the pH is 5 or 6, the client may be receiving medications to FIGURE 29-8 • (A) One end of a piece of tape is split, forming two nar-
decrease gastric acidity or the fluid may be from the duodenum. A rower strips, and the opposite end is left intact. (B) The wider intact end
pH of 7 or greater indicates that the tube is in the respiratory tract. of the tape is applied to the nose, and the narrower strips are wound
around the tube in opposite directions to secure the nasogastric tube.

Discuss the consequences of inserting a nasogastric tube
into the respiratory passages.
Use and Maintenance
Nasogastric tubes are connected to suction for gastric

decompression or are used for tube feeding.
Gastric Decompression
Suction is either continuous or intermittent. Continu-
ous suctioning with an unvented tube can cause the tube FIGURE 29-9 • Suction removes liquids and gas from the stomach.
to adhere to the stomach mucosa, resulting in localized

irritation and interfering with drainage. Using a vented
tube or intermittent suction prevents or minimizes these RESTORING PATENCY. The nurse assesses tube patency fre-
effects. quently by monitoring the volume and characteristics of
The tube is connected to a wall outlet or portable suc- drainage and observing for signs and symptoms suggesting
tion machine (Fig. 29-9). The suction setting is prescribed an obstruction (nausea, vomiting, and abdominal disten-
by the physician or indicated in the agency’s standards for tion). Inspection of the equipment helps to identify possi-
care. Usually low pressure (40 to 60 mm Hg) is used. ble causes for the assessment findings (Table 29-2). Once
The tube is clamped or plugged during ambulation or the cause is identified, a variety of simple nursing interven-
after instilling medications (see Chap. 32). tions can resolve it. Sometimes the nasogastric tube must
be irrigated to maintain or restore patency (Skill 29-2).
PROMOTING PATENCY. Even with intermittent suction- The nurse must obtain a medical order before attempting
ing, the tube may become obstructed. Giving ice chips or an irrigation.
occasional sips of water to a client who is otherwise NPO
promotes tube patency. The fluid helps to dilute the gas-
tric secretions. Both must be given sparingly, however, Stop • Think + Respond BOX 29-2
because water is hypotonic and draws electrolytes into Explain the reason for using an isotonic saline solution,
the gastric fluid. Because the diluted fluid is ultimately rather than a hypotonic or hypertonic solution, to irrigate
removed, giving the client liberal amounts of water can a nasogastric tube.
deplete serum electrolytes (see Chap. 16).
TABLE 29-2 TROUBLESHOOTING A POORLY DRAINING NASOGASTRIC TUBE

POSSIBLE CAUSES SOLUTIONS
Drainage holes are adhering to the gastric mucosal wall. Turn the suction off momentarily. Change the client’s position.
Tube is displaced above the cardiac sphincter. If measured mark is not at the tip of the nose, remove tape,
advance the tube, check placement, and resecure.
Portable suction machine is disconnected or turned off. Replace plug into electrical outlet or turn on power.
Drainage container is filled beyond capacity. Empty and record amount of drainage in 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 cap and restore port to atmospheric pressure.
The tubing is kinked or disconnected. Straighten tubing or reconnect to suction machine.
Suction is inadequate. Check that pressure is 40 to 60 mm Hg.
Cover on suction container is loose. Resecure the lid to the container.
Solid particle or thick mucus obstructs lumen. Increase suction pressure momentarily.
Obtain and implement a medical order for an irrigation.
Enteral Nutrition tice avoids subjecting the client to the discomfort associ-
ated with tube replacement.
Enteral nutrition (nourishment provided through the stom-
ach or small intestine rather than by the oral route) is
delivered by tube feeding. Although a nasogastric tube
can be used, it is more likely that liquid formula will be Stop • Think + Respond BOX 29-3
administered through a nasointestinal or transabdominal If the client who has just had a nasogastric tube removed
tube. Both are discussed later in this chapter. wants something to eat, what nursing actions are
appropriate?
Removal
Nurses remove a nasogastric tube (Skill 29-3) when the

NASOINTESTINAL TUBE MANAGEMENT
client’s condition improves, when the tube becomes
hopelessly obstructed, or according to the agency’s stan-
dards for maintaining the integrity of the nasal mucosa. Nurses also insert nasointestinal tubes used for enteral
Unobstructed larger-diameter tubes usually are removed feeding.
and changed at least every 2 to 4 weeks for adults. Small-
diameter, flexible tubes are removed and changed every
Insertion
4 weeks to 3 months, depending on agency policy. Tubes
used for pediatric clients are changed more frequently The techniques for client preparation, positioning, and
because the tissue is more fragile and there is greater advancement of nasointestinal tubes are similar to those
potential for infection. for nasogastric tubes. Some modifications are necessary,
Before permanent removal, some physicians prescribe however, because nasointestinal tubes are constructed
a trial period during which the tube is clamped and the differently.
client is allowed to consume oral fluids. Remaining asymp- To estimate the length of tube required for intestinal
tomatic (i.e., no nausea, vomiting, or gastric distention) placement, the nurse determines the NEX measurement
is a good indication that the client no longer requires and adds 9 inches (23 cm). He or she also marks the addi-
intubation. If symptoms develop, the tube is already in tional measurement on the tubing. See Nursing Guide-
place and can be easily reconnected to suction. This prac- lines 29-2.

Inserting a Nasointestinal Feeding Tube
❙ Wash hands or perform an alcohol-based handrub (see Chap. 10). ❙ Ambulate or position the client on his or her right side for at least 1 hour
Hand hygiene reduces the transmission of microorganisms. or the time specified in agency policy. This duration allows the tube to
❙ Don gloves. Gloves provide a physical barrier between the nurse’s move by gravity through the pyloric valve.
hands and body fluids. ❙ Secure the tube at the nose when the third measured mark is at the
❙ Follow the manufacturer’s suggestions for activating the lubricant nasal tip. This prevents the tube from migrating further than the desired
bonded to the tube. Two common techniques are to instill distance.
water through the tube and to immerse the tip in water. ❙ Verify placement by x-ray especially in unconscious clients or those with
Activation of the lubricant transforms the dry bond to a a depressed gag reflex. X-ray confirms the distal location.
gelatinous consistency. ❙ Remove the stylet using gentle traction (Fig. 29-11) or follow the
❙ Secure the stylet within the tube. This measure stiffens the tube manufacturer’s suggestions. Opening of the lumen allows instillation of
and facilitates insertion. water and liquid nourishment.
❙ Insert the tube to the second mark. Doing so places the tube in the ❙ Store the stylet in a clean wrapper at the client’s bedside. This measure
presumed area of the stomach. avoids charging the client for a new tube should the current one need
❙ Aspirate fluid using a 50-mL syringe (Fig. 29-10) and test fluid pH. to be removed and reintroduced.
The results provide data for determining gastric placement. ❙ Never reinsert the stylet while the tube is in the client. Reinsertion might
❙ Loop the tubing and tape it temporarily to the cheek, if the test for cause trauma to the client and damage to the tube.
placement suggests that the tip is in the stomach. Looping provides ❙ Measure and record the length of tubing extending from the nose.
slack so the tube can descend into the small intestine. Documentation provides data for reassessing distal placement.
verify the tube’s distal placement throughout its use by

modifying the aspiration technique after the initial x-ray.
The modification involves using a large-volume (50-mL)
rather than a small-volume (3- to 5-mL) syringe to obtain
a sample of fluid. The larger syringe creates less negative
pressure during aspiration and, therefore, provides enough
fluid to test the pH. Recently, the placement of weighted-
tip feeding tubes has been confirmed using bedside ultra-
sonography (Vigneau et al., 2005). In a small research
sample of adults, the technique proved to be 97% accurate
in determining distal tube location.
FIGURE 29-10 • Aspirating to assess pH. (Copyright B. Proud.) TRANSABDOMINAL TUBE

MANAGEMENT
New technologies that promise to promote safety and
efficacy in nasoenteric tube placement are becoming avail-
The physician inserts transabdominal tubes, such as gas-
able. A computer system that uses electromagnetic tech-
trostomy and jejunostomy tubes, but the nurse is respon-
nology to direct and locate a feeding tube as it is inserted
sible for assessing and caring for them and their insertion
has also been developed. This helps to identify misplace-
sites. Conscientious care is necessary because gastrostomy
ment immediately and eliminates the need for radio-
tubes may leak (Box 29-1) and cause skin breakdown. See
graphic verification of its location (Computer-guided
systems, 2007; Magnetically guided feeding tube, 2004).
Checking Tube Placement TUBE FEEDINGS
Initial tube placement is traditionally verified with an Providing nutrition by the oral route is always best. How-
x-ray because other techniques used with nasogastric ever, if oral feedings are impossible or jeopardize the
tubes are less reliable with small-diameter feeding tubes. client’s safety, nourishment is provided enterally or par-
Checking placement by auscultating air may be inconclu- enterally (see Total Parenteral Nutrition, Chap. 16). Tube
sive because the air that escapes from the distal tip is less feedings are used when clients have an intact stomach or
pronounced as a result of the small diameter of the tube. intestinal function but are unconscious, have undergone
Also, aspiration of stomach contents from small-diameter extensive mouth surgery, have difficulty swallowing, or
tubes is not always possible because the negative pres- have esophageal or gastric disorders. Skill 29-4 describes
sure causes the tube to collapse. Nonetheless, once the the technique for administering tube feedings.
feeding tube is inserted and secured to avoid slipping,
its continued safe location requires frequent checking.
Repeated x-rays to reassess tube placement are expensive, Benefits and Risks
impractical, and potentially harmful. Currently, nurses
Tube feedings are delivered through a nasogastric, naso-
intestinal, or transabdominal tube. Each has its advan-
tages and disadvantages (Table 29-3).
Instilling nutritional formulas into the stomach uses
the body’s natural reservoir for food. It also reduces the
BOX 29-1 ● 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,
coughing
❙ Underinflation of the balloon beneath the skin
❙ Less than optimal stoma or stomal location
FIGURE 29-11 • Removing stylet. (Copyright B. Proud.)

Managing a Gastrostomy
❙ Wash hands or perform an alcohol-based handrub (see Chap. 10). ❙ Clean the skin with half-strength hydrogen peroxide or 0.9% saline.
Hand hygiene reduces the transmission of microorganisms. After 1 week, using soap and water is sufficient. Dry the skin well using
❙ Don gloves. They provide a physical barrier between the nurse’s hands air or a blow dryer on a cool or low heat setting. Appropriate cleaning
and body fluids. removes secretions and reduces microorganisms.
❙ Assess and replace the gauze dressing over a new gastrostomy if it
❙ Rotate the direction of the external bumper 90 degrees or other external
becomes moist; slight bleeding or clear serous drainage from the retaining device at least once a day. Doing so relieves pressure and
wound is normal for a few weeks after the procedure. These measures maintains skin integrity.
reduce the conditions that support growth of microorganisms and ❙ Slide the external bumper down so it is flush with the skin. Sliding
maceration of the skin. restabilizes the tube.
❙ Remove and discontinue the dressing after the first 24 hours unless the ❙ Avoid placing any type of dressing material under the arms of the
physician orders otherwise. This facilitates assessment. external bumper. This helps to avoid creating pressure on the internal
❙ Inspect the skin around the tube daily. Regular monitoring provides bumper and damaging the tissue.
assessment data about the status of wound repair. ❙ Replace the water in the balloon weekly using a Luer-tip (not Luer-lok)
❙ Make sure that the sutures holding a surgically placed tube are intact. syringe. This keeps the balloon fully inflated and prevents tube migration.
Checking prevents tube migration. ❙ Tape the gastrostomy tube to the abdomen or secure it with an
❙ Report any redness or tissue maceration. These findings indicate early abdominal binder or commercial tube stabilizer. Appropriately securing
skin impairment. the tube maintains its position.
❙ Apply a skin barrier ointment such as zinc oxide, karaya gum wafer,
❙ Make sure the tube is not kinked or the skin stretched. These assessments
hydrocolloid dressing, or ostomy pouch if the skin appears irritated (see ensure tube patency and skin integrity.
section on Ostomy Care, Chap. 31). Such barriers protect the skin and ❙ Insert a Foley catheter (see Chap. 30), if the client is not sensitive to
promote healing. latex, 2 to 5 inches (5 to 10 cm) within the opening, and inflate the
❙ Press down on the skin at the base of the tube (Fig. 29-12A). If the client balloon if the tube comes out. Doing so maintains temporary access to
has a PEG tube, compress the arms of the external bumper together and the stomach and, if done within 3 hours of accidental extubation,
lift them about 1 inch (2.5 cm) (Fig. 29-12B). These steps aid in prevents the site from closing.
assessing for drainage, which normally disappears by the end of the ❙ Use the gastrostomy tube in a manner similar to how a nasogastric tube
first week. is used for administering feedings. The tube facilitates nourishment.
potential for enteritis (inflammation of the intestine) Although placement of tubes within the intestine
because the chemicals in the stomach tend to destroy reduces the risk for gastric reflux, it does not eliminate
microorganisms. Gastric feedings increase the potential that risk. Additional problems are associated with intesti-
for gastric reflux, however, because of their volume and nal tube feedings. For example, an intestinally placed
temporary retention within the stomach. tube may lead to dumping syndrome (cluster of symptoms
A B
FIGURE 29-12 • Inspection. (A) Inspecting for drainage. (B) Inspecting the skin.
TABLE 29-3 COMPARISON OF FEEDING TUBES

TUBE ADVANTAGES DISADVANTAGES
Nasogastric Low incidence of obstruction Can damage nasal and pharyngeal mucosa from pressure or
friction
Accommodates crushed medications Dilates esophageal sphincter, potentiating gastric reflux
Facilitates bolus or intermittent feedings Potential for aspiration
Easy to check distal placement and Requires frequent replacement to ensure integrity of nasal tissue
gastric residual
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
from the rapid deposition of calorie-dense nourishment Formula Considerations

into the small intestine). The symptoms, which include
weakness, dizziness, sweating, and nausea, are caused by In addition to the type of tube and the access site, the type
fluid shifts from the circulating blood to the intestine and of formula also is individualized, based on the client’s
low blood glucose level related to a surge of insulin. Diar- nutritional needs (Table 29-4). Factors include the client’s
rhea also may result when administering hypertonic for- weight, nutritional status, and concurrent medical condi-
mula solutions. tions and the projected length of therapy. The feeding
TABLE 29-4 TUBE-FEEDING FORMULAS

TYPE OF LIQUID NUTRITION EXAMPLES USE
Isotonic balanced Osmolite Meets total nutritional needs or supplements oral nutrition without
Isocal altering water distribution
Balanced Ensure Meets total nutritional needs or supplements oral nutrition
Nutren 1.0
Resource
Sustacal 8.8
High-calorie Ensure Plus Meets needs of clients who require more than usual caloric intake
Comply
Resource Plus
Nutren 1.5
High-nitrogen Ensure HN Furnishes more protein than other formulas
Promote
Magnacal
Attain
High-fiber Jevity Provides nutrition and decreases constipation or diarrhea
Ensure with Fiber
Compleat Modified
Ultracal
Partially hydrolyzed Alitraq Supplies elemental nutrients for people with malabsorption syndromes
Criticare HN or impaired GI function
TraumaCal
Impact Vivonex Plus
schedule also affects the choice of formula: calories may held in the reservoir of the stomach; it can be delivered
need to be concentrated if the client is being fed several directly into the small intestine. Instilling small amounts
times a day rather than continuously. Most formulas proof fluid beyond the stomach reduces the risk of vomiting
vide 0.5 to 2.0 kcal/mL of formula. and aspiration. Continuous feeding creates some inconve-
nience, though, because the pump must go wherever the
client goes.
Tube-Feeding Schedules
Tube feedings may be administered on bolus, intermit- Client Assessment
tent, cyclic, or continuous schedules.
The following daily assessments are standard for almost
Bolus Feedings every client who receives tube feedings: weight, fluid
intake and output, bowel sounds, lung sounds, tempera-
A bolus feeding (instillation of liquid nourishment in less
ture, condition of the nasal and oral mucous membranes,
than 30 minutes four to six times a day) usually involves
250 to 400 mL of formula per administration. This sched- breathing pattern, gastric complaints, status of abdominal
ule is the least desirable because it distends the stomach distention, vomiting, bowel elimination patterns, and skin
rapidly, causing gastric discomfort and increased risk for condition at the site of a transabdominal tube. Once tube
reflux. Bolus feedings may be used because they mimic, to feedings have been initiated, it is also necessary to rou-
some extent, the natural filling and emptying of the stom- tinely assess the client’s gastric residual (volume of liquid
ach. Some clients experience discomfort from the rapid within the stomach). The nurse measures gastric residual
delivery of this quantity of fluid. Clients who are un- to determine whether the rate or volume of feeding
conscious or who have delayed gastric emptying are at exceeds the client’s physiologic capacity. Overfilling the
greater risk for regurgitation, vomiting, and aspiration stomach can cause gastric reflux, regurgitation, vomiting,
with this method of administration. aspiration, and pneumonia. As a rule of thumb, the gas-
tric residual should be no more than 100 mL or no more
Intermittent Feedings than 20% of the previous hour’s tube-feeding volume
(Smeltzer & Bare, 2006). See Nursing Guidelines 29-4.
An intermittent feeding (gradual instillation of liquid nour-
ishment four to six times a day) is administered over 30
to 60 minutes, the time most people spend eating a meal.
The usual volume is 250 to 400 mL per administration. NURSING GUIDELINES 29-4
Intermittent feedings generally are given by gravity drip
Checking Gastric Residual
from a suspended container or with a feeding pump.
Gradual filling of the stomach at a slower rate reduces ❙ Wash hands or perform an alcohol-based handrub (see Chap. 10).
the bloated feeling that can accompany bolus feedings. Hand hygiene reduces the transmission of microorganisms.
The container that holds the formula requires thorough ❙ Don gloves. Gloves provide a physical barrier between the nurse’s
flushing after each feeding to reduce growth of micro- hands and body fluids.
organisms. Tube-feeding administration sets are replaced
every 24 hours regardless of the feeding schedule.
❙ Stop the infusion of tube-feeding formula. This measure facilitates
assessment.
Cyclic Feedings ❙ Aspirate fluid from the feeding tube using a 50-mL syringe. Doing
so allows collection of a large volume of fluid.
A cyclic feeding (continuous instillation of liquid nourish-
❙ Continue aspirating until no more fluid is obtained. This ensures an
ment for 8 to 12 hours) is followed by a 16- to 12-hour
accurate assessment.
pause. This routine often is used to wean clients from tube
feedings while continuing to maintain adequate nutrition. ❙ Measure the aspirated fluid and record the amount. Documentation
The tube feeding is given during the late evening and provides objective data for evaluation.
sleep. During the day, clients eat some food orally. As oral ❙ Reinstill the aspirated fluid. This measure returns partially digested
intake increases, the volume and duration of the tube feed- nutrients and electrolytes to the client.
ing gradually are decreased. ❙ Postpone tube feeding and report residual amounts that exceed
agency guidelines or those established by the physician. Doing so
Continuous Feedings reduces the risk of aspiration.
A continuous feeding (instillation of liquid nutrition with- ❙ Check gastric residual again in 30 minutes. This duration allows time
out interruption) is administered at a rate of approxi- for part of the stomach contents to empty into the small intestine.
mately 1.5 mL/minute. A feeding pump is used to regulate ❙ Provide or resume tube feeding if the gastric residual is within an
the instillation. Because only a small amount of fluid is acceptable range. Doing so prevents overfeeding.
instilled at any one time, the formula does not need to be
Stop • Think + Respond BOX 29-4 NURSING GUIDELINES 29-5

If a client’s nutritional needs are met entirely with tube Clearing an Obstructed Feeding Tube
feedings, what effects might that have on the person
physically, emotionally, and socially? ❙ Select a syringe with a capacity of at least 50 mL. This capacity
reduces negative pressure during aspiration, which could lead to
collapse of the tube walls.
❙ Wash hands or perform an alcohol-based handrub (see Chap. 10).
Nursing Management Hand hygiene reduces the transmission of microorganisms.
❙ Don gloves. They provide a physical barrier between the nurse’s
Caring for clients with feeding tubes generally involves
hands and potential contact with body fluids.
maintaining tube patency, clearing any obstructions, pro-
viding adequate hydration, dealing with common formula- ❙ Aspirate as much as possible from the feeding tube. Aspiration
related problems, and preparing clients for home care. clears the path above the obstructing debris.
❙ Instill 5 mL of the selected solution. Instillation allows direct contact
Maintaining Tube Patency between the irrigating solution and debris.
Feeding tubes, especially those smaller than 12 F, are ❙ Clamp the tube and wait 15 minutes. This duration gives the
prone to obstruction. Common causes are using formulas substance in solution time to physically affect the obstructing debris.
with large-molecule nutrients, refeeding partially digested ❙ Aspirate or flush the tube with water. Repeat if necessary. Use of
gastric residual, administering formula at a rate less than negative pressure or positive pressure restores patency.
50 mL/hour, and instilling crushed or hydrophilic (water-
absorbing) medications into the tube. To maintain pa-
tency, it is best to flush feeding tubes with 30 to 60 mL of
mine whether or not the client can excrete comparable
water immediately before and after administering a feed-
amounts (see Chap. 16).
ing or medications, every 4 hours if the client is being con-
tinuously fed, and after refeeding the gastric residual. Dealing With Miscellaneous Problems
Although tap water is effective as a flush solution,
cranberry juice and carbonated beverages may be used. Clients who require enteral feeding experience several
Formula tends to curdle when it comes in contact with common or potential problems. Many are associated with
cranberry juice, which detracts from the efficacy of this tube-feeding formulas or the mechanical effects of the
approach. tubes themselves (Table 29-5). Nurses report problems
promptly and make necessary adjustments to the plan
Clearing an Obstruction of care.
If an obstruction occurs, the nurse consults the physician. Preparing for Home Care
Occasionally, it is possible to clear the tube with a solu-
tion of meat tenderizer or pancreatic enzyme, but both Because of shortened lengths of stay in hospitals, some
methods require written medical orders. See Nursing clients who continue to need tube feedings are discharged
Guidelines 29-5. to care for themselves at home. Before demonstrating the
When an obstruction cannot be cleared, the tube is procedure, the nurse provides a written instruction sheet
removed and another inserted rather than compromising that includes the following:
nutrition by the delay. • Places to obtain equipment and formula
• The amount and schedule for each feeding and flush,
Providing Adequate Hydration using household measurements
Although tube feedings are approximately 80% water, • Guidelines for delaying a feeding
clients usually require additional hydration. Adults re- • Special instructions for skin, nose, or stomal care,
quire 30 mL of water per kilogram of body weight, or including frequency and types of products to use
1 mL/kcal, on a daily basis (Brockus, 1993). • Problems to report such as weight loss, reduced urina-
To determine whether or not a client’s hydration needs tion, weakness, diarrhea, nausea and vomiting, and
are being met, the nurse identifies the amount of water on breathing difficulties
the label of commercial formula. He or she can then add • Names and phone numbers of people to call if ques-
this amount to the total volume of flush solution and com- tions arise
pare with the recommended amount. If there is a signifi- • Date, time, and place for continued medical follow-up
cant deficit, the nurse revises the plan of care to increase Depending on the client’s self-confidence and com-
either the volume or, preferably, the frequency of flushing petence in self-administering tube feedings, health care
the tube. If the fluid volume is excessive, the nurse moni- providers often make a referral to a home health agency
tors the client’s urine output and lung sounds to deter- for postdischarge nursing support.
TABLE 29-5 COMMON TUBE-FEEDING PROBLEMS

PROBLEM COMMON CAUSES SOLUTIONS
Diarrhea Highly concentrated formula Dilute initial tube feeding to 1⁄4 to 1⁄2 strength.
Rapid administration Start at 25 mL/hour and increase rate by 25 mL q 12 h.
Bacterial contamination Wash hands.
Change formula bag and tubing q 24 h.
Hang no more than 4 hours’ worth of formula.
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 adminis-
ter 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 less than 100 mL or
less than 20% of hourly volume.
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.
Air in stomach 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 Calorie-concentrated formula Instill diluted formula and gradually increase concentration.
glucose level 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 Mouth breathing Provide frequent oral and nasal hygiene.
mucous membranes Dried nasal mucus
Middle ear Narrowing or obstruction of eustachian Turn from side to side q 2 h.
inflammation tube from presence of tube in pharynx Insert a small-diameter feeding tube.
Sore throat Pressure and irritation from tube Use a small-diameter feeding tube.
Plugged feeding tube Instilling crushed or powdered Use liquid medications.
medications through the tube Dilute crushed drugs.
Flush the tubing liberally after drug administration.
Formula coagulation from drug–food Flush tubing with water before and after drug
interactions 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 q 4 h.
Use a larger-diameter feeding tube.
Dumping syndrome Rapid and large instillation of highly Administer small, continuous volume.
concentrated formula into the intestine Adjust glucose content of formula.
INTESTINAL DECOMPRESSION NURSING GUIDELINES 29-6

Inserting an Intestinal Decompression Tube
Most nasogastric, nasointestinal, and transabdominal
tubes are used for enteral feeding or gastric decompression.
❙ Assemble all the necessary equipment as for any nasally
inserted tube. Doing so ensures organization and efficient time
Sometimes, however, clients require intestinal decompres-
management.
sion, which is performed with a tungsten-weighted tube
(see Table 29-1). Intestinal decompression sometimes ❙ Follow the techniques in Skill 29-1 for inserting a nasogastric tube.
makes it possible to avoid surgery. The same principles are involved during initial insertion.
❙ Thread excess tubing through a sling of folded gauze taped to the
forehead (Fig. 29-13) once gastric placement is confirmed. The sling
Tube Insertion supports the tube as it advances.
❙ Ambulate the client, if possible. Ambulation helps the tube to move
A nasointestinal decompression tube is inserted in the
through the pyloric valve into the small intestine.
same manner as a nasogastric tube. The nurse then pro-
motes and monitors its passage into the intestine. In the ❙ When the radiograph indicates that the intestinal tube has advanced
presence of peristalsis, the weight of the tungsten propels beyond the stomach, position the client on the right side for 2 hours,
the tip of the tube beyond the stomach. Openings through then on the back in a Fowler’s position for 2 hours, then on the left
side for 2 hours. Gravity and positioning promote movement
the distal end provide channels through which the intesti-
through intestinal curves.
nal contents are suctioned. An intestinal decompression
tube generally remains in place until the intestinal lumen ❙ Follow agency policy or physician’s instructions for manually
is patent or surgical treatment is instituted. See Nursing advancing the tube several inches each hour. This advancement
Guidelines 29-6. supplements natural peristaltic advancement.
❙ Observe the graduated marks on the tube. They provide a means
for monitoring the tube’s progression and approximate anatomic
Removal location.
❙ Request x-ray confirmation when the tube has reached the
Once the intestinal decompression tube has served its
prescribed distance. An x-ray provides objective evidence of the
purpose, the nurse begins the process of removing it. An
terminal location of the distal tip.
intestinal decompression tube is removed slowly because
removal is in a reverse direction through the curves of ❙ Secure the tube to the nose once its distal location has been confirmed.
the intestine and the valves of the lower and upper ends This measure stabilizes the tube and prevents further migration.
of the stomach. ❙ Coil the excess tubing and attach it to the client’s pajamas or gown.
First, the tube is disconnected from the suction source. Coiling and attachment prevent accidental extubation.
Next, the tape that secures the tube to the face is removed ❙ Connect the proximal end to a wall or portable suction source. This
and the tube is withdrawn 6 to 10 inches (15 to 25 cm) at measure produces negative pressure to pull substances from the
10-minute intervals. When the last 18 inches (45 cm) intestine.
remains, the tube is pulled gently from the nose. After-
ward, nasal and oral hygiene measures are provided.
Depending on data collected during client care, the

nurse may identify one or more of the following nursing
diagnoses:
• Imbalanced Nutrition: Less Than Body Requirements
• Self-Care Deficit: Feeding
• Impaired Swallowing
• Risk for Aspiration
• Impaired Oral Mucous Membranes
• Diarrhea
• Constipation
Nursing Care Plan 29-1 is a model for managing the
care of a client with a large gastric residual with a nurs-
ing diagnosis of Risk for Aspiration, defined by NANDA
(2005, p. 13) as “at risk for entry of gastrointestinal FIGURE 29-13 • Fashioning a gauze sling.
Risk for Aspiration
ASSESSMENT
• Note client’s level of consciousness and prescribed drug therapy that may cause sedation.
• Check for a cough and gag reflex.
• Determine client’s ability to swallow effectively or review the results of a swallow study ordered by the physician.
• Measure gastric residual if the client is receiving tube feedings.
• Auscultate bowel sounds.
• Palpate the abdomen and measure abdominal girth for evidence of distention.
• Ask an alert client about feeling full, nauseous, or vomiting.
• Check if any medical orders restrict the positioning of a client in a Fowler’s position.
Nursing Diagnosis: Risk for Aspiration related to slow gastric emptying as manifested by
measurement of gastric residual of 150 mL from a #16 nasogastric tube 4 hours after
previous bolus feeding of 400 mL, unresponsiveness 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: 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 prescribed An inflated cuff acts as a barrier that prevents stomach
pressure. contents from entering the airway.
Maintain head elevation at no less than 30 degrees at all Elevating the upper body promotes the deposition of 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
elimination of liquid nourishment.
Check placement of the distal end of the gastric tube Checking 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
refeeding helps to prevent obstruction within the tube and
provides additional water intake.
Postpone tube feeding for 1 hour if gastric residual Distention of the stomach with additional formula
measures 100 mL or more. predisposes the client to regurgitation and potential for
aspiration.
Report gastric residual volume to physician if 100 mL or Sharing assessment findings with the physician facilitates
more after delaying feeding for 1 hour and reassess. collaboration in modifying the plan of care by changing
the type, volume, or frequency of the tube feeding, or
administering a medication that promotes gastric
emptying.
(continued)
Risk for Aspiration
Maintain 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.
• Bowel sounds are present and active in all quadrants.
• Endotracheal tube cuff remains inflated.
• Head is elevated 30 degrees.
• Tube feeding is infusing at 100 mL/hr with feeding pump rather than bolus feeding following change in medical order.
secretions, oropharyngeal secretions, or solids or fluids In home and long-term care settings, registered dietitians may be
into tracheobronchial passages.” helpful in ongoing assessment of tube feedings. For older
adults living on a fixed income, dietitians can suggest ways to
prepare less costly, home-blended formulas that meet the
client’s nutritional needs.
GENERAL GERONTOLOGIC Long-term use of tube feedings in older adults with dementia or
CONSIDERATIONS other chronic declining conditions involves many ethical con-
siderations. Refusal to eat (intentional starvation) may be seen
An age-related reduction in the number of laryngeal nerve end- as a possible means of suicide in the older person or as a
ings contributes to diminished efficiency of the gag reflex. symptom of depression. Caregivers must carefully assess an
Other conditions that depress the gag reflex include neurologic individual client’s decision to refuse food or desire to have a
disorders such as dementia and strokes and repeated insertion feeding tube removed. Older people who are institutionalized
and removal of dentures. have more limited decision-making power in these cases than
Older adults are at increased risk for fluid and electrolyte distur- the person living at home may have. Nurses should follow the
bances and, as a result, may develop hyperglycemia (elevated 2001 American Nurses Association (ANA) position statement
blood glucose levels) when tube feedings are administered. regarding advance directives related to a client’s wish to avoid
Most tube-feeding formulas are highly concentrated; there- artificial nutrition and hydration. Nurses, especially those
working in home care and long-term care settings, need up-to-
fore, the hydration status of the older client must be closely
date knowledge about ethical and legal issues related to the
monitored.
use of tube feedings (see Chap. 3).
If an older client is receiving tube feedings with full-strength
formula concentrations, it is important to check capillary blood
glucose levels every 4 hours for a 48-hour period until the CRITICAL THINKING E X E R C I S E S
client’s results are within normal range.
Tube-feeding formulas may vary based on the older client’s con- 1. Describe the similarities and differences between inserting
dition (i.e., malabsorption syndromes, glucose intolerance). a tube for gastric decompression and one for intestinal
Several lactose-free tube-feeding formulas on the market decompression.
today may be beneficial to older clients who experience
malabsorption syndromes. 2. What questions would be important to ask if a client
Clients with, or at risk for, pressure sores benefit from formulas receiving tube feedings at home calls to report the onset
fortified with additional zinc, protein, and other nutrients. of diarrhea?
Older adults tend to tolerate small, continuous feedings.
Monitor older adults for agitation or confusion, which may cause
them to pull out feeding tubes inadvertently. Also, a change in NCLEX-STYLE REVIEW Q U E S T I O N S
mental status is an early indicator of a fluid or electrolyte
1. To determine the length for inserting a nasogastric sump
imbalance.
tube, the nurse is most correct in placing the distal tip of
When teaching older adults or older caregivers how to manage a
gastrostomy tube or administer tube feedings at home, allow
the tube at the client’s nose and measuring the distance
more time for processing information and include several from there to the
practice sessions. A referral for skilled nursing care, which may 1. Jaw and then midway to the sternum
be covered by Medicare/Medicaid or private health insurance 2. Mouth and then between the nipples
plans, may be appropriate for ongoing teaching and assess- 3. Midsternum and then to the umbilicus
ment for clients being discharged with tube feedings. 4. Ear and then to the xiphoid process
2. When a practical nurse assists with the insertion of a sin- 4. Immediately after insertion of a transabdominal gastros-
gle lumen nasogastric tube, which of the following tomy tube, which finding should the nurse consider nor-
instructions is correct when the tube is in the client’s mal when assessing the gastrostomy site?
oropharynx? 1. Milky-appearing drainage
1. “Breathe deeply as the tube is advanced.” 2. Serosanguineous drainage
2. “Hold your head in a sniffing position.” 3. Green-tinged drainage
3. “Press your chin to your upper chest.” 4. Bright bloody drainage
4. “Avoid coughing until the tube is down.” 5. When a client with a nasogastric tube for gastric decom-
3. The most appropriate technique for determining whether pression indicates that he is very thirsty, which nursing
the distal end of a tube for gastric decompression is in intervention is most appropriate to add to the plan of
the stomach is to care?
1. Request a portable x-ray of the stomach. 1. Offer fluids at least every 2 hours.
2. Check the pH of aspirated fluid. 2. Provide crushed ice in sparse amounts.
3. Instill 100 mL of tap water into the tube. 3. Increase oral liquids on dietary tray.
4. Feel for air at the tube’s proximal end. 4. Refill water carafe twice each shift.
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 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 Indicates the need for and level of health teaching
procedure.
Inspect the nose after the client blows into a paper tissue Provides data that will determine which naris to use
(Fig. A).
Clearing nose. (Copyright B. Proud.)
Unwrap and uncoil the tube. Straightens tube and releases bends from product packaging
Obtain the NEX measurements (Fig. B). Determines length for insertion
Measuring the tube. (Copyright B. Proud.)
(continued)
INSERTING A NASOGASTRIC TUBE (Continued)
Mark the tube at the NE (nose-to-ear) and NX (nose-to- Provides a guide during insertion
xiphoid) measurements (Fig. C).
Marking the tube. (Copyright 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
water, straw, towel, lubricant, tissues, tape, emesis basin, management
flashlight, stethoscope, clean gloves, 50-mL syringe.
Place a suction machine at the bedside if the client is Provides a method for clearing the client’s airway of
unresponsive or has difficulty swallowing. vomitus
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
(see Chap. 10).
Pull the privacy curtain. Demonstrates respect for dignity
Assist the client to sit in semi-Fowler’s or high-Fowler’s Ensures visualization of nasal passageway to facilitate
position and hyperextend the neck as if in a sniffing inserting the tube
position.
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 to Reduces friction and tissue trauma
8 inches (15 to 20 cm) at the distal tip.
(continued)
Insert the tube into the nostril while pointing the tip Follows the normal contour of the nasal passage
backward and downward (Fig. D).
Preparing to insert the tube. (Copyright B. Proud.)
Do not force the tube. Relubricate or rotate it if there is Prevents trauma

resistance.
Stop when the first mark on the tube is at the tip of the Places the tip above the area where the gag reflex may be
nose. 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 Narrows the trachea and opens the esophagus; helps to
swallow sips of water. advance the tube
Advance the tube 3 to 5 inches (7.5 to 12.5 cm) each time Coordinates insertion; reduces the potential for gagging or
the client 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 when the second mark is reached (Fig. E). Provides data on distal placement
Withdraw the tube to the first mark and reattempt Ensures safety
insertion if the assessment findings are inconclusive, or
consult with the physician about obtaining an x-ray.
Proceed to secure the tube if data indicate the tube is in Prevents tube migration
the stomach (Fig. F).
Connect the tube to suction or clamp it while awaiting Promotes gastric decompression or potential use
further orders.
Remove gloves and wash your hands or use an alcohol- Reduces the transmission of microorganisms
based 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 principles of medical
asepsis
(continued)
E F
Assessing placement. Securing the tube. (Copyright B. Proud.)
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 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 16 F Salem sump tube inserted without difficulty. Placement verified by aspirating gastric secretions,
which are yellowish-green and reveal a pH of 3 when tested. Salem sump tube secured to nose and con-
nected to low, intermittent wall suction. Positioned with head of bed elevated 30 degrees.
SIGNATURE/TITLE
Skill 29-2 • IRRIGATING A NASOGASTRIC TUBE
Assessment
Monitor the client’s symptoms, volume and rate of Provides data for future comparisons
drainage, and evidence of abdominal distention.
Check that a medical order has been written, if that is the Complies with the legal scope of nursing practice
agency’s policy.
correct client
Assess how much the client understands about the Provides an opportunity for client teaching
procedure.
Planning
Assemble the following equipment: Asepto or irrigating Contributes to organization and efficient time management
syringe, irrigating fluid (isotonic saline solution),
container, clean towel or pad, clean gloves, cover or
plug for end of tube.
Turn off the suction. Facilitates implementation
Implementation
(see Chap. 10).
Place a clean pad or towel beneath where the tube will be Avoids changing bed linen and protects the client from
separated. soiling
Don clean gloves. Complies with standard precautions
Disconnect the nasogastric tube from the suction tubing Keeps connection area clean
and apply cover or insert plug into suction tubing.
Check the distal placement of the tube. Ensures safety
Fill irrigating syringe with 30 to 60 mL of normal saline Provides an adequate quantity of isotonic solution to clear
solution. tubing
Insert the tip of the syringe within the proximal end of the Dilutes and mobilizes debris
tube and allow the solution to flow in by gravity or
apply gentle pressure (Fig. A).
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; Provides data for evaluating the effectiveness of the
measure and discard. procedure
Monitor for the flow of drainage through the suction Provides evidence that patency is being maintained
tubing (Fig. B).
Remove gloves and perform hand hygiene. Reduces the transmission of microorganisms
Record the volume of instilled and drained fluid on the Provides accurate data for determining fluid balance
bedside intake and output sheet.
(continued)
IRRIGATING A NASOGASTRIC TUBE (Continued)
A B
Instilling irrigation solution. (Copyright B. Proud.) Monitoring drainage. (Copyright B. Proud.)
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. 100
mL of solution returned with several large mucus particles. Reconnected to low, intermittent suction.
Gastric tube well at the present time. Abdomen is soft. No vomiting.
SIGNATURE/TITLE
Skill 29-3 • REMOVING A NASOGASTRIC TUBE
Assessment
Assess bowel sounds, condition of mouth and nasal Provides data for future comparisons and may affect how
mucosa, level of consciousness, and gag reflex. the procedure is performed
Check that a medical order has been written. Complies with the legal scope of nursing practice
correct 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
cotton-tipped applicator sticks, oral hygiene equipment, management
clean gloves.
Implementation
(see Chap. 10).
Place the client in a sitting position, if alert, or in a lateral Prevents aspiration of stomach contents
position if not.
Cover the chest with a clean towel and place the emesis Prepares for possible vomiting and protects the client from
basin 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 tube. Prepares for removal
Instill a bolus of air into the lumen that drains gastric Prevents residual fluid from leaking as the tube is
secretions. withdrawn
Clamp, plug, or pinch the tube (Fig. A). Prevents fluid from leaking as the tube is withdrawn
Occluding the tube. (Copyright B. Proud.)
Instruct the client to take a deep breath and hold it just Reduces the risk for aspirating gastric fluid
before removing the nasogastric tube.
Remove the tube from the client’s nose gently and slowly. Lessens the potential for trauma
(continued)
REMOVING A NASOGASTRIC TUBE (Continued)
Enclose the tube within the towel or glove and discard the Provides a transmission barrier against microorganisms
tube in a covered container (Fig. B).
Enclosing the tube. (Copyright B. Proud.)
Empty, measure, and record the drainage in the suction Provides data for evaluating the client’s fluid status
container.
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 Promotes integrity of nasal tissue
with paper tissues or cotton-tipped applicators.
Discard disposable equipment; rinse and return portable Preserves cleanliness and orderliness in the client’s unit;
suction equipment. demonstrates accountability for equipment
Evaluation
• Tube is removed.
• Client resumes eating and taking fluids.
• Client experiences no nausea or vomiting.
• Airway remains clear.
• 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
drainage emptied from suction container. Oral care provided. L. naris swabbed with applicator lubri-
cated with petroleum jelly. Mucosa is red but intact. SIGNATURE/TITLE
Skill 29-4 • ADMINISTERING TUBE FEEDINGS
Bolus Feeding
Assessment
Check the medical order for the type of nourishment, Complies with the legal scope of nursing practice
volume, and schedule to follow.
Check the date and identifying information on the Ensures accurate administration and avoids using
container of tube-feeding formula. outdated formula
(see Chap. 10).
correct client
Distinguish the tubing for gastric or intestinal feeding Prevents administering nutritional formula into the
from tubing to instill intravenous solutions. vascular system
Assess bowel sounds. Provides data indicating safety for instilling liquids through
the tube
Measure gastric residual if a 12 F or larger tube is in place Determines if the stomach has the capacity to manage the
(Fig. A). next instillation of formula; aspiration of fluid may be
impossible with small-lumen tubes.
Measuring gastric residual. (Copyright 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)
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 Avoids overfilling the stomach
exceeds 100 mL.
Assemble the following equipment: Asepto syringe, Contributes to organization and efficient time management
formula, tap water.
Warm refrigerated nourishment to room temperature in a Prevents chilling and abdominal cramping
basin 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 Prevents air from entering the tube
(Fig. B).
Add fresh formula to the syringe and adjust the height to Provides nourishment
allow a slow but gradual instillation.
Continue filling the syringe before it becomes empty. Prevents air from entering the tube
If a gastrostomy tube is being used, tilt the barrel of the Permits air displacement from the stomach
syringe during the feeding (Fig. C).
B C
Administering a bolus feeding. (Copyright B. Proud.) Bolus feeding through a gastrostomy tube.
Flush the tubing with at least 30 to 60 mL of water after Ensures that all nourishment has entered the stomach;
each feeding, or follow agency policy for suggested prevents fermentation and coagulation of formula in the
amounts. tube; provides water for fluid balance
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 to 60 minutes Prevents gastric reflux
after a feeding.
(continued)
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 Provides accurate data for assessing fluid balance and
the bedside intake and output record. caloric value of nourishment
Provide oral hygiene at least twice daily. Removes microorganisms and promotes comfort and
hygiene of client
Intermittent Feeding
Assessment
Follow the previous sequence for assessment. Principles remain the same.
Planning
In addition to those activities listed for bolus feeding, Reduces the potential for bacterial growth
replace 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
cramping; room-temperature formula will be instilled
before supporting 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 agency policy.
Check at 10-minute intervals (Fig. D). Ensures early identification of infusion problems
Flush the tubing with water after the formula has infused. Clears the tubing of formula, prevents obstruction, and
provides water for fluid balance
Pinch the feeding tube just as the last volume of water is Prevents air from entering the tube
administered (Fig. E).
D E
Checking the rate of flow. Pinching the feeding tube.
(continued)
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 Principles for care remain the same.
described with bolus feeding.
Continuous Feeding
Assessment
In addition to previously described assessments, check the Principles remain the same. This method ensures a
gastric residual every 4 hours. routine pattern for assessment to accommodate the
schedule of continuous feedings and prevents
inadvertent overfeeding.
Planning
In addition to previously described planning activities, Aids accurate administration and sounds an alarm if the
obtain equipment for regulating continuous infusion infusion is interrupted
(e.g., tube-feeding pump).
Replace unused formula, feeding containers, and tubing Reduces the potential for bacterial growth
every 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
passage of large protein molecules
Fill the feeding container with no more than 4 hours’ Prevents growth of bacteria; body heat will warm cold
worth of refrigerated formula. Exception: Commercially formula when infused at a slow rate.
prepared, sterilized containers of formula, or formula
that is kept iced while infusing may hang for longer
periods.
Purge the tubing of air (Fig. F). Prevents distention of the stomach or intestine
Thread the tubing within the feeding pump according to Ensures correct mechanical operation of equipment and
the manufacturer’s directions. accurate administration to the client
Connect the tubing from the feeding pump to the client’s Provides access to formula
feeding tube.
Set the prescribed rate on the feeding pump (Fig. G). Complies with medical order
Open the clamp on the feeding tube and start the pump Initiates infusion
(Fig. H).
Keep the client’s head elevated at all times. Prevents reflux and aspiration
Flush the tubing with 30 to 60 mL of water or more every Promotes patency and contributes to the client’s fluid
4 hours after checking and refeeding gastric residual balance
and after administering medications.
Provides accurate data for assessing fluid balance and
caloric value of nourishment
(continued)
F G
Preparing the pump. (Copyright B. Proud.) Programming the pump. (Copyright B. Proud.)
Releasing the clamp. (Copyright B. Proud.)
Record the instilled volume of formula and water. Principles for care remain the same
Follow recommendations for postprocedural care as

described with bolus feeding.
(continued)
Evaluation
• Client receives prescribed volume of formula accord-
ing to established feeding schedule.
• Weight remains stable or client reaches target weight.
• Lungs remain clear.
• Bowel elimination is within normal parameters
for client.
• Client has a daily fluid intake between 2000 and
3000 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 50 mL of gastric residual. Residual reinstilled and tube flushed with 60 mL of tap water. 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
U N I T 71

for Chapters
Chapters 1,
27,2 28, and 29
in parentheses.
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)

false statements.
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 re-establish 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
696
UNIT 7 ● End of Unit Exercises for Chapters 27, 28, and 29 697
Activity D: 1. Match the terms related to wound 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. Débridement 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/minute
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 criteria given below.
Open Drains Closed Drains
Definition
Method of drainage
Wound care
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?
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 tomorrow. What potential risks factors increase the
likelihood of perioperative complications?
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?
Activity K: Think over the following questions. Discuss them with your instructor
or peers.
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?
3. A client has been brought to the health care facility in a semi-conscious 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 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 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
UNIT 8
Promoting
Elimination
30 Urinary Elimination
31 Bowel Elimination
30
Chapter
Urinary
Elimination
LEARNING OBJECTIVES
● Identify the collective functions of the urinary system.
● Name at least five factors that affect urination.
● List four physical characteristics of urine.
● Name four types of urine specimens that nurses commonly collect.
● List six abnormal urinary elimination patterns.
● Identify three alternative devices for urinary elimination.
● Define continence training.
WORDS TO KNOW ● Name three types of urinary catheters.
● Describe two principles that apply to using a closed drainage system.
anuria ● Explain why catheter care is important in the nursing management of clients with retention
bedpan catheters.
catheter care ● Discuss the purpose for irrigating a catheter.
catheter irrigation ● Identify three ways of irrigating a catheter.
catheterization ● Define urinary diversion.
clean-catch specimen ● Discuss factors that contribute to impaired skin integrity in clients with a urostomy.
closed drainage system ● Describe two age-related changes in older adults that may affect urinary elimination.
commode
continence training
continuous irrigation THIS chapter reviews the process of urinary elimination and describes nursing skills
Credé’s maneuver for assessing and maintaining urinary elimination.
cutaneous triggering
dysuria
external catheter
fenestrated drape
frequency OVERVIEW OF URINARY ELIMINATION
incontinence
Kegel exercises
nocturia The urinary system (Fig. 30-1) consists of the kidneys, ureters, bladder, and urethra.
oliguria These major components, along with some accessory structures such as the ring-shaped
peristomal skin muscles called the internal and external sphincters, work together to produce urine
polyuria
residual urine (fluid within the bladder), collect it, and excrete it from the body.
retention catheter Urinary elimination (the process of releasing excess fluid and metabolic wastes), or
stasis urination, occurs when urine is excreted. Under normal conditions, the average per-
straight catheter son eliminates approximately 1500 to 3000 mL of urine each day. The consequences
24-hour specimen
urgency
of impaired urinary elimination can be life-threatening.
urinal Urination takes place several times each day. The need to urinate becomes appar-
urinary diversion ent when the bladder distends with approximately 150 to 300 mL of urine. The dis-
urinary elimination tention with urine causes increased fluid pressure, stimulating stretch receptors in
urinary retention
the bladder wall and creating a desire to empty it of urine.
urine
urostomy Patterns of urinary elimination depend on physiologic, emotional, and social fac-
voided specimen tors. Examples include the degree of neuromuscular development and integrity of the
voiding reflex spinal cord; the volume of fluid intake and the amount of fluid losses, including those
704
C H A P T E R 30 ● Urinary Elimination 705
Urine Specimen Collection
Health care professionals collect urine specimens, or

samples of urine, to identify microscopic or chemical
Kidney constituents. Common urine specimens that nurses col-
lect include voided specimens, clean-catch specimens,
Ureter
catheter specimens, and 24-hour specimens.
Voided Specimens
A voided specimen is a sample of fresh urine collected in a
clean container. The first voided specimen of the day is
preferred because it is most likely to contain substantial
Bladder
urinary components that have accumulated during the
Urethra night. Nevertheless, the specimen can be voided and col-
lected at any time it is needed.
The sample of urine is transferred into a specimen
container and delivered to the laboratory for testing and
FIGURE 30-1 • Major structures of the urinary system. analysis. If the specimen cannot be examined in less than
1 hour after collection, it is labeled and refrigerated.
from other sources; the amount and type of food con-
sumed; and the person’s circadian rhythm, habits, oppor- Clean-Catch Specimens
tunities for urination, and anxiety. A clean-catch specimen is a voided sample of urine consid-
General measures to promote urination include pro- ered sterile and is sometimes called a midstream specimen
viding privacy, assuming a natural position for urination because of how it is collected. To avoid contaminating the
(sitting for women, standing for men), maintaining an voided sample with microorganisms or substances other
adequate fluid intake, and using stimuli such as running than those in the urine, the external structures through
water from a tap to initiate voiding. which urine passes (the urinary meatus, which is the
opening to the urethra, and the surrounding tissues) are
cleansed. The urine is collected after the initial stream
CHARACTERISTICS OF URINE has been released.
Clean-catch specimens are preferred to randomly
The physical characteristics of urine include its volume, voided specimens. This method of collection is also prefer-
color, clarity, and odor. Variations in what is considered able when a urine specimen is needed during a woman’s
normal are wide (Table 30-1). 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
706 U N I T 8 ● Promoting Elimination
is labeled and taken to the laboratory. A clean-catch urine Catheter Specimens

specimen is refrigerated if the analysis will be delayed
A urine specimen can be collected under sterile condi-
more than 1 hour.
tions using a catheter, but this is usually done when
Research suggests that collecting a specimen in mid-
clients are catheterized for other reasons such as to con-
stream without prior cleansing provides results as reliable
trol incontinence in an unconscious client. For clients
as those in which cleansing was performed (Lifshitz &
who are already catheterized, the nurse can aspirate a
Kramer, 2000; Mousseau, 2001; Prandoni et al., 1996).
sample through the lumen of a latex catheter or from a
Nurses should follow their agency’s policy until the stan- self-sealing port (Fig. 30-2).
dard procedure is revised.
When a clean-catch specimen is needed, nurses can 24-Hour Specimens
instruct clients who are capable of performing the proce-
dure on the collection technique. See Client and Family The nurse collects, labels, and delivers a 24-hour specimen
Teaching 30-1. (collection of all urine produced in a full 24-hour period)
to the laboratory for analysis. Because the contents in urine
decompose over time, the nurse places the collected urine
in a container with a chemical preservative or puts the
container in a basin of ice or a refrigerator.
To establish the 24-hour collection period accurately,
Collecting a Clean-Catch Specimen the nurse instructs the client to urinate just before start-
The nurse teaches the female client as follows: ing the test and then discards that urine. All urine voided
thereafter becomes part of the collected specimen. Exactly
• Wash your hands.
24 hours later, the nurse asks the client to void one last
• Remove the lid from the specimen container.
time to complete the test collection. The final urination
• Rest the lid upside down on its outer surface,
and all collected voidings from the preceding 24 hours
taking care not to touch the inside areas.
represent the total specimen, which the nurse labels and
• Sit on the toilet and spread your legs.
takes to the laboratory.
• Separate your labia with your fingers.
• Cleanse each side of the urinary meatus with a
separate antiseptic swab, wiping from front to Abnormal Urine Characteristics
back toward the vagina.
• Use the final clean, moistened swab to wipe Laboratory analysis is a valuable diagnostic tool for iden-
directly down the center of the separated tifying abnormal characteristics of urine. Specific terms
tissue. describe particular abnormal characteristics of urine and
• Begin to urinate. urination. Many terms use the suffix -uria, which refers
• After releasing a small amount of urine into the to urine or urination. For example,
toilet, catch a sample of urine in the specimen
container. • Hematuria: urine containing blood
• Take care not to touch the mouth of the specimen • Pyuria: urine containing pus
container to your skin.
• Place the specimen container nearby on a flat
surface.
• Release your fingers and continue voiding
normally.
• Wash your hands.
• Cover the specimen container with the lid.
The male client should follow the same steps as
above but should perform the following cleansing
routine:
• Retract your foreskin, if you are uncircumcised,
or cleanse in a circular direction around the tip
of the penis toward its base using a premoistened
antiseptic swab.
• Repeat with another swab.
• Continue retracting the foreskin while initiating
the first release of urine and until you have FIGURE 30-2 • Location for collecting a catheter specimen. (Copyright
collected the midstream specimen. B. Proud.)
• Proteinuria: urine containing plasma proteins Nocturia

• Albuminuria: urine containing albumin, a plasma
protein Nocturia (nighttime urination) is unusual because the rate
• Glycosuria: urine containing glucose of urine production is normally reduced at night. Conse-
• Ketonuria: urine containing ketones quently, nocturia suggests an underlying medical problem.
In aging men, an enlarging prostate gland, which encircles
the urethra, interferes with complete bladder emptying.
ABNORMAL URINARY As a result, there is a need to urinate more frequently,
including during the usual hours of sleep.
ELIMINATION PATTERNS
Assessment findings may indicate abnormal urinary elim- Dysuria

ination patterns. Some common problems include anuria,
oliguria, polyuria, nocturia, dysuria, and incontinence. Dysuria is difficult or uncomfortable voiding and a common
symptom of trauma to the urethra or a bladder infection.
Frequency (need to urinate often) and urgency (strong feel-
Anuria ing that urine must be eliminated quickly) often accom-
pany dysuria.
Anuria means absence of urine or a volume of 100 mL or
less in 24 hours. It indicates that the kidneys are not
forming sufficient urine. In this case, the term “urinary Incontinence
suppression” is used. In urinary suppression, the bladder
Incontinence means the inability to control either urinary
is empty; therefore, the client feels no urge to urinate.
This distinguishes anuria from urinary retention, in which or bowel elimination and is abnormal after a person is
the client produces urine but does not release it from the toilet-trained. The term urinary incontinence should not
bladder. A sign of urinary retention is a progressively be used indiscriminately: anyone may be incontinent if
his or her need for assistance goes unnoticed. Once the
distending bladder.
bladder becomes extremely distended, spontaneous uri-
nation may be more of a personnel problem than a client
Oliguria problem. (The client may not be incontinent if staff mem-
bers are attentive to the client’s need to urinate.)
Oliguria, urine output less than 400 mL per 24 hours, indi-
cates inadequate elimination of urine. Sometimes oliguria
is a sign that the bladder is being only partially emptied ASSISTING CLIENTS WITH
during voidings. Residual urine, or more than 50 mL of URINARY ELIMINATION
urine that remains in the bladder after voiding, can sup-
port the growth of microorganisms, leading to infection.
Stable clients who can ambulate are assisted to the bath-
Also, when there is urinary stasis (lack of movement),
room to use the toilet. Clients who are weak or cannot
dissolved substances such as calcium can precipitate, lead-
walk to the bathroom may need a commode. Clients con-
ing to urinary stones.
fined to bed use a urinal or bedpan.
Polyuria
Commode
Polyuria means greater than normal urinary volume and
A commode (chair with an opening in the seat under
may accompany minor dietary variations. For example,
which a receptacle is placed) is located beside or near the
consuming higher than normal amounts of fluids, espe-
bed (Fig. 30-3). It is used for eliminating urine or stool.
cially those with mild diuretic effects (e.g., coffee, tea), or
Immediately afterward, the waste container is removed,
taking certain medications actually can increase urination. emptied, cleaned, and replaced.
Ordinarily urine output is nearly equal to fluid intake.
When the cause of polyuria is not apparent, excessive
urination may be the result of a disorder. Common dis- Urinal
orders associated with polyuria include diabetes mellitus,
an endocrine disorder caused by insufficient insulin, and A urinal is a cylindrical container for collecting urine. It
diabetes insipidus, an endocrine disease caused by insuf- is more easily used by males. When given to the client,
ficient antidiuretic hormone. the urinal should be empty; otherwise, the bed linen may
Using a Bedpan
A bedpan (seatlike container for elimination) is used to

collect urine or stool. Most bedpans are made of plastic and
are several inches deep. A fracture pan, a modified version
of a conventional bedpan, is flat on the sitting end rather
than rounded (Fig. 30-5). Clients with musculoskeletal
disorders who cannot elevate their hips and sit on a bed-
pan in the usual manner use a fracture pan. When a client
confined to bed feels the need to eliminate, the nurse places
a bedpan under the buttocks (Skill 30-1).

Describe measures that may reduce a client’s concerns
when he or she requires a bedpan.
FIGURE 30-3 • A bedside commode.
MANAGING INCONTINENCE
become wet and soiled. If the client needs help placing
the urinal,
Urinary incontinence, depending on its type, may be
permanent or temporary. The six types of urinary in-
• Pull the privacy curtain.
continence are stress, urge, reflex, functional, total, and
• Don gloves.
overflow (Table 30-2).
• Ask the client to spread his legs.
Management of incontinence is complex because there
• Hold the urinal by its handle.
are so many variations. Treatment is further complicated
• Direct the urinal at an angle between the client’s legs
when clients have more than one type of incontinence—
so that the bottom rests on the bed (Fig. 30-4).
for example, stress incontinence often accompanies urge
• Lift the penis and place it well within the urinal.
incontinence.
Some forms of incontinence respond to simple mea-
After use, the nurse promptly empties the urinal. He or
sures such as modifying clothing to make elimination
she measures and records the volume of urine if the client’s
easier. Other forms improve only with a more regimented
intake and output are being monitored (see Chap. 16).
approach, like continence training. Inserting a retention
The nurse washes his or her hands and always offers the
catheter is the least desirable approach to managing in-
client an opportunity to wash his hands after voiding.
continence because it is the leading cause of urinary tract
infections (Marchiondo, 1998).
Continence training to restore control of urination
involves teaching the client to refrain from urinating until
an appropriate time and place. This process sometimes is
FIGURE 30-5 • Two types of bedpans: fracture pan (left) and conven-
FIGURE 30-4 • Placement of urinal. tional bedpan (right). (Copyright B. Proud.)
TABLE 30-2 TYPES OF INCONTINENCE

TYPE DESCRIPTION EXAMPLE COMMON CAUSES NURSING APPROACH
Stress The loss of small amounts Dribbling is associated Loss of perineal and Pelvic floor muscle
of urine when intra- with sneezing, coughing, sphincter muscle tone strengthening
abdominal pressure lifting, laughing, or rising secondary to childbirth, Weight reduction
rises from a bed or chair. menopausal atrophy,
prolapsed uterus, or
obesity
Urge Need to void perceived Voiding commences when Bladder irritation Restriction of fluid intake of
frequently, with short- there is a delay in secondary to infection; at least 2,000mL/day
lived ability to sustain accessing a restroom. loss of bladder tone Omit bladder irritants, such
control of the flow from recent continuous as caffeine or alcohol
drainage with an Administration of diuretics in
indwelling catheter the morning
Reflex Spontaneous loss of urine The person automatically Damage to motor and Cutaneous triggering
when the bladder is releases urine and sensory tracts in the Straight intermittent
stretched with urine, but cannot control it. lower spinal cord sec- catheterization
without prior perception ondary to trauma,
of a need to void tumor, or other neuro-
logic conditions
Functional Control over urination Voiding occurs while Impaired mobility, Clothing modification
lost because of inacces- attempting to overcome impaired cognition, Access to a toilet, commode,
sibility of a toilet or a barriers such as door- physical restraints, or urinal
compromised ability to ways, transferring from a inability to communicate Assistance to a toilet
use one wheelchair, manipulat- according to a preplanned
ing clothing, acquiring schedule
assistance, or making
needs known.
Total Loss of urine without any The person passes urine Altered consciousness sec- Absorbent undergarments
identifiable pattern or without any ability or ondary to a head injury, External catheter
warning effort to control. loss of sphincter tone Indwelling catheter
secondary to prosta-
tectomy, anatomic leak
through a urethral/
vaginal fistula
Overflow Urine leakage because The person voids small Overstretched bladder or Hydration
the bladder is not amounts frequently, or weakened muscle tone Adequate bowel elimination
completely emptied; urine leaks around a secondary to obstruc- Patency of catheter
bladder distended with catheter. tion of the urethra by Credé’s maneuver
retained urine debris within a catheter,
an enlarged prostate,
distended bowel, or
postoperative bladder
spasms
referred to as bladder retraining, but this term is inaccurate

because the various techniques used involve mechanisms
CATHETERIZATION
other than those unique to the bladder.
Continence training primarily benefits clients with the Catheterization (act of applying or inserting a hollow tube),
cognitive ability and desire to participate in a rehabilitation in this case, refers to using a device inside the bladder or
program. This includes clients with lower body paralysis externally about the urinary meatus. A urinary catheter
who wish to facilitate urination without the use of uri- is used for various reasons:
nary drainage devices such as catheters. Clients who are
not candidates for continence training require alternative • Keeping incontinent clients dry (catheterization is a
methods such as absorbent undergarments. last resort that is used only when all other continence
Continence training is often a slow process that requires measures have been exhausted)
the combined effort and dedication of the nursing team, • Relieving bladder distention when clients cannot
client, and family. See Nursing Guidelines 30-1. void

Providing Continence Training
❙ Compile a log of the client’s urinary elimination patterns. The data help ❙ Suggest performing Credé’s maneuver (the act of bending forward
to reveal the client’s type of incontinence. and applying hand pressure over the bladder; Fig. 30-6). Credé’s
❙ Set realistic, specific, short-term goals with the client. Short-term goals maneuver increases abdominal pressure to overcome the resistance of
prevent self-defeating consequences and promote client control. the internal sphincter muscle.
❙ Discourage strict limitation of liquid intake. Intake maintains fluid
❙ Instruct paralyzed clients to identify any sensation that precedes voiding
balance and ensures adequate urine volume. such as a chill, muscular spasm, restlessness, or spontaneous penile
erection. These cues can help the client anticipate urination.
❙ Plan a trial schedule for voiding that correlates with the times when the
client is usually incontinent or experiences bladder distention. This
❙ Suggest that paralyzed clients with reflex incontinence use cutaneous
schedule reduces the potential for accidental voiding or sustained triggering (lightly massaging or tapping the skin above the pubic
urinary retention. area). Cutaneous triggering initiates urination in clients who have
retained a voiding reflex (spontaneous relaxation of the urinary
❙ In the absence of any identifiable pattern, plan to assist the client with sphincter in response to physical stimulation).
voiding every 2 hours during the day and every 4 hours at night. This
duration provides time for urine to form.
❙ Teach clients with stress incontinence to perform Kegel exercises
(isometric exercises to improve the ability to retain urine within the
❙ Communicate the plan to nursing personnel, the client, and the family. bladder; Box 30-1). Kegel exercises strengthen and tone the
Collaboration promotes continuity of care and dedication to reaching pubococcygeal and levator ani muscles used voluntarily to hold back
goals. urine and intestinal gas or stool.
❙ Assist the client to a toilet or commode; position the client on a bedpan ❙ Assist clients with urge incontinence to walk slowly and concentrate on
or place a urinal just before the scheduled time for trial voiding. These holding their urine when nearing the toilet. These measures reverse
measures prepare the client for releasing urine. previous mental conditioning in which the urge to urinate becomes
❙ Simulate the sound of urination such as by running water from the stronger and more overpowering close to the toilet.
faucet. Doing so simulates relaxation of the sphincter muscles, allowing
the release of urine.
• Assessing fluid balance accurately Types of Catheters

• Keeping the bladder from becoming distended during
procedures such as surgery The three common types of catheters are external, straight,
• Measuring the residual urine and retention. Most catheters are made of latex. For clients
• Obtaining sterile urine specimens who are sensitive or allergic to latex, latex-free catheters
• Instilling medication within the bladder are used.
External Catheters
An external catheter (urine-collecting device applied to
the skin) is not inserted within the bladder; instead, it
surrounds the urinary meatus. Examples of external
catheters are a condom catheter (Fig. 30-7) and a urinary
bag or U-bag. External catheters are more effective for
male clients.
BOX 30-1 ● Technique for Performing

Kegel Exercises
❙ Tighten the internal muscles used to prevent urination or interrupt urination
once it has begun.
❙ Keep the muscles contracted for at least 10 seconds.
❙ Relax the muscles for the same period.
❙ Repeat the pattern of contraction and relaxation 10 to 25 times.
❙ Perform the exercise regimen three or four times a day for 2 weeks to 1 month.
FIGURE 30-6 • Credé’s maneuver.
FIGURE 30-7 • A condom catheter is an example of an external

urine collection device. (Copyright B. Proud.)
FIGURE 30-8 • A leg bag collects urine from a catheter but is concealed
under clothing.
Condom catheters are helpful for clients receiving care

at home because they are easy to apply. A condom catheter
has a flexible sheath that is unrolled over the penis. The Straight Catheters
narrow end is connected to tubing that serves as a chan-
A straight catheter is a urine drainage tube inserted but not
nel for draining urine. The drainage tube is attached to a
left in place. It drains urine temporarily or provides a
leg bag (Fig. 30-8) or connected to a larger urine-collection
sterile urine specimen (Fig. 30-9).
device.
Three potential problems accompany use of condom
catheters. First, the sheath may be applied too tightly, Retention Catheters
restricting blood flow to the skin and tissues of the penis.
A retention catheter, also called an indwelling catheter, is
Second, moisture tends to accumulate beneath the sheath,
left in place for a period of time (see Fig. 30-9). The most
leading to skin breakdown. Third, condom catheters
common type is a Foley catheter.
frequently leak. Applying the catheter correctly and man-
Unlike straight catheters, retention catheters are
aging care appropriately can prevent these problems
secured with a balloon that is inflated once the distal tip
(Skill 30-2).
is within the bladder. Both straight and retention catheters

Discuss assessments that indicate common problems
associated with the use of a condom catheter and
nursing measures that can reduce or eliminate
abnormal findings.
B
A urinary bag (U-bag) is more often used to collect urine
A
specimens from infants. It is attached by adhesive backing
to the skin surrounding the genitals. Urine collects in the
self-contained bag. Once enough urine is collected, the FIGURE 30-9 • Types of urinary catheters. (A) Retention (Foley) catheter
bag is removed. with balloon. (B) Straight catheter. (Copyright B. Proud.)
are available in various diameters, sized according to the

French scale (see Chap. 29). For adults, sizes 14, 16, and
18 F are commonly used.
Inserting a Catheter
The techniques for inserting straight and retention

catheters are similar, although the steps for inflating the
retention balloon 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 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.

Discuss factors that predispose a female with a Foley
catheter to develop a urinary tract infection.
FIGURE 30-10 • Closed urine drainage system. (Copyright B. Proud.)
Connecting a Closed Drainage System
A closed drainage system (device used to collect urine from Providing Catheter Care
a catheter) consists of a calibrated bag, which can be
opened at the bottom, tubing of sufficient length to accom- A retention catheter keeps the meatus slightly dilated,
modate for turning and positioning clients, and a hanger providing pathogens with a direct pathway to the bladder
from which to suspend the bag from the bed (Fig. 30-10). where an infection could develop. “Catheters left in place
The nurse coils excess tubing on the bed but keeps the for more than a few weeks become encrusted or obstructed,
section from the bed to the collection bag vertical. Depen- and lead to infection. In addition, bacteria that adhere
dent loops in the tubing interfere with gravity flow. The to the urinary catheter develop a complex biologic struc-
nurse also takes care to avoid compressing the tubing, ture, which protects them from antibiotics” (Marchiondo,
which can obstruct drainage. Placing the tubing over the 1998, p. 38).
client’s thigh is acceptable. Catheter care (hygiene measures used to keep the mea-
The nurse always positions the drainage system lower tus and adjacent area of the catheter clean) helps to deter
than the bladder to avoid backflow of urine. When trans- the growth and spread of colonizing pathogens. Nursing
porting the client in a wheelchair, the nurse suspends the Guidelines 30-2 describe the technique for providing
drainage bag from the chair below the level of the bladder. catheter care. Nurses must follow agency policy for using
When the client is ambulating, the nurse secures the antiseptic and antimicrobial agents because the use of
drainage bag to the lower part of an IV pole or allows the these substances is not standard among all physicians or
client to carry the bag by hand (Fig. 30-11). agencies.
To reduce the potential for the drainage system becom-
ing a reservoir of pathogens, the entire drainage system
is replaced whenever the catheter is changed and at least
every 2 weeks in clients with a urinary tract infection. Catheter Irrigation
A catheter irrigation (flushing the lumen of a catheter) is a

technique for restoring or maintaining catheter patency.
Stop • Think + Respond BOX 30-4 A catheter that drains well, however, does not need irri-
Discuss possible explanations for why urine may not flow gating. A generous oral fluid intake is usually sufficient to
from a catheter. produce dilute urine, keeping small shreds of mucus or
tissue debris from obstructing the catheter. Occasionally,
A B
FIGURE 30-11 • Techniques for suspending a drainage system below the bladder: (A) wheelchair
patient; (B) ambulating patient with and without an IV pole.
however, the catheter may need to be irrigated, such as Using an Open System
after a surgical procedure that results in bloody urine.
An open system is one in which the retention catheter is
Depending on the type of indwelling catheter, nurses
separated from the drainage tubing to insert the tip of an
irrigate continuously through a three-way catheter
irrigating syringe. Opening the system creates the poten-
or periodically using an open system or closed system
tial for infection because it provides an opportunity for
(Skill 30-5).
pathogens to enter the exposed connection. Consequently,
it is the least desirable of the three methods.
Using a Closed System

Providing Catheter Care A closed system is irrigated without separating the catheter
from the drainage tubing. To do so, the catheter or drain-
❙ Plan to cleanse the meatus and a nearby section of the catheter at age tubing must have a self-sealing port. After cleansing
least once a day. Regular cleansing reduces colonizing the port with an alcohol swab, the nurse pierces the port
microorganisms. with an 18- or 19-gauge, 1.5-inch needle (see Chap. 34).
❙ Gather clean gloves, soap, water, washcloth, towel, and a He or she attaches the needle to a 30- to 60-mL syringe
disposable pad. Organization facilitates efficient time management. containing sterile irrigation solution. The nurse pinches
❙ Wash your hands or perform an alcohol-based handrub (see Chap. 10). or clamps the tubing beneath the port and instills the
Hand hygiene reduces the potential for transmitting microorganisms. solution. He or she releases the tubing for drainage. The
nurse records the volume of irrigant as fluid intake or
❙ Place a disposable pad beneath the hips of a female and beneath the
subtracts it from the urine output to maintain an accu-
penis of a male. The pad protects the bed linen from becoming wet
or soiled. rate intake and output record.
❙ Don clean gloves and wash the meatus, the catheter where it meets Continuous Irrigation
the meatus, the genitalia, and the perineum (in that order) with warm,
soapy water. Rinse and dry. Follow agency policy for using antiseptic A continuous irrigation (ongoing instillation of solution)
or antimicrobial agents. These methods remove gross secretions and instills irrigating solution into a catheter by gravity over
transient microorganisms while following principles of asepsis. a period of days (Fig. 30-12). Continuous irrigations keep
❙ Remove soiled materials and gloves, and repeat hand hygiene a catheter patent after prostate or other urologic surgery
measures. These steps remove colonizing microorganisms. in which blood clots and tissue debris collect within the
bladder.
714 UNIT 8 ● Promoting Elimination
• Connect the tubing to the catheter port for irrigation

(Fig. 30-13).
• Regulate the rate of infusion according to the medical
order.
• Monitor the appearance of the urine and volume of
urinary drainage.

Discuss what actions might be appropriate if irrigating a
catheter is unsuccessful in promoting catheter patency.
Indwelling Catheter Removal
A catheter is removed when it needs to be replaced or

when its use is discontinued. The best time to remove a
catheter is in the morning when there is more opportunity
to address any urination difficulties without depriving a
FIGURE 30-12 • Bladder irrigation using a three-way catheter. client of sleep. See Nursing Guidelines 30-3.
URINARY DIVERSIONS
A three-way catheter is necessary to provide a con-
tinuous irrigation. The catheter has three lumens or chan-
nels within the catheter, each leading to a separate port. In a urinary diversion, one or both ureters are surgically
One port connects the catheter to the drainage system; implanted elsewhere. This procedure is done for various
another provides a means for inflating the balloon in the life-threatening conditions. The ureters may be brought
catheter; and the third instills the irrigating solution. The to and through the skin of the abdomen (Fig. 30-14)
steps involved in providing a continuous irrigation are as or implanted within the bowel (called an ileal conduit).
follows: A urostomy (urinary diversion that discharges urine
from an opening on the abdomen) is the focus of this
• Hang the sterile irrigating solution from an intra- discussion.
venous pole.
• Purge the air from the tubing.

Removing a Foley Catheter
❙ Wash your hands or perform an alcohol-based handrub (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 10 hours;
measure the volume of each voiding. Findings determine whether
FIGURE 30-13 • Attaching irrigation tubing to a port on a three-way or not elimination is normal as well as characteristics of the urine.
catheter.
FIGURE 30-14 • Examples of urinary diversions.

(A) Ileal conduit. (B) Cutaneous ureterostomy. (Smeltzer,
S. C., & Bare, B. G. [2006]. Brunner and Suddarth’s text-
book of medical-surgical nursing [11th ed.]. Philadelphia:
Lippincott Williams & Wilkins.) A B
Care for an ostomy, a surgically created opening, is • Situational Low Self-Esteem

discussed in more detail in Chapter 31 because those • Risk for Impaired Skin Integrity
formed for bowel elimination are more common. Chap-
ter 31 also provides a detailed description of an ostomy Nursing Care Plan 30-1 is developed for a client with Urge
appliance, the device used for collecting stool or urine, Urinary Incontinence, defined by NANDA (2005, p. 101)
and the manner in which it is applied and removed from as “the involuntary passage of urine occurring soon after
the skin. a strong sense of urgency to void.”
Caring for a urostomy and changing a urinary appliance
are more challenging than the care of intestinal stomas.
Urine drains continuously from a urostomy, increasing GENERAL GERONTOLOGIC
the risk for skin breakdown. Additionally, because mois- CONSIDERATIONS
ture and the weight of the collected urine tend to loosen the
Older adults are likely to experience urinary urgency and
appliance from the skin, a urinary appliance may need to
frequency because of normal physiologic changes such as
be changed more frequently. When changing the appli- diminished bladder capacity and degenerative changes in
ance, it may help to place a tampon within the stoma to the cerebral cortex. Subsequently, when they perceive the
absorb urine temporarily while the skin is cleansed and urge to void, they need to access a bathroom as soon as
prepared for another appliance. possible.
It is often difficult to maintain the integrity of the peri- Age-related changes, such as diminished bladder capacity and
relaxation of the pelvic floor muscle tone, increase the risk
stomal skin (skin around the stoma) because of the fre-
for incontinence. Education regarding Kegel exercises may
quent appliance changes and the ammonia in urine. Skin promote strengthening of the pelvic floor muscles.
barrier products are used, and sometimes antibiotic or Older adults are more likely to have chronic residual urine
steroid ointment is applied. (excessive urine in the bladder after urinating), which increases
the risk for urinary tract infections. They may benefit from
learning “double-voiding,” in which the person voids then
waits a few more minutes to allow any residual urine to be
NURSING IMPLICATIONS voided.
Enlargement of the prostate, a common problem among older men,
can totally obstruct urinary outflow and make catheterization
Clients with urinary elimination problems may have one difficult or impossible. Insertion of a urinary catheter should
or more of the following nursing diagnoses: never be forced. Sometimes a catheter is inserted into the
bladder through the abdominal wall when it cannot be
inserted into a narrowed urethra.
• Self-Care Deficit: Toileting
Diuretic therapy commonly prescribed for older adults can
• Impaired Urinary Elimination increase the risk for urinary incontinence. Planning for access
• Risk for Infection to a toilet within 30 to 120 minutes following medication
• Stress Urinary Incontinence administration should be included in client education regard-
• Urge Urinary Incontinence ing diuretic therapy.
Loss of control over urination often threatens an older adult’s
• Reflex Urinary Incontinence independence and self-esteem. It also may cause an older
• Total Urinary Incontinence adult to restrict activities, possibly contributing to depression.
• Functional Urinary Incontinence Teaching older adults to structure activities with planned
Urge Urinary Incontinence
ASSESSMENT
• Inquire about the number of voidings per day; voiding more than 8 times in 24 hours or waking up 2 or more times at
night to urinate, or urinating soon after the bladder has been 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,
commonly referred to as warning time (Carpenito-Moyet, 2006).
• Ask the client if the need to urinate is less easily controlled as the person gets nearer the location of a toilet.
• Determine if the client experiences accidental loss of urine when there is an almost unstoppable need to urinate.
Nursing Diagnosis: Urge Urinary Incontinence related to uninhibited bladder muscle

contractions as manifested by 14 to 18 voidings per day including awakening 3 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; e.g., by 9/15.
Keep a record of the frequency of voidings and the length Documenting the client’s unique pattern of urination
of time between the warning sign for voiding and actual facilitates 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
after the warning sign is perceived. habit of over-responding to an urgent need to void.
Suggest that the client use a technique such as breathing Focusing thoughts on something other than urination may
deeply, singing a song, or talking about family to delay provide sufficient distraction to extend the interval
voiding. between the warning sign and actual voiding.
Encourage the client to eliminate the intake of beverages Caffeine promotes urination; alcohol inhibits antidiuretic
that contain caffeine or alcohol. Keep a record of the hormone, which prevents the reabsorption of water in the
frequency of voidings and the length of time between the nephrons and leads to an increased formation of urine.
warning sign for voiding and actual voiding for 3 days
beginning 8/1 through 8/3.
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
conditioning pattern of urination, i.e., approximately tone, and increases bladder capacity, which potentiates
q11⁄2 h, and extend the time by 15 minutes until there is achieving continence.
an interval of 2h between voidings.
Continue to extend the intervals between voiding until the Reconditioning control of urination is facilitated by
client is voiding no more frequently than q4h in a 24-hour repetition and gradually extending the efforts to control
period. voiding.
(continued)
Urge Urinary Incontinence
Praise the client every time a short-term goal of delaying Positive reinforcement helps to motivate the client to
or controlling urination is achieved. continue 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.
toileting breaks every 60 to 90 minutes results in less urine The National Association for Continence (800-252-3337;
in the bladder and thus diminishes urge incontinence. http://www.nafc.org) is an excellent source of information for
Fluid restriction, often used in an attempt to control urination, may products, resources, and continence programs.
actually contribute to incontinence by causing concentrated
urine and eliminating the normal perception of a full bladder.
Older adults who experience difficulty controlling urine need
evaluation of contributing factors, which may be treated to CRITICAL THINKING E X E R C I S E S
reverse the diminished control of urination. Such causes may
include constipation, urinary tract infection, and medication 1. An older adult client confides that she would like to par-
side effects. ticipate in activities outside her home, but she is worried
Older adults need encouragement to discuss urinary incontinence that others will notice her problem with urinary inconti-
with a knowledgeable, nonjudgmental health care provider. If nence. What response might help this client? What sug-
they understand that urinary incontinence is a condition that
gestions could you offer?
frequently responds to medication or behavioral retraining,
they are more likely to seek professional help. 2. A resident in a nursing home who has had a retention
Many resources are available to assist older adults in evaluating catheter for the last 6 months says, “I’d do anything if I
and treating incontinence. For example, some health care didn’t have to have this catheter.” What suggestions
facilities offer special incontinence clinics and physical therapy
would be appropriate at this time?
departments to teach pelvic muscle exercises. Additionally,
biofeedback has been used to strengthen bladder control.
Nurses can encourage older adults to take advantage of these
kinds of resources rather than accepting incontinence as an NCLEX-STYLE REVIEW Q U E S T I O N S
inevitable condition that compromises their quality of life.
In institutional settings, older adults may become incontinent 1. The most important nursing assessment before begin-
because they do not have the assistance needed to get to a ning continence retraining is
toilet in a timely manner. Routine toileting schedules must be
1. Recording the times when the client is incontinent
offered to these clients every 90 to 120 minutes. Absorbent
products are likely to interfere with the person’s indepen- 2. Checking the results of a routine urinalysis
dence in toileting and may lead to skin breakdown. Inconti- 3. Palpating the extent of bladder distention
nence products are never used primarily for staff convenience 4. Observing the characteristics of the client’s urine
in institutional settings. Additionally, an older person should
2. During continence retraining, what is the best nursing
never be reprimanded for an episode of incontinence.
When efforts to restore continence are unsuccessful, nurses can response when a client wants to restrict fluid intake to
encourage older adults to verbalize their feelings and identify remain dry for longer periods?
interventions helpful in maintaining dignity, ultimately 1. Encourage the practice because it shows evidence
enabling older adults to participate in meaningful activities. of client cooperation.
Older adults should be taught that odors may remain in clothing 2. Encourage the practice because it leads to accom-
because of ammonia from urine leakage. Adding vinegar plishing the goal.
or using odor-controlling detergents may be useful when
laundering soiled clothing.
3. Discourage the practice because it contributes to
Careful evaluation is necessary regarding the selection of constipation.
absorbent products or medications for the individual. Cost, 4. Discourage the practice because it predisposes to
effectiveness, and risks of each product are factors to consider. fluid imbalance.
3. When applying an external condom catheter, which nurs- 5. When the nurse instructs a female client on the tech-
ing action is correct? nique for collecting a clean-catch midstream urine speci-
1. Lubricate the penis before applying the catheter. men for routine urinalysis, which statement is correct?
2. Measure the length and circumference of the penis. 1. “Cleanse the urethral area using several circular
3. Leave space between the penis and bottom of motions.”
the catheter. 2. “Void into the plastic liner that is under the toilet
4. Retract the foreskin and roll the catheter over the seat.”
penis. 3. “After voiding a small amount, collect a sample of
4. After inserting an indwelling retention catheter into a urine.”
male client, which of the following describes an appro- 4. “Mix the antimicrobial solution with the collected
priate technique for stabilizing the catheter to avoid a urine specimen.”
penoscrotal fistula?
1. Tape the catheter to the abdomen.
2. Pass the catheter under the client’s leg.
3. Fasten the drainage tube to the bed with a safety pin.
4. Insert the catheter into the tubing of a collecting bag.
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 Demonstrates concern for the client’s comfort
especially if it is made of metal.
Implementation
(see 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 Prevents unnecessary exposure
the client’s hips and buttocks.
Instruct the client to bend the knees and press down with Helps to elevate the hips
the 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 from a sitting position.
Or roll the client to the side and position the bedpan Reduces work effort and the potential for a work-related
(Fig. B). injury; aids in placement if client cannot lift buttocks
Raise the head of the bed (Fig. C). Simulates the natural 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 Respects privacy yet provides a mechanism for
client, if doing so is safe. communicating a need for assistance
(continued)
PLACING AND REMOVING A BEDPAN (Continued)
B
C
Placing a bedpan from a side-lying position. Position for elimination.
Return and remove the bedpan. Prevents discomfort

Assist with removing residue of urine from the skin, if Prevents offensive odors and skin irritation
necessary.
Wrap the gloved hand with toilet tissue and wipe from the Supports principles of medical asepsis
meatus of a female toward the anal area.
Place soiled tissue in the bedpan. 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 Ensures accurate data collection
output are 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 Supports principles of asepsis
from 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 handrub 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 application Provides an opportunity for health teaching
and use of an external catheter.
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 Maintains client safety and prevents possible allergic
latex allergy. reaction
Planning
Gather supplies such as soap, water, towel, condom Promotes organization and efficient time management
catheter, drainage tubing, collection device, and clean
gloves. Some devices come packaged with an adhesive
strip or Velcro for securing the catheter.
Provide privacy. Demonstrates respect for dignity
Place the client in a supine position and cover him with a Facilitates application of the catheter and maintains
bath blanket. privacy
Implementation
Wash your hands or perform an alcohol-based handrub Reduces the transmission of microorganisms and follows
(see Chap. 10) and don clean gloves. standard precautions
Wash and dry the penis well. Promotes skin integrity
Wind the adhesive strip in an upward spiral around the Reduces the potential for restricting blood flow
penis (Fig. A).
Applying adhesive strip in a spiral.
(continued)
APPLYING A CONDOM CATHETER (Continued)
Roll the wider end of the condom toward the narrow tip Facilitates application to the penis
(Fig. B).
Hold approximately 1 to 2 inches (2.5 to 5 cm) of the Leaves space below the urethra to prevent irritation of the
lower sheath below the tip of the penis and unroll the meatus
sheath upward (Fig. C).
B C
A rolled condom sheath. Leaving space at the meatus.
Secure the upper end of the unrolled sheath to the skin Ensures that the catheter will remain in place
firmly with a second strip of adhesive or a Velcro strap
but not so tight as to interfere with circulation (Fig. D).
Securing a condom catheter.
D
Connect the drainage tip to a drainage bag. Allows for urine drainage and collection
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 Ensures that the catheter will not be pulled from the penis
filled with urine. by the weight of the collected urine
Remove and change the catheter daily or more often if it Maintains skin integrity
becomes loose or tight.
APPLYING A CONDOM CATHETER (Continued)
Substitute a waterproof garment during periods of nonuse. Provides a mechanism for absorbing urine
Wash the catheter and collection bag with mild soap and Extends the use of the equipment and reduces offensive
water and rinse with a 1:7 solution of vinegar and water. odors
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
catheter 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 Demonstrates the legal scope of nursing; catheterization is
been written. not an independent measure.
Inspect the medical record to determine if the client has a Determines if it is safe to use a latex catheter or if a latex-
latex allergy. free type is needed
Determine the type of catheter that has been prescribed. Ensures selection of appropriate catheter
Review the client’s record for documentation of Provides data by which to modify the procedure or
genitourinary problems. equipment
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 Provides an opportunity for health teaching
catheterization.
(continued)
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, bath Promotes organization and efficient time management
blanket, 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 handrub Reduces the potential for transmitting microorganisms
(see Chap. 10).
Cover the client with a bath blanket and pull the top linen Avoids unnecessary exposure
to the bottom of the bed.
Position an additional light at the bottom of the bed or ask Ensures good visualization
an 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 Provides access to the female urinary system
feet about 2 feet apart (Fig. B).
Draped and placed in a dorsal recumbent position.
B
(continued)
Use a lateral or Sims’ position for clients who have Provides access to the female urinary system, but neither
difficulty maintaining a dorsal recumbent position. is the preferred position
If the client is soiled, don gloves, wash the client, remove Supports principles of asepsis
gloves, and perform hand hygiene measures again.
Remove the wrapper from the catheterization kit and Provides a receptacle for collecting soiled supplies
position it nearby.
Unwrap the sterile cover to maintain the sterility of the Prevents contamination and potential for infection
supplies 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 Provides a sterile field
the client’s hips (Fig. D).
Place a fenestrated drape over the perineum (Fig. E). Provides a sterile field
Open and pour the packet of antiseptic solution Prepares sterile supplies before contaminating one of two
(Betadine) over the cotton balls. hands later in the procedure
D E
Placing a sterile towel. Placing a fenestrated drape over the perineum.
(continued)
Test the balloon on the catheter by instilling fluid from the Determines if the balloon is intact or defective
prefilled syringe; then aspirate the fluid back within the
syringe (Fig. F).
Spread lubricant on the tip of the catheter (Fig. G). Facilitates insertion
F
G
Testing the balloon. Lubricating the catheter.
Place the catheterization tray on top of the sterile towel Promotes access to supplies and reduces the potential for
between the client’s legs. contamination
Pick up a moistened cotton ball with the sterile forceps Cleanses outer skin before cleansing deeper areas of tissue
and wipe one side of the labia majora from an anterior
to posterior direction.
Discard the soiled cotton ball in the outer wrapper of the Completes bilateral cleansing
catheterization kit; repeat cleansing the other side of the
labia majora.
Separate the labia majora and minora with the thumb and Facilitates visualization of anatomic landmarks and
fingers of the nondominant hand, exposing the urinary prevents contaminating the catheter during insertion
meatus (Fig. H).
Separating the labia.
Consider the hand separating the labia to be Avoids transferring microorganisms to sterile equipment
contaminated. and supplies
(continued)
Clean each side of the labia minora with a separate cotton Removes colonizing microorganisms
ball while continuing to retract the tissue with the
nondominant hand.
Use the last cotton ball to wipe centrally, starting above Completes the cleaning of external structures
the meatus down toward the vagina (Fig. I).
Discard the forceps with the last cotton ball into the Follows principles of asepsis
wrapper for contaminated supplies.
Keep the clean tissue separated. Prevents recontamination
Pick up the catheter, holding it approximately 3 to Facilitates control during insertion
4 inches (7.5 to 10 cm) from its tip (Fig. J).
I J
Wiping from above the meatus downward. Preparing to insert the catheter.
Insert the tip of the catheter into the meatus approximately Locates the tip beyond the length of the female urethra,
2 to 3 inches (5 to 7.5 cm) or until urine begins to flow. which is approximately 1.5 to 2.5 inches (4 to 6.5 cm)
Recheck anatomic landmarks if there is no evidence of Indicates one of two possibilities: either the bladder is
urine; remove an incorrectly placed catheter and repeat, empty or the catheter has been placed within the vagina
using another sterile catheter. by mistake; ensures sterility of equipment
Advance the catheter another 1/2 to 1 inch (1.3 to 2.5 cm) Ensures that the catheter is well within the bladder,
after urine begins to flow. where the balloon can be safely inflated
Direct the end of the catheter so that it drains into the Avoids wetting the linen
equipment tray or specimen container.
Hold the catheter in place with the fingers and thumb that Stabilizes the catheter externally
were separating the labia.
Pick up the prefilled syringe with the sterile, dominant Stabilizes the catheter internally
hand, insert it into the opening to the balloon, and
instill the fluid (Fig. K).
Withdraw the fluid from the balloon if the client describes Prevents internal injury
feeling 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
(continued)
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 Prevents pulling on the balloon within the catheter
commercial device (Fig. L).
K L
Inflating balloon. Securing the catheter to the thigh.
Hang the collection bag below the level of the bladder; coil Ensures gravity drainage
excess tubing on the mattress.
Discard the catheterization tray and wrapper with soiled Follows principles of asepsis
supplies.
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
• Catheter is inserted under aseptic conditions.
• Urine is draining from the catheter.
• Client exhibits no evidence of discomfort during or
after insertion.
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 Demonstrates the legal scope of nursing; catheterization is
been written. not an independent measure
Inspect the medical record to determine if the client has a Determines if it is safe to use a latex catheter or if a latex-
latex allergy. free type is needed.
Determine the type of catheter that has been prescribed. Ensures selection of the appropriate catheter
Review the client’s record for documentation of Provides data by which to modify the procedure or
genitourinary problems. equipment
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
catheterization.
Familiarize yourself with the anatomic landmarks (Fig. A). Facilitates insertion
Male anatomic landmarks. (A) Circumcised.

(B) Uncircumcised.
Planning
Gather supplies which include a catheterization kit, bath Promotes organization and efficient time management
blanket, 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 handrub (see Reduces the potential for transmitting microorganisms
Chap. 10).
Place the client in a supine position. Provides access to the male urinary system
Cover the client’s upper body with a bath blanket and Provides minimal exposure
lower the top linen to expose just the penis.
Position an additional light at the bottom of the bed or ask Ensures good visualization
an assistant to hold a flashlight.
(continued)
INSERTING A FOLEY CATHETER IN A MALE (Continued)
If the client is soiled, don gloves, wash the client, remove Supports principles of asepsis
gloves, and repeat hand hygiene measures.
Remove the wrapper from the catheterization kit and Provides a receptacle for collecting soiled supplies
position it nearby.
Unwrap the sterile inner cover so as to maintain the Prevents contamination and the potential for infection
sterility of the 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 (one with an open circle in its Provides a sterile field
center) over the client’s penis without touching the
upper surface of the drape (Fig. B).
Placing a fenestrated drape.
Open and pour the packet of antiseptic solution (Betadine) Prepares sterile supplies before contaminating one of two
over the cotton balls. hands later in the procedure
Test the balloon on the catheter by instilling fluid from Determines whether the balloon is intact or defective
the prefilled syringe; then aspirate the fluid back within
the syringe.
Place the catheterization tray on top of the sterile drape Promotes ease of access to supplies and reduces the
over the client’s thighs. potential for contamination
Lift the penis at its base with the nondominant hand; Promotes visualization and support during catheter
retract the foreskin, if the client is uncircumcised. insertion
Consider the gloved hand holding the penis to be Avoids transferring microorganisms to sterile equipment
contaminated. and supplies
Pick up a moistened cotton ball with the sterile forceps Moves microorganisms away from the meatus
and wipe the penis in a circular manner from the
meatus toward the base; repeat using a different cotton
ball each time (Fig. C).
Discard the forceps with the last cotton ball into the Follows principles of asepsis
wrapper for contaminated supplies.
Apply gentle traction to the penis by pulling it straight up Straightens the urethra
with the nondominant gloved hand.
(continued)
Instill the contents of a prefilled syringe containing Avoids trauma to the urethra caused by insufficient
lubricant directly through the meatus into the urethra lubrication; this technique replaces the traditional
(Fig. D). practice of lubricating the outer surface of the catheter,
which resulted in its accumulation at the meatus only
(Gerard & Sueppel, 1997)
C D
Cleaning the penis Instilling lubricant
Insert, but never force the catheter; rather, rotate the Adjusts for passing the catheter beyond the prostate gland
catheter, apply more traction to the penis, encourage
the client to breathe deeply, or angle the penis toward
the toes (Fig. E).
Continue insertion until only the inflation and drainage Locates the tip beyond the length of the male urethra
ports are exposed and urine flows.
Pick up the prefilled syringe with the sterile, dominant Stabilizes the catheter internally
hand, insert it into the opening to the balloon, and
instill the fluid (Fig. F).
E F
Catheter insertion Inflating the balloon
Withdraw the fluid from the balloon if the client describes Prevents internal injury
feeling pain or discomfort, advance the catheter a little
more, and try again.
(continued)
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 Prevents pulling on the balloon within the catheter
other commercial device (Fig. G).
Securing a catheter
Hang the collection bag below the level of the bladder; coil Ensures gravity drainage
excess tubing on the mattress.
Discard the catheterization tray and wrapper with soiled Follows principles of asepsis
supplies.
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
• Catheter is inserted under aseptic conditions.
• Urine is draining from the catheter.
• 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
Skill 30-5 • IRRIGATING A FOLEY CATHETER
Assessment
Check the client’s record to verify that a medical order has Demonstrates the legal scope of nursing; a catheter
been written. irrigation is not an independent measure
Verify the type of irrigating solution prescribed, or follow Complies with medical directives or standards for care
the standard for practice, which usually advises 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 Provides an opportunity for health teaching
catheter irrigation.
Locate the port on the drainage tube through which fluid Ensures a safe procedure and maintains the integrity of
can be instilled (Fig. A). the catheter
Identifying the self-sealing irrigation port
Planning
Gather needed equipment and supplies: an irrigation kit, a Promotes organization and efficient time management
flask of sterile irrigating solution, 30 to 60 mL syringe,
and alcohol swabs.
Implementation
Wash hands or perform an alcohol-based handrub (see Follows principles of asepsis and standards of practice
Chap. 10).
Raise the height of the bed. Reduces back strain
Pull the privacy curtain. Demonstrates concern for the client’s dignity
Add 100 to 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
(continued)
IRRIGATING A FOLEY CATHETER (Continued)
Attach a needle to the tip of the irrigating syringe found in Provides a means for penetrating the self-sealing port
the irrigation kit. Fill the syringe with 30 to 60 mL of
solution (Fig. B).
Clean the port on the catheter with an alcohol swab (Fig. C). Removes gross debris and colonizing microorganisms
B C
Filling the syringe with solution Cleaning the irrigation port
Clamp or kink the tubing below the port through which Ensures that the solution will move forward into the
the irrigating solution will be instilled (Fig. D). catheter and not into the drainage system
While holding the catheter with one hand, insert the Maintains sterility
syringe into the port (Fig. E).
D E
Clamping the drainage tubing Instilling irrigation solution.
Gently instill the solution. Clears the catheter of debris and dilutes particles within
the catheter
Remove the syringe. Prevents leaking
(continued)
IRRIGATING A FOLEY CATHETER (Continued)
Release the clamp from the drainage tubing and observe Facilitates gravity drainage
the flow of urine through the tubing (Fig. F).
Draining the irrigation solution.
Repeat the instillation and drainage if the urine appears to Promotes patency
contain appreciable debris.
Record the volume of instilled solution as fluid intake. Maintains accurate assessment data
Discard or protect the sterility of the irrigating equipment, Complies with principles of infection control
which 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.
• Principles of asepsis have been maintained.
• Urine continues to drain well through the catheter.
• Client reports no discomfort.
Document
• Volume, 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
instilled into catheter. 120 mL drainage returned. Urine appears to have less sediment. Catheter
remains patent. SIGNATURE/TITLE
31
Chapter
Bowel
Elimination
LEARNING OBJECTIVES
● Describe the process of defecation.
● Name two components of a bowel elimination assessment.
● List five common alterations in bowel elimination.
● Name four types of constipation.
● Identify measures within the scope of nursing practice for treating constipation.
● Identify two interventions that promote bowel elimination when it does not occur naturally.
● Name two categories of enema administration.
● List at least three common solutions used in a cleansing enema.
● Explain the purpose of an oil retention enema.
● Name four nursing activities involved in ostomy care.
THIS chapter briefly reviews the process of intestinal elimination and discusses mea-
sures to help promote it. It also describes nursing skills that may assist clients with
alterations in bowel elimination.
WORDS TO KNOW DEFECATION

anal sphincters
appliance Defecation (bowel elimination) is the act of expelling feces (stool) from the body. To do
colostomy so, all structures of the gastrointestinal tract, especially the components of the large
constipation intestine (also referred to as the bowel or colon), must function in a coordinated man-
continent ostomy ner (Fig. 31-1). In the large intestine, a remarkable volume of water is removed from
defecation
the remnants of digestion, causing the bowel’s contents to become a consolidated mass
diarrhea
enema of residue before being eliminated.
enterostomal therapist Peristalsis means the rhythmic contractions of intestinal smooth muscle that facili-
excoriation tate defecation. Peristalsis moves fiber, water, and nutritional wastes along the ascend-
fecal impaction ing, transverse, descending, and sigmoid colon toward the rectum. Peristalsis becomes
fecal incontinence even more active during eating; this increased peristaltic activity is termed the gastro-
feces
colic reflex.
flatulence
flatus The gastrocolic reflex usually precedes defecation. Its accelerated wavelike move-
gastrocolic reflex ments, sometimes perceived as slight abdominal cramping, propel stool forward,
ileostomy packing it within the rectum. As the rectum distends, the person feels the urge to defe-
ostomy cate. Stool is eventually released when the anal sphincters (ring-shaped bands of muscles)
peristalsis
relax. Performing the Valsalva maneuver (closing the glottis and contracting the pelvic
retention enema
stoma and abdominal muscles to increase abdominal pressure) facilitates this process. Several
suppository dietary, physical, social, and emotional factors can influence the bowel’s mechanical
Valsalva maneuver function (Table 31-1).
736
C H A P T E R 31 ● Bowel Elimination 737
ticularly diagnostic includes stool color, odor, consistency,

shape, and unusual components (Table 31-2).
Whenever stool appears abnormal, a sample is saved
in a covered container for the physician’s inspection.
In some instances, nurses may independently perform
screening tests on stool samples, such as those that deter-
mine the presence of blood (See Nursing Guidelines 31-1).
Nurses then report the results, which can be falsely posi-
tive, to the physician, who may order more specific labo-
ratory or diagnostic tests.
By analyzing assessment findings, nurses may help
physicians to diagnose a medical problem or use the con-
clusions to identify alterations within the scope of nurs-
ing management.
FIGURE 31-1 • The large intestine. COMMON ALTERATIONS

IN BOWEL ELIMINATION
ASSESSMENT OF BOWEL ELIMINATION Clients often have temporary or chronic problems with
bowel elimination and intestinal function such as con-
stipation, fecal impaction, flatulence, diarrhea, and fecal
A comprehensive assessment of bowel elimination
involves collecting data about the client’s elimination incontinence. If these conditions are a component of a
patterns (bowel habits) and the actual characteristics serious disorder, nurses and physicians collaborate to
of the feces. address them. Nurses may treat alterations within the
scope of nursing practice independently.
Elimination Patterns
Constipation
Because various elimination patterns can be normal, it is
essential to determine the client’s usual patterns, includ- Constipation is an elimination problem characterized by
ing frequency of elimination, effort required to expel stool, dry, hard stool that is difficult to pass. Various accompa-
and what elimination aids, if any, he or she uses. nying signs and symptoms include the following:
• Complaints of abdominal fullness or bloating
Stool Characteristics • Abdominal distention
• Complaints of rectal fullness or pressure
Health care providers can obtain objective data about • Pain on defecation
stool characteristics by inspecting the stool or asking the • Decreased frequency of bowel movements
client to describe its appearance. Information that is par- • Inability to pass stool
TABLE 31-1 COMMON FACTORS AFFECTING BOWEL ELIMINATION

FACTOR EFFECT
Types of food consumed Influence color, odor, volume, and consistency of stool,
and fecal velocity
Fluid intake Influences moisture content of stool
Drugs Slow or speed motility
Emotions Alter bowel motility
Neuromuscular function Affects the ability to control rectal muscles
Abdominal muscle tone Affects the ability to increase intra-abdominal pressure
(Valsalva maneuver)
Opportunity for defecation Inhibits or facilitates elimination
seeds, and nuts). Dietary fiber, which becomes undigested

TABLE 31-2 CHARACTERISTICS OF STOOL cellulose, is important because it attracts water within the
CHARACTERISTIC NORMAL ABNORMAL
bowel, resulting in bulkier stool that is more quickly and
easily eliminated.
Color Brown Black Some researchers speculate that a shortened transit
Clay-colored (tan) time—the time between when a person eats food and
Yellow eliminates stool—protects against serious medical dis-
Green
orders. They argue that the longer stool is retained, the
Odor Aromatic Foul
more contact with and absorption of toxic substances
Consistency Soft, formed Soft, bulky
Hard, dry
takes place (Bingham, 2000).
Watery Constipation is classified into one of four distinct types
Pastelike (primary, secondary, iatrogenic, and pseudoconstipation),
Shape Round, full Unformed according to the underlying cause.
Flat
Pencil-shaped
Stonelike
Primary Constipation
Components Undigested fiber Worms Primary or simple constipation is well within the treat-
Blood ment domain of nurses. It results from lifestyle factors
Pus
Mucus
such as inactivity, inadequate intake of fiber, insufficient
fluid intake, or ignoring the urge to defecate.
Secondary Constipation
• Changes in stool characteristics such as oozing liquid
Secondary constipation is a consequence of a pathologic
stool or hard small stool
disorder such as a partial bowel obstruction. It usually
Infrequent elimination of stool does not necessarily resolves when the primary cause is treated.
indicate that a person is constipated. Some people may
be constipated even though they have a daily bowel move- Iatrogenic Constipation
ment, whereas others who defecate irregularly may have
normal bowel function. Iatrogenic constipation occurs as a consequence of other
The incidence of constipation tends to be high among medical treatment. For example, prolonged use of narcotic
those whose dietary habits lack adequate fiber (such as not analgesia tends to cause constipation. These and other
eating sufficient raw fruits and vegetables, whole grains, drugs slow peristalsis, delaying transit time. The longer
the stool remains in the colon, the drier it becomes, mak-
ing it more difficult to pass.
Pseudoconstipation
Testing Stool for Occult Blood
Pseudoconstipation, also referred to as perceived consti-
❙ Collect stool within a toilet liner or bedpan. Use of such devices pation by the North American Nursing Diagnosis Asso-
prevents mixing stool with water or urine. ciation (NANDA, 2005), is a term used when clients
❙ Don gloves and use an applicator stick to collect the specimen. believe themselves to be constipated even though they
These measures reduce the transmission of microorganisms. are not. Pseudoconstipation may occur in people who are
❙ Take a sample from the center area of the stool. A sample from here
extremely concerned about having a daily bowel move-
provides more diagnostic value because it is not superficially tainted ment. In their zeal for regularity, they often overuse or
with blood from local tissue. abuse laxatives, suppositories, and enemas. Such self-
treatment may ultimately cause rather than treat consti-
❙ Apply a thin smear of stool onto the test area supplied with the
screening kit. Correct use of kit ensures thorough contact with the pation. Chronic purging eventually weakens bowel tone;
chemical reagent. consequently, bowel elimination is less likely unless it
is artificially stimulated.
❙ Cover the entire test space. Doing so ensures more accurate findings.
❙ Place two drops of chemical reagent onto the test space. This step
promotes a chemical reaction.
Fecal Impaction
❙ Wait 60 seconds. This duration is the time needed for chemical
interaction with the stool. Fecal impaction occurs when a large, hardened mass of stool
❙ Observe for a blue color. This finding indicates that blood is present. interferes with defecation, making it impossible for the
client to pass feces voluntarily. Fecal impactions result
from unrelieved constipation, retained barium from an

intestinal x-ray, dehydration, and weakness of abdominal
muscles. Removing a Fecal Impaction
Clients with a fecal impaction usually report a frequent ❙ Wash your hands or perform an alcohol-based handrub (see Chap. 10).
desire to defecate but an inability to do so. Rectal pain Hand hygiene reduces the transmission of microorganisms.
may result from unsuccessful efforts to evacuate the lower
❙ Don clean examination gloves. Doing so complies with standard
bowel. Some clients with an impaction pass liquid stool,
precautions by providing a barrier between the hands and a
which they may misinterpret as diarrhea. Forceful mus-
substance that contains body fluid.
cular contractions of peristalsis in higher bowel areas,
where the stool is still fluid, cause the liquid stool. These
❙ Provide privacy. Privacy demonstrates respect for the client’s dignity.
contractions send the liquid around the margins of the ❙ Place the client in a Sims’ position (see Chap. 14). This position
impacted stool, but this passage of liquid stool does not facilitates access to the rectum.
relieve the initial condition. ❙ Cover the client with a drape and place a disposable pad under the
To determine whether or not fecal impaction is pres- client’s hips. Use of these materials prevents soiling.
ent, it may be necessary to insert a lubricated, gloved ❙ Place a bedpan conveniently on the bed. The bedpan acts as a
finger into the rectum. If the rectum is filled with a mass container for removed stool.
of stool, the nurse implements measures for its removal. ❙ Don clean gloves. Use of gloves reduces the transmission of
Sometimes nurses administer enemas, first oil retention microorganisms.
then cleansing. These therapeutic measures are discussed ❙ Lubricate the forefinger of your dominant hand. Lubrication eases
later in this chapter. Another intervention is to remove insertion within the rectum.
the stool digitally (See Nursing Guidelines 31-2). ❙ Insert your lubricated finger within the rectum to the level of the
hardened mass. Insertion to this level facilitates digital manipulation
of the stool.
Flatulence ❙ Move your finger about slowly and carefully to break up the mass of
stool. Movement facilitates removal or voluntary passage.
Flatulence or flatus (excessive accumulation of intestinal ❙ Withdraw segments of the stool (Fig. 31-2) and deposit them in the
gas) results from swallowing air while eating or sluggish bedpan. Removal reduces the internal mass of stool.
peristalsis. Another cause is the gas that forms as a by- ❙ Provide periods of rest but continue until the mass has been
product of bacterial fermentation in the bowel. Vegetables removed or sufficiently reduced. Doing so restores patency to the
such as cabbage, cucumbers, and onions are commonly lower bowel.
known for producing gas. Beans are other gas formers. ❙ Clean the client’s rectal area; dispose of the stool and soiled gloves;
Eating beans creates intestinal gas because humans lack repeat hand hygiene measures. These measures support principles
an enzyme to completely digest their particular form of of medical asepsis.
complex carbohydrate.
Regardless of its cause, flatus may be expelled rectally,
thus reducing intestinal accumulation and distention.
Sometimes, however, this is not sufficient to eliminate
the cramping pain or other symptoms. When clients are
extremely uncomfortable and ambulating does not elim-
inate flatus, the nurse may insert a rectal tube to help the
gas escape (Skill 31-1).

Discuss measures to include in a teaching plan that would
help clients to reduce or eliminate intestinal gas.
Diarrhea
Diarrheais the urgent passage of watery stool and com-

monly is accompanied by abdominal cramping. Simple
diarrhea usually begins suddenly and lasts for a short FIGURE 31-2 • Removing impacted stool.
period. Other associated signs and symptoms include

nausea and vomiting and blood or mucus in the stools.
Usually diarrhea is a means of eliminating an irritating Managing Fecal Incontinence
substance such as tainted food or intestinal pathogens. The nurse teaches the client and family as follows:
Diarrhea may also result from emotional stress, dietary
indiscretions, laxative abuse, or bowel disorders. • Eat regularly and nutritiously.
Resting the bowel temporarily may relieve simple • Monitor the pattern of incontinence to determine
diarrhea. This means the person drinks clear liquids but whether it occurs at a similar time each day.
avoids solid foods for 12 to 24 hours. Resumed eating • Sit on the toilet or bedside commode before the
begins with bland foods and those low in residue such as time elimination tends to occur.
bananas, applesauce, and cottage cheese. If diarrhea is not • Consult the physician about inserting a supposi-
relieved within 24 hours, it is best to consult a physician. tory or administering an enema every 2 to 3 days
to establish a pattern for bowel elimination.
• Use moisture-proof undergarments and
absorbent pads to protect clothing and bed linen.
Fecal Incontinence • Teach caregivers to do the following:
• Do not imply, verbally or nonverbally, that
Fecal incontinence is the inability to control the elimination
the client is to blame for the incontinence or
of stool. It does not necessarily imply that stool is loose or that cleaning him or her is disgusting.
watery, although that may be the case. In some instances, • Avoid anything that connotes diapering, to
bowel function is normal, but incontinence results from preserve the client’s dignity and self-esteem.
neurologic changes that impair muscle activity, sensa-
tion, or thought processes. Even a fecal impaction may be
an underlying cause of incontinence. Incontinence also irritating the wall of the rectum and anal canal to stim-
may occur when a person cannot reach a toilet in time to ulate smooth muscle contraction, and liberating carbon
eliminate, such as after taking a harsh laxative. dioxide, thus increasing rectal distention and the urge
Chronic fecal incontinence can be devastating socially to defecate. Drugs administered in suppository form to
and emotionally. Clients who cope with chronic fecal achieve systemic effects are chosen when clients have dif-
incontinence and their families require much support ficulty retaining or absorbing oral medications because of
and understanding. They may benefit from teaching chronic vomiting or an impaired ability to swallow.
the nurse offers. See Client and Family Teaching 31-1. Administering a suppository is a form of medication
administration (Skill 31-2). For additional principles, refer
to Chapters 32 and 33.
MEASURES TO PROMOTE
BOWEL ELIMINATION Stop • Think + Respond BOX 31-2
Discuss appropriate actions if a mass of stool is felt when
Nurses commonly use two interventions—inserting sup- inserting a suppository.
positories and administering enemas—to promote elimina-
tion when it does not occur naturally or when the bowel
must be cleansed for other purposes, such as preparation Administering an Enema
for surgery and endoscopic or x-ray examinations.
An enema introduces a solution into the rectum (Skill
31-3). Nurses give enemas to
Inserting a Rectal Suppository
• Cleanse the lower bowel (most common reason).
• Soften feces.
A suppository (oval or cone-shaped mass that melts at body
• Expel flatus.
temperature) is inserted into a body cavity such as the
• Soothe irritated mucous membranes.
rectum. The most common reason for inserting a suppos-
• Outline the colon during diagnostic x-rays.
itory is to deliver a drug that will promote expulsion of
• Treat worm and parasite infestations.
feces. Other medications, such as drugs to control vom-
iting and to reduce fever, also are available in supposi-
Cleansing Enemas
tory form.
Medications released from the suppository can have Cleansing enemas use different types of solution to remove
local or systemic effects. Depending on the drug, local feces from the rectum (Table 31-3). Defecation usually
effects may include softening and lubricating dry stool, occurs within 5 to 15 minutes after administration.
TYPES OF CLEANSING client safety, if stool continues to be expelled after the

TABLE 31-3 administration of three enemas, the nurse consults the
ENEMA SOLUTIONS
physician before administering any more.
MECHANISM
SOLUTION AMOUNT OF ACTION
SOAP SOLUTION ENEMAS. A soap solution enema is a
Tap water 500–1,000 mL Distends rectum, mixture of water and soap. Many disposable enema kits
moistens stool contain an envelope of soap mixed with up to 1 quart
Normal saline 500–1,000 mL Distends rectum, (1,000 mL) of water. If these soap packets are not avail-
moistens stool able, a comparable mixture is 1 mL of mild liquid soap
Soap and water 500–1,000 mL Distends rectum, per 200 mL of solution, or a 1:200 ratio. Therefore, 5 mL
moistens stool,
irritates local tissue
of soap is added to prepare a volume of 1,000 mL.
Hypertonic saline 120 mL Irritates local tissue
Soap causes chemical irritation of the mucous mem-
Mineral, olive, or 120–180 mL Lubricates and
branes. Adding too much soap or using strong soap can
cottonseed oil softens stool potentiate the irritating effect.
HYPERTONIC SALINE ENEMAS. A hypertonic saline (sodium

phosphate) enema draws fluid from body tissues into
Large-volume cleansing enemas may create discomfort the bowel. This increases the fluid volume in the intes-
because they distend the lower bowel. Nurses must admin- tine beyond what was originally instilled. The concen-
ister them cautiously to clients with intestinal disorders trated solution also acts as a local irritant on the mucous
such as colitis (inflammation of the colon) because large- membranes.
volume enemas may rupture the bowel or cause other Hypertonic enema solutions are available in commer-
secondary complications. In many health agencies and in cially prepared, disposable containers holding approx-
the home, commercially prepared disposable administra- imately 4 oz (120 mL) of solution (Fig. 31-3). The
tion sets have become the method of choice for cleansing container, which has a lubricated tip, substitutes for enema
the bowel. Their smaller volume makes them less fatigu- equipment and tubing. See Nursing Guidelines 31-3.
ing and distressing than large-volume enemas, and they
can be easily self-administered. Retention Enemas
TAP WATER AND NORMAL SALINE ENEMAS. Tap water A retention enema uses a solution held within the large
and normal saline solutions are preferred for their non- intestine for a specified period, usually at least 30 min-
irritating effects, especially for clients with rectal dis- utes. Some retention enemas are not expelled at all. One
eases or those being prepared for rectal examinations. type of retention enema is called an oil retention enema
Tap water and normal saline appear to have about the because the fluid instilled is mineral, cottonseed, or olive
same degree of effectiveness for cleansing the bowel. oil. Oils lubricate and soften the stool, so it can be expelled
Because tap water is hypotonic, the fluid can be ab- more easily.
sorbed through the bowel. Consequently, if several ene- The oil may come in a prefilled container similar to
mas are administered in succession, fluid and electrolyte those that contain hypertonic saline. If disposable equip-
imbalances may occur (see Chap. 16). Therefore, to ensure ment is not available, the nurse lubricates and inserts
A B
FIGURE 31-3 • (A) Technique for compressing a disposable enema container. Note the container is
compressed during administration. (B) Administering disposable enema using compression technique.

Administering a Hypertonic Enema Solution
❙ Warm the container of solution (if it is cold) by placing it in a basin or ❙ Insert the full length of the tip within the rectum. This positioning places
sink of warm water. Warmth promotes comfort. the tip at a level that promotes effectiveness.
❙ Assist the client to a Sims’ position or use a knee-chest position ❙ Apply gentle, steady pressure on the solution container for 1 to
(see Chap. 14). These positions promote gravity distribution of 2 minutes or until the solution has been completely administered. This
the solution. method instills a steady stream of solution.
❙ Wash hands or use an alcohol-based handrub (see Chap. 10) and don ❙ Compress the container as the solution instills. Compression provides
gloves. Hand hygiene reduces transmission of microorganisms; gloves positive pressure rather than gravity to instill fluid.
provide a barrier from contact with a substance that contains body fluid. ❙ Encourage the client to retain the solution for 5 to 15 minutes. This
❙ Remove the cover from the lubricated tip. This step facilitates duration promotes effectiveness.
administration. ❙ Clean the client and position for comfort. These measures demonstrate
❙ Cover the tip with additional lubricant. Lubricant eases insertion. concern for the client’s well-being.
❙ Invert the container. Inversion causes air in the container to rise toward ❙ Discard the container, remove gloves, and perform hand hygiene
the upper end. measures. Doing so follows principles of medical asepsis.
a 14 to 22 F tube in the rectum. A small funnel or large serve skin integrity. Another way to protect the skin is to
syringe is attached to the tube, and the nurse instills apply barrier substances such as karaya, a plant substance
approximately 100 to 200 mL of warmed oil slowly to that becomes gelatinous when moistened, and commercial
avoid stimulating an urge to defecate. Premature defeca- skin preparations around the stoma. An enterostomal ther-
tion defeats the purpose of retaining the oil. apist, a nurse certified in caring for ostomies and related
skin problems, may be consulted regarding skin and
stomal care.
List measures for preventing constipation.
Applying an Ostomy Appliance
Various appliances are available, but all consist of a pouch
for collecting stool and a faceplate, or disk, that attaches
OSTOMY CARE to the abdomen. The stoma protrudes through an open-
ing in the center of the appliance (Fig. 31-5). The pouch
A client with an ostomy (surgically created opening to the fastens into position when pressed over the circular sup-
bowel or other structure; see Chap. 30) requires additional port on the faceplate. Some clients prefer a type that also
care for promoting bowel elimination. Two examples of is fastened to an elastic belt worn around the waist. The
intestinal ostomies are an ileostomy (surgically created belt helps to support the weight of the fecal material and
opening to the ileum) and a colostomy (surgically created prevents the faceplate from being pulled away from the
opening to a portion of the colon; Fig. 31-4). Materials abdomen. The client empties the pouch by releasing the
enter and exit through a stoma (entrance to the opening). clamp at the bottom.
Most persons with an ostomy, also called ostomates, The faceplate usually remains in place for 3 to 5 days
wear an appliance (bag or collection device over the stoma) unless it becomes loose or causes skin discomfort. Pouches
to collect stool. Depending on the type and location of the are emptied and rinsed or detached and replaced period-
ostomy, client care may involve providing peristomal care, ically. The client empties the pouch when it is one-third
applying an appliance, draining a continent ileostomy, to one-half full; otherwise, it may become too heavy
and, for clients with a colostomy, administering irriga- and pull the faceplate from the skin. Although design
tions through the stoma. of the equipment varies, almost all types of appliances
are changed similarly (Skill 31-4).
Providing Peristomal Care

Draining a Continent Ileostomy
Preventing skin breakdown is a major challenge in ostomy
care. Enzymes in stool can quickly cause excoriation (chem- A continent ostomy (surgically created opening that controls
ical injury of skin). Washing the stoma and surrounding the drainage of liquid stool or urine by siphoning it from
skin with mild soap and water and patting it dry can pre- an internal reservoir) also is referred to as a Kock pouch,
FIGURE 31-4 • Locations of intestinal ostomies.
after the surgeon who developed the technique. This type Irrigating a Colostomy
of ostomy requires no appliance; however, the client must
drain the accumulating liquid stool or urine approximately Clients with a colostomy whose stool is more solid some-
every 4 to 6 hours. The client can use a gravity drainage times require the instillation of fluid to promote elimi-
system at night. See Client and Family Teaching 31-2. nation. Colostomy irrigation involves instilling solution
through the stoma into the colon, a process similar to
administering an enema (Skill 31-5).
The purpose of the irrigation is to remove formed
stool and in some cases to regulate the timing of bowel
movements. With regulation, a client with a sigmoid
colostomy may not need to wear an appliance. The
colostomy irrigation helps to train the bowel to elimi-
nate formed stool following the irrigation. Once the
client has eliminated the stool, he or she will expel no
more until the next irrigation. This mimics the pattern
of natural bowel elimination for most people. Because of
the predictability of bowel elimination, some clients
with a sigmoid colostomy feel it is unnecessary to wear
an appliance.

Discuss the various ways an ostomy affects the lives
FIGURE 31-5 • An ostomy appliance: faceplate and pouch. (Copyright of clients.
B. Proud.)
Constipation (2005, p. 40) as “a decrease in normal fre-

quency of defecation accompanied by difficult or incom-
Draining a Continent Ileostomy plete passage of stool and/or passage of excessively hard,
The nurse teaches the client or family as follows: dry stool.”
• Assume a sitting position.
• Insert a lubricated 22 to 28 F catheter into the GENERAL GERONTOLOGIC
stoma. CONSIDERATIONS
• Expect resistance after inserting the tube
approximately 2 inches; this is the location of Age-related changes, such as loss of elasticity in intestinal walls
and slower motility throughout the gastrointestinal tract,
the valve that controls the retention of liquid predispose older adults to constipation. Such changes alone,
stool or urine. however, do not cause constipation. Other factors, such as
• Gently advance the catheter through the valve adverse medication effects, diminished physical activity,
at the end of exhalation, while coughing, or and inadequate intake of fluid and fiber, contribute to the
while bearing down as if to pass stool. development of constipation.
Nurses can discuss constipation with older adults to identify any
• Lower the external end of the catheter at least contributing health beliefs and behaviors.
12 inches below the stoma. Older adults are likely to implement various home remedies
• Direct the end of the catheter into a container such as drinking prune juice or hot water in the morning
or toilet as stool or urine begins to flow. to promote bowel elimination. Consideration of benefits,
• Allow at least 5 to 10 minutes for complete potential risks, or lack of effect on an older person’s usual
health practices allows for collaboration regarding the
emptying. efficacy of continuing the health care behavior with the
• Remove the catheter and clean it with warm older adult.
soapy water. Older adults may be receptive to instructions about eating bran
• Place the clean catheter in a sealable plastic bag cereal or adding bran to casseroles or muffins as a means to
until its next use. increase fiber intake. Dietary fiber is a healthier alternative to
using laxatives to maintain bowel elimination.
• Cover the stoma with a gauze square or a large Health education regarding risk for constipation includes the
bandage. following points: (1) adults should identify their own
• If the catheter becomes plugged with stool or patterns of bowel regularity, which can range from 3 times
mucus: a day to 3 times a week; (2) daily exercise, high-fiber foods,
• Bear down as if to have a bowel movement. and 8 to 10 glasses of liquid a day (unless contraindicated)
contribute to good bowel elimination; (3) if medication
• Rotate the catheter tip inside the stoma.
is needed to promote bowel regularity, a bulk-forming
• Milk the catheter. agent is a better choice than laxatives or enemas;
• If these are not successful, remove the (4) adults should respond to the urge to defecate as
catheter, rinse it, and try again. soon as possible.
• Notify the physician if these efforts do not Older adults who live alone may rely on commercially prepared
meals that are easy to heat and eat. This consumption pattern
result in drainage. increases the risk for constipation because of inadequate fiber,
• Never wait longer than 6 hours without fresh fruit, vegetable, and fluid ingestion.
obtaining drainage. 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
mixed thoroughly and refrigerated. The older person can
begin with 1 tbsp/day and increase the amount by small
NURSING IMPLICATIONS increments daily until ease of bowel movement is achieved
and no disagreeable symptoms occur (Ebersole et al.,
2004, p. 155).
While assessing and caring for clients with altered bowel Some older adults may become very bowel conscious and
elimination, the nurse may identify one or more of the overuse laxatives or have a long-standing habit of laxative
following nursing diagnoses: abuse. They can develop healthier bowel elimination habits
through use of bulk-forming products containing psyllium or
• Constipation polycarbophil, which are more effective and less irritating than
• Risk for Constipation other types of laxatives. Examples of these agents include
• Perceived Constipation Metamucil (Procter & Gamble, Cincinnati, OH) and FiberCon
(Lederle Laboratories, Pearl River, NY).
• Diarrhea
Older adults who use mineral oil to prevent or relieve constipa-
• Bowel Incontinence tion need to be informed that prolonged use interferes with
• Toileting Self-Care Deficit absorption of fat-soluble vitamins (A, D, E, and K).
• Situational Low Self-Esteem The incidence of colorectal cancer increases with age. One early
sign is a change in bowel elimination patterns and stool
Nursing Care Plan 31-1 reflects the nursing process as characteristics. Therefore, advise older adults to have regular
it applies to a client with Constipation. NANDA defines endoscopic bowel examinations after 50 years of age. Any
Constipation
ASSESSMENT
• Note the frequency, amount, and texture of expelled stool.
• Ask the client about the effort required to eliminate stool.
• Inquire as to whether the client feels that he or she empties the bowel during stool elimination and if there is any
discomfort in the rectal area.
• Auscultate bowel sounds daily.
• Palpate the abdomen to determine if there is any distention.
• Determine if any of the client’s medications are constipating.
• Ask the client about measures he or she uses to promote bowel elimination and their frequency.
• Ask the client to describe daily intake of fluid and food including types of beverages and foods commonly eaten.
• Explore lifestyle patterns that may interfere with bowel elimination such as a lack of privacy or lengthy travel that
interferes with accessing a toilet when there is a need to eliminate stool.
• Note if any physical problems may compromise bowel elimination such as impaired physical mobility or dementia.
Nursing Diagnosis: Constipation related to inadequate dietary habits as manifested by

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 list three
ways to improve the regularity of bowel elimination by 10/25.
Give an oil retention enema as ordered for prn This type of enema lubricates the bowel and softens stool
administration. for easier expulsion.
Give prescribed laxative at bedtime 10/23 if no bowel Laxatives facilitate bowel elimination in various ways;
movement has occurred. some common mechanisms of action include increasing
intestinal peristalsis, irritating the bowel, and attracting
water into the large intestine.
Encourage drinking at least 8 to 10 glasses of fluid per day; Oral fluid promotes hydration and avoids dry stool; prune
offer prune juice or apple juice. juice is high in fiber, which promotes bulk; apple juice
contains pectin, which also adds bulk to the stool.
Instruct about high-fiber foods and that daily consumption Intestinal fiber adds bulk to and pulls water into stool; a
should consist of at least four servings. bulky soft stool distends the rectum and promotes the urge
to defecate.
• Client eliminated moderate amount of brown formed stool approximately 6 hours following the administration of oil
retention enema.
• Client identified a minimum goal of consuming eight 8-oz glasses of fluid daily.
• Client can name foods such as whole grain bread, cereal, fresh fruits and juices, uncooked vegetables and salads, and nuts
as sources of daily fiber.
• Client stated that increasing active exercise for a total of 30 minutes each day either all at once or divided and performed
several times during the day promotes bowel elimination.
change in bowel elimination that does not respond to simple 2. Which of the following assessments is the best indication
dietary or lifestyle changes requires further investigation. that a client has a fecal impaction?
Diarrhea can easily lead to dehydration and electrolyte imbalances 1. The client passes liquid stool frequently.
(especially hypokalemia) in older adults, who tend to have less 2. The client has extremely offending bad breath.
body fluid reserve than younger people.
3. The client requests medication for a headache.
Older adults may have benign lesions such as hemorrhoids or
polyps in their lower bowel, which may interfere with pas- 4. The client has not been eating well lately.
sage of stool. If digital removal of an impaction is required, 3. Before inserting a rectal tube, which of the following
a gentle procedure should be used to prevent bleeding and nursing measures is most helpful for eliminating intesti-
tissue trauma.
nal gas?
Musculoskeletal disorders, such as arthritis of the hands, may
1. Ambulate the client in the hall.
interfere with an older person’s ability to care for an ostomy
appliance or perform colostomy irrigations. An occupational 2. Provide a carbonated beverage.
or enterostomal therapist can offer suggestions for promoting 3. Restrict the intake of solid food.
self-care. 4. Administer a narcotic analgesic.
4. During administration of a cleansing soapsuds enema,
a client experiences cramping and has the urge to defe-
CRITICAL THINKING E X E R C I S E
cate. Which is the best nursing action to take at this
1. Formulate suggestions to promote bowel continence time?
among older adults with impaired cognition such as 1. Quickly finish instilling the remaining solution.
those with Alzheimer’s disease. 2. Tell the client to hold his or her breath and bear
down.
3. Briefly stop the administration of the enema
NCLEX-STYLE REVIEW Q U E S T I O N S solution.
4. Withdraw the tip of the enema tubing from the
1. When a client tells the nurse that he cannot have a bowel
rectum.
movement without taking a daily laxative, what informa-
tion is essential for the nurse to explain? 5. When the nurse assesses the stoma of a client with an
1. Chronic use of laxatives impairs natural bowel tone. ostomy, a normal appearance looks
2. Stool softeners are likely to be less harsh. 1. Pale pink
3. Daily enemas are more preferable than laxatives. 2. Bright red
4. Dilating the anal sphincter may aid bowel 3. Dark tan
elimination. 4. Dusky blue
Skill 31-1 • INSERTING A RECTAL TUBE
Assessment
Check the medical orders. Ensures collaboration between nursing activities and
medical treatment
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 Provides an opportunity for health teaching
procedure.
Planning
Obtain a 22 to 32 F catheter and lubricant. Ensures proper size and easy insertion
Implementation
(see Chap. 10); don gloves.
Pull the privacy curtain. Demonstrates respect for the client’s dignity
Place the client in a Sims’ position. Facilitates access to the rectum
Lubricate the tip of the tube generously (Fig. A). Eases insertion
Separate the buttocks well so that the anus is in plain Helps visualize insertion location
view (Fig. B).
A B
Lubricating the rectal tube. Separating the buttocks.
Insert the tube 4 to 6 inches (10 to 15 cm) in an adult Places the distal tip above the sphincter muscles, stimulates
(Fig. C). peristalsis, and prevents displacement of the tube
Enclose the free end of the tube within a clean, soft Provides a means for absorbing stool should it drain from
washcloth or gauze square (Fig. D). the 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 to 4 hours if discomfort returns. Reinstitutes therapeutic management
(continued)
INSERTING A RECTAL TUBE (Continued)
D
C
Inserting the rectal tube. Enclosing the rectal tube.
Evaluation
• Intestinal gas is eliminated.
• Client states symptoms are relieved.
• 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 any more.” Ambulated without relief. 26 F
straight catheter inserted into rectum for 20 minutes. Flatus expelled during tube insertion. Abdomen
softer. SIGNATURE/TITLE
Skill 31-2 • INSERTING A RECTAL SUPPOSITORY
Assessment
Check the medical orders. Ensures collaboration between nursing activities and
medical treatment
Compare the medication administration record (MAR) Ensures accuracy
with the written medical order.
Read and compare the label on the suppository with the Prevents errors
MAR at least three times—before, during, and after
preparing the drug.
Determine how much the client understands the purpose Provides an opportunity for health teaching
and technique for administering a suppository.
Planning
Prepare to administer the suppository according to the Complies with medical orders
time 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 Standard Precautions
Lubricate the suppository and index finger of the Reduces friction and tissue trauma and enhances
dominant hand and separate the buttocks so that the visualization
anus is in plain view (Fig. A).
Lubricated suppository and insertion finger.
(continued)
INSERTING A RECTAL SUPPOSITORY (Continued)
Instruct the client to take several slow, deep breaths. Promotes muscle relaxation and places the suppository in
Introduce the suppository, tapered end first, beyond the the best location for achieving a local effect
internal sphincter, 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 Promotes comfort
tissue.
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 Tightens the anal sphincters
premature urge to expel the suppository.
Ask the client to wait to flush the toilet until the stool has Provides an opportunity for evaluating the drug’s
been inspected. effectiveness
Remove your gloves and wash your hands. Reduces the transmission of microorganisms
Evaluation
• Client retains suppository for 15 minutes.
• Bowel elimination occurs.
Document
• Drug, dose, route, and time (see Chap. 32)
• Outcome of drug administration
Date and Time Biscodyl (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 Ensures collaboration between nursing activities and
prescribed solution. medical 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
Wash hands or perform an alcohol-based handrub Reduces the transmission of microorganisms
(see Chap 10).
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 Determines if a bedpan is necessary
solution and stool.
Obtain appropriate equipment including an enema set, Facilitates organization and efficient time management
solution, absorbent pad, lubricant, bath blanket, and
gloves.
Plan to perform the procedure according to the time Demonstrates collaboration and participation of the client
specified by the physician or when it is most in decision making
appropriate during client care.
Prepare the solution and equipment in the utility room. Provides access to supplies
Warm the solution to approximately 105°F to 110°F Promotes comfort and safety
(40°C to 43°C).
Clamp the tubing on the enema set. Prevents 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 Preserves modesty and protects bed linen
waterproof pad under the hips (Fig. A).
Draping for an enema.
A
(continued)
ADMINISTERING A CLEANSING ENEMA (Continued)
Don gloves. Reduces the transmission of microorganisms and complies
with Standard Precautions
Place (or hang) the solution container so that it is 12 to 20 Facilitates gravity flow
inches (30 to 50 cm) above the level of the client’s anus.
Open the clamp and fill the tubing with solution (Fig. B). Purges air from the tubing.
Reclamp.
Purging air.
Lubricate the tip of the tube generously (Fig. C). Eases insertion
Separate the buttocks well so that the anus is in plain view. Helps to visualize insertion
Insert the tube 3 to 4 inches (7 to 10 cm) in an adult. Places the distal tip above the sphincters
Direct the tubing at an angle pointing toward the Follows the contour of the rectum
umbilicus (Fig. D).
C D
Lubricating the tube. Direction for tube insertion.
Hold the tube in place with one hand (Fig. E). Avoids displacement
Release the clamp. Promotes instillation
Instill the solution gradually over 5 to 10 minutes (Fig. F). Fills the rectum
Clamp the tube for a brief period while the client takes Avoids further stimulation
deep breaths and contracts the anal sphincters if
cramping occurs.
(continued)
ADMINISTERING A CLEANSING ENEMA (Continued)
E F
Holding the tube in place. Instilling the enema solution.
Resume instillation when cramping is relieved. Facilitates effectiveness

Clamp and remove the tubing after sufficient solution has Completes the procedure
been instilled or the client states that he or she cannot
retain more.
Encourage the client to retain the solution for 5 to Promotes effectiveness
15 minutes.
Hold the enema tubing in one hand and pull a glove over Prevents direct contact
the inserting end of the tubing.
Remove and discard the remaining glove and dispose of Follows principles of medical asepsis
the enema equipment.
Assist the client to sit while eliminating the solution and Aids defecation
stool.
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 Demonstrates concern for well-being
position.
Evaluation
• Sufficient amount of solution is instilled.
• Comparable amount of solution is expelled.
• 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 handrub Reduces the transmission of microorganisms and complies
(see Chap. 10). Don gloves. with Standard Precautions.
Inspect the faceplate, pouch, and peristomal skin. Determines the necessity for changing the appliance and
provides data about the condition of the stoma and
surrounding skin
Determine how much the client understands about stomal Provides an opportunity for health teaching; prepares the
care and changing an ostomy appliance. client for assuming self-care
Wash hands and perform hand hygiene measures after Removes transient microorganisms
removing gloves.
Planning
Obtain replacement equipment, supplies for removing the Facilitates organization and efficient time management
adhesive (e.g., the manufacturer’s recommended solvent
if appropriate), and products for skin care.
Plan to replace the appliance immediately if the client has Prevents complications
localized symptoms.
Schedule an appliance change for an asymptomatic client Coincides with a time when the gastrocolic reflex is less
before a meal and before a bath or shower. active and prevents repeating hygiene
Plan to empty the pouch just before the appliance will be Prevents soiling
changed.
Implementation
Place the client in a supine or dorsal recumbent position. Facilitates access to the stoma
Wash your hands or perform an alcohol-based handrub; Reduces the transmission of microorganisms; complies
don gloves. with 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. (Copyright B. Proud.)
(continued)
CHANGING AN OSTOMY APPLIANCE (Continued)
Wash the peristomal area with water or mild soapy Cleans mucus and stool from the skin
water using a 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 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. (Copyright B. Proud.)
Trim the opening in the faceplate to the measured Avoids pinching of or pressure on the stoma and causing
diameter plus approximately 1⁄8 to 1⁄4 inch larger circulatory impairment
(Fig. C).
Attach a new pouch to the ring of the faceplate (Fig. D). Avoids pushing the pouch into place after the faceplate
has been applied
Fold and clamp the bottom of the pouch (Fig. E). Seals the pouch so leaking will not occur
C D E
Trimming the stomal opening. (Copyright B. Proud.) Attaching the pouch. (Copyright B. Proud.) Sealing the pouch. (Copyright B. Proud.)
(continued)
CHANGING AN OSTOMY APPLIANCE (Continued)
Peel the backing from the adhesive on the faceplate (Fig. F). Prepares the appliance for application
Have the client stand or lie flat. Keeps the skin taut and avoids wrinkles
Position the opening over the stoma and press into place Prevents air gaps and skin wrinkles
from the center outward (Fig. G).
Perform hand hygiene after removing gloves. Removes transient microorganisms
F G
Removing the adhesive backing. (Copyright B. Proud.) Attaching the appliance. (Copyright B. Proud.)
Evaluation
• Stoma appears pink and moist.
• Skin is clean, dry, and intact with no evidence of
redness, irritation, or excoriation.
• 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 Ensures collaboration between nursing activities and
type of solution to use. medical treatment
Determine how much the client understands about Provides an opportunity for health teaching; prepares the
colostomy irrigation. client to assume self-care
Planning
Obtain an irrigating bag and sleeve, lubricant, and belt Promotes organization and efficient time management
(Fig. A). A bedpan will be needed if the client is
confined to bed.
Prepare the irrigating bag with solution in the same way Provides the mechanism for cleansing the bowel
as for an 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 Facilitates collecting drainage
front or 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 inches (30 cm) Facilitates gravity flow
above the stoma.
Wash your hands or perform an alcohol-based handrub; Reduces the transmission of microorganisms; complies
don gloves. with Standard Precautions
Empty and remove the pouch from the faceplate, if the Provides access to the stoma
client is wearing one.
Secure the sleeve over the stoma and fasten it around the Provides a pathway for drainage
client with an elastic belt (Fig. B).
A
Irrigating the sleeve and bag.
B
Positioning the irrigation sleeve.
(continued)
IRRIGATING A COLOSTOMY (Continued)
Place the lower end of the sleeve into the toilet, commode, Collects drainage
or bedpan (Fig. C).
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
C D
Placing the distal end of sleeve. Inserting the irrigation cone.
Hold the cone in place and release the clamp on the Prevents expulsion of the cone and initiates the
tubing. installation
Clamp the tubing and wait if cramping occurs. Interrupts the instillation while the bowel adjusts
Release the clamp and continue once the discomfort Resumes instilling fluid without discomfort to the client
disappears.
Clamp the tubing and remove the cone when the irrigating Discontinues the administration of solution
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 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 Collects fecal drainage
the stoma or cover the stoma temporarily with a gauze
square.
Repeat hand hygiene measures after removing gloves. Removes transient microorganisms
(continued)
IRRIGATING A COLOSTOMY (Continued)
Evaluation
• Sufficient amount of solution is instilled.
• 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
U N I T 81

for Chapters
Chapters 1,
302and 31
in parentheses.
1. means greater than normal urinary volume accompanied by minor dietary variations.
(Anuria, Oliguria, Polyuria)
2. Hypertonic enema solutions are available in commercially prepared disposable containers holding approximately
mL of solution. (60, 120, 180)
3. constipation results from medical treatment. (Iatrogenic, Pseudo, Secondary)
4. A is a seatlike container used for the elimination of body waste. (bedpan, commode, urinal)

false statements.
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 and surrounding tissues.
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
760
UNIT 8 ● End of Unit Exercises for Chapters 30 and 31 761
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
Activity E: 1. Differentiate between fecal impaction and fecal incontinence based on

the criteria given below.
Fecal Impaction Fecal Incontinence
Definition
Causes
Symptoms
A B
1. Identify what is shown in the figure.

2. Explain the techniques in the figure.
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 bowel elimination assessment?
4. What are the various signs and symptoms of constipation?
5. What are the potential problems of using condom catheters?

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 to promote bowel elimination for a client with constipation?
b. How should the nurse administer a commercially prepared, disposable container of hypertonic enema
solution?
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 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 out-
comes 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, without an urge to
void. 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 Crede’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 alternatively for 10 seconds.
3. An elderly client with a musculoskeletal disorder cannot elevate her 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 frac-
ture 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 to the nurse a frequent desire to defecate, but he 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 the stool.
e. Provide periods of rest until the mass is removed.
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.
UNIT 9
Medication
Administration
32 Oral Medications
33 Topical and Inhaled Medications
34 Parenteral Medications
35 Intravenous Medications
32
Chapter
Oral
Medications
LEARNING OBJECTIVES
● Define the term “medication.”
● Name seven components of a drug order.
● Explain the difference between trade and generic drug names.
● Name four common routes for administration.
● Describe the oral route and two general forms of medication administered this way.
● Explain the purpose of a medication record.
● Name three ways that drugs are supplied.
● Discuss two nursing responsibilities that apply to the administration of narcotics.
● Name the five rights of medication administration.
● Give the formula for calculating a drug dose.
● Discuss at least one guideline that applies to the safe administration of medications.
● Discuss one point to stress when teaching clients about taking medications.
● Explain the circumstances involved in giving oral medications by an enteral tube and one
commonly associated problem.
● Describe three appropriate actions in the event of a medication error.
ONE of the nurse’s most important responsibilities is the administration of medications

(chemical substances that change body function). This chapter emphasizes the safe
preparation and administration of medications, particularly those given by the oral
route. This chapter uses the terms medications and drugs synonymously; information
on specific drugs can be found in pharmacology texts or drug reference manuals.
WORDS TO KNOW
dose MEDICATION ORDERS
enteric-coated tablet
generic name
individual supply A medication order lists the drug name and directions for its administration. Usually
medication administration physicians or dentists write a medication order. Other medical personnel, such as a
record
medication order
physician’s assistant or advanced practice nurse, also can write medication orders if
medications legally designated to do so by state statutes. Medication orders written on the client’s
oral route medical record are used here for the purposes of discussion.
over-the-counter
medication
polypharmacy
route of administration
Components of a Medication Order
scored tablet
stock supply All medication orders must have seven components:
sustained release
trade name 1. Client’s name
unit dose supply 2. Date and time the order is written
768
C H A P T E R 32 ● Oral Medications 769
3. Drug name apothecary system of measurement. For the purposes of

4. Dose to be administered safety, however, the Joint Commission on Accreditation of
5. Route of administration Healthcare Organizations (JCAHO, 2004) suggests that
6. Frequency of administration apothecary measurements may be subject to future exclu-
7. Signature of the person ordering the drug sion because they are unfamiliar to many practitioners and
may be confused with metric-system abbreviations. Refer
If any one of these components is absent, the nurse
to Table 32-1 for “Do Not Use” abbreviations that JCAHO
must withhold the drug until he or she has obtained the
mandates. For home use, metric and apothecary, if the lat-
missing information. Medication errors are serious. Nurses
ter is used, are converted to household measurements that
never implement a questionable medication order until after
are more easily interpreted by nonprofessionals.
consulting with the person who has written the order.
Route of Administration
Drug Name
The route of administration means how the drug is given,
Each drug has a trade name (name that the pharmaceutical
which may be by the oral, topical, inhalant, or parenteral
company who made the drug uses). A trade name some-
route (Table 32-2). Topical and inhalant routes of admin-
times is called a brand or proprietary name. A drug’s trade
istration are discussed in Chapter 33; parenteral admin-
name generally is capitalized and followed by an R within
istration is described in Chapters 34 and 35.
a circle, as in . ®
Drugs also have a generic name (chemical name not
The oral route (administration of drugs by swallowing
or instillation through an enteral tube) facilitates drug
protected by a company’s trademark), which is written in
absorption through the gastrointestinal tract. It is the most
lower case letters. For example, Demerol is a trade name
common route for medication administration because it
used by Winthrop Pharmaceuticals for the generically
is safer, more economical, and more comfortable than
named drug meperidine hydrochloride.
others. Medications administered by the oral route come
in both solid and liquid forms.
Drug Dose Solid medications include tablets and capsules. A scored
The dose means the amount of drug to administer and tablet (solid drug manufactured with a groove in the cen-
is prescribed using the metric system or, sometimes, the ter) is convenient when only part of a tablet is needed.
TABLE 32-1 JCAHO’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 “cc” Write “unit”
(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 (2004). Available at: http://www.jointcommission.org/PatientSafety/DoNotUseList/.
770 U N I T 9 ● Medication Administration
ROUTES OF DRUG • Stat—immediately

TABLE 32-2 • b.i.d.—twice a day
ADMINISTRATION
ROUTE METHOD OF ADMINISTRATION
• t.i.d.—three times a day
• q.i.d.—four times a day
Oral Swallowing • q.h.—hourly
Instillation through an enteral tube • q4h—every 4 hours
Topical Application to skin or mucous membrane
Chapter 9 and Appendix B list other common abbre-
Inhalant Aerosol
viations.
Parenteral Injection
When the medication order is implemented, drug ad-
ministration is scheduled according to the prescribed fre-
quency. The health agency sets a predetermined timetable
for drug administrations; hours of administration may
Enteric-coated tablets(solid drug covered with a substance vary among agencies. For example, if a physician orders
that dissolves beyond the stomach) are manufactured for a q.i.d. (four times a day) administration of a medication,
drugs that are irritating to the stomach. Enteric-coated it may be scheduled for administration at 8 a.m., noon,
tablets are never cut, crushed, or chewed because when the 4 p.m., and 8 p.m.; at 10 a.m., 2 p.m., 6 p.m., and 10 p.m.;
integrity of the coating is impaired, the drug dissolves pre- or at 6 a.m., noon, 6 p.m., and midnight.
maturely in gastric secretions. Some capsules also contain
beads or pellets of drugs for sustained release (drug that dis-
solves at timed intervals). Sustained-release capsules are Verbal and Telephone Orders
never opened or crushed: doing so affects the rate of drug
absorption. Verbal orders are instructions for client care that are
Liquid forms of oral drugs include syrups, elixirs, and given during face-to-face conversations. Telephone orders
suspensions. Nurses measure and administer liquid med- are obtained from a physician during a telephone conver-
ications in calibrated cups, droppers, or syringes or with sation. Both types of orders are more likely to result in
a dosing spoon (Fig. 32-1). misinterpretation than are written orders. If a prescriber
is physically present, it is appropriate to ask tactfully that
Frequency of Administration the order be handwritten. When obtaining phone orders,
it is important to repeat the dosages of drugs and to spell
The frequency of drug administration refers to how drug names for confirmation of accuracy. Some nurses
often and how regularly the medication is to be given. ask a second nurse to listen to a telephone order on an
Frequency of administration is written using standard extension. See Nursing Guidelines 32-1.
abbreviations of Latin origin. Some common examples
Taking Telephone Orders
❙ Have a second nurse listen simultaneously on an extension.
A second nurse serves as a witness to the communication.
❙ Record the drug order directly on the client’s medical record. Written
recording avoids errors in memory.
❙ Repeat the written information back to the prescriber. Repetition
clarifies understanding.
❙ Make sure the order includes the essential components. Doing so
complies with standards for care.
❙ Clarify any drug names that sound similar, such as Celebrex® and
Cerebrex®, Nicobid® and Nitro-Bid®. Checking avoids medication
errors.
❙ Spell or repeat numbers that could be misinterpreted such as 15
(one, five) and 50 (five, zero). This step avoids medication errors.
❙ Use the abbreviation “T.O.” at the end of the order. This
abbreviation indicates the order is a telephone order.
❙ Write the prescriber’s name and cosign with your name and title.
These steps comply with legal standards and demonstrate
FIGURE 32-1 • Measuring liquid medication with a calibrated cup accountability for the communication.
held at eye level. (Copyright B. Proud.)
Documentation in the Medication agencies keep narcotics in a double-locked drawer, box,

Administration Record or room on the nursing unit. Because narcotics usually
are delivered by stock supply, nurses are responsible for
Once the nurse has obtained the medication order, he or an accurate account of their use. They keep a record of
she transcribes it to the medication administration record each narcotic used from the stock supply.
(MAR; agency form used to document drug administra- Nurses count narcotics at each change of shift. One
tion). Use of the MAR ensures timely and safe medication nurse counts the number in the supply, while another
administration. Some agencies use a form on which nurses checks the record of their administration or amounts
transcribe the drug order by hand; others use a computer- that have been wasted. Both counts must agree with
generated form (Fig. 32-2). Regardless of the type, all inconsistencies accounted for as soon as possible.
MARs provide a space for documenting when a drug is
given, along with a place for the signature, title, and initials
of each nurse who administers a medication. The current MEDICATION ADMINISTRATION
MAR is usually kept separate from the client’s medical
record, but it eventually becomes a permanent part of it.
Safety is the main concern in medication administra-
tion. Taking various precautions before, during, and after
METHODS OF SUPPLYING each administration reduces the potential for medication
errors. Some precautions include ensuring the five rights
MEDICATIONS
of medication administration, calculating drug dosages
accurately, preparing medications carefully, and record-
After transcribing the medication order to the MAR, the ing their administration.
nurse requests the drug from the pharmacy with either a
paper or facsimile (fax) transmission request. Drugs are
supplied, or dispensed, in three major ways. An individ- Applying the Five Rights
ual supply is a container with enough of the prescribed
drug for several days or weeks and is common in long- To safeguard against medication errors, nurses follow
term care facilities such as nursing homes (Fig. 32-3). A the five rights of medication administration (Fig. 32-5).
unit dose supply (self-contained packet that holds one tablet Some nurses have added a sixth right, the right to refuse.
or capsule) is most common in acute care hospitals that Every rational adult client has the right to refuse medica-
stock drugs for individual clients several times in one day tion. If this happens, the nurse identifies the reason why
(Fig. 32-4). A stock supply (stored drugs) remains on the he or she did not administer the drug, circles the sched-
nursing unit for use in an emergency or so that a nurse uled time on the MAR, and reports the situation to the
can give a drug without delay. prescriber.
Some facilities use automated medication-dispensing
systems. These systems usually contain frequently used
medications for that unit, any as-needed (PRN) medica- Calculating Dosages
tions, controlled drugs, and emergency medications. The
nurse accesses the system by using a password and then One of the major nursing responsibilities, and one of the
selects the appropriate choice from a computerized menu. five rights, is preparing the dose accurately. Preparing an
This type of system automatically keeps a record of dis- accurate dose sometimes requires the nurse to convert
pensed medications. doses into metric, apothecary, and household equivalents.
Once the prescribed and supplied amounts are in the same
measurements and system of measurement, the quantity
Storing Medications for administration can be easily calculated using a stan-
dard formula (Box 32-1). See Nursing Guidelines 32-2.
Each health agency has one area for storing drugs. Some
agencies keep medications in a mobile cart; others store
them in a medication room. Each client has a separate Administering Oral Medications
drawer or cubicle to hold his or her prescribed medica-
tions. Regardless of their location, the supply of medica- Nurses prepare and bring oral medications to the client’s
tions remains locked until the drugs are administered. bedside in a paper or plastic cup (Skill 32-1). The nurse
administers only those medications that he or she has
personally prepared; never administer medications pre-
Accounting for Narcotics pared by another nurse. Once at the bedside, it also is
important for the nurse to remain with the client while
Narcotics are controlled substances, meaning that federal he or she takes medications. If the client is not on the
laws regulate their possession and administration. Health unit, the nurse returns the medications to the medication
FIGURE 32-2 • A computer-generated medication administration record (MAR).

BOX 32-1 ● Drug Calculation Formula
D Desired dose
×Q− × Quantity
H Dose on hand ( supplied dose )
= Amount to administer
Example
Drug order: Tetracycline 500 mg (desired dose) by mouth q.i.d.
Dose supplied: 250 mg (dose on hand) per 5 mL (quantity)
500 mg
Calculation: × 5 mL = 10 mL
250 mg
cart or room. Leaving medications unattended may result

in their loss or accidental ingestion by someone else.
Many opportunities exist for teaching when administer-
ing medications. Teaching is especially important before
FIGURE 32-3 • Medication from an individual supply. (Copyright discharge because the client often receives prescriptions for
B. Proud.) oral medications. Providing health teaching helps to ensure
that clients administer their own medications safely and
remain compliant. Compliance means that the client
follows instructions for medication administration. Even
clients who purchase over-the-counter medications (non-
prescription drugs) may benefit from instruction. See
Client and Family Teaching 32-1.

What actions are appropriate if a client cannot swallow
medications prescribed by the oral route?

FIGURE 32-4 • Unit dose medications. (Copyright B. Proud.) Preparing Medications Safely
❙ Prepare medications under well-lighted conditions. Light improves
the ability to read labels accurately.
BE SURE YOU Work alone without interruptions and distractions. This promotes
❙
concentration.
HAVE THE Check the label of the drug container three times: (1) when reaching
❙
for the medication, (2) just before placing the medication into an
administration cup, and (3) when returning the medication to the
Drug ❙
client’s drawer. Checking ensures attention to important information.
Avoid using medications from containers with a missing or obliterated
DOSE ❙
label. This eliminates speculating on the drug name or dose.
Return medications with dubious or obscured labels to the
ROUTE ❙
pharmacy. This step facilitates replacement or new labeling.
Never transfer medications from one container to another. Such
TIME ❙
transfers could lead to mismatching contents.
Check the expiration dates on liquid medications. Doing so ensures
CLIENT ❙
administration at desired potency.
Inspect the medication and reject any that appears to be
decomposing. These steps promote appropriate absorption.
FIGURE 32-5 • The five rights of medication administration.
32-1 • CLIENT AND FAMILY TEACHING NURSING GUIDELINES 32-3
Taking Medications Preparing Medications for Enteral

Tube Administration
• Inform the prescriber of all other drugs that ❙ Use the liquid form of the drug whenever possible. It promotes tube
you are currently taking. patency.
• Have prescriptions filled at the same pharmacy ❙ Add 15 to 60 mL of water to thick liquid medications. Water dilutes
so that the pharmacist can spot any potential the medication and facilitates instillation.
drug interactions. ❙ Pulverize tablets except those that are enteric coated. Pulverizing
• Consider asking for a new prescription to be creates small granules that may instill more readily.
partially filled. This provides an opportunity to ❙ Open the shell of a capsule to release the powdered drug. This step
evaluate the drug’s effect and side effects before facilitates mixing into a liquid form.
purchasing the full amount. ❙ Avoid crushing sustained-release pellets. Keeping them whole
• Read and follow label directions carefully.
ensures their sequential rate of absorption.
• Take prescription medication for the full time
that it has been prescribed.
❙ Mix each drug separately with at least 15 to 30 mL of water. Water
provides a medium and dilute volume for administration.
• Check with the prescriber before combining
nonprescription and prescription drugs. ❙ Use warm water when mixing powdered drugs. It promotes
• Dispose of old prescription drugs and outdated dissolving the solid form.
over-the-counter medications; they tend to dis- ❙ Pierce the end of a sealed gelatin capsule and squeeze out the liquid
integrate or change in potency. medication, or aspirate it with a needle and syringe. These
• Consult with the prescriber if a drug does measures facilitate access to the medication.
not relieve symptoms or causes additional ❙ As an alternative, soak a soft gelatin capsule in 15 to 30 mL of
discomfort. warm water for approximately 1 hour. Soaking dissolves the
• Ask the prescriber or pharmacist if it is appro- gelatin seal.
priate to take specific medications with food or ❙ Avoid administering bulk-forming laxatives through an enteral tube.
on an empty stomach. Such laxatives could obstruct the tube.
• Drink a liberal amount of water or other fluids ❙ Interrupt a tube feeding for 15 to 30 minutes before and after
each day to assist with appropriate absorption administration of a drug that should be given on an empty stomach.
and elimination of drugs. Doing so facilitates the drug’s therapeutic action or its absorption.
• Do not take drugs prescribed for someone else,
even if your symptoms are similar.
• Wear a Medic-Alert tag if you are taking pre-
scription drugs on a regular and long-term basis. Nurses can give medications while a client is receiving
• Use a pill organizer if you have trouble remem- tube feedings, but they instill the medications separately—
bering whether you took a medication. that is, they do not add the medications to the formula.
This is done for two reasons. First, some drugs may phys-
ically interact with the components in the formula, caus-
Administering Oral Medications ing it to curdle or otherwise change its consistency. Also,
by Enteral Tube a slow infusion would alter the drug’s dose and rate of
absorption.
When a client cannot swallow oral medications, they can
be instilled by enteral tube (Skill 32-2). Because the lumen
of a tube is smaller than the esophagus, special techniques Documentation
may be required to avoid obstruction. See Nursing Guide-
lines 32-3. Nurses document medication administration on the MAR,
Nurses use slightly different techniques for adminis- the client’s chart, or both as soon as possible (Fig. 32-6).
tering medications through an enteral tube than they do Timely documentation prevents medication errors: if the
for tubes used for decompression or nourishment (see nurse does not record the dose, another nurse may assume
Chap. 29). They may give medications through gastric that the client has not received the medication and may
tubes used for decompression (e.g., suctioning; see give a second dose. Some agencies are using computerized
Chap. 29). After administering the drug, the nurse clamps medication documentation, which involves scanning
or plugs the tube for at least 30 minutes to prevent remov- bar codes on the medication container, the MAR, and the
ing the drug before it leaves the stomach. client’s identification bracelet before administering each
Whenever nursing care involves the administration of

medications, one or more of the following nursing diag-
noses may be applicable:
• Risk for Aspiration
• Ineffective Therapeutic Regimen Management
• Ineffective Health Maintenance
• Noncompliance
Nursing Care Plan 32-1 shows how nurses can follow
the steps in the nursing process to manage the care of a
client with the nursing diagnosis of Noncompliance,
defined by NANDA (2005, p. 124) as a “. . . person’s or
caregiver’s behavior (that) is fully or partially nonadher-
ent (with a health-promoting or therapeutic plan) and
may lead to clinically or partially ineffective outcomes.”
FIGURE 32-6 • Documentation of medication administration is an
important nursing requirement. (Copyright B. Proud.)
drug. The computer validates that the nurse is about to CONSIDERATIONS
give the right dose of the right drug, through the right Several age-related changes can influence the actions of medica-
route, at the right time, to the right client. The computer tions in older people.
also documents the drug’s administration based on a pass- Diminished kidney and liver function increases the concentration
of many drugs. Increased proportions of body water and fat
word provided by the nurse. and decreased proportion of lean tissue affect the concentra-
If a nurse withholds a medication, he or she docu- tion of some medications. Decreased blood albumin levels
ments its omission according to agency policy. A common increase the active drug components for protein-bound med-
method of such documentation is to circle the time of ications. Decreased gastric acidity reduces or delays absorp-
tion of some drugs. The chemical properties of the medication
administration and initial the entry. The nurse may doc-
determine the degree to which these age-related changes
ument the reason for the omission in a comment section influence medication actions. For example, age-related urinary
on the MAR or elsewhere in the client’s medical record. changes influence only those medications excreted through
the kidneys. Thus, information regarding the metabolism of
each medication should be considered for older adults experi-
encing decreased renal, hepatic, gastrointestinal, or circulatory
Stop • Think + Respond BOX 32-2 functioning.
Give reasons to administer medications through a gastric or Polypharmacy (administration of multiple medications to the
intestinal tube rather than having the client swallow them. same person) in older adults increases the risk for drug inter-
actions 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
Medication Errors mental changes in older adults. Therefore, any change in an
older client’s mental status must be reported, with evaluation
Medication errors happen. When errors occur, nurses of the potential causative factors.
have an ethical and legal responsibility to report them to Older people who have had cerebrovascular accidents (CVAs or
strokes) or who are experiencing middle to late stages of
maintain the client’s safety.
dementia may have impaired swallowing. Speech therapists
As soon as he or she recognizes an error, the nurse are helpful in evaluating swallowing difficulties (dysphagia)
checks the client’s condition and reports the mistake to and recommending safe and effective methods of administer-
the prescriber and supervising nurse immediately. Health ing oral medications.
care agencies have a form for reporting medication errors Mixing oral medications with some soft food (such as applesauce)
may prevent medication from adhering to the tongue and,
called an incident sheet or accident sheet (see Chap. 3).
thus, facilitate administration. Enteric-coated medications
The incident sheet is not a part of the client’s permanent should never be crushed. Before altering oral medications,
record, nor does the nurse make any reference in the chart consult a drug reference or a pharmacist to determine whether
to the fact that he or she has completed an incident sheet. there are any contraindications to crushing or mixing them.
Noncompliance
ASSESSMENT
• Check if the client is returning for scheduled appointments with the prescribing physician or health care provider.
• Assess the current status of the client’s health problem to determine if the response to the prescribed plan of care is that
which is expected.
• Ask to examine the client’s containers of medications.
• Review the labels attached to prescription medications.
• Have the client identify the number of pills or capsules per dose, the frequency of self-administration, and time of the last
dose.
• Determine by the dates on the containers and the numbers of medications in the container(s) whether the client is using
or partially using medication.
• Encourage the client to relate problems encountered with self-administration of medications such as intolerance of side
effects, inability to pay for refills, belief that the medication is ineffective, difficulty remembering the dosing schedule, and
trouble opening the containers.
Nursing Diagnosis: Noncompliance related to inaccurate belief regarding the use and
benefit of prescribed medication therapy 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 to clarify the rationale for
1) The purpose for the prescribed beta blocker and medication therapy and promotes compliance.
diuretic medications is to reduce the work of the heart.
2) The diuretic helps to lower blood pressure so the heart
doesn’t have to pump as much circulating blood and
can eject the blood from the heart more easily.
3) Easing the work of the heart reduces the potential for
recurring chest pain, a subsequent myocardial
infarction (heart attack), or congestive heart failure.
Have client rephrase explanations for drug therapy in his Rephrasing provides evidence that the client has
own words. understood 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 Reviewing the schedule helps the client to plan a routine
the client. for self-administration.
Suggest that the client discuss any deviations in This offers an alternative if the client feels a need to alter
medication schedule or dosage with the physician. or discontinue self-administration.
(continued)
Noncompliance
• Client correctly paraphrased information regarding drug therapy.
• Client states: “I know people take nitroglycerin for heart problems, but I didn’t know how important these other drugs
are. I’d rather take some pills than to have to go back to the hospital again.”
• Client plans to have prescriptions filled before returning home following office visit.
• Client indicates that he will take one beta blocker each morning if his heart rate is at least 60 beats per minute and one
diuretic tablet every other day, which correlates with the dosing regimen.
• Client is scheduled for another office check-up in 1 month. He states, “I’ll be sure to call if I think there’s a reason I can’t
take my medications.”
If an older person has difficulty comprehending information Clients with visual impairments may benefit from methods of
about medication routines, include a second responsible per- identifying their medication containers other than reading
son in the discharge instructions to ensure client safety. A labels. Suggestions include using rubber bands or textured
referral for skilled nursing visits is appropriate for homebound materials on certain containers or using bright colors to mark
older adults who need additional instructions about medica- the labels. Many simple-to-use medication management sys-
tion routines after discharge. tems, sometimes called pill organizers, are available. Often a
Education regarding medications must include a visual description family member is helpful in setting up weekly medication
of the drug; action, dose, and time of administration; instruc- management systems. For example, a family member may
tion whether food or liquid should accompany administration; set out the medications in specially designed containers
a list of potential side effects; and a telephone number of a weekly. This method enables others to monitor patterns and
health care provider to contact should side effects occur. adherence to the medication regimen and may be especially
Older people should be taught to carry in their wallet or purse a helpful when working with older people experiencing memory
current list of all their medications, dosages, times of adminis- impairments.
tration, and names of the prescribing provider. Should an
older client be found wandering or unconscious, evaluation
for possible medication adverse effects can happen more
quickly if he or she has such information readily available. CRITICAL THINKING E X E R C I S E S
Older people should use eyeglasses or hearing aids as needed to
1. The nurse is administering medications to a client. The
optimize their learning conditions. Other important considera-
tions for the teaching-learning environment are adequate client says, “I’ve never taken that little yellow pill before.”
nonglare lighting and little, if any, background noise. What actions are appropriate next?
Evaluation of comprehension may be best done by having the 2. A client who lives alone says, “You have to be a genius
older person repeat instructions after they are provided. to keep all these pills straight.” How could you help this
Reinforce verbal instructions with written instructions at the
client organize her medication regimen?
older person’s reading level. A copier may be used to enlarge
instructions for clients with visual impairments. Written instruc-
tions are particularly important for clients with hearing impair-
ments. They provide a reference for older adults with difficulty NCLEX-STYLE REVIEW Q U E S T I O N S
recalling or comprehending information. Additionally, written
instructions serve as a point of reference for caregivers who 1. When a nurse checks the medication administration
may assist with medication administration. record (MAR) and reads diphenoxylate hydrochloride,
The prescribing health care provider may be able to simplify a 5 mg p.o. q.i.d., how many times a day will he or she
complex medication regimen by prescribing a longer-acting administer the drug?
drug to decrease the frequency of administration or a medica- 1. Once a day
tion combination to decrease the number of pills the client 2. Every other day
must take at one time.
3. Three times a day
Older adults with insurance coverage for prescription payments
may find it easier and more economical to have prescriptions 4. Four times a day
filled every 3 months. It may also be more economical to 2. If a physician orders 250 mg of a drug, and it is supplied
purchase prescriptions by mail or Internet if the insurance in 500-mg tablets, which of the following nursing actions
provider approves this option. is best?
Encourage older adults to question the primary health care
1. Ask the pharmacist to provide 250 mg tablets
provider about prescribing generic forms of medication for
cost savings. instead.
Older adults who have problems with manual dexterity or 2. Consult the physician about the prescribed dose.
strength may request that pharmacists use nonchildproof caps 3. Give the client half of the 500 mg tablet.
on their prescription containers. 4. Check if the drug is manufactured in a smaller dose.
3. What action is best when a nurse brings medication to a 5. Which of the following techniques is incorrect when ad-
room for a client named Anna Jones, but the client in that ministering oral medication through a nasogastric tube
room is not wearing an identification bracelet? used to administer a tube feeding?
1. The nurse asks the client, “Are you Anna Jones?” 1. Crush the medication finely and mix it with 30 mL
2. The nurse asks the client, “What is your name?” of warm water.
3. The nurse asks a nursing assistant to identify the 2. Flush the nasogastric tube with 30 mL of water be-
client. fore instilling the drug.
4. The nurse asks the client, “What medications do 3. Add the liquefied medication to the bag of tube feed-
you take?” ing formula.
4. When a nurse observes that a client has difficulty swallow- 4. Flush the nasogastric tube with 30 mL of water after
ing a capsule of medication, which action is best to take? instilling the drug.
1. Soak the capsule in water until soft.
2. Tell the client to chew the capsule.
3. Empty the capsule in the client’s mouth.
4. Offer the client water before giving the capsule.
Skill 32-1 • ADMINISTERING ORAL MEDICATIONS
Assessment
Compare the medication administration record (MAR) Prevents medication errors
Review the client’s drug, allergy, and medical history. Avoids potential complications
Consult a current drug reference concerning the drug’s Ensures appropriate administration based on a thorough
action, side effects, contraindications, and knowledge base
administration information.
Planning
Plan to administer medications within 30 to 60 minutes of Demonstrates timely administration and compliance with
their scheduled time. the medical order
Allow sufficient time to prepare the medications in a Promotes safe preparation of drugs
location with minimal distractions.
Make sure that there is a sufficient supply of paper and Facilitates organization and efficient time management
plastic medication cups.
Chill oily medications. Reduces their unpleasant odor and improves palatability
Implementation
Wash your hands or perform an alcohol-based handrub Removes colonizing microorganisms
(see Chap. 10).
Read and compare the label on the drug with the MAR at Ensures that the right drug is given at the right time by the
least three times—before, during, and after preparing right route
the drug (Fig. A).
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 Supports principles of asepsis
plastic cup without touching the medication itself (Fig. B).
A B
Comparing the drug label and MAR. (Copyright B. Proud.) Pouring medication into a paper cup. (Copyright B. Proud.)
Keep drugs that require special assessments or Helps to identify drugs that require special nursing actions
administration techniques in a separate cup. (continued)
780 UNIT 9 ● Medication Administration
ADMINISTERING ORAL MEDICATIONS (Continued)
Pour liquids with drug label toward the palm of hand. Prevents liquid from running onto the label
Hold the cup for liquid medications at eye level when Facilitates accurate measurement
pouring.
Prepare a supply of soft-textured food such as applesauce Facilitates administration for clients with impaired
or pudding, according to the client’s individual needs. swallowing
Help the client to a sitting position. Facilitates swallowing and prevents aspiration
Identify the client by checking the wristband or asking the Ensures that medications are given to the right client
client’s name (Fig. C).
Offer a cup of water with solid forms of oral medications Water moistens mucous membranes and prevents
(Fig. D). medication from sticking.
C D
Checking the identification band. (Copyright B. Proud.) Offering the patient medication and water. (Copyright B. Proud.)
Advise the client to take medications one at a time or in Prevents choking

amounts easily swallowed.
Encourage the client to keep his or her head in a neutral Protects the airway
position or one of slight flexion, rather than
hyperextending the neck (Fig. E).
Remain with the client until he or she has swallowed the Ensures appropriate administration
medications.
Restore the client to a position of comfort and safety. Shows concern for the client’s well-being
1 2 3
(1) Inappropriate neck position; (2) and (3) appropriate

neck positions.
E
(continued)
ADMINISTERING ORAL MEDICATIONS (Continued)
Record the volume of fluid consumed on the intake and Demonstrates responsibility for accurate fluid assessment
output record.
Record the administration of the medication. Prevents medication errors
Assess the client in 30 minutes for desired and undesired Aids in evaluating the client’s response and effect of drug
drug effects. therapy
Evaluation
• The five rights are upheld.
• Client experiences no choking or aspiration.
• Client exhibits a therapeutic response to the medication.
• 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 Prevents medication errors
compare the information with the written medical order.
Verify the location of the tube by auscultating instilled air Ensures airway protection and proper placement
or aspirating secretions.
Compare the length of the external tube with its Determines if the tube has migrated
measurement at the time of insertion.
Inspect the client’s mouth and throat. Determines if the tube has been displaced and is coiled at
the back of the throat
(continued)
ADMINISTERING MEDICATIONS THROUGH AN ENTERAL TUBE (Continued)
Planning
the scheduled time. the medical order
Separate and clamp or plug a feeding tube for 15 to 30 Ensures that the stomach will be relatively empty
minutes if the drug will interact with food.
Make sure that there is a sufficient supply of plastic Facilitates organization and efficient time management
medication cups.
Implementation
(see Chap. 10).
the drug.
Prepare each drug separately. Prevents potential physical changes when some drugs are
combined
Take to the bedside the cups containing diluted Facilitates instillation
medications, water for flushing, a 30- to 50-mL syringe,
a towel or disposable pad, and clean gloves.
client’s name.
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 to 30 mL of Flushes and reduces the surface tension of the tube
water by gravity (Fig. A).
Add the diluted medication to the syringe as it becomes Prevents instilling air
nearly empty.
Apply gentle pressure with the plunger or bulb of a Provides positive pressure
syringe if the medication fails to instill easily.
Instilling medication. (Copyright B. Proud.)
A
(continued)
ADMINISTERING MEDICATIONS THROUGH AN ENTERAL TUBE (Continued)
Flush with at least 5 mL of water between each Prevents drug interactions and obstruction of the tube;
instillation of medication and as much as 30 mL after fully instills all the prescribed drug
instilling all the medications.
Pinch the tube as the syringe empties. Prevents distending the abdomen with air; maintains
patency of the tube
Clamp or plug the tube for 30 minutes before reconnecting Prevents removing the medication after it has been
a tube to suction (Fig. B). instilled
Plugging a gastric tube. (Copyright B. Proud.)
Connect a tube used for nourishment immediately if the Facilitates the primary purpose of the enteral tube
medication and formula will not interact.
Keep the head of the bed elevated for at least 30 minutes. Reduces the potential for aspiration
Evaluation
• Tube placement is verified.
• Medications instill freely and are flushed afterward.
• Client experiences no abdominal distention, nausea,
vomiting, or other undesirable effects.
• 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 out-
put record
Date and Time Placement of NG tube verified by auscultation. No evidence of tube migration. Medications adminis-
tered (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
783
33
Chapter
Topical and
Inhalant
Medications
LEARNING OBJECTIVES
● Explain how topical medications are administered.
● Give at least five examples of where topical medications commonly are applied.
● Give three examples of an inunction.
● Name two forms of drugs applied by the transdermal route.
● Discuss at least two principles nurses follow when applying a skin patch.
● Describe where eye medications are applied.
● Explain how the administration of ear medications differs for adults and children.
● Explain the rebound effect that accompanies the administration of nasal decongestants.
● Describe the difference between sublingual and buccal administration.
● Name a common reason for vaginal applications.
● Give the form of medication used most often for rectal administration.
● Explain why inhalation is a good route for medication administration.
● Describe the mechanism for creating an aerosol.
● Name two types of inhalers.
● Name a device that can maximize absorption of an inhaled medication.
DRUGS are administered by routes other than oral (see Chap. 32). This chapter describes
the techniques used to administer drugs by the topical and inhalant routes.
TOPICAL ROUTE
WORDS TO KNOW Drugs given by the topical route (administration of medications to the skin or mucous
aerosol
membranes) can be applied externally or internally (Table 33-1). Topically applied
buccal application drugs have a local or systemic effect. Many are administered to achieve a direct effect
cutaneous application on the tissue to which they are applied.
inhalant route
inhalers
inunction
metered-dose inhaler Cutaneous Applications
ophthalmic application
otic application are drugs rubbed into or placed in contact with the skin. They
Cutaneous applications
paste include inunctions and transdermal patches and pastes.
rebound effect
skin patches
spacer Inunction Application
sublingual application
topical route
An inunction is a medication incorporated into an agent (e.g., ointment, oil, lotion, cream)
transdermal application that is administered by rubbing it into the skin. Alert clients may self-administer an
turbo-inhaler inunction after receiving proper instruction. In that situation, the nurse teaches proper
784
C H A P T E R 33 ● Topical and Inhalant Medications 785
TABLE 33-1 TOPICAL MEDICATIONS

ROUTES LOCATION VEHICLE EXAMPLES
Cutaneous Skin Ointment hydrocortisone (Cortaid)

Scalp Cream benzocaine (Lanacane)
Scalp Liquid permethrin (Nix)
Skin Lotion Lubriderm*
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 Cepacol*
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)
*Indicates a nonprescription item that is a combination of ingredients.
application techniques and checks that the client has

applied the medication appropriately and as often as pre-
scribed. For clients who cannot apply their own inunc- Applying an Inunction
tions, the nurse does so. See Nursing Guidelines 33-1.
❙ Wash your hands or perform an alcohol-based handrub (see Chap. 10).
Hand hygiene removes colonizing microorganisms.
Transdermal Applications ❙ Check the identity of the client. Doing so prevents administering the
Drugs incorporated into patches or paste are administered medication to the wrong person.
as transdermal applications (method of applying a drug on ❙ Don clean gloves if your skin or that of the client is not intact.
the skin and allowing it to become passively absorbed). Gloves provide a barrier to pathogens.
After application, the drug migrates through the skin and ❙ Cleanse the area of application with soap and water. Clean skin
eventually is absorbed into the bloodstream. promotes absorption.
❙ Warm the inunction, if it will be applied to a sensitive area
SKIN PATCHES. Skin patches are drugs bonded to an adhe-
of the skin, by holding it temporarily in your hands or placing
sive bandage and applied to the skin (Fig. 33-1). Several the sealed container in warm water. Warmth promotes
drugs are now prepared in patch form, including nitro- comfort.
glycerin (used to dilate the coronary arteries), scopol- ❙ Shake the contents of liquid inunctions. Shaking mixes the contents
amine (used to relieve motion sickness), and estrogen
uniformly.
(hormone used to treat menopausal symptoms). Nico-
tine withdrawal therapy and contraceptive drugs also are
❙ Apply the inunction to the skin with the fingertips, a cotton ball, or a
gauze square. Correct application distributes the substance over a
available as skin patches.
wide area.
Skin patches are applied to any skin area with adequate
circulation. Most patches are applied to parts of the upper ❙ Rub the inunction into the skin. Rubbing promotes absorption.
body such as the chest, shoulders, and upper arms. Small ❙ Apply local heat to the area if desired (see Chap. 28). Heat dilates
patches can be applied behind the ear. Each time a new peripheral blood vessels and speeds absorption.
patch is applied, it is placed in a slightly different location.

Applying Nitroglycerin Paste
❙ Wash your hands or perform an alcohol-based handrub (see
Chap. 10). Hand hygiene removes colonizing microorganisms.
❙ Check the identity of the client. Doing so prevents administering
medication to the wrong person.
❙ Squeeze a ribbon of paste from the tube onto an application paper
(Fig. 33-2). This complies with the medication order, which usually
specifies the dose in inches.
❙ Fold the paper or use a wooden applicator to spread the paste over
approximately a 2.25 × 3.5-inch (5.6 × 8.8-cm) area of the paper.
These techniques facilitate distributing the drug over a wide area for
quick absorption.
❙ Do not touch the paste with your bare fingers. Touching the paste
could cause self-absorption of the drug.
❙ Place the application paper on a clean, nonhairy area of skin. Such
placement facilitates drug absorption.
FIGURE 33-1 • Pathway for absorption from a transdermal skin patch. ❙ Cover the paper with a square of plastic kitchen wrap or tape all the
edges of the paper to the skin. This seals the drug between the
paper and the skin.
Clipping extremely hairy skin areas before application ❙ Remove one application before applying another and remove any
may help adhesion. residue remaining on the skin. Careful application prevents
After application of the patch, it may take approxi- excessive drug levels.
mately 30 minutes for the drug to reach a therapeutic ❙ Rotate the sites of medication placement. Site rotation reduces the
level. Thereafter, the patch provides a continuous supply potential for skin irritation.
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 older patch is removed when
the new patch is applied. Stop • Think + Respond BOX 33-1
What actions should the nurse take if the tip of the
DRUG PASTE. A paste contains a drug within a thick base ophthalmic medication becomes contaminated?
and is applied but not rubbed into the skin. Nitroglycerin
can be applied as a paste. Although sometimes the prod-
uct is referred to as an ointment, the term is a misnomer Otic Applications
because the skin is not massaged once the drug is applied.
See Nursing Guidelines 33-2. An otic application is a drug instilled in the outer ear. It usu-
ally is administered to moisten impacted cerumen or instill
medications to treat a local bacterial or fungal infection.
Ophthalmic Applications
Ophthalmic application is a method of applying drugs onto

the mucous membrane of one or both eyes. It is described
in Skill 33-1. The mucous membrane of the eyes is called
the conjunctiva. It lines the inner eyelids and the anterior
surface of the sclera (Fig. 33-3).
Ophthalmic medications are supplied either in liq-
uid form and instilled as drops or as ointments applied
along the lower lid margin. Blinking, rather than rub-
bing, distributes the drug over the surface of the eye.
The eye is a delicate structure susceptible to infection
and injury, just like any other tissue. Therefore, nurses
take care to keep the applicator tip of the medication
container sterile. FIGURE 33-2 • Paste and applicator paper. (Copyright B. Proud.)
application (drug placed against the mucous membranes of

the inner cheek) is another method of drug administration.
When giving sublingual or buccal administrations,
nurses instruct clients not to chew or swallow the med-
ication. Eating and smoking also are contraindicated dur-
ing the brief time needed for the medication to dissolve.
Conjunctiva
over sclera
Conjunctiva
Vaginal Applications
Topical vaginal applications are used most often to treat

local infections, which are common and usually result
FIGURE 33-3 • Ophthalmic application sites. (Copyright B. Proud.)
from colonization of vaginal tissue by microorganisms
abundant in stool (e.g., yeasts). The microorganisms usu-
ally become transferred during bowel elimination if the
When instilling ear medication, the nurse first manip- client wipes stool from the rectal area toward (not away
ulates the ear to straighten the auditory canal. The tech- from) the vagina. Symptoms of a yeast infection include
nique varies depending on whether the client is a young intense vaginal itching and a white, cheeselike vaginal
child (the nurse pulls the ear down and back) or an adult discharge.
(the nurse pulls the ear up and back) (see Chap. 13). Several nonprescription drugs useful in treating vagi-
Tilting the client’s head away, the nurse instills the nal yeast infections are available in suppository, tablet,
prescribed number of drops of medication within the ear. and cream form. Early and appropriate self-treatment
The client remains in this position briefly as the solution restores normal tissue integrity. Providing clients with
travels toward the eardrum. The nurse can place a small instructions about how to administer vaginal medications
cotton ball loosely in the ear to absorb excess medication. for most effective action may be helpful. See Client and
He or she waits at least 15 minutes before instilling med- Family Teaching 33-1.
ication in the opposite ear, if a bilateral administration is If the client cannot self-administer vaginal medication,
prescribed. Briefly postponing the application within the the nurse wears gloves to avoid contact with secretions.
second ear avoids displacing the initially instilled med- After removing the gloves, handwashing or an alcohol-
ication when repositioning the client. based handrub is critical. The same advice holds true for
rectal applications.
Nasal Applications
Rectal Applications
Topical medications are dropped or sprayed within the
nose (Skill 33-2). Proper instillation is important to avoid Drugs administered rectally are usually in the form of sup-
displacing the medication into nearby structures such as positories (see Chap. 31); however, creams and ointments
the back of the throat. Adults often self-administer their also may be prescribed. The technique for using a rectal
own nasal medications, but sometimes nurses must assist applicator is similar to that for using a vaginal applicator.
older adults and children.
Nurses warn clients who use over-the-counter decon-
gestant nasal sprays that if they use the medication too
frequently or administer more than the recommended
INHALANT ROUTE
amount, a rebound effect (swelling of the nasal mucosa
within a short time of drug administration) can occur. The inhalant route administers drugs to the lower airways.
Clients can avoid rebound effect by following label direc- This method of medication administration is effective
tions or using nasal sprays containing only normal saline because the lungs provide an extensive area from which
solution. the circulatory system can quickly absorb the drug. To
distribute medication to the distal areas of the airways,
liquid medication is converted to an aerosol. An aerosol
Sublingual and Buccal Applications (mist) results after a liquid drug is forced through a nar-
row channel using pressurized air or an inert gas. Exam-
A tablet given by sublingual application (drug placed under ples of common household aerosol products are hairspray
the tongue) is left to dissolve slowly and become absorbed and furniture polish.
by the rich blood supply in the area. Some drugs in spray A simple method of administering aerosolized medica-
or liquid form also are administered sublingually. A buccal tions is through an inhaler. Inhalers are handheld devices
788 UNIT 9 ● Medication Administration
Administering Medications Vaginally • Separate the labia and insert the applicator into
The nurse teaches the client as follows: the vagina to the length recommended in the
package directions, usually 2 to 4 inches (5 to
• Obtain a form of medication based on personal 10 cm) (see Fig. B below).
preference; all come with a vaginal applicator • Depress the plunger once it reaches the
(see Fig. A below). proper distance within the vagina to insert
• Plan to instill the medication before going to the medication.
bed so that it can be retained for a prolonged • Remove the applicator and place it on a clean
period. tissue.
• Empty the bladder just before inserting the • Apply a sanitary pad if you prefer.
medication. • Remain recumbent for at least 10 to 30 minutes.
• Place the drug in the applicator. • Discard the applicator if it is disposable. Wash
• Lubricate the applicator tip with a water-soluble a reusable applicator with soap and water when
lubricant such as K-Y Jelly. you wash your hands.
• Lie down, bend your knees, and spread your legs. • Consult a physician if symptoms persist.
A B
for delivering medication into the respiratory passages. dered medication. The propellers are activated during
They consist of a canister containing the medication and inhalation. A metered-dose inhaler, much more common, is
a holder with a mouthpiece through which the aerosol is a canister that contains medication under pressure. The
inhaled (Fig. 33-4). inhaler is placed into a holder containing a mouthpiece;
There are two types of inhalers. A turbo-inhaler is a pro- when the container is compressed, a measured volume
peller-driven device that spins and suspends a finely pow- (metered dose) of aerosolized drug is released.
Clients who use metered-dose inhalers do not always
do so correctly. As a result, they may swallow, rather than
inhale, much of the medication. As a result, their respira-
tory symptoms may not be relieved. See Client and Fam-
ily Teaching 33-2.
Some clients find that the inhaled drug leaves an
Canister unpleasant aftertaste. Gargling with salt water may dimin-
Holder ish this. Drug residue may accumulate in the mouthpiece,
Mouthpiece so the client should rinse the mouthpiece in warm water
after use.
Clients who have problems coordinating their breath-
ing with inhaler use do not receive the full dose of aerosol.
A spacer (chamber attached to an inhaler; Fig. 33-6) may
be helpful in this situation. Spacers provide a reservoir
FIGURE 33-4 • Parts of an inhaler. for the aerosol medication. As the client takes additional
Using a Metered-Dose Inhaler

• Insert the canister into the holder.
• Shake the canister to distribute the drug in the
pressurized chamber.
• Remove the cap from the mouthpiece.
• Tilt your head back slightly and exhale slowly
through pursed lips.
• Open your mouth and place the inhaler 1 to
2 inches away (Fig. 33-5). If you have difficulty
with this method, place the inhaler in your
mouth and close your lips around the mouth-
piece.
FIGURE 33-6 • Using a metered dose inhaler with a spacer.
• Press down on the canister once to release the

medication. breaths, he or she continues to inhale the medication held
• As the medication is released, breathe in slowly in the reservoir. This tends to maximize drug absorption
through your mouth for approximately 3 to because it prevents drug loss. Some clients also find that
5 seconds. prolonging inhalation of the drug reduces side effects
• Hold your breath for 10 seconds to let the med- such as tachycardia or tremulousness.
ication reach your lungs.
• Exhale slowly through pursed lips.
• Wait 1 full minute before doing another inhala- NURSING IMPLICATIONS
tion if more than one is ordered.
• Clean the inhaler (holder and mouthpiece)
daily by rinsing it in warm water and weekly When administering topical or inhalant drugs, nurses
with mild soap and water. Allow the inhaler to often assess and take steps to maintain the integrity of
air-dry. Have another inhaler available to use the skin and mucous membranes. Health teaching may
while the first is drying. be important to prevent improper self-administration.
• Check the amount of medication in the canister Applicable nursing diagnoses may include the following:
by floating it in a bowl of water; the higher the
canister floats, the less medication it contains.
• Ineffective Therapeutic Regimen Management
• Obtain a refill of inhalant medication when the
• Impaired Gas Exchange
current canister shows signs of becoming
• Impaired Skin Integrity
empty.
• Impaired Tissue Integrity
Nursing Care Plan 33-1 shows how nurses use the steps
of the nursing process when managing the care of a client
with the diagnosis of Ineffective Breathing Patterns,
defined in the NANDA taxonomy (2005, p. 25) as “inspi-
ration and/or expiration that does not provide adequate
ventilation.”
CONSIDERATIONS
Some older people have difficulty instilling eye medications
independently. Devices are available that can diminish the
frequency of instillation or facilitate administration. For exam-
ple, one type of medication for glaucoma is inserted inside
FIGURE 33-5 • A metered-dose inhaler can be used by holding the the lower eyelid, requiring administration only every 7 days.
mouthpiece 1 to 2 inches away prior to depressing the canister and Sight Centers, which provide assistive devices for people with
inhaling, or the mouthpiece can be placed in the mouth and sealed by visual impairment, are a good resource for other devices that
lips prior to administering the drug. facilitate the instillation of eye drops.
Ineffective Breathing Patterns
ASSESSMENT
• Count the client’s respiratory rate for a full minute.
• Observe the client’s pattern of respirations such as effort, nasal or mouth breathing, position used to enhance breathing,
and use of accessory muscles.
• Establish if the client feels comfortable or anxious in regard to breathing.
• Measure hemoglobin saturation with a pulse oximeter.
• Determine techniques the client uses to restore quiet, effortless breathing.
Nursing Diagnosis: Ineffective Breathing Patterns related to 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 to 28 breaths per minute with correct
use of metered-dose inhaler.
Re-demonstrate the correct use of a metered-dose inhaler. Visual and verbal techniques enhance learning.
Observe client’s technique when using the metered-dose Observation provides a means for evaluating the client’s
inhaler at least four times after demonstration. level of understanding.
Monitor SpO2 with pulse oximeter before and after use of Results will help to evaluate the client’s technique using a
metered-dose inhaler. metered-dose inhaler and the drug’s effectiveness.

• Client is shown how to use metered-dose inhaler.
• Client has been observed to perform technique appropriately with each of two puffs from the inhaler.
• Breathing changes from 32 breaths per minute with effort and an SpO2 of 88% to 28 quiet breaths per minute and an SpO2
of 90% within 15 minutes of using the inhaler.
Older clients often require complex medication regimens for Onset of drug action may be atypical when administering topical
glaucoma that involve instillation of one or more types of medications to older adults because of their diminished sub-
drops up to four times daily. Recently, longer-acting medica- cutaneous fat, which leads to more rapid absorption of topical
tions have been developed that may be useful in decreasing medications.
the frequency of medication routines. Encourage the older Some older clients have difficulty reaching areas of the body to
person to collaborate with the prescribing practitioner on which topical drugs are applied. For example, arthritis may
ways to simplify the routine. interfere with applying medication within the vagina or rectum,
Some older adults use two or more types of eye medications once or to skin lesions on the lower extremities.
or several times daily. If the tops of the eye medications are The mechanics of inhaling and compressing an inhaler simultane-
not color coded, suggest ways to color-code the containers ously may be awkward for some older adults. Spacer devices help
to help distinguish the different medications. to compensate for less-than-optimal administration techniques.
When more than one eye medication is prescribed, it is common Sometimes two inhalers containing different drugs are prescribed.
to wait 5 minutes between instillation of eye drops. Older During teaching sessions, it is important to educate how and
adults can use a simple timer to serve as a reminder when when each drug is used, and the anticipated action. For exam-
the time period has elapsed. ple, one drug may act to expand the bronchioles and would
Eye medications can have adverse systemic effects and improve the overall outcome to be administered before a med-
interact with other medications, herbal supplements, ication that loosens secretions. Providing simple written instruc-
or both. tions, including illustrations, with each medication is also helpful.
Monitoring heart rate and blood pressure of older adults who use 2. Which instruction is best when teaching a client about
inhaled bronchodilators is important because these medications inserting vaginal medication?
commonly cause tachycardia and hypertension. Either or both 1. Place the applicator just inside the vaginal opening.
of these effects increase the risks for complications, especially 2. Insert the applicator while sitting on the toilet.
in older adults with underlying cardiovascular disease.
3. Instill the medication just before retiring for sleep.
4. Don disposable gloves before applying the drug.
CRITICAL THINKING E X E R C I S E S 3. The best technique for instilling eye drops is for the nurse
to dispense the medication
1. Before discharge from the hospital, a client who has had 1. Onto the cornea
a heart attack says, “You nurses always put my nitroglyc- 2. At the inner canthus
erin patches on my back. How can I do that when I have 3. At the outer canthus
to do it myself?” How would you respond? 4. In the conjunctival sac
2. How might you help a client who is legally blind and lives 4. The most appropriate nursing action before instilling ear
alone identify two different containers of eye medication? drops is to
1. Warm the medication to room temperature.
2. Refrigerate the medication for 30 minutes.
NCLEX-STYLE REVIEW Q U E S T I O N S 3. Clean the outer surface of the dropper.
1. The nurse is correct in instructing clients who use nose 4. Fill the dropper with no more than 1 mL.
drops that to promote accurate application, the best posi- 5. After instilling medication within an ear, what instruction
tion for instilling the medication is is most appropriate for the nurse to give the client?
1. Bending the head forward 1. Remain in position for at least 5 minutes.
2. Pushing the nose laterally 2. Pack a cotton pledget tightly in the ear.
3. Tilting the head backward 3. Don’t blow your nose for at least 1 hour.
4. Opening the mouth wide 4. Avoid drinking very warm or cold beverages.33-1
Skill 33-1 • INSTILLING EYE MEDICATIONS
Assessment
Planning
Allow sufficient time to prepare medications in a location Promotes safe preparation of drugs
with minimal distractions.
Warm eye drops and ointments by holding them between Promotes comfort
the hands if they have not been stored at room
temperature.
the drug.
Implementation
(see Chap. 10).
client’s name.
Position the client supine or sitting with the head tilted Prevents the drug from passing into the nasolacrimal duct
back and slightly to the side into which the medication or being blinked onto the cheek
will be instilled.
Don clean gloves. Acts as a barrier to pathogens in body fluids
Clean the lids and lashes if they contain debris. Use a Promotes comfort and maximizes the potential for
cotton ball or tissue moistened with water. absorption
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 Provides a natural reservoir for depositing liquid
downward over the bony orbit. medication
Move the container of medication from below the client’s Prevents a blink reflex
line of vision or from the side of the eye.
Steady the container above the location for instillation Prevents injury
without touching the eye surface.
(continued)
INSTILLING EYE MEDICATIONS (Continued)
Instill the prescribed number of drops into the appropriate Complies with the medical order by administering the
eye within the conjunctival pouch (Fig. A). right dose
If using ointment, squeeze a ribbon onto the lower lid Applies the ointment to the conjunctiva
margin (Fig. B).
A
B
Instilling eye drops. Instilling eye ointment.
Instruct the client to close the eyelids gently then blink Distributes the drug
several times.
Wipe the eyes with a clean tissue. Removes excess drug and promotes comfort
Evaluation
• The tip of the container remains uncontaminated.
• Sufficient 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
action, side effects, contraindications, and knowledge of the drug
Planning
the drug.
Implementation
(see Chap. 10).
client’s name.
Help the client to a sitting or lying position with his or her Facilitates depositing the drug where its effect is desired
head 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 Provides support and aids in positioning
client cannot sit.
Remove the cap from liquid medication to which a Provides a means for administering the drug
dropper usually is attached.
Aim the tip of the dropper toward the nasal passage and Deposits the drug within the nose rather than into the
squeeze the rubber portion of the cap to administer the throat and ensures administering the right dose
number of drops prescribed (Fig. A).
Instilling nasal medication.
A
(continued)
ADMINISTERING NASAL MEDICATIONS (Continued)
Instruct the client to breathe through the mouth as the Prevents inhaling large droplets
drops are instilled.
If the drug is in a spray form, place the tip of the container Confines the spray within the nasal passage
just 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 minutes.
Recap the container and replace where medications are Supports principles of asepsis and demonstrates
stored. responsibility for the client’s property
Evaluation
• Sufficient drug is distributed within the nose.
• Client reports decreased nasal congestion.
Document
• Assessment data
Date and Time Indicates nasal passages are congested. Observed to be breathing through the mouth. Nasal medi-cation
administered (see MAR). States symptoms are relieved. SIGNATURE/TITLE
34
Chapter
Parenteral
Medications
LEARNING OBJECTIVES
● Name three parts of a syringe.
● List five factors to consider when selecting a syringe and needle.
● Explain the rationale for redesigning conventional syringes and needles.
● Name three ways that pharmaceutical companies prepare parenteral drugs.
● Discuss an appropriate action before combining two drugs in a single syringe.
● List four injection routes.
● Identify common sites for intradermal, subcutaneous, and intramuscular injections.
● Name a type of syringe commonly used to administer an intradermal, subcutaneous, and
intramuscular injection.
● Describe the angles of entry for intradermal, subcutaneous, and intramuscular injections.
● Discuss why most insulin combinations must be administered within 15 minutes of
being mixed.
● Describe two techniques for preventing bruising when administering heparin subcutaneously.
WORDS TO KNOW THE parenteral route means a route of drug administration other than oral or through
ampule the gastrointestinal tract. This term commonly is used when referring to medications
barrel given by injection. This chapter discusses techniques for administering injections.
deltoid site Preparation and administration of injections follow the principles of asepsis and
dorsogluteal site
gauge
infection control.
induration
insulin syringe
intradermal injection
intramuscular injection PARENTERAL ADMINISTRATION EQUIPMENT
intravenous injection
lipoatrophy
lipohypertrophy The major equipment used to administer parenteral drugs consists of a syringe and a
parenteral route needle. Numerous types of syringes and needles are available.
plunger
prefilled cartridge
reconstitution
rectus femoris site Syringes
scoop method
shaft
subcutaneous injection All syringes contain a barrel (part of the syringe that holds the medication), a plunger
tip (part of the syringe within the barrel that moves back and forth to withdraw and instill
tuberculin syringe the medication), and a tip or hub (part of the syringe to which the needle is attached;
vastus lateralis site Fig. 34-1). Syringes are calibrated in milliliters (mL) or cubic centimeters (cc),
ventrogluteal site
vial
units (U), and, in some cases, minims (m). When drugs are administered parenterally,
wheal syringes that hold 1 mL, or its equivalent in units, and up to 3 to 5 mL are used most
Z-track technique commonly.
796
C H A P T E R 34 ● Parenteral Medications 797
FIGURE 34-1 • Parts of a syringe.
Needles
Needles are supplied in various lengths and gauges. The

shaft (length of the needle) depends on the depth to which
the medication will be instilled. Needle lengths vary from A B
approximately 0.5 to 2.5 inches. The tip of the shaft is FIGURE 34-2 • Safety injection devices. (A) Syringe with a circular
beveled, or slanted, to pierce the skin more easily (see sleeve that covers the needle. (B) Syringe with an articulated levered
Skill 16-3, Starting an Intravenous Infusion). Filter nee- shield that glides over the needle after it is used.
dles that provide a barrier for glass particles are available
when withdrawing medication from a glass ampule. medications without needles. Most health agencies already
The needle gauge (diameter) refers to its width. For are using one or several types of modified equipment to
most injections, 18- to 27-gauge needles are used; the enclose or cover the needle. Some syringes contain blunt
smaller the number, the larger the diameter. For exam- substitutes for needles that can pierce laser-cut rubber ports.
ple, an 18-gauge needle is wider than a 27-gauge needle. Twenty-one states now require safety needles or needle-
A wider diameter provides a larger lumen, or opening, less devices for administering medications and withdraw-
through which drugs are administered into the tissue. ing bodily fluids since California enacted legislation for
Several factors are considered when selecting a syringe using safer needles in 1998 (National Institute for Occu-
and needle: pational Safety and Health, 2002).
If modified safety injection devices are not available,
• Type of medication two techniques are used with standard equipment to pre-
• Depth of tissue vent needlestick injuries. Before administering an injection,
• Volume of prescribed drug the protective cap covering a needle is replaced by using the
• Viscosity of the drug scoop method (technique of threading the needle within the
• Size of the client cap without touching the cap itself; Fig. 34-3). After admin-
Table 34-1 lists common sizes of syringes and needles istering an injection, the needle is left uncapped and depos-
used for various types of injections. ited in the nearest biohazard container, which is usually
at the client’s bedside.
Should an accidental injury occur, health care workers
should follow these recommendations:
Modified Safety Injection Equipment
• Report the injury to a supervisor.
Conventional syringes and needles are being redesigned to • Document the injury in writing.
avoid needlestick injuries and thus to reduce the risk for • Identify the client if possible.
acquiring a blood-borne viral disease such as hepatitis or • Obtain HIV and hepatitis B virus client status results,
AIDS. Currently there are three different safety injection if it is legal to do so.
devices: (1) those with plastic shields that cover the nee- • Obtain counseling on the potential for infection.
dle after use (Fig. 34-2), (2) those with needles that retract • Receive the most appropriate postexposure drug treat-
into the syringe, and (3) gas-pressured devices that inject ment prophylaxis.
TABLE 34-1 COMMON SIZES OF SYRINGES AND NEEDLES

TYPE OF INJECTION SIZE OF SYRINGE SIZE OF NEEDLE
Intradermal (tuberculin) 1 mL calibrated in 0.01 mL or in minims 25-, 26-, or 27-gauge, 1⁄2- to 5⁄8-inch
Subcutaneous 1, 2, 2.5, or 3 mL calibrated in 0.1 mL 23-, 25-, or 26-gauge, 1⁄2- or 5⁄8-inch
Insulin, given subcutaneously 1 mL calibrated in units 25-, 26-, or 27-gauge, 1⁄2- or 5⁄8-inch
Intramuscular 3 or 5 mL calibrated in 0.2 mL 20-, 21-, 22-, or 23-gauge, 11⁄2- or 2-inch

Withdrawing Medication From an Ampule
❙ Select an appropriate syringe and filter needle. Proper equipment
ensures appropriate drug administration and prevents aspirating
glass particles within the barrel of the syringe.
❙ Tap the top of the ampule. Tapping distributes all the medication
to the lower portion of the ampule.
❙ Protect your thumb and fingers with a gauze square or alcohol
swab. These devices reduce the potential for injury.
❙ Snap the neck of the ampule away from your body. Doing so avoids
accidental injury.
❙ Insert the filter needle into the ampule. Avoid touching the outside
of the ampule. These methods ensure sterility of the needle.
FIGURE 34-3 • Scoop method for covering a needle. (Copyright
B. Proud.) ❙ Invert the ampule (Fig. 34-5). Inversion facilitates withdrawing
medication.
❙ Pull back on the plunger. This step fills the syringe.
• Be tested for the presence of antibodies at appropriate ❙ Remove the needle from the ampule when a sufficient volume has
intervals.
been withdrawn. This prepares for drug administration.
• Monitor for potential symptoms and obtain medical
follow-up. ❙ Tap the barrel of the syringe near the hub. Tapping moves air
toward the needle.
❙ Push carefully on the plunger. Pushing expels air or excess
DRUG PREPARATION medication.
❙ Empty the unused portion of medication from the syringe. Doing so
prevents illegal drug use.
Drug preparation involves withdrawing medication from
an ampule or vial or assembling a prefilled syringe car- ❙ Discard the glass ampule in a puncture-resistant container. Proper
tridge (Fig. 34-4). disposal prevents accidental injury.
❙ Scoop the needle within its protective cap or extend a guard that
recesses the needle. These measures reduce the risk of a needlestick
Ampules injury.
❙ Remove the filter needle and attach a sterile needle for
An ampule (sealed glass drug container) must be broken to administering the injection. These techniques prevent injecting glass
withdraw the medication. See Nursing Guidelines 34-1. particles into the client.
Vials
A vial (glass or plastic container of parenteral medication

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 doses. Any unused drug is dated before it is
stored for future use. See Nursing Guidelines 34-2.
Usually drugs in vials are in liquid form, but sometimes
they are supplied as powders that must be dissolved.
Reconstitution (process of adding liquid, known as diluent,
to a powdered substance) is done before administering the
drug parenterally. Common diluents for injectable drugs
are sterile water or sterile normal saline. Reconstituting a
drug just before it is needed ensures maximum potency.
FIGURE 34-4 • Ampule, vial, and prefilled cartridge. (Copyright When reconstitution is necessary, the drug label lists the
B. Proud.) following:
FIGURE 34-6 • Withdrawing drug from a vial.

FIGURE 34-5 • Withdrawing drug from an ampule.
• Type of diluent to use

• Amount of diluent to add
Withdrawing Medication From a Vial • Dosage per volume after reconstitution
• Directions for storing the drug
❙ Select an appropriate syringe and needle. Correct equipment
ensures appropriate drug administration. If the medication will be used for more than one admin-
❙ Remove the metal cover from the rubber stopper. This step facilitates istration, the preparer writes the date and time on the vial
inserting the needle or needleless adaptor. label and initials it. In some cases, when the directions
❙ Clean a pre-opened vial with an alcohol swab. Alcohol swabs
provide several options in diluent volumes, the preparer
remove colonizing microorganisms. also writes the amount on the vial.
❙ Fill the syringe with a volume of air equal to the volume that will be
withdrawn from the vial. This step provides a means for increasing
pressure within the vial.
Prefilled Cartridges
❙ Pierce the rubber stopper with the needle or tip of a needleless Pharmaceutical companies supply some drugs in a pre-
syringe and instill the air. Doing so facilitates drug withdrawal.
filled cartridge (sealed glass cylinder of parenteral medica-
❙ Invert the vial, hold, and brace it while pulling on the plunger tion). The cartridge comes with an attached needle. The
(Fig. 34-6). This step locates medication near the tip of the needle or cylinder is made so that it fits in a specially designed
needleless adaptor to facilitate its withdrawal. syringe (Fig. 34-7).
❙ Remove the needle or adaptor when the desired volume has entered
the barrel of the syringe. Doing so leaves remaining drug for
additional administrations.
❙ If the medication is a controlled substance such as a narcotic, aspi-
rate the entire contents from the vial. Full aspiration prevents illegal
drug use.
❙ Discard any excess medication; if the drug is a narcotic, have
someone witness this action. These measures comply with federal
laws to prevent illegal drug use.
❙ Cover the needle or needleless adaptor and care for used supplies
as described in the guidelines for withdrawing from an ampule.
Nurses follow aseptic and safety principles.
❙ Date and initial the vial if the remaining drug will be used in the
near future. Doing so supports principles of asepsis.
FIGURE 34-7 • Inserting a prefilled cartridge. (Copyright B. Proud.)
Combining Medications in One Syringe ing a half-inch in length commonly is used when admin-
istering an intradermal injection.
Sometimes it is necessary or appropriate to combine more
than one drug in a single syringe. Exact amounts must Injection Technique
be withdrawn from each drug container because once the When giving an intradermal injection, the nurse instills
drugs are in the barrel of the syringe, there is no way to the medication shallowly at a 10- to 15-degree angle of
expel one without also expelling some of the other (see
entry (Skill 34-1).
the discussion on mixing insulins). Before mixing any
drugs, however, the nurse consults a drug reference or
compatibility chart because some drugs interact chemi- Stop • Think + Respond BOX 34-1
cally when combined. The chemical reaction often causes
a precipitate to form. What actions are appropriate if the client shows signs of
an allergic reaction to the agent given intradermally?
INJECTION ROUTES
Subcutaneous Injections
There are four injection routes for parenteral adminis-
A subcutaneous injection is administered more deeply
tration: intradermal injections (between the layers of the
skin), subcutaneous injections (beneath the skin but above than an intradermal injection. Medication is instilled be-
the muscle), intramuscular injections (in muscle tissue), tween the skin and muscle and absorbed fairly rapidly:
and intravenous injections (instilled into veins; Fig. 34-8). the medication usually begins acting within 15 to 30 min-
Each site requires a slightly different injection technique. utes of administration. The volume of a subcutaneous
Intravenous medication administration is discussed in injection is usually up to 1 mL. The subcutaneous route
Chapter 35. commonly is used to administer insulin and heparin.
Injection Sites
Intradermal Injections The preferred site for giving a subcutaneous injection of
insulin and heparin is the abdomen. When using the
Intradermal injections are commonly used for diagnostic
abdomen, avoid a 2-inch central area around the umbili-
purposes. Examples include tuberculin tests and allergy
cus. Additional or alternative injection sites for insulin
testing. Small volumes, usually 0.01 to 0.05 mL, are injected
are the outer back area of the upper arm, where it is
because of the small tissue space.
fleshier, and outer areas of the thigh and upper buttocks
Injection Sites (Fig. 34-10).
Rotating within one injection site, preferably the abdo-
A common site for an intradermal injection is the inner men, is recommended rather than rotating to a different
aspect of the forearm. Other areas that may be used are area with each injection (American Diabetes Associa-
the back and upper chest. tion, 2003). Injection sites are rotated a finger’s width
apart (about 1 inch) from a previous site to avoid repeat-
Injection Equipment edly injecting into the same area in a short amount of
A tuberculin syringe holds 1 mL of fluid and is calibrated in time. Rotating sites avoids tissue injury. The rate of drug
0.01-mL increments (Fig. 34-9). It is used to administer absorption at various subcutaneous sites from fastest to
intradermal injections. A 25- to 27-gauge needle measur- slowest is abdomen, arms, thighs, and buttocks.
FIGURE 34-8 • Injection routes: intradermal (A), subcutaneous (B), intramuscular and subcutaneous in
other than thin persons (C), and intravenous (D).
Injection Equipment
Equipment used for a subcutaneous injection may depend
on the type of medication prescribed. Insulin is prepared
in an insulin syringe (see section on administering in-
sulin). Heparin is prepared in a tuberculin syringe, or it
may be supplied in a prefilled cartridge. A 25-gauge nee-
dle is used most often because medications administered
subcutaneously usually are not viscous. Needle lengths
may vary from 1⁄2 to 5⁄8 inch.
Injection Technique
To reach subcutaneous tissue in a normal-sized or obese
person who has a 2-inch tissue fold when it is bunched,
the nurse inserts the needle at a 90-degree angle. For thin
clients who have a 1-inch fold of tissue, the nurse inserts
the needle at a 45-degree angle (Rushing, 2004). Skill 34-2
describes the technique for administering a subcutaneous
injection.
The tissue usually is bunched between the thumb and
fingers before administering the injection to avoid instill-
ing 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.
Administering Insulin
Insulin is a hormone required by some clients with dia-
betes. The most common route for administration is sub-
FIGURE 34-9 • A tuberculin syringe. cutaneous or intravenous injection; however, an inhaled
FIGURE 34-10 • Subcutaneous

injection sites.
FIGURE 34-11 • Angles and needle lengths for subcutaneous

injections.
form of insulin called Exubera has been recently been ap-

proved. Injectable insulin is supplied and prescribed in a
dosage strength called units; a special syringe called an
insulin syringe (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 100 units per mL.
Typically, low-dose insulin syringes are used to deliver
insulin dosages of 30 to 50 units or less. A standard in-
sulin syringe can administer up to 100 units of insulin FIGURE 34-12 • Low-dose and standard insulin syringes.
(Fig. 34-12).
Clients who require insulin receive one or more daily
injections. Over time, the injection sites tend to undergo than rapid-acting and short-acting insulin or the long-
changes that interfere with insulin absorption. To avoid acting insulin glargine (Lantus), the nurse rotates the
lipoatrophy (breakdown of subcutaneous fat at the site of vial between the palms to redistribute the additive and
repeated insulin injections) and lipohypertrophy (buildup insulin before filling the syringe.
of subcutaneous fat at the site of repeated insulin in-
jections), the sites are rotated each time an injection is
MIXING INSULINS. When mixed together, insulins tend
administered.
to bind and become equilibrated. This means that the
unique characteristics of each are offset by those of the
other. For this reason, most types of insulin are com-
Stop • Think + Respond BOX 34-2 bined just before administration. When injected within
In addition to documenting the site of an insulin injection, 15 minutes of being combined, they act as if they had
discuss additional techniques for ensuring rotation of sites been injected separately. Rapid-acting insulin and
with each subsequent injection. short-acting insulin, which are additive-free, often are
combined with an intermediate-acting insulin. The long-
acting insulin, glargine, is never mixed with any other
type of insulin. See Nursing Guidelines 34-3.
PREPARING INSULIN. Types of insulin vary in their onset, Pharmaceutical companies provide some combina-
peak effect, and duration of action. The nurse must read tions of insulin premixed in a single vial. Novolin 70/30
the vial labels carefully because they look similar. contains 70% of an intermediate-acting insulin and 30%
Some preparations of insulin contain an additive that of a short-acting insulin. Humulin 50/50 contains equal
delays its absorption. Insulin and the additive tend to amounts of intermediate-acting and short-acting insulins.
separate on standing. Therefore, when preparing other Commercially premixed insulins are stable and can be

Mixing Insulins
❙ Roll the vial of insulin containing an additive between the palms.
Rolling between the palms mixes the insulin without damaging the
protein molecules.
❙ Cleanse the rubber stoppers of both vials of insulin. Cleaning
removes colonizing microorganisms. Vial A
Vial B
❙ Instill an amount of air equal to the volume that will be withdrawn
from the vial containing the insulin with the additive. Do not insert
the needle into the insulin itself (Fig. 34-13). These measures avoid
coating the needle.
❙ Withdraw the needle and use the same syringe to repeat the above
step, but this time invert and withdraw the prescribed number of A
additive-free insulin units (see Fig. 34-13). Clear insulin is always
placed in the syringe before adding the cloudy insulin to avoid
altering the additive-free insulin within the vial.
❙ Ask another nurse to check the label on the insulin and the number
of units in the syringe. An additional check helps to prevent a
medication error.
❙ Swab the rubber stopper of the other vial and pierce it with the
needle of the partially filled syringe. This step facilitates
withdrawing the other type of insulin.
Vial B Vial A
❙ Withdraw the specified number of units from the vial containing the
insulin with the additive. Doing so prepares the full prescribed dose.
❙ Ask another nurse to check the label on the insulin and the number
of units in the syringe. This step prevents a medication error.
❙ Administer within 15 minutes of mixing. Prompt administration
avoids equilibration.
B
administered without concern for time after withdrawal

from the vial.
Vial B
Administering Heparin
Heparin is an anticoagulant drug, meaning that it prolongs
the time it takes for blood to clot. Heparin frequently is
administered subcutaneously as well as intravenously. Its
unique characteristics require special techniques when
using the subcutaneous route for administration.
Heparin is supplied in multiple-dose vials or prefilled
cartridges. The dosages are very small volumes that may
require a tuberculin syringe to ensure accuracy. The
nurse removes the needle after withdrawal of the drug C
from a multidose vial and replaces it with another before
FIGURE 34-13 • Mixing insulin. (A) Instilling air into vial with additive
administration. insulin. (B) Instilling air. (C) Withdrawing from additive-free insulin vial.
Certain modifications are necessary to prevent bruising
in the area of the injection. The nurse changes the needle
before injecting the client. He or she rotates the sites with Intramuscular Injections
each injection to avoid a previous area where there has
been local bleeding. The nurse does not aspirate the An intramuscular injection is the administration of up
plunger once the needle is in place. Massaging the site is to 3 mL of medication into one muscle or muscle group.
contraindicated because this can increase the tendency for Because deep muscles have few nerve endings, irritating
local bleeding. medications commonly are given intramuscularly. Except
for medications injected directly into the bloodstream, gluteal site: it has no large nerves or blood vessels, and it
absorption from an intramuscular injection occurs more is usually less fatty and cleaner because fecal contamina-
rapidly than from the other parenteral routes. tion is rare at this site. The ventrogluteal site is also safe
for use in children.
Injection Sites To locate the ventrogluteal site:
The five common intramuscular injection sites are named • Place the palm of the hand on the greater trochanter
for the muscles into which the medications are injected: and the index finger on the anterior-superior iliac spine
dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, (Fig. 34-15).
and deltoid. • Move the middle finger away from the index finger as
far as possible along the iliac crest.
DORSOGLUTEAL SITE. The dorsogluteal site is the upper • Inject into the center of the triangle formed by the
outer quadrant of the buttocks and is a common location index finger, middle finger, and iliac crest.
for intramuscular injections. The primary muscle in this
site is the gluteus maximus, which is large and therefore VASTUS LATERALIS SITE. The vastus lateralis site uses the
can hold a fair amount of injected medication with mini- vastus lateralis muscle, one of the muscles in the quadri-
mal postinjection discomfort. This site is avoided in clients ceps group of the outer thigh. Large nerves and blood ves-
younger than 3 years because their muscle is not suffi- sels usually are absent in this area, which makes it safer.
ciently developed. It is a particularly desirable site for administering injec-
If the dorsogluteal site is not identified correctly, tions to infants and small children and clients who are
damage to the sciatic nerve with subsequent paralysis of thin or debilitated with poorly developed gluteal muscles.
the leg can result. To locate the appropriate landmarks The nurse locates the vastus lateralis site by placing one
(Fig. 34-14): hand above the knee and one hand just below the greater
trochanter at the top of the thigh (Fig. 34-16). He or she
• Divide the buttock into four imaginary quadrants. then inserts the needle into the lateral area of the thigh
• Palpate the posterior iliac spine and the greater (Fig. 34-17).
trochanter.
• Draw an imaginary diagonal line between the two RECTUS FEMORIS SITE. The rectus femoris site is in the
landmarks. anterior aspect of the thigh. This site may be used for
• Insert the needle superiorly and laterally to the mid- infants. The nurse places an injection in this site in the
point of the diagonal line. middle third of the thigh, with the client sitting or supine
(Fig. 34-18).
VENTROGLUTEAL SITE. The ventrogluteal site uses the glu-
teus medius and gluteus minimus muscles in the hip for DELTOID SITE. The deltoid site in the lateral aspect of the
injection. This site has several advantages over the dorso- upper arm (Fig. 34-19) is the least-used intramuscular
Greater trochanter of the femur

(not illustrated) Superior gluteal artery
Gluteus maximus Gluteus medius
Sciatic nerves
Posterior-superior iliac spine
FIGURE 34-14 • Dorsogluteal site. (Courtesy

of Wyeth Laboratories, Philadelphia.)
Ventrogluteal area Anterior-superior Iliac crest

(in triangle) iliac spine (not illustrated)
FIGURE 34-15 • Ventrogluteal site. (Courtesy of Greater trochanter of Posterior edge iliac crest
Wyeth Laboratories, Philadelphia.) the femur
injection site because it is a smaller muscle than the Injection Technique

others. It is used only for adults because the muscle is not
When administering intramuscular injections, nurses
sufficiently developed in infants and children. Because of
use a 90-degree angle for piercing the skin (Skill 34-3).
its small capacity, intramuscular injections into this site
Nurses may administer drugs that may be irritating to
are limited to 1 mL of solution.
the upper levels of tissue by the Z-track technique (tech-
There is a risk for damaging the radial nerve and
nique for manipulating the tissue to seal medication,
artery if the deltoid site is not well identified. To use this
especially an irritant, in the muscle). Sometimes called
site safely: the zigzag technique, the maneuver resembles the letter
• Have the client lie down, sit, or stand with the shoulder Z. See Nursing Guidelines 34-4.
well exposed. Nurses can give any intramuscular injection by the
• Palpate the lower edge of the acromion process. Z-track technique. Clients report slightly less pain dur-
• Draw an imaginary line at the axilla. ing and the next day after a Z-track injection compared
• Inject in the area between these two landmarks. with the usual intramuscular injection technique.
Injection Equipment Stop • Think + Respond BOX 34-3

Generally, 3- to 5-mL syringes are used to administer med- What could occur if parenteral medication intended for
ications by the intramuscular route. A 22-gauge needle the intramuscular route is instilled into a blood vessel?
that is 1.5 to 2 inches long usually is adequate for deposit- How could this be prevented?
ing medication in most sites.
FIGURE 34-16 • Locating the vastus lateralis muscle. (Copyright FIGURE 34-17 • Spreading the skin at the vastus lateralis site and
B. Proud.) darting the tissue. (Copyright B. Proud.)

Giving an Injection by Z-Track Technique
❙ Fill the syringe with the prepared drug, then change the needle. This
measure prevents tissue contact with the irritating drug.
❙ Attach a needle at least 1.5 to 2 inches long. Correct length helps to
deposit the drug deep within the muscle.
❙ Add a 0.2-mL bubble of air in the syringe. Air flushes all the
medication from the syringe during the injection.
❙ Select a large muscular injection site such as the ventrogluteal site.
A large site provides a location with the capacity for depositing and
absorbing the drug.
❙ Wash your hands and don gloves. These measures reduce
transmission of microorganisms.
FIGURE 34-18 • Location of rectus femoris injection site. (Craven, R. F.,
& Hirnle, C. J. [2007]. Fundamentals of nursing [5th ed., p 592]. ❙ Use the side of the hand to pull the tissue laterally about 1 inch
Philadelphia: Lippincott Williams & Wilkins.) (2.5 cm) until the tissue is taut (Fig. 34-20). Taut tissue creates the
mechanism for sealing the drug within the muscle.
❙ Insert the needle at a 90-degree angle while continuing to hold the
tissue laterally. Correct placement directs the tip of the needle well
REDUCING INJECTION DISCOMFORT within the muscle.
❙ Steady the barrel of the syringe with the fingers and use the thumb
All injections cause discomfort, and some cause more than to manipulate the plunger (see Fig. 34-20). These measures avoid
releasing the tissue held taut by the nondominant hand.
others. A few products are available that produce anesthe-
sia when applied to the skin or mucous membranes. One ❙ Aspirate for a blood return. Doing so determines whether or not the
example is EMLA (eutectic mixture of local anesthetic), needle is in a blood vessel.
which reduces or eliminates the local discomfort of inva- ❙ Instill the medication by depressing the plunger with the thumb.
sive procedures that pierce the skin. It can take 60 to This measure deposits the medication into the muscle.
120 minutes after application for EMLA cream to take ❙ Wait 10 seconds with the needle still in place and the skin held
effect. Because these time constraints make EMLA imprac- taut. This duration provides time to distribute the medication in a
tical for most situations when time is of the essence in larger area.
administering an injection, the nurse can use the follow- ❙ Withdraw the needle and immediately release the taut skin. Doing
ing alternative techniques to reduce discomfort associated so creates a diagonal path that prevents leaking into the
with injections: subcutaneous and dermal layers of tissue (see Fig. 34-20).
❙ Apply pressure but do not massage the site. This ensures that the
• Use the smallest-gauge needle that is appropriate.
medication remains sealed.
• Change the needle before administering a drug that is
irritating to tissue. ❙ Discard the syringe without recapping the needle. Proper disposal
reduces the potential for needlestick injury.
❙ Remove gloves and wash your hands or perform an alcohol-based
handrub. These measures reduce the transmission of
microorganisms.
❙ Document the medication administration. Proper recording
maintains a current record of client care.
X
• Select a site that is free of irritation.

• Rotate injection sites.
• Numb the skin with an ice pack before the injection.
• Insert and withdraw the needle without hesitation.
• Instill the medication slowly and steadily.
• Use the Z-track method for intramuscular injections.
• Apply pressure to the site during needle withdrawal.
FIGURE 34-19 • Deltoid site. • Massage the site afterward, if appropriate.
A B C
FIGURE 34-20 • (A) Stretching tissue laterally. (B) Manipulating the plunger. (C) Interrupted pathway to
sealed medication.
The client also can assist in minimizing the pain asso- GENERAL GERONTOLOGIC
ciated with injections. Instructions commonly focus on CONSIDERATIONS
positioning and relaxation techniques. See Client and
Family Teaching 34-1. Pinching the muscular tissue together may be needed to avoid
striking bone when administering an intramuscular injection,
if the older person has decreased subcutaneous fat.
Older clients with diabetes often have visual problems interfering
NURSING IMPLICATIONS with their ability to self-administer insulin. Collaborate with the
prescribing practitioner about teaching clients who are visually
impaired how to use a loading gauge that prevents filling a
Nurses who administer parenteral medications may iden-
syringe with more than the prescribed dose. Sight Centers are
tify nursing diagnoses such as the following: a good resource for obtaining assistive devices to facilitate
self-administration of insulin.
• Acute Pain
Older adults learning to administer insulin may benefit from a
• Anxiety referral for skilled nursing or diabetic health education fol-
• Fear lowing discharge. Health insurance companies sometimes
• Risk for Trauma reimburse such services.
• Deficient Knowledge Older clients who can administer insulin injections but cannot fill
• Ineffective Therapeutic Regimen Management their own syringes may choose to use prefilled syringes or an
insulin pen. The person should be taught to roll the prefilled
Nursing Care Plan 34-1 demonstrates the nursing process syringe gently to mix the insulin solution before administering
for a client with the nursing diagnosis Ineffective Thera- the injection.
Age-related changes and possible chronic diseases may impair the
peutic Regimen Management, defined in the NANDA older person’s ability to absorb and metabolize medications.
taxonomy (2005, p. 198) as “a pattern of regulating and A lower dose of parenteral medications may be indicated to
integrating into daily living a program for treatment of ill- prevent adverse effects.
ness and the sequelae of illness that is unsatisfactory for Injections should not be administered into limbs that are paralyzed,
meeting specific health goals.” inactive, or affected by poor circulation. If an older client has
had a mastectomy or has a vascular site for hemodialysis, the
arm on the affected side should be avoided, if possible.
The deltoid or ventrogluteal muscles may be the preferred intra-
muscular sites for older adults experiencing impaired mobility.
34-1 • CLIENT AND FAMILY TEACHING The dorsogluteal site should be avoided because of the risk for
damage to the sciatic nerve with diminished musculature.
Reducing Injection Discomfort Selection and identification of injection site landmarks may
The nurse teaches the client and family as follows: be difficult when working with older adults experiencing
dementia or musculoskeletal deformities such as contractures.
• Lie prone and point the toes inward when Assistance from a second person to maintain the required
receiving an injection into the dorsogluteal site. position for an injection may be helpful. An explanation of
• Perform deep breathing and other relaxation what will be done is always indicated before the intervention.
The second person may be able to assist with providing
techniques before receiving an injection.
comfort.
• Avoid watching when the injection is given. Assessment for an adverse drug effect should be considered
• Ambulate or move the extremity where the when any change in mental status or behavior coincides with
injection was given as much as possible. administration of a new medication.
Risk for Ineffective Therapeutic Regimen Management
ASSESSMENT
• Determine the client’s desire to learn about his or her illness.
• Assess the client’s ability and interest in managing the disorder.
• Review the client’s history for evidence that complications developed from mismanagement of his or her disorder.
• Consider the complexity of self-care skills necessary after the client is discharged.
• Identify any problems that may pose a barrier to carrying out a regimen of self-care (e.g., dementia, physical weakness,
pain, diminished self-confidence).
• Explore any health beliefs that may cause conflict in achieving the goals of therapy.
• Inquire about the client’s financial resources for complying with the health care regimen.
• Observe the client’s network of significant others and their potential for providing physical and emotional support.
• Evaluate the client’s level of understanding of ongoing health teaching throughout the period of nursing care.
Nursing Diagnosis: Risk for Ineffective Therapeutic Regimen 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
insulin administration and ways to raise blood glucose level if symptoms of hypoglycemia
develop.
Review onset, peak, and duration of Humulin N insulin Repetition of information enhances learning.
each morning when administering the client’s dose of
insulin.
Emphasize that breakfast is provided within 30 minutes of Demonstrating a regular pattern between administering
administration of the prescribed dose of insulin. 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
level before and 2 hours after meals. of 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
ask client to recall as many signs and symptoms as accurately recall the information measure the client’s
possible. learning
Give the client a list of foods or beverages that can raise Identifying techniques for resolving the problem of low
blood glucose level when signs or symptoms of low blood blood glucose level provides the client with options for
glucose level occur. managing self-care.

• Client noted time of insulin administration at 0730 and delivery of breakfast at 0745.
• Client stated, “I will eat a meal within a half hour of giving 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.
• Client named grape juice, orange juice, graham crackers, and milk as foods or beverages to consume if she experienced
symptoms of low blood glucose level.
3. The nurse is administering an injection using the Z-track

technique. Just before inserting the needle into the mus-
1. How does administration of an intramuscular injection cle, the nurse is correct to pull the tissue at the injection site
differ for a 3-year-old versus a 33-year-old? 1. Laterally
2. Diagonally
2. You are to administer an intramuscular injection to a
3. Downward
76-year-old client. What factors are important to con-
4. Upward
sider before choosing the equipment and injection site?
4. When administering an intradermal tuberculin skin test,
the nurse’s injection technique is correct if he or she
NCLEX-STYLE REVIEW Q U E S T I O N S inserts the needle at a
1. 180-degree angle
1. The nurse chooses to inject a prescribed intramuscular 2. 90-degree angle
medication into the dorsogluteal site. If the nurse selects 3. 45-degree angle
the site correctly, the injection is administered into the 4. 10-degree angle
1. Hip
5. Which of the following actions best indicates that the
2. Arm
client needs more practice to combine two insulins, short-
3. Thigh
and intermediate-acting, before discharge?
4. Buttock
1. The client rolls the vial of intermediate-acting insulin
2. The recommended technique to help reduce discomfort to mix it with its additive.
when giving an intramuscular injection into the dorso- 2. The client instills air into the short-acting and
gluteal site is to have the client intermediate-acting insulin vials.
1. Point the toes inward. 3. The client instills intermediate-acting insulin into
2. Tighten the gluteal muscles. the vial of short-acting insulin.
3. Cross the legs at the ankles. 4. The client inverts each vial before withdrawing the
4. Flex the knees. specified amount of insulin.
Skill 34-1 • ADMINISTERING INTRADERMAL INJECTIONS
Assessment
Read and compare the label on the drug with the MAR at Prevents errors
least 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 Provides an opportunity for health teaching
purpose and technique for administering the injection.
Planning
Prepare to administer the injection according to the Complies with medical orders
schedule prescribed.
Obtain clean gloves, tuberculin syringe, appropriate Facilitates drug preparation and administration
needle, and alcohol swabs.
Prepare the syringe with the medication. Fills the syringe with the appropriate volume
Implementation
Select an area on the inner aspect of the forearm, Provides a convenient and easy location for accessing
approximately a hand’s breadth above the client’s wrist. intradermal tissue
Cleanse the area with an alcohol swab using a circular Removes microorganisms following principles of asepsis
motion 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 placement of the needle
Hold the syringe almost parallel to the skin at a 10- to Facilitates delivering the drug between the layers of the
15-degree angle with the bevel pointing upward.* Then skin and advances the needle to the desired depth
insert the needle about 1⁄8 inch (Fig. A).
Push the plunger of the syringe and watch for a small Verifies correct injection of the drug
wheal (elevated circle) to appear (Fig. B).
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 transmission of microorganisms
(continued)
ADMINISTERING INTRADERMAL INJECTIONS (Continued)
A B
Entering the skin. (Copyright B. Proud.) Forming a wheal. (Copyright B. Proud.)
Observe the client’s condition for at least the first Ensures that emergency treatment can be quickly
30 minutes after performing an allergy test. administered
Observe the area for signs of a local reaction at standard Determines the extent to which the client responds to the
intervals such as 24 and 48 hours after the injection. injected substance
Evaluation
• Injection is administered.
• 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
*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).
Skill 34-2 • ADMINISTERING SUBCUTANEOUS INJECTIONS
Assessment
Read and compare the label on the drug with the MAR at Prevents errors
least three times—before, during, and after preparing
the drug.
Check for any documented allergies to food or drugs. Ensures safety
Determine where the last injection was given to ensure Prevents tissue injury
site rotation.
Inspect the potential injection site for signs of bruising, Indicates injured tissue areas to avoid
swelling, redness, warmth, or tenderness.
Planning
Obtain clean gloves, appropriate syringe and needle, and Facilitates drug preparation and administration
alcohol swabs.
Add 0.1 to 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 Removes colonizing microorganisms
an 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 Facilitates placement in the subcutaneous level of tissue
(Fig. B) angle of entry. according to the length of the needle used and the
client’s body composition
Release the tissue once the needle is inserted; use the Steadies the syringe
hand to support the syringe at its hub.
Do not aspirate. Aspirating does not confirm or negate that the needle is in
a blood vessel (American Diabetes Association, 2002).
The current standard is to omit what was once a
common practice.
(continued)
ADMINISTERING SUBCUTANEOUS INJECTIONS (Continued)
A B
Entering the tissue at a 45° angle. (Copyright B. Proud.) Entering the tissue at a 90° angle. (Copyright B. Proud.)
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 Controls bleeding
against the medication site.
Massage the site, unless contraindicated. Promotes absorption and relieves discomfort
Remove gloves; perform hand hygiene. Reduces the transmission of microorganisms
Assess the client’s condition at least 30 minutes after Aids in evaluating the drug’s effectiveness
giving the injection.
Evaluation
• Client experiences no untoward effects.
Document
• Site assessment data
Date and Time 10 Units 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
* The administration of drugs usually is documented on the MAR.

Skill 34-3 • ADMINISTERING INTRAMUSCULAR INJECTIONS
Assessment
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 drug allergies. Ensures safety
Determine where the last injection was given. Prevents tissue injury
Inspect the potential injection site for signs of bruising, Indicates tissue injury
swelling, redness, warmth, tenderness, or induration
(hardness).
Planning
Obtain clean gloves, 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
Implementation
Select and prepare an appropriate site by cleansing it with Removes colonizing microorganisms
an alcohol swab.
Spread the tissue taut. Facilitates placement in the muscle
Hold the syringe like a dart and pierce the skin at a Reduces discomfort
90-degree angle (Fig. A).
Steady the syringe and aspirate to observe for blood. Determines if the needle is in a blood vessel
Instill the drug if no blood is apparent. Deposits the drug into the muscle
Withdraw the needle quickly at the same angle it was Reduces discomfort and controls bleeding
inserted while applying pressure against the site (Fig. B).
Massage the injection site with the alcohol swab unless Distributes the medication and reduces discomfort
contraindicated (Fig. C).
Remove gloves; perform hand hygiene. Reduces the transmission of microorganisms
Assess the client’s condition at least 30 minutes after Aids in evaluating the drug’s effectiveness
giving the injection. (continued)
ADMINISTERING INTRAMUSCULAR INJECTIONS (Continued)
A B
Holding syringe like a dart. (Copyright B. Proud.) Withdrawing the needle. (Copyright B. Proud.)
Massaging the site. (Copyright B. Proud.)
Evaluation
• 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 #8 on a scale of 0–10. No signs of
irritation at the site. Rates pain at #5 30 min. after injection. SIGNATURE/TITLE
*The administration of drugs usually is documented on the MAR; prn drugs may be documented both in the
nurse’s notes and the MAR.
35
Chapter
Intravenous
Medications
LEARNING OBJECTIVES
● Name two types of veins into which intravenous medications are administered.
● Describe at least three appropriate situations for administering intravenous medications.
● Name two ways intravenous medications are administered.
● Describe one method for giving bolus administrations of intravenous medications.
● Describe two methods for administering medicated solutions intermittently.
● Explain the technique for administering a piggyback infusion.
● Discuss two purposes for using a volume-control set.
● Describe a central venous catheter.
● Name three types of central venous catheters.
● Discuss two techniques for protecting oneself when administering antineoplastic drugs.
ADMINISTERING intravenous solutions (see Chap. 16) is considered a form of intra-

venous medication administration. The focus of this chapter, however, is on the
methods for administering intravenous drugs, not fluid replacement solutions, and
the techniques for using various venous access devices.
The intravenous (IV) route (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 manner cannot be retrieved once they have
been delivered. For this reason, only specially qualified nurses are permitted to admin-
ister IV medications. Those responsible for IV medication administration must use
extreme caution in preparation and instillation.
INTRAVENOUS MEDICATION ADMINISTRATION
Despite its risks, IV administration given either continuously or intermittently is the

route chosen when
WORDS TO KNOW
• A quick response is needed during an emergency.
antineoplastic drugs
bolus administration • Clients have disorders (e.g., serious burns) that affect the absorption or metabolism
central venous catheter of drugs.
continuous infusion • Blood levels of drugs need to be maintained at a consistent therapeutic level such
intermittent infusion as when treating infections caused by drug-resistant pathogens or providing post-
intravenous route
port
operative pain relief.
secondary infusion • It is in the client’s interest to avoid the discomfort of repeated intramuscular
volume-control set injections.
816
C H A P T E R 35 ● Intravenous Medications 817
• A mechanism is needed to administer drug therapy

over a prolonged period, as with cancer.
Continuous Administration
A continuous infusion (instillation of a parenteral drug over

several hours), also called a continuous drip, involves
adding medication to a large volume (500–1,000 mL) of IV
solution (Skill 35-1). Drugs may be added to a new con-
tainer of IV solution or to an existing infusion if there is a
sufficient volume to dilute the drug. After the medication
is added, the solution is administered by gravity infusion
or more commonly with an electronic infusion device FIGURE 35-1 • An intravenous port. (Copyright B. Proud.)
such as a controller or pump (see Chap. 16).
device. The insertion and technique for maintaining the

Stop • Think + Respond BOX 35-1 patency of a medication lock are described in Chapter 16.
Briefly, a medication lock is a plug that, when inserted
What are some advantages of administering IV medication
by a continuous infusion?
into the end of an IV catheter, allows instant access to the
venous system. One of its best features is that it elimi-
nates the need for a continuous, and sometimes unnec-
essary, administration of IV fluid.
Intermittent Administration
is short-term (from minutes up to

Intermittent infusion
1 hour) parenteral administration of medication. Inter-
mittent infusions are administered in three ways: bolus Administering Medications Through
administrations, secondary administrations, and those an Intravenous Port
in which a volume-control set is used. ❙ Prepare the medication in a syringe. This provides a means for
accessing the port.
Bolus Administration
❙ Locate the port nearest the IV insertion site. This location provides
The term bolus refers to a substance given all at one time. the most rapid placement of medication in the circulatory system.
A bolus administration (undiluted medication given quickly ❙ Swab the port with an alcohol sponge. Alcohol swabbing removes
into a vein) sometimes is described as a drug given by IV colonizing microorganisms.
push. Although the term “push” is used, the medication ❙ Pierce the port with the needle or needleless adapter. Piercing
is administered at the rate specified in a drug reference or provides access to inside the tubing.
at a rate of 1 mL per minute if no information is available.
❙ Pinch the tubing above the access port. Pinching temporarily stops
Bolus administrations are given in one of two ways:
the flow of IV fluid.
through a port in an existing IV line or through a medica-
tion lock (see Chap. 16). ❙ Pull back on the plunger of the syringe. Pulling back creates
negative pressure.
USING AN IV PORT. A port (sealed opening) extends from ❙ Observe for blood in the tubing near the IV catheter or insertion
the IV tubing (Fig. 35-1). The seal is made of latex or device. Blood validates that the IV catheter is in the vein.
another substance that can be pierced with a needle or ❙ Gently instill a few tenths of a milliliter of medication (Fig. 35-2).
needleless adapter. See Nursing Guidelines 35-1. This amount initiates the bolus administration.
Because the entire dose is administered quickly, bolus ❙ Release the tubing. Releasing allows some IV fluid to flow.
administration has the greatest potential for causing life- ❙ Continue the pattern of pinching the tubing, instilling a small
threatening changes should a drug reaction occur. If the amount of drug, and releasing the tubing until the medication has
client’s condition changes for any reason, the adminis- been administered over the specified period. This method delivers
tration is ceased immediately, and emergency measures the drug gradually and keeps the catheter or venous insertion
are taken to protect the client’s safety. device patent when medication is not being instilled. Pinching the
tubing while instilling the drug ensures administration of the drug to
USING A MEDICATION LOCK. A medication lock is also the client rather than backfilling the tubing.
called a saline or heparin lock or an intermittent infusion
FIGURE 35-2 • Instilling medication.
FIGURE 35-3 • Bull’s eye on a medication lock. (Copyright B. Proud.)
Instilling IV medication through a lock is similar to

the routine for keeping it patent (see Skill 16-7). The To maintain patency, nurses usually flush medica-
technique varies depending on whether the agency’s pol- tion locks every 8 to 12 hours with saline or heparin.
icy is to maintain patency with saline or heparin. The The flushing technique is the same except only one
trend is to use saline. syringe of flush solution is required. Nurses change
Nurses use the mnemonic “SAS” or “SASH” as a guide medication locks when changing the IV site or at least
to the steps involved in administering IV medication into every 72 hours. If the nurse cannot verify patency by
a lock. SAS stands for flush with Saline—Administer obtaining a blood return, and if there is resistance or
drug—flush again with Saline; SASH refers to flush with leaking when administering the flush solution, she or
Saline—Administer drug—flush again with Saline— he removes the IV catheter, changes the site, and replaces
instill Heparin. See Nursing Guidelines 35-2. the lock.

Administering Medications Through a Lock
❙ Prepare three syringes, two with at least 1 mL of sterile normal saline ❙ Instill the saline (the first “S” in the mnemonic). Saline clears the lock
and one with the prescribed medication. This preparation facilitates and venous access device.
flushing the lock before and after medication administration. ❙ Remove the syringe when empty, wipe the tip of the lock, and insert the
❙ Prepare a fourth syringe with heparin (10 units/mL), if it is the agency’s syringe containing the drug. These steps facilitate administering the
policy to use it. Heparin maintains patency by interfering with clot medication.
formation. ❙ Gently and gradually administer the medication over the specified time
❙ Label all the syringes in some way such as attaching pieces of tape with period (the letter “A” in the mnemonic). Following recommendations
the letters “S” and “H.” Labels can help to identify the contents of syringes. from an authoritative source ensures safety.
❙ Check the client’s identity. Checking prevents medication errors. ❙ Remove the syringe when it is empty, wipe the lock again, insert the
❙ Wipe the medication port with an alcohol swab. Alcohol swabs remove second syringe with saline, and instill the fluid (the second “S” in the
colonizing microorganisms. mnemonic). This pushes the medication that remains in the lock into
the venous system and fills the lock with saline.
❙ Insert the needle or needleless device from the syringe containing
saline through the “bull’s eye” of the rubber seal on the medication ❙ Begin to withdraw the syringe while instilling the last of the fluid in the
lock (Fig. 35-3). Such insertion provides the least resistance when syringe. Doing so prevents drawing blood, which may clot, into the
introducing the needle or needleless device. lumen of the IV catheter and ensures future patency.
❙ Hold the lock and pull back on the plunger of the syringe. Doing so ❙ Wipe, insert, and instill the heparin (the “H” in the mnemonic), if that is
stabilizes the lock while aspirating for blood. agency policy, using the same technique for withdrawal as with the
final flush with saline. Heparin maintains patency using an
❙ Observe for blood in the tubing at the tubing connected to the venous
catheter or in the barrel of the syringe. Blood verifies that the lock is still anticoagulant.
patent and in the vein (depending on the gauge of the needle, blood ❙ Deposit all uncapped syringes in the nearest puncture-resistant
return may not always be observed). biohazard container. Proper disposal prevents needlestick injuries.
Secondary Infusions
A secondary infusion is the administration of a parenteral
drug that has been diluted in a small volume of IV solu-
tion, 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 (discussed later). When adminis-
tered this way, the medications are actually independent
of a primary infusion. There are also instances when small
volumes of medicated solution are given simultaneously
with a primary 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 infusing primary solution.

Other than using a drug reference book, whom or what
might you consult to determine the compatibility of two
drugs that will infuse through the same IV tubing?
Volume-Control Set FIGURE 35-5 • Volume-control set. (Copyright B. Proud.)
A volume-control set is a chamber in IV tubing that holds a

portion of the solution from a larger container (Fig. 35-5). essentially substitutes for the separate secondary con-
It is known by various commercial names such as Volutrol, tainer of solution, therefore eliminating the need for addi-
Soluset, and Buretrol. A volume-control set is used to tional fluid.
administer IV medication in a small volume of solution When caring for clients who are at risk for or manifest
at intermittent intervals and to avoid accidentally over- signs of fluid excess, it is appropriate to consult the physi-
loading the circulatory system. The volume-control set 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 secondary
or continuous infusion when the client is an infant or
small child?
CENTRAL VENOUS CATHETERS
A central venous catheter (CVC; venous access device that

extends to the superior vena cava) provides a means of
administering parenteral medication in a large volume of
blood. A CVC is used when
• Clients require long-term IV fluid or medication admin-
istration.
• IV medications are irritating to peripheral veins.
• It is difficult to insert or maintain a peripherally inserted
FIGURE 35-4 • Piggyback arrangement. catheter.
CVCs have single or multiple lumens (Fig. 35-6). With

multiple lumens, incompatible substances or more than
one solution or drug can be given simultaneously. Each
infuses through a separate channel and exits the catheter
at a different location near the heart. Thus, the drugs or
solutions never interact. When a lumen is used only
intermittently, it is capped with a medication lock. The
unused lumen is kept patent by scheduled flushes with
normal saline or heparin.
There are three types of CVCs: percutaneous, tun-
neled, and implanted.
Percutaneous Catheters
A percutaneous catheter is inserted through the skin in
a peripheral vein (e.g., the jugular or subclavian vein; see
Chap. 16). This type of catheter is used when clients
require short-term fluid or medication therapy lasting a
few days or weeks. Most are inserted by a physician and
then sutured to the skin.
FIGURE 35-7 • A tunneled catheter. (Ellis, J. R., Nowlis, E. A., & Bentz,
P. M. [1996]. Modules for basic nursing skills [6th ed.]. Philadelphia:
Tunneled Catheters Lippincott-Raven.)
Tunneled catheters are inserted into a central vein with

part of the catheter secured in the subcutaneous tissue.
The end of the catheter exits from the skin lateral to the tection against infection. Implanted catheters have a self-
xiphoid process (Fig. 35-7). Tunneled catheters are used sealing port pierced through the skin with a special nee-
when the client requires extended therapy. Tunneling dle when administering IV medications or solutions. To
helps to stabilize the catheter and also reduces the poten- reduce skin discomfort, a local anesthetic is first applied
tial for infection because an internal cuff acts as a barrier topically. Implanted ports can sustain approximately
against migrating microorganisms. Some examples of tun- 2,000 punctures; thus, the catheter can remain in place
neled catheters are the Hickman, Broviac, and Groshong for several years, barring complications. A dressing is ap-
catheters. plied only when the port is pierced and the catheter is being
used. Implanted catheters remain patent with periodic
Implanted Catheters flushing with heparin.
An implanted catheter (e.g., the Porta-Cath) is sealed

beneath the skin (Fig. 35-8). It provides the greatest pro-
Resealing
diaphragm
for entry
with needle
Entire device
is implanted
under the skin
FIGURE 35-8 • Placement of an implanted catheter. (Ellis, J. R., Nowlis,

FIGURE 35-6 • A triple-lumen central venous catheter. (Copyright E. A., & Bentz, P. M. [1996]. Modules for basic nursing skills [6th ed.].
B. Proud.) Philadelphia: Lippincott-Raven.)
Medication Administration Using a CVC
IV medications may be instilled through any type of CVC.

Continuous or intermittent infusions may be used. See
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 in the pharmacists who mix them and the nurses
who administer them. Caregivers can absorb antineo-
plastic drugs through skin contact, inhalation of tiny FIGURE 35-9 • Flushing the lumen. (Copyright B. Proud.)
fluid droplets or dust particles on which the droplets
fall, or oral absorption of drug residue during hand-
to-mouth contact. When transferred to the caregiver,
ing sperm, ova, or fetal tissue. It is important, there-
these drugs can cause headaches, nausea, dizziness,
fore, that nurses use safety measures when administer-
and burning or itching of the skin. Long-term exposure
ing these drugs and avoid exposure and contact with
can lead to changes in fast-growing body cells, includ-
hazardous materials.
In most cases, these drugs are reconstituted or diluted
with sterile IV solutions in the pharmacy. The pharma-
NURSING GUIDELINES 35-3 cist wears protective clothing when preparing the drugs
Using a Central Venous Catheter under a vertical flow containment hood or biologic safety
cabinet (Fig. 35-10). The pharmacist usually attaches a
❙ Prepare the IV solution, tubing, and drug using the steps for special label to warn nurses to take special precautions
administering a continuous or secondary infusion. Preparation during drug administration.
principles are similar.
❙ Prepare a syringe with 3 to 5 mL of sterile normal saline solution.
Saline facilitates clearing the catheter of heparin if used to maintain
patency.
❙ Release the clamp, if there is one, on the exposed section of the
catheter. Release facilitates flushing the catheter.
❙ Swab the sealed port at the end of the catheter with alcohol. Alcohol
swabbing removes colonizing microorganisms.
❙ Pierce the port with the syringe containing the saline and instill the
flush solution (Fig. 35-9). This clears the catheter of previous flush
solution.
❙ Swab again and insert the needle, recessed needle, or needleless
adapter that connects to the prepared IV medication through the
port. Doing so provides access to the circulatory system.
❙ Tape the connection. Taping prevents displacement.
❙ Release the clamp on the tubing and regulate the rate of infusion.
These steps administer the medication according to the prescribed
rate.
❙ Remove the needle or adapter from the port when the medicated
solution has instilled. Removal terminates current use of the
catheter.
❙ Flush the catheter with saline or heparin according to agency
protocol. Flushing maintains catheter patency.
❙ Reclamp the catheter. Reclamping prevents complications such as
air embolism (see Chap. 16). FIGURE 35-10 • Pharmacy preparation of antineoplastic drugs. (Copy-
right B. Proud.)
Common recommendations for avoiding self-con-

tamination with antineoplastic drugs include the
following:
Although administration of all parenteral drugs involves
• Cover the drug preparation area with a disposable paper
specialized skills, administration of IV medications in
pad, which will absorb small drug spills. general and antineoplastic drugs in particular requires
• Wear a long-sleeved, cuffed, low-permeability gown extreme caution. Nurses may identify the following nurs-
with a closed front. ing diagnoses:
• Wear one or two pairs of surgical latex, nonpowdered
gloves to reduce the potential for skin contact and • Anxiety • Risk for Infection
inhalation of drug powder. • Fear • Excess Fluid Volume
• Cover the cuffs of the gown with the cuffs of the gloves. • Risk for Injury • Ineffective Protection
• Wear a mask or respirator and goggles if there is a Nursing Care Plan 35-1 demonstrates the nursing
potential for aerosolization or drug splash. process as applied to a client with the nursing diagnosis
• Pour 70% alcohol over any drug spill to inactivate the Ineffective Protection, defined in the 2005 NANDA tax-
drug. onomy (p. 147) as “a decrease in the ability to guard self
• Clean the spill area with detergent and water at least from internal or external threats such as illness or injury.”
three times, then rinse with clean water. This diagnosis may be associated with the undesirable
• Dispose of all substances that contain drug material in consequences of antineoplastic medication therapy; an
a biohazard container. example might be deficient immunity or a decreased abil-
• Perform scrupulous handwashing. ity to control bleeding.
Ineffective Protection
ASSESSMENT
• Review laboratory findings for evidence of decreased mature white blood cells, reduced platelets, insufficient erythrocytes
and hemoglobin, or the potential for prolonged clotting.
• Read the client’s history for information indicating a bleeding disorder from an acquired or inherited condition in which
a clotting factor is missing.
• Analyze the client’s weight in relation to height or calculate body mass index (BMI) for evidence of inadequate nutrition.
• Refer to the client’s medical record for current diagnoses such as cancer, alcohol or other forms of substance abuse, and
immune-related disorders.
• Determine if the client is undergoing therapeutic management of disorders with drugs that suppress bone marrow
function, cause immunosuppression, or interfere with clot formation.
Nursing Diagnosis: Ineffective Protection related to debilitated state and 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 normal range, negative occult blood tests on
urine and stool throughout hospital stay.
Monitor platelet count from specimen drawn from central Platelets play a role in blood clotting; normal range of
venous catheter. platelets is 150,000–250,000/mm3.
Report platelet counts below normal and expect that The nurse informs the physician of data that put the client
chemotherapy will be held if count is less than at risk for complications; holding a chemotherapeutic drug
100,000/mm3. that suppresses bone marrow function protects the client
by avoiding further decline in platelets.
Ineffective Protection
Assess skin for bruising and catheter site for bleeding, and Physical assessments provide data that indicate evidence
test urine and stool for occult blood every day. of 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 risk
drugs that interfere with clotting. for bleeding.
Use a soft-bristle toothbrush or foam swabs for mouth These devices avoid oral and dental trauma that can result
care. in blood loss.
Apply pressure for at least 3 minutes to control bleeding at Direct pressure helps to control bleeding.
an injection site if parenteral medications must be given
by a route other than through the central venous catheter.

• Platelet count remains in low normal range.
• There is no evidence of bleeding from central venous catheter insertion site.
• No bruises are noted on the skin.
• Urine and stool test negative for occult blood.
• There is no evidence of active bleeding from gums after mouth care with soft-bristled toothbrush.
GENERAL GERONTOLOGIC Older adults tend to metabolize and excrete drugs at a slower
rate. This factor may predispose them to toxic effects from
CONSIDERATIONS accumulation of medications. This toxicity may occur more
rapidly when the drug is administered IV. Adjustments may be
Older adults comprise the largest age group of clients cared for in
needed in the amount or frequency of dosing.
acute and long-term health care facilities. Administration of
A portion of many drugs is bound to protein in the blood. The por-
IV medications is quite common in older clients. Increasing
tion not bound is called “free drug,” the physiologically active
emphasis on early discharges may require teaching older
form. Older adults tend to have more free drug in proportion to
adults, family caregivers, or both how to flush venous access
bound drug because of diminished protein components in their
equipment. Medication locks on peripheral and central venous
blood.
catheters may be needed for future medication administration.
Health insurance coverage of IV medications is highly variable
Normal age-related problems (e.g., decreased visual acuity and
and may change depending on the health care setting. Older
manual dexterity) may require additional instructions, with
adults may need assistance in determining whether their
time allowed for repeated practice. health insurance covers IV medications, especially in long-term
Older clients needing continued IV therapy after being discharged care settings.
may require a referral for skilled nursing care. Older adults with dementia often experience more confusion
Older adults require frequent and comprehensive assessment and disorientation with an acute illness. Assessment of con-
before, during, and after IV medication administration. fused older adults’ needs and prevention of pulling IV tubing
The veins of older adults tend to be quite fragile. Insertion of a and the venipuncture device is required to ensure safe
percutaneous central venous line is often better than risking administration of IV medications and maintenance of the IV
the trauma of repeated attempts at restarting or changing insertion site. Family members or paid companion services
peripheral IV sites. are helpful in providing close observation in acute care settings.
To avoid the hazards of infiltrating tissue with medications deliv-
ered intravenously, it is appropriate to collaborate with the
prescribing practitioner on the possibility of administering the
same drug by another route.
Older adults are often reluctant to ask questions of health care 1. Discuss the advantages and disadvantages of giving IV
professionals. Therefore, it is imperative that providers explain medications to older adults.
the purpose and potential side effects for each drug adminis-
tered, especially by the IV route. 2. When preparing to administer an IV medication through
Observe older clients who are receiving IV medications such as an IV port or lock, you find no blood return on aspiration.
anticoagulants, sulfonamides, opiates, and antimicrobial med- Discuss the significance of this finding and appropriate
ications for adverse effects. actions.
4. When a client asks why the physician recommended

inserting an implanted central venous catheter for admin-
1. Before a nurse administers an intravenous medication by istering cancer medications, the best answer the nurse
bolus (IV push) through a port of an infusing solution that can provide is that an implanted catheter
also contains a medication, it is essential to 1. Has the lowest incidence of infection
1. Dilute the bolus drug in a small volume of solution. 2. Is best for short-term use
2. Check that the bolus and infusing drugs are com- 3. Will never need to be removed
patible. 4. Is easy to cover with a dressing
3. Stop the infusing solution for approximately
5. Which of the following techniques is best for avoiding self-
3 minutes.
contamination with intravenous antineoplastic drugs?
4. Flush the port with 5 mL of sterile normal saline.
1. Stay at least 5 feet away from a client receiving an
2. When the nurse instills a medication intravenously by infusion of an antineoplastic drug.
bolus administration (IV push), which technique is correct 2. Wear a high-efficiency air filter respirator while in the
for determining that the IV catheter is within the vein? area where an antineoplastic drug is being given.
1. The nurse increases the rate of infusion and looks 3. Perform meticulous handwashing for about 5 min-
for edema at the site. utes after handling a container of antineoplastic
2. The nurse inspects the site looking for redness drugs.
along the course of the vein. 4. Don two pairs of nonpowdered gloves when pre-
3. The nurse palpates the area of the infusion to note paring to administer the antineoplastic drug.
a difference in temperature.
4. The nurse pulls back on the plunger of the syringe
and looks for a blood return.
3. What does the nurse instill first before administering intra-
venous medication through a peripherally inserted inter-
mittent infusion device (medication lock)?
1. Sterile bacteriostatic water
2. Sterile normal saline
3. Sterile isopropyl alcohol
4. Sterile hydrogen peroxide
ADMINISTERING INTRAVENOUS MEDICATION

Skill 35-1 • BY CONTINUOUS INFUSION
Assessment
Read the label on the drug and compare it with the MAR Prevents errors
(see Fig. A).
Comparing the drug label with the MAR. (Copyright 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
purpose and technique for administering the
medication.
Perform assessments that will provide a basis for Provides a baseline for future comparisons
evaluating the 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 Avoids medication errors
label at least three times.
Have a second nurse double-check your drug calculations. Ensures accuracy
Implementation
(see Chap. 10).
(continued)

BY CONTINUOUS INFUSION (Continued)
Check the client’s identification band (see Fig. B). Prevents a medication error
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).
B C
Checking the client’s identification band. (Copyright B. Proud.) Swabbing the port on the container. (Copyright B. Proud.)
Instill the medication through the port into the full Promotes dilution of concentrated additive
container of 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
Regulate the rate of flow by using the roller clamp or Promotes continuous infusion at prescribed rate
programming the rate on the electronic infusion device
(see Fig. E).
D E
Instilling medication. (Copyright B. Proud.) Programming the rate. (Copyright B. Proud.)
(continued)

BY CONTINUOUS INFUSION (Continued)
Attach a label to the container of fluid identifying the drug, Provides information for others and demonstrates
its dose, time it was added, and your initials (see Fig. F). accountability for nursing actions
Record the medication administration in the MAR. Documents nursing care; avoids medication errors
Check the client and the progress of the infusion at least Promotes early intervention for complications
hourly.
Attaching the drug label. (Copyright B. Proud.)
Evaluation
• Medication instills at 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 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/hr. Heart rate is regular and ranges between 65 and 75 bpm.
SIGNATURE/TITLE
*The administration of drugs usually is documented on the MAR.

Skill 35-2 • ADMINISTERING AN INTERMITTENT SECONDARY INFUSION
Assessment
Read the label on the medicated solution and compare Prevents errors
with 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
purpose and technique for administering the
medication.
Perform assessments that will provide a basis for Provides a baseline for future comparisons
Planning
Plan to administer the secondary infusion within 30 to Complies with agency policy
60 minutes of the scheduled time for drug
administration established by the agency.
Remove a refrigerated secondary solution at least Warms the solution slightly to promote comfort during
30 minutes before administration. instillation
Check the drop factor on the package of secondary Ensures that the secondary infusion will be instilled
(short) IV tubing and calculate the rate for infusion within the specified time
(see Chap. 16).
Have a second nurse double-check your calculations for Ensures accuracy
the rate of infusion.
Attach the tubing to the solution (see Skill 15-2), fill the Prepares the medicated solution for administration
drip chamber, and purge air from the tubing.
Attach a needle, recessed needle, or needleless adapter. Facilitates piercing the port while minimizing the risk for
needlestick injury
Implementation
(see Chap. 10).
Check the client’s identity (see Fig. A). Prevents medication errors
Hang the secondary solution on the IV pole or standard. Prepares the solution for administration
Lower the container of primary solution approximately Positions the secondary solution to instill under greater
10 inches (25 cm) below the height of the secondary hydrostatic pressure
solution using a plastic or metal hanger (see Fig. B).
(continued)
ADMINISTERING AN INTERMITTENT SECONDARY INFUSION (Continued)
A B
Confirming client’s identity. Lowering primary bag below the secondary solution.
Wipe the uppermost port on the primary tubing with an Removes colonized microorganisms
alcohol swab (see Fig. C).
Insert the needle or modified adapter within the port (see Provides access to the venous system
Fig. D).
C D
Swabbing the port on primary tubing. (Copyright B. Proud.) Inserting needless adapter. (Copyright B. Proud.)
Lock the connection. Prevents separation from the port

Release the roller clamp on the secondary solution. Initiates the infusion
(continued)
ADMINISTERING AN INTERMITTENT SECONDARY INFUSION (Continued)
Regulate the rate of flow by counting the drip rate and Establishes the maintenance rate of flow to instill the
adjusting the roller clamp or by programming an solution in the time specified
electronic infusion device.
Clamp the tubing when the solution has instilled. Prevents backfilling with the primary solution
Rehang the primary container of solution and readjust the Continues fluid replacement therapy at its appropriate
rate of flow. rate
Leave the secondary tubing in place within the port if Controls health care costs without jeopardizing client
another secondary infusion of the same medication is safety; different tubing, however, is used if other drugs
scheduled again within the next 24 hours. are administered as secondary infusions.
Evaluation
• Secondary infusion instills at prescribed rate.
• 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 admin-
istered in 100 mL of NSS as a secondary infusion over 60 minutes without signs of a reaction.
SIGNATURE/TITLE
Skill 35-3 • USING A VOLUME-CONTROL SET
Assessment
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 Prevents errors
the MAR.
(continued)
USING A VOLUME-CONTROL SET (Continued)
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
tenderness.
purpose and technique for administering the medication.
Planning
Plan to administer the medication within 30 to 60 minutes Complies with agency policy
of the 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 Differs, in some instances, from the drop size on IV tubing
calculate the rate of infusion.
Have a second nurse double-check your calculations for Ensures accuracy
the rate of infusion.
Implementation
(see Chap. 10).
Close all the clamps on the volume-control set and insert Prepares the equipment for medication administration
the spike into the IV solution (see Fig. A).
Seal the air vent located to the side of the spike on the Facilitates administration of fluid from collapsible or
volume-control set if the solution is in a plastic bag; if noncollapsible containers
the container is glass, leave the air vent open.
Inserting the spike. (Copyright B. Proud.)
Release the clamp above the fluid chamber. Permits fluid to enter the calibrated container
Fill the calibrated chamber with approximately 30 mL of Provides a small volume with which to fill the drip
IV solution and retighten the clamp. chamber and purge air from the distal tubing
(continued)
Squeeze and release the drip chamber until it is half full Fills the drip chamber with fluid
(see 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.
Open the lower clamp until the tubing is filled with fluid; Purges air from the tubing
then reclamp.
Open the clamp above the calibrated container, fill the Provides diluent for the medication
chamber with the desired volume of fluid, and reclamp.
Swab the injection port on the calibrated container. Removes colonizing microorganisms
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
B C
Squeezing the drip chamber. (Copyright B. Proud.) Instilling medication. (Copyright B. Proud.)
Connect the tubing to the client’s IV catheter. Completes the circuit for administering 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 Provides information for other health professionals
the drug, dose, time it was added, and your initials (see
Fig. D).
Return before the time the medication is due to finish Facilitates further fluid therapy
instilling.
Release the upper clamp when the fluid chamber is empty Continues the administration of fluid replacement
and refill it with the next hour’s worth of fluid.
(continued)
Attaching a drug label. (Copyright B. Proud.)
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
Evaluation
• Medicated solution instills within the specified
period.
• 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 not irritated, tender, or swollen. Lungs sound clear. 100 mL urine output in the past hour.
SIGNATURE/TITLE

U N I T 91

for Chapters 32,
1, 233, 34, and 35
in parentheses.
1. Drugs have a name, which is the chemical name and is not protected by a company’s
trademark. (brand, generic, proprietary)
2. 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)

false statements.
1. T F Drugs that dissolve at time 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 2.5 to 3.5 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.
834

1. Chemical substances that change body function
2. 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. Process of adding a diluent to a powdered drug before parenteral administration
6. Medications used to destroy or slow the growth of malignant cells
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 parental drug over several hours
2. Intravenous route B. Instillation of parental 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 criteria 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 criteria given below.
Tunneled Catheters Percutaneous Catheters
Method of Insertion
Uses
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 record?
3. What is an inunction application?
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. Why are metric and apothecary 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?
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 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?
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 per-
form 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?

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 third day
d. For three 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. Place the medication cup on a side table when pouring the drug.
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 properly.
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 method to inject medica-
tions? Select all that apply.
a. Use the Z-track method 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.
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.
UNIT 10
Intervening in
Emergency
Situations
36 Airway Management
37 Resuscitation
36
Chapter
Airway
Management
LEARNING OBJECTIVES
● Define airway management.
● Identify the structural components of the airway.
● Discuss four natural mechanisms that protect the airway.
● Explain methods nurses use to help maintain the natural airway.
● Name two techniques for liquefying respiratory secretions.
● Explain the three techniques of chest physiotherapy.
● Describe at least three suctioning techniques used to clear secretions from the airway.
● Discuss two indications for inserting an artificial airway.
● Name two examples of artificial airways.
● Identify three components of tracheostomy care.
THE primary function of the respiratory system is to permit ventilation (movement of

air in and out of the lungs) for appropriate exchange of oxygen and carbon dioxide
at the cellular level (see Chap. 21). A clear airway (the collective system of tubes in the
upper and lower respiratory tract) is necessary for adequate ventilation. Many factors
can jeopardize airway patency:
• Increased volume of mucus (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
• Decreased level of consciousness
WORDS TO KNOW • Ineffective cough
airway • Impaired airway
airway management
Consequently, nurses sometimes need to assist clients with measures that support or
chest physiotherapy
inhalation therapy replace their own natural efforts. This chapter focuses on airway management, or those
mucus essential nursing skills that maintain natural or artificial airways for compromised
nasopharyngeal suctioning clients.
nasotracheal suctioning
oral airway
oral suctioning THE AIRWAY
oropharyngeal suctioning
percussion
postural drainage The upper airway consists of the nose and pharynx, which is subdivided into the
sputum nasopharynx, oropharynx, and laryngopharynx. The lower airway consists of the tra-
suctioning
chea, bronchi, bronchioles, and alveoli. Gases travel through these structures to and
tracheostomy
tracheostomy care from the blood (Fig. 36-1).
tracheostomy tube Certain structures protect the airway from a wide variety of inhaled substances.
vibration These structures include the epiglottis, tracheal cartilage, mucous membrane, and cilia.
844
CHAPTER 36 ● Airway Management 845
From pulmonary physiotherapy, and mechanically clearing mucus from

artery the airway by suctioning.
Alveolar
Terminal
duct
bronchiole
Alveoli Liquefying Secretions

To pulmonary
vein The body continuously produces mucus. The volume of
water in mucus affects its viscosity, or thickness. Hydra-
Capillaries tion, the process of providing adequate fluid intake, tends
to keep mucous membranes moist and mucus thin. A
thin consistency promotes expectoration (see Chap. 16).
An essential nursing activity is ensuring that clients are
Section of lung enlarged well hydrated.
FIGURE 36-1 • The airway and related structures. In addition, nurses may assist with inhalation therapy
(respiratory treatments that provide a mixture of oxygen,
The epiglottis is a protrusion of flexible cartilage above the humidification, and aerosolized medications directly
larynx. It acts as a lid that closes during swallowing, help- to the lungs). The aerosol is delivered through a mask
ing direct fluid and food toward the esophagus rather than or hand-held mouthpiece (Fig. 36-3). Aerosol therapy
the respiratory tract. The rings of tracheal cartilage ensure improves breathing, encourages spontaneous coughing,
that the trachea, the portion of the airway beneath the and helps clients to raise sputum for diagnostic purposes.
larynx, remains open. Mucous membrane, a type of tis- See Nursing Guidelines 36-1.
sue from which mucus is secreted, lines the respiratory
passages. The sticky mucus traps particulate matter. Hair-
like projections called cilia beat debris that collects in the Mobilizing Secretions
lower airway upward (Fig. 36-2).
Various mechanisms keep the airway open. For exam- To help clients mobilize secretions from distal airways,
ple, sneezing or blowing the nose can clear debris there. health care professionals often use chest physiotherapy
Coughing, expectoration, or swallowing clears sputum (techniques including postural drainage, percussion, and
(mucus raised to the level of the upper airways). vibration). Chest physiotherapy usually is indicated for
clients with chronic respiratory diseases who have diffi-
culty coughing or raising thick mucus.
NATURAL AIRWAY MANAGEMENT
The most common methods of maintaining the natural

airway are keeping respiratory secretions liquefied, pro-
moting their mobilization and expectoration with chest
FIGURE 36-2 • Cilia and mucus-producing cells. FIGURE 36-3 • Aerosol therapy. (Copyright B. Proud.)
846 UNIT 10 ● Intervening in Emergency Situations

Collecting a Sputum Specimen
❙ Plan to collect a sputum specimen just after the client awakens or
after an aerosol treatment. This timing allows collection when more
mucus is available or is in a thin state.
❙ Obtain a sterile sputum specimen cup. Sterility prevents
contamination of the specimen.
❙ Help the client to a sitting position. Sitting provides for an increased
volume of inspired air and more forceful coughing to expel mucus.
❙ Encourage the client to rinse the mouth with tap water. Tap water
removes some microorganisms and food residue.
❙ Explain that the desired specimen should be from deep within the
respiratory passages, not saliva from within the mouth. Correct
instruction helps to prevent inconclusive or invalid test results.
❙ Instruct the client to take several deep breaths, attempt a forceful
cough, and expectorate into the specimen container. These
measures help to mobilize secretions from the lower airway.
❙ Collect at least a 1- to 3-mL (nearly a half-teaspoon) specimen. This
quantity is sufficient for analysis.
❙ Wear gloves and cover and enclose the specimen container in a
clear plastic bag. These steps reduce the potential for transmission
of microorganisms.
❙ Offer oral hygiene. It promotes comfort and well-being.
❙ Attach a label and laboratory request form to the specimen. Doing
so ensures correct specimen identification and test procedure.
❙ Take the specimen to the laboratory immediately. Prompt delivery
facilitates timely and accurate analysis of the specimen.
❙ Document in the client’s medical record the appearance of the
specimen and its delivery to the laboratory. Such recording
provides assessment data and information about the disposition FIGURE 36-4 • Lung segments and corresponding postural drainage
of the specimen. positions. (Rosdahl, C. [1999]. Textbook of basic nursing [7th ed., p. 1201].
Philadelphia: Lippincott Williams & Wilkins.)
Postural Drainage 36-1 • CLIENT AND FAMILY TEACHING

Postural drainage is a positioning technique that promotes
Performing Postural Drainage
gravity drainage of secretions from various lobes or seg-
ments of the lungs (Fig. 36-4). In most hospitals, respira-
tory therapists are responsible for postural drainage. In • Plan to perform postural drainage two to four
long-term care facilities and home health care, however, times daily (e.g., before meals and at bedtime).
nurses may teach clients and families to perform this • Administer prescribed inhalant medications (see
technique (see Client and Family Teaching 36-1). Com- Chap. 33) before performing postural drainage.
bining postural drainage with percussion and vibration • Have paper tissues and a waterproof container
enhances overall effectiveness. nearby for collecting expectorated sputum.
• Position yourself to drain the appropriate lung
areas.
Percussion
• Cough and expectorate secretions that drain
Percussion (rhythmic striking of the chest wall) helps to dis- into the upper airway.
lodge respiratory secretions that adhere to the bronchial • Remain in each prescribed position for 15 to
walls. To perform percussion, the nurse cups the hands, 30 minutes (no longer than 45 minutes).
keeping the fingers and thumb together, as if carrying • Resume a comfortable position after expecto-
water. He or she then applies the cupped hands to the rating the usual volume of sputum or if you
client’s chest as if trapping air between them and the tho- become tired, feel lightheaded, or have a rapid
racic wall (Fig. 36-5). The nurse performs percussion for pulse rate, difficulty breathing, or chest pain.
FIGURE 36-6 • Placement of a nasopharyngeal trumpet.

FIGURE 36-5 • Performing percussion.
3 to 5 minutes in each postural drainage position, taking catheter). Nurses perform oral suctioning (removal of secre-
care to avoid striking the breasts of female clients and tions from the mouth) with a suctioning device called a
any areas of chest injury or bone disease. Yankeur-tip or tonsil-tip catheter (Fig. 36-7).
Vibration
Vibration uses the palms of the hands to shake underlying Stop • Think + Respond BOX 36-1
tissue and loosen retained secretions. The nurse positions In addition to an SpO2 less than 90%, what signs or
the hands on the client’s chest or back during inhalation symptoms does a person with hypoxia manifest?
and then vibrates them as the client exhales to increase
the intensity of expiration. Vibration is used with or as an
alternative to percussion, especially for frail clients.
ARTIFICIAL AIRWAY MANAGEMENT
Suctioning Secretions
Clients at risk for airway obstruction or requiring long-
Suctioning relies on negative (vacuum) pressure to remove
term mechanical ventilation are candidates for an artifi-
liquid secretions with a catheter. The amount of negative cial airway. Two common types are an oral airway and
pressure varies depending on the client and type of suc- a tracheostomy tube.
tion equipment (Table 36-1). Nurses may suction the
upper airway, lower airway, or both. In all cases, they suc-
tion the airway from the nose or mouth (Skill 36-1). Oral Airway
Nasopharyngeal suctioning (removing secretions from
An oral airway is a curved device that keeps a relaxed
the throat through a nasally inserted catheter) is more
tongue positioned forward within the mouth, preventing
common than nasotracheal suctioning (removing secretions
the tongue from obstructing the upper airway. It is most
from the upper portion of the lower airway through a
commonly used in clients who are unconscious and can-
nasally inserted catheter). A nasopharyngeal airway,
not protect their own airway, such as those recovering
sometimes called a trumpet (Fig. 36-6), can be used to
from general anesthesia or a seizure. Nurses insert oral
protect the nostril if frequent suctioning is necessary. An
alternative method is oropharyngeal suctioning (removing
secretions from the throat through an orally inserted
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 36-7 • Yankeur-tip suction device for oral suctioning. (Copy-
right B. Proud.)
airways, which usually are in place for a brief time only.

Tracheostomy
Clients who are less stable, have an upper airway obstruc-

tion, or require prolonged mechanical ventilation and
oxygenation are more likely to be candidates for a tra-
cheostomy (surgically created opening into the trachea).

A
Inserting an Oral Airway
❙ Gather the following supplies: various sizes of oral airways (most
adults can accommodate an 80-mm airway), gloves, tongue blade,
and suction equipment. Gathering equipment promotes
organization and efficient time management.
❙ Place the airway on the outside of the client’s cheek so that the front
is parallel with the front teeth. Note whether or not the back of the
airway reaches the angle of the jaw. Assessment determines the
appropriate size to use. (An airway that is too short will be
ineffective. An airway that is too long will depress the epiglottis,
increasing the risk of airway obstruction.)
❙ Wash your hands or perform an alcohol-based handrub (see Chap. 10);
B
don clean gloves. These measures reduce the transmission of
microorganisms. FIGURE 36-8 • Oral airway insertion. (A) Initial insertion position.
❙ Explain the procedure to the client. Instruction provides information (B) Final position after rotation.
that even unconscious clients may comprehend, despite being
unable to respond verbally.
A tube is inserted through the opening to maintain the
❙ Perform oral suctioning if necessary. It clears saliva from the mouth airway and provide a new route for ventilation.
and prevents aspiration.
❙ Position the client supine with the neck hyperextended unless Tracheostomy Tube
contraindicated. This position opens the airway and facilitates
insertion. A tracheostomy tube (curved, hollow plastic tube) is also
called a cannula. Some devices have an inner and an outer
❙ Open the client’s mouth using a gloved finger and thumb or
cannula. Tracheostomy tubes also may have a balloon cuff
a tongue blade. Doing so prevents injury to the teeth during
insertion. (Fig. 36-9); when inflated, the cuff seals the upper air-
way to prevent aspiration of oral fluids and provide more
❙ Hold the airway so that the curved tip points upward toward the
efficient ventilation. During insertion of a tracheostomy
roof of the mouth (Fig. 36-8A) or side of the cheek. Insert it about
tube, an obturator, a curved guide, is used. Once the tube
halfway. Such placement prevents pushing the tongue into the
pharynx during insertion. is in place, the obturator is removed.
Because a tracheostomy tube is below the level of the
❙ Rotate the airway over the top of the tongue and continue inserting
larynx, clients usually cannot speak. Communication may
it until the front flange is flush with the lips (see Fig. 36-8B). This
involve writing or reading the client’s lips. Being unable
ensures that the artificial airway follows the natural curve of the
upper airway. to call for help is frightening; therefore, the nurse should
check these clients frequently and respond immediately
❙ Assess breathing. Checking breathing validates that the natural
when they signal.
airway is patent.
❙ Remove the airway every 4 hours, provide oral hygiene, and clean
and reinsert the airway. Hygiene and cleaning remove transient Stop • Think + Respond BOX 36-2
bacteria and promote the integrity of the oral mucosa. Discuss the physical and psychological effects a client with
❙ As the client’s level of consciousness improves, many clients a tracheostomy may develop as a consequence of being
extubate themselves independently. unable to speak.
cannula (Skill 36-2). Nurses perform tracheostomy care

at least every 8 hours or as often as clients need to keep
the secretions from becoming dried, then narrowing or
occluding the airway. They may do tracheal suctioning
separately from or at the same time as tracheostomy care.
Maintaining an open and patent airway is a priority for

nursing care. Lack of oxygen for more than 4 to 6 min-
utes can result in death or permanent brain damage.
FIGURE 36-9 • A cuffed tracheostomy tube. (Copyright B. Proud.) Therefore, it is essential to identify nursing diagnoses that
apply to respiratory problems and to plan care accord-
ingly for clients at risk. Some possible nursing diagnoses
Tracheostomy Suctioning include the following:
Most clients with a tracheostomy require frequent suc- • Ineffective Airway Clearance
tioning. Although they can cough, the force of the cough • Impaired Gas Exchange
may be ineffective in completely clearing the airway, or • Risk for Infection
the cough may be inadequate to clear the volume of res- • Impaired Spontaneous Ventilation
piratory secretions. Therefore, suctioning is necessary • Anxiety
when secretions are copious. • Deficient Knowledge
Tracheostomy suctioning is similar to nasotracheal
suctioning except that catheter insertion is through the Nursing Care Plan 36-1 shows how the nursing process
tracheostomy tube rather than the nose (Fig. 36-10). applies to a client with the nursing diagnosis of Ineffec-
When suctioning a tracheostomy, the nurse inserts the tive Airway Clearance, defined in the 2005 NANDA
catheter a shorter distance (approximately 4 to 5 inches taxonomy (p. 6) as the “inability to clear secretions or
obstructions from the respiratory tract to maintain a
[10 to 12.5 cm] or until resistance is felt) because the tube
clear airway.”
already lies in the trachea. The resistance is caused by
contact between the catheter tip and the carina, the ridge
at the lower end of the tracheal cartilage where the main GENERAL GERONTOLOGIC
bronchi are located. The nurse then raises the catheter
about 1⁄2 inch (1.25 cm) and applies suction.
CONSIDERATIONS
Conditions affecting the respiratory system are among the most
Tracheostomy Care common life-threatening disorders that older adults experience.
Severity of chronic pulmonary diseases increases with age.
Tracheostomy caremeans cleaning the skin around the Many older adults with pathologic pulmonary changes have a
stoma, changing the dressing, and cleaning the inner history of smoking cigarettes since their youth, working in
occupations where they inhaled pollutants that affected their
lungs, or living for an extended time in industrial areas known
for toxic emissions.
Reduced air exchange and efficiency in ventilation 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 retention of secretions, decreased air exchange,
and compromised ventilation. Respiratory cilia become less
efficient with age, predisposing older adults to a high incidence
of pneumonia.
Diminished strength of accessory muscles for respiration,
increased rigidity of the chest wall, and diminished cough
reflex make it difficult for older adults to cough productively
and effectively.
Inquiring about a current history of coughing, determining how
long the cough has been present, and observing and describing
any sputum are important when assessing older adults.
FIGURE 36-10 • Suctioning through a tracheostomy tube. (Copyright If not relieved quickly, a persistent, dry cough may consume the
Swedish Hospital Medical Center.) older adult’s energy and result in fatigue.
Ineffective Airway Clearance
ASSESSMENT
• Observe characteristics of the client’s breathing and ability to cough forcefully.
• Inspect sputum for evidence of a viscid consistency.
• Auscultate the lungs to detect adventitious breath sounds suggestive of retained secretions.
• Assess vital signs to detect manifestations of impaired oxygenation.
• Review the client’s medical record for conditions that may alter the ability to protect and clear the airway: decreased level
of consciousness, unusual weakness or easy fatigability, moderate to severe pain, surgical incision about the thorax or
abdomen.
• Note if the client’s fluid intake is adequate.
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 R. upper lobe both
anteriorly and posteriorly, and history of smoking 2 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 lungs every shift and before and after coughing Auscultation provides data indicating the presence or
or other respiratory therapy. absence of retained respiratory secretions.
Elevate the head of the bed at all times. Fowler’s position helps to provide maximum room for
lung expansion.
Maintain 2,000 to 3,000 mL fluid intake of client’s choice Keeping the client well hydrated helps thin respiratory mucus.
(avoid milk) for 24 hours.
Instruct client to take three deep breaths in through the Deep breathing dilates the airways, stimulates surfactant
nose and out the mouth, lean forward, and cough forcefully. production, and expands the lung surface. Coughing
Repeat every 1 to 2 hours while the client is awake. loosens and forces secretions into the bronchi (Carpenito-
Moyet, 2005).
Perform oral/pharyngeal suctioning if secretions are loose Negative pressure produces a pulling effect, which can remove
but the client does not expectorate them. mucoid secretions that the client cannot clear independently.

• Client is instructed on deep breathing and coughing technique.
• Client can raise tenacious, purulent sputum after breathing and coughing.
• Lungs sound less congested.
Weather, such as high humidity or damp conditions, influences Older adults are at increased risk for cardiac dysrhythmias during
the production of respiratory secretions. suctioning because many have preexisting hypoxemia from
Deep-breathing exercises improve the older adult’s ability to illnesses and age-related changes in ventilation.
eliminate respiratory secretions. Maintenance of adequate
hydration is important to liquefy secretions.
Older adults with difficulty swallowing (dysphagia), often associated CRITICAL THINKING E X E R C I S E
with strokes or middle and late stages of dementia, are more
vulnerable to aspiration pneumonia. Evaluation of dysphagia 1. Discuss ways to relieve the anxiety of a client with a tra-
is important for implementing appropriate interventions to cheostomy who needs frequent suctioning but fears he
prevent aspiration. or she will be unable to obtain assistance when needed.
4. When suctioning a client with a tracheostomy tube, when

is the best time to occlude the vent on the suction catheter?
1. Although all the following information is appropriate to 1. When inserting the catheter
gather when assessing a client with a cough, it is most 2. When inside the inner cannula
important to document the characteristics of the cough 3. When withdrawing the catheter
and the 4. When the client begins coughing
1. Client’s family history of respiratory disease 5. When suctioning the airway of a client with a trache-
2. Current assessment of the client’s vital signs ostomy, the nurse applies suction for no longer than
3. Appearance of the respiratory secretions 1. 5 to 7 seconds
4. Types of self-treatment that the client is using 2. 10 to 15 seconds
2. If all the following nursing measures are possible, which 3. 15 to 20 seconds
helps most when planning to obtain a sputum specimen? 4. 20 to 30 seconds
1. Provide the client with a generous fluid intake.
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.
3. What time of the day is it best for the nurse to attempt to
obtain a sputum specimen?
1. Before bedtime
2. After a meal
3. Between meals
4. Upon awakening
Skill 36-1 • SUCTIONING THE AIRWAY
Assessment
Assess lung sounds, respiratory effort, and oxygen Determines the need for suctioning
saturation level.
suctioning 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 The nurse can choose to wear a face shield and cover
addition to gloves when suctioning a client. gown as part of Standard Precautions.
Obtain a suction kit. All kits contain a basin and one or Promotes organization and efficient time management
two sterile gloves. Some also contain a sterile suction
catheter.
If the kit does not include a catheter, select one that will Promotes comfort and reduces the potential for injury
not occlude the nostril; usually a 12 to 18 F catheter is
appropriate for adults.
Obtain a flask of sterile normal saline and a suction Provides items that are not prepackaged
machine, if a wall outlet is unavailable.
Attach the suction canister to the wall outlet or plug a Provides a source for negative pressure
portable 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, Ensures safe pressure during suctioning
and 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 ventilation
(see Chap. 10).
Pre-oxygenate the client for 1 to 2 minutes until the SpO2 Reduces the risk for hypoxemia
is maintained at 95% to 100%.
Open the suction kit without contaminating the contents. Follows principles of asepsis
Don sterile glove(s). If the kit provides only one, don a Prevents the transmission of microorganisms
clean glove on the nondominant hand and then don the
sterile glove on the dominant hand.
Pour sterile normal saline into the basin with your Prepares solution for wetting and rinsing the suction
nondominant hand. catheter
Consider the nondominant hand contaminated. Follows principles of asepsis
(continued)
SUCTIONING THE AIRWAY (Continued)
Pick up the suction catheter with your sterile (dominant) Completes the circuit for applying suction
hand and connect it to the suction tubing (Fig. A).
Place the catheter tip in the saline and occlude the vent Wets the outer and inner surfaces of the catheter; reduces
(Fig. B). friction and facilitates insertion
A B
Connecting the catheter. (Copyright B. Proud.) Wetting the catheter. (Copyright B. Proud.)
Insert the catheter without applying suction along the Reduces the potential for sneezing or gagging
floor of the nose or side of the mouth (Fig. C).
C
Catheter placement: nasopharyngeal (left), oropharyngeal (center), and nasotracheal (right).
Advance the catheter 5 to 6 inches (12.5 to 15 cm) in the Places the distal tip in the pharynx
nose or 3 to 4 inches (7.5 to 10 cm) in the mouth.
For tracheal suctioning, wait until the client takes a breath Eases insertion below the larynx
then advance the tubing 8 to 10 inches (20 to 25 cm).
Encourage the client to cough if coughing does not occur Breaks up mucus and raises secretions
spontaneously.
Occlude the air vent and rotate the catheter as it is Maximizes effectiveness of suctioning
withdrawn.
(continued)
SUCTIONING THE AIRWAY (Continued)
Complete the process in no more than 15 seconds from Prevents hypoxemia
insertion to removal of the catheter, occluding the vent
no longer than 10 seconds.
Rinse secretions from the catheter by inserting its tip in Flushes the mucus from the inner lumen
the basin of saline and applying suction.
Provide 2 to 3 minutes of rest while the client continues to Re-oxygenates the blood
breathe oxygen.
Suction again if necessary. Bases decision on individual assessment data
Remove the gloves to enclose the suction catheter in an Encloses the soiled catheter, reducing transmission of
inverted glove (Fig. D). microorganisms
Enclosing the catheter. (Copyright 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.
• 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 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 Provides a data base for comparison
previous tracheostomy care.
Assess the condition of the dressing and the skin around Determines need for dressing change and skin care
the tracheostomy tube.
Determine the client’s understanding of tracheostomy care. Provides an opportunity for health teaching
Planning
Consult with the client on an appropriate time for Demonstrates respect for the client’s right to participate
tracheostomy care if only routine care is needed. in decisions.
Consider using a face shield and wearing a cover gown The nurse can choose to wear a face shield and cover
in addition to gloves when suctioning a client. gown as part of Standard Precautions.
Obtain a container of hydrogen peroxide and a flask of Provides items that are not prepackaged and prevents
normal saline. Remove the cap from each container. contamination of one gloved hand later in the
procedure
Implementation
(see 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 Follows principles of asepsis
discard it, glove and all, in a lined waste receptacle.
Wash your hands or perform an alcohol-based handrub again. Reduces the transmission of microorganisms
Open the tracheostomy kit, taking care not to contaminate Provides access to and maintains sterility of supplies
its contents.
Don sterile gloves. Prevents transferring microorganisms to the lower airway
Add equal parts sterile normal saline and sterile hydrogen The diluted hydrogen peroxide cleans mucoid secretions;
peroxide to one basin and sterile normal saline to the the sterile normal saline rinses the peroxide solution
other (Fig. A). from the skin and inner cannula.
Adding cleaning solutions. (Copyright Swedish Hospital Medical Center.)
A
(continued)
PROVIDING TRACHEOSTOMY CARE (Continued)
Unlock the inner cannula (using one hand, which is now Loosens protein secretions and reduces colonizing
considered contaminated) by turning it counterclockwise; microorganisms
deposit it in the basin with the hydrogen peroxide and
saline solution (Fig. B).
Clean the inside and outside of a plastic cannula with pipe Removes gross debris; pipe cleaners are less likely to
cleaners; use pipe cleaners or a soft brush for a metal scratch a plastic cannula
cannula (Fig. C).
B C
Removing the inner cannula. (Copyright Swedish Hospital Medical Center.) Cleaning the inner cannula. (Copyright Swedish Hospital Medical Center.)
Deposit contaminated supplies in a lined or waterproof Reduces the potential for contaminating sterile supplies
waste 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 Removes large droplets of fluid
wipe the excess solution with a gauze square.
Replace the inner cannula and turn it clockwise within Secures the inner cannula
the outer cannula (Fig. D).
Clean around the stoma with an applicator moistened Removes secretions and colonizing microorganisms from
with the diluted peroxide (Fig. E). Never go back over the tracheal opening
an area once you have cleaned it.
D E
Replacing the inner cannula. (Copyright Swedish Hospital Medical Center.) Cleaning the stoma. (Copyright Swedish Hospital Medical Center.)
(continued)
Wipe the same area in the same manner with another Removes hydrogen peroxide from the skin
applicator moistened with saline.
Place the sterile stomal dressing beneath the flanges and Absorbs secretions and keeps the stomal area clean
outer cannula of the tracheostomy tube (Fig. F).
Applying the stomal dressing. (Copyright B. Proud.)
Change the tracheostomy ties by threading them through Holds the tracheostomy tube in place
the slits of each flange of the tracheostomy tube and
tying them in place (Fig. G).
Securing the tracheostomy ties. (Copyright Swedish Hospital Medical Center.)
Wait to remove the previous ties until after the new ones Prevents accidental extubation
are secure, if working alone. Otherwise have an
assistant stabilize 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 Prevents skin impairment
neck. 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 Follows principles of asepsis
your hands or perform an alcohol-based handrub.
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 Facilitates meeting the client’s needs in emergencies and
assistance (e.g., call button, bell). nonemergencies
(continued)
Evaluation
• The tracheostomy tube remains patent.
• The stomal opening is clean 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, ten-
derness, swelling, or purulent drainage. Neck skin is intact; skin color is comparable to surrounding
areas. SIGNATURE/TITLE
37
Chapter
Resuscitation
LEARNING OBJECTIVES
! Explain why an airway obstruction is life threatening.
! Give at least three signs of an airway obstruction.
! Describe two appropriate actions if a client has a partial airway obstruction.
! Explain the purpose of the Heimlich maneuver.
! Describe the circumstances for using subdiaphragmatic thrusts and chest thrusts.
! Discuss the technique used to dislodge an object from an infant’s airway.
! Identify the recommended action for relieving an airway obstruction in an unconscious person.
! List the four steps in the Chain of Survival.
! Explain cardiopulmonary resuscitation (CPR) and its associated “ABCs.”
! Name two techniques for opening the airway.
! List three ways to administer rescue breathing.
! Describe the purpose of chest compression.
! Discuss appropriate use of an automated external defibrillator.
! Identify the maximum time allowed for interrupting CPR.
! Name at least three criteria used in the decision to discontinue resuscitation efforts.
NURSES are often the first people to respond to pulmonary or cardiac emergencies.
The information in this chapter reflects the American Heart Association’s (AHA’s)
International Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular
Care (ECC) Guidelines of 2006 for performing basic life support techniques.
AIRWAY OBSTRUCTION
WORDS TO KNOW The upper airway, which includes the pharynx and trachea, can become occluded for
various reasons (Box 37-1). Sometimes the airway swells because of injury; in such
automated external
cases, the client may need an artificial airway to promote and sustain breathing (see
defibrillator
cardiac arrest Chap. 36). A bolus of food or some other foreign object may cause mechanical airway
cardiopulmonary obstruction. Regardless of the cause, airway obstruction compromises air exchange
resuscitation and subsequent oxygenation of cells and tissues. For this reason, unrelieved airway
Chain of Survival obstruction will lead to loss of consciousness and eventually death.
code
head tilt/chin lift technique
Heimlich maneuver
jaw-thrust maneuver Stop • Think + Respond BOX 37-1
recovery position
rescue breathing Discuss circumstances in which a person is at high risk for
resuscitation team mechanical airway obstruction.
subdiaphragmatic thrust
859
BOX 37-1 ● 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 reddens then becomes pale or blue.
FIGURE 37-1 • Universal sign for choking. (Copyright B. Proud.)
Relieving an Obstruction
• For infants (children younger than 1 year), the rescuer
If the victim can speak or cough, he or she is exchanging
supports the baby over his or her forearm. Holding the
some air, which indicates only a partial obstruction.
infant prone with the head downward, the rescuer
Because infants cannot talk or make the universal chok-
uses the heel of one hand to administer five back slaps
ing sign, ability to cry is the best evidence of partial
between the shoulder blades (Fig. 37-2A). The rescuer
obstruction in this age group. Other than encouraging
turns the infant supine and uses two fingers to give
and supporting the victim, partial obstruction requires
no additional resuscitation efforts. five chest thrusts at approximately one per second to
If the victim’s independent efforts to relieve a partial the middle of the breastbone, just below the nipple line
obstruction are unsuccessful or if the situation worsens, (see Fig. 37-2B). He or she repeatedly alternates five
activating the emergency medical system is appropriate. back blows and chest thrusts until the object is dis-
In the hospital, staff members do this by calling a code lodged or the infant fails to respond. The rescuer does
(summoning personnel trained in advanced life support not use finger sweeps unless he or she can see the
techniques). In the community, people can obtain assis- obstructing object. If the infant becomes unconscious,
tance by dialing 911 or another emergency number. the rescuer performs cardiopulmonary resuscitation
If an obstruction becomes complete, immediate action (described later).
is necessary to dislodge the obstruction. When the victim
is conscious, the Heimlich maneuver (method for relieving
a mechanical airway obstruction) is appropriate. It
involves the use of subdiaphragmatic thrusts (pressure to
the abdomen) or chest thrusts. The victim’s age deter-
mines how these thrusts should be performed:
BOX 37-2 ● Signs of Partial or Complete

Airway Obstruction
❙ Coughing or gagging while eating
❙ Audibly wheezing
❙ Persistently attempting to clear throat
❙ Making hoarse or wet vocal sounds
❙ Resisting efforts to be fed
❙ Being unable to speak
❙ Holding throat
A B
❙ Being unable to breathe
❙ Exhibiting cyanosis FIGURE 37-2 • Assisting an infant with an obstruction. (A) Giving back
blows. (B) Delivering chest thrusts.
CHAPTER 37 ● Resuscitation 861
• For all people older than 1 year of age, the rescuer gives gency services, (2) early CPR, (3) early defibrillation, and
a series of five quick subdiaphragmatic (abdominal) (4) early advanced life support. Survival rates following
upward thrusts slightly above the navel to increase cardiac arrest depend greatly on the speed with which
intrathoracic pressure, equivalent to a cough (Fig. 37-3). rescuers initiate the Chain of Survival. The faster the
The rescuer opens the victim’s airway with the head steps occur, the better the victim’s chances. Outcomes are
tilt/chin lift maneuver (described later) and continues best when rescuers perform these steps rapidly.
administering upward thrusts if initial efforts are not
successful. He or she avoids blind finger sweeps unless
the object in the airway is visible. If the person becomes Early Recognition and Access
unconscious, the rescuer supports the victim to the floor, of Emergency Services
activates the emergency response system, and begins
performing cardiopulmonary resuscitation (described Rescuers place the victim supine on a dry, firm surface
later). The victim’s mouth is checked for any visible and remove clothing from the upper body and any trans-
object when each attempt at ventilation is made. dermal medication patches on the victim’s chest. They
When the victim is unconscious, the AHA recommends perform a quick assessment of breathing, taking no more
than 5 to 10 seconds, followed by an assessment of circu-
the use of basic cardiopulmonary resuscitation (CPR),
lation for a similar amount of time.
described later in this chapter, using chest compressions
As described earlier, if the victim is not breathing,
rather than abdominal thrusts. Chest compression in CPR
coughing, or moving, it is essential to activate the emer-
creates enough pressure in unconscious victims to eject a
gency medical response system, whether outside or within
foreign body from the airway (American Heart Associa-
a health care facility, and to procure an automatic elec-
tion, 2005; Salati, 2006).
tronic defibrillator, if one is available. In most locations,
emergency medical assistance is obtained by dialing 911
and providing information to a central phone operator.
CHAIN OF SURVIVAL The person making the call gives the following facts:
• The address where assistance is needed
If a person’s unresponsiveness may be the result of car- • A description of the situation
diac arrest (the cessation of heart contraction or a life- • The victim’s current condition
sustaining heart rhythm), rescuers implement a four-step • What actions have been taken
intervention process known as the Chain of Survival. The
steps involve (1) early recognition and access of emer- Emergency medical technicians or paramedics are then
dispatched to the scene. If the emergency involves some-
one within a health care agency, the initial rescuer can
alert the resuscitation team (a group of people who have
been trained and certified in advanced cardiac life sup-
port [ACLS] techniques) by notifying the switchboard
operator that assistance is needed and the location of the
emergency.
Early Cardiopulmonary Resuscitation

The rescuers, in the meantime, must proceed with the
ABCDs (Airway, Breathing, Circulation, and Defibrilla-
tion) of cardiopulmonary resuscitation (CPR), a technique
used to restore breathing and circulation.
Opening the Airway

Opening the airway may be all that is necessary to restore
ventilation. Rescuers position the victim supine on a firm
surface, taking care not to twist the spine in case there
is unidentified trauma. In the absence of head or neck
trauma, they use the head tilt/chin lift technique (method of
choice for opening the airway; Fig. 37-4A) or the jaw-
thrust maneuver (alternative method for opening the air-
FIGURE 37-3 • Giving subdiaphragmatic thrusts. way by grasping the lower jaw and lifting it while tilting
reduce the potential for acquiring infectious diseases

(e.g., hepatitis, AIDS); however, lack of a barrier device
should not interfere with attempting rescue breathing.
Because many bystanders are unwilling to perform
mouth-to-mouth ventilation because of fears of disease
transmission, the AHA advises that administering chest
compressions without mouth-to-mouth ventilation is bet-
ter than totally avoiding efforts at resuscitation (Becker
et al., 1997).
MOUTH-TO-MOUTH BREATHING. In mouth-to-mouth

breathing, a rescuer seals the victim’s nose, uses his or
her mouth to cover the victim’s mouth, and blows air
into the victim (Fig. 37-5). After the initial two breaths,
each lasting 1 second, the victim’s pulse is assessed. Giv-
A ing a breath that lasts a full second reduces the potential
for distending the esophagus and stomach, which may
promote regurgitation and aspiration. If breathing is not
restored, the victim remains supine, and rescue breath-
ing continues at the rate of 1 breath every 5 to 6 seconds.
MOUTH-TO-NOSE BREATHING. Mouth-to-nose breathing

is necessary when the victim is an infant or small child or
when mouth-to-mouth breathing is impossible or unsuc-
cessful. In mouth-to-nose breathing, the rescuer closes the
victim’s mouth and blows breaths into the nose.
B
MOUTH-TO-STOMA BREATHING. The rescuer can give res-
FIGURE 37-4 • Techniques to open the airway. (A) Head tilt/chin lift cue breathing to a client with a laryngectomy by sealing
technique. (B) Jaw-thrust technique. his or her mouth over the victim’s stoma. Because the
upper airway is essentially a blind pathway, the nose does
the head backward; Fig. 37-4B). The jaw-thrust maneu- not require sealing.
ver is not recommended for lay rescuers because it is dif- For clients with a tracheostomy tube, rescue breathing
ficult to perform safely and may cause injury to the spine. is through the tube with the mouth or a one-way valve
When the airway is opened, rescuers remove any foreign
material that is visible within the victim’s mouth.
After opening the airway, assessment for spontaneous
breathing is necessary. Rescuers observe for rising and
falling of the chest and listen and feel for air escaping from
the nose or mouth. They then place a breathing victim in
the recovery position (side-lying position that helps to main-
tain an open airway and prevent aspiration of fluid). If
breathing is not restored within 10 seconds, the victim
remains supine, and two rescue breaths are administered.
Each rescue breath should last one second and cause the
chest to rise visibly. Rescue breathing continues at the
rate of 1 breath every 5 to 6 seconds (10 to 12 breaths
per minute) for adults and every 3 to 5 seconds (12 to
20 breaths) for children 8 years old to puberty.
Performing Rescue Breathing

Rescuers perform rescue breathing (process of ventilating
the lungs) through the victim’s mouth, nose, or stoma.
They should use a one-way valve mask or other protec-
tive face shield if available. These devices theoretically FIGURE 37-5 • Mouth-to-mouth rescue breathing.
mask. If the tracheostomy tube does not have an inflated but above the xiphoid process and the other hand on top,
cuff, the rescuer must seal the victim’s nose. interlocking or extending his or her fingers. The rescuer
positions his or her body over the hands to deliver a
Promoting Circulation straight-down motion with each compression (Fig. 37-7).
The hands remain in contact with the chest, and the
To determine whether or not chest compressions are nec-
elbows stay locked to avoid rocking back and forth over
essary, rescuers must assess circulation. Health profes-
the victim. Table 37-1 lists variations in rescue breathing
sionals do so by using two fingers to compress the carotid
and chest compressions to accommodate anatomic differ-
artery to the side of the trachea for an adult (Fig. 37-6) and ences and physiologic needs of various age groups.
simultaneously observing for breathing, coughing, or Basic CPR is not interrupted for more than 7 seconds
movement. The carotid artery is the most accessible site, except when
but the femoral artery in the groin also can be used. For
infants, rescuers use the brachial artery in the upper arm. • There is a pulse and the victim resumes breathing.
Because people who are not health professionals may • The rescuer becomes exhausted.
waste valuable time trying to locate a pulse, they may omit • The victim’s condition deteriorates despite resuscita-
checking the pulse and assess circulation solely by observ- tion efforts.
ing the victim for breathing, coughing, or movement. If the • There is written evidence that resuscitation is contrary
victim appears lifeless, chest compressions are indicated. to the victim’s wishes.
Chest compression promotes circulation in one of • Advanced cardiac life support measures such as defi-
two ways. Squeezing the heart between the sternum and brillation are administered.
vertebrae increases pressure in the ventricles, which is
thought to push blood into the pulmonary arteries and
aorta. Chest compressions also are thought to increase Early Defibrillation
pressure in thoracic blood vessels, promoting systemic
blood flow. For chest compressions to be effective, the If there is no circulation, cardiac compressions continue at
a rate of 100/minute until an automated external defibrillator
rescuer must deliver them at a rate of 100 times/minute
(AED) is available and ready to attach. An AED is a
for adult victims.
portable, battery-operated device that analyzes heart
The correct sequence is 30 chest compressions fol-
rhythms and delivers an electrical shock to restore a func-
lowed by 2 rescue breaths, or a ratio of 30:2 (whether
tional heartbeat. It is used as soon as possible in victims at
by one or two rescuers) for children older than 1 year.
least 8 years old or weighing 55 lbs (25 kg) or more when
If there are two rescuers and the victim is younger than
the heart is not beating effectively (Fig. 37-8). Use of an
1 year old, the ratio is 15 compressions to 2 breaths
AED in children from 1 to 8 years of age or weighing less
(15:2); if the rescuer is alone, a 30:2 ratio is maintained.
than 55 lbs is not recommended unless the device can
Compressions must be of sufficient force (depression of
deliver a pediatric shockable dose (Sampson et al., 2003).
the chest of at least 1.5 to 2 inches in an adult) to cause
a pulsation in the carotid artery.
Correct placement of the hands and the body is essen-
tial during chest compressions. The rescuer puts the heel
of one hand over the lower half of the victim’s sternum
FIGURE 37-6 • Assessing the carotid artery. FIGURE 37-7 • Correct hand and body position.
TABLE 37-1 DIFFERENCES IN CPR AMONG INFANTS, CHILDREN, AND ADULTS

TECHNIQUE INFANT (≤1 YEAR OF AGE) CHILD (1 TO PUBERTY) ADULT (≥PUBERTY)
Rescue breaths
Initial 2 breaths 2 breaths 2 breaths
Subsequent breaths 1 every 3–5 seconds 1 every 3–5 seconds 1 every 5–6 seconds
Rate 12–20/minute 12–20/minute 10–12/minute
Duration 11⁄2 seconds 11⁄2 seconds 11⁄2 seconds
Compressions
Location In the midline, one finger width Center of the chest between the Center of the chest between the
below the nipples nipples nipples
Hand use Two thumbs with the hands encir- Heel of one hand with 2nd hand Two hands; heel of one hand
cling the chest for 2 rescuers or on top, or heel of one hand with other hand on top
2 fingers on the breastbone if only
alone
Rate 100/minute 100/minute 100/minute
Depth 1
⁄3 to 1⁄2 the depth of the chest 1
⁄3 to 1⁄2 the depth of the chest 11⁄2–2 in or more
Ratio 30:2 (1 rescuer) 30:2 (1 rescuer) 30:2 (1 or 2 rescuers)
15:2 (2 rescuers) 15:2 (2 rescuers)
Ideally, an AED is used within 5 minutes of resusci- tion is delayed (Cummins, 1989; Eisenberg et al., 1990;
tation efforts outside the hospital and within 3 minutes Larsen et al., 1993).
of resuscitation efforts within a health care facility. AEDs are located in many public access locations such
Survival rates after cardiac arrest decrease approxi- as schools, airports, and police stations. Once obtained,
mately 7% to 10% with every minute that defibrilla- the user turns on the AED, so that he or she can observe
ASSESS VICTIM
within 10 seconds
ACCESS ADVANCED LIFE SUPPORT TEAM
BEGIN CPR
Within 3-5 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 37-8 • Algorithm for resuscitation.
its monitor screen. Most AEDs have pictorial instructions gives a no shock message, the victim begins to move, or
and the capacity to provide voice instructions. personnel with advanced cardiac life support skills arrive
to assist.
Attaching the Electrode Pads
The rescuer attaches the preconnected electrode pads to
the victim’s skin (Fig. 37-9). If the monitor displays an Stop • Think + Respond BOX 37-2
error message, it may be because the victim’s skin is Review the differences in resuscitating infants, children,
diaphoretic or extremely hairy, which interferes with and adults.
effective contact. The rescuer can wipe the skin with a
towel, shave or clip chest hair, and apply a second set of
electrode pads. Continuing CPR without Defibrillation
Analyzing the Rhythm When an AED is not available and the arrival of emer-
gency resuscitation personnel is delayed, CPR contin-
When the electrode pads are in place and the victim is ues at a rate of 30 compressions to 2 ventilations.
motionless, the rescuer presses an analyze button on Periodically, rescuers assess the victim to determine
the AED or the process occurs automatically. After 5 to whether or not CPR is effective. They should perform
15 seconds, the AED provides a message indicating that an assessment after five cycles of compressions and
the victim needs “shock” or “no shock.” ventilations. Assessment for signs of spontaneous breath-
ing can take place only by interrupting chest compres-
Administering a Shock sions; such interruptions should last no more than
5 seconds.
When the AED indicates “shock,” the rescuer looks
to make sure that no one is touching the victim. Say-
ing “clear” or “everybody clear” in a loud voice is re-
commended before pressing the shock button. The
Early Advanced Life Support
AED discharges the shock, which is confirmed by
Emergency medical support personnel such as paramedics
the victim’s sudden muscle contraction. CPR resumes
provide early advanced life support. They are trained in
immediately after the shock and continues for five
techniques for inserting endotracheal tubes and adminis-
cycles (approximately 2 minutes) before analyzing the
tering supplemental oxygen. They also carry an AED as
rhythm again with the AED. The rescuer then facil-
part of their resuscitative equipment and can administer
itates another analysis of the rhythm and waits for
defibrillation if a public access defibrillator is unavailable.
the next message to shock or not shock. The rescuer
Paramedics administer emergency medications that can
repeats the shock, if indicated, 2 minutes of CPR, and improve the potential for resuscitation before and dur-
analysis steps again and again until either the AED ing the transport of the victim to a hospital’s emergency
department.
RECOVERY
When there is evidence of circulation and breathing,

rescuers place the victim in a recovery position. If an
AED has been used, the electrodes remain in place. Res-
cuers continue to monitor the victim and stand prepared
to reactivate the defibrillator if the victim’s condition
worsens again.
Once the victim is stable, rescuers evaluate their
interventions and operation of the AED for quality
assurance. Internal self-evaluation provides a means to
improve similar resuscitation efforts in the future.
Health care facility personnel are admonished to fol-
low the steps in the Chain of Survival and use an AED
as soon as possible when discovering an unresponsive
FIGURE 37-9 • An automated external defibrillator (AED). (Courtesy client rather than waiting for the arrival of the resus-
of Medtronic, Inc.) citation team.
Nursing Care Plan 37-1 shows how nurses can use the
DISCONTINUING RESUSCITATION steps in the nursing process for a client with Impaired
Spontaneous Ventilation, defined in the NANDA taxon-
Not every resuscitation attempt is successful. Severe neu- omy (2005, p. 214) as “decreased energy reserves (that)
rologic deficits often result even when a victim’s life is result in an individual’s inability to maintain breathing
saved. Success is measured more appropriately by the vic- adequate to support life.”
tim’s quality of life rather than its quantity. Therefore,
there often comes a time, in the absence of a “Do Not
Resuscitate” (DNR) order or advanced directive, when a GENERAL GERONTOLOGIC
team must decide to discontinue both basic and advanced CONSIDERATIONS
life support efforts.
Some older adults fear that if they specify that they do not wish to
Because no clear-cut guidelines for suspending resus-
be resuscitated, they will receive less-than-appropriate care and
citation have been established, efforts may extend for treatment of their illness. The client’s record must contain his or
long periods. The decision in a health care facility to stop her resuscitation status. If no information is documented, CPR is
resuscitation is a medical judgment made by the physi- administered in any life-threatening situation regardless of the
cian or leader of the code. client’s age.
Congress legislated a person’s right to refuse medical treatment in
The decision to stop resuscitation efforts often is based 1990. All states implemented the Patient Self-Determination
on the time that elapsed before resuscitation began, the Act (PSDA) in 1991. This act recognizes that the client, not the
length of time that resuscitation has continued without health care provider, is the ultimate authority in making deci-
any change in the victim’s condition, the age and diagno- sions related to life-sustaining treatments.
sis of the victim, and objective data such as arterial blood Federal law mandates that all health care institutions that partici-
pate in Medicare and Medicaid provide information about
gas results and electrolyte studies. Regardless of the basis PSDA to clients and inquire if the client has a preexisting
for the decision, it is not made lightly and those involved advance directive or living will.
in an unsuccessful code need support from their col- Although nurses cannot provide legal information, they serve as a
leagues. It has been noted that family presence during valuable resource in decisions related to advance directives.
For example, nurses may be required to ascertain if an older
resuscitation has positive psychological value regardless client has an existing advance directive and to ensure that the
of the outcome (MacClean et al., 2003). It is also impor- directions continue to reflect the client’s wishes. If possible, an
tant that a staff member support the observers through- older adult’s advance directive should specify exactly the type
out the experience as well as afterward. of resuscitation he or she wishes. For example, some approve
emergency drugs but refuse mechanical ventilation.
Older adults may need very clear and pertinent descriptions of
various treatments and measures for resuscitation addressed
NURSING IMPLICATIONS in advance directives. Involving family caregivers, particularly
those designated as having health care power of attorney, is
important during any such discussions. A helpful booklet, Hard
Nurses have several responsibilities associated with resus- Choices for Loving People: CPR, Artificial Feeding, Comfort Measures
citation. They must learn to perform basic cardiac life sup- Only and the Elderly Patient by Hank Dunn, is available at
port measures, which include correct use of an AED, and http://www.hardchoices.com.
When possible, it is important to allow several days for older adults
maintain their certification to do so. If nurses do not use to consider advance directives before they sign legal documents.
or refresh these skills at least every 2 years, their abilities They may benefit from consulting trusted members of their reli-
may be less than adequate. They also must support and gious affiliation or trusted medical authorities. Also, discussing
participate in efforts to teach lay people, both adults and the implications of advance directives as they apply to various
children, how to perform CPR and carry out the Chain of settings is important. For example, if a person at home has an
advance directive prohibiting resuscitation, family members and
Survival. Nurses must discuss advance directives (see caregivers need to understand that it may not be appropriate to
Chap. 3) with all clients regardless of the reason for admis- call 911 or begin basic life support procedures.
sion to a health care agency. Honoring the client’s right to Advance directives are to be reviewed periodically (at least annually
participate in the decision-making process is important. and whenever a major change occurs in the older adult’s health
status) and updated according to the current situation and living
The following nursing diagnoses may be relevant in a
arrangement. For example, if an older adult is in a long-term care
resuscitation situation: institutional setting, the staff needs specific directives about when
to send him or her to an emergency room. Similarly in home care
• Ineffective Airway Clearance situations, caregivers need very specific guidelines about what
• Impaired Spontaneous Ventilation course of action to take under various circumstances.
• Impaired Gas Exchange Older adults need to be informed that they may change their mind
• Decreased Cardiac Output about advance directives and instructions for resuscitation at
• Ineffective Cardiopulmonary Tissue Perfusion any time. All changes must be communicated to the physician,
and a written copy should be stored in a safe location.
• Ineffective Cerebral Tissue Perfusion When performing CPR, older adults are at a greater risk for frac-
• Ineffective Renal Tissue Perfusion tured ribs because of the increased likelihood of osteoporosis.
• Decisional Conflict Similarly, those with vascular disease may not receive adequate
Risk for Inability to Sustain Spontaneous Ventilation
ASSESSMENT
• Monitor respiratory rate and breathing pattern.
• Observe for tachypnea, bradypnea, and periods of apnea.
• Note signs of respiratory distress such as use of accessory muscles, sitting upright, nasal flaring, restlessness, and cyanosis.
• Ask the client if he or she is choking or look for the universal sign of the hand to the throat.
• Check for tachycardia.
• Apply a pulse oximeter and note the SpO2 level.
• Obtain and analyze the findings of an arterial blood gas.
• Determine if the client has received medication that causes respiratory depression.
• Check the cause for high- or low-pressure alarms on a mechanical ventilator; it could be malfunctioning.
• Assess level of consciousness and responsiveness.
• Determine if there is an absence of breathing, coughing, and 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 min; SpO2 of 85% with oxygen
at 6 L per Venturi mask; difficulty talking and swallowing; resuscitation by paramedics who
responded to the family’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 breath spontaneously at a ventilation rate to sustain life.
Monitor SpO2 with pulse oximeter at all times. Pulse oximetry measures the amount of oxygen bound to
hemoglobin; sustained SpO2 levels of <90% indicate a need
for supplemental oxygen. SpO2 level of 80% equals an
approximate PaO2 of 45 mm Hg. This finding indicates
moderate to severe hypoxemia and a need for mechanical
ventilation.
Administer oxygen at 45% using Venturi mask. A Venturi mask delivers the exact amount of prescribed
oxygen; 45% oxygen is slightly double the amount of oxygen
in room air; supplemental oxygen helps to relieve hypoxemia.
Maintain client in 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 Venturi mask with a non-rebreather mask if SpO2 A non-rebreather mask can deliver 90% to 100% oxygen
falls below 80%. until the client can receive ventilation assistance.
Obtain arterial blood gas when SpO2 is sustained below An arterial blood gas identifies several important
80% for more than 10 minutes. measurements 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 The Chain of Survival has the greatest potential for
arrest occurs. resuscitating a lifeless person.

• Client continues to breathe spontaneously.
• SpO2 is 90% with 45% oxygen via Venturi mask.
blood perfusion of the brain during CPR, and they may expe- 2. Which of the following should the nurse instruct parents
rience brain damage as a result. of a 6-month-old to avoid when purchasing a toy because
Some older adults with a history of chronic, life-threatening dys- of the risk for accidental choking?
rhythmias that are unresponsive to drug therapy require an 1. Teething ring with gel filling
automatic internal cardiac defibrillator surgically inserted
2. Stuffed animal with button eyes
within their chest. The device senses the dysrhythmia and
almost instantaneously delivers an electrical current to restore 3. Mobile with suspended objects
normal heart rhythm. 4. Ball measuring 5 inches in diameter
If a person has an implanted defibrillator or pacemaker evidenced 3. Which of the following is the best evidence that the nurse
by a hard object beneath the skin with an overlying scar, the should implement the Heimlich maneuver to relieve an
AED pad must be placed at least 1 inch to the side of the
airway obstruction in a conscious person?
implanted device. Wait 30 to 60 seconds after the implanted
defibrillator finishes giving a shock before using an AED. 1. Forceful coughing
Older adults who take daily doses of aspirin or other anticoagulant 2. Attempts to clear throat
drugs are more apt to bleed internally during chest compressions. 3. Inability to speak
4. Audible wheezing
4. When a person is in cardiac arrest, which is the first step
CRITICAL THINKING E X E R C I S E the nurse takes in the Chain of Survival?
1. Arrange the following resuscitation steps in the correct 1. Early cardiopulmonary resuscitation (CPR)
sequence: open the airway; activate the emergency med- 2. Early cardiac defibrillation
ical system; check the carotid pulse; shake and shout; 3. Early access of emergency services
administer chest compressions at a rate of 30:2 breaths; 4. Early advanced life support
give two rescue breaths; attach an AED and follow instruc- 5. Before administering the shock from an automated exter-
tions; give CPR for 2 minutes and reanalyze heart rhythm; nal defibrillator (AED), which of the following actions
listen for breathing. should the nurse take?
1. Place the victim in the recovery position.
2. Loosen the victim’s belt.
NCLEX-STYLE REVIEW Q U E S T I O N S 3. Shout, “Everybody clear.”
1. A nurse is managing care for all the following clients. 4. Give three rescue breaths.
For whom would the nurse most anticipate an airway
obstruction?
1. Client A, who has had a cerebral vascular accident
(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
UUNNI ITT 101

for Chapters 36
1, 2and 37
parentheses.
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 ABCs of cardiopulmonary resuscitation are airway, breathing, and . (circulation, conges-
tion, cyanosis)
statements.
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. Collective system of tubes in the upper and lower respiratory tract
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 to maintain an open airway and prevent aspi-
ration of fluid
Activity D: Match the terms related to resuscitation in Column A with their explana-
tions 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. 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
869 869
Activity E: Differentiate between mouth-to-mouth breathing and mouth-to-stoma

breathing based on the criteria 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 four-

step survival process known as the chain of survival. Write in the boxes provided below
the correct sequence of the chain of survival.
1. Early advanced life support
2. Early cardiopulmonary resuscitation
3. Early recognition and access to emergency services
4. Early defibrillation

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 or 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 undergone 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 attachment of an electrode pad?
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 her 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 from for 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 treatment 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 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.
2. A nurse is caring for a client with a weak and persistent cough. Which of the following interventions 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 tracheostomy for upper airway obstruction. Which of the following interventions
should the nurse perform when providing tracheostomy care for this client?
a. Remove the inner cannula and place it in saline solution.
b. Clean the area around the stoma with diluted peroxide.
c. Blow-dry the cannula after cleaning with 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’s 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/minute.
5. A nurse is caring for a client with impaired ventilation. Which of the following interventions 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.
UNIT 11
Caring for the

Terminally Ill
38 End-of-Life Care
38
Chapter
End-of-Life
Care
LEARNING OBJECTIVES
● Define terminal illness.
● Name the five stages of dying.
● Describe two methods by which nurses can promote acceptance of death in dying clients.
● Define respite care.
● Discuss the philosophy of hospice care.
● List at least five aspects of terminal care.
● Name at least five signs of multiple organ failure.
● Explain why a discussion of organ donation must take place as expeditiously as possible
following a client’s death.
● Name three components of postmortem care.
● Discuss the benefit of grieving.
● Describe one sign that a person is resolving his or her grief.
IN the United States, life expectancy continues to lengthen each year (Fig. 38-1). Never-
WORDS TO KNOW theless, death remains a certainty for all people; the only unknowns are when, where,
and how it will occur.
acceptance Nurses and other health care personnel probably are more involved than any other
anger
anticipatory grieving
group with people who experience impending death. This chapter deals with aspects
autopsy of caring for terminally ill clients and the grieving experience for all those involved
bargaining in the dying process.
brain death
coroner
death certificate
denial TERMINAL ILLNESS AND CARE
depression
dying with dignity
grief response A terminal illness means a condition from which recovery is beyond reasonable expec-
grief work
tation. Such a diagnosis is devastating news. On learning that they will die soon,
grieving
hospice clients tend to experience several stages as they process the information.
morgue
mortician
multiple organ failure
paranormal experiences Stages of Dying
pathologic grief
postmortem care Dr. Elisabeth Kübler-Ross, an authority on dying, has described stages through which
respite care many terminally ill clients progress. These are denial, anger, bargaining, depression,
shroud
terminal illness
and acceptance (Table 38-1). These stages may occur in a progressive fashion, or a
waiting for permission person can move back and forth through the stages. There is no specific time period
phenomenon for the rate of progression, duration, or completion of the stages.
876
CHAPTER 38 ● End-of-Life Care 877
85 Bargaining
Bargaining, a psychological mechanism for delaying the
80 White females inevitable, involves a process of negotiation usually with
God or some other higher power. Usually, dying clients
Life expectancy at birth
are willing to accept death but want to extend their lives

75 Black females temporarily until some significant event takes place
(e.g., a child’s wedding).
White males
70 Depression
Depression (sad mood) indicates the realization that death
65 will come sooner rather than later. The sad mood is a
Black males result of confronting potential losses.
60 Acceptance
Acceptance (attitude of complacency) occurs after clients
55 have dealt with their losses and completed unfinished
1970 1974 1978 1982 1986 1990 1994 2000 2004 business. Kübler-Ross describes unfinished business in
Year two ways. Literally it refers to completing legal and finan-
FIGURE 38-1 • Life expectancy in the United States, 1970–2004. cial matters to provide the best security for survivors. It
(Centers for Disease Control and Prevention. [2002]. United States Life also refers to addressing social and spiritual matters such
Tables, 2007. National Center for Health Statistics. (Available at: http:// as saying goodbye to loved ones and making peace with
www.cdc.gov/nchs/products/pubs/lftbls/lftbls.htm). God. It is as important for dying clients as it is for their
families to say, “Thank you for . . .” and “I’m sorry for . . .”
After tying up all loose ends, dying clients feel prepared
Denial to die. Some even happily anticipate death, viewing it as a
bridge to a better dimension.
Denial, the psychological defense mechanism by which a
person refuses to believe certain information, helps peo-
ple to cope initially with the reality of death. Terminally Promoting Acceptance
ill clients may first refuse to believe that their diagnosis is
accurate. They may speculate that test results are wrong Nurses can help clients to pass from one stage to another
or that their reports have been mixed up with those of by providing emotional support and by supporting the
others. client’s choices concerning terminal care. Facilitating the
client’s directives helps to maintain the client’s personal
Anger dignity and locus of control.
Anger (emotional response to feeling victimized) occurs Emotional Support
because there is no way to retaliate against fate. Clients
often displace their anger onto nurses, physicians, family Emotional support is always part of nursing care; how-
members, even God. They may express anger in less-than- ever, it may be more necessary for dying clients than in
obvious ways—for example, by complaining about care or any other situation. Sometimes a dying client simply
overreacting to even the slightest annoyances. wants an opportunity to express feelings and verbally
work through emotions. Nurses can act as a nonjudg-
mental sounding board in such instances (see Nursing
Guidelines 38-1).
TABLE 38-1 STAGES OF DYING In addition to being available for conversation, nurses
provide emotional support to dying clients by acknowledg-
TYPICAL EMOTIONAL TYPICAL ing them as unique and worthwhile. Dying with dignity
STAGE RESPONSE COMMENT means the process by which the nurse cares for dying
clients with respect, no matter what their emotional, phys-
First stage Denial “No, not me”
ical, or cognitive state. This process reflects the concepts
Second stage Anger “Why me?” stated in the Dying Patient’s Bill of Rights (Box 38-1).
Third stage Bargaining “Yes, me,
but if only. . . .”
Arrangements for Care
Fourth stage Depression “Yes, me.”
Fifth stage Acceptance “I am ready.” Respecting the rights of dying clients includes helping
them to choose how and where they want to receive
878 UNIT 11 ● Caring for the Terminally Ill

Helping Dying Clients Cope
❙ Accept the client’s behavior, no matter what it is. Doing so
demonstrates respect for individuality.
❙ Provide opportunities for the client to express feelings freely. Giving
such opportunities demonstrates attention to meeting individual
needs.
❙ Try to understand the client’s feelings. Understanding reinforces the
client’s uniqueness.
❙ Use statements with broad openings such as, “It must be difficult for
you” and “Do you want to talk about it?” Such language
encourages communication and allows the client to choose the
topic or manner of response.
FIGURE 38-2 • Home care.

terminal care. Clients may find it comforting to prepare
an advance directive (see Chap. 3). Many also appreciate
learning about available settings for care. In general, evaluations. Nurses may help to coordinate community
clients have four choices: home care, hospice care (which services, secure home equipment, and arrange for home
may be the same as home care), residential care, and nursing visits.
acute care. Because the major burden of home care often falls on a
spouse, family member, or significant other, nurses who
HOME CARE. Many clients with a terminal illness remain care for home-bound clients periodically assess the toll this
at home (Fig. 38-2). They may travel to and from a hos- burden takes on the primary caregiver. The focus of sup-
pital or clinic for brief treatments, tests, and medical port may shift back and forth from the client to the care-
giver. 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 encour-
BOX 38-1 ● The Dying Person’s Bill of Rights age the caregiver to identify relatives or friends who will
I have the right to be treated as a living human being until I die.
volunteer relief time with the client. If no one is available,
I have the right to maintain a sense of hopefulness, however changing its focus nurses can refer the caregiver to services through a home
may be. health care agency or Hospice Care.
I have the right to be cared for by those who can maintain a sense of hopeful-
ness, however changing this might be. HOSPICE CARE. The term hospice is used to indicate both a
I have the right to express my feelings and emotions about my approaching
facility for providing the care of terminally ill clients and
death in my own way.
I have the right to participate in decisions concerning my care. the concept of such care itself. The word originally derives
I have the right to expect continuing medical and nursing attention even from a place of refuge for travelers. Today’s hospice move-
though “cure” goals must be changed to “comfort” goals. ment is modeled after facilities established by Dr. Cicely
I have the right not to die alone. Saunders in England in the late 1960s; the movement
I have the right to be free from pain. spread to the United States in the 1970s. The National
I have the right to have my questions answered honestly.
Hospice Organization, now known as the National Hos-
I have the right not to be deceived.
I have the right to have help from and for my family in accepting my death. pice and Palliative Care Organization, was formed in
I have the right to die in peace and dignity. 1978. Its goals are relief from distressing symptoms, eas-
I have the right to retain my individuality and not be judged for my decisions ing pain, and enhancing quality of life (Lattanzi-Licht
which may be contrary to beliefs of others. et al., 1998). In 1982, the U.S. Congress adopted the
I have the right to discuss and enlarge my religious and/or spiritual experi- Medicare Hospice Benefits program to provide funds for
ences, whatever these may mean to others.
I have the right to expect that the sanctity of the human body will be respected
hospice care (Hall, 2003). Hospice care involves helping
after death. clients to live their final days in comfort, with dignity, and
I have the right to be cared for by caring, sensitive, knowledgeable people who in a caring environment (Fig. 38-3).
will attempt to understand my needs and will be able to gain some satisfac-
tion in helping me face my death. Eligibility for Hospice Care. In general, clients with 6 months
or less to live as certified by a physician are accepted for
From Barbus AJ. The Dying Person’s Bill of Rights. © 1975, American
Journal of Nursing Company. Reprinted with permission from the Ameri- hospice care in the United States. If a client survives
can Journal of Nursing, January 1975;75;99. beyond 6 months, he or she continues to receive care as
long as the physician certifies that the client continues to
offer individual and group counseling both during and

after the client’s death to help survivors cope with grief.
Terminating Hospice Care. According to Hall (2003), hospice

services can be terminated in one of two ways: (1) when
the client withdraws for any reason to receive treatment
not covered in the hospice plan of care or (2) when the
client no longer meets the Medicare criteria. Once Medi-
care Hospice Benefits are discontinued, the client forfeits
the remaining days of the benefit period; however, he or
she can reapply for benefits if circumstances change.
RESIDENTIAL CARE. Residential care is a form of inter-

mediate care. Nursing homes or long-term care facilities
are the usual settings for this type of subacute care. These
facilities provide around-the-clock nursing care for clients
who cannot live independently (Fig. 38-4). Family mem-
bers have the peace of mind of knowing that their loved
FIGURE 38-3 • A hospice patient and nurse. one is receiving care, and they enjoy the opportunity to
visit as much as possible. Such care, however, is costly.
Once clients have exhausted their savings, programs
meet hospice criteria. While receiving hospice care, the such as Medicaid may pay their expenses.
client can “transfer to another hospice program, but may
not be discharged because of inability to pay, high cost of ACUTE CARE. A client needs acute care, with its sophis-
treatment, ‘high-tech’ palliative care ordered by the physi- ticated technology and labor-intensive treatment, if his
cian, or ‘difficult’ behavior” (Hall, 2003, p. 6). or her condition is unstable (Fig. 38-5). This form of
care is the most expensive. Bills for acute care provided
Hospice Services. Most hospice clients receive care in their in the hours, days, or weeks before a client’s death can
own homes. A multidisciplinary team of hospice profes- be significant.
sionals and volunteers supports care given by the family
(Box 38-2). Hospice organizations also provide support
programs for family members and significant others. They Providing Terminal Care
Throughout a terminal illness and immediately before a
client’s death, nurses meet his or her basic physical needs
BOX 38-2 ● Medicare Home Hospice Benefits* for hydration, nourishment, elimination, hygiene, posi-
tioning, and comfort. Nurses implement many of the skills
❙ Visiting nurse for skilled and supportive care
❙ Private physician 80% covered under Part B; consulting hospice physician
described throughout this text to meet the multiple prob-
100% covered lems that dying clients experience.
❙ Social work and counseling services for client and caregivers
❙ Pastoral counseling and chaplain services
❙ Home care aid as specified in the hospice plan of care
❙ Volunteers for client and caregivers
❙ Medications related to primary illness
❙ Durable medical equipment as specified in the hospice plan of care
❙ Respite care
❙ 24-hour on-call nurse
❙ Bereavement care
❙ Inpatient care as specified in the hospice plan of care
❙ Medical and personal supplies
❙ Care management
❙ Dietitian as specified in the hospice plan of care
❙ Physical therapy, occupational therapy, and speech-language pathology as
specified in the hospice plan of care
❙ Services to nursing facility residents
❙ Skilled continuous care/private duty nursing during crisis periods as speci-
fied in the hospice plan of care
*Medicare will pay for hospice care if all the following requirements are
met: (1) terminal illness is certified by physician; (2) client elects hospice
benefit; (3) hospice program is Medicare-certified (Hall, 2003).
FIGURE 38-4 • Residential care.
and throat free of accumulating secretions. The lips may

need periodic lubrication because they may become dried
from mouth breathing or administration of oxygen.
Positioning
The lateral position helps to prevent choking and aspira-
tion. Nevertheless, the nurse changes the client’s position
at least every 2 hours (as for any other client) to promote
comfort and circulation.
Comfort
Relieving pain may be the most challenging problem
when caring for dying clients. The goal is to keep clients
free from pain but not to dull consciousness, suppress
respirations, or inhibit the ability to communicate.
FIGURE 38-5 • Acute care. Most clients receive non-narcotics for pain initially;
later the physician may change the drug order to a combi-
nation of a non-narcotic and narcotic analgesic or eventu-
Hydration ally a potent narcotic. He or she also may change the route
Hydration involves the maintenance of an adequate fluid from oral to parenteral or transdermal.
volume. If the client’s swallowing reflex remains intact, Analgesia may be more effective when the client
the nurse offers water and other beverages frequently. receives the drug on a routine schedule. Giving pain med-
As swallowing becomes impaired, the client is at risk for ication regularly, such as every 4 hours or by continuous
aspiration followed by pneumonia. Sucking is one of the release through a transdermal patch, rather than on an as-
last reflexes to disappear as death approaches. Therefore, needed (prn) basis maintains a consistent level of pain
the nurse can provide a moist cloth or wrapped ice cubes relief. The dosage will probably need to be increased
for the client to suck. Eventually the client may need because of drug tolerance (see Chap. 20).
intravenous fluids. Fear of addiction should not interfere with efforts to
relieve pain. The frequency of addiction in previously
Nourishment non–drug-abusing clients is less than 1% (Hall, 2003;
McCaffery et al., 1990). Unfortunately nurses and physi-
Some terminally ill clients have little interest in eating.
cians often misinterpret increased requests for pain med-
The effort may be too exhausting, or nausea and vomit-
ication as evidence of addiction. In reality, an increased
ing may result in inadequate consumption of food. Poor
desire for pain medication may be the result of the devel-
nutrition leads to weakness, infection, and other compli-
opment of drug tolerance or an increase in pain related
cations such as pressure sores. Consequently, the client
to disease progression.
may need tube feedings or total parenteral nutrition to
maintain nutritional and fluid intake. Clients develop tolerance to the pain-relieving property
of analgesic drugs; however, clients who are tolerant to opi-
Elimination oids concomitantly develop resistance to respiratory
depression, a common side effect of narcotic analgesics
Some terminally ill clients are incontinent of urine and (Hall, 2003; McCaffery & Beebe, 1999; Porter & Jick,
stool; others experience urinary retention and constipa- 1980). Sedation generally precedes respiratory depres-
tion. All these conditions are uncomfortable. A physician sion. Therefore, as long as the client is alert, the potential
may order cleansing enemas or suppositories. Catheteriza- for respiratory depression is minimized. Narcotic antago-
tion also may be necessary. Skin care becomes particularly nists can be given for severe respiratory depression, should
important for incontinent clients because urine and stool it develop, but the dosage must be reduced to avoid produc-
left in contact with the skin contribute to skin breakdown ing withdrawal symptoms and eliminating the desired
and produce foul odors. analgesic state. Constipation may be a more common con-
sequence of continuous narcotic analgesia.
Hygiene
The dignity of clients is related largely to their personal
appearance. Therefore, nurses strive to keep dying clients Family Involvement
clean, well groomed, and free of unpleasant odors.
Frequent mouth care may be necessary. Suctioning Family members may appreciate involvement in the
helps to remove mucus and saliva that the client cannot client’s care because they often feel helpless. Involvement
swallow or expectorate. A lateral position keeps the mouth tends to maintain family bonds and helps survivors to
cope with future grief. Many welcome the opportunity to SIGNS OF MULTIPLE
assist. Nevertheless, nurses should not burden family TABLE 38-2
ORGAN FAILURE
members with major responsibilities. ORGAN SIGNS
Some terminally ill clients forestall dying when they
feel that their loved ones are not yet prepared to deal with Heart • Hypotension
their death. This has been described as the “waiting for per- • Irregular, weak, rapid pulse
mission phenomenon,” because death often occurs shortly • Cold, clammy, mottled skin
after a significant family member communicates that he Liver • Internal bleeding
or she is strong enough and ready to “let go.” Nurses must • Edema
• Jaundice
support family members at this time because family mem-
• Impaired digestion, distention, anorexia,
bers may feel as though they have given up and let down nausea, vomiting
their loved one. Lungs • Dyspnea
• Accumulation of fluid (“death rattle”)
Kidneys • Oliguria
Approaching Death • Anuria
• Pruritus (itching skin)
As death nears, the client exhibits signs indicating a Brain • Fever
• Confusion and disorientation
decrease then ultimately a cessation of function. As these
• Hypoesthesia (reduced sensation)
signs appear, the nurse informs the client’s family that • Hyporeflexia (reduced reflexes)
death is approaching. • Stupor
• Coma
Multiple Organ Failure
The signs of approaching death are the result of multiple
organ failure (condition in which two or more organ sys-
tems gradually cease to function), which directly relates
to the quality of cellular oxygenation. When the supply
of oxygen begins to fall below levels required to sustain
life, cells, followed by tissues and organs, begin to deteri- Summoning the Family of a Dying Client
orate. The cardiovascular, pulmonary, hepatic, and renal
systems are most vulnerable to failure.
❙ Plan to notify the family in a timely manner. Prompt attention
allows the family to be with the client at death.
As they cease to function, cells release their intracellu-
lar chemicals. Preexisting hypoxia is first complicated by ❙ Check the client’s medical record for the next of kin or a responsible
a localized then a generalized inflammatory response (see party. Doing so ensures that the nurse notifies someone
Chap. 28) that causes the signs of multiple organ failure, significantly involved in the client’s well-being.
heralding approaching death (Table 38-2). This process ❙ Identify yourself by name, title, and location. Identification provides
may take place gradually over hours or days. more personal communication.
❙ Ask for the family member by name. Doing so ensures that you
Family Notification communicate information to the appropriate person.
As the client shows signs of approaching death, the nurse ❙ Speak in a calm and controlled voice. Doing so conveys a serious,
must make the family aware that the end is near. The competent demeanor.
nurse informs the physician first, however. See Nursing ❙ Use short sentences to provide small bits of information. This
Guidelines 38-2. technique helps the listener to process and comprehend the news.
If death has already occurred, the physician is respon- ❙ Explain that the client’s condition is deteriorating. This explanation
sible for contacting the family and releasing that informa- clarifies the purpose for the call.
tion. Sometimes the physician delays the news until he or
❙ Pause after giving the most important information. A pause allows
she can talk with the family in person to avoid precipitat-
the family member to respond.
ing acts such as suicide or contributing to a traffic accident.
❙ Give brief answers to questions. Emphasize the level of care that the
MEETING RELATIVES. To promote a smooth transition, client is receiving. Such responses reinforce that the client is
relatives of the dying client are met by the nurse who receiving appropriate care.
informed them. If that is not possible, another support ❙ Urge family members to come as soon as possible. This ensures that
person is designated. the people most important to the client are there at death.
On arrival, the nurse shows family members to a pri- ❙ Document the time, the person to whom you communicated the
vate room or area or takes them directly to the client’s bed- information, and the message. Appropriate documentation
side, depending on their wishes. Privacy allows people the provides a permanent record.
freedom to express feelings without social inhibitions.
People have different ways of expressing grief. Some weep tee of the Harvard Medical School released a report on the
and sob uncontrollably; others do not. Nurses remember definition of brain death, a condition in which there is an
that those with less outward signs of grief may be feeling irreversible loss of function of the whole brain including
sorrow that is just as strong as those who cry and grieve the brainstem (Sullivan et al., 1999). Their recommenda-
openly. tions served as the basis for the Uniform Definition of
Death Act in 1980.
DISCUSSING ORGAN DONATION. Virtually anyone, from Consequently, irreversible cessation of circulatory and
the very young to older adults, may be an organ donor. If respiratory functions or cessation of all brain functions
the donor is younger than 18 years, he or she must sign is now considered the most incontestable criterion for
a donor card, along with the parents or legal guardian. establishing whether a person is dead or alive. Although
Age requirements and organ acceptance are determined more than 30 different sets of criteria for determining
on an individual basis at the time of organ procurement “brain death” have appeared in the medical literature
(Table 38-3). since 1978 (Byrne, 1999), the following standards com-
Some people have the foresight to communicate monly are used as guidelines to ensure that brain activ-
whether or not they are interested in organ donation; ity is assessed consistently and accurately. Irreversible
others do not. In either case, if the dying or dead client brain death is considered to be present if, in the absence
meets the donation criteria, the possibility of harvesting of hypothermia, central nervous system depressants, or
organs after death is discussed with the next of kin. This conditions that may simulate brain death, there is
is done delicately by an organ procurement officer. This
person is trained in techniques for sensitively requesting • Unreceptiveness and unresponsiveness to even intense
organ donations from family members grieving the death painful stimuli
of a loved one. The health care agency selects the person • No movement or spontaneous respiration after being
who will solicit organ donations. Typically the facility’s disconnected for 8 minutes from a mechanical ven-
transplant coordinator is the organ procurement officer. tilator
This matter cannot be delayed; some organs, such as • PaCO2 greater than or equal to 60 mm Hg (in the
the heart and lungs, must be harvested within a few hours absence of metabolic alkalosis) after being preoxyge-
to ensure a successful transplant. To protect the health nated with 100% oxygen
care facility from any legal consequences, permission is • Complete absence of central and deep tendon reflexes
always obtained in writing (Fig. 38-6). • Flat electroencephalogram for at least 10 minutes or
confirmation of neurologic inactivity using other stan-
dard neuroimaging techniques
Confirming Death • No change in clinical findings on a second assessment
6, 12, or 24 hours later (Byrne, 1999; Sullivan et al.,
Death is determined on the basis that breathing and circu-
1999). The time frame relates to each state’s medical
lation have ceased. In most cases when these criteria are
standard.
met, there is no question that the person is dead. Legally a
physician is responsible for pronouncing a client dead, but Once death is confirmed, the physician issues a death
in a few states, nurses are authorized to do so. certificate and obtains written permission for an autopsy
if one is desirable.
Brain Death
Death Certificate
In some situations involving irreversible brain damage, a
mechanical ventilator can sustain breathing, and circula- A death certificate (legal document attesting that the person
tion continues reflexively. In 1968, the Ad Hoc Commit- named on the form has been found dead) also indicates the
presumptive cause of the person’s death. Death certifi-
cates are sent to local health departments that use the
TABLE 38-3
AGE CRITERIA FOR information to compile mortality statistics. The statistics
ORGAN DONATION are important in identifying trends, needs, and problems
ORGAN AGE RANGE in the fields of health and medicine.
The mortician (person who prepares the body for bur-
Kidney 6 months–55 years
ial or cremation) is responsible for filing the death certifi-
Liver <50 years cate with the proper authorities. The death certificate
Heart <40 years also carries the mortician’s signature and, in some states,
Pancreas 2–50 years his or her license number.
Corneas Any age
Skin 15–74 years Permission for Autopsy
Guidelines established by the Organ Procurement Agency of Michigan, Ann An autopsy is an examination of the organs and tissues of
Arbor, MI. a human body after death. It is not necessary after all
FIGURE 38-6 • Organ procurement form.
deaths, but it is useful for determining more conclusively A coroner (person legally designated to investigate
the cause of death. The findings may affect the medical deaths that may not be the result of natural causes) has
care of blood relatives who may be at risk for a similar the authority to order an autopsy. The coroner, who may
disorder, or the results may contribute to medical sci- or may not be a physician, does not need permission from
ence. It is usually the physician’s responsibility to obtain the next of kin to do so. In general, a coroner orders an
permission for an autopsy. autopsy if the death involved a crime, was of a suspicious
nature, or occurred without any recent medical consul- a prolonged period. Others may attempt to contact the
tation. deceased through seances. In rare instances, survivors
may keep a corpse in the home for an extended period
after death.
Performing Postmortem Care
Postmortem care (care of the body after death) involves Resolution of Grief
cleaning and preparing the body to enhance its appear-
ance during viewing at the funeral home, ensuring proper Mourning takes longer for some than for others; there is
identification, and releasing the body to mortuary person- no standard length of time for “normal” grieving. One
nel (Skill 38-1). sign that a person is resolving his or her grief is an ability
to talk about the dead person without becoming emotion-
Stop • Think + Respond BOX 38-1 ally overwhelmed. Another sign is that the grieving per-
son describes the good and bad qualities of the deceased.
Discuss nursing activities that demonstrate dignity and
respect for the dead person’s body.
GRIEVING Nurses who care for dying clients, their family members,
and their friends may identify many different nursing
Grieving means the process of feeling acute sorrow over a diagnoses:
loss. It is a painful experience, but it helps survivors to • Acute (or Chronic) Pain
resolve the loss. Some people experience anticipatory griev- • Fear
ing, or grieving that begins before the loss occurs. The • Spiritual Distress
longer people have to anticipate a loss, the more quickly • Social Isolation
they eventually resolve it. Grief work (activities involved in • Ineffective Role Performance
grieving) includes participating in the burial rituals com- • Interrupted Family Processes
mon to a culture. Although such rituals differ, the grief • Ineffective Coping
response (psychological and physical phenomena experi- • Disabled Family Coping
enced by those grieving) is universal. Psychological reac- • Decisional Conflict
tions commonly are identified as the stages of grief: • Hopelessness
• Shock and disbelief: refusal to accept that a loved one • Powerlessness
is about to die or has died • Dysfunctional Grieving
• Developing awareness: physical and emotional res- • Anticipatory Grieving
ponses such as feeling sick, sad, empty, or angry • Caregiver Role Strain
• Restitution period: recognition of the loss • Death Anxiety
• Idealization: exaggeration of the good qualities of the • Chronic Sorrow
deceased Nursing Care Plan 38-1 applies the nursing process to
the care of a client with a diagnosis of Hopelessness,
Some survivors have paranormal experiences (experiences
defined in NANDA’s 2005 taxonomy (p. 93) as a “subjec-
outside scientific explanation) such as seeing, hearing, or
tive state in which an individual sees limited or no alter-
feeling the continued presence of the deceased.
natives or personal choices available and is unable to
Survivors feel physical symptoms more acutely imme-
mobilize energy on (his) own behalf.” Lynda Carpenito-
diately after the death of a loved one. Some grieving peo-
Moyet (2007) further explains, “Hopelessness differs from
ple report symptoms such as anorexia, tightness in the
powerlessness in that a hopeless person sees no solution
chest and throat, difficulty breathing, lack of strength,
to his problem and/or way to achieve what is desired, even
and sleep disturbances. No identifiable pathologic state
if he has control of his life. A powerless person, on the
other than grief can explain these symptoms.
other hand, may see an alternative or answer to the prob-
lem, yet be unable to do anything about it because of lack
Pathologic Grief of control and resources.”
In pathologic grief, also called dysfunctional grief, a person

cannot accept someone’s death. Sometimes people mani-
fest pathologic grief by bizarre or morbid behaviors. For CONSIDERATIONS
example, survivors may keep the possessions of a deceased Families and health care providers should understand that the
loved one exactly as they were at the time of death for dying older adult is a living person who may desire to main-
Hopelessness
ASSESSMENT
• Monitor physical manifestations such as loss of appetite, weight loss, fatigue, and sleep disturbances.
• Observe behavioral manifestations such as reduced motivation, passivity, neglect of hygiene, withdrawal, reduced verbal
interaction, and disinterest in the future.
• Observe emotional manifestations such as feelings of helplessness, apathy, sadness, defeat, and abandonment.
• Observe cognitive manifestations such as suicidal ideation, decreased attention and concentration, illogical thinking,
decreased ability to process or integrate information, and fixation on loss(es).
• Listen for verbal cues that suggest despair, resignation, and surrender.
Nursing Diagnosis: Hopelessness related to psychological distress over development of

HIV-related complication (Pneumocystis 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 Remaining compliant with HIV drug therapy reduces the
cure the pneumonia and control the primary illness potential for drug resistance and extends survival.
indefinitely.
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
illness. toward 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 to 12 months. that the client may feel over accomplishing unrealistic
long-term goals.
Encourage the client to develop a plan for accomplishing Developing a plan provides a tool for accomplishing goals.
one future-related goal.

• Client lists evidence that current health problem is resolving, such as clearer lung sounds and slight weight gain.
• Client discusses various literary works that he has published and was working on prior to his illness.
• Client describes plans to contact a publisher who was interested in a collection of his poems.
tain the same interpersonal relationships as someone who is actually be an effective coping mechanism in helping to
not dying. develop a peaceful and accepting attitude toward death.
Research has shown that some people develop life-threatening Death is a very individualized experience that is highly influ-
illnesses and die within 6 months of the death of a spouse. enced by prior experiences, cultural practices, and level of
Encouraging older adults who have experienced the death of personal development. Many older adults are realistically
a close friend or family member to express feelings associated aware of their pending and inevitable death. Often they
with grieving is important. Referrals for individual counseling are relieved when health care providers are comfortable
or grief support groups are appropriate. discussing death with them. Older adults may benefit from
Older adults may read obituaries and death notices in the news- counseling regarding their own death and dying, especially
paper daily in an effort to keep up with acquaintances. Fami- if they have a history of accepting help in coping with chal-
lies may view this activity as potentially depressing, but it may lenging issues.
Older adults and their families should consider hospice care if a

client meets the medical criteria of having 6 months or less to
live. Even older adults with chronic illnesses, such as dementia, 1. When the nurse cares for a client with no hope of recov-
and family may benefit from the hospice approach to care and
ery, which of the following is the most conclusive criterion
available support services. Often families and older adults are
for declaring the person “brain dead”?
relieved when providers discuss hospice care so they can be
involved in choices about the type of care they receive. 1. Lack of response to verbal stimulation
Include all older adults, as well as those who are dying, in as many 2. Urine output less than 100 mL/24 hours
aspects of care as possible. The emphasis is on maintaining 3. No spontaneous respiratory efforts
self-esteem and personal dignity. 4. Unequal pupils in response to light
Clients of all ages may feel that the use of machines and equip-
2. If a terminally ill client made the following statements to
ment designed to maintain life support threatens their dignity.
a nurse, which is the best evidence that the client is in the
Many older adults prepare advance directives concerning their
health care and identify a person with durable power of health bargaining stage?
care at the same time they prepare a will. These advance 1. “There must be some mistake in the pathology
directives must be reviewed and updated periodically and be report.”
accessible to all those involved in care. 2. “If I can just live until my son graduates, I won’t ask
Evaluation for the use of antidepressants and other therapies for for anything else.”
older adults who are seriously depressed often is appropriate. 3. “I don’t know why I would deserve to die at such a
Older adults have the highest rate of suicide as well as the young age.”
highest rate of completed suicides in proportion to unsuccess- 4. “I hope my death comes quickly; I’m ready to go.”
ful attempts. Health care professionals need to assess suicide
risk in older adults and implement appropriate precautions. 3. When a client has died, under what circumstance can
health care professionals proceed with the protocol for
harvesting organs for transplantation?
CRITICAL THINKING E X E R C I S E S 1. The deceased client has a card indicating his or her
desire to be an organ donor.
1. Does being maintained on life support equipment con- 2. The nursing supervisor believes the deceased has
tradict the right to die in peace and dignity (see the Dying suitable organs for transplantation.
Person’s Bill of Rights)? 3. The deceased client’s next of kin gives permission
2. Select a right from the Dying Person’s Bill of Rights and to harvest the organs.
explain how it might be violated. How can nurses protect 4. The physician has declared and documented the
this right? client’s time of death.
Skill 38-1 • PERFORMING POSTMORTEM CARE
Assessment
Determine that the client is dead by assessing breathing Confirms that the client is lifeless in all but cases in which
and circulation. life 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 Makes others aware of a change in the client’s status
client’s death.
Check the medical record for the name of the mortuary Facilitates collaboration
where the body will be taken.
Planning
Inform mortuary personnel that the family has chosen Communicates a need for services
them to manage the burial.
Ask when to expect mortuary personnel. Facilitates efficient time management
Contact any individuals involved in organ procurement. Promotes timely harvesting of organs
Obtain a postmortem kit or supplies for cleaning, Promotes organization
wrapping, and identifying the body.
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 Prevents skin discoloration in areas that will be visible in
or folded over the abdomen. a casket
Remove all medical equipment* such as intravenous Eliminates unnecessary equipment
catheters, 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 Promotes a natural appearance
mouth.
Cleanse secretions and drainage from the skin. Ensures delivery of a hygienic body
Apply one or more disposable pads between the legs and Absorbs urine or stool should they escape
under the buttocks.
Attach an identification tag to the ankle or wrist; pad the Facilitates accurate identification of the body; prevents
wrist first if it is used. damage to tissue that will be visible
Wrap the body in a paper shroud (covering for the body); Demonstrates respect for the dignity of the deceased
cover the body with a sheet. person
Tidy the bedside area; dispose of soiled equipment. Follows principles of medical asepsis
Remove gloves and wash your hands. Removes colonizing microorganisms
(continued)
PERFORMING POSTMORTEM CARE (Continued)
Leave the room and close the door, or transport the body Provides a temporary location for the body until mortuary
to the morgue (area where dead bodies are temporarily personnel arrive
held or examined) (Fig. A).
A morgue cart. (Copyright B. Proud.)
Make an inventory of valuables and send them to an Ensures safekeeping and accountability for valuables until
administrative office for placement in a safe. a family member can claim them
Notify housekeeping after the body is removed from the Facilitates cleaning and preparation for another admission
room.
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 @ 1400. Dr. Williams notified @ 1415. Dr. Williams pronounced
death and called client’s wife. Foster’s Funeral Home notified. Mortuary personnel unavailable until
1800. Postmortem care provided. Body transported to morgue after wife and children departed.
SIGNATURE/TITLE
*Except in coroner’s cases.

UUNNI ITT 111

for Chapter
Chapters38
1, 2
parentheses.
1. involves a process of negotiation, usually with God or some higher power, in an attempt to
delay the inevitably 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)
statements.
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. Person legally designated to investigate an unnatural death
2. Legal document attesting that the person named on the form is deceased
3. 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
889 889
Activity E: Differentiate between home care and residential care based on the criteria
given below.
Home Care Residential Care
Role of Nurses
Delivery of Care
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?

UNIT 11 ● End of Unit Exercises for Chapter 38 891
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?
Activity I: Answer the following questions, focusing on nursing roles and responsibilities.
1. What are two methods that nurses can use to promote 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: Think over 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
completely 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?
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
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a A P P E N D I X
Chapter Summaries
CHAPTER 1 • Several trends are affecting health care. One of the major issues is
the growing shortage of nurses. Additionally many people, such as
• The art of nursing declined in England with the exile of Catholic reli-
older adults, minorities, and the poor, are not receiving adequate
gious orders, forcing the government to assume responsibility for
health care. The number of uninsured people is rising. Various
caring for the sick, aged, and infirm. Eventually the state delegated this cost-containment practices reduce access to tests, treatment, and
care to untrained and generally uninterested people of questionable services, increase ratios of clients per nurse in employment set-
character. tings, and contribute to a higher acuity of clients in previously
• Florence Nightingale changed the image of nursing by training nurses nonacute settings.
to care for the sick, selecting only those with upstanding character • To address the nursing shortage, the federal Nurse Reinvestment
as potential nurses, improving the sanitary conditions within clients’ Act authorizes loan repayment programs and scholarships; funding
environments, significantly reducing the morbidity and mortality rates for public service announcements; career ladder programs; and
of British soldiers, providing formal nursing classes separate from grants for nurse retention, client safety enhancement, and gerontol-
clinical experience, and arguing that nursing education should be a ogy. Nurses are proactively pursuing post-licensure education; training
lifelong process. for advanced practice; cross-training; learning more about multi-
• Training schools in the United States deviated from the pattern estab- cultural diversity; supporting national health insurance legislation;
lished by Nightingale. No criteria established which hospitals were to promoting community-based programs; emphasizing health pro-
train nurses. Students staffed the hospitals without being paid. There motion; referring clients with health problems for early treatment;
was no uniformity in what was taught; students learned more by coordinating nursing services across care settings; developing and
experience than by formal instruction. Nursing students were taught implementing clinical pathways; participating in quality assurance;
from a physician’s perspective. Students were required to work and and focusing on geriatric populations.
to live at the beck and call of the hospital administrator and after grad- • Regardless of educational background, all nurses use assessment,
uation students were left to seek employment elsewhere. caring, counseling, and comforting skills in clinical practice.
• In addition to employment within hospitals, early graduates of nurs-
ing programs met the health needs of poor immigrants by living
among them in settlement houses in the ghettos of large cities, by CHAPTER 2
serving as midwives for rural women who lacked medical care, and • The nursing process is an organized sequence of steps used to iden-
by caring for sick and wounded soldiers. tify health problems and to manage client care.
• What started as an art, passing on the skills of nursing from one prac- • Characteristics of the nursing process are that it is within the legal
titioner to another, was soon augmented by science, a unique body scope of nursing, based on unique knowledge, planned, client-
of knowledge that made it possible to predict which nursing inter- centered, goal-directed, prioritized, and dynamic.
ventions would be most appropriate for producing desired outcomes. • The steps in the nursing process are assessment, diagnosis, planning,
Most recently nursing has become theory-based, which means that implementation, and evaluation.
nursing scholars are proposing what the process of nursing encom- • Resources for data include the client, the client’s family, medical
passes by explaining the relationship between four essential compo- records, and other health care workers.
nents: humans, health, environment, and nursing. • Data base assessments provide vast information about a client at the
• One of the earliest definitions of nursing outlined the scope of prac- time of admission. Focus assessments, which are ongoing, expand
tice as caring for the sick. More recently the definition has been the database with additional information.
refined with the addition of the nurse’s role in health promotion and • A nursing diagnosis is a health problem that nurses can treat indepen-
independent practice. dently. A collaborative problem is a physiologic complication that
• Those who wish to pursue a career in nursing may choose from a requires the skills and interventions of both nurses and physicians.
practical/vocational nursing program or a registered nursing pro- • A nursing diagnostic statement generally consists of three parts: the
gram taught in a career center, hospital school, community or junior problem, the etiology for the problem, and the signs and symptoms
college, or university. or evidence for the problem.
• The choice of nursing educational program depends on one’s career • Setting priorities for care helps to maximize efficiency in minimal
goals, location of schools, costs involved, length of the program, rep- time.
utation and success of graduates, flexibility in course scheduling, • Short-term goals are those the nurse expects to accomplish in a few
opportunities for part-time or full-time enrollment, and ease of artic- days to 1 week usually when caring for clients in acute care settings
ulation to the next level of education. (e.g., hospitals). Long-term goals may take weeks to months to
• Continuing education is necessary for contemporary nurses because accomplish after discharge from the health care agency. They are
it demonstrates personal accountability, promotes the public’s trust, identified when caring for clients with chronic problems who are
ensures competence in current nursing practice, and keeps the nurse receiving nursing care in a long-term health facility or through com-
abreast of how technology is affecting client care. munity health agencies or home health care.
914
APPENDIX A ● Chapter Summaries 915
• Methods of documentation include writing the problems, goals, and • Values are the ideals that an individual believes are honorable attri-
nursing orders by hand; individualizing a standardized or computer- butes. Beliefs are concepts that individuals hold to be true.
generated care plan; or following an agency’s written standards for • Most Americans believe that health is a resource, a right, and a per-
care or clinical pathways. sonal responsibility.
• Nurses demonstrate implementation of the plan of care by correlating • How “whole” or well a person feels is the sum of his or her physical,
the written plan with nursing documentation in the medical record. emotional, social, and spiritual health, a concept referred to as holism.
• When evaluating the client’s progress, nursing orders are discontin- Any change in one component, positive or negative, automatically
ued if the client has met the goal and the problem no longer exists. creates repercussions in the others.
The nurse revises the care plan if the client has made progress but • There are five levels of human needs: physiologic (first level), safety
the goal remains unmet or if there has been no progress in reaching and security (second level), love and belonging (third level), esteem
a desired outcome. and self-esteem (fourth level), and self-actualization (fifth level). By
• Concept mapping (also known as care mapping) is a method of orga- satisfying needs at each subsequent level, individuals can realize
nizing information in a graphic or pictorial form. The process their maximum potential for health and well-being.
involves drawing lines or arrows to link or correlate relationships • Illness is a state of discomfort that results when a person’s health
within the map. This foundation provides a bridge for developing becomes impaired through disease, stress, or an accident or injury.
more complex skills like identifying nursing diagnoses, setting goals • Morbidity refers to the incidence of a specific disease, disorder, or
and expected outcomes, implementing nursing interventions, and injury. Mortality refers to the death rate from a specific condition. An
evaluating the results of care. acute illness is one that comes on suddenly and lasts a short time. A
chronic illness is one that comes on slowly and lasts a long time. A
terminal illness is one in which there is no potential for cure. A pri-
CHAPTER 3 mary illness is one that developed independently of another disease.
• The six types of laws are constitutional, statutory, administrative, Any subsequent disorder that develops from a pre-existing condition
common, criminal, and civil. is referred to as a secondary illness. Remission refers to the disappear-
• Each state’s nurse practice act defines the unique role of the nurse ance of the signs and symptoms associated with a particular disease.
and differentiates it from that of other health care practitioners. Each An exacerbation refers to the time when the disorder becomes re-
state’s board of nursing is the regulatory agency for managing its activated or reverts from a chronic to an acute state. A hereditary
nurse practice act. condition is one acquired from the genetic codes of one or both par-
• Violations of civil laws include intentional and unintentional torts. ents. Congenital disorders are those that are present at birth but
In an intentional tort, a private citizen sues another for a deliberately result from faulty embryonic development. An idiopathic illness’s
aggressive act. In an unintentional tort, the lawsuit charges that cause is unexplained.
harm resulted from a person’s negligence even though he or she • Primary care refers to the services provided by the first health care
intended no harm. professional or agency an individual contacts. Secondary care per-
• Negligence lawsuits allege that a person’s actions, or lack thereof, tains to the services to which primary care givers refer clients for
caused harm. The defendant is held to a standard expected of any consultation and additional testing such as a cardiac catheterization
other reasonable person. In the case of malpractice, the plaintiff laboratory. Tertiary care takes place in a hospital where complex
alleges that a professional’s actions, or lack thereof, caused harm. technology and specialists are available. Extended care involves
The defendant is held to the standard expected of others with simi- meeting the health needs of clients who no longer require hospital
lar knowledge and education. care but who continue to need health services.
• Professional liability insurance is advantageous for nurses to obtain • Two programs that help to finance healthcare for the aged, disabled,
because (1) nurses are increasingly being named in medical law- and poor are Medicare and Medicaid.
suits, (2) financial damages, when awarded, can be extremely high, • Methods for controlling escalating healthcare costs include a system
and (3) it ensures having an attorney working on the nurse’s behalf. of prospective payment known as the diagnosis-related group, man-
• A nurse’s professional liability can be mitigated by laws such as a aged care, health maintenance organizations, preferred provider
state’s Good Samaritan Act, expiration of the statute of limitations, organizations, and capitation.
legal principles such as a client’s assumption of risk, accurate and • Two national health goals have been set for the year 2010: to
complete documentation, and aggressive risk management. increase years of healthy life and to eliminate health disparities.
• Ethics refers to moral or philosophical principles that classify actions • One of several patterns may be used when providing nursing care for
as right or wrong. clients. In functional nursing, each nurse on a unit is assigned specific
• A code of ethics is a written statement that describes ideal behavior tasks. The case method involves assigning one nurse to administer all
for members of a particular discipline. the care a client needs for a designated period of time. In team nurs-
• There are two ethical theories: teleology and deontology. Teleology ing, many nursing personnel divide the client care and all work until
proposes that the best ethical decision is the one that will result in everything is completed. Primary nursing is a method in which the
benefits for the majority of individuals. Deontology proposes that the admitting nurse assumes responsibility for planning client care and
basis for an ethical decision is simply whether the action is morally evaluating the progress of the client. In managed care, a nurse man-
right or wrong. ager plans the nursing care of clients based on their illness or medical
• Six principles that form a foundation for ethical practice are benefi- diagnosis and evaluates client progress so that each client is ready for
cence, nonmaleficence, autonomy, veracity, fidelity, and justice. discharge by the time designated by prospective payment systems.
• Some common ethical issues that nurses encounter in everyday prac-
tice include telling the truth, protecting clients’ confidentiality, ensur-
ing that clients’ wishes for withholding and withdrawing treatment CHAPTER 5
are followed, advocating for the nondiscriminatory allocation of • Homeostasis refers to a relatively stable state of physiologic equi-
scarce resources, and reporting incompetent or unethical practices. librium.
• Physiologic, psychological, social, and spiritual stressors affect home-
ostasis.
CHAPTER 4
• The philosophic concept of holism leads to two commonly held beliefs:
• The World Health Organization (WHO) defines health as “a state of both the mind and body directly influence humans, and the relation-
complete physical, mental, and social well-being and not merely the ship between the mind and body has the potential for sustaining health
absence of disease or infirmity.” as well as causing illness.
916 APPENDIX A ● Chapter Summaries
• Adaptation refers to how an organism responds to change. Success- keeping government separate from religion; and seeking assistance
ful adaptation is the key to maintaining and preserving homeostasis. from licensed individuals when health care is necessary.
Unsuccessful adaptation leads to illness and death. • A subculture is a unique cultural group that coexists within the dom-
• Adaptive changes occur through the cortex, which communicates inant culture. The four major U.S. subcultures are African American,
with and through the reticular activating system, the hypothalamus, Latino, Asian American, and Native American.
the autonomic nervous system, and the pituitary gland along with • Subcultural groups differ from Anglo-Americans in one or more of
other endocrine glands under its control. the following ways: language, communication style, biologic and
• The sympathetic nervous system, a division of the autonomic nervous physiologic variations, prevalence of diseases, and health beliefs and
system, accelerates the physiologic functions that ensure survival practices.
through strength or a rapid escape. The parasympathetic nervous • The four characteristics of culturally sensitive nursing care are data
system, a second division of the autonomic nervous system, inhibits collection of a cultural nature, acceptance of each client as an indi-
physiologic stimulation, which restores homeostasis and provides an vidual, knowledge of health problems that affect particular cultural
alternative mechanism for dealing with stressors. groups, and planning care within the client’s health belief system to
• Stress involves the physiologic and behavioral reactions that occur achieve the best health outcomes.
when the body’s equilibrium is disturbed. • Some ways that nurses can demonstrate cultural sensitivity include
• People vary in their response to stressors depending on the intensity learning a second language, performing physical assessments and care
and duration of the stressor, the number of stressors at one time, according to the client’s unique biologic differences, consulting each
physical status, life experiences, coping strategies, social support sys- client as to his or her cultural preferences, arranging for modifications
tem, and personal beliefs, attitudes, and values. in diet and dress according to the client’s customs, and allowing
• The general adaptation syndrome, a physiologic stress response clients to continue relying on cultural health practices (if they are not
described by Hans Selye, consists of the alarm stage, stage of resis- harmful).
tance, and stage of exhaustion. In most cases, the alarm stage and stage
of resistance restore homeostasis. When the stage of resistance is pro- CHAPTER 7
longed, however, adaptive resources are overwhelmed and the person
enters the stage of exhaustion, which is characterized by stress-related • In a nurse–client relationship, nurses meet client needs by perform-
disorders and, in some cases, death. ing any or all of the following roles: caregiver, educator, collaborator,
• Stress-related disorders and their consequences are minimized at and delegator.
three levels. Primary prevention involves reducing the potential for • The role of clients is to be actively involved in their care, to commu-
a disorder. Secondary prevention involves public screening and early nicate, to ask questions, to assist in planning their care, and above all
diagnosis. Tertiary prevention uses rehabilitation and aggressive to retain as much independence as possible.
management when a disorder develops. • Some principles underlying a therapeutic nurse–client relationship
• Psychological adaptation occurs through the use of coping mecha- include treating each client as a unique person; respecting the client’s
feelings; striving to promote the client’s physical, emotional, social,
nisms and coping strategies. Healthy use of coping mechanisms and
and spiritual well-being; encouraging the client to participate in
coping strategies allows people to postpone the emotional effects of
problem solving and decision making; and accepting that a client has
stress, permitting them to deal with reality eventually and gain emo-
the potential for growth and change.
tional maturity. Unhealthy use of coping mechanisms tends to dis-
• A nurse–client relationship usually encompasses three phases: intro-
tort reality to such an extent that the person fails to see or correct his
ductory, working, and termination.
or her weaknesses. Nontherapeutic coping strategies provide tempo-
• Communication involves sending and receiving messages between
rary relief but eventually cause problems.
two or more people followed by feedback indicating that the infor-
• Nursing care of clients under stress includes identifying stressors,
mation was understood or requires further clarification. Therapeu-
assessing the client’s response to stressors, eliminating or reduc-
tic communication refers to using words and gestures to accomplish
ing stressors, preventing additional stressors, promoting adaptive
a particular objective.
responses, supporting coping strategies, maintaining a client’s net- • Examples of therapeutic verbal communication techniques include
work of support, and implementing stress reduction and stress man- questioning, reflecting, paraphrasing, sharing perceptions, and clari-
agement techniques. fying. Examples of nontherapeutic verbal communication techniques
• Four methods for preventing, reducing, or eliminating a stress response include giving false reassurance, using clichés, giving approval or dis-
include using stress reduction techniques such as providing adequate approval, demanding an explanation, and giving advice.
explanations in understandable language; implementing stress man- • Some factors that may affect oral communication include language
agement interventions such as progressive relaxation; promoting the compatibility; verbal skills; hearing and visual acuity; motor func-
release of endorphins through massage, for example; and manipulat- tions involving the throat, tongue, and teeth; sensory distractions;
ing sensory stimuli as might be done with aromatherapy. and interpersonal attitudes.
• The four forms of nonverbal communication are kinesics (body lan-
guage), paralanguage (vocal sounds), proxemics (how space is used
CHAPTER 6
in communication), and touch.
• Culture refers to the values, beliefs, and practices of a particular • Task-related touch involves the personal contact required when per-
group. Race refers to biologic variations such as skin color, hair tex- forming nursing procedures. Affective touch is used to demonstrate
ture, and eye shape. Ethnicity is the bond or kinship a person feels concern or affection.
with his or her country of birth or place of ancestral origin. • Affective touch is appropriate in many situations. Examples include
• Two factors that interfere with perceiving others as individuals are caring for clients who are lonely, uncomfortable, near death, or anx-
stereotyping, which involves ascribing fixed beliefs about people ious and those with sensory deprivation.
based on some general characteristic, and ethnocentrism, the belief
that one’s own ethnicity is superior to all others.
• U.S. culture is said to be Anglicized because many of the values,
CHAPTER 8
beliefs, and practices evolved from the early English settlers. • The three learning domains are the cognitive domain (information
• Some examples of Anglo-American culture include speaking Eng- usually provided in oral or written forms), the affective domain
lish; valuing work, time, and technology; holding parents responsi- (information that appeals to a person’s feelings, beliefs, or values),
ble for the health care, behavior, and education of minor children; and the psychomotor domain (learning by doing).
• Three age-related categories of learners are pedagogic (children), • Nonpathogens are generally harmless microorganisms, whereas patho-
androgogic (young and middle-aged adults), and gerogogic (older gens have a high potential for causing infections and contagious dis-
adults). eases. Resident microorganisms are generally nonpathogens that
• Examples of characteristics unique to gerogogic learners are that are always present on the skin. Transient microorganisms are gener-
they are motivated to learn by a personal need, they may be experi- ally pathogens that are more easily removed through handwashing.
encing degenerative physical changes, and they can draw on a vast Aerobic microorganisms require oxygen for survival, whereas anaer-
repertoire of past experiences. obic microorganisms do not.
• Before teaching a client, the nurse assesses the client’s learning style, • Some microorganisms have ensured their survival by developing the
age and development, capacity to learn (includes level of literacy, any capacity to form spores and resist antibiotic drug therapy.
sensory deficits, and cultural differences), ability to pay attention • The components of the chain of infection are an infectious agent,
and concentrate, motivation, learning readiness, and learning needs. a reservoir for growth and reproduction, an exit route from the
reservoir, a mode of transmission, a port of entry, and a suscepti-
CHAPTER 9 ble host.
• Several biologic defenses reduce susceptibility to infectious agents.
• Medical records are used as a permanent account of a person’s health Examples include intact skin and mucous membranes; reflexes such
problems, care, and progress; to share information among health care as sneezing, coughing, and vomiting; infection-fighting blood cells;
personnel; as a resource for investigating the quality of care in an enzymes such as lysozyme, which is present in tears, saliva, and
institution; to acquire and maintain JCAHO accreditation; to obtain other secretions; the acidity of gastric acid; and antibodies.
reimbursement for billed services and products; to conduct research; • Nosocomial infections are those acquired by previously uninfected
and as legal evidence in malpractice cases. clients while they are being cared for in a health care facility.
• Medical records generally contain an information sheet about the • Asepsis refers to practices that decrease the numbers of infectious
client, medical information, a plan of care, nursing documentation, agents, their reservoirs, and vehicles for transmission.
medication administration records, and laboratory and diagnostic • Medical asepsis involves practices that confine or reduce micro-
test results. organisms. Surgical asepsis involves measures that render supplies
• Health care agencies may organize information in the medical record
and equipment totally free of microorganisms and practices that
using a source-oriented or a problem-oriented format. Source-oriented
avoid contamination during their use.
records categorize information according to the source reporting it;
• Principles of medical asepsis include frequent handwashing or hand
problem-oriented records are organized according to the client’s health
antisepsis and maintaining intact skin (the best methods for reduc-
problems regardless of who does the documentation.
ing the transmission of microorganisms); using personal protective
• Nurses may document information in the medical record using one
equipment (gloves, gown, mask, goggles, and hair and shoe covers);
of the following methods: narrative charting, SOAP charting, focus
and maintaining a clean environment.
charting, PIE charting, charting by exception, and computerized
• Surgical asepsis involves sterilization measures such as ultraviolet
charting.
radiation, heat, or chemicals.
• HIPAA legislation was enacted originally to protect health informa-
• Three of the principles of surgical asepsis are as follows: sterility is
tion communicated from one insurance company to another when a
preserved by touching one sterile item with another sterile item;
person changed employment. Recent revisions to that legislation
once a sterile item touches something that is not sterile, it is consid-
now regulate methods for further ensuring the client’s privacy in the
ered contaminated; and any partially unwrapped sterile package is
workplace and security of data.
• Regardless of the charting style, all documentation in an acute health considered contaminated.
care agency includes ongoing assessment data, a plan of care, a record • Nurses apply principles of surgical asepsis when they create a ster-
of the care provided, and the outcomes of the implemented care. ile field, add supplies or liquids to a sterile field, and don sterile
• Nurses use only agency-approved abbreviations when documenting gloves.
information to promote clarity in communication among health pro-
fessionals and to ensure accurate interpretation of the documented CHAPTER 11
information if the chart is subpoenaed as legal evidence.
• Military time is based on a 24-hour clock. Each time is indicated • The process of admission involves obtaining authorization from a
using a different four-digit number. After noon, the time is identified physician, obtaining billing information, completing nursing respon-
by adding 12 to each hour. sibilities such as orienting the client and obtaining a data base assess-
• Some principles of charting include the following: ensure that the ment, developing an initial plan for nursing care, and fulfilling medical
documentation form identifies the client; use a pen; print or write responsibilities such as documenting the client’s history and results of
legibly; record the time of each entry; fill all the space on a line; use a physical examination.
only approved abbreviations; describe information objectively, pro- • Some common reactions of newly admitted clients are anxiety, lone-
viding precise measurements when possible; avoid obliterating infor- liness, potential for compromised privacy, and loss of identity.
mation; and sign each entry by name and title. • The discharge process consists of obtaining a written medical order
• Written forms of communication other than the medical record for discharge, completing discharge instructions, notifying the busi-
include the nursing care plan, nursing Kardex, checklists, and flow ness office, helping the client leave the agency, writing a summary of
sheets. the discharge in the medical record, and requesting that the room be
• In addition to the written record, the health care team may exchange cleaned.
information during change of shift reports, client care assignments, • Examples of the use of transfers in client care include moving a client
team conferences, rounds, and telephone calls. from one level of care to another when his or her condition improves,
worsens, or no longer meets the criteria initially established but still
needs some type of attention.
CHAPTER 10 • A transfer involves discharging a client from one unit or agency and
• Microorganisms are living animals or plants visible only with a admitting him or her to another without going home in the interim.
microscope. A referral involves sending a client who will be discharged to another
• Some examples of microorganisms are bacteria, viruses, fungi, rick- person or agency for special services.
ettsiae, protozoans, mycoplasmas, helminths, and prions. • Nursing homes may provide skilled, intermediate, or basic care.
• To determine the level of care a client requires, federal law requires CHAPTER 13
licensed extended care facilities to complete a Minimum Data Set
assessment form on admission and every 3 months thereafter or • Physical assessments are performed to evaluate the client’s current
whenever the client’s condition changes. physical condition, to detect early signs of developing health prob-
• The demand for home health care services has increased due to limits lems, to establish a database for future comparisons, and to evaluate
on insurance reimbursement for hospital stays and the growing num- responses to medical and nursing interventions.
ber of older adults in the population who need health care assistance. • There are four physical assessment techniques: inspection, percus-
sion, palpation, and auscultation.
• Before performing a physical assessment, the nurse needs gloves,
CHAPTER 12 examination gown, cloth or paper drape, stethoscope, penlight, and
• Vital signs include temperature, pulse, respirations, and blood tongue blade as well as other assessment instruments for taking vital
pressure. signs and weighing and measuring the client.
• Shell temperature is the degree of warmth at the skin surface; core • The assessment environment should be near a restroom, private,
temperature is the degree of warmth near the center of the body warm, and adequately lit. There should be an adjustable examination
where vital organs are located. table or bed.
• Temperature is measured using the Celsius or Fahrenheit scale. • During an initial survey of a client, the nurse observes physical
• The mouth, rectum, axilla, and ear are common sites for assessing appearance, level of consciousness, body size, posture, gait, move-
body temperature; the temperature of the tympanic membrane in the ment, use of ambulatory aids, and mood and emotional tone.
ear is the closest approximation of core temperature. • Drapes during a physical examination protect the client’s modesty
• Electronic, infrared, chemical, and digital thermometers are used to and provide warmth.
assess body temperature; glass mercury thermometers are no longer • There are two approaches for data collection. The head-to-toe
recommended for use because mercury is an environmental and approach involves gathering data from the top of the body then work-
human toxin. ing toward the feet. The systems approach organizes data collection
• A fever exists when a client has a body temperature that exceeds according to the functional systems of the body.
99.3°F (37.4°C). Hyperthermia is a life-threatening condition char- • The body may be divided into six general components when organiz-
acterized by a body temperature that exceeds 105.8°F (40.6°C). ing data collection: the head and neck, the chest, the extremities, the
• A fever generally has four phases: prodromal, onset or invasion, sta- abdomen, the genitalia, and the anus and rectum.
tionary, and resolution or defervescence. • Whenever an opportunity arises, nurses teach adult clients how to
• A fever is accompanied by chills, flushed skin, irritability, and perform breast and testicular self-examinations.
headache as well as several other signs and symptoms.
• An infrared tympanic thermometer is the best assessment tool for CHAPTER 14
measuring subnormal temperatures because other common clinical
thermometers cannot accurately measure temperatures in hypother- • An examination is a procedure that involves the physical inspection
mic ranges and the blood flow in the mouth, rectum, and axilla is gen- of body structures and evidence of their functions. A test involves
erally so low that measurements taken from these sites are inaccurate. the examination of body fluids or specimens.
• Subnormal temperatures are accompanied by shivering, pale skin, • Whenever clients undergo special examinations and tests, the nurse
listlessness, and impaired muscle coordination as well as several is generally responsible for determining the client’s understanding of
other signs and symptoms. the procedure, checking that the consent form is signed, following test
• A pulse assessment includes the rate per minute, rhythm, and volume. preparation requirements or teaching outpatients how to prepare
• The radial artery is the most common pulse assessment site; how- themselves, obtaining equipment and supplies, arranging the exami-
ever, similar data may be obtained by assessing the apical heart rate nation area, positioning and draping clients, assisting the examiner,
or the apical-radial rate or by using a Doppler ultrasound device. providing clients with physical and emotional support, caring for
• Respiration refers to the exchange of oxygen and carbon dioxide. specimens, and recording and reporting significant information.
Ventilation is the movement of air in and out of the chest. The rate • The five common examination positions are dorsal recumbent, Sims’,
of ventilations is assessed when obtaining vital signs. lithotomy, knee–chest, and modified standing.
• Some abnormal breathing characteristics that may be noted are • A pelvic examination involves the inspection and palpation of the
tachypnea (rapid breathing), bradypnea (slow breathing), dyspnea vagina and adjacent organs. This examination often includes the col-
(labored breathing), and apnea (absence of breathing). lection of secretions for a Pap test to identify any abnormal cells, lev-
• Blood pressure measurements reflect the ability of the arteries to els of hormone activity, and identity of infectious microorganisms.
stretch, the volume of circulating blood, and the amount of resistance • Tests and examinations commonly involve the use of specimens,
the heart must overcome when it pumps blood. x-rays, endoscopes, radioactive substances, sound waves, and elec-
• Systolic pressure is the pressure within the arterial system when the trical activity.
heart contracts. Diastolic pressure is the pressure within the arterial • When determining how particular tests are performed, it is helpful
system when the heart relaxes and fills with blood. to understand four word endings: -graphy, as in angiography,
• A stethoscope, an inflatable cuff, and a sphygmomanometer are usu- means to record an image; -scopy, as in bronchoscopy, means to
ally required for measuring blood pressure. look through a lensed instrument; -centesis, as in amniocentesis,
• During an auscultated blood pressure assessment, five distinct sounds, means to puncture; and -metry, as in pelvimetry, means to measure
called Korotkoff sounds, are heard. Phase I is characterized by faint with an instrument.
tapping sounds; in phase II, the sounds are swishing; in phase III, the • Nurses often are called on to assist with sigmoidoscopy (inspecting
sounds are loud and crisp; in phase IV, the sound becomes suddenly the rectum and sigmoid section of the lower intestine with an endo-
muffled; and in phase V there is one last sound, followed by silence. scope), paracentesis (puncturing the skin and withdrawing fluid from
• Blood pressure may be measured with an electronic sphygmo- the abdominal cavity), and lumbar puncture (inserting a needle
manometer, which provides a digital display of the pressure mea- between lumbar vertebrae in the spine but below the spinal cord
surements. The blood pressure also can be measured by palpating the itself); to collect a throat culture specimen; and to measure capillary
brachial pulse while releasing the air from the cuff bladder, by using blood glucose levels using a glucometer.
a Doppler stethoscope or an automated blood pressure machine, or • When the client undergoing special examinations and tests is an
taking the blood pressure at the thigh. older adult, the nurse faces special challenges such as preventing
fatigue and dehydration, maintaining or adjusting current drug ther- • IV fluids are administered to maintain or restore fluid balance, main-
apy and avoiding misinterpretation of laboratory test results that are tain or replace electrolytes, administer water-soluble vitamins, pro-
based on norms for younger adults. vide calories, administer drugs, and replace blood and blood products.
• Crystalloid solutions are mixtures of water and substances such as
salt and sugar that totally dissolve. Colloid solutions are mixtures of
CHAPTER 15
water and suspended, undissolved substances such as blood cells.
• Nutrition is the process by which the body uses food. Malnutrition • An isotonic solution has the same concentration of dissolved sub-
results from inadequate consumption of nutrients. stances as plasma; a hypotonic solution has fewer dissolved sub-
• The components of basic nutrition include adequate calories, proteins, stances; and a hypertonic solution is more concentrated than plasma.
carbohydrates, fats, vitamins, and minerals. • When selecting tubing for administering IV solutions, the nurse
• Some factors that affect nutritional needs include age, height and must consider whether to use primary or secondary tubing and
weight, growth, activity, and health status. vented or unvented tubing, which drop size is most appropriate, and
• MyPyramid from the United States Department of Agriculture is a whether or not a filter is needed.
guide for promoting a healthy daily intake of food. • IV fluids may be infused by gravity or with the assistance of an infu-
• Nutrition labels must indicate the serving size in household mea- sion device such as a pump or volumetric controller.
surements and the daily value for specific nutrients per serving. • When selecting a vein for venipuncture, the nurse gives priority to a
They must meet specified criteria if they make health-related claims vein in the nondominant hand or arm that is fairly straight, is larger
for the product. than the needle or catheter gauge, is likely to be undisturbed by joint
• Protein complementation is the practice of combining two or more movement, and appears unimpaired by previous trauma or use.
plant protein sources to obtain all the essential amino acids required • Complications of IV fluid therapy include infiltration, phlebitis, infec-
for healthy nutrition. tion, circulatory overload, thrombus formation, pulmonary embolus,
• Data that provide objective information about a person’s nutritional and air embolism.
status include anthropometric measurements, physical examination • An intermittent venous access device is used in clients who require
data, and results from laboratory tests. intermittent IV fluid or medication administration or for emergency
• A diet history is the information obtained by asking a person to access to the vascular system.
describe his or her eating habits and factors that may affect nutrition.
• When administering blood, the nurse assesses vital signs before and
• Problems commonly identified after a nutritional assessment include
during the transfusion; uses no smaller than a 20-gauge needle or
weight problems, anorexia, nausea, vomiting, and stomach gas.
catheter, normal saline solution, and Y-set tubing; and infuses the
• If a nutritional problem is beyond the scope of independent nursing
blood within 4 hours or less.
practice, the nurse consults with the physician. If the problem can be
• During a blood transfusion, the nurse monitors the client closely for
resolved through independent nursing measures, the nurse may pro-
incompatibility; febrile, septic, and allergic reactions; chilling; circu-
ceed by collaborating with the dietitian, selecting appropriate nurs-
latory overload; and signs of hypocalcemia.
ing interventions, and continuing to monitor the client to evaluate
• Parenteral nutrition is a technique for providing nutrients, such as
the effectiveness of the nursing care plan.
protein, carbohydrate, fat, vitamins, minerals, and trace elements,
• Common hospital diets are regular, light, soft, mechanical soft, full
intravenously rather than orally.
liquid, and clear liquid, and various therapeutic modifications to
these diets.
• Nurses are generally responsible for ordering and canceling diets for CHAPTER 17
clients, serving and collecting meal trays, helping clients to eat, and
• Hygiene refers to practices that promote health through personal
recording the percentage of food eaten.
cleanliness.
• Nurses must know the type of diet prescribed for each client, the pur-
• Hygiene practices that most people perform regularly include bathing,
pose for the diet, and its characteristics.
• Influences on the nutritional status of older adults include age- shaving, oral hygiene, hair care, and nail care.
related physical changes, underlying medical conditions, adverse • A partial bath is more appropriate for older adults than a daily tub
effects of medication therapy, functional impairments, psychosocial bath or shower, because they do not perspire as much as young
conditions, and socioeconomic and environmental barriers. adults and soap tends to dry their skin.
• Towel and bag baths add lubrication to the skin; avoid friction to pre-
serve skin integrity; reduce transmission of microorganisms from one
CHAPTER 16 part of the body to another; save time; provide more opportunity for
• Body fluid is a mixture of water, chemicals called electrolytes and self-care; and promote comfort because of the warmth of the liquid.
nonelectrolytes, and blood cells. • Use of a safety razor is contraindicated for clients who have clotting
• Fluid and its components are distributed within each fluid compart- disorders, those receiving anticoagulants and thrombolytics, and those
ment by means of osmosis, filtration, passive diffusion, facilitated who are depressed and suicidal.
diffusion, and active transport. • Most dentists recommend using a soft-bristled or electric toothbrush,
• The nurse assesses fluid volume status by measuring a client’s intake tartar-control toothpaste with fluoride, and dental floss.
and output, obtaining daily weights, obtaining vital signs, monitor- • The chief hazard in providing oral hygiene for unconscious clients
ing bowel elimination patterns and stool characteristics, observing is aspiration of liquid into the lungs. To prevent aspiration, nurses
the color of urine, and assessing skin turgor, the condition of the oral position unconscious clients on the side with the head lower than the
mucous membranes, lung sounds, and level of consciousness. body. They use oral suction equipment to remove liquid from the
• Fluid volume is restored by treating the underlying disorder, increas- mouth.
ing oral intake, administering IV fluid replacements, controlling fluid • To prevent damage during cleaning, the nurse holds dentures over a
losses, or a combination of these measures. plastic or towel-lined container and uses cold or tepid water.
• Fluid volume excess is reduced or eliminated by treating the under- • The nurse can detangle a client’s hair by applying conditioner, using
lying disorder, restricting or limiting oral fluids, reducing salt con- a wide-toothed comb, and combing from the end of the hair toward
sumption, discontinuing IV fluid infusions or reducing the infusing the scalp.
volume, administering drugs that promote urine elimination, or a • The nurse consults the physician about nail care for clients with dia-
combination of these interventions. betes or poor circulation.
• Daily hygiene also includes cleaning and caring for visual or hear- CHAPTER 19
ing devices such as eyeglasses, contact lenses, artificial eyes, or hear-
• Accidental injuries vary according to the victim’s stage of develop-
ing aids.
ment. Because infants must rely on their caretakers, they are suscep-
• Clients who cannot insert and care for contact lenses may consider
tible to falls. Poisonings are common among toddlers. School-aged
wearing eyeglasses, using a magnifying lens, or doing without while
children suffer play-related injuries, and adolescents are often the vic-
they are ill.
tims of sport-related injuries. Young adults commonly are involved in
• The sound that a hearing aid produces may be altered as a result of
motor-vehicle accidents. Middle-aged adults suffer a variety of phys-
dead or weak batteries, batteries that are not making full contact,
ical traumas such as back injuries. Falls are common among older
corroded batteries, malposition within the ear, excessive volume,
adults.
impacted cerumen, and dirty or damaged components.
• Environmental hazards often contribute to injuries and deaths from
• Infrared listening devices are an alternative to hearing aids. They
latex sensitization, burns, asphyxiation, electrical shock, poisoning,
convert sound into infrared light then reconvert the light to sound
and falls.
through a receiver worn in a headset with earphones.
• Measures to reduce latex sensitization include using nonlatex gloves
and medical equipment, washing hands after removing latex gloves,
CHAPTER 18 and avoiding use of petroleum-based hand creams or lotions, which
retain latex protein on the skin.
• Comfort is a state in which a person is relieved of distress. Rest is a
• Most fire plans incorporate four steps: rescue those in danger, sound
waking state characterized by reduced activity and mental stimula-
an alarm, confine the fire, and extinguish the blaze.
tion. Sleep is a state of arousable unconsciousness.
• There are four classes of fire extinguishers. Class A extinguishers are
• Some environmental factors that promote comfort, rest, and sleep
used for paper, wood, and cloth fires. Class B extinguishers are used
are colorful walls and room decor, reduced noise, increased natural
on fuels and flammable liquids. Class C extinguishers are used for elec-
sunlight, and a comfortable climate.
trical fires. Class ABC extinguishers can be used on any type of fire.
• Standard furnishings in all client rooms are the bed, the overbed
• Methods of preventing burns include installing and maintaining
table, the bedside stand, and at least one chair.
smoke detectors, developing and practicing a fire evacuation plan,
• Sleep is a basic human need. Among other things, it reduces fatigue,
and never going back into a burning building.
stabilizes mood, increases protein synthesis, promotes cellular growth
• Common causes of asphyxiation include smoke inhalation, carbon
and repair, and improves the capacity for learning and memory monoxide poisoning, and drowning.
storage. • Measures to prevent drowning are wearing approved flotation devices,
• The two phases of sleep are nonrapid and rapid eye movement sleep. avoiding alcohol consumption when around water, and never swim-
During nonrapid eye movement (NREM) sleep and its four subdivi- ming alone.
sions, the body is active but the brain is not. During rapid eye move- • Humans are susceptible to injury from electrical shock because the
ment (REM) sleep, the body is physically inactive but the brain is human body is predominately composed of water and electrolytes,
highly active. which are good conductors of electrical current.
• As humans age, they sleep fewer hours and spend less time in REM • Electrical shock may be prevented by using three-pronged grounded
sleep. Newborns spend 16 to 20 hours of each day sleeping, approx- equipment, making sure all cover plates are intact, and replacing
imately half in the REM phase. Older adults require 7 to 9 hours of equipment with frayed electrical cords.
sleep and spend only 13% to 15% in the REM phase. • Substances commonly implicated in poisonings include chemicals
• Circadian rhythms, activity, the environment, motivation, emotions such as drugs, cleaning agents, paint solvents, heavy metals, cosmet-
and moods, food and beverages, illness, and drugs can affect the ics, and plants.
amount and quality of sleep. • Poisonings may be prevented by using childproof caps on medication
• Four major categories of drugs either promote or interfere with bottles, installing latches on storage cupboards, and never transfer-
sleep. Sedatives and tranquilizers produce a relaxing and calming ring a toxic substance to a container generally associated with food.
effect, hypnotics induce sleep, and stimulants excite structures in the • Although physical restraints prevent falls, they create concomitant
brain, causing wakefulness. risks for constipation, incontinence, infections such as pneumonia,
• Sleep questionnaires, sleep diaries, polysomnographic evaluations, pressure ulcers, and a progressive decline in the ability to perform
and the multiple sleep latency test are techniques used to assess sleep activities of daily living.
patterns. • The overuse of physical restraints in health care facilities has led to the
• Sleep disorders fall into four major categories: insomnia (difficulty passage of legislation and accreditation standards regulating their use.
falling asleep or staying asleep, or early-morning awakening), hyper- • Restraints are devices that restrict movement; restraint alterna-
somnias (conditions resulting in daytime sleepiness despite adequate tives are protective and adaptive devices that clients can remove
nighttime sleep), sleep–wake cycle disturbances (resulting from independently.
desynchronized periods of sleeping and wakefulness), and parasom- • Restraint use may be justified when clients have a history of previ-
nias (associated with activities that cause arousal or partial arousal ous falls or may experience life-threatening consequences, when
usually during transitions in NREM periods of sleep). there has been an unsatisfactory response to restraint alternatives,
• Sleep is promoted by exercising regularly during the day; avoiding when clients are seriously impaired mentally or physically, or if their
alcohol, nicotine, and caffeine; performing sleep rituals; going to bed movement must be restricted during a life-threatening event.
and getting up at about the same time every day; and getting out of bed • If an accident occurs, the nurse’s first concerns are the safety of the
if sleep does not come easily and returning after some nonstimulating client and the potential for allegations of malpractice.
activity. • Older adults in general are prone to falling because they have gait and
• To promote relaxation, which facilitates the onset of sleep, nurses balance problems resulting from age-related changes, visual impair-
assist clients with progressive relaxation exercises or provide a back ment, postural hypotension, and urinary urgency.
massage.
• Older adults tend to have more difficulty falling asleep, they awaken
CHAPTER 20
more readily, and they spend less time in the deeper stages of sleep.
This explains why some older adults feel tired even though they have • Pain is an unpleasant sensation usually associated with disease or
slept an appropriate time. injury.
• The four phases of pain are transduction, transmission, perception, • Oxygen may be supplied through a wall outlet, in portable tanks,
and modulation. within a liquid oxygen unit, or with an oxygen concentrator.
• The pain threshold is the point at which pain-transmitting neuro- • Most clients receive oxygen therapy through a nasal cannula, any
chemicals reach the brain and cause conscious awareness known as one of several types of masks, or a face tent. Those who have had an
pain perception. Pain tolerance is the amount of pain a person opening created in their trachea may receive oxygen through a tra-
endures once the threshold has been reached. cheostomy collar, T-piece, or transtracheal catheter.
• Endogenous opioids are naturally produced chemicals with morphine- • Whenever oxygen is administered, nurses must be concerned about
like characteristics. It is believed that these chemicals bind to sites two hazards: the potential for fire and oxygen toxicity.
on the nerve cell’s membrane, blocking the transmission of pain- • Water seal chest tube drainage and hyperbaric oxygen chambers are
producing neurotransmitters. two therapeutic techniques related to oxygenation.
• The five general types of pain are cutaneous pain, visceral pain, neuro- • Older adults have unique respiratory risk factors for several reasons.
pathic pain, acute pain, and chronic pain. They often have age-related structural and functional changes that
• Acute pain differs from chronic pain in its duration, etiology, and may compromise ventilation and respiration.
response to therapeutic measures.
• When performing a basic pain assessment, the nurse asks the client CHAPTER 22
to describe the pain’s onset, quality, intensity, location, and duration.
• Four commonly used pain-intensity assessment tools are a numeric • Infectious diseases, also called community-acquired, contagious, or
scale, a word scale, a linear scale, and a picture scale like the Wong- communicable diseases, are spread from one person to another.
Baker FACES Pain Rating Scale. • An infection is a condition that results when microorganisms cause
• A pain assessment is performed, at a minimum, on admission, once injury to their host. Colonization refers to a condition in which
per shift when pain is an actual or potential problem, and before and microorganisms are present but the host is not damaged and has no
after implementing a pain-management intervention. signs or symptoms.
• The physiologic basis for pain management involves interrupting • Infectious diseases usually follow five stages: incubation, prodromal,
pain-transmitting chemicals at the site of injury, using gate-closing acute, convalescent, and resolution.
mechanisms, altering pain transmission at the spinal cord, and block- • Infection control measures are designed to curtail the spread of infec-
tious diseases.
ing pain perception in the brain.
• The two major categories of infection control measures are standard
• Three categories of drugs used to manage pain are nonopioids, opioids,
precautions and transmission-based precautions.
and adjuvant drugs. The injection of botulinum toxin is a fairly new
• Standard precautions are measures for reducing the risk of micro-
method for treating painful skeletal muscle conditions and headaches.
organism transmission from both recognized and unrecognized
• Rhizotomy and cordotomy are surgical pain-management techniques
sources of infection. Transmission-based precautions are measures to
used when other methods are ineffective.
control the spread of infectious agents from clients known to be or
• Examples of nondrug/nonsurgical methods of pain management are
suspected of being infected with pathogens.
educating clients about pain and its control and using imagery, medi-
• Airborne precautions are used to block very small pathogens that
tation, distraction, relaxation, and interventions such as applications
remain suspended in the air or are attached to dust particles. Droplet
of heat and cold, transcutaneous electrical nerve stimulation, acupunc-
precautions are used to block larger pathogens contained within
ture and acupressure, percutaneous electrical nerve stimulation,
moist droplets. Contact precautions are used to block the transmis-
biofeedback, and hypnosis.
sion of pathogens by direct or indirect contact.
• Clients often request frequent doses of pain-relieving medications
• Personal protective equipment is defined as garments that block the
because the dosage or schedule for administration is not controlling transfer of pathogens from a person, place, or object to oneself or
the pain. others.
• Addiction is “a pattern of compulsive drug use characterized by a • When removing personal protective equipment, nurses perform an
continued craving for an opioid and the need to use the opioid for orderly sequence, accompanied by handwashing, to prevent self-
effects other than pain relief.” contamination and transmission of pathogens to others.
• The fear of addiction leads to inadequate pain management. • Double-bagging is an infection control measure for removing contam-
• A placebo is an inactive substance given as a substitute for an actual inated items such as trash or laundry from the client’s environment.
drug. The positive effect some clients have from placebos probably It involves placing one bag within another held by someone outside
results from the trust they have in the physician or nurse. the client’s room.
• Clients with infectious diseases often have decreased social interaction
CHAPTER 21 and sensory deprivation because they are confined to their room.
• To prevent infections, people should obtain appropriate immuniza-
• Ventilation is the act of moving air in and out of the lungs. Respira- tions; practice a healthy lifestyle such as eating the recommended
tion refers to the mechanisms by which oxygen is delivered to the cells. number of servings from the Food Pyramid; and avoid sharing per-
• External respiration takes place through alveolar–capillary mem- sonal items such as washcloths and towels, razors, and cups.
branes. Internal respiration occurs at the cellular level via hemo- • Symptoms of infectious disorders tend to be subtler in older adults.
globin and body cells.
• The oxygenation status of clients can be determined at the bedside
by performing focused physical assessments, monitoring ABGs, and CHAPTER 23
using pulse oximetry. • When standing, keep the feet parallel and distribute weight equally on
• Five signs of inadequate oxygenation are restlessness, rapid breathing, both feet to provide a broad base of support. When sitting, the buttocks
rapid heart rate, sitting up to breathe, and using accessory muscles. and upper thighs are the base of support on the chair; both feet rest on
• Nurses can improve the oxygenation of clients by positioning clients the floor. Correct posture for lying down is the same as for standing
with the head and chest elevated and teaching them to perform breath- but in the horizontal plane; body parts are in neutral position.
ing exercises. • Principles of correct body mechanics include the following: distrib-
• When oxygen therapy is prescribed, a source for the oxygen, a ute gravity through the center of the body over a wide base of sup-
flowmeter, an oxygen delivery device, and in some cases an oxygen port; push, pull, or roll objects rather than lifting them; and hold
analyzer or humidifier are all needed. objects close to the body.
• Ergonomics is a field of engineering science devoted to promoting inactive clients, and to evaluate the client’s response to a therapeu-
comfort, performance, and health in the workplace by improving the tic exercise program.
design of the work environment and equipment that is used. • Nurses encourage older adults to exercise by walking in shopping
• Two examples of ergonomic recommendations are to use assistive malls or joining social groups that include activities such as line
devices when lifting or transporting heavy items and to use alter- dancing or ballroom dancing.
natives for tasks that require repetitive motions.
• Disuse syndrome is associated with weakness, atony, poor alignment,
CHAPTER 25
contractures, foot drop, impaired circulation, atelectasis, urinary tract
infections, anorexia, and pressure sores. • Immobilization is used to relieve pain and muscle spasm, support and
• Common client positions are supine (on the back), lateral (on the align skeletal injuries, and restrict movement while injuries heal.
side), lateral oblique (on the side with slight hip and knee flexion), • Four types of splints include inflatable splints, traction splints,
prone (on the abdomen), Sims’ (semiprone on the left side with the immobilizers, and molded splints.
right knee drawn up toward the chest), and Fowler’s (semisitting or • Slings are cloth devices used to elevate and support parts of the body.
sitting). Braces are custom-made or custom-fitted devices designed to support
• Positioning devices include the following: adjustable bed—allows the weakened structures during activity.
position of the head and knees to be changed; pillows—provide sup- • Cast are rigid molds used to immobilize an injured structure that has
port and elevate a body part; trochanter rolls—prevent legs from been restored to correct anatomic alignment. Casts are formed from
turning outward; hand rolls—maintain function of the hand and plaster of Paris or fiberglass.
prevent contractures; and foot boards—keep the feet in normal • Three types of casts are cylinder, body, and spica.
walking position. • Appropriate nursing care of clients with casts includes checking cir-
• Pressure-relieving devices include the following: siderails—help culation, mobility, and sensation in the area of the cast; using the
clients to change position; mattress overlays—reduce pressure and palms of the hands to handle a wet cast; elevating the casted extrem-
restore skin integrity; and cradle—keeps linen off client’s feet or legs. ity to reduce swelling; circling areas where blood has seeped through;
• Devices used to help transfer clients include a transfer handle, a and padding and reinforcing the cast edges to prevent skin breakdown.
transfer belt, a transfer board, and a mechanical lift. • Most casts are removed with an electric cast cutter, an instrument
that looks like a circular saw.
• Guidelines to follow when transferring clients include the following:
• Traction is the application of a pulling effect on a part of the skeletal
know the client’s diagnosis, capabilities, weaknesses, and activity
system.
level; be realistic about how much you can safely lift; transfer clients
• Three types of traction are manual traction, skin traction, and skele-
across the shortest distance possible; solicit the client’s help; and use
tal traction.
smooth rather than jerky movements.
• To be effective, traction must produce a pulling effect on the body,
countertraction must be maintained, the pull of traction and the coun-
CHAPTER 24 terpull must be in exactly opposite directions, splints and slings must
be suspended without interference, ropes must move freely through
• Regular exercise has many benefits including reduced blood pres-
each pulley, the prescribed amount of weight must be applied, and the
sure, blood glucose and blood lipid levels, tension, and depression
weights must hang free.
and increased bone density.
• An external fixator is used to stabilize fragments of broken bones
• Fitness refers to a person’s capacity to perform physical activities.
during healing.
• Factors that interfere with fitness include chronic inactivity, concur-
• Pin site care is essential for preventing infection because the inser-
rent health problems, impaired musculoskeletal function, obesity,
tion of pins impairs skin integrity and provides a port of entry for
advancing age, smoking, and high blood pressure.
pathogens.
• Several approaches can be used to determine a person’s level of fit-
ness. Two objective methods are a stress electrocardiogram and a
submaximal fitness test such as a step test. CHAPTER 26
• Exercise, regardless of type, should be performed within the person’s • Activities that help to prepare clients for ambulation include per-
target heart rate, which is calculated by subtracting the person’s age forming isometric exercises with the lower limbs, strengthening the
from 220 (maximum heart rate) then multiplying that number by upper arms, dangling at the bedside, and using a tilt table.
60% (0.6) to 90% (0.9), based on the person’s fitness level. • Two isometric exercises that tone and strengthen the lower extrem-
• Metabolic energy equivalent (MET) is the measure of energy and oxy- ities are quadriceps setting and gluteal setting.
gen consumption that a person’s cardiovascular system can support • The upper arms are strengthened by a regimen of flexing and extend-
safely. When an exercise prescription is given, exercises are correlated ing the arms and wrists, raising and lowering weights with the hands,
with their MET value. squeezing a ball or spring grip, and performing modified hand push-
• Fitness exercises are physical activities that develop and maintain car- ups while in a bed or chair.
diorespiratory function, muscular strength, and endurance in healthy • Clients dangle or are placed on a tilt table to normalize their blood
adults. Therapeutic exercises involve physical activities designed to pressure and help them adjust to being upright.
prevent health-related complications from an established medical • Parallel bars and walking belts are devices used to assist clients with
condition or its treatment or to restore lost physical functions. ambulation.
• Isotonic exercise involves movement and work; an example is aero- • Three types of ambulatory aids are canes, walkers, and crutches.
bic exercise. Isometric exercise refers to stationary activities per- • Walkers are the most stable form of ambulatory aid. Straight canes
formed against a resistive force; examples are body building and are the least stable.
weight lifting. • Crutches should permit the client to stand upright with the shoulders
• Active exercise is performed independently after proper instruction. relaxed, provide space for two fingers between the axilla and the axil-
Passive exercise is performed with the assistance of another person. lary bar, and facilitate approximately 30 degrees of elbow flexion and
• Range-of-motion (ROM) exercise is a form of therapeutic exercise slight hyperextension of the wrist.
that moves joints in the directions they normally permit. ROM exer- • The four types of crutch-walking gaits are four-point, three-point
cises can be active or passive. Two common reasons for perform- (non-weight-bearing or partial weight-bearing), two-point, and
ing them are to maintain joint mobility and flexibility, especially in swing-through.
• A temporary prosthesis facilitates early ambulation, promotes an Also, the cardiac status of older adults must be monitored carefully
intact body image, and controls stump swelling immediately after after surgery because they may not be able to circulate or eliminate
surgery. intravenous fluids given at standard rates.
• The permanent prosthesis is constructed when the surgical wound
heals and the stump size is relatively stable.
CHAPTER 28
• Components of permanent prostheses for BK amputees are a socket,
a shank, and an ankle/foot system; AK prostheses also include a • A wound is damaged skin or soft tissue.
knee system. • Wound repair involves three sequential phases: inflammation, pro-
• To apply a prosthetic limb, the client covers the stump with an liferation, and remodeling.
optional nylon sheath over which one or more stump socks are • Signs and symptoms classically associated with inflammation are
applied. A nylon stocking is used to ease the sock-covered stump into swelling, redness, warmth, pain, and decreased function.
the socket and is eventually removed. The client pumps the stump • Phagocytosis, a process that removes pathogens, coagulated blood,
within the socket to expel air and create a vacuum seal. If the socket and cellular debris, is performed by white blood cells known as neu-
has supportive belts or slings, they are fastened when the stump is trophils and monocytes.
well seated in the socket. • The integrity of damaged skin and tissue is restored by resolution,
• Older adults tend to acquire flexion of the spine as they get older; this regeneration, or scar formation.
may alter their center of gravity. They tend to compensate by flexing • Wounds heal by first, second, or third intention.
their hips and knees when walking and may have a swaying or shuf- • Two common types of wounds that require special care are pressure
fling gait. ulcers and surgical wounds.
• Some purposes for covering a wound with a dressing are keeping it
CHAPTER 27 clean, absorbing drainage, and controlling bleeding.
• A moist wound heals more quickly because new cells grow more
• Perioperative care refers to the nursing care that clients receive rapidly in a wet environment.
before, during, and after surgery. • Open or closed drains are placed in or near a wound to remove blood
• Perioperative care spans the preoperative, intraoperative, and post- and drainage.
operative periods. • Sutures or staples hold the edges of an incision together.
• Inpatient surgery is performed on clients who remain in the hospi- • A bandage or binder helps to hold a dressing in place especially when
tal at least overnight. Outpatient surgery is performed on clients who tape cannot be used or the dressing is extremely large; reduces pain
return home the same day.
by supporting the wound; or limits movement to promote healing.
• Laser surgery, which can be performed on an outpatient basis, offers
• A T-binder is used to secure a dressing to the anus, perineum, or groin.
several advantages: it is cost effective, requires smaller incisions,
• Four methods used to debride nonliving tissue from a wound are
results in minimal blood loss, and produces less pain.
sharp debridement, enzymatic debridement, autolytic debridement,
• Some clients choose to donate their own blood before surgery or ask
and mechanical debridement. A wound irrigation is an example of
specific donors to do so.
mechanical debridement.
• Four major activities for nurses to complete during the immediate
• An irrigation is used to flush debris from a wound or body area such
preoperative period are conducting a nursing assessment, providing
as the eye, ear, or vagina.
preoperative teaching, preparing the skin, and completing the surgi-
• Heat is applied to promote circulation and speed healing; cold is used
cal checklist.
to prevent swelling and control bleeding.
• Nurses teach preoperative clients how to perform deep breathing,
• Methods for applying heat or cold include ice bags, compresses,
coughing, and leg exercises.
• Surgical clients wear antiembolism stockings to prevent thrombi and soaks, and therapeutic baths.
emboli. • Five factors that place clients at risk for developing pressure ulcers are
• Preoperative skin preparation consists of the removal of hair with inactivity, immobility, malnutrition, dehydration, and incontinence.
electric clippers, depilatory agents, or a safety razor depending on • Techniques for preventing pressure ulcers include changing clients’
agency policy and medical orders. positions every 1 to 2 hours, keeping the skin clean and dry, and pre-
• On the preoperative checklist, the nurse verifies that the history and venting friction and shearing force on the skin.
physical examination have been completed, the name of the procedure
matches the one scheduled, the surgical consent form has been signed CHAPTER 29
and witnessed, the client is wearing an identification bracelet, and all
laboratory test results have been returned and reported if abnormal. • Intubation refers to the insertion of a tube into a body structure.
• The receiving room, the operating room, and the surgical waiting • GI intubation is used to provide nourishment; administer medications;
room are three areas in the surgical department used during the obtain diagnostic samples; remove poisons, gases, and secretions; and
intraoperative period. control bleeding.
• During immediate postoperative care, nurses focus on monitoring • Four types of tubes used to intubate the GI system are orogastric,
the client for complications, preparing the client’s room, and contin- nasogastric, nasointestinal, and transabdominal tubes.
uing assessments to detect developing problems. • Common assessments performed before inserting a tube nasally
• Common postoperative complications are airway obstruction, hem- include determining the client’s level of consciousness, the charac-
orrhage, pulmonary embolus, and shock. teristics and location of bowel sounds, the structure and integrity of
• During recovery, a pneumatic compression device may be prescribed the nose, and the client’s ability to swallow, cough, and gag.
to promote circulation of venous blood and relocation of excess fluid • A NEX measurement helps to determine how far to insert a tube for
into the lymphatic vessels. stomach placement. It is the distance from the nose to the earlobe
• Discharge instructions for surgical clients include how to care for the then to the xiphoid process.
incisional site, signs of complications to report, and how to self- • Nurses check stomach placement of tubes by aspirating gastric fluid,
administer prescription drugs. auscultating the abdomen as they instill a bolus of air, and testing the
• Older adults have unique surgical needs and problems. For example, pH of aspirated fluid.
the period of fluid restriction before surgery may be shortened for • Nasointestinal feeding tubes differ from their nasogastric counter-
older adults to reduce their risk for dehydration and hypotension. parts in that they are longer, narrower, and more flexible; their lubri-
cant is bonded to the tube; they are frequently inserted with a stylet; • Constipation, fecal impaction, flatulence, diarrhea, and fecal incon-
and an x-ray is used to confirm their placement. tinence are common alterations in bowel elimination.
• Although transabdominal feeding tubes can be used for long periods, • The four types of constipation are primary constipation (which
they are prone to leaking and causing skin impairment. nurses can treat independently), secondary constipation, iatrogenic
• Enteral nutrition refers to nourishing clients by means of the stom- constipation, and pseudoconstipation.
ach or small intestine rather than the oral route. • When bowel elimination does not occur naturally, inserting a rectal
• Four common schedules for administering tube feedings are bolus, suppository or administering an enema can promote defecation.
intermittent, cyclic, and continuous. • Two categories of enemas are cleansing and oil retention.
• Nurses check gastric residual to determine if the rate or volume of • Cleansing enemas are administered by instilling tap water, normal
feeding exceeds the client’s physiologic capacity. saline, soap and water, and other solutions.
• Caring for clients with feeding tubes involves maintaining tube • Oil retention enemas are given to lubricate and soften dry stool.
patency, clearing any obstructions, providing adequate hydration, • When caring for clients with intestinal ostomies, nursing activities
dealing with common formula-related problems, and preparing clients are likely to include providing peristomal care, applying an ostomy
for home care. appliance, draining a continent ileostomy, and irrigating a colostomy.
• Before discharge, nurses provide clients who will administer their
own tube feedings at home with written instructions on ways to
CHAPTER 32
obtain equipment and formula, the amount and schedule for each
feeding, guidelines for delaying a feeding, and skin or nose care. • A medication is a chemical substance that changes body function.
• When assisting with the insertion of a tungsten-weighted tube, • A complete drug order contains the date and time of the order; the
nurses are responsible for promoting and monitoring its movement name of the client; the name of the drug, its dose, route, and frequency
into the intestine. of administration; and the signature or name of the writer.
• A drug’s trade name is the name used by the manufacturer of the
drug. The drug’s generic name is a chemical name that is not the
CHAPTER 30
exclusive use of any drug company.
• The urinary system is composed of the kidneys, ureters, bladder, and • Common routes of medication administration are oral, topical,
urethra. Collectively these organs serve to produce urine, collect it, inhalant, and parenteral.
and excrete it from the body. • The oral route is used to administer drugs intended for absorption in
• Various factors affect urination such as a person’s neuromuscular the gastrointestinal tract. Oral medications can be instilled by enteral
development, the integrity of the spinal cord, the volume of fluid tube when clients cannot swallow them.
intake, fluid losses from other sources, and the amount and type of • A medication administration record (MAR) is a form used to docu-
food consumed. ment and ensure timely and safe drug administration.
• The physical characteristics of urine include its volume, color, clarity, • Methods of supplying drugs to nursing units include an individual
and odor. supply, a supply of unit dose packets, and a stock supply.
• Nurses often collect voided urine specimens, clean-catch urine spec- • Nurses are responsible for keeping the supply of narcotic medica-
imens, catheter specimens, and 24-hour urine specimens. tions locked and maintaining an accurate record of their use.
• Some common abnormal patterns of urinary elimination include • The five rights involve making sure that the right client receives the
anuria, oliguria, polyuria, nocturia, dysuria, and incontinence. right drug, in the right dose, at the right time, and by the right route.
• Other than a conventional toilet, a person may eliminate urine in a • Once nurses have converted drug doses to the same system of mea-
commode, urinal, or bedpan. surement and the same measurement within that system, they can
• Continence training is the process used to restore the ability to empty calculate the amount to administer by dividing the desired dose by
the bladder at an appropriate time and place. the dose on hand then multiplying it by the quantity of the supply.
• The three general types of catheters are external, straight, and • The nurse checks drug labels three times before administering the
retention. medication.
• When using a closed drainage system, it is important to avoid depen- • When teaching clients about taking medications, nurses advise them
dent loops in the tubing and the collection bag must be kept below to inform each health care provider of all prescription and non-
the level of the bladder. prescription drugs currently being taken.
• Catheter care is important because it helps to deter the growth and • A common problem when administering drugs through an enteral
spread of colonizing pathogens. tube is maintaining the tube’s patency.
• Catheters are irrigated to keep them patent, or free-flowing. • If a medication error occurs, nurses must report it to the prescriber
• Catheters may be irrigated using an open or closed system or contin- and supervisor, assess the client for ill effects, and document the situ-
uously by way of a three-way catheter. ation on an incident report or accident sheet.
• A urinary diversion is a procedure in which one or both ureters are
surgically implanted elsewhere.
CHAPTER 33
• Skin impairment is a common problem in clients with a urostomy
because they require frequent appliance changes and the contact of • Topical medications are applied to the skin or mucous membranes.
urine with the skin causes skin irritation. • Common locations for topical medications are the skin, eye, ear,
• Older adults tend to have diminished bladder capacity and relaxation nose, mouth, vagina, and rectum.
of pelvic floor muscles. • An inunction is a medication incorporated into a vehicle, or trans-
porting agent, such as an ointment, oil, lotion, or cream.
• Skin patches and applications of paste are two methods for adminis-
CHAPTER 31
tering transdermal medications.
• Defecation, the elimination of stool, occurs when peristalsis moves • Skin patches can be applied to any skin area with adequate circulation.
fecal waste toward the rectum and the rectum distends, creating an Each time a new patch is applied, it is placed in a different location.
urge to relax the anal sphincters; this releases stool. • Eye medications are applied onto the mucous membrane, or conjunc-
• Two components of a bowel elimination assessment include elimi- tiva, of the eye, which lines the inner eyelids and the anterior surface
nation patterns and stool characteristics. of the sclera.
• The major difference in the technique for administering ear med- • Two methods for administering a bolus of IV medication are via a
ications to adults and children is how the ear is manipulated to port on the IV tubing or a medication lock.
straighten the auditory canal. • IV medication solutions may be administered intermittently using
• The rebound effect is a phenomenon characterized by rapid swelling secondary (piggyback) infusions or a volume-control set.
of the nasal mucosa. It is likely when clients chronically administer • A piggyback solution is a small volume of diluted medication that is
more than the recommended amount of nasal decongestant or use connected to and positioned higher than the primary solution.
the drug too frequently. • A volume-control set is used to administer IV medication in a small
• For sublingual administration, the drug is placed under the tongue. volume of solution at intermittent intervals to avoid overloading the
For buccal administration, the medication is placed in contact with circulatory system.
the mucous membrane of the cheek. • A central venous catheter is a venous access device that extends to
• Vaginal applications are used most often to treat local infections. the vena cava or right atrium.
• Drugs administered rectally usually are in the form of suppositories. • The three general types of central venous catheters are percuta-
• The inhalant route is used for medication administration because the neous, tunneled, and implanted.
lungs provide an extensive area of tissue from which drugs may be • When administering antineoplastic drugs, the nurse should wear a
absorbed. cover gown, one or two pairs of gloves, and a disposable or respirator
• To create an aerosol, liquid medication is forced through a narrow mask to protect against contact with or inhalation of the medication.
channel under high pressure.
• Drugs are commonly inhaled using turbo-inhalers or metered-dose
CHAPTER 36
inhalers. A turbo-inhaler delivers a burst of fine powder at the time
of inhalation. A metered-dose inhaler releases a measured volume of • Airway management refers to skills that nurses use to maintain nat-
aerosolized drug when its canister is compressed. ural or artificial airways for compromised clients.
• A spacer provides a reservoir for aerosol medication, which can then • Structures of the airway are the nose, pharynx, trachea, bronchi,
be inhaled beyond the time of the initial breath. bronchioles, and alveoli.
• The airway serves as the collective system of tubes in the upper and
lower respiratory tract through which gases travel during their pas-
CHAPTER 34
sage to and from the blood.
• Three parts of a syringe are the barrel, plunger, and tip. • Structures to protect the airway include the epiglottis, which seals
• When selecting a syringe and needle, the nurse considers the type of the airway when swallowing food and fluids; the rings of tracheal
medication, depth of tissue, volume of prescribed drug, viscosity of cartilage, which keep the trachea from collapsing; the mucous mem-
the drug, and size of the client. brane, which traps particulate matter; and the cilia, which beat
• Conventional syringes and needles are being redesigned to reduce the debris upward in the airway so it can be coughed, expectorated, or
potential for needlestick injuries and transmission of blood-borne swallowed.
pathogens. • Methods of airway management include liquefying secretions, mobi-
• Pharmaceutical companies supply drugs for parenteral administration lizing secretions to promote their expectoration with chest physio-
in ampules, vials, and prefilled cartridges. therapy, and mechanically suctioning mucus from the airway.
• Before combining two drugs in a single syringe, it is important to • When suctioning the airway, nurses use one of several approaches:
consult a drug reference or a compatibility chart to determine nasopharyngeal, nasotracheal, oropharyngeal, oral, and tracheal
whether or not a chemical interaction may occur. suctioning.
• Nurses use any of four parenteral injection routes: intradermal, sub- • Artificial airways are used when clients are at risk for airway
cutaneous, intramuscular, and intravenous. obstruction or when long-term mechanical ventilation is necessary.
• A common site for an intradermal injection is the inner forearm; • Two examples of artificial airways are an oral airway and a tra-
subcutaneous injections are commonly given in the thigh, arm, or cheostomy tube.
abdomen; intramuscular injections are given in the buttocks, hip, • Tracheostomy care includes cleaning the skin around the stoma,
thigh, or arm. changing the dressing, and cleaning the inner cannula.
• An intradermal injection is given with a tuberculin syringe. Insulin
is administered subcutaneously with an insulin syringe. Intramus-
CHAPTER 37
cular injections are usually given with a syringe that holds a volume
of 3 mL. • Airway obstruction is life-threatening because it interferes with ven-
• For an intradermal injection, the needle is inserted at a 10° to 15° tilation and subsequently deprives cells and tissues of oxygen.
angle. For a subcutaneous injection, a 45° or 90° angle is used depend- • Signs of airway obstruction include grasping the throat with the
ing on the client’s size. For an intramuscular injection, a 90° angle hands, making aggressive efforts to cough and breathe, and produc-
is used. ing a high-pitched sound while inhaling.
• When two separate insulins are combined, they must be adminis- • In cases of partial airway obstruction, appropriate actions include
tered within 15 minutes to avoid equilibration (the loss of each encouraging and supporting the victim’s efforts to clear the obstruc-
insulin’s unique characteristics). tion independently and preparing to call for emergency assistance if
• To prevent bruising when heparin is administered, the nurse avoids the victim’s condition worsens.
aspirating with the plunger and massaging the site afterward. • The Heimlich maneuver is the technique used to relieve a complete
airway obstruction by performing a series of subdiaphragmatic
thrusts or chest thrusts on conscious victims.
CHAPTER 35
• Subdiaphragmatic thrusts are appropriate for almost all adults and
• IV medications can be given into peripheral or central veins. children beyond infancy. Chest thrusts are appropriate for obese
• The IV route is appropriate when a quick response is needed during adults and women in advanced pregnancy.
an emergency, when clients have disorders that affect the absorption • To dislodge an object from an infant’s airway, the rescuer delivers a
or metabolism of drugs, and when blood levels of drugs need to be series of back blows followed by a series of chest thrusts.
maintained at a consistent therapeutic level. • When a person with an airway obstruction becomes unconscious,
• IV medications can be administered continuously or intermittently. rescuers perform basic CPR rather than the Heimlich maneuver
because chest compressions create enough pressure in unconscious CHAPTER 38

victims to eject a foreign body from the airway.
• A terminal illness is one from which recovery is beyond reasonable
• The Chain of Survival is a series of four steps that improve the outcome
expectation.
of resuscitating a person in cardiac arrest. The steps include early
• The five stages of dying, as described by Dr. Elisabeth Kübler-Ross,
recognition and access of emergency services, early cardiopulmonary
are denial, anger, bargaining, depression, and acceptance.
resuscitation (CPR), early defibrillation, and early advanced life
• Nurses can promote acceptance by providing emotional support to
support.
dying clients and helping them to arrange their care.
• CPR refers to the techniques used to restore breathing and circulation.
• Respite care provides relief for caregivers of dying loved ones.
• The ABCs of resuscitation involve opening the airway and assessing
• Hospice care involves helping clients to live their final days in com-
and initiating breathing and circulation.
fort, with dignity, and in a caring environment.
• Rescuers can safely open a victim’s airway under most circumstances • Some aspects that nurses address when providing terminal care
by using the head tilt/chin lift technique or the jaw-thrust maneuver. are hydration, nourishment, elimination, hygiene, positioning, and
• Methods of administering rescue breathing are mouth-to-mouth, comfort.
mouth-to-nose, or mouth-to-stoma. • Many terminal illnesses result in death from multiple organ failure.
• The purpose of chest compressions is to circulate blood systemically. Signs of multiple organ failure include hypotension, rapid heart rate,
• An automated external defibrillator is a portable, battery-operated difficulty breathing, cold and mottled skin, and decreased urinary
device that analyzes heart rhythm and can deliver a series of electri- output.
cal shocks to resuscitate a person who is lifeless or experiencing a • When the criteria for organ donation are met, permission for organ
lethal dysrhythmia. Ideally an AED is used within 5 minutes of removal must be obtained in a timely manner to ensure a successful
resuscitation efforts outside the hospital and within 3 minutes of transplant.
resuscitation efforts within a health care facility. • Criteria used to confirm that a client has died include cessation of
• Once CPR begins, it is never interrupted for more than 7 seconds breathing and heart beat and absence of whole brain function.
(except in certain circumstances such as when advanced electronic • Postmortem care involves cleaning the body, ensuring proper iden-
equipment is used). tification, and releasing the body to mortuary personnel.
• The decision to stop resuscitation efforts often is based on the time • Although grieving is painful, it promotes resolution of the loss.
that elapsed before resuscitation began, the length of time that resus- • One sign that a person is resolving his or her grief is that he or she
citation has continued without any change in the victim’s condition, can talk about the deceased person without becoming emotionally
and the age and diagnosis of the victim. overwhelmed.
A P P E N D I X b
Commonly Used Abbreviations and Acronyms
SYMBOLS mL milliliter (one-thousandth L)
mm Hg millimeters of mercury
< less than
mph miles per hour
≤ equal to or less than
MRI magnetic resonance imaging
> more than
NANDA North American Nursing Diagnosis Association
≥ equal to or more than
NAPNES National Association for Practical Nurse
± plus or minus
Education and Service
° degree
NCLEX-PN National Council Licensure Examination for
Practical Nurses
WORDS NCLEX-RN National Council Licensure Examination for
Registered Nurses
ADL activities of daily living
NEX nose, earlobe, xiphoid process
AHCPR Agency for Health Care Policy and Research
NKA no known allergies
AIDS acquired immune deficiency syndrome
NLN National League for Nursing
ANA American Nurses Association
NPO nil per os, nothing by mouth
AMA against medical advice; or American Medical
NREM nonrapid eye movement (sleep phase)
Association
BP blood pressure NSS normal saline solution
bpm beats per minute NWB nonweight bearing
cal calorie O2 oxygen
CBC complete blood count OTC over the counter (eg, nonprescription)
CDC Centers for Disease Control and Prevention PACU postanesthesia care unit
CHO carbohydrate PaCO2 partial pressure of carbon dioxide; that which is
CO2 carbon dioxide dissolved in plasma
CPR cardiopulmonary resuscitation PaO2 partial pressure of oxygen; that which is
CT computed tomography (also CAT) dissolved in plasma
CVC central venous catheter PCA patient-controlled analgesia
dL deciliter (100 mL) PEG percutaneous endoscopic gastrostomy
ECG electrocardiogram (also EKG) PEJ percutaneous endoscopic jejunostomy
EEG electroencephalogram PERRLA pupils equally round and respond to light and
EMG electromyography accommodation
EOMs extraocular movements PET positron emission tomography
g gram pH degree of acidity or alkalinity
GI gastrointestinal PICC peripherally inserted central catheter
HIV human immunodeficiency virus PPN peripheral parenteral nutrition
I&O intake and output PWB partial weight bearing
ICN International Council of Nurses QA quality assurance
IM intramuscular RBC red blood cell
IV intravenous REM rapid eye movement (sleep phase)
IVP IV push RN registered nurse
IVPB IV piggyback R/O rule out; either confirm or eliminate
JCAHO Joint Commission on Accreditation of ROM range of motion
Healthcare Organizations 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
927
GLOSSARY OF KEY TERMS
A Airway management skills that maintain the patency of nat-

Acceptance attitude of complacency; last stage of dying, ural or artificial airways
according to Dr. Kübler-Ross Alignment proper relation of one part to another
Accommodation pupil constriction when looking at an object Allocation of scarce resources process of deciding how to
close by and dilation when looking at an object in the distance distribute limited life-saving equipment or procedures
Active exercise therapeutic activity performed independently Alternative medical therapy treatment outside the main-
Active listening demonstrating full attention to what is stream of traditional medicine
being said; hearing both the content being communicated Ambulatory electrocardiogram continuous recording of
and the unspoken message heart rate and rhythm during normal activity
Active transport process of chemical distribution that re- Ampule sealed glass container for a drug
quires an energy source Anaerobic bacteria microorganisms that exist without
Activities of daily living acts that people normally do every oxygen
day Analgesic pain-relieving drug
Actual diagnosis problem that currently exists Anal sphincters ring-shaped bands of muscles in the anus
Acultural nursing care care that lacks concern for cultural Anatomic position standing with arms at the sides and palms
differences forward
Acupressure technique that involves tissue compression to Androgogy principles of teaching adult learners
reduce pain Anecdotal record personal, handwritten account of an
Acupuncture pain-management technique in which long, incident
thin needles are inserted into the skin Anesthesiologist physician who administers chemical agents
Acute illness one that comes on suddenly and lasts a short that temporarily eliminate sensation and pain
time Anesthetist nurse specialist who administers anesthesia
Acute pain discomfort that is of short duration under the direction of a physician
Adaptation manner in which an organism responds to change Anger emotional response to feeling victimized
Adjuvants drugs that assist in accomplishing the desired Anglo-Americans people who trace their ancestry to the
effect of a primary drug United Kingdom or Western Europe
Administrative laws legal provisions through which fed- Anions electrolytes with a negative charge
eral, state, and local agencies maintain self-regulation Ankylosis permanent loss of joint movement
Admission entering a health care agency for nursing care Anorexia loss of appetite
and medical or surgical treatment Anthropometric data measurements of body size and
Advance directive written statement identifying a compe- composition
tent person’s wishes concerning terminal care Anticipatory grieving grieving that begins before a loss
Advanced practice specialized areas of nursing expertise, actually occurs
such as nurse practitioner and nurse midwifery Antiembolism stockings elastic stockings
Aerobic bacteria microorganisms that require oxygen to live Antimicrobial agents chemicals that limit the number of
Aerobic exercise rhythmically moving all parts of the body infectious microorganisms by destroying them or suppressing
at a moderate to slow speed without hindering the ability to their growth
breathe Antineoplastic drugs medications used to destroy or slow
Aerosol mist the growth of malignant cells
Afebrile absence of a fever Antipyretics drugs that reduce fever
Affective domain learning by appealing to a person’s feelings, Antiseptics chemicals such as alcohol that inhibit the growth
beliefs, or values of, but do not kill, microorganisms
Affective touch touching that demonstrates concern or Anuria absence of urine, or up to a 100-mL volume in 24 hours
affection Apical heart rate number of ventricular contractions per
African Americans those whose ancestral origin is Africa minute
Afterload force against which the heart pumps when ejecting Apical-radial rate number of sounds heard at the heart’s
blood apex and the rate of the radial pulse during the same period
Air embolism bubble of air in the vascular system Apnea absence of breathing
Airborne precautions measures that reduce the risk of trans- Appliance collection bag over a stoma
mitting infectious agents via air Aquathermia pad electrical heating or cooling device
Airway collective system of tubes in the upper and lower Arrhythmia irregular pattern of heartbeats
respiratory tract Art ability to perform an act skillfully
928
Glossary of Key Terms 929
Arterial blood gas laboratory test using blood from an Body composition amount of body tissue that is lean ver-
artery sus fat
Asepsis practices that decrease or eliminate infectious Body-mass index numeric data used to compare a person’s
agents, their reservoirs, and vehicles for transmission size in relation to norms for the adult population
Aseptic techniques measures that reduce or eliminate micro- Body mechanics efficient use of the musculoskeletal system
organisms Body systems approach collection of data according to the
Asian Americans people who come from China, Japan, functional systems of the body
Korea, the Philippines, Thailand, Indochina, and Vietnam Bolus larger dose of a drug administered initially or when
Asphyxiation inability to breathe pain is intense
Assault act in which there is a threat or attempt to do bodily Bolus administration undiluted medication given fairly
harm quickly in a vein
Assessment systematic collection of information Bolus feeding instillation of liquid nourishment four to six
Assessment skills acts that involve collecting data times a day in less than 30 minutes
Atelectasis airless, collapsed lung areas Braces custom-made or custom-fitted devices designed to
Audiometry measurement of hearing acuity at various sound support weakened structures
frequencies Bradycardia a pulse rate less than 60 beats per minute
Auditors inspectors who examine client records (bpm) in an adult
Auscultation listening to body sounds Bradypnea slower-than-normal respiratory rate at rest
Auscultatory gap period during which sound disappears Bridge dental device that replaces one or several teeth
then reappears when taking a blood pressure measurement Bruxism grinding of the teeth
Autologous transfusion self-donated blood Buccal application drug placement against the mucous mem-
Automated external defibrillator device that delivers an branes of the inner cheek
electrical charge to the heart
Automated monitoring devices equipment that allows the
simultaneous collection of multiple vital sign data C
Autopsy postmortem examination Cachexia general wasting of body tissue
Axillary crutches standard type of crutches Calorie amount of heat that raises the temperature of 1 gram
of water 1°C
Cane hand-held ambulatory device made of wood or alu-
minum with a rubber tip
B
Capillary action movement of a liquid at the point of contact
Bag bath technique for bathing that involves the use of 8 to
with a solid
10 premoistened, warmed, disposable cloths contained in a
Capillary refill time time duration for blood to resume flow-
plastic bag
ing in the base of the nail beds
Balance steady position
Capitation strategy for controlling health care costs by paying
Bandage strip or roll of cloth
a fixed amount per member
Bargaining psychological mechanism for delaying the
Carbohydrates nutrients that contain molecules of carbon,
inevitable
hydrogen, and oxygen
Barrel part of a syringe that holds the medication Cardiac arrest cessation of heart contraction or life-sustaining
Base of support area on which an object rests heart rhythm
Basic care facility agency that provides extended custodial Cardiac ischemia impaired blood flow to the heart
care Cardiac output volume of blood ejected from the left ventri-
Battery unauthorized physical contact cle per minute
Bed bath washing with a basin of water at the bedside Cardiopulmonary resuscitation techniques used to restore
Bed board rigid structure placed under a mattress breathing and circulation for lifeless victims
Bedpan seat-like container for elimination Caregiver one who performs health-related activities that a
Beliefs concepts that a person holds to be true sick person cannot perform independently
Beneficial disclosure an exemption whereby an agency can Caries dental cavities
release private health information without a client’s prior Caring skills nursing interventions that restore or maintain
authorization a person’s health
Bilingual able to speak a second language Case method pattern in which one nurse manages a patient’s
Binder type of bandage care for a designated period
Biofeedback technique in which the client learns to control Cast rigid mold around a body part
or alter a physiologic phenomenon Cataplexy sudden loss of muscle tone, triggered by an emo-
Biologic defense mechanisms methods that prevent micro- tional change such as laughing or anger
organisms from causing an infectious disorder Catheter care hygiene measures used to keep the meatus
Bivalved cast cast that is cut in two lengthwise pieces and adjacent area of the catheter clean
Blood pressure force exerted by blood in the arteries Catheter irrigation flushing the lumen of a catheter
Board of nursing regulatory agency that manages the provi- Catheterization act of applying or inserting a hollow tube
sions of a state’s nurse practice act Cations electrolytes with a positive charge
Body cast form of a cylinder cast that encircles the trunk of Cellulose undigestible fiber in the stems, skin, and leaves of
the body instead of an extremity fruits and vegetables
930 Glossary of Key Terms
Center of gravity point at which the mass of an object is Collagen protein substance that is tough and inelastic
centered Colloidal osmotic pressure force for attracting water
Centigrade scale scale that uses 0°C as the temperature at Colloids undissolved protein substances
which water freezes and 100°C as the point at which it boils Colloid solutions water and molecules of suspended sub-
Central venous catheter venous access device that extends stances, such as blood cells, and blood products such as
to the vena cava albumin
Cerumen ear wax Colonization condition in which microorganisms are present
Cervical collar foam or rigid splint around the neck but the host manifests no signs or symptoms of infection
Chain of infection sequence that enables the spread of disease- Colostomy opening to some portion of the colon
producing microorganisms Comfort state in which a person is relieved of distress
Chain of Survival intervention and rescue process includ- Comforting skills interventions that provide stability and
ing early (1) recognition and access of emergency services, security during a health crisis
(2) CPR, (3) defibrillation, and (4) advanced life support Commode portable chair used for elimination
after cardiac arrest Common law decisions based on prior cases of a similar
Change of shift report discussion between a nurse from the nature
shift that is ending and personnel coming on duty Communicable diseases infectious diseases that can be
Chart binder or folder that enables the orderly collection, transmitted to other people
storage, and safekeeping of a client’s medical records Communication exchange of information
Charting process of writing information Community-acquired infections infectious diseases that
Charting by exception documentation method in which only can be transmitted to other people
abnormal assessment findings or care that deviates from the Complete proteins those that contain all of the essential
standard is charted amino acids
Checklist form of documentation in which the nurse indi- Compresses moist cloths that may be warm or cool
cates with a check mark or initials that routine care has been Computed tomography form of roentgenography that shows
performed planes of tissue
Chest physiotherapy techniques for mobilizing pulmonary Computerized charting documenting client information
electronically
secretions
Concept mapping organizing information in a graphic or
Chronic illness one that comes on slowly and lasts a long time
pictorial form
Chronic pain discomfort that lasts longer than 6 months
Concurrent disinfection measures that keep the client
Circadian rhythm phenomena that cycle on a 24-hour basis
environment clean on a daily basis
Circulatory overload severely compromised heart function
Confidentiality safeguarding a client’s health information
Civil laws statutes that protect the personal freedoms and
from public disclosure
rights of individuals
Congenital disorder disorder present at birth that results
Clean-catch specimen voided sample of urine that is consid-
from faulty embryonic development
ered sterile
Conscious sedation state in which clients are sedated,
Climate control mechanisms for maintaining temperature,
relaxed, and emotionally comfortable, but not unconscious
humidity, and ventilation Consensual response brisk, equal, and simultaneous con-
Clinical pathways standardized multidisciplinary plans for striction of both pupils when one eye and then the other are
a specific diagnosis or procedure that identify specific aspects stimulated with light
of care to be performed during a designated length of stay Constipation condition in which dry, hard stool is difficult
Clinical résumé summary of previous care to pass
Clinical thermometers instruments used to measure body Contact precautions measures used to block the transmission
temperature of pathogens by direct or indirect contact
Closed drainage system device used to collect urine from a Contagious diseases infectious diseases that can be trans-
catheter mitted to other people
Closed wound one in which there is no opening in the skin Continence training process of restoring control of urination
or mucous membrane Continent ostomy surgically created opening in which liquid
Code summoning personnel to administer advanced life sup- stool or urine is removed by siphoning
port techniques Continuity of care uninterrupted client care despite the
Code of ethics statements describing ideal behavior change in caregivers
Code status manner in which nurses or health care personnel Continuous feeding instillation of liquid nutrition without
must manage the care of a client during cardiac or respiratory interruption
arrest Continuous infusion instillation of a parenteral drug over
Cognitive domain style of processing information by listen- several hours
ing or reading facts and descriptions Continuous irrigation ongoing instillation of solution
Cold spot area with little or no radionuclide concentration Continuous passive motion machine electrical device that
Collaborative problem physiologic complication whose exercises joints
treatment requires both nurse- and physician-prescribed Continuous quality improvement process of promoting
interventions care that reflects established agency standards
Collaborator one who works with others to achieve a com- Contractures permanently shortened muscles that resist
mon goal stretching
Contrast medium substance that adds density to a body Defamation act in which untrue information harms a per-
organ or cavity, such as barium sulfate or iodine son’s reputation
Controlled substances drugs whose prescription and dis- Defecation bowel elimination
pensing are regulated by federal law because they have the Defendant person charged with violating the law
potential for abuse Dehydration fluid deficit in both extracellular and intra-
Coping mechanisms unconscious tactics used to protect the cellular compartments
psyche Delegator one who assigns a task to someone
Coping strategies stress-reduction activities selected on a Deltoid site injection area in the lateral upper arm
conscious level Denial psychological defense mechanism in which a person
Cordotomy surgical interruption of pain pathways in the refuses to believe that certain information is true
spinal 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 Depilatory agent chemical that removes hair
may not be the result of natural causes Depression sad mood
Counseling skills interventions that include communicat- Diagnosis identification of health-related problems
ing with clients, actively listening to the exchange of infor- Diagnostic examination procedure that involves physical
mation, offering pertinent health teaching, and providing inspection of body structures and evidence of their function
emotional support Diagnostic-related group classification system used to
CPAP mask device that maintains positive pressure in the group clients with similar diagnoses
airway throughout the respiratory cycle Diaphragmatic breathing breathing that promotes the use
Credé maneuver act of bending forward and applying hand of the diaphragm rather than upper chest muscles
pressure over the bladder to stimulate urination Diarrhea urgent passage of watery stools
Criminal laws penal codes that protect citizens from per- Diastolic pressure pressure in the arterial system when the
sons who are a threat to the public good heart relaxes and fills with blood
Critical thinking process of objective reasoning; analyzing Diet history assessment technique used to obtain facts about
facts to reach a valid conclusion a 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
depending on the census or levels of client acuity on any a client
given day Discharge termination of care from a health care agency
Crutches ambulatory aid, generally in pairs, constructed of Discharge instructions directions for managing self-care
wood or aluminum and medical follow-up
Crutch palsy weakening of forearm, wrist, and hand mus- Discharge planning predetermining a client’s post-discharge
cles because of nerve impairment in the axilla caused by needs and coordinating the use of appropriate community
incorrectly fitted crutches or poor posture resources to provide a continuum of care
Crystalloid solution water and other uniformly dissolved Disinfectants chemicals that destroy active microorganisms
crystals, such as salt and sugar but not spores
Cultural shock bewilderment over behavior that is cultur- Distraction intentional diversion of attention
ally atypical Disuse syndrome signs and symptoms that result from
Culturally sensitive nursing care care that is respectful of inactivity
and is compatible with each client’s culture Documenting process of writing information
Culture (1) values, beliefs, and practices of a particular group; Doppler stethoscope device that helps detect sounds cre-
(2) incubation of microorganisms ated by the velocity of blood moving through a blood vessel
Cutaneous application drug administration by rubbing Dorsal recumbent position reclining posture with the knees
medication into or placing it in contact with the skin bent, hips rotated outward, and feet flat
Cutaneous pain discomfort that originates at the skin level Dorsogluteal site injection area in the upper outer quadrant
Cutaneous triggering the act of lightly massaging or tapping of the buttocks
the skin above the pubic area to stimulate urination Dose amount of drug
Cuticles thin edge of skin at the base of the nail Double-bagging infection control measure in which one bag
Cyclic feeding continuous instillation of liquid nourishment of contaminated items, such as trash or laundry, is placed
for 8 to 12 hours within another
Cylinder cast rigid mold that encircles an arm or leg Douche procedure for cleansing the vaginal canal
Drains tubes that provide a means for removing blood and
drainage from a wound
D Drape sheet of soft cloth or paper
Dangling sitting on the edge of a bed Drawdown effect cooling of the ear when it comes in con-
Data base assessment initial information about the client’s tact with a thermometer probe
physical, emotional, social, and spiritual health Dressing cover over a wound
Death certificate legal document confirming a person’s death Drop factor number of drops per milliliter in intravenous
Débridement removal of dead tissue tubing
Decompression removal of gas and secretions from the Droplet precautions measures that block pathogens in
stomach or bowel moist droplets larger than 5 microns
Drowning situation in which fluid occupies the airway and Ergonomics field of engineering science devoted to promot-
interferes with ventilation ing comfort, performance, and health in the workplace
Drug tolerance diminished effect of a drug at its usual dosage Eructation belching
range Essential amino acids protein components that must be
Dumping syndrome cluster of symptoms resulting from the obtained from food because they cannot be synthesized by
rapid deposition of calorie-dense nourishment into the small the body
intestine Ethical dilemma choice between two undesirable alternatives
Durable power of attorney for healthcare proxy for mak- Ethics moral or philosophical principles
ing medical decisions when a client becomes incompetent or Ethnicity bond or kinship a person feels with his or her
incapacitated and cannot make decisions independently country of birth or place of ancestral origin
Duty obligation to provide care for a person claiming injury Ethnocentrism belief that one’s own ethnicity is superior to
or harm all others
Dying with dignity treating a terminally ill person with Evaluation process of determining whether a goal has been
respect regardless of his or her emotional, physical, or cog- reached
nitive state Exacerbation reactivation of a disorder, or one that reverts
Dysphagia difficult swallowing from a chronic to an acute state
Dyspnea difficult or labored breathing Excoriation chemical skin injury
Dysrhythmia irregular pattern of heartbeats Exercise purposeful physical activity
Dysuria difficult or uncomfortable voiding Exit route means by which microorganisms escape from
their original reservoir
Expiration exhalation; breathing out
E Extended care services that meet the health needs of clients
Echography soft tissue examination that uses sound waves who no longer require acute hospital care
in ranges beyond human hearing
Extended care facility health care agency that provides
Edema excessive fluid in tissue
long-term care
Educator one who provides information
External catheter device applied to the skin that collects
Electrical shock discharge of electricity through the body
urine
Electrocardiography examination of the electrical activity
External fixator metal device inserted into and through one
in the heart
or more bones
Electrochemical neutrality balance of cations with anions
Extracellular fluid fluid outside cells
Electroencephalography examination of the energy emitted
Extraocular movements eye movements controlled by sev-
by the brain
eral pairs of eye muscles
Electrolytes chemical compounds, such as sodium and chlo-
ride, that are dissolved, absorbed, and distributed in body
fluid and possess an electrical charge
F
Electromyography examination of the energy produced by
Face tent device that provides oxygen in an area around the
stimulated muscles
Emaciation excessive leanness nose and mouth
Emboli moving clots Facilitated diffusion process in which certain dissolved
Emesis substance that is vomited substances require the assistance of a carrier molecule to
Empathy intuitive awareness of what the client is pass from one side of a semipermeable membrane to the
experiencing other
Emulsion mixture of two liquids, one of which is insoluble Fahrenheit scale scale that uses 32°F as the temperature at
in the other which water freezes and 212°F as the point at which it boils
Endogenous opioids naturally produced morphine-like False imprisonment interference with a person’s freedom
chemicals to move about at will without legal authority to do so
Endoscopy visual examination of internal structures Fat nutrient that contains molecules composed of glycerol
Enema introduction of a solution into the rectum and fatty acids called glycerides
Energy capacity to do work Fat-soluble vitamins those carried and stored in fat; vita-
Enteral nutrition nourishment provided via the stomach or mins A, D, E, and K
small intestine rather than the oral route Febrile elevated body temperature
Enteric-coated tablet tablet covered with a substance that Fecal impaction condition in which it is impossible to pass
does not dissolve until it is past the stomach feces voluntarily
Enterostomal therapist a nurse certified in caring for Fecal incontinence inability to control the elimination of
ostomies and related skin problems stool
Environmental hazards potentially dangerous conditions Feces stool
in the physical surroundings Feedback loop mechanism that turns hormone production
Environmental psychologist specialist who studies how off and on
the environment affects behavior Felony serious criminal offense
Equianalgesic dose oral dose that provides the same level of Fenestrated drape one with an open circle in its center
pain relief as a parenteral dose Fever body temperature that exceeds 99.3°F (37.4°C)
Fifth vital sign client’s pain assessment that is checked and Gauge diameter
documented, in addition to his or her temperature, pulse, Gavage provision of nourishment
respirations, and blood pressure General adaptation syndrome collective physiologic pro-
Filtration process that regulates the movement of water and cesses that occur in response to a stressor
substances from a compartment where the pressure is high Generalization supposition that a person shares cultural
to one where the pressure is lower characteristics with others of a similar background
Finger sweep insertion of the index finger into the mouth Generic name chemical drug name that is not protected by a
along the inside of the cheek and deeply into the throat to manufacturer’s trademark
the base of the tongue Gerogogy techniques that enhance learning among older
Fire plan procedure followed if there is a fire adults
First-intention healing reparative process when wound Gingivitis inflammation of the gums
edges are directly next to one another Glucometer instrument that measures the amount of glu-
Fitness capacity to exercise cose in capillary blood
Fitness exercise physical activity performed by healthy adults Gluteal setting contraction and relaxation of the gluteus
Flatulence accumulation of intestinal gas muscles to strengthen and tone them
Flatus gas formed in the intestine and released from the Goal expected or desired outcome
rectum Good Samaritan laws legal immunity for passersby who
Flow sheet form of documentation that contains sections for provide emergency first aid to accident victims
recording frequently repeated assessment data Gram staining process of adding dye to a microscopic
Flowmeter gauge used to regulate the number of liters of specimen
oxygen delivered to the client Granulation tissue combination of new blood vessels,
Fluid imbalance condition in which the body’s water is not fibroblasts, and epithelial cells
in proper volume or location in the body Gravity force that pulls objects toward the center of the
Fluoroscopy form of radiography that displays an image in earth
real time Grief response psychological and physical phenomena expe-
Focus assessment information that provides more details rienced by those who grieve
about specific problems Grief work activities involved in grieving
Focus charting modified form of SOAP charting Grieving process of feeling acute sorrow over a loss
Folk medicine health practices unique to a particular group
of people
Food pyramid guide for promoting the healthful intake of food H
Foot drop permanent dysfunctional position caused by short- Hand antisepsis removal and destruction of transient micro-
ening of the calf muscles and lengthening of the opposing organisms from the hands
muscles on the anterior leg Handwashing aseptic practice that involves scrubbing the
Forced coughing coughing that is purposely produced hands with plain soap or detergent, water, and friction
Forearm crutches crutches with an arm cuff but no axil- Head tilt/chin lift technique preferred method for opening
lary bar the airway
Fowler’s position upright seated position Head-to-toe approach gathering data from the top of the
Fraction of inspired oxygen portion of oxygen in relation body to the feet
to total inspired gas Health state of complete physical, mental, and social well-
Frenulum structure that attaches the undersurface of the being; not merely the absence of disease or infirmity
tongue to the fleshy portion of the mouth Health care system network of available health services
Frequency need to urinate often Health maintenance organizations corporations that charge
Functional braces braces that provide stability for a joint members preset, fixed, yearly fees in exchange for providing
Functional mobility alignment that maintains the potential health care
for movement and ambulation Hearing acuity ability to hear and to discriminate sound
Functional nursing pattern in which each nurse on a unit Heimlich maneuver method for removing a mechanical air-
is assigned specific tasks way obstruction
Functional position position that promotes continued use Hereditary condition disorder acquired from the genetic
and mobility codes of one or both parents
Functionally illiterate possessing minimal literacy skills Holism philosophical concept of interrelatedness
Home health care in-home health care provided by an
employee of a home health agency
G Homeostasis relatively stable state of physiologic equilibrium
Gastric reflux reverse flow of gastric contents Hospice facility for or concept addressing the care of termi-
Gastric residual volume of liquid remaining in the stomach nally ill clients
Gastrocolic reflex increased peristaltic activity Hot spot area where radionuclide is intensely concentrated
Gastrostomy tube, G-tube transabdominal tube located in Human needs factors that motivate behavior
the stomach Humidifier device that produces small water droplets
Gate-control theory belief about how pain is transmitted Humidity amount of moisture in the air
and blocked Hydrostatic pressure pressure exerted against a membrane
Hydrotherapy therapeutic use of water Infectious diseases diseases spread from one person to
Hygiene personal cleanliness practices that promote health another
Hyperbaric oxygen therapy delivery of 100% oxygen at Infiltration escape of intravenous fluid into the tissue
three times the normal atmospheric pressure in an airtight Inflammation physiologic defense that occurs immediately
chamber after tissue injury
Hypercarbia excessive levels of carbon dioxide in the blood Inflatable splints immobilizing devices that become rigid
Hyperendemic infections infections that are considered when filled with air
highly dangerous in all age groups Informed consent permission that a person gives after hav-
Hypersomnia sleep disorder characterized by feeling sleepy ing the risks, benefits, and alternatives explained
despite getting a normal amount of sleep Infusion pump device that uses pressure to infuse solutions
Hypersomnolence excessive sleeping Inhalant route drug administration into the lower airways
Hypertension high blood pressure Inhalation therapy respiratory treatments that provide a mix-
Hyperthermia excessively high core temperature ture of oxygen, humidification, and aerosolized medication
Hypertonic solution solution that is more concentrated than Inhalers hand-held devices for delivering medication to the
body fluid respiratory passages
Hyperventilation rapid or deep breathing, or both Inpatient surgery operative procedures performed on per-
Hypervolemia higher-than-normal volume of water in the sons admitted to a hospital and expected to remain for a
intravascular fluid compartment period of time
Hypnogogic hallucinations dream-like auditory or visual Insomnia sleep disorder involving early awakening or diffi-
experiences while dozing or falling asleep culty falling asleep or staying asleep
Hypnosis therapeutic technique in which a person enters a Inspection purposeful observation
trance-like state Inspiration inhalation; breathing in
Hypnotic agent that produces sleep Insulin syringe syringe that is calibrated in units and holds
Hypoalbuminemia deficit of albumin in the blood a volume of 0.5 to 1 mL of medication
Hypopnea hypoventilation Intake and output record of a client’s fluid intake and fluid
Hypotension low blood pressure loss over a 24-hour period
Hypothalamus temperature-regulating structure in the brain Integrated delivery system network that provides a full
Hypothermia core body temperature less than 95°F (35°C) range of healthcare services in a highly coordinated, cost-
Hypotonic solution one that contains fewer dissolved sub- effective manner
stances than normally found in plasma Integument covering
Hypoventilation diminished breathing Intentional tort lawsuit in which a plaintiff charges that a
Hypovolemia low volume in the extracellular fluid defendant committed a deliberately aggressive act
compartments Intermediate care facility agency that provides health-
Hypoxemia insufficient oxygen in arterial blood related care and services to people who, because of their
Hypoxia inadequate oxygen at the cellular level mental or physical condition, require institutional care but
not 24-hour nursing care
Intermittent feeding gradual instillation of liquid nourish-
I ment four to six times a day
Idiopathic illness one whose cause is unexplained Intermittent infusion parenteral administration of medica-
Ileostomy surgically created opening to the ileum tion over a relatively short period
Illiterate unable to read or write Intermittent venous access device sealed chamber that
Illness state of discomfort provides a means for administering intravenous medica-
Imagery using the mind to visualize an experience tions or solutions on a periodic basis
Immobilizers commercial splints made from cloth and foam Interstitial fluid fluid in tissue space between and around
Implementation carrying out a plan of care cells
Incentive spirometry technique for deep breathing using a Intestinal decompression removal of gas and intestinal
calibrated device contents
Incident report written account of an unusual event involv- Intimate space distance within 6 inches of a person
ing a client, employee, or visitor that has the potential for Intracellular fluid fluid inside cells
being injurious Intractable pain pain unresponsive to methods of pain
Incomplete proteins those that contain some, but not all, of management
the essential amino acids Intradermal injection parenteral drug administration
Incontinence inability to control either urinary or bowel between the layers of the skin
elimination Intramuscular injection parenteral drug administration
Individual supply single container of drugs with several into muscle
days’ worth of doses Intraoperative period time when a client undergoes surgery
Induration area of hardness Intraspinal analgesia method of relieving pain by instilling
Infection condition that results when microorganisms cause a narcotic or local anesthetic via a catheter into the sub-
injury to a host arachnoid or epidural space of the spinal cord
Infection control precautions physical measures designed Intravascular fluid watery plasma, or serum, portion of
to curtail the spread of infectious diseases blood
Intravenous fluids solutions infused into a client’s vein and financial assistance when a policyholder is involved in
Intravenous injection parenteral drug administration into a malpractice lawsuit
a vein Libel damaging statement that is written and read by others
Intravenous route drug administration via peripheral and Line of gravity imaginary vertical line that passes through
central veins a center of gravity
Introductory phase period of getting acquainted Lipoatrophy breakdown of subcutaneous fat at the site of
Intubation placement of a tube into a structure of the body repeated insulin injections
Inunction medication incorporated into an agent such as an Lipohypertrophy buildup of subcutaneous fat at insulin
ointment, oil, lotion, or cream injection sites
Invasion of privacy failure to leave people and their prop- Lipoproteins combinations of fats and proteins
erty alone Liquid oxygen unit device that converts cooled liquid oxygen
Ions substances that carry either a positive or negative elec- to a gas by passing it through heated coils
trical charge Literacy ability to read and write
Irrigation technique for flushing debris Lithotomy position reclining posture with the feet in metal
Isometric exercise stationary exercises that are generally supports called stirrups
performed against a resistive force Living will a person’s advance, written directive identifying
Isotonic exercise activity that involves movement and work medical interventions to use or not to use in cases of termi-
Isotonic solution solution that contains the same concentra- nal condition, irreversible coma, or vegetative state with no
tion of dissolved substances as normally found in plasma hope of recovery
Loading dose larger dose of a drug administered initially or
when pain is intense
J Long-term goals desirable outcomes that take weeks or
Jaeger chart visual assessment tool with small print months to accomplish
Jaw-thrust maneuver alternative method for opening the Lumbar puncture procedure that involves insertion of a
airway
needle between lumbar vertebrae in the spine but below the
Jejunostomy tube; J-tube transabdominal tube that leads to
spinal cord itself
the jejunum of the small intestine
Lumen channel
Jet lag emotional and physical changes experienced when
arriving in a different time zone
M
Macrophages white blood cells that consume cellular debris
K
Macroshock harmless distribution of low-amperage electric-
Kardex quick reference for current information about the
ity over a large area of the body
client and the client’s care
Magnetic resonance imaging technique that produces an
Kegel exercises isometric exercises to improve the ability to
image by using atoms subjected to a strong electromagnetic
retain urine within the bladder
field
Kilocalories 1,000 calories, or the amount of heat that raises
Malingerer someone who pretends to be sick or in pain
the temperature of 1 kilogram of water 1°C
Kinesics body language Malnutrition condition resulting from a lack of proper nutri-
Knee-chest position position in which the client rests on ents in the diet
the knees and chest Malpractice professional negligence
Korotkoff sounds sounds that result from the vibrations of Managed care organizations private insurers who care-
blood in the arterial wall or changes in blood flow fully plan and closely supervise distribution of their clients’
health care services
Managed care practices cost-containment strategies used to
L plan and coordinate a client’s care to avoid delays, unneces-
Laboratory test procedure that involves the examination of sary services, or overuse of expensive resources
body fluids or specimens Manual traction pulling on the body using a person’s hands
Lateral oblique position variation of a side-lying position and muscular strength
Lateral position side-lying position Massage stroking the skin
Latex-safe environment room stocked with latex-free equip- Mattress overlay layer of foam or other devices placed on
ment and wiped clean of glove powder top of the mattress
Latex sensitivity allergic response to the proteins in latex Maximum heart rate highest limit for heart rate during
Latinos people who trace their ethnic origin to South America exercise
Lavage wash out; remove poisonous substances Medicaid state-administered program designed to meet the
Laws rules of conduct established and enforced by the govern- needs of low-income residents
ment of a society Medical asepsis practices that confine or reduce the num-
Leukocytes white blood cells bers of microorganisms
Leukocytosis increased production of white blood cells Medical records written collection of information about a
Liability insurance contract between a person or corpora- person’s health problems, the care provided by health prac-
tion and a company who is willing to provide legal services titioners, and the progress of the client
Medicare federal program that finances health care costs of N

persons 65 years and older, permanently disabled workers N95 respirator device that is individually fitted to each care-
and their dependents, and people with end-stage renal disease giver and can filter particles 1 micron in size, with a filter
Medication administration record agency form used to efficiency of 95% or more, provided it fits the face snugly
document drug administration Narcolepsy sleep disorder characterized by the sudden onset
Medication order name and directions for administering a of daytime sleep, a short NREM period before the first REM
drug phase, and pathologic manifestations of REM sleep
Medications chemical substances that change body function Narrative charting style of documentation generally used
Meditation concentrating on a word or idea that promotes in source-oriented records
tranquility Nasal cannula hollow tube with prongs that are placed into
Megadoses amounts exceeding those considered adequate the client’s nostrils for delivering oxygen
for health Nasal catheter tube for delivering oxygen that is inserted
Melatonin hormone that induces drowsiness and sleep through the nose into the posterior nasal pharynx
Mental status assessment technique for determining the Nasogastric intubation insertion of a tube through the nose
level of a client’s cognitive functioning into the stomach
Metabolic energy equivalent measure of energy and oxy- Nasogastric tube tube that is placed in the nose and advanced
gen consumption during exercise to the stomach
Metabolic rate use of calories for sustaining body functions Nasointestinal intubation insertion of a tube through the
Metered-dose inhaler canister that contains medication nose to the intestine
under pressure Nasointestinal tube tube inserted through the nose for dis-
Microabrasions tiny cuts in the skin that provide an entrance tal placement below the stomach
for microorganisms Nasopharyngeal suctioning removal of secretions from the
Microorganisms living animals or plants visible only with a throat through a nasally inserted catheter
microscope Nasotracheal suctioning removal of secretions from the
Microshock low-voltage but high-amperage electricity trachea through a nasally inserted catheter
Microsleep unintentional sleep lasting 20 to 30 seconds National Patient Safety Goals objectives designed to reduce
Midarm circumference measurement used to assess skele- the incidence of injuries to those being cared for in health
tal muscle mass agencies
Military time time based on a 24-hour clock Native Americans Indian nations found in North America,
Minerals noncaloric substances in food that are essential to including the Eskimos and Aleuts
all cells Nausea feeling that usually precedes vomiting
Minimum disclosure portions or isolated pieces of informa- Necrotic tissue nonliving tissue
tion necessary for an immediate purpose Needleless systems intravenous tubing that eliminates the
Minority people who differ from the majority in cultural need for access needles
characteristics like language, physical characteristics such Negligence harm that results because a person did not act
as skin color, or both. reasonably
Misdemeanor minor criminal offense Neuropathic pain pain with atypical characteristics
Mode of transmission manner in which infectious microor- Neurotransmitters chemical messengers synthesized in
ganisms move to another location neurons
Modified standing position position in which the upper Neutral position limb that is turned neither toward nor
half of the body leans forward away from the body’s midline
Modulation last phase of pain impulse transmission when NEX measurement distance from the nose to the earlobe to
the brain interacts downward with spinal nerves to alter a the xiphoid process
pain experience Nociceptors nerve receptors that transmit pain impulses
Molded splints orthotic devices made of rigid material Nocturia nighttime urination
Montgomery straps strips of tape with eyelets Nocturnal enuresis bedwetting
Morbidity incidence of a specific disease, disorder, or injury Nocturnal polysomnography technique used to obtain
Morgue area where dead bodies are temporarily held or physiologic data during nighttime sleep
examined Nonelectrolytes chemical compounds that remain bound
Mortality incidence of deaths together when dissolved in solution
Mortician person who prepares the body for burial or Nonessential amino acids protein components manufac-
cremation tured in the body
Mucus substance that keeps mucous membranes moist Nonopioids nonnarcotic drugs
Multicultural diversity unique characteristics of ethnic Nonpathogens harmless and beneficial microorganisms
groups Nonrebreather mask oxygen delivery device in which all
Multiple organ failure condition in which two or more the exhaled air leaves the mask rather than partially enter-
organ systems gradually cease to function ing the reservoir bag
Multiple sleep latency test assessment of daytime sleepiness Nonverbal communication exchange of information with-
Muscle spasms sudden, forceful, involuntary muscle out using words
contractions Normal flora microorganisms that reside in and on humans
Nosocomial infections infections acquired while a person Orthoses orthopedic devices that support or align a body
is being cared for in a hospital or other health care agency part and prevent or correct deformities
Nuclear medicine department unit responsible for radio- Orthostatic hypotension sudden but temporary drop in
nuclide imaging blood pressure when rising from a reclining or seated position
Nurse-managed care pattern in which a nurse manager Osmosis process that regulates the distribution of water
plans the nursing care of clients based on their illness or Ostomy surgically created opening
medical diagnosis Otic application drug instillation in the outer ear
Nurse practice act statute that legally defines the unique Outpatient surgery operative procedures from which clients
role of the nurse and differentiates it from that of other recover and return home on the same day
health care practitioners, such as physicians Over-the-counter medication nonprescription drug
Nursing care plan written list of the client’s problems, Oxygen analyzer humidifier
goals, and nursing orders for client care Oxygen concentrator machine that collects and concen-
Nursing diagnosis health problem that can be prevented, trates oxygen from room air and stores it for client use
reduced, or resolved through independent nursing measures Oxygen tent clear plastic enclosure that provides cooled,
Nursing orders directions for a client’s care humidified oxygen
Nursing process organized sequence of problem-solving Oxygen therapy therapeutic intervention for administering
steps: assessment, diagnosis, planning, implementation, and more oxygen than exists in the atmosphere
evaluation Oxygen toxicity lung damage that develops when oxygen
Nursing skills activities unique to the practice of nursing concentrations of more than 50% are administered for
Nursing team personnel who care for clients directly longer than 48 to 72 hours
Nursing theory proposal detailing what is involved in the
process of nursing
Nutrition process by which the body uses food P
Pack commercial device for applying moist heat
Pain unpleasant sensation usually associated with disease or
O
injury
Obesity condition in which a person’s body-mass index
Pain management techniques for preventing, reducing, or
exceeds 30/m2 or the triceps skinfold measurement exceeds
relieving pain
15 mm
Pain threshold point at which sufficient pain-transmitting
Objective data facts that are observable and measurable
neurochemicals reach the brain to cause awareness of
Occupied bed changing linen while the client remains in bed
discomfort
Offsets predictive mathematical conversions
Pain tolerance amount of pain a person endures once the
Oliguria urine output of less than 400 mL per 24 hours
pain threshold is surpassed
Open wound wound in which the surface of the skin or
Palpation lightly touching the body or applying pressure
mucous membrane is no longer intact
Palpitation awareness of one’s own heart contraction with-
Ophthalmic application method of applying drugs onto the
mucous membrane of one or both eyes out having to feel the pulse
Ophthalmologist medical doctor who treats eye disorders Pap test screening test that detects abnormal cervical cells, the
Opioids narcotic drugs; synthetic narcotics status of reproductive hormone activity, or the presence of
Opportunistic infections disorders caused by nonpathogens normal or infectious microorganisms in the uterus or vagina
that occur in people with compromised health Paracentesis procedure for withdrawing fluid from the ab-
Optometrist person who prescribes corrective vision lenses dominal cavity
Oral airway curved device that keeps the tongue positioned Paralanguage vocal sounds that are not actually words
forward within the mouth Parallel bars double row of stationary bars
Oral hygiene practices used to clean the mouth, especially Paranormal experiences those outside scientific explanation
the teeth Parasomnia condition associated with activities that cause
Oral route drug administration by swallowing or instillation arousal or partial arousal, usually during transitions in
through an enteral tube NREM periods of sleep
Oral suctioning removal of secretions from the mouth Parenteral nutrition nutrients, such as proteins, carbohy-
Orientation helping a person to become familiar with a new drate, fat, vitamins, minerals, and trace elements, which are
environment administered intravenously
Orogastric intubation insertion of a tube through the mouth Parenteral route route of drug administration other than
into the stomach oral or through the gastrointestinal tract; administration by
Orogastric tube tube that is inserted from the mouth into injection
the stomach Partial bath washing only the areas of the body that are sub-
Oropharyngeal suctioning removal of secretions from the ject to the greatest soiling or that are sources of body odor
throat through a catheter inserted through the mouth Partial rebreather mask oxygen delivery device through
Orthopnea breathing that is facilitated by sitting up or which a client inhales a mixture of atmospheric air, oxygen
standing from its source, and oxygen contained in a reservoir bag
Orthopneic position seated position with the arms sup- Passive diffusion physiologic process in which dissolved
ported on pillows or the arm rests of a chair substances, such as electrolytes and gases, move from an
area of higher concentration to one of lower concentration selecting appropriate interventions, and documenting the
through a semipermeable membrane plan for care
Passive exercise therapeutic activity performed with Plaque substance composed of mucin and other gritty sub-
assistance stances 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
Pathologic grief condition in which a person cannot accept laser surgery
someone’s death Plunger part of a syringe inside the barrel that moves back
Patient-controlled analgesia intervention that allows clients and forth to withdraw and instill medication
to self-administer pain medication Pneumatic compression device machine that promotes cir-
Pedagogy science of teaching children or those who have culation of venous blood and the movement of excess fluid
comparable cognitive ability into the lymphatic vessels
Pelvic examination physical inspection of the vagina and Pneumonia lung infection
cervix, 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
Percussion (1) striking or tapping a part of the body; (2) type absorption of a toxic substance
of chest physiotherapy performed by rhythmically striking Polypharmacy administration of multiple drugs to the same
the chest wall person
Percutaneous electrical nerve stimulation pain manage- Polyuria larger-than-normal urinary volume
ment technique involving a combination of acupuncture Port sealed opening
needles and transcutaneous electrical nerve stimulation Port of entry site where microorganisms find their way onto
Percutaneous endoscopic gastrostomy (PEG) tube trans- or into a host
abdominal tube inserted into the stomach under endoscopic Positron emission tomography radionuclide scanning with
guidance the layered analysis of tomography
Percutaneous endoscopic jejunostomy (PEJ) tube tube Possible diagnosis problem that may be present, but more
information is needed to rule out or confirm its existence
that is passed through a PEG tube into the jejunum
Postanesthesia care unit area in the surgical department
Perineal care techniques used for cleansing the perineum
where clients are intensively monitored
Periodontal disease condition that results in destruction of
Postmortem care care of the body after death
the tooth-supporting structures and jawbone
Postoperative care nursing care after surgery
Perioperative care care that clients receive before, during,
Postoperative period interval that begins after surgery is
and after surgery
completed
Peripheral parenteral nutrition isotonic or hypotonic intra-
Postural drainage positioning technique that facilitates
venous nutrient solution instilled in a vein distant from the
drainage of secretions from the lungs
heart
Postural hypotension sudden but temporary drop in blood
Peristalsis rhythmic contractions of smooth muscle
pressure when rising from a reclining or seated position
Peristomal skin skin around a stoma
Posture position of the body, or the way in which it is held
Persistent vegetative state condition in which there is no Potential diagnosis problem a client is at risk for developing
cognitive function or capacity to experience emotions Powered Air Purifying Respirator alternative device for
Personal protective equipment garments that block the a caregiver who has not been fitted for an N95 respirator;
transfer of pathogens from one person, place, or object to works by blowing atmospheric air through belt-mounted,
oneself or others air-purifying canisters to the facepiece via a flexible tube
Personal space distance of 6 inches to 4 feet Preferred provider organizations agents for health insur-
Phagocytosis process in which white blood cells consume ance companies that control health care costs on the basis of
cellular debris competition
Phlebitis inflammation of a vein Prefilled cartridge sealed glass cylinder of parenteral med-
Photoperiod number of daylight hours ication with a preattached needle
Phototherapy technique for suppressing melatonin by stim- Preload volume of blood that fills the heart and stretches the
ulating light receptors in the eye heart muscle fibers during its resting phase
Physical assessment systematic examination of body Preoperative checklist form that identifies the status of
structures essential presurgical activities
PIE charting method of recording the client’s progress under Preoperative period time that starts when the client is
the headings of problem, intervention, and evaluation informed that surgery is necessary and ends when he or she
Piloerection contraction of arrector pili muscles in skin is transported to the operating room
follicles Pressure ulcer wound caused by prolonged capillary com-
Pin site location where pins, wires, or tongs enter or exit the pression sufficient to impair circulation to the skin and
skin underlying tissue
Placebo inactive substance Primary care first health care worker or agency to assess a
Plaintiff person who claims injury person with a health need
Planning process of prioritizing nursing diagnoses and collab- Primary illness one that develops independently of any
orative problems, identifying measurable goals or outcomes, other disease
Primary nursing pattern in which the admitting nurse Rebound effect swelling of the nasal mucosa within a short
assumes responsibility for planning client care and evaluat- time of drug administration
ing the progress of the client Receiving room presurgical holding area
Problem-oriented records records organized according to Reciprocity licensure based on evidence of having met
the client’s health problems licensing criteria in another state
Progressive care units units for clients who were once in Reconstitution process of adding liquid to a powdered
critical condition but have recovered sufficiently to require substance
less intensive nursing care Recording process of writing information
Progressive relaxation therapeutic exercise whereby a per- Recovery index guide for determining a person’s fitness
son actively contracts and then relaxes muscle groups level
Projectile vomiting vomiting that occurs with great force Recovery position side-lying position that helps to maintain
Proliferation period during which new cells fill and seal a an open airway and prevent aspiration of liquids
wound Rectus femoris site injection area in the anterior thigh
Prone position position in which the client lies on the Referral process of sending someone to another person or
abdomen agency for special services
Prophylactic braces braces used to prevent or reduce the Referred pain discomfort perceived in an area of the body
severity of a joint injury away from the site of origin
Prosthetic limb substitute for an arm or leg Regeneration cell duplication
Prosthetist person who constructs prosthetic limbs Regurgitation bringing stomach contents to the throat and
Protein nutrient composed of amino acids, chemical com- mouth without the effort of vomiting
pounds made up of nitrogen, carbon, hydrogen, and oxygen Rehabilitative braces braces that allow protected motion of
Protein complementation combining plant sources of protein an injured joint that has been treated surgically
Relationship association between two people
Proxemics relation of space to communication
Relative humidity ratio between the amount of moisture in
Psychomotor domain learning by doing
the air and the greatest amount of water vapor the air can
Public space distance of 12 or more feet
hold at a given temperature
Pulmonary embolus blood clot that travels to the lung
Relaxation technique for releasing muscle tension and qui-
Pulse wave-like sensation that can be palpated in a periph-
eting the mind
eral artery
Remission disappearance of signs and symptoms associated
Pulse deficit difference between the apical and radial pulse
with a particular disease
rates
Remodeling period during which a wound undergoes changes
Pulse oximetry noninvasive, transcutaneous technique for
and maturation
periodically or continuously monitoring the oxygen satura- Repetitive strain injuries disorders that result from cumu-
tion of blood lative trauma to musculoskeletal structures
Pulse pressure difference between systolic and diastolic Rescue breathing process of ventilating a nonbreathing
blood pressure measurements victim’s lungs
Pulse rate number of peripheral arterial pulsations palpated Reservoir place where microbes grow and reproduce provid-
in a minute ing a haven for sustaining microbial survival
Pulse rhythm pattern of the pulsations and pauses between Resident microorganisms generally nonpathogens that are
them constantly present on the skin
Pulse volume quality of the pulsations that are felt Residual urine urine that remains in the bladder after voiding
Pursed-lip breathing form of controlled ventilation in which Resolution process by which damaged cells recover and
the expiration phase of breathing is consciously prolonged reestablish their normal function
Purulent drainage white- or green-tinged fluid Respiration exchange of oxygen and carbon dioxide
Pyrexia fever Respiratory rate number of ventilations per minute
Respite care relief for a caregiver
Rest waking state characterized by reduced activity and
Q reduced mental stimulation
Quadriceps setting isometric exercise in which a client Restless legs syndrome movement, typically in the legs, but
alternately tenses and relaxes the quadriceps muscles occasionally in the arms or other body parts, to relieve dis-
Quality assurance process of promoting care that reflects turbing skin sensations
established agency standards Restraint alternatives protective or adaptive devices that
promote client safety and postural support, but which the
client can release independently
R Restraints devices or chemicals that restrict movement or
Race biologic variations access to one’s body
Radiography diagnostic procedures that use x-rays Resuscitation team group of people trained and certified in
Radionuclides elements whose molecular structures are advanced cardiac life support [ACLS] techniques
altered to produce radiation Retching act of vomiting without producing vomitus
Range-of-motion exercises therapeutic activity in which Retention catheter urinary tube that is left in place for a
joints are moved period of time
Retention enema solution held temporarily in the large Skeletal traction pull exerted directly on the skeletal system
intestine by attaching wires, pins, or tongs into or through a bone
Reversal drugs medications that counteract the effects of Skilled nursing facility nursing home that provides 24-hour
those used for conscious sedation nursing care under the direction of a registered nurse
Rhizotomy surgical sectioning of a nerve root close to the Skin patches drugs that are bonded to an adhesive bandage
spinal cord Skin tear shallow break in the skin
Rinne test assessment technique for comparing air versus Skin traction pulling effect on the skeletal system by apply-
bone conduction of sound ing devices to the skin
Risk management process of identifying and reducing the Slander character attack uttered in the presence of others
costs of anticipated losses Sleep state of arousable unconsciousness
Roentgenography general term for procedures that use Sleep apnea/hypopnea syndrome sleep disorder in which
x-rays the sleeper stops breathing or the breathing slows for 10 sec-
Rounds visits to clients on an individual basis or as a group onds or longer, five or more times per hour
Route of administration oral, topical, inhalant, or par- Sleep diary daily account of sleeping and waking activities
enteral route where a drug is administered Sleep paralysis inability to move for a few minutes just
before falling asleep or awakening
Sleep rituals habitual activities performed before retiring
S Sleep-wake cycle disturbance condition that results from
Safety measures that prevent accidents or unintentional a sleep schedule that involves daytime sleeping
injuries Sling cloth device used to elevate, cradle, and support parts
Saturated fats lipids that contain as much hydrogen as their of the body
molecular structure can hold Smelling acuity ability to smell and identify odors
Scar formation replacement of damaged cells with fibrous Snellen eye chart tool for assessing far vision
tissue Soak procedure in which a part of the body is submerged in
Science body of knowledge unique to a particular subject fluid
Scoop method technique for threading the needle of a SOAP charting documentation style more likely to be used
in a problem-oriented record
syringe into the cap without touching the cap itself
Social space distance of 4 to 12 feet
Scored tablet tablet with a groove in its center
Somatic pain discomfort generated from deeper connective
Secondary care health services to which primary caregivers
tissue
refer clients for consultation and additional testing
Somnambulism sleep-walking
Secondary illness disorder that develops from a preexisting
Sordes dried crusts around the mouth containing mucus,
condition
microorganisms, and epithelial cells shed from the oral
Secondary infusion administration of a diluted intravenous
mucous membrane
drug at the same time a solution is infusing, or inter-
Source-oriented records records organized according to the
mittently with an infusing solution
source of information
Second-intention healing reparative process when wound
Spacer chamber that is attached to an inhaler
edges are widely separated
Specimens samples of tissue or body fluids
Sedative drug that produces a relaxing and calming effect Speculum metal or plastic instrument for widening the vagina
Sepsis potentially fatal systemic infection or other body cavity
Sequelae consequences of a disease or its treatment Sphygmomanometer device for measuring blood pressure
Serous drainage leaking plasma Spica cast rigid mold that encircles one or both arms or legs
Set point optimal body temperature and the chest or trunk
Shaft long portion of a needle Spinal tap procedure that involves insertion of a needle
Shearing force exerted against the surface and layers of the between lumbar vertebrae in the spine but below the spinal
skin as tissues slide in opposite but parallel directions cord itself
Shearing force effect that moves layers of tissue in opposite Splint device that immobilizes and protects an injured part
directions of the body
Shell temperature warmth at the skin surface Spore temporarily inactive microbial life form
Short-term goals outcomes that can be met in a few days to Sputum mucus raised to the level of the upper airways
a week Standard precautions measures for reducing the risk of
Shroud covering for a dead body microorganism transmission from both recognized and
Signs objective data; information that is observable and unrecognized sources of infection
measurable Standards for care policies that ensure quality client care
Silence intentionally withholding verbal comments Staples wide metal clips
Simple mask device for administering oxygen that fits over Stasis lack of movement
the nose and mouth Statute of limitations designated amount of time within
Sims’ position lying on the left side with the chest leaning which a person can file a lawsuit
forward, the right knee bent toward the head, the right arm Statutory laws laws enacted by federal, state, or local
forward, and the left arm extended behind the body legislatures
Sitz bath soak of the perianal area Stent tube that keeps a channel open
Stepdown units units for clients who were once in critical Susceptible host one whose biologic defense mechanisms
condition but have recovered sufficiently to require less are weakened in some way
intensive nursing care Sustained release drug that dissolves at timed intervals
Step test submaximal fitness test involving a timed stepping Sutures knotted ties that hold an incision together
activity Sympathy feeling as emotionally distraught as the client
Stereotypes fixed attitudes about all people who share a Symptoms subjective data; that which only the client can
common characteristic identify
Sterile field work area free of microorganisms Syndrome diagnosis cluster of problems that are present
Sterile technique practices that avoid contaminating due to an event or situation
microbe-free items Systolic pressure pressure in the arterial system when the
Sterilization physical and chemical techniques that destroy heart contracts
all microorganisms, including spores
Stertorous breathing noisy ventilation
Stethoscope instrument that carries sound to the ears T
Stimulants drugs that excite structures in the brain Tachycardia heart rate between 100 and 150 beats per
Stock supply drugs kept in a nursing unit for use in an minute (bpm) at rest
emergency Tachypnea rapid respiratory rate
Stoma entrance to a surgically created opening Tamponade pressure
Straight catheter urine drainage tube that is inserted but Target heart rate goal for heart rate during exercise
not left in place Tartar hardened plaque
Strength power to perform Task-oriented touch personal contact that is required when
Stress physiologic and behavioral reactions that occur in performing nursing procedures
response to disequilibrium Team nursing pattern in which nursing personnel divide
Stress electrocardiogram test of electrical conduction the clients into groups and complete their care together
Teleology ethical theory based on final outcomes
through the heart during maximal activity
Temperature translation conversion of tympanic temper-
Stressors changes that have the potential for disturbing
ature into an oral, rectal, or core temperature
equilibrium
Tension pneumothorax extreme air pressure in the lung
Stridor harsh, high-pitched sound heard on inspiration
when there is no avenue for its escape
when there is laryngeal obstruction
Terminal disinfection measures used to clean the client
Stylet metal guidewire
environment after discharge
Subcultures unique cultural groups that coexist within the
Terminal illness illness with no potential for cure
dominant culture
Terminating phase ending of a nurse–client relationship
Subcutaneous injection parenteral drug administration
when there is mutual agreement that the client’s immediate
beneath the skin but above the muscle
health problems have improved
Subdiaphragmatic thrust pressure to the abdomen
Tertiary care health services provided at hospitals or med-
Subjective data information that only the client feels and ical centers that offer specialists and complex technology
can describe Theory opinion, belief, or view that explains a process
Sublingual application placement of a drug under the tongue Therapeutic baths baths performed for other than hygiene
Submaximal fitness test exercise test that does not stress a purposes
person to exhaustion Therapeutic exercise activity performed by people with
Substituted judgment court belief that a client would issue health risks or those being treated for a health problem
consent if he or she had the capacity to do so Therapeutic verbal communication using words and ges-
Suctioning technique for removing liquid secretions with a tures to accomplish a particular objective
catheter Thermal burn skin injury caused by flames, hot liquids, or
Suffering emotional component of pain steam
Sump tubes tubes that contain a double lumen Thermister temperature sensor
Sundown syndrome onset of disorientation as the sun sets Thermistor catheter heat-sensing device at the tip of an
Sunrise syndrome early-morning confusion internally placed tube
Supine position position in which the person lies on the Thermogenesis heat production
back Thermoregulation ability to maintain stable body
Suppository medicated oval or cone-shaped mass temperature
Surfactant lipoprotein produced by cells in the alveoli that Third-intention healing reparative process when a wound
promotes elasticity of the lungs and enhances gas diffusion is widely separated and later brought together with some
Surgical asepsis measures that render supplies and equip- type of closure material
ment totally free of microorganisms Third-spacing movement of intravascular fluid to nonvas-
Surgical scrub skin and nail antisepsis performed prior to cular fluid compartments, where it becomes trapped and
the nurse’s donning sterile gloves and garments in an oper- useless
ative or obstetrical procedure Thrombophlebitis inflammation of a vein caused by a
Surgical waiting area room where family and friends await thrombus
information about the surgical client Thrombus stationary blood clot
Thrombus formation development of a stationary blood clot Transitional care unit area for clients initially in a critical
Tidaling rhythmic rise and fall of water in a chest tube or unstable condition, but sufficiently recovered to require
drainage system less intensive nursing care
Tilt table device that raises client from a supine to a stand- Transmission phase during which stimuli move from the
ing position peripheral nervous system toward the brain
Tip part of a syringe to which the needle is attached Transmission-based precautions measures for controlling
Tone ability of muscles to respond when stimulated the spread of infectious agents from clients known to be or
Topical route drug administration to the skin or mucous suspected of being infected with highly transmissible or epi-
membranes demiologically important pathogens
Tort litigation in which one person asserts that an injury, Transtracheal catheter hollow tube inserted in the trachea
which may be physical, emotional, or financial, occurred as to deliver oxygen
a consequence of another’s actions or failure to act Trauma injury
Total parenteral nutrition hypertonic solution of nutrients Truth telling ethical principle proposing that all clients have
designed to meet almost all the caloric and nutritional needs the right to receive complete and accurate information
of clients Tuberculin syringe syringe that holds 1 mL of fluid and is
Total quality improvement process of promoting care that calibrated in 0.01-mL increments
reflects established agency standards Turbo-inhaler propeller-driven device used to instill pow-
Touch tactile stimulus produced by making personal contact dered medication into the airways
with another person or an object Turgor resiliency of the skin
Towel bath technique for bathing in which a single large Twenty-four-hour specimen collection of all the urine pro-
towel is used to cover and wash a client duced in a full 24-hour period
T-piece device that fits securely onto a tracheostomy tube or
endotracheal tube
Tracheostomy surgically created opening into the trachea U
Tracheostomy care hygiene and maintenance of a tracheos- Ultrasonography soft tissue examination that uses sound
tomy and tracheostomy tube waves in ranges beyond human hearing
Tracheostomy collar device that delivers oxygen near an Unintentional tort situation that results in an injury,
artificial opening in the neck although the person responsible did not mean to cause harm
Tracheostomy tube curved, hollow plastic tube in the trachea Unit dose self-contained packet that holds one tablet or capsule
Traction pulling on a part of the skeletal system Unoccupied bed changing the linen when the bed is empty
Traction splints metal devices that immobilize and pull on Unsaturated fats lipids that are missing some hydrogen
muscles that are in a state of contraction Urgency strong feeling that urine must be eliminated quickly
Trade name name used by the pharmaceutical company for Urinal cylindrical container for collecting urine
the drug it sells Urinary diversion procedure in which one or both ureters
Traditional time time based on two 12-hour revolutions on are surgically implanted elsewhere
a clock Urinary elimination process of releasing excess fluid and
Training effect heart rate and consequently pulse rate become metabolic wastes
consistently lower than average with regular exercise Urinary retention condition in which urine is produced but
Tranquilizer drug that produce a relaxing and calming effect is not released from the bladder
Transabdominal tubes tubes placed through the abdominal Urine fluid in the bladder
wall Urostomy urinary diversion that discharges urine from an
Transcultural nursing providing nursing care in the con- opening on the abdomen
text of another’s culture
Transcutaneous electrical nerve stimulation medically
prescribed pain management technique that delivers bursts V
of electricity to the skin and underlying nerves Valsalva maneuver act of closing the glottis and contracting
Transdermal application method of applying a drug on the the pelvic and abdominal muscles to increase abdominal
skin and allowing it to become passively absorbed pressure
Transducer instrument that receives and transmits bio- Values ideals that a person believes are important
physical energy Vastus lateralis site injection area in the outer thigh
Transduction conversion of chemical information at the cel- Vegans persons who rely exclusively on plant sources for
lular level into electrical impulses that move toward the protein
spinal cord Vegetarians persons who restrict consumption of animal
Trans fats unsaturated, hydrogenated fats food sources
Transfer (1) discharging a client from one unit or agency and Venipuncture accessing the venous system by piercing a
immediately admitting him or her to another; (2) moving a vein with a needle
client from place to place Ventilation (1) movement of air in and out of the lungs;
Transfer summary written review of the client’s previous (2) movement of air in the environment
care Ventrogluteal site injection area in the hip
Transient microorganisms pathogens picked up during Venturi mask oxygen delivery device that mixes a precise
brief contact with contaminated reservoirs amount of oxygen and atmospheric air
Verbal communication communication that uses words Walk-a-mile test fitness test that measures the time it takes
Vial glass or plastic container of parenteral medication with a person to walk a mile
a self-sealing rubber stopper Walker ambulatory aid constructed of curved aluminum bars
Vibration type of chest physiotherapy used to loosen retained that form a three-sided enclosure, with four legs for support
secretions Walking belt safety device applied around the client’s waist
Viral load number of viral copies used to provide ambulatory support and assistance
Visceral pain discomfort arising from internal organs Water-seal chest tube drainage technique for evacuating
Visual acuity ability to see both far and near air or blood from the pleural cavity
Visual field examination assessment of peripheral vision Water-soluble vitamins vitamins present and carried in
and continuity in the visual field body water; B complex and vitamin C
Vital signs body temperature, pulse rate, respiratory rate, Weber test assessment technique for determining equality
and blood pressure or disparity of bone-conducted sound
Vitamins chemical substances that are necessary in minute Wellness full and balanced integration of all aspects of health
amounts for normal growth, maintenance of health, and Wellness diagnosis situation in which a healthy person
functioning of the body obtains nursing assistance to maintain his or her health or
Voided specimen freshly urinated sample of urine perform at a higher level
Voiding reflex spontaneous relaxation of the urinary Wheal elevated circle on the skin
sphincter in response to physical stimulation Whistle-blowing reporting incompetent or unethical practices
Volume-control set chamber in intravenous tubing that Whitecoat hypertension condition in which the blood pres-
holds a portion from a larger volume of intravenous solution
sure is elevated when taken by a health care worker but is
Volumetric controller electronic infusion device that instills
normal at other times
intravenous solutions by gravity
Working phase period during which the nurse and client
Vomiting loss of stomach contents through the mouth
plan the client’s care and put the plan into action
Vomitus substance that is vomited
Wound damaged skin or soft tissue
W
Waiting-for-permission phenomenon a terminally ill Z
client’s forestalling of death when he or she feels that loved Z-track technique injection method that prevents medica-
ones are not yet prepared to deal with the client’s death tion from leaking outside the muscle
I N D E X
Note: Page numbers followed by f indicate figures; those followed by t indicate tables; and those followed by d indicate display text.
A procedures in, 163, 179d–181d oral airway in, 847–848

Abbreviations room preparation in, 164–165, 165d postural drainage in, 846, 846f
in documentation, 117, 118t types of, 164t in resuscitation, 859–863. See also
in drug administration, 769t, 770 undressing client and, 166 Resuscitation
Abdominal assessment, 245–246 Admission assessment form, 19f, 110t, 166 subdiaphragmatic thrusts in, 860–861,
Abdominal girth, 246, 247f Admissions clerk, 163 861f
Abdominal quadrants, 246 Admitting department, 163 suctioning in, 847, 847f, 847t, 852d–855d
Abrasions, 639t. See also Wound(s) Adolescents. See also Children tracheostomy in, 848–849, 849f
Acceptance, in terminal illness, 877 acne in, 363t Airway obstruction
Accommodation, visual, 235, 235f informed consent of, 618 causes of, 859, 860d
Accreditation, documentation in, 111 safety concerns for, 416 management of, 860–861. See also Airway
Acne, 363t Advance directives, 47, 48d, 110t management; Resuscitation
Acquired immunodeficiency syndrome, 489d Advanced life support, 865 signs of, 860, 860d, 860f
Active exercise, 547. See also Exercise Advanced practice nursing, 11 Airway occlusion, postoperative, 627t
Active listening, 15, 96 Adventitious lung sounds, 242–243, 243f, 244f Alarm stage, of stress response, 65, 65f
Active transport, 314 Adynamic ileus, postoperative, 627t Albumin
Activities of daily living, 12–15 Aerobic bacteria, 135 deficit of, third-spacing and, 319
assistance with, 175, 175f Aerobic exercise, 547. See also Exercise replacement of, 321t. See also
Activity. See Exercise Afebrile, 192 Transfusion(s)
Actual diagnosis, 20t Affective domain, in learning, 102 Alcohol, in antisepsis, 139, 139t
Acultural nursing care, 71 Affective touch, 99, 99f Alcohol dehydrogenase (ADH), 80–81
Acupressure, 445 African Americans, 73, 74t. See also under Alcohol hand rubs, 140, 140f, 141t
Acupuncture, 445 Cultural; Culture Alcohol use/abuse
Acute illness, 52 communication with, 75 ADH deficiency and, 80
Acute pain, 437, 438t. See also Pain G-6-PD deficiency in, 80, 81t cultural aspects of, 80–81
Acute stage, in infections, 489t health beliefs and practices of, 82t sleep and, 394
Adaptation leading causes of death for, 81t Alignment, 517t
of microorganisms, 136 Afterload, 198 Allen test, 461d, 461f
physiologic, 61–64, 63f. See also Against-medical-advice release, 39, 39f, 168 Allergic reaction
Homeostasis AIDS, 489d in contact dermatitis, 363t
to stress, 65–66, 65f, 66t Airborne precautions, 490–492, 491t to latex, 142, 417f, 426–427
Adaptation theory, 7t Air embolism, in intravenous infusion, to transfusion products, 331, 331t
Addiction, to opioids, 446–447 327–328, 328t Alpha-tocopherol, 293t
A-delta fibers, 435 Air-fluidized bed, 525–526, 526t, 527f Alternating air mattresses, 525, 525f, 526t
Adenosine triphosphate (ATP), 314 Air mattresses, 525, 525f, 526t Alternative activities, in stress management,
ADH deficiency, 80–81 Airway 69–70
Adipocytes, brown, 187 anatomy of, 844, 845f Alternative therapies, 81–82, 82d
Adjuvants, in pain management, 441, 443 definition of, 844 for pain, 443, 444–445
Administrative law, 35–37, 35t oral, 847–848 Ambulation. See also Mobility
Admission, 163–168 Airway burns, 419–420 assistive devices for, 584–604, 587f
assessment for, 19f, 110t, 166 Airway management, 844–858 with crutches, 588–589, 590t, 599d–602d.
care plan for, 166 anatomic aspects of, 844–845, 845f See also Crutches
client orientation in, 165 artificial, 847–849 preparation for, 584–585
client’s personal items in, 165–166 cardiopulmonary resuscitation in, dangling for, 585, 586f
client’s response to, 166–168 861–865 exercises for, 584–585, 585f
client welcome in, 165 chest physiotherapy in, 845–847 tilt table for, 585–586, 586f
definition of, 163 Heimlich maneuver in, 860–861, 861f prosthetic limbs for, 589–591, 590f
identification bracelet in, 164, 164f inhalation therapy in, 845, 845f Ambulatory aids, 584–604
medical authorization for, 164 liquefying secretions in, 845, 845f arm strengthening exercises for, 585, 585f
medical history in, 166 mobilizing secretions in, 845–847 canes, 587–588, 587f, 588d
nursing data base for, 166 natural, 845–847 crutches, 588–589, 589f, 590t, 599d–602d
to nursing home, 173 nursing care plan for, 850 nursing implications of, 591–593
physical assessment in, 166 nursing implications of, 849 for older adults, 593–594
physician’s responsibilities in, 166 in older adults, 849–850 walkers, 588, 588f
945
946 Index
Ambulatory electrocardiogram, 544–545, Anxiety, 167 Atherosclerosis, risk factors for, 291
545f nursing care plan for, 177d–178d ATP, 314
Ambulatory surgery, 615–616, 616t Apical heart rate, 195–196. See also Pulse(s) Attention, learning and, 105
American Indians. See Native Americans Apical-radial rate, 196–197. See also Pulse(s) Audiologist, 236
American Nurses Association (ANA) Apnea, 198 Audiometry, 236, 237t
ergonomic guidelines of, 519–520 sleep, 397 Auditors, 111
nursing definition of, 6 Appliance, ostomy, 742, 743f Auscultation
policy statement on client teaching, 102 changing of, 754d–756d of body sounds, 231, 231f
Amino acids, dietary, 289 Aquathermia pad, 649, 649f of bowel sounds, 246, 246d
Amish, 78t Arm, assessment of, 244–245, 244f, 245f of heart sounds, 241, 242f
Ampules, 798, 798f Arm circumference, 298–299, 299t of Korotkoff sounds, 202–203, 203f
Amputees, prosthetic limbs for, 589–591, Arm slings, 566, 566f, 576d–579d of lung sounds, 241–243, 242f, 244f
590f Arm strengthening exercises, 585, 585f Auscultatory gap, 203
application of, 599d–602d Arrhythmias, 195 Autoclave, 145
preoperative management of, 622 Art, nursing as, 6 Autologous transfusion, 618, 618t
Anaerobic bacteria, 135 Arterial blood gas assessment, 460, 460t, Autolytic débridement, 646
Anal assessment, 246–247 461d Automated external defibrillator, 863–865,
Analgesics, 440–443. See also Pain Arteriosclerosis, risk factors for, 291 865f
management Artificial eye, 369 Automated monitoring devices, 192, 192f
definition of, 439 Ascending colostomy, 743f Autonomic nervous system, 62–63, 63f, 63t
equianalgesic dose of, 447d Ascorbic acid, 293t Autonomy, 46
in patient-controlled analgesia, 451d–454d Asepsis, 134, 138–146. See also Infection Autopsy, 882–884
Anal sphincters, 736 control consent for, 882–883
Anatomic position, 517t definition of, 138 Avulsion, 639t. See also Wound(s)
Androgogy, 103, 103t hand, 139–141 Axillary crutches, 589, 589f
Anecdotal reports, 42 medical, 138–139 measuring for, 595d–597d
Aneroid manometer, 200, 200f, 201t surgical, 144–147 Axillary temperature, 188t, 189,
Anesthesia, 615, 624–625 Asian Americans, 73–74, 74t. See also under 212d–213d
dentures and, 622 Cultural; Culture
for diagnostic procedures, 255, 257f, 260 communication with, 75
general, 616t, 624–625 health beliefs and practices of, 82t B
local, for injections, 806 leading causes of death for, 81t Baccalaureate programs, 9, 9t, 10, 10f
recovery from, 625 Asphyxiation Back injuries, in nurses, 519–520
regional, 616t, 625 in carbon monoxide poisoning, 420–421 Back massage, 398–399, 399t, 411d–414d
reversal drugs for, 625 in smoke inhalation, 419–420 Bacteria, 135, 135f
Anesthesiologist, 615 Aspiration Bactericides, 139
Anesthetist, 615 nursing care plan for, 679d–680d Bacteriostatic agents, 139
Anger, in terminal illness, 877 prevention of, 679d Bag bath, 362–364, 364d
Anglo-Americans, 72 in tube feeding, 669, 669d, 669f, 677t Balance, 517t
health beliefs and practices of, 82t Assault, 37 Bandages, 644–646
Anions, 312, 313t Assessment, 12, 17–20, 17f butterfly, 644
Ankle, range-of-motion exercises for, 559d admission, 19f, 110t, 166 roller, 644–646, 645f
Ankle padding, for ulcer prevention, 652d, in client teaching, 102–105 Bargaining, in terminal illness, 877
652f cultural, 74–77 Barrel, of syringe, 796, 797f
Ankylosis, 547 data base, 18, 18t, 19f Base of support, 517f, 517t
Anorexia, 300, 301d data for, 18, 18t Basic care facilities, 173
Anorexia nervosa, 300 objective, 18, 18b Basic needs theory, 7t
Anthropometric data, 297–298. See also organization of, 20, 20d Baths/bathing, 361–364
Height; Weight sources of, 18 bag, 362–364, 364d
Antibacterial agents, 139 subjective, 18, 18b bed, 362–364, 364f, 380d–383d
Antibiotics, 139, 139t diagnostic procedures in, 252–278. See also medicated, 361t
Anticipatory grieving, 884 Diagnostic examinations and tests nursing care plan for, 372d
Antiembolism stockings, 621, 622, focus, 18–20, 18t nursing guidelines for, 362d
631d–632d levels of responsibility for, 9t partial, 361–362
Anti-infective drugs, 139, 139t nutritional, 297–299, 298d, 298f, 299t shower, 361
Antimicrobial agents, 139, 139t pain, 438–439 sitz, 361t, 650, 660d–663d
Antineoplastic drugs, infusion of, 821–822 physical, 229–251. See also Physical sponge, 361t
Antipyretics, 193–194 assessment therapeutic, 650
Antisepsis. See also Asepsis; Infection control for touch, 245, 245d towel, 362, 364d, 364f
hand, 139–141, 140d, 141t Assistive devices tub/shower, 361, 374d–375d
in medical asepsis, 139–140, 140d, 141t, for ambulation, 586, 587f whirlpool, 361t
150d–153d for lifting/transporting clients, 519–520, Battery, 37–39
in surgical scrub, 140–141, 141t, 520d Bed(s), 389–390, 389f, 390f
153d–155d for transfer, 526–528 air-fluidized, 525–526, 526t, 527f
Antiseptics, 139, 139t Associate degree programs, 9, 9t, 10, 10f circular, 526, 526t, 527f
Antiviral agents, 139 Assumption of risk, 42 hospital (adjustable), 389–390, 389f,
Anuria, 707 Atelectasis, postoperative, 620 390f
Index 947
low-air-loss, 525, 526f, 526t low, 204–205. See also Hypotension in older adults, 744–746
mattresses for, 389–390, 390f, 524–525, assessment for, 226d–228d ostomy for
526t. See also Mattresses measurement of, 199–204 patterns of, 737
moving client up in, 522, 535d–537d auscultatory gap in, 203 peristalsis in, 736
occupied, linen change for, 390, automatic monitoring in, 204 preoperative, 622
409d–411d cuff in, 201, 201f, 220 promotion of, 740–742
oscillating support, 526, 526t, 527f Doppler stethoscope in, 203–204, 203f pseudoconstipation and, 738
pillows for, 390 equipment for, 200–202, 200f, 201t Valsalva maneuver in, 736
privacy curtain for, 390 errors in, 202t Bowel sounds, 246, 246d
removable headboard for, 389, 389f Korotkoff sounds in, 202–203, 203f Braces, 566–567, 567f
side rails for, 389, 524, 524f number bias in, 203 functional, 567
specialty, 525–526, 526t palpation in, 203 prophylactic, 566
transfer to/from, 526–529, 529f, 538–539 in postural hypotension, 226d–228d rehabilitative, 566–567, 567f
trapezes for, 524, 524f procedures for, 219d–228d Bradycardia, 194
unoccupied, linen change for, 389, sites for, 200 Bradypnea, 198
403d–408d sphygmomanometer in, 200–201, 200f, Brain, structure of, 61–62, 62f
Bed baths, 362–364, 380d–382d 201t, 220d–223d Brain death, 882
Bed board, 522 stethoscope in, 201–202, 202f, 203–204, Breach of duty, 40–41
Bed cradle, 525 204f Breast examination, 240–241
Bed linens, 390 at thigh, 204, 224d–226d by client, 241, 241d, 242f
change of units in, 199 Breathing, 198. See also Oxygenation; Respi-
for occupied bed, 390 normal variations in, 200 ration; Ventilation
for unoccupied bed, 389 in older adults, 205–208 abnormal, 198
handling of, 143 pulse pressure and, 199 anatomy and physiology of, 458–459
Bedpans, 708, 708f regulation of, 199–200 deep, 462–464
fracture, 708, 708f systolic, 199 preoperative teaching of, 620, 620f
placing and removing, 719d–720d Blood pressure cuff, 201, 201f, 220 diaphragmatic, 464–465
Bed restraints, 432 for venipuncture, 325 mouth-to-mouth, 862, 862f
Bedside stand, 390 Blood products, 321, 321t. See also mouth-to-nose, 862, 862f
Bed-sling scale, 232, 233f Transfusion(s) mouth-to-stoma, 862–863
Bed-to-chair transfer, 538–539 Blood substitutes, 321–322 pursed-lip, 464
Bed wetting, 398 Blood types, compatibility of, 330, 330t rescue, 862–863, 862f
Behavior modification, in stress manage- Boards of nursing, 35–36 Breathing patterns, ineffective, nursing care
ment, 70 Body casts, 567 plans for, 790, 476d–477d, 790d
Belching, 302 Body composition, assessment of, 543–544 Breathing techniques, 462–465
Beliefs, 50 Body drag, 419f Breath sounds, 241–243, 242f, 244f
definition of, 50 Body fluids. See under Fluid Bridge, dental, 366
health, 50–51 Body image, postoperative, 629d–630d Brown adipocytes, 187
Beneficence, 45 Body language, 96–100, 98d Bruxism, 398
Beneficial disclosure, 115, 116d Body mass index, 298, 298d Buccal drug administration, 787
Bicarbonate, serum, 312, 313t Body mechanics, 519. See also Position; Posi- Buck’s traction, 571, 571f
Bilingual nurses, 75 tioning; Posture Burns, 417–419
Binders, 646 nursing implications of, 528–529 airway, 419–420
Biodegradable waste, disposal of, 495 terminology for, 517t Burping, 302
Biofeedback, 69t Body-mind connection, 61 Business office, notification of discharge for,
in pain management, 446 Body substance isolation, 489 169–170
Biologic defense mechanisms, 137 Body systems approach, 233 Butterfly bandages, 644
Biotin, 293t Body temperature. See Temperature Butterfly needle, 325f, 326
Bivalved casts, 567–568, 568f Boiling sterilization, 145
Bladder retraining, 709 Boils, 363t
Bleeding, postoperative, 627t Bolus administration C
Blindness in intravenous infusion, 817 Cachexia, 300
client teaching and, 104, 104d of opioids, 442–443 Caffeine, sleep and, 394
feeding in, 303 in tube feeding, 675 Calciferol, 293t
Blood, 313 Boots, for foot drop prevention, 523, 524f Calcium
collection and storage of, 329 Botulinum toxin, for pain, 443 dietary, 292t
cross-matching of, 330, 330t Bovine spongiform encephalopathy, 330 serum, 312, 313t
in stool, 738d Bowel elimination, 736–759 Calories, 289
viscosity of, 198 alterations in, 737–740 Canadian crutches, 589
Blood banking, preoperative, 618, 618t anatomic aspects of, 737f Cancer
Blood disorders, 313 constipation and, 737–738 breast, self-examination for, 241, 241d,
Blood glucose testing, 264–266, 266f diarrhea and, 739–740 242f
Blood group compatibility, 330, 330t factors affecting, 737t cervical, Pap test for, 257
Blood pressure, 198–205 fecal impaction and, 738–739, 739d, 739f chemotherapy infusion for, 821–822
diastolic, 199 fecal incontinence and, 740 skin, 363t
factors affecting, 199 with hip spica casts, 568f, 569 testicular, self-examination for, 246, 247d,
high, 204, 204t, 205t nursing implications of, 744 247f
948 Index
Candidiasis, 363t Catheterization, definition of, 709 Choking. See Airway obstruction
Canes, 587–588, 587f, 588d Catheter-related infection, in intravenous Cholesterol, 290–291, 291t
measuring for, 598d therapy, 327, 328t Christian Science, 78t
Cannula, nasal, 467, 467f, 468t Catheter specimen, 706, 706f Chronic illness, 52
Capillary action, in wound drainage, 643 Catholicism, 78t Chronic pain, 437, 438t. See also Pain
Capillary blood glucose testing, 264–266, Cations, 312, 313t Church of Latter Day Saints, 78t
266f Cavities, dental, 361 Cilia, 845, 845f
Capillary refill, casts and, 568d, 569f Cellulose, 290 Circadian rhythms
Capillary refill time, 244 Center of gravity, 517f, 517t disturbances of, 397–398
Capitation, 12t, 56 Centigrade temperature, 186 sleep and, 392–393, 393f
Capsules, sustained-release, 770 Central nervous system, in homeostasis, 62, 62f temperature and, 187
Carbohydrates, 290, 290d Central venous catheters, 819–822, 820f, Circular bed, 526, 526t, 527f
Carbon monoxide poisoning, 420–421, 421d 821f Circulatory overload, 319
Cardiac arrest, cardiopulmonary resuscita- for antineoplastic drugs, 821–822 in intravenous infusion, 327, 328t
tion for, 861–868 implanted, 820, 820f Civil law, 37–41
Cardiac contractility, 198 multilumen, 820, 820f Civil War, 4
Cardiac disease, risk factors for, 291 percutaneous, 820 Clean-catch specimen, 705–706, 706d
Cardiac ischemia, 544 tunneled, 820, 820f Cleaning procedures
Cardiac output, 198 Cerebral cortex, 62, 62f in infection control, 143–144. See also
Cardiopulmonary resuscitation (CPR), 421, Cerebral subcortex, 62, 62f Infection control
861–866. See also Resuscitation Cerumen, 236, 359 postdischarge, 170
algorithm for, 864t tympanic thermometer and, 189 Cleansing enemas, 740–741, 741t, 742d
carotid artery assessment in, 863, 863f Cervical cancer, Pap test for, 257 administration of, 751d–753d
chest compression in, 863, 863f Cervical collars, 565–566, 565f, 566f Clean technique, 138–139
defibrillation and, 863–865, 865f C-fibers, 435 Client, in therapeutic relationship, 94
definition of, 861 Chain of infection, 136–138, 137f Client belongings
early, 861–863 Chain of Survival, 861 inventory of, 165–166, 165f
head tilt/chin lift in, 861, 862f Chairs, in client room, 390 return of, 170
in infants and children, 864t Change of shift reports, 121, 121d, 123 storage of, 165–166, 622
jaw-thrust maneuver in, 861–862, 862f Charting, 112–115. See also Documentation; Client care assignments, documentation of,
recovery position in, 862 Form(s) 121–123, 122f
rescue breathing in, 862–863 computerized, 114–115, 116f Client environment, 388–390
Caregiver, nurse as, 93, 93d DAR, 114, 114f Client positioning. See Positioning
Care mapping, 25–26, 26f focus, 113–114 Client referral, 173–175
Care plan. See Nursing care plan narrative, 112, 113f Client rooms, 388–390
Caries, 361 PIE, 114, 114f bed in, 389–390, 389f, 390f. See also
Caring, 12–15 SOAP, 113, 114t Bed(s)
Caring acts, vs. nursing acts, 93, 93d Charting by exception, 114 climate control in, 388
Carotid artery, assessment of, in cardiopul- Charts, 109 furnishings in, 388–390
monary resuscitation, 863, 863f Chemical cold/hot packs, 648 lighting in, 388
Case histories, in teaching, 111 Chemical sterilization, 145 preparation of, 164–165
Case managers, 58 Chemical thermometer, 190–191, 190f, 191f privacy curtains for, 390
Case method, 58 Chemotherapy, intravenous infusion for, walls and floors in, 388
Casts, 567–570 821–822 Client rounds, documentation of, 123
application of, 569, 579d–581d Chest Client teaching, 93, 93d, 101–108
bivalved, 567–568, 568f assessment of, 240, 240f for adults, 103, 103t, 107d–108d
body, 567 percussion of, 846, 847f affective domain in, 102
care of, 569, 579d–581d Chest compression, 863, 863f, 864t age/developmental level and, 104, 104t
cylinder, 567 Chest physiotherapy, 845–847 assessment in, 102–105
definition of, 567 Chest thrusts, 860, 860f attention and, 105
materials for, 567t Chest tube drainage, water-seal, 474, 474f, for breast self-examination, 241d
peripheral neurovascular dysfunction due 483d–487d cognitive domain in, 102
to, 568d, 574d–575d Cheyne-Stokes respiration, 198 concentration and, 105
removal of, 569–570, 570f Chicanos. See Latinos cultural aspects of, 104–105
spica, 568–569, 568f Children for deep breathing, 620, 620f
Cataplexy, 397 airway obstruction in, 860–861, 860f for diaphragmatic breathing, 464d
Catheter(s) cardiopulmonary resuscitation in, 864t discharge, 169–170, 170d, 626–627
central venous, 819–822 client teaching for, 103, 103t documentation of, 110t
nasal, 472, 473f consent for, 39 for douching, 648d
over-the-needle, 325f, 326 nocturnal enuresis in, 398 for examinations and tests, 253–254, 254d
thermistor, 188 pain assessment in, 439, 440f for fall prevention, 424d
through-the-needle, 325f, 326 safety concerns for, 416 formal vs. informal, 105
for transfusions, 330–331 temperature in, 186–187 for ice packs, 649
transtracheal, 473 Chiropractic, 82d importance of, 101–102, 102d
urinary, 709–714. See also Urinary Chloride for infection control, 144d, 148–149, 497
catheters dietary, 292t for inhalers, 789d
Catheter care, 712, 713d serum, 312, 313t for injection discomfort, 807
Index 949
for intake and output recording, 317, Communication Contrast media, radiographic, 259
317d of approaching death, 881, 881d Controlled substances, 441–442. See also
learning capacity in, 104–105 of care plan, 23 Opioids
learning styles and, 102 cultural aspects of, 75–76, 76t Contusions, 639t. See also Wound(s)
for medications, 773, 774d definition of, 95 Convalescent stage, 489t
needs assessment for, 105 documentation of, 121–123, 121d, 122f Conversion formulas, for temperature, 186,
for older adults, 103, 103t, 105–106 listening in, 96 186d
for pain management, 444, 444d, 445d nontherapeutic, 96, 97t Coping mechanisms, 66, 67t
postoperative, 626–627 nonverbal, 96–100, 98d Cordotomy, for pain, 443
preoperative, 619–621 with older adults, 99–100 Core temperature, 185
psychomotor domain in, 102 paralanguage in, 98 Coronary artery disease, risk factors for, 291
readiness for, 105 personal space (proxemics) in, 76, 98–99, Coroner, 883–884
in sensory deficits, 104, 104d 99t Cortisol, 65, 66t
for sleep promotion, 396 silence in, 96–97 Cost containment, 55–56
subject areas for, 101 therapeutic, 96, 96t Coughing
for testicular self-examination, 246, 247d touch in, 99 forced, 620, 620d, 620f
for vegetarians, 297 verbal, 95–97 preoperative teaching for, 620, 620f
for weight loss, 300d zones of, 76, 98–99, 99t splinting for, 620, 620d, 620f
Client transfer, 170–173, 526–529, 529f, Community-acquired infections, 135 Counseling skills, 15
537d–542d Community services, 174, 174t, 176 Cover gowns. See Gowns
Client transport Complementary and alternative therapies, COX-2 inhibitors, 441
assistive devices for, 519–520, 520d 81–82, 82d CPR. See Cardiopulmonary resuscitation
infection control aspects of, 496 for pain, 443, 444–445 (CPR)
Climate control, in client room, 388 Complete proteins, 289 Crackles, 242
Clinical pathways, 12–15, 13f–14f Compresses, 648, 649 Cradles, 525
Clinical resumé, 171 Computed tomography, 259 Credé’s maneuver, 710, 710f
Clinical thermometers. See Thermometers Computerized charting, 114–115, 116f Crimean War, 3
Closed urine drainage systems, 712, 712f Concentration, learning and, 105 Critical thinking, 17
irrigation of, 713 Concept mapping, 25–26, 26f Cross-training, 11
Clothing, client, 165–166 Concurrent disinfection, 144 Crutches, 588–589, 589f
removal of, 166 Condom catheter, 711, 711f, 721d–723d arm strengthening exercises for, 585
storage of, 165–166 Condoms, client teaching for, 248–249, 248f assisting with, 599d–602d
Clubbing, of nails, 244, 244f Conferences, in team nursing, 58 axillary, 589, 589f, 595d–597d
Code for Nurses, 44d Confidentiality forearm, 589, 589f, 597d
Codes of ethics, 44, 44d breach of, 40 gait for, 589, 590t
Code status, 47, 48d of medical records, 115–117 human, 419f
Cognitive domain, in learning, 102 Congenital disorders, 53 measuring for, 595d–596d
Cold application. See also Thermal therapy Conscious sedation, 260, 625 platform, 589, 589f
for casts, 568d, 570f Consensual response, pupillary, 235, 235f stair climbing with, 601
for pain, 444–445 Consent, 37–39, 38f, 616–618 Crutch palsy, 598
in wound management, 647–650, 648d, for autopsy, 882–883 Cryoprecipitate, 321t
649f for examinations and tests, 253, 253d Crystalloid solutions, 320–321, 320t, 321f.
Cold spots, in radionuclide imaging, 261 Constipation, 737–738 See also Intravenous infusion
Collaborative problems, 21, 21f, 22t nursing care plan for, 745 Cuff, blood pressure, 201, 201f, 220
goals for, 23 in tube feeding, 677t for venipuncture, 325
Collaborator, nurse as, 93, 93d Constitutional law, 35, 35t Cultural aspects
Collagen, 640 Contact dermatitis, 363t of ADH deficiency, 80–81
Collars latex allergy and, 142, 417f, 418t, 426–427 of client teaching, 104–105
cervical, 565–566, 565f, 566f Contact lenses, 268f, 269f, 368–269 of diet, 77
ice, 648 Contact precautions, 490–491, 491t, 492 of disease prevalence, 81t
Colloidal osmotic pressure, 314 Contagious diseases, 135 of emotional expression, 77
Colloid solutions, 313–314, 320. See also Containers, volume equivalents for, 317 of eye contact, 75–76
Intravenous infusion; Transfusion(s) Contaminated supplies, handling of, 143 of G-6-PD deficiency, 80, 81t
Colon, anatomy of, 737f Continence training, 708–709, 710d of hair characteristics, 79–80
Colonization, 488 Continent ileostomy, draining of, 742–743 of health beliefs and practices, 81–82, 82t
Colostomy, 742–744. See also under Ostomy Continuing education, 11, 12d of illness beliefs, 77
irrigation of, 743, 757d–759d Continuity of care, 59, 174 of lactase deficiency, 80, 80d
Coma, oral care in, 362, 383d–385d Continuous feedings, 675 of language and communication, 75, 76t
Comforting skills, 15 Continuous infusion (drip), 817, 825d–827d of mortality, 81t
Comfort measures, 387 Continuous irrigation, of urinary catheter, of personal space, 76
back massage, 398–399, 411d–414d 713–714, 714f of skin characteristics, 78–79, 79f, 80f
for dying client, 880 Continuous passive motion machine, of time perception, 77
for older adults, 399–400 548–549, 560d–562d of touch, 76–77
progressive relaxation, 398, 399d Continuous quality improvement, 12, 111 Cultural assessment, 74–77
Commode, 707, 708f Contraception, client teaching for, 248–249, Cultural groups, 72–74, 72t
Communicable diseases, 135. See also 248f Culturally sensitive nursing care, 71, 82
Infection(s) Contractures, prevention of, 523 Cultural shock, 72
950 Index
Culture, 71 Deep palpation, 230, 231f postprocedural, 255–257

African-American, 73, 74t Defamation, 40 preprocedural, 253–254
Anglo-American, 72, 74d Defecation, 736. See also Bowel elimination procedural, 254–255
Asian-American, 73–74 Defendants, 37 for older adults, 266–267
definition of, 71 Defense mechanisms, biologic, 137 Pap test, 257–258, 258t, 269d–272d
ethnicity and, 72 Defibrillation, 863–865, 865f paracentesis, 262, 263d
ethnocentrism and, 73 Deficient Knowledge, nursing care plan for, pelvic examination, 257–258, 269d–272d
health beliefs and practices and, 81–82, 82t 146–147. See also Client teaching radiography, 258–260
Latino, 73, 74t Deficient knowledge, nursing care plan for, radionuclide imaging, 261
minorities and, 27t, 72 146–147 specimens for, 257. See also Specimen
Native-American, 74, 74t Dehiscence, 641, 641f collection
race and, 72 postoperative, 627t terminology for, 252, 253d
stereotypes and generalizations about, Dehydration, 318 throat culture, 262–263
72–73 nursing care plan for, 334d–335d ultrasonography, 261
subcultures and, 73 Delegator, nurse as, 93–94, 93d Diagnostic-related groups (DRGs), 55
transmission of, 71 Deltoid injection, 804–805, 806f Diagnostic reports, 110t
Cultures, 262–264 Dementia, feeding in, 303 Diaphragmatic breathing, 464–465
definition of, 262 Denial, in terminal illness, 877 Diarrhea, 739–740
Gram staining in, 262–263 Dental care, for unconscious client, 366, in tube feeding, 677t
throat, 262–264, 265d, 265f 383d–385d Diastolic pressure, 199, 199f
Curandero, 81 Dental plaque, 361 Diet. See also Feeding; Food; Nutrition
Curtain, privacy, 390 Denture care, 267f, 366 calories in, 289
Cutaneous drug administration, 784–786 preoperative, 622 cultural aspects of, 77, 78t
Cutaneous pain, 436 Deontology, 45 factors affecting, 296
Cutaneous triggering, 710 Depilatory agents, 634d hospital, 302–303
Cutaneous ureterostomy, 714–715, 715f Depression for older adults, 303–305
Cuticles, 368 sleep in, 394 preoperative, 622
Cyanocobalamin, 293t in terminal illness, 877 protein in, 289, 290d, 290f
Cyclic feedings, 675 Dermatitis, contact, 363t sodium sources in, 319d
Cylinder casts, 567 latex allergy and, 142, 417f, 418t, 426–427 vegan, 297
Cysts, 239t Dermis, 359, 359f vegetarian, 296–297
Descending colostomy, 743f for weight gain, 300, 300d
Despair, in terminal illness, 885 for weight loss, 300d
D Detergents, 139t Diet history, 297
Daily nursing assessment and flow sheet, Dextran 40 (Rheomacrodex), 322 Diffusion, 314
110t, 121 Diabetes mellitus, glucose testing in, facilitated, 314
Dangling, 585, 585f, 586d 264–266, 266f, 275d–279d Digital thermometers, 190t, 191–192, 192f
DAR charting, 114, 114f Diagnosis Diploma programs, 9–10, 10f
Data definition of, 20 Directed-donation transfusion, 618, 618t
objective, 18, 18d medical, 20, 20f, 22t, 166 Dirty utility rooms, in infection control, 143
sources of, 18 nursing, 20–21, 20f. See also Nursing Discharge, 168–170
subjective, 18, 18d diagnoses arranging transportation in, 170
Data base assessment, 18, 18t, 19f Diagnostic examinations and tests, 252–278 authorization for, 168
Data security, 117 amniocentesis, 267d business office notification of, 169–170
Deafness anesthesia for, 255, 257f client teaching for, 169–170, 170d,
assessment for, 236, 236t, 237f arranging examination area for, 254 626–627
client teaching and, 104d capillary blood glucose testing, 264–266, definition of, 168
hearing aids for, 369, 370f, 370t, 371d 266f documentation of, 170, 183d
infrared hearing devices for, 369–371 client positioning for, 254–255, 256t escorting client in, 170
Death and dying. See End-of-life issues client preparation for, 253–254 against medical advice, 39, 39f, 168
Death certificate, 882 client teaching for, 253–254, 254d procedures in, 170, 181d–183d
Débridement, 646–647 computed tomography, 259 return of belongings in, 170
autolytic, 646 contrast media for, 259 terminal cleaning after, 170
ear irrigation, 647, 648f definition of, 252 Discharge instructions, 169–170, 170d,
enzymatic, 646 documentation of, 257 626–627
eye irrigation, 647, 647f, 647t draping for, 255 Discharge planning, 12, 110t, 168, 169d
mechanical, 646 electrocardiography, 261–262 for older adults, 176
sharp, 646 electroencephalography, 261, 262 referral in, 173–175
vaginal irrigation, 647, 648d electromyography, 261, 262 transfer in, 171–173, 174d
Decisional Conflict, 267 endoscopy, 260 Discharge summary, 170, 183d
Decompression, gastrointestinal, 678 errors in, 257, 257d Disease(s). See also Illness
definition of, 666 fluoroscopy, 259 chronic, 52
nasogastric intubation in, 670, 670f informed consent for, 253, 253d communicable, 135
nasointestinal tube for, 666–667, 666t lumbar puncture, 262, 264d, 264f congenital, 53
Decubitus ulcers. See Pressure ulcers magnetic resonance imaging, 259 exacerbation in, 53
Deep breathing, 462–464 nursing care plan for, 267d hereditary, 53
preoperative teaching of, 620, 620f nursing responsibilities in, 253–257 idiopathic, 53
Index 951
infectious, 488–502. See also Infection(s) Dorsal recumbent position, 255, 256t Education
race/ethnicity and, 81, 81t Dorsogluteal injection, 804, 804f client. See Client teaching
remission in, 53 Dosage nursing, 6–11
sequelae in, 52 calculation of, 771, 773d case histories in, 6–11
stress-related, 67, 67b errors in, 775 Effleurage, 399t
Disinfection, 138–139, 139t Dose, 769 Egg-crate foam mattresses, 525
concurrent, 144 equianalgesic, 447d Elbow, range-of-motion exercises for, 555d
terminal, 144 Double-bagging, in waste disposal, 495, Elderly. See Older adults
Distraction, in pain management, 444, 444f 495f Electrical shock, 421–422
Disturbed body image, postoperative, Double effect, 46 Electric cast cutters, 569, 570f
629d–630d Douche, 647, 648d Electrocardiography (ECG/EKG), 261–262,
Disuse syndrome, 516, 517t Drainage 262f
nursing care plan for, 530d–531d of continent ileostomy, 742–743, 744d ambulatory, 544–545
in older adults, 531 postural, 846, 846f stress, 544, 544f
unilateral neglect and, 550 from pressure ulcers, 651 Electrochemical neutrality, 314
Dix, Dorothea, 4 purulent, 651 Electrodes, 261, 262f
DNR status, 47, 48d serous, 651 Electroencephalography (EEG), 261, 262
Doctoral programs, 10–11 from urinary catheter, 712, 712f Electrolytes, 312, 313t
Documentation, 109–125 water-seal chest tube, 474, 474f, imbalances of, in tube feeding, 677t
abbreviations in, 117, 118t 483d–487d Electromyography (EMG), 261, 262
for accreditation, 111 wound, 643–644, 643f Electronic oscillometric manometer, 200,
of care plan, 23, 24f, 119, 120f Drains, 643–644, 643f 200f, 201t
change of shift reports in, 121, 121d, 123 Drapes Electronic thermometer, 189, 190t, 191f,
charting in, 112–115. See also Charting for examinations and tests, 254–255 209d–213d
checklists in, 119–121 fenestrated, 730 Elimination. See Bowel elimination; Urinary
of client admission, 110t for physical assessment, 232, 233f elimination
of client discharge, 170, 183d Drawdown effect, 189 Emaciation, 300
of client rounds, 123 Dressings, 642–643, 642f–643f Embolism. See also Thrombosis
of client’s belongings, 165–166, 165f changing of, 655d–658d air, in intravenous infusion, 327–328,
of client teaching, 110t for venipuncture, 328 328t
of client transfer, 171, 171d, 172f DRGs (diagnostic-related groups), 55 definition of, 621
concept mapping in, 25–26, 26f Drop factor, 323 postoperative, 621, 626, 627t
confidentiality and, 47 Droplet precautions, 490–492, 491t, 492 pulmonary
content of, 117d Drop size, 323 in intravenous infusion, 327, 328t
of death, 882 Drowning, 421 postoperative, 621, 626, 627t
of discharge planning, 110t Drugs. See Medication(s) Emergency medical services, 861. See also
of drug administration, 771, 774–775 Drug tolerance, 394 Resuscitation
of examinations and tests, 257 Dry heat sterilization, 145 Emergency splints, 564, 564f
flow sheets in, 110t, 121 Dry mouth, in tube feeding, 677t Emesis, 301–302
forms for. See Form(s) Dumping syndrome, 673–674, 677t EMLA cream, 806
of history, 110t Durable power of attorney for health care, Emollients, 362
incident reports in, 42, 43f 47 Emotional expression, cultural aspects of,
of intake and output, 315, 316f, Duty, 37 77
337d–339d breach of, 40–41 Empathy, 15, 93
of interpersonal communication, 121–123, Dying with dignity, 877 Emulsions
121d, 122f Dynorphins, 436 definition of, 332
Kardex in, 119, 120f Dysfunctional grief, 884 lipid, 332–333, 333f
as legal evidence, 111, 112d Dysphagia, 303 Endocrine system
liability and, 42 Dyspnea, 198 in homeostasis, 63–64, 64f
of medication administration, 110t Dysrhythmias, 195 in temperature regulation, 186, 186f
of nursing care assignments, 121–123, 122f Dysuria, 707 End-of-life issues, 52, 876–888
of nursing interventions, 110t acute care, 879
for organ donation, 882, 883f advance directives, 47, 48d, 110t
of physical assessment, 110t E approaching death, 881–882
privacy and, 115–117 Ear arrangements for care, 877–879
in quality assurance, 111 cerumen in, 189, 236, 359 autopsy, 882–884
for reimbursement, 111 inflammation of, in tube feeding, 677t brain death, 882
of restraint, 39–40, 425 irrigation of, 647, 648f code status, 47, 48d, 4747
of team conferences, 123 medications for, 786–787 comfort, 880
of telephone conversations, 123 temperature measurement in, 188, 188f, confirming death, 882
traditional vs. military time in, 117, 119f 213d–215d death certificate, 882
of vital signs, 205, 206f Early advanced life support, 865 discussing organ donation, 882, 883f
workplace policies for, 117 Ear wax, 236, 359 durable power of attorney for health care,
Do-not-use abbreviations, for drug dose, 769t tympanic thermometer and, 189 47
Doppler stethoscope, 203–204, 203f Echography, 261 dying with dignity, 877
Doppler ultrasonography, in pulse assess- Edema, 318–319 elimination, 880
ment, 197, 197f pitting, 244–245, 245d emotional support, 877
952 Index
End-of-life issues (contd.) end-of-life, 47–49 External catheters, 710–711

ethical, 47–49 ethical codes, 44 External fixators, 572, 573f, 581d–583d
family involvement, 880–881 fidelity, 46 External respiration, 459
grieving, 884 justice, 46 Extracellular fluid, 312, 312f, 312t
hopelessness, 885 nonmaleficence, 45 Extraocular movements, 235, 235f
hospice care, 878–879, 879d resource allocation, 49 Extremities. See also Arm; Leg
hydration, 880 treatment withholding/withdrawal, assessment of, 244–245, 244f, 245f
hygiene, 880 47–49, 48f, 866 Eye. See also Vision
leading causes of death, 53t, 81, 81t truth telling, 47 artificial, 369
life expectancy, 876, 877f values, 46 assessment of, 234–236
living wills, 47, 48f veracity, 46 irrigation of, 647, 647f, 648d
multiple organ failure, 881, 881t whistle-blowing, 49 medications for, 786, 787f, 792d–793d
nourishment, 880 Ethical theories, 44 Eye charts, 234–235, 234f
nursing implications, 884 Ethics, 44 Eyeglasses, 368
older adults, 884–886 Ethics committees, 46–47 Eye protection, 143, 144d
paranormal experiences, 884 Ethnicity, 27t, 72, 73–74
positioning, 880 Ethnocentrism, 73
postmortem care, 884, 887d–888d Ethylene oxide sterilization, 145 F
promoting acceptance, 877–879 Evaluation, 9t Face masks, oxygen, 468t–470t
residential care, 879 in nursing process, 9t, 25, 25t Faceplate, for ostomy appliance, 742, 743f
stages of dying, 876–877 Evisceration, postoperative, 627t, 641, 641f FACES pain scale, 439, 440f
terminal care, 879–881 Ewald tube, 665, 666t Face tent, 470t, 472
treatment withholding/withdrawal, Exacerbation, 53 Facilitated diffusion, 314
47–49, 48d, 48f Examination gloves. See Gloves Fact sheets, 110t
waiting for permission, 881 Excoriation, 742 Fahrenheit temperature, 185–186
Endogenous opioids, 436 Exercise, 543–562 Falls, 422–423, 423f
Endorphins, 69 active, 547 prevention of, 423
Endoscopy, 260, 260d, 272d–274d aerobic, 546–547 client teaching for, 424d
Enemas, 740–742 benefits of, 544d restraints for, 423–426
cleansing, 740–741, 741t, 751d–753d continuous passive motion machine for, False imprisonment, 39–40
hypertonic saline, 741, 741t, 742d 548–549, 549f Family notification, of approaching death,
normal saline, 741, 741t definition of, 543 881, 881d
reasons for, 740 fitness and, 543–547. See also Fitness Family teaching. See Client teaching
retention, 741–742 metabolic energy equivalents for, 546, Fasting, preoperative, 622
soap and water, 741, 741t 546t Fat, brown, 187
tap water, 741, 741t national goals for, 549t Fats, 290–291
Energy, 517t nursing implications of, 549–551 Fat-soluble vitamins, 291
Enkephalins, 436 for older adults, 551 Febrile, 192
Enteral nutrition. See Tube feeding passive, 547–549 Fecal impaction, 738–739, 739d, 739f
Enteric-coated tablets, 770 promotion of, 529d Fecal incontinence, 740
Enterostomal therapist, 742 safety concerns for, 547d Feces, 736, 737. See also Bowel elimination;
Environmental factors, in stress manage- sleep and, 393, 393t Stool
ment, 69 target heart rate in, 546 Feedback loop, in endocrine system, 63–64,
Environmental hazards, 416–423. See also therapeutic, 546–547 64f
Safety concerns Exercise prescriptions, 546 Feeding. See also Diet; Nutrition
Environmental medicine, 82d Exercises assistance with, 302–303, 308d–310d
Environmental psychologist, 388 arm strengthening, 585, 585f in dying client, 880
Environmental theory, 7t gluteal setting, 585, 585d preoperative, 622
Enzymatic débridement, 646 isometric, 547 tube. See Tube feeding
Enzyme deficiencies, 80–81 for ambulation, 584–585 Feet. See under Foot
Epidermis, 359, 359f isotonic, 546–547 Felonies, 37
Epiglottis, 845 Kegel, 710 Fenestrated drape, 730
Episiotomy, sitz bath for, 650 leg Fever, 192–194, 193f
Equianalgesic dose, 447d for ambulation, 585, 585d nursing care plan for, 207d–208d
Equipment, asepsis for. See Infection control postoperative, 620–621 Fiber, dietary, 290, 738
Ergonomics, 519–520. See also Body quadriceps setting, 585, 585d Fiberglass casts, 567t, 568d. See also Casts
mechanics range-of-motion, 547–548, 548t, 552d–560d Fidelity, 46
Eructation, 302 continuous passive motion machine for, Fifth vital sign, pain as, 438
Erythrocytes, 313 548–549, 560d–562d Filters, in-line, 323, 324f
Essential amino acids, 289 procedure for, 552d–560d Filtration, 314
Ethical decision making, 46 Exercise stress test, 544, 544f Fingernails. See Nail(s)
Ethical dilemmas, 44 Exhaustion stage, of stress response, 65–66, Fingers, range-of-motion exercises for,
Ethical issues, 44–49 65f 557d
autonomy, 46 Exit route, for microorganisms, 137 Finger sweeps, 860
beneficence, 45 Expiration, 458, 459, 459f FIO2, 466–467
confidentiality, 47 Extended care facilities, 54, 171–173, 174d, Fire extinguishers, 419, 420d, 420f
double effect, 46 879 Fire plans, 417–418
Index 953
Fires Fluid therapy, 320–331 external fixation in, 572, 573f

burns in, 417–420 blood transfusion in, 329–331. See also traction for, 570–572, 571f, 572f, 573d
in oxygen therapy, 474 Transfusion(s) Fracture pan, 569, 708, 708f
prevention/management of, 417–419 intravenous infusion in, 320–329. See also Frenulum, oral thermometer and, 210
smoke inhalation and, 419–420 Intravenous infusion Friction rubs, 243, 399t
First-intention healing, 640, 640f, 641f Fluid volume assessment, 315–320 Frölement, 399t
Fitness Fluoroscopy, 259 Functional illiteracy, 104
assessment of, 543–546 Foam mattresses, 524–525, 526t Functional incontinence, 709t
ambulatory electrocardiogram in, Focus assessment, 18–20, 18t Functional mobility, 520
544–545, 545f Focus charting, 113–114 Functional nursing, 58
body composition in, 543–544 Foley catheter, 711–714, 711f Functional position, 517t
recovery index in, 545 insertion of Functional status, assessment of, 528–529,
step test in, 545, 545t in female, 723d–728d 529d
stress electrocardiogram in, 544, 544f in male, 729d–732d Fungal infections
submaximal fitness tests in, 544 irrigation of, 712–714, 714f, 733d–735d of nails, 363t
vital signs in, 544 removal of, 714 of skin, 363t
walk-a-mile test in, 545, 546t Folic acid, 293t Fungi, 135
exercise prescriptions for, 546 Folk medicine, 81–82 Furuncles, 363t
Fitness exercise, 546–547. See also Exercise Food. See also Diet; Feeding; Nutrition
Five rights of drug administration, 771, 773f fortified, 291
Fixation, external, 572, 573f, 581d–583d high-sodium, 319d G
Flatus/flatulence, 302, 739 sleep and, 394 Gait, crutch-walking, 589, 590t
rectal tube for, 747d–748d Food intake, temperature and, 186 Gas
Flora, normal, 135. See also Microorganisms Food pyramid, 294, 295f intestinal, 739
Flossing, 365, 366f Foot boards, 523 stomach, 302, 302d, 666–668, 666t, 670,
Flow charts, in concept mapping, 25, 26f Foot care, 367–368 670f
Flowmeter, 466–467, 466f, 467f in edema, 319f Gas sterilization, 145
Flow sheets, 121 Foot drop, 520, 521f Gastric decompression, 670, 670f, 678
Fluid(s) prevention of, 520, 523, 523f definition of, 666
aspiration of. See Aspiration Foot padding, for ulcer prevention, 652d, nasogastric intubation in, 670, 670f
distribution of, 312, 312f, 312t 652f Gastric fluid
mechanisms of, 313–314, 313f Foot splints, 523 aspiration of, in tube feeding, 669, 669d,
electrolytes in, 312, 313t Forced coughing, 620, 620d, 620f 669f, 677t
extracellular, 312, 312f, 312t Forearm crutches, 589, 589f pH of, 669, 669d, 669f
interstitial, 312, 312f, 312t measuring for, 597d Gastric lavage, 665
intracellular, 312, 312f, 312t Foreign language speakers, 75 Gastric reflux, 665
intravascular, 312, 312f, 312t Form(s). See also Charting; Documentation Gastric residual, 675, 675d
in third-spacing, 319–320, 319f admission assessment, 19f, 110t, 166 Gastric tamponade, 665
intravenous. See Intravenous infusion advance directives, 110t Gastrocolic reflex, 736
nonelectrolytes in, 312 assessment, 110t Gastrointestinal intubation, 664–695
Fluid compartments, 312 care plan, 110t nasogastric
Fluid imbalances client belongings inventory, 165–166, 165f for decompression, 670, 670f
definition of, 317 daily nursing assessment and flow sheet, for feeding, 671, 672–677, 674t,
in hypervolemia, 317–319 110t, 121 690d–695d. See also Tube feeding
in intravenous infusion, 327, 328t discharge plan, 110t, 168, 169f fluid aspiration in, 669, 669d, 669f
in hypovolemia, 317 fact sheets, 110t NEX measurement for, 668, 668f
nursing care plan for, 334d–335d graphic sheet, 110t troubleshooting for, 670d
insensible losses in, 314 incident report, 42, 43f tube insertion in, 667–670, 668f,
nursing care plan for, 334d–335d informed consent, 617f 682d–685d
in older adults, 333–335 intake and output, 315, 316f tube irrigation in, 686d–687d
signs of, 315t Kardex, 119, 120f tube maintenance in, 671–672
in third-spacing, 319–320 laboratory and diagnostic reports, 110t tube removal in, 671, 688d–689d
Fluid intake, 314, 314t medication administration, 110t, 771, 772d nasointestinal
assessment of, 315–317 nursing notes, 110t for decompression, 666–667, 678
documentation of, 315, 316f, 337d–339d for organ donation, 882, 883f for feeding, 665–666, 671–677, 674t. See
increase in, 318d physician’s orders, 110t also Tube feeding
normal values for, 314, 314t preoperative checklist, 623–624 tube insertion in, 671–672, 671d
restriction of, 319d progress notes, 110t tube placement assessment in, 671d,
Fluid management release against medical advice, 39, 39f, 168 672
for dying client, 880 teaching summary, 110t tube types for, 665–667, 666t
preoperative, 622 Formula, enteral, 674–675, 674t orogastric, 664, 665t
in tube feeding, 677 aspiration of, 677t ostomy for, 664
Fluid movement, 313–314, 313f Four-point gait, 590t reasons for, 665
Fluid output, 314, 314t Fowler’s position, 462, 521–522, 521f Gastrostomy tubes, 664, 666t, 667, 668f,
documentation of, 315, 316f, 337d–339d Fraction of inspired oxygen (FIO2), 466–467 674t. See also Gastrointestinal intuba-
normal values for, 314, 314t Fracture(s) tion; Tube feeding
Fluid regulation, 314 casts for, 567–570 for drug administration, 774, 781d–783d
954 Index
Gauze dressings, 642 Gynecologic examination, 257–258, Hearing acuity, 236

changing of, 655d–658d 269d–272d Hearing impairment
Gavage feeding. See Tube feeding assessment for, 236, 236t, 237f
Gel mattresses, 525, 526t client teaching and, 104d
General adaptation syndrome, 65–66, 65f H hearing aids for, 369, 370f, 370t, 371d
General anesthesia, 615, 616t, 624–625. See Hair, 360 infrared hearing devices for, 369–371
also Anesthesia assessment of, 238 Hearing tests, 236, 236t
Generalizations, 72–73 care of, 80, 366–367, 385d–386d Heart. See also under Cardiac
Generic names, 769 cultural aspects of, 79–80 Starling’s law for, 198
Genitals, cleansing of, 276d–279d, 362 Hair covers, 143 Heart disease, risk factors for, 291
Genupectoral position, 255, 256t Hallucinations, hypnogogic, 397 Heart rate
Germicides, 139 Hand antisepsis, 140–141, 140d, 141t apical, 195–196, 196f
Gerogogy, 103, 103t in medical asepsis, 139–140, 140d, 141t, apical-radial, 196–197, 196f
Gingivitis, 361 150d–153d maximum, 546
Girth, abdominal, 246, 247f in surgical scrub, 140–141, 141t, target, 546
Glands 153d–155d Heart sounds, 241, 242f
ceruminous, 359t Hand rolls, 523, 523f Heat application
ciliary, 359t Handwashing, 139–140, 150d–153d for pain, 444–445
endocrine, 63–64, 64f Head, assessment of, 234–238 in wound management, 647–650, 648d,
in homeostasis, 63–64, 64f Headboard, removable, 389, 389f 649f
in temperature regulation, 186, 186f Head tilt/chin lift, 861, 862f Heat conservation, 186, 186f
sebaceous, 359t Head-to-toe approach, 233 Heat production, 186, 186f, 187
sudoriferous, 359t Health, 50–51 Heat transfer, mechanisms of, 185t
sweat, 359t definition of, 50 Heel padding, for ulcer prevention, 652f
Glasses, 368 illness and, 52–53 Height
Glass thermometers, 189–190, 190t, 191d as limited resource, 51 measurement of, 232, 232d, 232f, 297–298
national goals for, 56–57 in nutritional assessment, 297–298, 298f
Gloves, 494–495
as personal responsibility, 51 Heimlich maneuver, 860–861, 861f
examination, 142, 143d, 143f
as right, 51 Helminths, 136
latex allergy and, 142, 417f, 418t,
trends in, 54d Hemorrhage, postoperative, 627t
426–427
wellness and, 51–52 Hemorrhoidectomy, sitz bath for, 650
sterile, 146, 160d–162d
Health beliefs and practices, 51 Henderson, Virginia
types of, 418t
cultural aspects of, 81–82, 82t nursing definition of, 6
Glucometer, 265–266, 266f, 275d–278d
religious aspects of, 78t–79t nursing theory of, 7t
Glucose, elevated, in tube feeding, 677t
Health care Hendrich Fall Risk Tool, 424f
Glucose-6-phosphate dehydrogenase defi-
access to, 12t, 54 Heparin, injection of, 803
ciency, 80, 81t
continuity of, 59 Heparin lock, 329, 329f, 352d–354d,
Glucose testing, 264–266, 266f, 275d–279d
cost control measures in, 55–56 817–818, 818d, 818f
Gluteal setting exercises, 585, 585d
extended, 54 Hepatitis
Goals, 22–23
financing of, 12t, 54–56 client teaching for, 148d–149d
for collaborative problems, 23 transfusion-related, 329
future trends in, 11–12, 12t
long-term, 22–23 integrated delivery systems for, 56, 56b Herbert, Sidney, 3
short-term, 22, 23b managed care and, 55–56 Hereditary conditions, 53
vs. outcomes, 22b primary, 53–54 Hetastarch (Hespan), 322
Goggles, 143, 144d prospective payment systems for, 55. See Hierarchy of needs, 52
Good Samaritan laws, 42 also Reimbursement High-density lipoproteins, 290, 291t
Gowns, 141, 494, 494f resource allocation for, 49 High-sodium diet, 319d
removal of, 495, 495f, 501d–502d right to, 51 Hinduism, 78t
sterile, 146, 147d secondary, 54 Hip, range-of-motion exercises for, 557d–558d
G-6-PD deficiency, 80, 81t tertiary, 54 HIPAA (Health Insurance Portability and
Graduate nursing programs, 10–11 trends in, 54d Accountability Act), 111, 115–117
Gram staining, 263 Health care system, 53–56 Hip spica casts, 568–569, 568f
Granulation tissue, in wound repair, 640 Health care team, 25f, 57–58, 58f, 93, 93f Hispanics. See Latinos
Granulocytes, 321t. See also Transfusion(s) Health-illness continuum, 50, 51f History, diet, 297
Graphic sheet, 110t Health insurance, 12t, 54. See also History taking, on admission, 166, 167d
for vital signs, 206f Medicare/Medicaid HIV infection, transmission of, 489d
Gravity, 517t HIPAA regulations for, 111, 115–117 HMOs, 56
Grief, 884 lack of, 54 Holism, 51–52, 77
anticipatory, 884 Health Insurance Portability and Account- body-mind connection and, 61
definition of, 884 ability Act (HIPAA), 111, 115–117 homeostasis and, 60–61
pathologic, 884 Health maintenance organization (HMOs), 56 Holter monitor, 544–545
resolution of, 884 Health promotion, 56–57 Home health care, 174–175, 175d
Grief response, 884 national goals for, 56–57 infection control in, 144d, 148–149
Grief work, 884 wellness and, 51–52 reimbursement for, 176
Ground, electrical, 421 Health-seeking behaviors, 248–249 respite care in, 878
Gums, 361 Healthy People 2010, 56–57, 57d, 57f, 293, tube feeding in, 677
Gurgles, 242 294d Homeopathy, 82d
Index 955
Homeostasis, 60–64 Hyperpigmentation, 79, 79f Immediate postoperative prosthesis, 589

adaptation and, 61–64, 63f Hypersensitivity Immobilization. See Mechanical immobilization
autonomic nervous system in, 62–63, 63f in contact dermatitis, 363t Immobilizers, 564–565, 565f
central nervous system in, 62, 62f to latex, 142, 417f, 426–427 Immunologic defenses, 137
definition of, 60 to transfusion products, 331, 331t Impaired physical mobility, nursing care
endocrine system in, 63–64, 64f Hypersomnia, 397 plan for, 592d–593d
feedback loops in, 63–64, 64f Hypersomnolence, 397 Impaired swallowing, nursing care plan for,
holism and, 60–61 Hypertension, 204, 204t, 205t 304d–305d
neurotransmitters in, 61–62, 61f Hyperthermia, 186, 193 Impaired tissue integrity, nursing care plan
Hopelessness, nursing care plan for, 885 nursing care plan for, 207d–208d for, 653–654
Hormones Hypertonic saline enemas, 741, 741f Implanted catheters, 820, 820f
in homeostasis, 63–64, 64f Hypertonic solutions, 320t, 321, 321f Inactivity, 516
in temperature regulation, 186, 186f Hyperventilation, 198 complications of, 516, 517t
Hospice care, 878–879, 879d Hypervolemia, 319 nursing care plan for, 530–531
Hospital-based diploma programs, 9–10, 10f from intravenous infusion, 327, 328t Incentive spirometry, 464, 464d
Hospital beds, 389–390, 389f, 390f, 522. See Hypnogogic hallucinations, 397 Incident reports, 42, 43f
also Bed(s) Hypnosis, in pain management, 446 Incisions, 639t. See also Wound(s)
Hospital diets, 302 Hypnotic effect, of tryptophan, 394 Incomplete proteins, 289
Hospitalization Hypnotics, 394, 395t Incontinence
admission in, 163–168. See also Admission Hypoalbuminemia, third-spacing and, 319 fecal, 740
client environment in, 388–390 Hypocalcemia, transfusion-related, 331t urinary. See Urinary incontinence
discharge in, 168–170, 169f, 170d. See also Hypopigmentation, 79, 79f Incubation period, 489t
Discharge Hypopnea, sleep, 397 Individual supply, 771, 773f
emotional response to, 166–168 Hypotension, 204–205 Ineffective airway clearance, nursing care
length of stay in, 55 assessment for, 226d–228d plan for, 850
loss of identity in, 168 postural (orthostatic), 205, 226d–228d Ineffective breathing pattern, nursing care
loss of privacy in, 167–168 Hypothalamus, in temperature regulation, plans for, 476–477, 790
of older adults, 175–176 186, 186f Ineffective protection, nursing care plan for,
stressors in, 68, 69b Hypothermia, 186, 194 822–823
transfer in, 170–173. See also Transfer Hypotonic solutions, 320t, 321, 321f Ineffective therapeutic regimen manage-
Hot air sterilization, 145 Hypoventilation, 198 ment, nursing care plan for, 808
Hot/cold theory, 77 Hypovolemia, 318 Infants
Hot spots, in radionuclide imaging, 261 nursing care plan for, 334d–335d airway obstruction in, 860, 860f
Housekeeping procedures Hypoxemia, postoperative, 627t cardiopulmonary resuscitation in, 864t
in infection control, 143–144 Hypoxia, 459 safety concerns for, 416
postdischarge, 170 in sleep apnea, 397 temperature in, 186–187
Housing options, for older adults, 176d Infection(s), 488–502. See also Disease(s)
Human immunodeficiency virus infection, catheter-related, in intravenous therapy,
transmission of, 489d I 327, 328t
Human needs, hierarchy of, 52 Ice bag/collar, 648, 649d chain of, 136–138, 137f
Humectants, 362–364 Identification bracelet, 164, 164f colonization in, 488
Humidifier, 467, 467f Identity, loss of, in hospitalization, 168 communicable, 135
Humidity, in client room, 388 Idiopathic illness, 53 course of, 489, 489t
Hydration, in dying client, 880 Ileal conduit, 714–715, 715f definition of, 488
Hydrocolloid dressings, 642–643, 643f Ileostomy, 742–744, 743f. See also under nosocomial, 138
Hydrostatic pressure, 314 Ostomy opportunistic, 137
Hygiene, 358–386 continent, draining of, 742–743 reservoir of, 137
artificial eye, 369 Ileus, adynamic, postoperative, 627t stages of, 489, 489t
bathing, 361–364, 372d–375d. See also Illiteracy, functional, 104 susceptibility to, 138
Baths/bathing Illness, 52–53. See also Disease(s) transmission of, 137, 138t
contact lenses, 368–369, 368f, 369f acute, 52 Infection control, 134–162, 489–502
for dying client, 880 chronic, 52 airborne precautions in, 490–492, 491t
eyeglasses, 368 cultural aspects of, 77 antimicrobial agents in, 139, 139t
foot, 367–368 definition of, 52 antiseptics in, 139, 139t
hair care, 80, 366–367, 385d–386d exacerbation in, 53 asepsis in, 134, 138–146
hearing aids, 369, 370f, 370t, 371d in health-illness continuum, 50, 51f definition of, 138
nail care, 367–368 idiopathic, 53 hand, 139–141
nursing care plan for, 372d morbidity and mortality in, 52 medical, 138–139
nursing implications for, 371 primary, 52 surgical, 144–147, 156d–162d
for older adults, 371–372 remission in, 53 client environment in, 493–494
oral, 364–366 secondary, 52–53 client teaching for, 144d, 148–149, 497
perineal, 362, 376d–379d sequelae of, 52 client transport in, 496
preoperative, 622 sleep disturbances in, 394 contact precautions in, 490–491, 491t, 492
shaving, 364, 365f terminal, 52. See also End-of-life issues definition of, 489
Hyperbaric oxygen therapy, 475, 475f Imagery, 69t disinfection in, 138–139, 139t, 144
Hypercarbia, 464 in pain management, 444, 444f droplet precautions in, 490–492, 491t, 492
Hyperglycemia, in tube feeding, 677t Imaging studies, 258–260, 258t, 259f, 260f environmental measures in, 143–144
956 Index
Infection control (contd.) Intermittent venous access devices, 329, filters in, 323
housekeeping in, 143–144 329f, 352d–354d macrodrip vs. microdrip, 323
microorganisms and, 134–136 Internal respiration, 459 primary vs. secondary, 322
nursing care plan for, 498–499 International Council of Nurses, 6 replacement of, 328, 349d–350d
nursing implications of, 146–147, Interpreters, 75, 75d selection of, 322–323
496–497 Interstitial fluid, 312, 312f, 312t vented vs. unvented, 322–323, 323f
for older adults, 147–148 Intestinal decompression, 678 venipuncture for, 325–326, 325f, 326d,
personal protective equipment in, definition of, 666 326f, 328, 343d–347d. See also
141–143, 492–493. See also Personal nasogastric intubation in, 670, 670f Venipuncture
protective equipment nasointestinal tube for, 666–667, 666t volume-control set for, 819, 819f,
psychological implications of, 496 Intestinal gas, 302, 302d, 739 830d–833d
specimen handling in, 496 rectal tube for, 747d–748d volumetric controllers for, 324–325
standard precautions in, 489, 490d Intimate space, 98, 99t Intravenous injections, 800, 800f
sterile technique in, 144–147, 156d–162d Intracellular fluid, 312, 312f, 312t Intubation
surgical scrub in, 140–141, 141t, Intradermal injections, 800, 800f, 810d–811d definition of, 664
153d–155d Intramuscular injections, 803–806 gastrointestinal, 664–695. See also Gas-
transmission-based precautions in, administration of, 805, 814d–815d trointestinal intubation; Tube(s)
490–491, 491t, 496 deltoid, 804–805, 806f Inunctions, 784–785
waste disposal in, 143, 495–496, 495f dorsogluteal, 804, 804f Invasion of privacy, 40
Infection control room, 493–494, 493f, 494f equipment for, 805 Iodine, dietary, 292t
Infiltration, in intravenous infusion, 327, 328t rectus femoris, 804, 806f Ions, 312, 313t
Inflammation, 639, 639f vastus lateralis, 804, 805f Iron, dietary, 292t
Inflatable splints, 564, 564f ventrogluteal, 804, 805f Irrigation
Informed consent, 37–39, 38f, 616–618 Z-track, 805 of colostomy, 743, 757d–759d
for autopsy, 882–883 Intraspinal analgesia, 443 of ear, 647
for examinations and tests, 253, 253d Intravascular fluid, 312, 312f, 312t of eye, 647, 647f, 648d
Infrared hearing devices, 369–371 Intravenous infusion, 320–329, 816–819. See of Foley catheter, 712–714, 714f,
Infrared thermometer, 189, 190t, 191f, also Medication(s) 733d–735d
213d–215d of blood products, 330–331. See also of nasogastric tube, 686d–687d
Infusion pumps, 324, 325f Transfusion(s) of vagina, 647, 648d
Inhalant medications, 787–791. See also bolus, 817–819 of wound, 658d–660d
Medication(s) central venous catheter for, 819–822, Ischemia, cardiac, 544
aerosol, 787 820f, 821f Islam, 79t
client teaching for, 789d continuous, 817, 825d–827d Isolation precautions, 489, 490–492, 491t.
inhalers for, 787–789, 788f, 789f discontinuation of, 329 See also Infection control
nursing implications of, 789 drop size in, 323 Isometric exercises, 547
for older adults, 790–791 gravity, 324 for ambulation, 584–585
Inhalation injury, 419–420 initiation of, 343d–347d gluteal setting, 585, 585d
Inhalation therapy, 845, 845f intermittent, 817–819, 828d–830d quadriceps setting, 585, 585d
Inhalers, 787–789, 788f, 789 intermittent venous access devices for, Isotonic exercises, 546–547
Injections. See Parenteral medications 329, 329f, 352d–354d Isotonic solutions, 320–321, 320t, 321f
In-line filters, 323, 324f monitoring and maintenance of, 326–328
Insensible losses, 314 needleless systems for, 323–324, 324f
Insomnia, 396–397 nursing care plan for, 822–823 J
assessment of, 394–396 nursing implications of, 333, 822–823 Jackson-Pratt drain, 643, 643f
causes of, 394 for older adults, 823 Jaeger chart, 235
Inspection, in physical assessment, 230, in parenteral nutrition, 332–333, 332f, Jaw-thrust maneuver, 861–862, 862f
230f 333f Jehovah’s Witnesses, 78t
Inspiration, 458–459, 459f piggyback, 819, 819f, 828d–830d blood substitutes for, 321–322
Insulin ports for, 323, 817, 817f Jejunostomy tubes, 666t, 667, 668f, 674t. See
injection of, 801–803, 802f, 803d pumps for, 324, 325f also Gastrointestinal intubation; Tube
mixing of, 802–803, 803d, 803f rate of feeding
preparation of, 802 calculation of, 327d Jet lag, 397
Insulin syringe, 802, 802f regulation of, 326–327 Jewelry, safeguarding of, 165–166
Insurance saline (medication) lock for, 329, 329f, Joint Commission on Accreditation of
health, 12t, 54. See also Medicare/Medicaid 352d–354d, 817–818, 818d, 818f Healthcare Organizations (JCAHO)
HIPAA regulations for, 111, 115–117 secondary, 819 abbreviations approved by, 118
lack of, 54 solutions for accreditation by, 111
liability, 41–42 colloid, 313–314, 320, 321–322. See also do-not-use abbreviation list of, 769, 769t
long-term care, 173 Transfusion(s) fire prevention and, 419
Intake and output. See Fluid intake; Fluid crystalloid, 320–321, 320t, 321f National Patient Safety Goals of, 415,
output preparation of, 339d–343d 416d
Integrated delivery systems, 56, 56b replacement of, 328 pain assessment and, 438t
Integument, 358. See also Hair; Nail(s); Skin selection of, 322 restraints and, 423–425
Intentional torts, 37–40 tubing for, 322–323, 323f Judaism, 78t
Intermediate care facilities, 173 air bubbles in, 327–328, 328d, 329 Judicial law, 37
Intermittent feedings, 675 components of, 322, 323f Justice, 46
Index 957
K application of, 602d–604d Lofstrand crutches, 589

Karaya, 742 preoperative removal of, 622 Loneliness, 167
Kardex, 119, 120f Legal issues, 34–44. See also Law(s) Long-term care facilities, 171–173, 174d, 879
Kegel exercises, 710 advice for nurses, 44b Long-term goals, 22–23
Keloids, 79, 79f assault, 37 Lordosis, 240, 241f
Keofeed tube, 666t battery, 37–39 Loss of identity, in hospitalization, 168
Keratin defamation, 40 Low-air-loss bed, 525, 526f, 526t
in hair, 360 documentation, 42, 111, 112d. See also Low-density lipoproteins, 290, 291t
in skin, 249 Documentation Lower limb prosthesis, 589–591, 590f
Kilocalories, 289 duty, 37 application of, 602d–604d
Kinesics, 98, 98d false imprisonment, 39–40 preoperative removal of, 622
Knee, range-of-motion exercises for, 559d Good Samaritan laws, 42 Lumbar puncture, 262, 264d, 264f
Knee-chest position, 255, 256t informed consent, 37–39, 38f, 616–618 Lumen, of tube, 665
Knots, quick-release, for restraints, 431 invasion of privacy, 40 Lung sounds, 241–243, 242f, 243f, 244f
Kock pouch, drainage of, 742–743 libel, 40 Lying posture, 518–519, 518f
Korotkoff sounds, 202–203, 203f licensure, 35–37, 36f Lymphocytes, 313
K-pad, 649, 649f malpractice, 40–41
Kübler-Ross, Elisabeth, 876 medical records, 42, 111, 112d
Kyphosis, 240, 241f negligence, 40–41 M
practice standards, 35, 36d Macrophages, 639
restraints, 39–40, 424, 424d Macroshock, 421
L statute of limitations, 42 Macules, 239t
Labels, nutritional, 294–296, 296f Leukocytes, 639 Mad cow disease, 330
Laboratory reports, 110t Leukocytosis, 639, 639f Magico-religious perspective, 77
Laboratory tests. See Diagnostic examina- Levin tube, 665, 666t Magnesium
tions and tests Liability, 40–44 dietary, 292t
Lacerations, 639t. See also Wound(s) litigation and, 42–44 serum, 312, 313t
Lactase deficiency, 80, 80d risk reduction for, 42 Magnetic resonance imaging, 259, 259d,
Language. See also Communication Liability insurance, 41–42 259f
body, 96–99, 98d Libel, 40 Malingering, 447
cultural aspects of, 75, 76t Lice, 363t Malnutrition
Large intestine, anatomy of, 737f Licensed practical/vocational nursing, 7–9, definition of, 289
Laser surgery, 615–616 8f, 9t. See also Nursing emaciation in, 300
Lateral oblique position, 520–521, 521f Licensure, 9, 35–37, 36f Malpractice, 40–44. See also Liability
Lateral position, 520, 521f Life expectancy, 876, 877f Managed care, 12t, 55–56
Latex allergy, 142, 417f, 426–427 Lifestyle factors, in stress management, 70 Masks
Latex gloves, 142, 143d, 143f Lifting clients, 519–520 CPAP, 473, 473f
Latex-safe environment, 417 mechanical aids for, 528, 528f, 529f, oxygen, 468t–470t, 471–472
Latinos, 73, 74t. See also under Cultural; 540d–542d protective, 141–142, 142f, 492, 494
Culture Light palpation, 230, 231f Maslow’s hierarchy of needs, 52, 52f
communication with, 75 Limbs. See also Arm; Leg Massage, 398–399, 399t, 411d–414d
health beliefs and practices of, 82t assessment of, 244–245, 244f, 245f Master’s programs, 10–11
leading causes of death for, 81t Linear flow charts, 25, 26f Mattresses, 389–390, 390f, 522
Lavage, gastric, 665 Linens, 390 alternating air, 525, 525f, 526t
Law(s), 35–41. See also Legal issues changing of foam, 524–525, 526t
administrative, 35–37, 35t for occupied bed, 390, 409d–411d gel, 525, 526t
civil, 37–41 for unoccupied bed, 389, 403d–408d static air, 525, 526t
Constitutional, 35, 35t handling of, 143 water, 525, 526t
definition of, 35 Line of gravity, 517f, 517t Mattress overlays, 524
Good Samaritan, 42 Lipid emulsions, 332–333, 333f Maximum heart rate, 546
judicial, 37 Lipoatrophy, 802 Maxter tube, 666t
nurse practice acts, 35, 36d Lipohypertrophy, 802 Meal trays, 302, 307d–308d
statutory, 35, 35t Lipoproteins, 290–291, 291t Measurement conversion, for temperature,
Lead apron, 259, 260f Lipping container, 146 186, 186d
Learning. See also Client teaching Liquid medications, 770, 770f Mechanical débridement, 646
literacy and, 104 Liquid oxygen units, 465, 465f Mechanical immobilization, 563–583
motivation in, 105 Listening, 96 braces in, 566–567, 567f
readiness for, 105 active, 15 casts in, 567–570, 567t, 568f–570f
sensory deficits and, 104, 104d Literacy, 104 nursing care plan for, 572, 573d
Learning styles, 102, 103t Lithotomy position, 255, 256t nursing implications of, 572
Leaving against medical advice, 168 Litigation. See also Law(s); Legal issues in older adults, 572–575
Leg. See also under Foot malpractice, 42–44 orthoses in, 563–566
assessment of, 244–245, 244f, 245f Living wills, 47, 48f peripheral neurovascular dysfunction in,
exercises for Loading dose, of opioid, 442–443 568d, 574d–575d
for ambulation, 585, 585d Local anesthesia pin site care in, 572, 581d–583d
postoperative, 620–621, 621d for diagnostic procedures, 255, 257f purposes of, 563–564
prosthetic, 589–591, 590f for injections, 806 slings in, 566, 566f
958 Index
Mechanical immobilization (contd.) parenteral, 796–815. See also Parenteral Microshock, 421
splints in, 564–566, 564f–566f medications Microsleep, 397
traction, 570–572 pill organizers for, 422, 423f Midarm circumference, 298–299, 299t
Mechanical lifts, 528, 528f, 529f, polypharmacy and, 775 Military nursing, 4, 5
540d–542d in preoperative period, 622 Military time, in documentation, 117, 119f
Medicaid. See Medicare/Medicaid reversal, 625 Milk, lactose intolerance and, 80, 80d
Medical diagnoses, 20, 20f, 166 sleep and, 394, 395t Milliequivalents (mEq), 312
Medical futility, 47–49 stock supply, 771 Minerals, dietary, 291, 292t
Medical orders, 110t storage of, 771 Minimum disclosure, 115
implementation of, 23–24 in tablet form, 769–770 Minorities, 27t, 72, 73–74
for restraints, 425 temperature and, 187 Minors, consent for, 618
Medical records, 23–25, 109–125 topical, 784–787. See also Topical Misdemeanors, 37
care plan in, 23. See also Nursing care plan medications Mitt restraints, 429, 430f. See also Restraints
client access to, 111–112 trade name of, 769 Mobility. See also Ambulation
components of, 23–25 unit dose supply, 771, 773f functional, 520
confidentiality of, 47, 115–117 Medication administration record (MAR), impaired, nursing care plan for, 592d–593d
definition of, 109 110t, 771, 772d promotion of, 529d
as legal evidence, 111, 112d Medication errors, 775 Modeling, 69t
making entries in, 124d–125d Medication lock, 329, 329f, 352d–354d, Mode of transmission, for microorganisms,
problem-oriented, 112, 112t 817–818, 818d, 818f 137
source-oriented, 112 Medication orders, 768–771 Modified safety injection devices, 797, 797f
uses of, 110 components of, 768–770 Modified standing position, 256
Medicare/Medicaid, 54–55, 55t definition of, 768 Molded splints, 565, 565f
for home health care, 176 do-not-use abbreviations in, 769t Mongolian spots, 79, 80f
for hospice care, 878–879, 879d telephone, 770, 770d Montgomery straps, 642, 642f
for nursing home care, 172–173 verbal, 770 Morbidity, 52
prescription drug benefit of, 55, 55t Medicine Morgue, 888
Medication(s) alternative, 82d Mormons, 78t
administration of, 769–775, 769t for pain, 443, 444–445 Mortality, 52, 53t. See also End-of-life issues
client teaching for, 773, 774d environmental, 82d cultural aspects of, 81, 81t
documentation of, 771, 772f, 774–775 folk, 81–82 leading causes of, 53t, 81, 81t
by enteral tube, 774, 781d–783d Meditation, 69t Mortician, 882
errors in, 775 for pain, 444, 444f Motivation, in learning, 105
five rights of, 771, 773f Megadoses, of nutritional supplements, Mouth. See under Oral
frequency of, 770 291–292 assessment of, 237–238
by inhalant route, 787–791 Melatonin, 393 dry, in tube feeding, 677t
by intravenous route, 816–833 Menadione, 293t Mouth care, 364–366
by oral route, 769–774, 779d–781d Mental status assessment, 234 agents for, 367t
by parenteral route, 796–815 Mercury, in thermometers, 190, 191d dental care in, 365, 366f
routes of, 769–770, 770t Metabolic energy equivalent (MET), 546, 546t denture care in, 267f, 366
safety concerns for, 773, 774d Metabolic rate, 300d for unconscious client, 366, 383d–385d
by topical route, 784–787 temperature and, 187 Mouth-to-mouth breathing, 862, 862f
transdermal, 785–786 Metered-dose inhaler, 788, 789d Mouth-to-nose breathing, 862, 862f
in capsule form, 769–770 METHOD discharge planning guide, 169, 170t Mouth-to-stoma breathing, 862–863
definition of, 768 Mexican Americans. See Latinos Mucous membranes, 359, 845
dosage of Microabrasions, 621 Mucus, 844
calculation of, 771, 773d Microorganisms, 134–136 liquefaction of, 845
errors in, 775 bacteria, 135, 135f mobilization of, 845–847
dose of, 769 in chain of infection, 136–137 suctioning of, 847
equianalgesic, 447d colonization of, 488 Multicultural diversity, 11
generic name of, 769 exit route for, 137 Multiple organ failure, 881, 881t
G-6-PD deficiency and, 80, 81t fungi, 135 Multiple sleep latency test, 396
individual supply, 771, 773f helminths, 136 Muscle spasms, 516
inhalant, 787–791. See also Inhalant mycoplasma, 136 Muscle strength, 584
medications nonpathogens, 135 assessment of, 244, 244f
intravenous, 816–833. See also Intra- pathogens, 135, 137 Muscle tone, 584
venous infusion port of entry for, 137–138 Muslims, 79t
inunction, 784–785 prions, 136 Mycoplasma, 136
nasal, 787, 794d–795d protozoans, 135–136 MyPyramid, 294, 295f
noncompliance with, 776–777 reservoirs for, 137
for older adults, 775 resident, 139
ophthalmic, 786, 787f Rickettsiae, 135 N
oral, 771–774, 779d–781d. See also Oral survival of, 136 Nail(s), 360, 360f
medications transient, 139 assessment of, 244, 244f
otic, 786–787 transmission of, 137, 138t care of, 367–368
overdose of, 422, 423f virulence of, 135 clubbing of, 244, 244f
over-the-counter, 773 viruses, 135 fungal infections of, 363t
Index 959
Nail polish, pulse oximetry and, 622 Nightingale training schools, 4, 4t nursing acts vs. caring acts in, 93d
NANDA (North American Nursing Diagno- Nitroglycerin paste, 786d origins of, 2–3
sis Association), 20 Nociceptors, 435 primary, 58
Narcolepsy, 397 Nocturia, 707 team, 58
Narcotics. See Opioids Nocturnal enuresis, 398 transcultural, 74–82. See also under Cul-
Narrative charting, 112, 113f Nocturnal polysomnography, 395, 396f tural; Culture
Nasal assessment, 236–237 Nodules, 239t Nursing: A Policy Statement (ANA), 6
Nasal cannula, 467, 467f, 468t Noncompliance, nursing care plan for, Nursing acts, vs. caring acts, 93, 93d
Nasal catheter, 472, 473f 776–777 Nursing care assignments, documentation of,
Nasal medications, 787, 794d–795d Nonelectrolytes, 312 121–123, 122f
Nasal strips, 465 Nonessential amino acids, 289 Nursing care plan, 21–23
Nasogastric intubation, 664, 665f, 665t, Nonmaleficence, 45 for admitted client, 166
672–677, 674t, 682d–685d. See also Nonpathogens, 135. See also Microorganisms for amniocentesis, 267d
Gastrointestinal intubation; Tube Non-rebreather mask, 469t, 472 for anxiety, 177d–178d
feeding Non-REM sleep, 391–392, 391f, 392t. See for bathing/hygiene, 372d
Nasointestinal intubation, 664, 665–667, also Sleep for body image disturbance, 629d–630d
665t, 674t. See also Gastrointestinal Nonsteroidal antiinflammatory drugs, 441 communication of, 23
intubation Normal flora, 135. See also Microorganisms for constipation, 745
Nasopharyngeal suctioning, 847, 847t Normal saline enemas, 741, 741f for deficient knowledge, 146–147
Nasotracheal suctioning, 847, 847t North American Nursing Diagnosis Associa- for discharge, 168, 169d
National Association for Practical Nurse tion (NANDA), 20 for disturbed body image, 629d–630d
Education and Service, Inc., 8 Nose. See also under Nasal documentation of, 23, 24f, 119, 120f
National Council of State Boards of Nursing, assessment of, 236–237 for fever, 207d–208d
8 Nosocomial infections, 138 for fluid volume deficit, 334d–335d
National Federation of Licensed Practical N95 respirator, 492, 492f forms for, 110t
Nurses, 8 NSAIDs, 441 for health-seeking behaviors, 248–249
National Patient Safety Goals, 415, 416d Nuclear medicine, 261 for hopelessness, 885
Native Americans, 74, 74t. See also under Nurse(s) for hyperthermia, 207d–208d
Cultural; Culture back injuries in, 519–520 for impaired physical mobility, 592d–593d
alcohol use/abuse by, 80–81 prevention of, 528, 528f, 529f, for impaired swallowing, 304d–305d
communication with, 75 540d–542d for impaired tissue integrity, 653–654
health beliefs and practices of, 82t ethical code for, 44, 44d for ineffective airway clearance, 850
leading causes of death for, 81t levels of responsibility for, 9t for ineffective breathing pattern, 476–477
Naturalistic perspective, 77 licensing of, 35–37, 36f for ineffective breathing patterns, 790d
Naturopathy, 82d needlestick injuries in, 797, 797f, 798f for ineffective protection, 822–823
Nausea, 300–301 practical/vocational, 7–9, 8f, 9t, 10f for ineffective therapeutic regimen man-
in tube feeding, 677t registered, 8f, 9–11, 9t, 10f agement, 808
Near-drowning, 421 Nurse-client relationship, 92 for infection control, 146–147
Neck barriers to, 95, 95d levels of responsibility for, 9t
assessment of, 238 caregiving in, 93, 93d in medical record, 23
injuries of, cervical collar for, 565–566, client roles in, 94, 94d for noncompliance, 776–777
565f, 566f collaboration in, 93, 93d for pain management, 447d, 448d–449d
range-of-motion exercises for, 552d–553d communication in, 95–100 priority setting for, 21–23
Needle(s), 797 nonverbal, 95–97, 98d for risk for aspiration, 679d
gauge of, 797 verbal, 95–97 for risk for disuse syndrome, 530–531
selection of, 797, 797t delegation in, 93–94 for risk for inability to sustain sponta-
shaft of, 797 foundations of, 94 neous ventilation, 867
Needleless systems, 323–324, 324f nursing roles in, 92–94, 94d for risk for infection transmission,
Needlestick injuries, prevention of, 797, phases of, 94 498–499
797f, 798f therapeutic, 94–95 for risk for injury, 427
Negligence, 40–44. See also Liability Nurse licensure compacts, 36–37, 36f for risk for peripheral neurovascular dys-
Nervous system, 62–63, 63f, 63t Nurse-managed care, 58 function, 574d–575d
autonomic, 62–63, 63f, 63t Nurse managers, 58 for sleep disturbances, 401d–402d
central, 61–62, 62f Nurse practice acts, 35, 36d standardized, 23
parasympathetic, 63, 63f, 63t Nursing for unilateral neglect, 550, 551
sympathetic, 62–63, 63f, 63t acultural, 71 for urge urinary incontinence, 716–717
Neuropathic pain, 437 advanced practice, 11 Nursing diagnoses, 20–21
Neurotransmitters, in homeostasis, 61–62, as art and science, 6 collaborative problems and, 21, 21f, 22t
61f cross-training in, 11 components of, 20–21, 21d
Neurovascular dysfunction, in mechanical culturally sensitive, 71, 82 definition of, 20
immobilization, 568d, 574d–575d definition of, 6 levels of responsibility for, 9t
Neutral position, 517t essential features of, 6 NANDA-approved, 20
Newborn, temperature in, 187 functional, 58 prioritization of, 22t
NEX measurement, 668, 668f future trends in, 11–12, 12t types of, 20t
Niacin, 292t history of, 2–5, 3f, 4t Nursing education, 6–11
Nightingale, Florence, 3–4, 3f, 4t, 6 holistic, 51–52 case histories in, 111
environmental theory of, 7t levels of responsibility in, 9t, 17 continuing, 11, 12d
960 Index
Nursing education (contd.) intravenous solution preparation, preoperative, 622

cross-training in, 11 339d–342d vegetarian diet and, 289, 290f, 296–297
history of, 3–4, 4t intravenous solution replacement, Nutritional assessment, 297–299, 298d,
for practical/vocational nurse, 7–9 347d–349d 298f, 299t
for registered nurses, 9–11 intravenous tubing replacement, Nutritional labeling, 290, 290d, 294–296, 296f
associate degree programs in, 10 349d–350d Nutritional problems, 299–302
baccalaureate programs in, 10 meal trays, 307d–308d anorexia, 300, 301d
graduate programs in, 10–11 measuring for crutches, canes and walk- malnutrition, 289
hospital-based diploma programs in, ers, 595d–598d nausea, 300–301, 301d
9–10 nasal medication administration, obesity, 299–300
Nursing Home Reform Act of the Omnibus 794d–795d vomiting, 301–302, 301d
Budget Reconciliation Act (OBRA), 39 nasogastric tube irrigation, 686d–687d Nutritional support, 331–333, 332d, 332f,
Nursing homes, 54, 171–173, 174d, 879 nasogastric tube removal, 688d–689d 333f. See also Parenteral nutrition;
Nursing notes, 110t oral care for unconscious client, Tube feeding
Nursing orders, 23, 24b 383d–385d
Nursing process, 16–26 oral medication administration,
assessment in, 9t, 17–20, 17f. See also 779d–781d O
Assessment ostomy appliance change, 754d–756d Obesity, 299–300, 300d
characteristics of, 17 oxygen administration, 480d–482d sleep apnea and, 397
definition of, 16 pelvic examination, 269d–272d weight measurement in, 232, 233f
evaluation in, 9t, 25, 25t perineal care, 376d–379d Objective data, 18, 18d
guidelines for, 26t physical assessment, 250d–251d Occupational Health and Safety Act,
implementation in, 9t, 23–25. See also physical restraints, 429d–433d 519–520
Nursing skills postmortem care, 887d–888d Occupational injuries, in nurses
levels of responsibility for, 9t, 17 preparation for patient-controlled analge- back, 519–520
nursing diagnosis in, 9t, 20–21, 20f, 20t, sia, 451d–454d needlestick, 797, 797f, 798f
21d, 21f pulse oximetry, 478d–479d Offsets, thermometer, 189
planning in, 9t, 21–23. See also Nursing range of motion exercises, 552d–560d Ointments, medicated, 786
care plan rectal suppository insertion, Older adults
in standard of care, 25 749d–750d airway management in, 849–850
steps in, 17–25, 17f rectal tube insertion, 747d–748d ambulatory aids for, 593–594
Nursing shortage, 11–12 removing personal protective equipment, body mechanics in, 531
Nursing skills 501d–502d bowel elimination in, 744–746
applying leg prosthesis, 602d–604d secondary (piggyback) infusion, comfort measures for, 399–400
assessment, 12 828d–830d communication with, 99–100
assisting with crutch-walking, shampooing, 385d–386d community services for, 174, 174t, 175–176
599d–602d sigmoidoscopy, 272d–274d diet for, 303–305
back massage, 411d–414d sterile technique, 157d–162d disuse syndrome in, 531
bed bath, 380d–382d suctioning, 852d–854d end-of-life issues and, 884–886. See also
bedmaking surgical scrub, 153d–156d End-of-life issues
for occupied bed, 409d–411d temperature measurement, 209d–215d examinations and tests for, 266–267
for unoccupied bed, 403d–408d tracheostomy care, 855d–858d exercise for, 551
caring, 12–15 transcutaneous electrical nerve stimula- extended care facilities for, 52, 54,
cleansing enema, 751d–753d tion, 445d, 454d–457d 171–173, 174d, 879
client teaching, 103, 103t, 107d–108d transferring client, 537d–542d falls in, 422–423, 424d, 424f
comforting, 15 transfusion administration, 355d–357d fluid and electrolyte balance in, 333–335
continuous IV infusion, 825d–827d tub bath or shower, 374d–375d functional limitations in, 175, 175f
counseling, 15 tube feeding, 688d–695d home health care for, 174–175
documentation, 124d–125d turning and moving client, 533d–537d hospitalization of, 175–176
of intake and output, 337d–339d wound irrigation, 658d–660d housing options for, 176d
dressing change, 655d–658d Nursing team, 57–58, 58f, 93, 93f hygiene for, 371–372
enteral drug administration, 774, Nursing theories, 6, 7t infection control for, 147–148, 497–499
781d–783d Nutrition, 288–310. See also Diet; Feeding; inhalant medications for, 790–791
entries in client’s record, 124d–125d Food intravenous infusion for, 823
eye medication administration, 792d–793d calories in, 289 long-term care facilities for, 171–173,
feeding assistance, 308d–310d definition of, 289 174d, 879
glove donning, 160d–162d in dying client, 880 mechanical immobilization in, 572–575
glucometer, 275d–278d eating habits and, 296–297 Medicare benefits for. See Medicare/
handwashing, 150d–153d enteral. See Tube feeding Medicaid
intermittent intravenous infusion, feeding assistance and, 302–303 medications for, 775
828d–830d food pyramid and, 294, 295f nutrition in, 303–305
intravenous infusion discontinuation, goals for, 293–294, 294d oxygenation in, 475
350d–352d for hospitalized client, 302–303 parenteral medications for, 807
intravenous infusion medication lock, nutrient requirements in, 289–293 personal response services for, 423
352d–354d in older adults, 303–305 physical assessment for, 247–249
intravenous solution administration, overview of, 288–289 polypharmacy and, 775
343d–347d parenteral, 331–333, 332d, 332f, 333f positioning for, 531
Index 961
restraints for, 39–40 Orthopneic position, 462, 463f CPAP mask in, 473
resuscitation of, 866–868 Orthoses, 563–566. See also Mechanical definition of, 465
safety concerns for, 416, 417t, 422–423, immobilization equipment for, 466–467, 466f, 467f
426–428 Orthostatic hypotension, 205 face tent in, 470t, 472
sleep in, 392, 393f, 399–400 assessment for, 226d–228d hyperbaric oxygen, 475, 475f
surgery in, 628–630 Oscillating support bed, 526, 526t, 527f liquid oxygen units for, 465, 465f
teaching of, 103, 103t, 105–106 OSHA requirements, for lifting clients, nasal cannula in, 467, 467f, 468t
topical medications for, 789–790 519–520 nasal catheter in, 472, 473f
transfer methods for, 531 Osmosis, 313–314, 313f oxygen concentrator, 466, 466f
tube feeding for, 680 Osmotic pressure, colloidal, 314 oxygen masks in, 468t–470t
urinary elimination in, 715–717 Ostomy, 742–744. See also specific types oxygen sources in, 465–466, 465f, 466f
vital signs in, 205–208 definition of, 664, 742 oxygen tent in, 472–473
wounds in, 651–652 locations of, 743f procedures in, 480d–482d
Oliguria, 707 nursing implications of, 744 safety concerns in, 473–474, 474d
Omnibus Budget Reconciliation Act in older adults, 744–746 T-piece in, 471t, 472
(OBRA), restraints and, 424 Ostomy appliance, 742, 743f tracheostomy collar in, 471t, 472
Open urine drainage systems, irrigation of, changing of, 754d–756d transtracheal oxygen in, 473, 473f
713 Ostomy care wall outlet for, 465
Open wound, 638, 639t appliance change in, 754d–756d Oxygen toxicity, 474
Operating room, 624 for colostomy/ileostomy, 742–744
Ophthalmic medications, 786, 787f, drainage in, 742–743, 744d
792d–793d irrigation in, 743, 757d–759d P
Ophthalmologist, 369 for urostomy, 715 Packed cells, 321. See also Transfusion(s)
Opioids OTC medications, 773 Packs, moist, 649–650
accounting for, 771 Otic medications, 786–787 Padding, for ulcer prevention, 652d, 652f
addiction to, 446–447 Otitis media, in tube feeding, 677t Pain, 435–457
bolus (loading) dose of, 442–443 Outcomes acute, 437, 438t
as controlled substances, 771 from evaluation, 25t assessment of, 438–439, 438t, 439t, 440f
endogenous, 436 vs. goals, 22b chronic, 437, 438t
equianalgesic dose of, 447d Outpatient surgery, 615–616, 616t cutaneous pain, 436–437
intraspinal, 443 Overbed table, 390 definition of, 435
for pain, 441–443 Overdose, drug, 422, 423f malingering and, 447
in patient-controlled analgesia, 442–443 Overflow incontinence, 709t modulation of, 435f, 436
regulation of, 441–442 Over-the-counter medications, 773 neuropathic, 437
storage and handling of, 771 Over-the-needle catheter, 325f, 326 nursing implications of, 446
Opportunistic infections, 137 Oxygen analyzer, 467, 467f perception of, 435f, 436
Optometrist, 369 Oxygenation, 458–487. See also Breathing; phantom limb, 437
Oral airway, 847–848, 848d, 848f Respiration; Ventilation phases of, 435–436, 435f
Oral assessment, 237–238 assessment of, 459–461 receptors for, 435
Oral dryness, in tube feeding, 677t arterial blood gases in, 460, 460t referred, 437, 437f
Oral hygiene, 364–366 physical examination in, 459 somatic, 436
agents for, 367t pulse oximetry in, 460, 462f, 462t suffering and, 435
dental care in, 365, 366f factors affecting, 463d theories of, 436
denture care in, 267f, 366 inadequate tolerance to, 436
for unconscious client, 366, 383d–385d breathing techniques for, 462–465 transduction of, 435, 435f
Oral medications, 768–783. See also causes of, 463d transmission of, 435–436, 435f–437f
Medication(s) hypercarbia in, 464 types of, 436–438
administration of, 771–774, 779d–781d hypoxemia in, 459 visceral, 437
capsule, 770 hypoxia in, 459 Pain intensity scales, 439, 440f
liquid, 770, 770f nursing care plan for, 476–477 Pain management, 440–447
tablet, 769–770 oxygen therapy for, 465–474. See also acupressure in, 445
Oral suctioning, 847, 847t Oxygen therapy acupuncture in, 445
Oral temperature, 188, 188f, 209d–211d. See positioning for, 462, 463f addiction concerns in, 446–447
also Temperature signs of, 460d adjuvant drugs in, 441, 443
Orders water-seal chest tube drainage for, 474, alternative therapies in, 443, 444–445
nursing, 23, 24b 474f, 483d–487d biases in, 439d, 440
physician’s, 23–24, 110t nursing implications of, 475 biofeedback in, 446
implementation of, 23–24 in older adults, 475 botulinum toxin in, 443
for restraints, 425 promotion of, 462–465 client teaching in, 444, 444d
Orem, Dorothea, 7t Oxygen concentrator, 466, 466f cold application in, 445
Organ donation, 882, 883f Oxygen flowmeter, 466–467, 466f, 467f cordotomy in, 443
Orientation, admission, 165 Oxygen masks, 468t–470t, 471–472 definition of, 440
Orogastric intubation, 664, 665t. See also Oxygen tanks, portable, 465, 465f distraction in, 444
Gastrointestinal intubation Oxygen tent, 472–473 drug therapy in, 440–443
Oropharyngeal suctioning, 847, 847t Oxygen therapy, 465–474 nonopioids in, 441
Orthodox Judaism, 78t ambulatory, 465, 465f opioids in, 441–443. See also Opioids
Orthopnea, 198 complications of, 474 WHO guidelines for, 440–441, 441f
962 Index
Pain management (contd.) Pathogens, 135–136, 137. See also Phone conversations, documentation of,
heat application in, 445 Microorganisms 123
hypnosis in, 446 Pathologic grief, 884 Phosphate, serum, 312, 313t
imagery in, 444, 444f Patient-controlled analgesia, 442–443, Phosphorus, dietary, 292t
for injections, 806–807 451d–454d Photoperiod, 397
meditation in, 444, 444f Patient’s Bill of Rights, 45d Phototherapy, for seasonal affective disorder,
nursing care plan for, 447d, 448d–449d Pedagogy, 103, 103t 398, 398d
for older adults, 447 Pediculosis, 363t Physical assessment, 229–251, 250d–251d
patient-controlled analgesia in, 442–443 PEG tube, 667, 668f of abdomen, 245–246
percutaneous electrical nerve stimulation drug administration via, 774 admission, 166
in, 445–446, 446f PEJ tube, 667, 668f of anus, 246–247, 247f
placebo effect in, 447 Pelvic belt, 571, 571f body systems approach in, 233
relaxation in, 444–445 Pelvic examination, 257–258, 269d–272d of chest, 240, 240f
rhizotomy in, 443 Peracetic acid sterilization, 145 data collection in, 233–247
standards for, 440, 440d Percussion documentation of, 232
surgical, 443 in chest physiotherapy, 846, 847f draping in, 232, 233f
transcutaneous electrical nerve stimula- in physical assessment, 230, 230f, 230t environment for, 231, 231d
tion in, 445d, 454d–457d Percutaneous electrical nerve stimulation, equipment for, 231, 231d
Pain threshold, 436 445–446, 446f of extremities, 244–245, 244f, 245f
Palpation Percutaneous endoscopic gastrostomy (PEG) of eyes, 234–236
deep, 230, 230t, 231f tube, 667, 668f, 674t. See also Tube general data for, 232
light, 230, 230t, 231f feeding of genitalia, 246, 247f
mass characteristics on, 246d drug administration via, 774 of head, 234–238
of pulse, 216–217 Percutaneous endoscopic jejunostomy (PEJ) head-to-toe approach in, 233
Palpitations, 194 tube, 667, 668f, 674t. See also Tube of hearing, 236, 236t, 237f
Pantothenic acid, 293t feeding of height, 232, 232d, 232f
Pap test, 257–258, 258t, 269d–272d Perfluorocarbons, as blood substitutes, 322 inspection in, 230, 230f
Papules, 239t Perineal care, 362, 376d–379d mental status assessment in, 234
Paracentesis, 262, 263d, 263f Periodontal disease, 361 of nails, 244, 244f
Paradoxical sleep, 391 Perioperative care, 614–637. See also Surgery of neck, 238
Parallel bars, 586, 587f Peripheral neurovascular dysfunction, in of nose, 236–237
Paranormal experiences, 884 mechanical immobilization, 568d, nursing implications of, 247
Parasomnias, 398 574d–575d for older adult, 247–249
Parasympathetic nervous system, 63, 63f, 63t Peripheral parenteral nutrition, 332 of oral cavity, 237–238
Parenteral medications, 796–815. See also Peristalsis, 736 overview of, 229
Medication(s) Peristomal skin care, 715, 742 palpation in, 230, 230t, 231f
in ampules, 798, 798f Peritoneal cavity, fluid accumulation in, mass characteristics on, 246d
combined in one syringe, 800 319–320, 319f percussion in, 230, 230f, 230t
definition of, 796 Personal hygiene. See Hygiene positioning in, 233, 233f
injection of, 800–807 Personal property, of client of skin, 238
intradermal, 800, 810d–811d inventory of, 165–166, 165f of smell acuity, 237
intramuscular, 803–806, 804f–806f, return of, 170 of spine, 240, 240f
814d–815d storage of, 165–166 of taste, 237–238, 238f
intravenous, 800, 800f Personal protective equipment, 141–143, of vision, 234–236
reducing discomfort of, 806–807, 807f 142f–144f, 160d–162d, 492–493, of weight, 232, 232d, 233f
subcutaneous, 800–803, 800f, 492f, 494–495 Physician’s orders, 110t
812d–183d disposal of, 495, 495f implementation of, 23–24
Z-track, 805 face-protection devices, 494 for restraints, 425
modified safety injection devices for, 797, gloves, 494–495 PIE charting, 114, 114f
797f examination, 142, 143d, 143f Piggyback infusion, 819, 819f, 828d–830d
needles for, 797. See also Needle(s) latex allergy and, 142, 417f, 418t, Pigmentation, 78–79, 79f, 80f
nursing implications of, 807 426–427 Pill organizers, 422, 423f, 777
for older adults, 807 sterile, 146, 160d–162d Pillows, for positioning, 522
in prefilled cartridges, 799 types of, 418t Piloerection, 186
preparation of, 798–800 gowns, 141, 494, 494f Pin site care, 572, 581d–583d
reconstitution of, 798 removal of, 495, 495f, 501d–502d Pitting edema, 244–245, 245d
syringes for, 796, 797f sterile, 146, 147d Pituitary gland, in homeostasis, 63, 64f
in vials, 798–799, 798f, 799d removal of, 495, 495f, 501d–502d Placebo effect, 69t
Parenteral nutrition, 331–333, 332d, 332f, sterile, 144–146, 157d–162d in pain management, 447
333f Personal response services, 423 Plaintiffs, 37
Partial bath, 361–362 Personal space, 76, 98–99, 99t Planning. See also Nursing care plan
Partial rebreather mask, 469t, 472 PET (positron emission tomography), 261 communication in, 23
Particulate air filter respirators, 141–142, Pétrissage, 399t goal setting in, 22–23, 22b, 24b
142d, 142f pH, of gastric fluid, 669, 669d, 669f intervention selection in, 23
Passive diffusion, 314 Phagocytosis, 639, 639f levels of responsibility for, 9t
Passive exercise, 547–549. See also Exercise Phantom limb pain, 437 in nursing process, 9t, 21–23
Pastes, medicated, 786, 786d, 786f Phlebitis, in intravenous infusion, 327, 328t Plaque, 361
Index 963
Plasma, 321t. See also Transfusion(s) Potassium Prosthesis

Plasma expanders, 322 dietary, 292t lower limb, 589–591, 590f
Platelets, 313 serum, 312, 313t application of, 599d–602d
transfusion of, 321t. See also Transfusion(s) Potential diagnosis, 21 preoperative care of, 622
Platform crutches, 589, 589f Powered Air Purifying Respirator, 492, Prosthetist, 602
Plume, in laser surgery, 616 492f Protective devices
Plunger, of syringe, 796, 797f Power pudding, 744 for clients, 524–526
Pneumatic compression device, 626, PPOs, 56 for health care workers. See Personal pro-
635d–637d Practical/vocational nursing, 7–9, 8f, 9t, 10f. tective equipment
Pneumatic splints, 564, 564f See also Nursing Protein complementation, 289, 290f, 297
Pneumonia, postoperative, 620 Practice standards, 17d Proteins, dietary, 289, 290d, 290f
Podiatrist, 367–368 Prayer, 69t Protocols, definition of, 425
Poisoning, 422, 422d, 422f, 423f Precautions, 489–492, 490d. See also Infec- Protozoans, 135–136
carbon monoxide, 420–421, 421d tion control Proxemics, 76, 98–99, 99t
Polypharmacy, 775 Preferred provider organizations (PPOs), Pseudoconstipation, 738
Polysomnography, nocturnal, 395, 396f 56 Psoriasis, 363t
Polyuria, 707 Prefilled cartridges, 799, 799f Psychomotor domain, in learning, 102
Portable oxygen tanks, 465, 465f Pregnancy, amniocentesis in, 267d Public space, 98, 99t
Port of entry, 137–138 Preload, 198 Pulmonary embolism
Ports, 323–324, 324f, 817, 817f Preoperative period, 614–625. See also in intravenous infusion, 327, 328t
Position Surgery postoperative, 621, 626, 627t
anatomic, 517t blood donation in, 618, 618t Pulmonary secretions
dorsal recumbent, 255, 256t care of valuables in, 622 liquefaction of, 845
Fowler’s, 462, 521–522, 521f checklist for, 623–624, 623f mobilization of, 845–847
functional, 517t client preparation in, 621–624 suctioning of, 847, 852d–854d
joint, 548, 548t client teaching in, 619–621 Pulse(s), 194–197
knee-chest, 255, 256t clothing and hygiene in, 622 apical heart rate and, 195–196
lateral, 520, 521f fluid intake in, 622 apical-radial heart rate and, 196–197
lateral oblique, 520–521, 521f leg exercise teaching in, 620–621 assessment of, 195–197, 196f, 197f
lithotomy, 255, 256t medications in, 622 procedure for, 216d–217d
modified standing, 255, 256t nursing assessment in, 618–619, 619t sites for, 195–197, 196f, 197f
neutral, 517t nutrition in, 622 definition of, 194
orthopneic, 462, 463f oral care in, 622 peripheral, 195, 196f
prone, 521, 521f psychosocial preparation in, 622 radial, 196–197, 216d–217d
recovery, 862 skin preparation in, 621 training effect on, 195
side-lying, 520, 521f Pressure ulcers, 650–651, 650f Pulse deficit, 196–197
Sims’, 255, 256t, 521, 521f management of, 641 Pulse oximetry, 460, 462f, 462t, 478–479
supine, 520, 521f prevention of, 651, 652d, 652f preoperative, 622
Trendelenburg, 522, 522f risk factors for, 651d Pulse pressure, 199. See also Blood pressure
Positioning, 520–524 shearing forces and, 526, 652 Pulse rate, 194–195, 195t
in cardiopulmonary resuscitation, 862 sites of, 650, 650f Pulse rhythm, 195
devices for, 522, 522f stages of, 650–651, 651f Pulse volume, 195, 196d
for examinations and tests, 254–255, 256t Prevention Pumps, infusion, 324, 325f
guidelines for, 520 primary, 68 Puncture wounds, 639t. See also Wound(s)
for oxygenation, 462, 463f secondary, 68 Pupil
for physical assessment, 233, 233f tertiary, 68 in accommodation, 235, 235f
turning and moving methods for, 523, Primary care, 11, 53–54 assessment of, 235, 235f
523f, 533d–537d Primary illness, 52 consensual response of, 235, 235f
in wheelchair, 426t, 430f Primary nursing, 58 Pursed-lip breathing, 464
Positron emission tomography, 261 Primary prevention, 68 Purulent drainage, from pressure ulcers, 651
Possible diagnosis, 20t, 21 Prion diseases, 136, 329–330 Pustules, 239t
Postanesthesia care unit, 625 transfusion-related, 329–330 Pyrexia, 192
Postmortem care, 884, 887d–888d Privacy Pyridoxine, 293t
Postoperative period, 625–627. See also documentation and, 115–117
Surgery HIPAA regulations for, 111, 115–117
body image in, 629d–630d in hospitalization, 167–168 Q
nursing care plan for, 629d–630d Privacy curtain, 390 Quad cane, 587, 587f
thrombosis in, 620–621 Problem-oriented records, 112, 112t. See also Quadriceps setting exercises, 585, 585d
wound management in, 641–650. See also Medical records Quality assurance, 12
Wound management Prodromal stage, 489t documentation in, 111
Postural drainage, 846, 846f Progressive care units, transfer to, 170–171 Questionnaires, in sleep assessment, 395
Postural hypotension, 205 Progressive relaxation, 69t, 398, 399d Quick-release knots, for restraints, 431
assessment for, 226d–228d Progress notes, 110t
Posture, 516–519 Projectile vomiting, 301
lying, 518–519, 518f Proliferation, in wound repair, 640 R
sitting, 518, 518f Prone position, 521, 521f Race, 27t, 72, 73–74. See also Culture
standing, 518, 518f Prospective payment systems, 55 RACE mnemonic, for fire safety, 419
964 Index
Radial pulse, 196–197, 216d–217d. See also Residual urine, 707 Retention enemas, 741–742
Pulse(s) Resistance stage, of stress response, 65, 65f Reticular activating system, 62, 62f
Radiation, in sterilization, 145 Resolution, in wound repair, 640 Retinol, 292t
Radiography, 258–260, 258t, 259f, 260f Respiration. See also Breathing; Oxygenation; Reversal drugs, for conscious sedation, 625
Radiology, 258–260 Ventilation Rheomacrodex (dextran 40), 322
Radionuclide imaging, 261 Cheyne-Stokes, 198 Rh factor, 330
Rales, 242 definition of, 197, 458 Rhizotomy, for pain, 443
Range-of-motion exercises, 547–548, 548t external, 459 Rhonchi, 242
continuous passive motion machine for, internal, 459 Riboflavin, 292t
548–549, 560d–562d ventilation and, 458 Rickettsiae, 135
procedure for, 552d–560d Respirators, 141–142, 142d, 142f Rinne test, 236, 237f
Rapid eye movement (REM) sleep, 391–392, N95, 492, 492f Risk diagnosis, 20t
391f, 392t Powered Air Purifying, 492, 492f Risk for aspiration, nursing care plan for,
Razors, 364 Respiratory rate, 197–198 679d
Reading ability, 104d measurement of, 218d–219d Risk for disuse syndrome, nursing care plan
Rebound effect, 787 Respiratory secretions for, 530–531
Receiving room, 624 liquefaction of, 845 Risk for inability to sustain spontaneous
Reciprocity, in licensure, 36 mobilization of, 845–847 ventilation, nursing care plan for, 867
Reconstitution, of parenteral medications, 798 suctioning of, 847 Risk for infection transmission, nursing care
Records. See Documentation; Medical records Respite care, 878 plan for, 498–499
Recovery index, 545 Rest, 387. See also Sleep Risk for injury, nursing care plan for, 427
Recovery position, in cardiopulmonary Restless legs syndrome, 398 Risk for peripheral neurovascular dysfunc-
resuscitation, 862 Restraints, 39–40, 423–426, 429f–433d tion, nursing care plan for,
Recovery room, 625 alternatives to, 425, 425f 574d–575d
Rectal assessment, 246–247 bed, 432 Risk management, 42
Rectal suppositories, 787 definition of, 423 Roentgenography, 258–260, 258t, 259f, 260f
insertion of, 740, 749d–750d documentation of, 425 Roller sheet, 522, 536d–537d
Rectal temperature, 188t, 189, 211d–212d. JCAHO standards for, 424, 425 Rolls
See also Temperature legal aspects of, 39–40, 424, 424d hand, 523, 523f
Rectal tube, insertion of, 747d–748d medical orders for, 425 trochanter, 523, 523f
Rectus femoris injections, 804, 806f mitt, 429, 430f Roman Catholicism, 78t
Red blood cells, 313 monitoring of, 425 Rooms. See Client rooms
Referral, 173–175 proper use of, 425, 425f, 429d–433d Rounds, documentation of, 123
Referred pain, 437, 437f protocol for, 425 Route of administration, 769–770, 770t
Reflex quick-release knots for, 431 Roy, Callista, 7t
gastrocolic, 736 wheelchair, 425, 425f, 429–431 Rubs, 243
voiding, 710 wrist, 429, 430f Russell’s traction, 571, 571f
Reflex incontinence, 709t Resuscitation, 421, 859–868, 861–866
Reflux, gastric, 665 algorithm for, 864t
Reframing, 70 cardiopulmonary, 421 S
Regeneration, in wound repair, 640 carotid artery assessment in, 863, 863f Safe sex, client teaching for, 248–249, 248f
Regional anesthesia, 616t, 625 chest compression in, 863, 863f, 864t Safety concerns, 415–433
Registered nurse, 8f, 9–11, 9t, 10f contacting emergency services in, 861 for adolescents, 416
Regurgitation, 301 defibrillation in, 863–865, 865f for adults, 416, 417t
Reimbursement definition of, 861 for burns, 417–419
documentation for, 111 discontinuation of, 866 for carbon monoxide poisoning, 420–421,
for home health care, 176 early, 861–863 421d
Medicare/Medicaid, 54–55, 55t. See also early advanced life support in, 865 for drowning, 421
Medicare/Medicaid fluid. See Intravenous infusion for electrical shock, 421–422
for nursing home care, 172–173 head tilt/chin lift in, 861, 862f for falls, 422–423
Relationship in infants and children, 864t for fires, 417–419
definition of, 92 jaw-thrust maneuver in, 861–862, 862f for infants, 416
nurse-client, 92–100 nursing care plan for, 867 for lifting clients, 519–520
Relative humidity, in client room, 388 nursing implications of, 866 for medications, 773d
Relaxation techniques, 69t, 398, 399d of older adults, 866–868 nursing implications of, 426
in pain management, 444–445, 444f rapid assessment in, 861 for older adults, 416, 417t, 422–423,
Release against medical advice, 39, 39f, 168 recovery in, 865 426–428
Religion, health beliefs and practices and, recovery position in, 862 for oxygen therapy, 473–474, 474d
78t–79t removable headboard for, 389, 389f for poisoning, 422–423
Remission, 53 rescue breathing in, 862–863, 864t for restraints, 423–426
Remodeling, in wound repair, 640 Resuscitation team, 861 for school-age children, 416
REM sleep, 391–392, 391f, 392t. See also Sleep Retching, 301 for smoke inhalation, 419–420
Repetitive strain injuries, 519 Retention catheter, 711–712, 711f for surgery, 624, 624d
Rescue breathing, 862–863, 864t insertion of for therapeutic exercise, 547d
Research, medical records in, 111 in female, 723d–728d for toddlers, 416
Reservoir, of infection, 137 in male, 729d–732d for transfusions, 329–330
Resident microorganisms, 139 irrigation of, 733d–735d Salem sump tube, 666t, 667f
Index 965
Saline enemas, 741, 741f Shoe covers, 143 nocturnal polysomnography in, 395, 396f
Saline lock, 329, 329f, 352d–354d, 817–818, Short-term goals, 22, 23b questionnaires in, 395
818d, 818f Shoulder exercises, range-of-motion, 554d sleep diary in, 395
Salt, dietary sources of, 292t, 319d Shoulder spica casts, 568–569, 568f Sleep cycles, 391–392, 392t
Same-day surgery, 615–616, 616t Shower, 361 Sleep deprivation, 391d
SASH mnemonic, 818 Side-lying position, 520, 521f Sleep diary, 395
Saturated fats, 290 Side rails, 389, 524, 524f Sleep disorders, 396–398
Scabies, 363t Sigmoid colostomy, 743f in depression, 394
Scales, 232, 233f Sigmoidoscopy, 260, 260d, 272d–274d hypersomnia, 397
Scalp, assessment of, 238 Signs and symptoms, 18 insomnia, 396–397
Scars, 238 Silence, in communication, 96–97 jet lag, 397
formation of, 640 Simple oxygen mask, 471–472 narcolepsy, 397
keloid, 79, 79f Sims’ position, 255, 256t, 521, 521f nursing care plan for, 401d–402d
Science Sitting posture, 518, 518f parasomnias, 398
definition of, 6 Sitz bath, 361t, 650, 660d–663d seasonal affective disorder, 397–398
nursing as, 6 Skeletal traction, 571, 572f in shift workers, 397
Scoliosis, 240, 241f Skilled nursing facilities, 172–173 sleep apnea/hypopnea syndrome, 397
Scoop method, 797, 798f Skin. See also under Cutaneous sleep-wake cycle disturbances, 397–398
Scored tablets, 769 assessment of, 238 Sleep paralysis, 397
Screening. See Diagnostic examinations and cultural aspects of, 78–79, 79f, 80f Sleep rituals, 394
tests color variations in, 238 Sleep-wake cycle disturbances, 397–398
Scrub suits, 141 disorders of, 363t Sleep walking, 398
Seasonal affective disorder, 397–398, 398d excoriation of, 742 Slider sheet, 522, 536d–537d
Seat carry, 419f lesions of, 238, 239t Slings, 566, 566f, 576d–579d
Secondary care, 54 structure and function of, 358–359, 359f Slow wave sleep, 391
Secondary illness, 52–53 Skin cancer, 363t Smelling acuity, assessment of, 237
Secondary infusion, 819, 819f, 828d–830d Skin care. See also Wound management Smoke inhalation, 419–420
Secondary prevention, 68 after cast removal, 570 Snellen eye charts, 234–235, 234f
Second-intention healing, 640, 640f peristomal, 715, 742 Soaks, 649–650
Secretions pin site, 572, 581d–583d Soap, 139t
liquefaction of, 845 Skin color, assessment of, 238 SOAP charting, 113, 114t
mobilization of, 845–847 Skin patches, medicated, 785–786, 786f Soap solution enemas, 741, 741f
suctioning of, 847, 852d–854d Skin preparation, preoperative, 621, Social interaction, for clients in isolation,
Sedation 633d–635d 496, 497d
conscious, 260 Skin tears, in pressure ulcers, 651 Social Readjustment Rating Scale, 68, 68b
sleep and, 394, 593t Skin traction, 571, 571f Social space, 98, 99t
Self-care theory, 7t Skin turgor, 240 Sodium
Self-examination assessment of, 318, 318f dietary, 292t, 319d
breast, 241, 241d, 242f Sleep, 391–398 serum, 312, 313t
testicular, 246, 247f activity and, 393, 393t Sodium phosphate enemas, 741, 741t, 742d
Selye’s general adaptation syndrome, 65 alcohol and, 394 Sodium-potassium pump, 314
Sengstaken-Blakemore tube, 666t caffeine and, 394 Soiled supplies, handling of, 143
Sensory assessment, for skin, 245, 245d circadian rhythms and, 392–393, 393f Solutions
Sensory deficits, client teaching and, 104, 104d in depression, 394 intravenous. See also Intravenous
Sensory manipulation, in stress manage- emotions and, 394 infusion
ment, 69 environmental factors in, 393–394, 393t colloid, 313–314, 320
Sensory stimulation, for clients in isolation, factors affecting, 393–394, 393t crystalloid, 320
496, 497d food and drink and, 394 hypertonic, 320t, 321, 321f
Sepsis, pressure ulcers and, 651 functions of, 391 hypotonic, 320t, 321, 321f
Sequelae, 52 in illness, 394 isotonic, 320–321, 320t, 321f
Serous drainage, from pressure ulcers, 651 light and, 392–393, 393f preparation of, 339d–343d
Set point, temperature, 186 medications and, 394, 395t selection of, 322
Seventh Day Adventists, 78t mood and, 394 sterile, 146, 159d
Sexual behavior, client teaching for, 248–249, motivation and, 394 Somatic pain, 436
248f non-REM, 391–392, 391f, 392t Somnambulism, 398
Shaman, 81–82 nursing implications of, 398 Sonograms, 261
Shampooing, 367, 385d–386d in older adults, 392, 393f, 399–400 Sordes, 366
Sharp débridement, 646 paradoxical, 391 Sore throat, in tube feeding, 677t
Shaving, 364, 365f phases of, 391, 391f Source-oriented records, 112. See also Med-
Shearing forces, 526, 652 promotion of, 396, 398–399 ical records
Sheet. See also Bed(s); Linens REM, 391–392, 391f, 392t Space, personal, 98–99, 99t
roller (slider), 522, 536d–537d requirements for, 392, 392t Spacer, 788, 789f
Shell temperature, 185 resistance to, 394 Spasms, 516
Shift workers, sleep disorders in, 397 slow wave, 391 Specimen collection, 496
Shock Sleep apnea/hypopnea syndrome, 397 for Pap test, 257–258, 258t, 269d–272d
electrical, 421–422 Sleep assessment, 394–396 sputum, 846d
postoperative, 627t multiple sleep latency test in, 396 stool, 737
966 Index
Specimen collection (contd.) Stoma care. See also Ostomy care anesthesia for, 615, 616t, 624–625
for throat culture, 262–264, 265d, 265f for colostomy/ileostomy, 742 client preparation for, 621–624
urine, 705–706, 706d for urostomy, 715 complications of, 619, 619t
Speculum Stomach gas, 302, 302d cosmetic, 615t
tympanic, 213 evaluation of, 666–668, 666t, 670, 670f curative, 615t
vaginal, 269 Stool, 736, 737. See also Bowel elimination diagnostic, 615t
Sphincters, anal, 736 characteristics of, 738t elective, 615t
Sphygmomanometer, 200–201, 200f, 201t, impacted, 738–739, 739d, 739f emergency, 615t
220d–223d occult blood in, 738d error prevention for, 624d
Spica casts, 568–569, 568f Straight catheter, 711, 711f exploratory, 615t
Spider diagrams, 25, 26f Strength, 584 inpatient, 614–615
Spinal tap, 262, 264d, 264f assessment of, 244, 244f intraoperative period in, 624–625
Spine Stress, 64–70 laser, 615–616
assessment of, 240, 240f adaptation to, 65–66, 65f nursing implications of, 627–628
curvature of, 240, 241f assessment of, 68, 68b in older adults, 628–630
Spirometry, incentive, 464, 464d causes of, 61t, 68b, 69b operating room in, 624
Splinting, for coughing, 620, 620d, 620f coping mechanisms for, 66, 67t optional, 615t
Splints, 564–566, 564f–566f definition of, 64 outpatient, 615–616, 616t
cervical collar, 565–566, 565f, 566f in hospitalization, 68, 69b palliative, 615t
commercial, 564–566 management of, 68–70 postanesthesia care unit in, 625
emergency, 564 nursing implications of, 67–70 postoperative period in, 625–628, 628d
foot, 523 physical disorders due to, 67, 67b atelectasis in, 620
immobilizer, 564–565, 565f physiologic response to, 65–66, 65f, 66t complications in, 626, 627t
inflatable, 564, 564f prevention of, 68 continuing care in, 626
molded, 565, 565f psychological response to, 66–67, 67t discharge instructions in, 626–627
Thomas, 564, 565f reduction of, 68 food and fluids in, 626
traction, 564, 565f risk factors for, 68, 68b immediate care in, 625–626
Sponge bath, 361t signs and symptoms of, 64 initial assessment in, 626
Spores, 136 Stress electrocardiogram, 544, 544f nursing implications of, 627–628, 628d
Sputum, 845 Stress incontinence, 709t pneumonia in, 620
Stains, Gram, 263 Stress-related disorders, 67–68, 67b room preparation in, 626
Standardized care plans, 23 Stridor, 198 thrombosis in, 620–621, 622, 626,
Standard precautions, 489, 490d Stylets, 665–666, 672f 631d–637d
Standards of care, 17d, 23, 41f Subcultures, 73, 74t venous circulation in, 626
Standing assist devices, 528, 529f Subcutaneous injections, 800–803, 800f, wound management in, 626
Standing posture, 518, 518f 812d–183d preoperative period in, 614–625
Staples, 644, 644f administration of, 801, 812d–813d blood donation in, 618, 618t
Starch, dietary, 290 equipment for, 801, 802f care of valuables in, 622
Stare decisis, 37 of heparin, 803 checklist for, 623–624, 623f
Starling’s law, 198 of insulin, 801–803, 802f, 803d client preparation in, 621–624
Stasis, urinary, 707 sites of, 800, 801f client teaching in, 619–621
State boards of nursing, 35–36 Subcutaneous layer, 359, 359f clothing and hygiene in, 622
Static air mattresses, 525, 526t Subdiaphragmatic thrusts, 860, 861, 861f fluid intake in, 622
Statute of limitations, 42 Subjective data, 18, 18d leg exercise teaching in, 620–621
Statutory law, 35, 35t Sublingual drug administration, 787 medications in, 622
Steam sterilization, 145 Substance P, 435–436 nursing assessment in, 618–619, 619t
Stents, in transtracheal oxygen therapy, 473 Substituted judgment, 617 nutrition in, 622
Stepdown units, transfer to, 170–171 Suctioning oral care in, 622
Step test, 545, 545t oropharyngeal, 847, 847f, 847t skin preparation in, 621, 633d–635d
Stereotypes, 72 procedure for, 852d–854d psychosocial preparation for, 622
Sterile field, 146, 157d–160d of tracheostomy, 849, 849f reasons for, 615t
Sterile technique, 144, 157d–162d Suffering, 435. See also Pain receiving room in, 624
Sterilization, 144–145 Sugar. See also Glucose recovery room in, 625
Steri-Strips, 644 dietary, 290, 290d required, 615t
Stertorous breathing, 198 Sump tubes, 665, 666t, 667f risk assessment for, 619, 619t
Stethoscope Sundown syndrome, 400, 400d thrombosis after, prevention of, 620–621,
in blood pressure measurement, 201–202, Sunrise syndrome, 400, 400d 626, 627t
202f, 203–204, 204f Supine position, 520, 521f urgency of, 615t
for body sounds, 231, 231f Suppositories urgent, 615t
for bowel sounds, 246, 246d rectal, 787 waiting area for, 625
for heart sounds, 241, 242f insertion of, 740, 749d–750d Surgical asepsis, 144–147
for Korotkoff sounds, 202–203, 203f vaginal, 787, 788d Surgical scrub, 140–141, 141t, 153d–155d
for lung sounds, 241–243, 242f, 244f Surfactant Surgical waiting area, 625
Stimulants, sleep and, 394, 395t pulmonary, 474 Susceptible, 138, 138t
Stockings, antiembolism, 621, 622, for skin, 362 Sustained-release capsules, 770
631d–632d Surgery Sutures, 644, 644f
Stock supply, 771 ambulatory, 615, 616t Swing-through gait, 590t
Index 967
Sympathetic nervous system, 62–63, 63f, 63t regulation of, 185, 185t, 186, 186f Thrombocytes, 313
Sympathy, 15 set point for, 186 Thrombosis. See also Embolism
Symptoms, 18 shell, 185 in intravenous infusion, 327, 328t
Syndrome diagnosis, 20t tympanic, 188, 188f, 213d–215d postoperative, prevention of, 620–621,
Syringes, 796, 797f, 797t Temperature translation, 213 622, 626, 631d–637d
insulin, 802, 802f TENS (transcutaneous electrical nerve stim- Through-the-needle catheter, 325f, 326
needles for, 797, 797t. See also Needle(s) ulation), 445d Thumb, range-of-motion exercises for, 557d
size of, 796, 797t Terminal disinfection, 144 Tilt tables, 585–586, 585f
tuberculin, 800, 801f Terminal illness, 52, 876–888. See also End- Time, in documentation, 117, 119f
Systolic pressure, 199, 199f of-life issues Time perception, cultural aspects of, 77
Tertiary care, 54 Tinea infections, 363t
Tertiary prevention, 68 Tip, of syringe, 796, 797f
T Testicular self-examination, 246, 247d, 247f a-Tocopherol, 293t
Table, overbed, 390 Tests. See Diagnostic examinations and tests Toddlers, safety concerns for, 416
Tablets Thalamus, in pain transmission, 436 Toenails. See Nail(s)
enteric-coated, 770 Theory Toes. See also Foot
scored, 769 definition of, 6 range-of-motion exercises for, 560d
Tachycardia, 194 nursing, 6, 7t Tone, muscle, 584
Tachypnea, 197–198 Therapeutic baths, 650. See also Tooth. See Teeth
Tamponade, gastric, 665 Baths/bathing Topical medications, 784–787. See also
Tapotement, 399t Therapeutic exercise, 547–562. See also Medication(s)
Tap water enemas, 741, 741f Exercise buccal, 787
Target heart rate, 546 Therapeutic relationship, 94–95. See also cutaneous, 784–786
Tartar, 361 Nurse-client relationship inunction, 784–785
Task-oriented touch, 99 communication in, 95–100 nasal, 787, 794d–795d
Taste, assessment of, 237–238, 238f Thermal burns, 417–419 nursing implications of, 789
Team conferences, documentation of, 123 airway, 419–420 for older adults, 789–790
Team nursing, 58 Thermal therapy ophthalmic, 786, 787f, 792d–793d
Teeth, 360–361 aquathermia pads in, 649, 649f otic, 786–787
care of, 365–366, 366f baths in, 650 paste, 786, 786d, 786f
decay of, 361 chemical packs in, 648 rectal, 787
eruption of, 360–361 client teaching for, 649d skin patches for, 785–786, 786f
grinding of, 398 common uses for, 648d sublingual, 787
structure of, 360, 360f compresses in, 648 transdermal, 785–786, 786f
Telenursing, 36 guidelines for, 647–648 types of, 785t
Teleology, 44–45 ice bags/collars in, 648 Torts, 37–41
Telephone conversations, documentation of, moist packs in, 649–650 intentional, 37–40
123 for pain, 445 unintentional, 40–41
Telephone orders, 770, 770d soaks in, 649–650 Total incontinence, 709t
Temperature, 185–194 temperature ranges for, 649t Total parenteral nutrition, 331–333, 332d,
axillary, 188t, 189, 212d–213d in wound management, 647–650, 648d, 332f, 333f
centigrade, 186 649f Total quality improvement, 12, 111
circadian rhythms and, 187 Thermistor catheter, 188 Touch
in client room, 388 Thermogenesis, 186, 186f, 187 affective, 99, 99f
climate and, 187 Thermokinetics, 185 assessment of, 245, 245d
conversion formulas for, 186, 186d Thermometers, 189–192, 209d–215d in communication, 99
core, 185 chemical, 190–191, 190f, 191f cultural aspects of, 76–77
elevated, 186, 192–194, 193f. See also clinical, 189 task-oriented, 99
Fever; Hyperthermia digital, 190t, 191–192, 192f Tourniquet, for venipuncture, 325, 327d,
emotions and, 187 disinfection of, 493 327f
exercise and activity and, 187 disposable, 493 Towel bath, 362, 364d, 364f
factors affecting, 186–187 electronic, 189, 190t, 191f, 209d–213d T-piece, 471t, 472
Fahrenheit, 185–186 glass, 189–190, 190t Tracheal cartilage, 845
food intake and, 186–187 oral, 188, 188t Tracheostomy, 855d–858d
gender and, 187 rectal, 188t, 189 rescue breathing with, 862–863
low, 186, 194 tympanic, 188, 213d–215d Tracheostomy collar, 471t, 472
measurement of, 187–192 Thermoregulation, 388 Traction, 570–572, 572d
automated monitoring devices for, 192, Thiamine, 292t Buck’s, 571, 571f
192f Third-intention healing, 640, 640f manual, 570–571, 571f
procedure for, 209d–215d Third-party payment nursing guidelines for, 572, 573d
sites for, 187–188 documentation for, 111 Russell’s, 571, 571f
thermometers for, 189–192, 190t, 191f Medicare/Medicaid, 55 skeletal, 571, 572f
medication effects on, 187 Third-spacing, 319 skin, 571, 571f
metabolic rate and, 187 Thomas splint, 564, 565f Traction splints, 564, 565f
normal, 186 Three-point gait, 590t Trade names, 769
oral, 188, 188f, 209d–211d Throat culture, 262–264, 265d, 265f Traditional vs. military time, in documenta-
rectal, 188t, 189, 211d–212d Throat soreness, in tube feeding, 677t tion, 117, 119f
968 Index
Training effect, on pulse, 195 Tube(s) Uniforms, 141

Tranquilizers, sleep and, 394, 395t gastrointestinal, 664–695. See also Gas- Unilateral neglect, 550d, 551
Transabdominal tubes, 666t, 667, 668f, trointestinal intubation Unit conversion
672–677. See also Gastrointestinal decompression, 666–667, 666t, 670, for temperature, 186, 186d
intubation; Tube feeding 670f, 678 for traditional vs. military time, 119t
Transcultural nursing, 74–82. See also under feeding, 672–677, 682d–685d. See also Unit dose supply, 771, 773f
Cultural; Culture Tube feeding Units of measure, for drug dose, 769
assessment in, 74–77 nasogastric, 664, 665f, 665t, 672–677, Universal precautions, 489
Transcutaneous electrical nerve stimulation, 674t, 682d–685d Unlicensed assistive personnel, 56
445d, 454d–457d nasointestinal, 665–666, 666t Upper arm strengthening exercises, 585,
Transdermal medications, 785–786 lumen of, 665 585f
Transducer, 261 stylets for, 665–666, 672f Ureterostomy, 714–715, 715f
Trans fats, 290, 291 sump, 665, 666t, 667f Urge incontinence, 709t
Transfer, 170–173 tracheostomy, 848, 849f Urgency, urinary, 707
bed-to-chair, 538–539 Tube feeding, 671–678 Urinal, 707–708, 708f
definition of, 170 administration of, 690d–695d Urinary bag, 711, 711f
documentation of, 171, 171d, 172f aspiration in, 677t, 679d Urinary catheters, 709–714
to extended care facility, 171–173 benefits and risks of, 672–674 closed drainage systems for, 712, 712f
guidelines for, 171d bolus, 675 condom, 711, 711f, 721d–723d
of older adults, 171–173 client assessment in, 675 external, 710–711
to stepdown unit, 170–171 common problems in, 677t hygiene for, 712, 713d
Transfer belt, 527, 528f, 538d–539d continuous, 675 retention (Foley), 711–714, 711f
Transfer board, 528, 528f, 539d–540d cyclic, 675 insertion of, 712, 723d–732d
Transfer devices, 526–529, 529f, dumping syndrome in, 673–674, 677t irrigation of, 712–714, 714f, 733d–735d
537d–542d formulas for, 674–675, 674t removal of, 714
Transfer handle, 527, 528f gastric residual in, 675, 675d specimen collection from, 706, 706f
Transfer summary, 171, 172f in home care, 677 straight, 711, 711f
Transfusion(s), 330–331 hydration in, 676 three-way, 714f
administration of, 355d–357d intermittent, 675 U-bag for, 711, 711f
autologous, 618, 618t leaks in, 672d Urinary diversion, 714–715, 715f
blood products for, 321, 321t medication administration and, 774, Urinary elimination, 704–735. See also Fluid
collection and storage of, 329 781d–783d output
preoperative donation of, 618, 618t nursing guidelines for, 673d abnormal, 707
blood substitutes for, 321–322 nursing management in, 676 anatomic aspects of, 705f
directed donation for, 618, 618t in older adults, 680 anuria and, 707
equipment for, 330–331, 330f schedule for, 675 assisting with, 707–708
hepatitis C transmission via, 329 tube insertion in, 682d–685d bedpans for, 708, 708f, 719d–720d
plasma expanders for, 322 tube irrigation in, 686d–687d commode for, 707, 708f
prion transmission via, 329–330 tube obstruction in, 676, 676d, 677t definition of, 704
safety measures for, 329–330 tube removal in, 688d–689d in dying client, 880
Transfusion reactions, 331, 331t tube selection for, 674t dysuria and, 707
Transient microorganisms, 139 Tuberculin syringe, 800, 801f with hip spica casts, 568f, 569
Transitional care units, transfer to, 170–171 Tuberculosis, particulate filter respirators nocturia and, 707
Transmission-based precautions, 490–492, for, 141–142, 142d, 142f nursing implications of, 715
491t Tubing in older adults, 715–717
psychological implications of, 496 for intravenous infusions. See Intravenous oliguria and, 707
Transparent dressings, 642, 642f infusion, tubing for overview of, 704–705
Transplantation, organ procurement for, for transfusions, 330–331, 330f polyuria and, 707
882, 883f Tunneled catheters, 820, 820f preoperative, 622
Transport, client Turbo-inhaler, 788 urinal for, 707–708, 708f
assistive devices for, 519–520, 520d Turgor, 240 Urinary frequency, 707
infection control aspects of, 496 assessment of, 318, 318f Urinary incontinence, 707
Transportation, post-discharge, 170 Turning methods, 523, 523f, 533d–537d continence training for, 708–709, 710d
Transtracheal oxygen, 473, 473f 24-hour urine specimen, 706 functional, 709t
Transverse colostomy, 743f Two-point gait, 590t management of, 708–709
Trapeze, 524, 524f Tympanic temperature, 188, 188f, in nocturnal enuresis, 398
Trauma, 638. See also Wound(s) 213d–215d. See also Temperature nursing care plan for, 716–717
Treatment overflow, 709t
refusal of, 39, 39f reflex, 709t
withholding/withdrawal of, 47–49, 48d, U stress, 709t
48f, 866 U-bag, 711, 711f total, 709t
Trendelenburg position, 522, 522f Ulceration, 639t. See also Pressure ulcers; urge, 709t, 716–717
Triangular slings, 578d–579d Wound(s) Urinary retention, 707
Triceps skinfold thickness, 298–299, 298f, Ultrasonography, 261 postoperative, 627t
299t Doppler, in pulse assessment, 197, 197f Urinary stasis, 707
Trochanter rolls, 523, 523f Unconscious client, oral care for, 362, Urinary system, anatomy of, 705f
Tryptophan, hypnotic effect of, 394 383d–385d Urinary urgency, 707
Index 969
Urine Vision assessment, 234–236 Wellness, 51–52. See also Health

characteristics of, 705t Vision impairment definition of, 51
abnormal, 706–707 client teaching and, 104, 104d health-seeking behaviors and, 248–249
clarity of, 705t feeding in, 303 hierarchy of needs and, 52
color of, 705t Visual accommodation, 235, 235f holism and, 51–52
odor of, 705t Visual acuity testing, 234–235 Wellness diagnosis, 20t
residual, 707 Visual field examination, 235–236 Wheals, 239t
volume of, 705t Vital signs, 184–228 Wheelchairs
Urine collection. See also Urine specimens automated monitoring devices for, 192, 192f positioning in, 426t, 430f
for intake-output assessment, 317, 317f, blood pressure, 198–205 pressure ulcers and, 650–651, 650f
318f definition of, 185 restraints for, 429d–431d. See also
Urine drainage systems documentation of, 205, 206f Restraints
closed, 712, 712f in fitness assessment, 544 Wheezes, 243
irrigation of, 713 measurement of, 185d Whiplash, cervical collar for, 565–566, 565f,
irrigation of, 713 nursing implications of, 205 566f
open, 713 in older adults, 205–208 Whirlpool bath, 361t
Urine specimens, 705–706 pain, 438 Whistle-blowing, 49
catheter, 706, 706f pulse, 194–197, 216d–217d White blood cells, 313
clean-catch, 705–706, 706d respiratory rate, 197–198, 218d–219d in inflammation, 639
24-hour, 706 temperature, 185–194 White-coat hypertension, 204
voided, 705 Vitamins, 291–293, 292t–293 Wong-Baker FACES scale, 439, 440f
Urostomy, 714–715, 715f. See also Ostomy megadoses of, 291 World Health Organization analgesic ladder,
care Vitiligo, 79, 79f 440–441, 441f
Utility rooms, in infection control, 143 Vocational nursing, 7–9, 8f, 9t, 10f. See also Wound(s), 638–663
Nursing closed, 639t
Voice test, 236, 236t, 237f definition of, 638
V Voided specimen, 705 nursing implications of, 651
Vaginal irrigation (douche), 647, 648d Voiding reflex, 710 in older adults, 651–652
Vaginal medications, 787, 788d Volume-control set, 819, 819f, 830d–833d open, 638, 639t
Vaginal speculum, 269 Volume deficit, 318 pressure-related, 650–651. See also Pres-
Valsalva maneuver, 736 nursing care plan for, 334d–335d sure ulcers
Values, 46. See also Ethical issues Volume equivalents, for common containers, types of, 639t
definition of, 50 317 Wound dehiscence, 641, 641f
health, 50–51 Volume excess, 319 postoperative, 627t
Vastus lateralis injections, 804, 805f from intravenous infusion, 327, 328t Wound drainage, 643–644, 643f
Vegan diet, 297 Volumetric controllers, 324–325 Wound evisceration, 627t, 641, 641f
Vegetarian diet, 289, 290f, 296–297 Vomiting, 300–301, 301–302, 301d Wound healing, 640–641
Venipuncture, 325–326, 326d, 326f, 327d, projectile, 301 complications of, 641
327f in tube feeding, 677t stages of, 640, 640f, 641f
complications of, 327–328, 328t Wound infection, postoperative, 627t
devices for, 325, 325f Wound management, 641–650
insertion of, 325, 344d–346d W binders in, 646
site care in, 328t Waiting for permission phenomenon, 881 débridement in, 646–647
technique of, 325, 343d–347d Walk-a-mile test, 545, 546t drains in, 643–644, 643f
vein distention for, 325, 327d, 343d–344d Walkers, 588, 588f dressings in, 642–643
Ventilation. See also Breathing; Oxygenation; measuring for, 598d irrigation in, 658d–660d
Respiration Walking belt, 586, 587f postoperative, 626
abnormal, 198 War, nursing in, 4, 5 thermal therapy in, 647–650, 648d, 649f
anatomy and physiology of, 458–459, 459f Waste disposal, 143, 495–496, 495f Wound repair, 639–640, 649f
in client room, 388 of biodegradable items, 495 Wrist, range-of-motion exercises for,
definition of, 197, 458 double-bagging in, 495, 495f 555d–556d
respiration and, 458 Water. See also under Fluid Wrist restraints, 429, 430f. See also
Ventrogluteal injection, 804, 805f body stores of, 312 Restraints
Venturi mask, 470t, 472 Water mattresses, 525, 526t
Veracity, 46 Water-seal chest tube drainage, 474, 474f,
Verbal medication orders, 770 483d–487d X
Vertebra, 240 Water-soluble vitamins, 291 X-ray studies, 258–260, 258t, 259f, 260f
Vesicles, 239t Water sterilization, 145
Vials, 798–799, 798f, 799d Weber test, 236, 237f
Vibration Weight Y
in chest physiotherapy, 847 body mass index and, 298, 298d Yin/Yang theory, 77
in massage, 399t measurement of, 232, 232d, 233f, 297–298 Yoga, 69t
Vinyl gloves, 142, 143d, 143f in nutritional assessment, 297–298, 298d,
Viral load, 139 298f, 299t
Virulence, 135 Weight loss Z
Viruses, 135 strategies for, 299, 300d Zinc, dietary, 292t
Visceral pain, 437 in tube feeding, 677t Z-track injection, 805

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Fundamental Nursing

Skills and Concepts

Barbara Kuhn Timby, RN, BC, BSN, MA

Copyright  2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Library of Congress Cataloging-in-Publication Data

Timby, Barbara Kuhn.

Contributors Muriel Greene, BSN, Med

Reviewers Dionne Jackson, LVN Sherri Smith, RN

Sally Flesch, PhD Deborah W. Potter, RN, MSN

Section I • Fundamental Nursing Concepts Common Law 37

Stress 64 Types of Client Records 112

Notifying the Business Office 169 Extremities 244

Intravenous Fluid Administration 320 Sleep Requirements 392

21 OXYGENATION 458 Cradle 525

UNIT 7 THE SURGICAL CLIENT 613 Benefits and Risks 672

Measures to Promote Bowel Drug Preparation 798

BOX 1-1 ● Rules of Employment for

THE NIGHTINGALE REFORMATION

In the midst of deplorable health care conditions, Florence

The Crimean War

Nightingale’s Contributions 1862, Dix followed Nightingale’s advice and established

Stop • Think + Respond BOX 1-1

TABLE 1-1 DIFFERENCES IN NIGHTINGALE SCHOOLS AND U.S. TRAINING SCHOOLS

moved into communities and established “settlement

Other definitions have been offered by nurses recog-

To clarify for the public, and nurses themselves, what

TABLE 1-2 NURSING THEORIES AND APPLICATIONS

Florence Nightingale Environmental Theory

TABLE 1-3 LEVELS OF RESPONSIBILITIES FOR THE NURSING PROCESS*

among all registered nurse programs. Despite the con-

BOX 1-2 ● Rationales for Acquiring

TABLE 1-4 TRENDS IN HEALTH CARE AND NURSING

UNIQUE NURSING SKILLS Caring Skills

Increasingly, however, the nurse’s role is expanding to

The nursing process has seven distinct characteristics:

DATA BASE ASSESSMENT. A data base assessment (initial

TABLE 2-1 COMPARISON OF DATA BASE AND FOCUS ASSESSMENTS

Obtained on admission Compiled throughout subsequent care

Diagnosis TABLE 2-2

BOX 2-4 ● Parts of a Nursing Diagnostic Statement

The third step in the nursing process is planning, or the

TABLE 2-3 CORRELATION OF COLLABORATIVE PROBLEMS

Myocardial infarction (heart attack) Abnormal heart rhythm PC: Dysrhythmias

BOX 2-6 ● Components of Short-Term Goals

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

DATE PROBLEM GOAL TARGET DATE NURSING ORDERS

FIGURE 2-4 • Sample nursing care plan.

charting (see Chap. 9) reflects the written plan. Nurses

both nurse and client can speculate on what activities

Dietitian USE OF THE NURSING PROCESS

TABLE 2-5 OUTCOMES FROM EVALUATION

NURSING GUIDELINES 2-1

2. According to most nurse practice acts, if a charge nurse

End of Unit Exercises

SECTION I: REVIEWING WHAT YOU’VE LEARNED

Activity B: Mark each statement as either T (True) or F (False). Correct any

Activity C: Write the correct term for each description below.

Activity F: The nursing process is an organized sequence of problem-solving steps used

Activity G: Answer the following questions.

2. How did Virginia Henderson define nursing?

I, _________________, the undersigned “principal”, presently residing at _, __,