RN Fundamentals of Nursing

Unlawful to replicate or distributeCopyright © 2006, The College Network, Inc. All rights reserved FNX 070106 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, inclusion in any information storage and retrieval system, or otherwise, without prior written permission of The College Network, Inc. Unlawful to replicate or distribute About the Authors BOBBIE BERKOWITZ, PHD, RN, CNAA, FAAN, is a professor and the chair of the University of Washington School of Nursing, Department of Psychosocial and Community Health. She is also the director of the Turning Point National Program office. Dr. Berkowitz received her master’s degree from the University of Washington and her PhD in Nursing Science with Executive Focus from Case Western Reserve University. She is on the board of directors for the Public Health Foundation and PROWest. She is a consultant for the University of Nebraska Medical Center College of Nursing and a reviewer for Prentice Hall Health and the Health Career Awards Program, Social Sciences and Humanities Research Council of Canada. Dr. Berkowitz’s recent publications have appeared in Washington Public Health and the Journal of Public Health Management and Practice. She has a chapter in the book Public Health Informatics and Information Systems: A Contributed Work and wrote Using Informatics Systems to Build Capacity: A Public Health Improvement Toolbox. SHARON FISH MOONEY, RN, MSN, PHD, is an affiliate faculty member for distance nursing education at Regis University in Denver, Colorado, and Indiana Wesleyan University in Marion, Indiana. She teaches nursing courses in research and gerontology. She has worked as a research nurse with the University of Colorado Health Sciences Center, Center on Aging Research, and as an adjunct faculty member for parish nursing at McMaster Divinity College in Hamilton, Ontario, Canada. Dr. Mooney received her BSN from Alfred University and her MSN and Ph.D. from the University of Rochester. She has coauthored both Spiritual Care: The Nurse’s Role and “Instruments to Measure Aspects of Spirituality” in Instruments for Clinical Health-Care Research and is the author of two books, Alzheimer’s: Caring for Your Loved One, Caring for Yourself, and Quiet Moments for Nurses. Recent articles on developing a “ministry of memory” for persons with dementia are published in the Journal of Christian Nursing and the Journal of Long-Term Home Health Care. She is a contributing author for the Christian Research Journal on issues related to worldviews and alternative and complementary therapies. She teaches workshops and is a conference speaker on aging and spirituality, alternative health care modalities, parish nursing, and philosophical and theoretical frameworks of nursing. MARIANNE FRASER, MSN, teaches community health nursing as an assistant professor (clinical) at the University of Utah’s College of Nursing. She currently holds bachelor’s level clinical certification in community health from the American Nurses Association and is a member of Sigma Theta Tau International Nursing Honor Society. She received her bachelor’s degree in nursing in 1972 from the University of Utah and her master’s degree from the University of Washington in 1977. She has also served as an assistant professor of community health at the University of Arizona. Her past publications include “The Development of an Educational Support Group for Families of Children with Seizure Disorders” in Epilepsia, studies on coal miners in Utah Historical Quarterly Unlawful to replicate or distribute and Utah History, and “Community Health Nursing: A Specialty Area for the 21st Century” in Excellence. Marianne Fraser has served as a regional patient education coordinator for the VA Hospital System, a project coordinator for the Merck Drug Research Project, and a data collector for the Robert Wood Johnson National Rehabilitation Alternatives Study. She has also worked as a weekend case manager for IHC-LDS Hospital in Salt Lake City, Utah. PATRICIA A. JAMERSON, PHD, RNC, has served as an assistant professor at the University of Missouri-St. Louis College of Nursing. She received her BSN from the University of Illinois and her MSN from St. Louis University. She earned her doctorate in nursing in 1998 from the University of Kansas. She was awarded a Jean Johnson Research Award in 1996 and is a member of AWHONN, Sigma Theta Tau, and the Midwest Nursing Research Society. Jamerson also has NCC certification in neonatal intensive care nursing. Jamerson has published articles in journals and contributed chapters to numerous nursing textbooks, including Fundamentals of Nursing and Nursing Care of Infants and Children. She is a coauthor of (among other titles) Nursing Leadership and Management in Action. MARY ANN LAVIN, SCD, is an associate professor at Saint Louis University School of Nursing in Saint Louis, Missouri. She received her post-master’s ANP from Saint Louis University School of Nursing. She currently holds ANP recognition and an RN license from the Missouri State Board of Nursing. Previously, she served as an adult nurse practitioner for the HOPE Consortium (Rural Health Outreach Demonstration Program) in Washington County, Missouri, and a research associate at Washington University School of Medicine in Saint Louis. She has also been an assistant professor at Catholic University of Quito, Ecuador, and a community health nurse in La Paz, Bolivia. Her published work includes “Advanced Practice and the Use of Nursing Diagnoses in Rantz, M. and LeMone” in Classification of Nursing Diagnoses: Proceedings of the 13th Conference of NANDA, and she is the primary author of “Interdisciplinary Health Professional Education: A Historical Review” in Advances in Health Sciences Education. Other publications include work in Journal of Allied Health and American Journal of Maternal-Child Nursing and the prologue to the third edition of Diagnosticos Enfermeros. Dr. Lavin is currently working as Principal Investigator on the Community and University Partnership in Promoting Health and Health Profession Education as part of a $25,000 award from the Group Health Foundation. Unlawful to replicate or distribute TABLE OF CONTENTS UNIT I: THEORY AND FOUNDATIONS CHAPTER 1: THE NURSING PROCESS CHAPTER 2: PRINCIPLES OF TEACHING AND LEARNING CHAPTER 3: THEORETICAL MODELS OF HEALTH, WELLNESS, AND ILLNESS CHAPTER 4: THE LAW AND NURSE AND PATIENT RIGHTS AND RESPONSIBILITIES UNIT II: PRINCIPLES OF BASIC CARE AND COMFORT CHAPTER 5: PAIN AND PAIN MANAGEMENT CHAPTER 6: REST AND SLEEP CHAPTER 7: CARING FOR PATIENTS WITH CANCER UNIT III: PRINCIPLES OF NUTRITION CHAPTER 8: CONCEPTS AND COMPONENTS OF NUTRITION CHAPTER 9: COMMON NUTRITIONAL DISTURBANCES CHAPTER 10: ASSESSMENT OF AND DIAGNOSTIC TESTS FOR NUTRITIONAL HEALTH CHAPTER 11: INTERVENTIONS FOR PROMOTING, MAINTAINING, AND RESTORING NUTRITIONAL HEALTH CHAPTER 12: APPLYING THE NURSING PROCESS TO MEET BASIC NUTRITIONAL NEEDS UNIT IV: SAFETY AND INFECTION CONTROL CHAPTER 13: THEORETICAL FRAMEWORKS USED AS THE BASIS OF CARE TO ENSURE ENVIRONMENTAL SAFETY CHAPTER 14: THE NURSING PROCESS RELATED TO INJURY PREVENTION CHAPTER 15: THEORETICAL FRAMEWORKS UNDERLYING PRINCIPLES OF BIOLOGICAL SAFETY CHAPTER 16: THE NURSING PROCESS AND BIOLOGICAL SAFETY REFERENCES Unlawful to replicate or distribute Pediatric Text Icons Take note of the special pediatric information throughout the series. Pediatric patients often have different symptoms, require different diagnostic exams, and have different needs than adult patients. Throughout the books, the pediatric symbol (pictured below) will indicate new information that applies only to pediatric patients. You will be expected to know how nursing care treatments differ across age groups on the NCLEX® examination. Be sure to note these special pediatric sections as you study. Please note that when the icon is found adjacent to a chapter title, it means that all of the information in the chapter pertains to the pediatric population. Similarly, when the icon is found adjacent to the title of a specific section within a chapter, it applies to all (or most) of the content in that section. Pediatric Symbol Unlawful to replicate or distribute UNIT I: THEORY AND FOUNDATIONS Chapter 1: The Nursing Process Objectives Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Describe the nursing process and its specific components or steps. Describe the various types of nursing assessments. Differentiate between primary, secondary, baseline, subjective, and objective data. Explain the subject matter of a nursing diagnosis and its various components. Explain the ANA standards for nursing outcomes. Discuss the attributes of a nursing plan of care. Explain the relationship of nursing goals to expected outcomes. Discuss the purpose of nursing interventions. Explain the ANA standards of care for implementing interventions. Explain the focus of an evaluation assessment. Describe the techniques used to assess the neurological system. Describe the techniques used to assess the respiratory system. Describe the techniques used to assess the cardiovascular system. Describe the techniques used in an abdominal assessment. Compare activities of daily living (ADL) to instrumental activities of daily living (IADL). Explain techniques for testing orientation and memory in a mental status assessment. Key Terms activities of daily living (ADL) assessment auscultation baseline data diagnosis evaluation expected outcomes focused health assessment Glasgow coma scale goals implementation initial nursing assessment inspection instrumental activities of daily living (IADL) nursing nursing process objective data palpation percussion planning practice of nursing primary data secondary data subjective data and caring that constitutes the art and science of nursing. We then discuss implementing nursing interventions and the ANA Standards of Care on Implementation. and advocacy in the care of individuals. the nursing diagnosis. implementing. nursing is the “protection. Our discussion then turns to the components of the second part of the nursing process. We begin our discussion by defining the steps in the nursing process and analyzing the American Nurses Association’s definition of each component. the abdomen. Nurses use the nursing process in the care of all patients in all settings. families. patient-derived information sources: subjective data and objective data. and the qualities of nursing goals. the ANA Standards of Care for Outcome Identification and Planning. prevention of illness and injury. We analyze expected outcomes that are included in the goal statements and look at ordering nursing interventions. From there. respiratory.1. and then look at the attributes of a focused nursing assessment and the difference between primary. Definition of the Nursing Process According to the American Nurses Association Social Policy Statement (2003). The American Nurses Association definitions of each of the component parts of or steps in the nursing process are presented in Table 1. The nursing process framework provides the structure for the unique combination of knowledge. and baseline data sources. This nursing process is a clinical framework and the means by which the majority of the Nurse Practice Acts in the United States define the practice of nursing. secondary. and optimization of health and abilities. we move into a detailed discussion of the planning phase and consider such issues as identifying patient goals and outcomes. the nursing assessment. which is a systematic method of assessing. planning. .Unlawful to replicate or distribute Introduction This chapter discusses the foundation for professional nursing practice—the nursing process. alleviation of suffering through the diagnosis and treatment of human response. skills.” Effective nursing employs the nursing process. and evaluating the care required by any patient in any setting. diagnosing and identifying outcomes. and mental status. We also differentiate between two important primary. Finally. communities and populations. promotion. each standard of the American Nurses Association is an elaboration upon a step in the nursing process. In fact. We consider the first component. and cardiovascular systems. we examine the last phase of the nursing process—evaluation—in which we describe assessments of the neurological. • Expected outcomes guide planning. • Patient responses are the substance of nursing diagnoses. The client.1 The Components of the Nursing Process The process is cyclical because each component of the nursing process naturally flows into the next. • The patient is the main source of the data collected and assessed. The process is dynamic because it changes as the patient’s clinical status improves or worsens. spiritual. functional ability. and coordinating. The diagnosis provides the basis for determination of expected outcomes that are individualized to the patient’s needs or circumstances. Figure 1. Data may include the following dimensions: physical.Unlawful to replicate or distribute Table 1. sociocultural. psychological. collects and analyzes data about the client. significant others.1 The Nursing Process Assessment Assessment is a systematic. Diagnosis is a clinical judgment about the client’s response to actual or potential health conditions or needs. economic. Evaluation is the process of determining both the client’s progress toward attaining expected outcomes and the effectiveness of nursing care. . or health care providers may be designated to implement interventions within the plan of care. Implementation may include any or all of these activities: intervening. cognitive. through interaction with the client. and patient-centered manner. dynamic process by which the nurse. developmental. and lifestyle. • The nurse prescribes the strategies implemented for each patient. dynamic. significant others. The process is patient centered in several ways: • The patient is the chief collaborator with the nurse throughout the process. A plan of care is a comprehensive outline of care to be delivered to attain expected outcomes. and health care providers. delegating. Diagnosis (Outcomes Identification) Planning Implementation Evaluation The components of the nursing process relate to each other in a cyclical. male genitalia and inguinal lymph nodes. Data that the nurse derives directly from interaction with the patient is called primary data and is either subjective or objective data. and rectum. hair. level of consciousness. which includes checking vital signs. . and sinuses. abdomen. and the nurse’s clinical judgment. An initial assessment includes a nursing history. musculoskeletal system. ears and hearing. nasal passages. including a review of systems. or vigilance Focused assessments are one of the primary tools by which nurses nurture and sustain life and contribute to the success of the health care team. peripheral perfusion. and the cycle continues. respiratory. heart.g. and the cardiovascular systems are presented below. The sum of all primary and secondary information collected on any one patient is called the patient database. nausea/vomiting. or intake/output) • Laboratory. anus. A focused health assessment is performed when: • A patient complains of a new or changed symptom (e. nails. thorax and lungs. Evaluation data feed into ongoing assessment. observable behavior change or a change in color. nose. electrocardiogram. The performance of an initial assessment depends upon the policies of the agency. telemetry. Assessment techniques focusing on the abdomen and the neurological. Data Data is another word for information.g. monitoring. eyes and vision. or x-ray results indicate a change in the patient’s health status • A new or changed nursing diagnosis is being considered • A particular diagnosis requires the frequent assessment of repeated measures. the patient’s presenting needs and condition. skin. An initial assessment may also include a complete physical health examination.. Assessment Types of Assessment An initial nursing assessment is performed upon admission of a patient to a hospital or extended care facility or upon a first encounter with a patient in a home or primary care setting. Data derived from all other sources is called secondary data. new onset of pain or an increase in its severity) • A new or changed sign occurs (e. female genitalia and inguinal lymph nodes. respiratory rate. Performing selected portions of the history and examination is called a focused health assessment. mental status. neck..Unlawful to replicate or distribute • • The nurse evaluates care on the basis of the outcomes attained. neurological system. blood pressure. general appearance. temperature. breast and axillae. mouth and oropharynx. heart rate. head. or community. Objective data may also include diagnostic report data such as laboratory blood values. classification manuals. family. An example of a family-focused nursing diagnosis is ineffective family coping. or clinical judgments the nurse makes after assessing the patient. Thus. The subject matter of the diagnosis may be a health problem or a life process. The latter might occur when a community does not have the resources it needs to manage a public health problem. subjective data relies on a conscious patient providing a narrative statement or report. For example. The nursing diagnosis directs the planning of Copyright © 2008. cyanosis is a sign that a nurse observes that can be objectively verified by another. altered family processes (alcoholism). Symptoms are frequently defined as reports of subjective patient experiences. the nurse collects both subjective and objective data. such as tuberculosis. Thus. a patient’s admission weight is called the baseline weight and serves as a marker against which future weights may be compared. other nurses and health professionals on the patient’s health care team. radiography. the clinical record.0 . Nursing Diagnosis Definition of Nursing Diagnosis Diagnoses flow from (are derived from) assessment. and culture and sensitivity results from urine. Primary. stool. Secondary Data Data that is not derived from the patient directly is called secondary data. or sputum specimens. such as. Examples of diagnoses that focus on life processes are impaired home maintenance management. reference manuals.” Signs or observations made directly by the nurse that are capable of being verified by another are called objective data. clinical inferences made on the basis of assessment.Unlawful to replicate or distribute Baseline data is another term frequently used in nursing. Sources of secondary data are the patient’s family and friends. An example of a community-focused nursing diagnosis is ineffective community management of a therapeutic regimen. and impaired social interaction. An example of a patient-focused nursing diagnosis is body image disturbance. Examples of diagnoses that represent health problems are constipation. nausea is a subjective experience or symptom that cannot be objectively observed or verified. The subject of the nursing diagnosis may be a patient. For example. impaired bed mobility. or articles) related to the patient’s condition. risk for fluid volume deficit. and anticipatory grieving. including laboratory reports and reports of the results of diagnostic procedures. It refers to the data taken at the time of the first encounter. Patient-Derived Data Whether a complete or a focused health assessment is being performed. and relevant literature (such as published protocols. Inc. “I feel nauseated. Diagnoses are also conclusions drawn from an analysis of the assessment data. standards. guidelines. NXP 070106 v1. The College Network. Definitions capture the meaning of the diagnosis and differentiate one diagnosis from another. NXP 070106 v1. For example. the nurse may be thinking that a family with three children in high school is ready for developing enhanced parenting skills. This example points out the necessity for validating nursing diagnoses. I get the impression that you are interested in learning new parenting strategies. Formulating Outcomes When formulating outcomes. the patient’s therapeutic management is not likely to improve. Diagnoses require validation. Inc. This complaint may be addressed even as the laboratory tests are being obtained. Copyright © 2008. and risk factors. Components of the Nursing Diagnosis A nursing diagnosis consists of a diagnostic label. families. This does not mean that the nurse avoids the complaint of stress. Sometimes. For example. For example. The diagnostic label is the name of the diagnosis. related factors. a nurse indicates during the report. A patient taking a drug that is hepatotoxic may attribute the experience of fatigue to stress. and steps need to be taken to ensure that liver function tests are obtained as soon as possible. then the nurse may proceed with a diagnosis of fatigue related to sleep deprivation. The College Network. This case requires laboratory validation and collaboration with the physician. 2003) on outcomes identification provides an excellent method of organizing study content. The nurse may say. it is the family that validates the diagnosis. the definition of the diagnosis. the registered nurse validates this diagnosis with the patient. Often. Before inviting a parent to attend a series of classes on the modern teenagers and parenting strategies. Each diagnosis has its own definition. Acquiescing to the patient’s hunch is not validating the diagnosis. it is the patient who validates the diagnosis.Unlawful to replicate or distribute patient goals and the selection of appropriate nursing interventions designed to achieve outcomes for which the nurse is accountable. Would you assess the patient and see if you agree?” Validation of diagnoses with patients. If the liver function tests are negative. while the nurse suspects that the fatigue is related to drug therapy. The diagnosis that is of a higher priority is a drug-related fatigue. and its defining characteristics. and even colleagues does not mean that the registered nurse suspends clinical judgment. It is possible for patients to have two diagnoses—stress as well as fatigue related to hepatoxic effects of drug therapy.0 . Without this meeting. the registered nurse consults with patients with ineffective management of the therapeutic regimen and their families. “In my interactions with you. before making a diagnosis that the patient is grieving. Is that so?” Diagnoses may also be validated with colleagues. Outcomes Identification The criteria established for the ANA Standard of Practice (ANA. The nurse may need to meet with both the patient and family so that mutually agreed upon outcomes can be achieved. “I think the patient may be experiencing some decisional conflict about being discharged home. the nurse validates the readiness diagnosis first. other times.0 . if. and oral hygiene needs to be explored and applied in practice. sometimes it is not possible to consult with others. volume of feedings. For example. end gastric volume. and oral hygiene. the outcomes will need to be reformulated. the likelihood of the desired outcome being attained is greater when all members of the team are working together. These interventions can include keeping the patient calm. It should also be apparent that the clinical expertise of the registered nurse comes into play as well. However. is that the nurse knows and formulates outcomes that are specific to the diagnosis with which the patient presents. For example. however. there is no single diet plan that will accomplish this for all patients. or others. social workers. if needed. such as location of the feeding tube in the gastrointestinal tract. Therefore. physicians. there may be multiple parameters identified. if the outcome is that the patient with diabetes will achieve better blood sugar control. a nurse finds that a patient’s breathing is ineffective. It should be apparent from this example that the evidence underlying the relationship between gastric tube placement. the outcome is not that the patient will not aspirate but that the risk for aspiration will be reduced. It may be more realistic to establish an outcome that risk for aspiration will reduce. NXP 070106 v1. The nurse must keep cultural differences in mind when developing patient outcomes and planning methods of attaining those outcomes. it is often necessary to obtain the cooperation of other health care providers on the team.Unlawful to replicate or distribute Fundamentals of Nursing 7 When formulating outcomes. Copyright © 2008. multiple factors that play into risk for aspiration will have to be considered. The College Network. Develops Expected Outcomes that are Culturally Appropriate There are many ways in which outcomes may be achieved. calling 911. Inc. Sometimes. Again. and Clinical Expertise when Formulating Outcomes An outcome may be that the patient on a mechanical ventilator will not aspirate. Patients from the Mideast will achieve blood sugar control using a diet that is different than someone whose heritage is traced back to Northern Europe or to South America or to Asia. To accomplish this outcome. Benefits. A registered nurse who is a novice will need assistance not only in formulating such diagnoses but also help in developing a plan to achieve their attainment. Costs. end gastric volume. they will just need to be communicated. volume of feedings. For the single diagnosis of risk for aspiration. Evidence. On the other hand. location. The point in each of these examples. therefore. it is best to keep the head of the bed elevated between 30 to 45 degrees. then the nurse is responsible for setting in motion interventions needed to achieve effective breathing. on a home visit. To accomplish this outcome. Does the outcome change. each of which decreases or reduces the risk for aspiration. and outcomes will need to be formulated independently. this cannot be done if the patient has a spinal injury. Considers Risks. maintaining an airway. therefore? Perhaps. such as nurses. and initiating resuscitation. “I don’t walk just for the sake of walking. for example. Beliefs. that a timeframe needs to be established. there is no point in saying in three weeks I will be walking eight blocks. as in the reestablishment of an effective breathing pattern. Mutually agreed upon disease prevention activities to be achieved over the next six months follow. Documents Outcomes as Measurable Goals Although this seems to be a clear-cut criteria. as in the case of critically ill patients in intensive care units. NXP 070106 v1. The College Network. In addition. and Environment and Considers the Ethical Implications of the Outcomes These criteria are similar to those that discuss the need for outcomes that are culturally sensitive. outcomes are diagnostic-specific.0 . the expected outcomes may simply be bulleted in the patient’s health record. the time frame is considerably longer. sometimes the environment is not conducive to its attainment. the patient does not value walking just to walk. the time frame needed to lose thirty pounds. Environment is also an important factor. when outcomes are formulated with the patient. It is perhaps an achievable outcome. they are dynamic and require ongoing evaluation as to their appropriateness for the patient’s present condition. Therefore. In the case of the walking example. are not static. Therefore. once identified. or months. Modifies Outcomes on the Basis of Changes in the Patient’s Condition or Situation Sometimes outcomes are changed minute by minute. Sometimes the time period is quite short. nurses sometimes indicate that they have difficulty documenting outcomes. The point is that outcomes. The point is. because I won’t. Remember. for any one diagnosis. Let’s say that the patient has a diagnosis of health-seeking behavior and wants to know more about what screening procedures are recommended.” Obviously. These are examples of considerations that need to be made when addressing outcomes identification. weeks. This holds true for the patient’s belief system as well. For example. Documentation may be as simple as: Patient exhibits health-seeking behavior. Inc. it seems appropriate to add that outcomes also need to be consistent with the patient’s financial situation.Unlawful to replicate or distribute Ensures that Outcomes are Consistent with the Patient’s Values. but the risks of being hit by a car outweigh the benefits of walking in the street. Sometimes. On the other hand. sometimes outcomes are achieved over a period of days. however. Develops a Time Plan Within Which the Outcomes are Expected to Occur Outcomes are expected to occur within a specified period of time. Patient will: • • • Obtain PSA in the next month Obtain a lipid panel in the next three months Measure weight weekly Copyright © 2008. the patient will simply say something like. walking outdoors is not an achievable outcome when there are no sidewalks and the patient would have to walk in the streets. Sometimes. Another outcome will need to be explored that is consistent with the patient’s values. “the patient will maintain a heart rate between 60–100/minute” is a patient goal. verbs that express an action or a behavior (such as achieve. If a patient with impaired mobility has the goal “patient will walk with assistance. “Empty the drainage bottle” is what the nurse will do or have a nursing assistant do. Prescribing Nursing Strategies Once patient goals and outcomes have been identified. and action/direction-oriented. Goals include modifiers when a modifier is needed. It is not sufficient to write “maintain adequate oral intake. Patient goals are not statements of what treatments are to be performed. 1000 ml between 1500–2300. Another example of a patient goal is “the patient will correctly administer insulin prior to discharge. Planning Plans Prescribe Strategies to Achieve Expected Outcomes All plans share common characteristics.” then the phrase “with assistance” is a modifier. Inc. each of the headings may be used in the evaluation of one’s own practice in this regard. the patient will be taken to surgery) is not a patient goal.g. usually by using the verb “will. 2003). Patient goals do not refer to a to-do list for the nurse. walk. and cough) are used to refer to these goals. future-oriented. they are expressed in the future tense.. write “distribute oral intake over twenty-four hours so that patient receives 1200 ml between 0700–1500. Nursing strategies must be written precisely.” Because goals are action-oriented. NXP 070106 v1.” Instead. The College Network. a statement such as “patient will be turned every two hours” is not a patient goal. It is a nursing strategy or an intervention that a nurse or nurse assistant will be employing. The ANA speaks of these activities in its Standards of Practice (ANA.Unlawful to replicate or distribute • • Achieve a 10 lb weight loss over the next six months Engage in a daily exercise program of 30 minutes Note that these goals are patient-centered.0 . appropriate and diagnosis-specific nursing strategies are selected and prescribed. Thus. maintain. Thus. and 500 Copyright © 2008. A patient goal uses the word “will” in the active tense. As such.” ANA Standard of Practice on Outcomes Identification —The Registered Nurse Identifies Expected Outcomes for a Plan Individualized for the Patient or Situation Each of the above divisions refers to a criteria established by the ANA (2003) to measure whether or not the practice of the registered nurse is in accord with the standard on outcomes identification. It is not a patient goal. they are always expressed in terms of patient goals to be achieved and not in terms of the nurse’s work goals. Because patient goals are futureoriented. Because goals are patient-centered. A goal using the word “will” in the passive tense (e. Plans specify nursing strategies used to achieve patient outcomes. and evidence-based practice Take into consideration the economic impact of the plan Rely on standardized language for documentation purposes These characteristics represent the criteria that the ANA has established for its Standard of Practice on Planning. the nurse has as an objective that the patient or caregiver at the time of discharge will know how to do the following tasks: • • Accomplish activities of daily living Implement appropriate disease prevention and health promotion strategies Copyright © 2008. Effective medical treatment has a positive impact on nursing outcomes.0 . Characteristics of the Plan Nursing plans need to: • • • • • • • • • • Be individualized for each patient or situation.Unlawful to replicate or distribute ml between 2300–0700. research. Discharge Planning Discharge planning: • • • • Begins at the time of the patient’s admission to a nursing unit Involves the active participation of the patient and the patient’s family or friends Is facilitated by an interdisciplinary team approach Requires teaching so that the patient or the patient’s primary caregiver is capable of therapeutically managing post-discharge care To accomplish the teaching requirement. that is: The Registered Nurse Develops a Plan that Prescribes Strategies and Alternatives to Attain Expected Outcomes (ANA. NXP 070106 v1. This aspect is described more thoroughly under implementation. both medical and nursing treatments need to be effective. effective nursing treatment has a positive impact on medical outcomes. 2003). with a set of strategies written for each diagnosis Provide for continuity of care Include a pathway or a timeline for goal achievement Prioritize diagnoses and related strategies appropriately Available for communication with and use by other members of the professional nursing and interprofessional health care team Integrate current trends. and culturally appropriate Be developed in conjunction with the patient and family when appropriate Be diagnostic-specific. and as evidence that standards have been met.” Such documentation is necessary as a reference for other health professionals involved in the care of the patient. The College Network. as a legal record. Inc. Coordinating Nursing and Medical Plans For the patient to become well as quickly as possible. age-appropriate. At that point. Other systems allow the user to create an individualized plan from a drop-down list of nursing Copyright © 2008. some systems rely on standardized care plans specific to that diagnosis. which includes the following information: • • • Patient identification and background information (such as allergies. The College Network.0 . while others are web-based. Preferred systems are password protected. dislikes) Listing of patient problems or diagnoses Listing of problem or diagnosis-specific interventions Kardex™ information is updated as the patient’s condition and related interventions change. Some systems are CDROM based. secure. likes. These systems allow plans to be shared across departments or units within hospitals when patients are transferred. which is selected from drop-down menus.Unlawful to replicate or distribute • • • • • • • Administer medication safely Perform needed procedures safely Use specialized equipment correctly Evaluate signs of progress Detect complications or any undesired sequelae Make return appointments for follow-up care Obtain emergency treatment. Inc. Entry is by means of the nursing diagnosis. These systems can also be available to home health or other health care agencies when proper statutory and legal guidelines have been met. NXP 070106 v1. if needed Types of Plans Handwritten Care Plans The traditional care plan is handwritten onto a Kardex™. Standardized Care Plans Standardized care plans refer to preprinted plans that accomplish the following guidelines: • • • • • Are specific for particular diagnoses Allow for additions or deletions to accommodate the standards and policies of the agency in which the nurse is working Use a nursing process format Provide space for the nurse to tailor the standardized plan to the individual needs of the patient Are included in the patient’s chart Electronic Care Plans Electronic care plans remain in an early stage of development. and interoperable. Implementation The plan is the vehicle by which care is coordinated. infection control policies to prevent infection spread.. and Standing Orders Policies are written instructions designed to address a commonly occurring problem in an institutionally approved manner. standards. it is imperative that nursing documentation is included and stored. Additionally. protocols governing wound care. e..g. and processes are part of any documentation system and help present the content in meaningful ways” (2007). e.g.g. NXP 070106 v1. This allows the nurse to select an outcome from the drop-down list. preprinted instructions governing interventions or actions to be taken in the care of groups of patients with particular problems. placement of nasogastric tubes. Protocols are institutionally approved. Opportunity to provide narrative input provides flexibility in individualizing care. preprinted. Regardless of the electronic record used within a health care system. Finally. Protocols. policies. Procedures are institutionally approved. the ANA Nursing Information and Dataset Evaluation Center recommends that “Specific principles. The College Network. The rationale is that while vocabulary can be standardized. Standing orders are institutionally and departmentally approved instructions granting the nurse the authority to act in the absence of a physician.. Finally. which is the next step in the nursing process. Policies. any electronic care plan needs to have electronic access to a clinical information database available. Procedures.g. The purposes of nursing strategies are to achieve the following objectives: • • • • Manage health problems or nursing diagnoses Provide patient information and instructional needs related to the patient’s health problem Tailor health-promotion and disease-prevention strategies Address continuity-of-care issues such as referring the patient to appropriate patient care and community resources Copyright © 2008. care must remain individualized. preferred systems allow for narrative input by the nurse. e. Inc. This allows for retrieval for patient care and professional and legal purposes. e.. procedures.Unlawful to replicate or distribute activities or strategies. Outcomes may be standardized (that is. the type of outcome is preselected and included in the care plan) or non-preselected.0 . Preferred systems also allow for the care plan and electronic reports of patient progress to be incorporated into a patient’s electronic health record. detailed instructions on how to perform specific clinical tasks. It consists primarily of implementing nursing strategies. standing orders authorizing coronary care nurses to administer antiarrhythmic medication. Each of the above steps is intended to ensure that interventions are implemented safely and in a manner that respects the dignity and individuality of the patient. Conduct nursing rounds. assist the patient in becoming comfortable. This is especially true with medically ordered interventions in which the patient’s condition has changed. use universal precautions when indicated. begin to teach the procedure to the patient if the patient will eventually bear responsibility for its implementation. NXP 070106 v1. gather needed equipment or supplies. Document the intervention and the patient’s response during and after implementation. indicating a needed change in the order.0 . 2003) Steps in Implementing Interventions 1. organize any needed equipment and supplies in a suitable manner. Evaluation Evaluation involves assessment of the patient’s responses to care received. In a community setting. and decreases worker strain (as in turning an unconscious. 2. maximizes patient safety (includes using reference and other resource material). observe the patient’s response during and after the action is performed. check the identity of the patient. 3. Does the plan incorporate the use of community resources or systems? 5. and be sure the patient has access to call buttons in a hospital situation. 3. elicit the patient’s cooperation/consent.Unlawful to replicate or distribute ANA Standard of Practice on Implementation: The Registered Nurse Implements the Identified Plan The criteria established to measure the attainment of this standard are expressed as the following questions: Is the plan implemented in a safe and timely manner? Are the plan and any modifications documented? Is the plan evidence-based. explain the intervention. perform the specific nursing action and explain the process to the patient. When implementing an intervention. including progress made toward the anticipated outcomes or goals set during the planning stage. or if the patient had an untoward response to the intervention. Inc. Does the registered nurse collaborate with nursing colleagues and others in implementing the plan? (ANA. It Copyright © 2008. 5. Determine the amount of assistance needed to implement the intervention in a way that minimizes patient discomfort. 1. 250-pound patient). 4. and reassess the patient’s need for an intervention. Consult as needed with other health professionals. be sure the patient has access to telephone or beeper numbers. provide for patient privacy. and are the interventions or treatment diagnosticspecific? 4. 2. The College Network. be sure to notice any related changes in the patient’s condition.” evaluation would include an assessment of whether or not this goal was met. NXP 070106 v1. no pain relief has been obtained. Inc. outcomes. adapt the nursing interventions to adjust to the current clinical situation. ANA Standard of Care on Evaluation: The Nurse Evaluates Progress Toward Attainment of Outcomes The measurement includes the following criteria: Evaluation is systematic. pain relief (expected outcome) has been achieved. Some Copyright © 2008. e. If a goal set in the planning stage of the nursing process stated. If the expected outcomes were not obtained. as needed • Appropriately disseminates results to patients.. and criterion-based Patient. however. a different strategy or an adjunct strategy needs to be employed. and other health care providers are involved in the evaluation process. 2003) Comparing Expected and Obtained Outcomes When comparing the expected outcomes with the obtained outcomes. every four hours. choose one of the following decision paths: 1. In the case of the question about pain.0 .Unlawful to replicate or distribute also focuses on the effectiveness of nursing interventions utilized to meet those goals. ongoing. a patient is assessed as having acute pain with a rating of 8 on a 10 point pain scale. • • 2. An analgesic is given for pain. The College Network. family. Most patient outcomes in a hospital setting are evaluated in an ongoing manner at specified time intervals. every two hours. The diagnosis is acute pain. Any changes require reassessment. There are other instruments. When evaluating patients. or discontinue nursing interventions that are no longer needed. If the patient answers 7 or higher. family. For example.g. we can assume reliability. continue with the same nursing interventions if indicated. If the patient answers 2. “the patient will correctly administer his own insulin prior to discharge. or once each shift. ensure the measure is reliable. and other providers involved in care (ANA. and the plan of care. How is the effectiveness of the analgesic to be evaluated? The answer is that the nurse asks the patient after the medication has had time to take effect how much pain is now experienced on a scale of 1 to 10. as appropriate • Effectiveness of interventions is evaluated in relation to outcomes • Results of the evaluation are documented • Ongoing assessment data are used to revise diagnoses. that may not measure reliably one moment to the next. If the expected outcomes were obtained. ask the patient to close eyelids tightly [cranial nerve VII. NXP 070106 v1. Evaluation of outcomes also occurs prior to the discharge of a patient from the hospital or prior to a case being closed in a community setting. outcomes related to wound care might be evaluated every other day or every third day. Ask if there is any double vision [cranial nerve VI. Assess eye movement in all six directions. outward movement controlled by cranial nerve VI [abducens]. Inspect the eyelids for ptosis or drooping. moving in a head-to-toe or top-to-bottom direction. Normally there is none. Inspect for symmetrical alignment of face. Covering one of the patient’s eyes. The specific nerve tested is listed in brackets. We will start with an assessment of the cranial nerves. The College Network. and cranial nerve VII. with upward and outward movement being controlled by cranial nerve IV [trochlear]. respiratory. facial]. pupils are equal and reactive to light and accommodation. bilaterally or unilaterally. While inspecting for symmetry. eyes move symmetrically in all directions. assess peripheral vision in the uncovered eye by testing the visual fields [cranial nerve II. oculomotor]. depending on how the order is written. facial]. mouth. in hospital settings. and level of consciousness. Copyright © 2008. Techniques for Physical Assessment of the Major Body Systems In this section we will be concentrating on a review of techniques used in the physical assessment of the neurological. deep tendon reflexes. Evaluation of outcomes may occur intermittently.0 . optic]. oculomotor]. Normally. olfactory nerve]. and downward movement controlled by cranial nerve III [oculomotor]. The Neurological System Techniques used in the physical assessment of the neurological system include assessments of the cranial nerves. Inc. are evaluated continuously by telemetry. Inspect the eyes for visual acuity using the Snellen chart—normal vision is 20/20. those related to compliance with lead poisoning prevention strategies) may be evaluated on a weekly or monthly basis. Test for or ask patient about the sense of smell [cranial nerve I. sensory and motor function.. outcomes (e. facial]. For example. a person sees objects in the periphery. abducens]. Normally. and lips while the patient is first at rest and then while attempting to smile and whistle [cranial nerve VII. Assess the pupils for equality and reaction to light and accommodation [cranial nerve III.Unlawful to replicate or distribute outcomes. Cranial Nerves Inspect the forehead for alignment of the eyebrows and the patient’s ability to wrinkle the forehead and raise the eyebrows first in general and then symmetrically [cranial nerve V.g. In a community setting. There should be no drooping [cranial nerve III. and cardiovascular systems and of the abdomen. trigeminal branch to the forehead. such as heart rhythms. Normally. Normally. Test taste by asking patient to identify foods [cranial nerve IX. or nausea and vomiting. With your dominant hand. Inspect the ability of the patient to extend the tongue without it deviating to one side or another and clarity of speech without slurring of words [cranial nerve XII. triceps [spinal cord level C7 and C8]. tap the tendon directly. Triceps: Supporting the patient’s flexed arm with your nondominant hand. Brachioradialis: Resting the patient’s arm in your nondominant arm or on the patient’s thigh. flex the arm at the elbow. Deep Tendon Reflexes We will now assess the deep tendon reflexes. and L4]. tap the tendon directly. take the percussion hammer and tap the tendon directly while observing slight elbow extension. with the palm of the hand down. We will also assess the plantar (Babinski) reflex. moving in a head-to-toe or top-to-bottom direction. L3. find the patellar tendon directly inferior to the patella (kneecap). dizziness or vertigo. not a deep tendon reflex. tap your thumb. find the triceps tendon two to five cm (one to two inches) above the elbow. Assess cranial nerve XI [spinal accessory] by inspecting symmetry of shoulders or the drooping of one more than the other and by the patient’s ability to move head side to side even when opposed with mild pressure. Inc. Using the percussion hammer.0 . Place your thumb over the biceps tendon. NXP 070106 v1. The College Network. which is a superficial. hypoglossal]. and the Achilles [spinal cord level S1 and S2]. glossopharyngeal and cranial nerve X. • Biceps: Resting the patient’s arm on his or her thigh. • • • Copyright © 2008. Using the percussion hammer. patellar [spinal cord level L2.Unlawful to replicate or distribute Assess cranial nerve VIII [vestibulocochlear] by testing hearing (whisper test. glossopharyngeal] and. if swallowing is assumed to be intact. Observe slight elbow flexion. using a slightly downward motion. vagus]. test the quality of swallowing with small amounts of food and water [cranial nerve IX. Feel the biceps muscle contract under your thumb. brachioradialis [spinal cord level C3 and C6]. Patellar: With the patient in a sitting position and the legs hanging freely. while observing extension (kicking up) of the leg as the quadriceps muscle contracts. Using the percussion hammer. find the brachioradialis tendon situated along the radium about two to five cm (one to two inches) above the wrist. Weber and Rinne tests) and asking if patient experiences ringing in the ears (tinnitus). while observing arm flexion and supination. There are five deep tendon reflexes—biceps [spinal cord level C3 and C6]. a patient swallows easily. without choking. the toes flare and move upward. moving from the heel to the ball of the foot and then moving across the ball to the great toe. balanced gait while swinging opposing arms. Plantar (Babinski): Using the percussion hammer handle or a key. neck. Now ask the patient to assume the Copyright © 2008. support the patient’s foot in your nondominant hand and dorsiflex it (move it up toward the head) slightly. Ask the patient to sit on the examining table and perform the following: • • • • • Finger-to-nose test Finger-to-nurse’s-finger test Finger-to-fingers test Finger-to-thumb test Alternating supination/pronation of hands on thighs test Ask the patient to lie down and perform the following: • • Heel-down-shin test Toe-to-nurse’s finger test Ask the patient to stand and perform the following: • • Walking gait test. ask the patient to stand upright. NXP 070106 v1. This movement stretches the Achilles’ tendon slightly. with feet close together. They are described below. legs. Normal gait includes upright posture and unaided. This is the normal response and it is called a negative plantar or a negative Babinski response. upper and lower legs. When assessing arms. and feet. Sensory Function Light touch may be used to assess sensory function.Unlawful to replicate or distribute • • Achilles: With the patient in the same sitting position with the legs hanging freely. steady. Document exactly those areas in which sensation was decreased or absent. It may be performed by using a wisp of rolled cotton and touching the patient’s face. Romberg test. Motor Function A variety of tests are used to assess motor function. lying. and arms at sides. upper and lower arms. categorized according to whether they are performed in sitting. while observing a bending downward of the toes. stroke the lateral foot. and feet. tap the tendon directly. Inc. Facing the patient so that you may steady or catch the patient should loss of balance occur.0 . In an abnormal response. The College Network. be sure to perform lateral and medial assessments. Using the percussion hammer. Find the large Achilles’ tendon immediately above the heel. while observing plantar flexion (jerking downward) of the foot. with eyes open. or standing positions. Note that an infant normally has a positive Babinski until about six months of age. Table 1.0 . Standing on one foot with eyes closed test. The College Network.. frontward. A score of fifteen is the best possible score and a score of seven or less indicates coma. Observe sway or its absence.e. Observe ability to walk a straight line while placing the heel of one foot directly in front of the toes of the other. If sway occurs. Ask the patient to stand on one foot with the eyes closed. or verbal response. a person can maintain this stance for at least five seconds. motor. the patient will move the feet apart to maintain balance. Inc. Then ask patient to walk for several steps on the heels.2 Level of Consciousness as Measured by the Glasgow Coma Scale Response Score Spontaneously 4 Opens eyes (circle one score) To speech 3 To pain Absent 2 1 6 5 4 3 2 1 5 4 3 2 1 Motor response (circle one Obeys verbal command score) Localizes pain Flexes and withdraws Abnormal flexion (decorticate rigidity) Abnormal extension (decerebrate rigidity) Absent Converses and is oriented Converses but is disoriented Uses words inappropriately Uses words incomprehensibly Absent Verbal response (circle one score) (Teasdale 1974) Copyright © 2008. Toe walking. The lowest possible score is three. These abilities are normally present. i. Normally. Consciousness exists along a continuum from “fully alert and oriented” to “comatose. to the right. this ability is present. Heel-to-toe walking test.” This continuum has been scaled and is called the Glasgow Coma Scale. Ask the patient to walk for several steps on the toes. NXP 070106 v1. heel walking tests. Be sure to stand near the client to steady or catch the client should loss of balance occur.Unlawful to replicate or distribute • • • same stance with eyes closed. with no eye. Once sway occurs. or backward. Level of Consciousness The assessment of level of consciousness is part of the neurological examination. Observation of sway or of moving the legs apart to maintain balance is an abnormal result. Normally. document the direction. to the left. abscesses. In the infant. changes the shape of the chest. While examining the chest for size and shape.g. and injuries. the shape is oval and elliptical. also be sure to check for other deformities (e. pectus excavatum). wounds (knife or puncture). Inspect for normal chest size and shape. • Normal breath sounds are called bronchial. percussion. NXP 070106 v1. and the A-P diameter equals the transverse. The College Network. By six years of age. In the adult. fremitus (bilaterally symmetrical tactile sensations in palmar surface of fingertips upon patient’s vocalization of words.5–2. chest abscesses. Gently palpate areas of suspected chest abscesses. intercostal retractions. and tympany. as well as the overall shape. resonance. and describe findings. the shape is less round because the A-P diameter is decreasing in relationship to the transverse. long expiration) at the bronchial level − 1:1 ratio (inspiratory time equals expiratory time) at the bronchovesicular level − 5:2 ratio (very long inspiration with an expiration less than half as long) at the vesicular level Sounds are − high-pitched and harsh at the bronchial level − moderately pitched and softening at the bronchovesicular level − low-pitched and softly sighing at the vesicular level The various sounds correspond to the following locations: − bronchial sounds correspond to apex of the lung − bronchovesicular sounds correspond to the area between the apex and the base of the lungs − vesicular sounds correspond to the base of the lungs • • Copyright © 2008. Go back and forth from the right side to the left side while progressing from the apex to the base of the lungs.Unlawful to replicate or distribute The Respiratory System Techniques used in the physical assessment of the respiratory system are inspection. e.. and nonpenetrating injuries (bruises. Note that the inspiratory to expiratory ratio is − 1:2 (short inspiration. bronchovesicular.g. Percuss intercostal spaces of anterior and posterior chest wall for flatness. hyperresonance.0 inches) on inspiration. expansion (3–5 cm or 1.0 . dullness. the shape is like a round cylinder. hematomas). Auscultate for normal and abnormal (adventitious) breath sounds. the A-P diameter is two times smaller than the transverse. Aging. wounds.. Palpate for chest excursion (equal bilateral movement on inspiration and expiration). wounds. “blue moon”). Inc. or injuries. deformities. Observe the anterior-posterior (A-P) diameter in relationship to the transverse diameter. and vesicular. with the apex being smaller than the base (think of the shape of the adult lung x-ray). and auscultation. The back-and-forth movement is to make sure that you are making accurate bilateral comparisons. palpation. with its osteoporosis and resultant kyphosis. in the adult. Also. however. If there is no distention. It is not usually relieved by coughing. The College Network. If there is distention. Visualize the sternal angle and look between it and the ear tip. gurgles (rhonchi). lower the head of the bed to thirty degrees and observe for distention. Inc. assess the neck for jugular venous distention (inspection) and the carotids (inspection. Heard at the base of the lungs. Distention that extends more than three to four centimeters above the sternal angle is considered abnormal. − The pleural friction rub. NXP 070106 v1. palpation [only one carotid at a time]. Now. and crackles (rales). Listen to determine if the crackles cleared on coughing. The Cardiovascular System Techniques used in the physical assessment of the cardiovascular system vary according to what part of the system is being assessed. These sounds are usually emitted by secretions in the bronchi and hence. fine. and auscultation. − Crackles (rales) sound like noise emitted when salt is thrown into fire or like the noise that occurs when you use your fingers to rub a lock of hair harshly and quickly near your ear (i.Unlawful to replicate or distribute • Abnormal breath sounds (or adventitious sounds) that include wheezing. rales may or may not be cleared on coughing. on occasion the femoral arteries may be auscultated. measure its height in centimeters or inches above the sternal angle. and auscultation). are heard best over the bronchial areas. whistling sound heard especially over the anterior and posterior bronchial areas. usually by using inspection and palpation only. ask the patient to cough and then take a deep breath. To evaluate clearing. measure the height of the distention in centimeters or inches above the sternal angle.0 . It is caused by bronchoconstriction due to bronchial edema (causing a narrowing of the lumen) and secretions (as occurs in asthma) or bronchial obstruction (as occurs with a tumor). If there is distention. Be sure to document results. short.e. but also throughout the lungs. Inspect both jugulars to see if the distention is symmetrical. Assessment of the Jugular Veins Inspect the jugular veins with the patient lying at a forty-five-degree angle in semiFowler’s position. palpation. It occurs throughout inspiration and expiration and is not cleared by coughing. find the jugular vein. crackling noises). Assess the peripheral vascular system. It is caused by a rubbing together of the surfaces of the pleural membrane surrounding the lung. − Wheezing is a high-pitched. Moving in a head-to-toe direction.. which is heard best along the lateral or anterior chest. Inspect for distention of the jugular vein. sounds like the noise that occurs when you use your fingers to rub a lock of hair back and forth slowly and gently near your ear. Copyright © 2008. Assess the heart using inspection. − Gurgles (rhonchi) are low-pitched gurgling sounds heard best on expiration and frequently cleared on coughing. Auscultate the same areas for heart sounds and murmurs with the patient lying in a semiFowler’s position at a thirty to forty-five degree angle. Inc. pulsating masses. An appreciation of the sounds will follow. Copyright © 2008. The main reason for palpation is simply to locate the position of the artery so that you know where to place the stethoscope for auscultation. Palpate the same areas for abnormal pulsations. the pulmonic area (second intercostal space to the left of the intercostal border). ask the patient to turn slightly to the side being examined. listening for a bruit. Palpate gently only one carotid artery at a time so that carotid blood flow to the brain is maintained at all times. ask the patient to turn to the left side. Realize. NXP 070106 v1. Assessment of the Heart Inspect the anterior chest. or both sounds are heard. there should be none. whether before or after age forty. a bruit is not heard. To make the carotid more accessible. Turbulence occurs in the presence of a partial obstruction or arterial narrowing. When a third. If failure is suspected. To avoid stimulating a carotid sinus response and a possibly injurious bradycardia. the resulting combination of sounds is called a gallop rhythm. S1 may be thought of as the “lub” sound and S2 may be thought of as the “dub” sound. It is found with decreased flexibility of the wall of the left ventricle. S1 is followed by systole and S2 is followed by diastole. This brings the left ventricle closer to the chest wall. never massage nor apply pressure to the carotid artery. This is the sound that occurs immediately after the second heart sound. although it may be present in a healthy-appearing older adult. In children and in young adults. It takes a very good ear and much practice. a murmur-like sound caused by turbulence in carotid artery blood flow. fourth. the tricuspid or right ventricular area (fifth intercostal space to the left of the sternal border). lifts. or heaves. This is the sound that occurs immediately before the first heart sound. The fourth (S4) sound is abnormal in the child or adult. The first (S1) and second (S2) heart sounds are normal sounds.Unlawful to replicate or distribute Assessment of the Carotid Arteries Inspect both carotids for visible. A pathologic S3 occurs in the presence of left ventricular failure. however. Beginners need to concentrate on obtaining an accurate apical heart rate and an accurate description of the rhythm. a physiologic third heart sound may be heard. and an S3 may be detected more easily. listen first with the diaphragm and then with the bell of the stethoscope and concentrate on identifying each sound separately before moving on to the next. This occurs in the presence of left ventricular hypertrophy or with significant hypertension. Normally. that auscultating heart sounds is like being able to identify the various instruments in Beethoven’s Ninth Symphony.0 . but no S3 is heard with the patient in the supine position. Normally. visually locating the aortic area (second intercostal space to the right of the sternal border). and the apex (at the fifth or sixth intercostal space along the mid-clavicular line). Inspect for abnormal pulsations. because it sounds like a horse galloping. Palpate in the middle area of the neck to avoid the carotid sinus. The College Network. Auscultate the carotid. When auscultating. or heaves. lifts. the hands. radial. A delay in capillary refill is associated with arterial insufficiency. iliac. Bilaterally weak pulses may indicate decreased cardiac output. Copyright © 2008. Before saying that bowel sounds are absent. normal (gurgling sounds every five to twenty seconds). legs. Auscultate the femoral artery if one side is exceptionally weak or absent. masses. femoral. scars) and abnormal findings (rash. looking for abdominal distension. tense or glistening skin indicative of ascites. moving in a head-to-toe direction: brachial. Perform Buerger’s test (arterial adequacy test). and dorsalis pedis. If distention is present. If the friction rub continues when the breath is being held. semi-Fowler’s. A bruit indicates turbulent flow caused by a partial femoral obstruction. cyanosis. diastole. posterior popliteal. soft systolic murmurs heard over the pulmonic area). listen for a full three to five minutes. Inc.0 . A pericardial friction rub occurs when the surfaces of the pericardial membrane rub together. Unequal pulses may indicate circulatory impairment on the weaker side. The College Network. Excessively strong pulses bilaterally may indicate a high cardiac output state.. They are caused by turbulent blood flow through one or more heart valves. Inspect the feet of patients with diabetes mellitus carefully. Absence of a pulse indicates a complete obstruction—a definite emergency. especially between the toes.Unlawful to replicate or distribute Murmurs are not normal heart sounds. femoral. Inspect for contour and symmetry in supine. rubor (ruddy redness). Auscultate for bowel (peristalsis) and arterial sounds. measure the girth at the level of the umbilicus. Murmurs are swooshing noises that occur during systole. Assess asymmetry in volume and strength. requiring prompt notification of the patient’s physician. predispose the patient to undetected skin infections that may become gangrenous. Listen for hypoactive. NXP 070106 v1. although some murmurs may be considered benign in children and young adults (e. purple striae indicative of Cushing’s disease). along with decreased peripheral circulation. arms. or throughout the cardiac cycle. and the legs for venous stasis ulcers. protrusions. it is a pericardial friction and not a pleural rub. Normally. neuropathy and its decreased sensation. The sound can be distinguished from a pleural friction rub by asking the patient to hold his or her breath for a second. The diabetic patient’s increased susceptibility to infection. and gangrene. The Abdomen Inspect the skin for normal findings (silver-white striae. pulses are full and strong. and feet for edema. Inspect the hand and feet digits for temperature. blanching. and renal arteries. bilaterally. posterior tibial. and standing positions. Listen for arterial bruit over the abdominal. Assessment of the Peripheral Vascular System Inspect fingernails for early or late clubbing and fingernails and toenails for capillary refill (color returns normally in less than three seconds).g. Palpate the pulses bilaterally. and pulsations. or hyperactive bowel sounds in all four quadrants of the abdomen. launder clothes. ascites. These include the ability to: use a telephone. a hospitalized patient may need assistance with turning in bed. For example. toileting and continence. The nurse assesses permanent impairments to plan for the provision of services. bathing. After light palpation is concluded. tense mass. For example. Functional Assessment Techniques Activities of daily living (ADL) refer to the basic self-care tasks of living. They need to be assessed for the type and severity of the impairment so that appropriate interventions can be planned and implemented. prepare meals. normally absent or soft and smooth at the level of the costal border upon inspiration. and toileting during the immediate postoperative period.0 . Beginning at the upper right sternal border. indicative of a distended bladder. Palpate the area above the pubic symphysis for a smooth. Tenderness along the liver border or in the right upper quadrant may indicate liver tenderness or gallbladder tenderness. Normally. dressing and grooming. progressing up over the ascending colon. or distention (intestinal or bladder). Mark this area. especially noting tenderness (indicative of appendicitis) or protrusion (indicative of umbilical hernia). and handle finances (including writing checks and balancing accounts). clean house. NXP 070106 v1. across over the transverse colon. abdominal muscle guard. These are feeding and eating. These temporary needs require assessment by the nurse. not only while the patient remains in the hospital. the bladder is not palpable. patients recovering from major surgery experience temporary impairments in the ability to perform some ADL. Mark this area. Inc. percuss downward until lung resonance sounds change to the dullness associated with the liver. The College Network. Beginning at the right midclavicular line. Beginning at the umbilicus. Palpate to assess outline and position of organs and to assess tenderness. percuss downward until the sounds of lung resonance change to dull sounds. it is the lower left margin of the liver. walking. beginning at the ileocecal area in the right lower quadrant. eating. but also upon discharge. Age or illness may interfere Copyright © 2008. and down over the descending colon. take medicine. and moving and transferring (or locomotion). Palpate the colon. Beginning in the right lower quadrant. Advancing years or debilitating illnesses may cause permanent impairments. it is the upper left margin of the liver. masses. Palpate the inguinal areas for the presence or absence of tenderness or protrusions indicative of a hernia. percuss upward until tympany changes to dullness. round. perform deep palpation. It is a good idea to percuss the abdomen to obtain an idea of liver size before beginning palpation. bathing and hygiene. Instrumental activities of daily living (IADL) refer to tasks involving the basic tools or instruments of daily life needed to live independently. Measure the distance between the upper and lower marks to estimate the lateral and medial liver span. Mark this area. Gently palpate the liver border. it is the upper right margin of the liver. percuss in a straight line upward until the sounds of tympany change to dullness.Unlawful to replicate or distribute Percuss the abdomen to locate the outline and position of the liver. it is the lower right margin of the liver. Palpate the periumbilical area. ADL assessment is performed upon admission of a client to the hospital or health-care agency and at those points in time when changes are expected. Mark this area. and clock. cerebral hypoxia (e. To test for visual aphasia. Another test of immediate recall is to ask the patient to repeat a sequence of three to eight digits in reverse. It involves attention span. memory problems or confusion. ask the patient to repeat three to eight digits. ask more specific questions. The College Network. Recent memory is assessed by asking a patient to recall today’s events. book. place. an assessment of speech and language. during a resuscitation procedure). Loss of the ability to interpret spoken words is auditory aphasia. The ability to repeat five to eight digits is considered to be within normal limits.g. such as bed. have the patient follow simple commands. and remote. NXP 070106 v1. If there is a suspicion that orientation may be impaired. The ability to recall four to six digits in reverse order is considered to be normal. Speech and language ability has sensory (receptive) and motor components.Unlawful to replicate or distribute temporarily or permanently with a patient’s ability to perform these instrumental activities. or a pencil. Loss of the ability to interpret both written and spoken words is sensory aphasia. Loss of the ability to use words appropriately is called motor or expressive aphasia. Orientation is characterized by correct references to person. This may be assessed by asking a patient the name of their significant other (person). and they are routine for anyone who has experienced a head injury. To test for auditory aphasia. assuming that the nurse has a way of validating the information obtained.. place. and assessment of orientation to person. It may be tested by having a patient name common objects like a wristwatch. such as: • • • Who is the President of the United States? In what city are we? What year are we in? What month? What day? What date? People accept these questions if they are introduced as routine. Sensory ability is either visual (ability to interpret written words) or auditory (ability to interpret spoken words). • For immediate recall.0 . memory. Tell the patient that you will be asking him or her to recall • Copyright © 2008. ability to calculate. Loss of ability to interpret only written words is visual aphasia. the city and state in which the patient resides (place). or time. and the day’s date and time (time). Mental Status Assessment A mental status assessment is part of the neurological examination. have the patient match written words to pictures. Memory may be classified as immediate recall. a pair of eyeglasses. recent. or someone who is reported to have memory problems or confusion. Inc. and time. such as “point to your nose” or “open your mouth.” Motor language or speech ability is characterized by using words appropriately. Start with three digits and build up to eight. Another way is to give the patient the names of three common objects. a person can complete this task within ninety seconds. 37.0 . Remote memory is also called long-term memory. 79. 51. Attention span is assessed by asking a patient to count backwards from one hundred or to recite the alphabet. If recent memory is intact. Eisenhower. Normally. Johnson. Inc. The College Network. 58. Truman. Reagan. The test also may not be valid if English is a second language. Clinton. 2). 65.Unlawful to replicate or distribute Fundamentals of Nursing 25 • the names of those objects later in the interview. Ford. 86. These tests are called the serial threes or the serial sevens. then the test is not a valid test. Calculation ability is assessed by asking a patient to subtract seven or three from one hundred and then to continue subtracting seven or three from each answer obtained (100. Carter. Remote memory is assessed by asking the patient to recall and describe an event from the past. Copyright © 2008. Kennedy. This assumes that the nurse knows the reverse order of Presidents. Roosevelt). However. 9. NXP 070106 v1. Nixon. the patient will be able to recall the objects. Immediate and recent memory are categorized as short-term memory. Bush. also (Bush. 23. 93. Another way is to ask the patient to recall each of the Presidents in reverse order. where there is a suspicion that a person never had this ability in the past. 72. 44. 16. 30. This assumes that the information can be validated. Unlawful to replicate or distribute Copyright © 2008.0 . The College Network. NXP 070106 v1. Inc. along with a brief explanation of Bloom’s Copyright © 2008. it is good to define what teaching and learning mean and to place learning within a particular framework. List the three principles of learning the nurse must consider when preparing to teach a patient. NXP 070106 v1. Thus. Next. 5. Describe intrinsic and extrinsic motivation and readiness. 6. Describe the components of an effective educational objective.0 . A Conceptual Framework for Teaching and Learning Before exploring the principles of teaching and learning. Explain Bloom’s three domains of learning. Define teaching and learning. We then look at principles of learning. Establishing priorities. definitions of teaching and learning follow. we identify Bloom’s classic domains of learning. 3. you should be able to do the following: 1. Inc. and teaching methods are topics discussed. such as motivation. We first discuss how learning occurs. The chapter is concluded by exploring the flip side of learning—teaching. and the learning environment. 4.Unlawful to replicate or distribute Fundamentals of Nursing 27 Chapter 2: Principles of Teaching and Learning Objectives Upon completion of this chapter. writing educational objectives. The College Network. which includes engaging in an internal experience or an evolving process. Key Terms affective domain cognitive domain conclusions extrinsically motivated behaviors intrinsically motivated behaviors learning learning environment motivation psychomotor domain readiness teaching Introduction This chapter analyzes the concepts of teaching and learning. Identify and explain the steps involved in planning a specific educational or learning session. readiness. 2. an intellectual accomplishment (the “ah ha!” experience).” The focus in teaching is on the transmission of new knowledge and skill. glucometer readings. Nurses are often asked to teach health personnel. swimming. and. NXP 070106 v1. Copyright © 2008. comprehending. a collaborative and cooperative process. In 1956. It addresses the intellectual skills of knowing. occurring over time. These skills progress from the simple to the complex. The College Network. Bloom identified three domains of learning: cognitive. in the cognitive domain. 3. and an emotional experience (e. It involves a dynamic interaction between the teacher and the learner..Unlawful to replicate or distribute three domains of learning. giving an injection. In the psychomotor domain. The affective domain is involved with emotional responsiveness. For example. selfadministration of insulin. and psychomotor (Anderson and Sosniak 1994). The latter classification helps us conceptualize the various kinds of learning. affective. 2008). patients with diabetes mellitus need thinking skills as they master their diet and its exchanges. According to Berman et al. Skiing. There are many ways in which learning occurs. The psychomotor domain addresses motor skills. Learning is “a change in human disposition or capability that persists and that cannot be solely accounted for by growth” (Berman et al. and appreciation.g. Inc. patients with diabetes need to accept their condition in an emotionally healthy manner.0 . and inserting a catheter are psychomotor skills. an evolving process. The term “appreciation” is used here as in art or music appreciation. Learning is • • • • • • • an internal experience. In the affective domain. Practicing nurses are often asked to assist with the instruction of nursing students. although the results or effects are visible. The cognitive domain is involved with thinking. Each of these domains may be applied to client education. occurring as a function of experience and a reflection upon experience. The focus of learning is on the acquisition of new knowledge and skill. attitude. 1. emotions. the sense of accomplishment that accompanies successfully ice skating or bicycle riding for the first time). in some cases. teaching is “a system of activities intended to produce learning. (2008). an experiential event. patients with diabetes need to master finger sticks. 2. the discovery of the meaning and relevance of ideas. This domain addresses feelings. Teaching occurs with individual clients and families and in the community. and applying knowledge. Level of motivation. Anesthesia. To accommodate the child’s readiness to learn. motor coordination. we can speak of three domains of readiness to learn: 1. a young child may not be cognitively ready to learn dosage amounts. Higher levels of intrinsic relative to extrinsic motivation predict successful cessation of smoking and weight loss. type of motivation and level of self-esteem are determinants in health. depression. Intrinsic and extrinsic refer to the origins of the desire to engage in a particular behavior. and some sedatives may interfere with cognitive readiness to learn. Copyright © 2008. extrinsically motivated behaviors are a response to external rewards or punishments. 2. 2. Higher levels of self-esteem are generally associated with more intrinsically motivated people. but also to an ability to learn. 3. Inc. Such emotional issues have to be addressed before a person is affectively ready to learn. NXP 070106 v1. and sensory acuity. The client’s motivation to learn The client’s readiness to learn The learning environment Motivation to learn refers to a desire to learn. At this point. 3. a better moment for teaching must be selected. A client with diabetes mellitus needs or wants to know about the condition when diagnosed with diabetes. Three principles of learning need to be considered: 1. In such cases.Unlawful to replicate or distribute Basic Principles of Learning In preparing to teach a patient. the child’s mother may prepare the dose and allow the child to administer it. but also how the patient learns. we say the client is motivated to learn. the nurse not only needs to know how to teach. Nurses can target specific interventions with a better understanding of how a person is motivated. A client must also be affectively (emotionally) ready to learn. People learn when they experience a need. A person learns how to use a VCR when they need or want to see videos. A client needs to be cognitively ready to learn. or grieving over a perceived loss of wellness are emotional conditions or responses that impair learning. For example. energy. Readiness to learn refers not only to motivation to learn.0 . Intrinsically motivated behaviors are ones for which the rewards are internal to the person. but may have sufficient psychomotor readiness to self-administer the injection. The need for physical readiness to learn is apparent in working with clients with Type I diabetes mellitus. Ask if the client is thinking in a sufficiently clear manner to learn. The College Network. narcotics. Just as there are three domains of learning. A client must be ready to learn from a psychomotor or physical development point of view. Severe anxiety. A person learns how to surf the Web for medical or nursing information when they need quick access to information. Psychomotor readiness to learn involves adequacy of muscle strength. Also. readiness to learn. the nurse provides for adequate lighting. foot care. the nurse recognizes the need for privacy and provides it.Unlawful to replicate or distribute The learning environment is an essential part of learning. develop educational (or learning) objectives. calculating the proper insulin dose. preventing hypoglycemia. this means that the nurse selects time when patient visitors will not interrupt learning. recognizing hypoglycemia. Inc. When selecting the length of the session. When selecting the time. the length of the session. In teaching clients. and selecting content and methods (analogous to identifying interventions). the most basic of all needs in Maslow’s hierarchy.g. a nurse may elicit client interest areas or encourage a client to rank content areas from a list generated by the nurse. These steps are analogous to the planning phase of the nursing process.. Again. Maslow ranks content that addresses safety needs next. in teaching clients various procedures. preventing hyperglycemia). The College Network. eye care. which the nurse ranks according to the patient’s interests (e. consider the client’s energy level and the workload of the nurse. quiet. Maslow’s hierarchy of needs may be used to help establish teaching priorities. That is. These tasks have the same relative priority level because they address physiologic needs. Subsequent planning involves understanding the basic principles of teaching. In education. learning is promoted if students have a role to play or some choice in setting the teaching/learning priorities. treating hypoglycemia. Write Educational Objectives Once priorities are established and a time has been assigned for the class. Schedule and Plan Schedule and plan for the teaching and learning session or class. NXP 070106 v1. the nurse may give the client a list of content areas that include fingersticks. comfortable room temperature and air ventilation. learning is maximized if these objectives are a collaborative effort on the part of the client and nurse and the client’s family. Words like Copyright © 2008. the client is motivated and ready to learn insulin self-administration. Determine the date and the time of the session. Learning objectives are to be stated behaviorally. reading a glucometer.0 . e. Basic Principles of Teaching Steps in planning a specific educational or learning class or session involve establishing teaching priorities. and adequacy of the learning environment leads to the formation of conclusions (diagnoses). Therefore. establish priorities. or evening sessions. In the hospital. consider the client’s preference for morning. and minimal interruptions. and the interval between sessions (if more than one class is planned). they must be demonstrable. Intervals between sessions may depend on the length of the patient’s hospital stay. After the client successfully learns content in this area.g. and recognizing signs of hyperglycemia. drawing up and administering insulin. The content areas that the client ranks may have the same relative priority level.. minimal distraction. For example. writing learning objectives (analogous to patient goals and expected outcomes). afternoon. Establish Priorities First. Assessment of the client’s motivation to learn. using proper technique. the client will be able to draw up the right dose of insulin into the insulin syringe.g.g. demonstrates.g. using proper technique. culture. There are many methods of learning: lecture. the client will draw up the right dose of insulin into the syringe. the client will draw up the right dose of insulin into the syringe. current. Thus. Mastery of simple content is needed before progressing to the complex. The client needs a hands-on experience under supervision because insulin Copyright © 2008. discussion.” Guide Content with Objectives Content needs to progress logically. 3.. reading with question and answer periods. the client will draw up the right dose of insulin into the syringe. “By the end of this session. “By the end of this session. computer-assisted learning.. At the end of this teaching/learning session.0 . use behavioral terms that can be observed. Build on what the patient already knows. It is logical to begin with the gathering of equipment needed. articulates. illustrates. handouts. Insulin pumps and sophisticated dosing methods are complex information. e.. using proper technique. an appropriate objective for a client learning to self-administer insulin is. using proper technique. and psychomotor ability. e. and practice or demonstration/return demonstration. and cognitive. begin with a low-level anxiety issue and progress to a higher-level anxiety issue when the client shows a readiness to handle more anxiety-producing material. Instead. reads. Objectives are best if they contain an expected outcome within them. “By the end of this session. e.” Modifier (if necessary). It may be a year or two before this newly diagnosed. Address anxiety as it arises. the client will draw up the right dose of insulin into the syringe. 2. Select Appropriate Teaching Methods The content being taught to a great extent determines the methods of teaching. progress from what the client knows to what the client does not know. Content must also focus on the significant or relevant elements.Unlawful to replicate or distribute “understanding” are to be avoided because understanding cannot be observed. e. or a handout. For example. it would not be logical to begin a session on insulin administration by discussing how to dispose of the syringe and needle after use. but in general. guided or discovery learning. role-playing. Of course. discusses. Schedule sufficient time for questions and answers. expresses.” Time period needed to accomplish objective. video. The College Network. A client learning how to administer insulin needs more than a lecture. Note that the objective contains four parts: 1.. injects. affective. insulin-dependent diabetic client decides he wants to explore insulin pumps. etc. and adjusted to the client’s age. 4. NXP 070106 v1. In other words. It is not relevant content for the person who is learning to self-administer insulin for the first time.g. Inc. Teach basics before showing the client how to adjust the basics. discussion. using proper technique. this would not be the only objective. e. Client behavior.” Observable behavior.g.. “By the end of this session. There are other principles involved in choosing content. video. but it serves as an example. modeling. It must be accurate. withdraws. watch and then evaluate how well the client has mastered this skill. in this particular case. When the client shows evidence that he can perform the skill correctly and then repeat the correct performance.Unlawful to replicate or distribute 32 Fundamentals of Nursing administration is a psychomotor skill. but the psychomotor component must be taught for learning to occur. the skill has been learned. for each behavioral objective. are excellent methods of teaching psychomotor skills to clients learning any self-care procedure. Demonstration and return demonstration. Inc.0 . Copyright © 2008. Evaluation Evaluation depends on the degree to which the client achieves the behavioral objectives. and evaluate the last performance of the day. if the objective is that the client will draw up the right dose of insulin into the syringe using the correct technique. Allow the client time to practice as needed to perfect the skill. It does have cognitive and affective components. “Did the client achieve this objective?” For example. The College Network. ask. demonstrate how insulin is withdrawn into a syringe and then ask the client to return the demonstration. Learning can be considered retained if the client can perform the same skill the following day without coaching. For example. NXP 070106 v1. Allow for practice with the same skill. along with practice. In other words. it Copyright © 2008. 8. and Illness Berman et al. sickness and disease. Wellness. Provide examples of developmentally related health problems from infanthood through adulthood. Although this chapter covers considerable content. and Illness Objectives Upon completion of this chapter. 3. promotion. it may be necessary to relate the major concepts and approaches to real-life situations with which you are familiar. NXP 070106 v1. To master this content. wellness. and health behaviors. 9. wellness. health beliefs. wellness and illness. and factors that influence health behavior change. and ecologic models of health and illness. it is logically related. health beliefs. 7. their tendency to engage in healthy behavior. Key Terms adaptive model agent clinical model environment eudemonistic model health behaviors health beliefs Health Belief Model Health Promotion Model health status host locus of control role performance model self-efficacy theory sick role Introduction This chapter covers such topics as general models of health. Explain the various models used to examine a person’s beliefs about health. The College Network. Differentiate between illness. Compare Travis’s illness-wellness continuum with Dunn’s high-level wellness grid.Unlawful to replicate or distribute Chapter 3: Theoretical Models of Health. (2008) described a variety of models that relate to health. Describe four models of health. Wellness. and environment.0 . and illness. Describe Parsons’s sick role. 4. 5. Models of Health. 2. Define health status. Inc. The clinical model most narrowly defines health as the absence of disease. and behavior change models. you should be able to do the following: 1. and illness. Explain the relationship between the agent. host. 6. the concept of wellness. continuums of health. Relate wellness to personal responsibility. body. When the health status (meaning stable/unstable) is questioned. NXP 070106 v1. These definitions are consistent with the eudemonistic model of health as well-being. or it can refer to condition. with its responsibilities and expectations. means the resumption of one’s social role. in which emphasis on disease treatment outweighs emphasis on health promotion and disease prevention. The aspect of the person’s health this definition refers to depends upon the context in which the phrase is used.0 . or satisfactory. Health status is sometimes used in terms of a patient’s level of alertness (e. mental. The eudemonistic 1 model focuses on health as well-being. giving up the sick role. 2008). Florence Nightingale defined health as “being well and using every power the individual possesses to the fullest extent. a sociologist. and self-actualization. semi-comatose). the expected response is that a nurse should report on the patient’s vital signs. Sometimes it refers to whether the patient is in a stable or unstable condition. and self-actualization. There is an alternative spelling: eudaimonistic. The adaptive model views health as adaptation to the physical and social world in which a person lives. The latter is used by Laffrey (1986). Conversely. Related Health Concepts: Health Status. or expectations. self-fulfillment. and social well-being and not just the absence of disease” (Berman et al. This spelling is supported by others who write in nursing literature. He found that the assumption of the sick role confers upon the person a release from his or her usual roles. This is consistent with the adaptive model or view of health. moderately. Copyright © 2008. such as critical. This clinical definition of health might also be called a traditional definition. The role performance model views health in functional terms: “If I can function. and spirit. and presumably assuming a well role. Talcott Parsons.” We will now compare these definitions with other commonly employed or referenced definitions. and views disease as maladaptation. Health Beliefs. and Health Practices Health status refers to a person’s health state or condition at one particular point in time. Thinking of health in terms of the ability to function within one’s role is the role performance model of health. Sister Callista Roy.. MerriamWebster’s Collegiate Dictionary defines health as “a condition of being sound in mind. who developed a Health Conception Scale. alert. responsibilities. fair. or severely ill. thinks of health as adaptation and of illness as maladaptation.g.Unlawful to replicate or distribute often limits the analysis to physiologic systems. especially freedom from physical disease or pain. Inc.” The World Health Organization defines health as a “state of complete physical. self-fulfillment. I am healthy. who developed Roy’s Adaptation Model. as in mildly. it may 1 This is the spelling provided by Berman (2008). Sometimes it refers to acuity. Finally. serious. To define health as the absence of disease is called a clinical model. studied the sick role. The College Network.” Only secondarily does Webster’s define health as well-being. confused. translates to some people being internally controlled and others externally controlled. Therefore. when applied to nursing. So. Research is needed to determine what means are most effective in moving a person from Copyright © 2008. stressed. These are the locus of control model. Health Promotion. Locus of Control Model Jullian B. the health professional helps to provide or build in external reinforcement or positive rewards in response to healthy behavior change. fatigued. using child safety seats.or health-protecting behaviors are looking both ways before crossing a street. they are more likely to do it than the person who believes they can’t. which. they do it. protect health.0 . Self-Efficacy Theory Developed by Bandura (1977. 1997). Pender’s Health Promotion Model. their tendency to engage in healthy behavior. if a person believes they can quit smoking. keeping immunizations up to date. The College Network.g. Rotter developed the locus of control model in 1966. The former believe they can change their own behavior (internally controlled). Examples of disease-preventing behaviors are practicing safe sex. or prevent illness and disease. There are also government health-protection standards and those developed by industry. So. and having home fire detectors and extinguishers. the health professional helps internally controlled people build up internal rewards. Health behaviors refer to actions taken to promote health. Health beliefs refer to health-related convictions. The Aymara of the Bolivian altiplano (high plateau) believe that loss of blood is associated with loss of the person’s spirit. wearing seat belts. Health Beliefs. and sufficient rest. and Prochaska and DiClemente’s Stages of Behavior Change Model. undernourished. anxious. Applied to health promotion. driving safely. NXP 070106 v1. and conducting monthly breast or testicular selfexaminations. self-efficacy theory. and factors that influence health behavior change. using sunscreen. they hesitate to have blood drawn for laboratory purposes or to donate blood to a blood bank.Unlawful to replicate or distribute refer to a descriptor related to a patient’s health condition (e. and Health Behavior Change Models A number of models examine a person’s beliefs about health. The latter believe that factors or forces external to them are responsible for any change that occurs (externally controlled). Externally controlled people require external motivators. the self-efficacy theory simply says that if a person believes they can do it. depressed). adequate exercise. Internally controlled people are selfmotivated or self-directed in effecting healthy behavior change. Examples of personal life. Examples of health-promoting behaviors include a healthy diet. Rosenstock and Becker’s Health Belief Model.. Health beliefs reflect the influence of a person’s culture and can also influence the health behaviors of a group or person. Inc. Individual characteristics and experiences (prior related behaviors and personal behavioral. knowledge about the disease) − Perceived threat of disease − Cues to action (e. action barriers. illness of relative. but its emphasis is on health promotion behavior change (Berman et al. news articles. examines three categories of variables: 1. psychologic. Pender incorporates self-efficacy in her Health Promotion Model. friend. The model examines the following: • • Individual perceptions (perceived susceptibility to and perceived severity of the disease) Modifying factors − Personal o Demographic characteristics (age.) o Structural characteristics (prior experience with health-care providers and/or the disease. it may be applied to health-promotion. peer pressure. or disease-prevention behavior change. Therefore. etc. It. and health-promoting behavior) 3. commitment to an action plan. The College Network. social reference groups.g. and activity-related affect as well as situational and interpersonal influences) Behavioral outcomes (immediate competing demands. Copyright © 2008.. 1992) Stages of Behavior Change examines any kind of behavior change. 2.Unlawful to replicate or distribute 36 Fundamentals of Nursing a low to a high self-efficacy level. or prominent figure) Likelihood of action variables (perceived benefit and perceived barriers to health behavior change) • Health Promotion Model Pender’s (1996) Health Promotion Model shares similarities with the Health Belief Model. health-protection. selfefficacy. Health Belief Model Rosenstock and Becker’s Health Belief Model (1974) examines motivational influences on health behavior change as it relates primarily to compliance with a treatment regimen for a disease. Inc. NXP 070106 v1.) o Sociopsychologic characteristics (personality. education. etc. income.. Stages of Behavior Change Prochaska and DiClemente’s (1983. gender. too. which is presented below. health professional prompting. 2008). media advertising.0 . acquaintance. and sociocultural factors) Behavior-specific cognitions and affect (perceived barriers. actively participate in their own recovery. Wellness—A Concept Directly Related to Personal Responsibility High-level wellness requires making healthy lifestyle choices daily to maximize one’s health potential. High-level wellness requires making those parental and personal decisions needed to promote the achievement of life’s developmental tasks. However. The costs of change outweigh the benefits. there are some individuals who may never arrive at this stage and require lifelong maintenance. If relapse does occur. the individual experiences freedom from the prior behavior to the extent that the individual feels that the issue never existed. exercise to maximize physical fitness. Each of the following developmental stages looks at the many parental or personal behaviors required for a healthy life as viewed by leading scientists and psychologists. the person is considering change. the person continues to integrate the change into daily life. The College Network. improve stress management techniques and communication skills). and practice stress management techniques. 2. During the preparation stage. as suggested by Leighton (1998). and engage in positive mental health practices (e. During the maintenance stage. attend health education classes. Cognitively and behaviorally. all while continuing under medical care. incorporate preventive health care (e. There are also organized wellness programs in which clients join support groups. High-level wellness requires deciding to modify those behaviors that place a person at high risk of injury or illness. 6. Inc. 4. 3. make healthy food and nutrition choices.. NXP 070106 v1.. Examples of these healthy choices are to allow for sufficient rest and sleep. The actual change occurs in the action stage. the person has decided that the benefits of the change outweigh its costs.0 . To prevent its occurrence. self-testicular examination) into one’s schedule.g. Strategies are initiated to effect the change. Examples designed to decrease the risk for injury or illness include using seat belts and practicing safe sex. recreate. the strategies initiated in the action stage may need to continue for months or years. the person begins to plan the change.Unlawful to replicate or distribute Its stages are as follows: 1. During the termination stage. In the contemplation stage. Copyright © 2008. immunizations. practice good hygiene. discuss healthy choices. Cardiovascular rehabilitation is one example. Such programs in whole or in part are common.g. self-breast examination. then the person reenters the change process at the precontemplation or contemplation stage and moves forward again. The precontemplation stage. 5. Relapse may occur. share commitment and motivation. in which the person is unready for change. The costs and benefits are being weighed. This model includes the following levels of wellness: physical. its signs and symptoms. environmental. social. Hamrik.1 The Health–Illness Continuum ¼ Illness » » » » » » » ¼ ¼ ¼ ¼ ¼ ¼ Health Travis’s Illness-Wellness Continuum In 1988. Inc. John W. On the other hand. and Rosato model. and premature death. These levels of health can be examined independently. to achieve higher personal levels of health. and work. (2008) describes the Anspaugh. the integration of body-mind-spirit. Movement toward wellness is characterized by passage through increasing wellness awareness. Copyright © 2008. the person chooses healthy lifestyles and makes healthy choices regarding food. This concept helps the nurse to work with patients or groups. wellness education. intellectual. a philosophy or way of life. rest. lack of a wellness orientation that inhibits the person from engaging in wellness behaviors may lead to premature death. Wellness. but a relative placement along a continuum of health and illness. NXP 070106 v1. and high-level self-acceptance. sleep. occupational. Figure 3. In the wellness model. exercise. well or ill. The College Network. a patient with a chronic disease may consider themselves healthy compared to where they were six months ago or compared with a friend who has the same condition. and emotional. but each level overlaps in the human person. Continuums and Grids Relating To Health.0 .Unlawful to replicate or distribute 38 Fundamentals of Nursing Berman et al. For example.” Their reasoning was that wellness is a choice. and wellness growth and away from disease. The person actively seeks out and engages in healthpromoting behaviors. and Illness The Health-Illness Continuum The health or illness status of a person is not an absolute state. spiritual. Travis and Regina Sara Ryan differentiated the term “wellness” from the term “health. Unlawful to replicate or distribute Figure 3. Inc. Dunn does not emphasize distinctions between health and wellness as Travis does. Dunn looks at the person within the context of the family. 2008) Dunn’s High-Level Wellness Grid Dunn (1973) looked at two dimensions. The other is the wellness-death dimension. The College Network. varying from favorable to unfavorable. One is environment. Copyright © 2008.2 Travis’s Illness-Wellness Continuum (Berman et al. community. NXP 070106 v1..0 . and society. The outer layer consists of factors that surround the self.3 Dunn’s High-Level Wellness Grid Very Favorable Environment LUQ Death RUQ Peak Wellness LLQ RLQ Very Unfavorable Environment RUQ = right upper quadrant. poor health. infants born with AIDS because mothers did not receive AZT during pregnancy) (Berman et al. a fetus infected with HIV. The role of the nurse is to assist the patient in achieving inner balance among the four domains and to mitigate the negative influences. when not in excess.g. physical. finances. 2008) The 4+ Model of Wellness The 4+ Wellness Model consists of two layers. and spiritual. flood victims exposed to high levels of stress who are provided with crisis intervention. Visualizing wellness in this manner is intended to help the nurse identify factors that deplete or nurture wellness. such as the environment. shelter. Strengths within one domain. emergent wellness in a less than favorable environment (e. communities. in a very unfavorable environment (e. and social resources needed to survive and rebuild) LUQ = left upper quadrant.0 . nutrition. but in a very favorable environment (e. and many other external systems. culture. whether inner or outer. safety.. NXP 070106 v1. poor health. Depletion within any domain weakens the other domains. health. but whose mother receives AZT during pregnancy and infant is born HIV negative) LLQ = left lower quadrant. people engaging in positive health behaviors and living within functional families. moving toward death. Inc.g.Unlawful to replicate or distribute Figure 3.. Copyright © 2008. education. strengthen other domains.g.. world events. emotional. and societies) RLQ = right lower quadrant.g. The College Network. One layer concerns the inner self and consists of four domains: the intellectual. peak wellness in a very favorable environment (e. moving toward death. while nurturing the positive inner strengths and outer influences. Excess within any domain creates an imbalance within the self. The inner self interacts with and engages with the systems in the outer layer. Excessive striving within any one domain can be destructive to wellness within all domains.. Sickness is the opposite of wellness. and disease are related but not synonymous terms. NXP 070106 v1. host. Copyright © 2008. sickness. An illness is an unhealthy state or condition of the mind or body in which physical. For example. illness or disease occurs due to an interaction between the diseasecausing agent. as in.4 The Agent. a state of not being well. or spiritual functioning is compromised. This model is called an ecologic model because it looks at the agent. animal. Sickness. but. • • • A disease is a specific pathologic state with defined signs and symptoms. and environment within an interactive system where each component is interdependent on the other. it has also entered the vernacular to mean disgust. It may be used as a conceptual nursing or health education model as well. causing illness in a person (host). or insect hosting the disease. intellectual. For example. emotional. Host. take the case of a nurse or health educator (change agent) who brings to people (hosts) concepts and practices that prevent illness within their homes and the community (environment). A discussion of the ecologic or epidemiologic model of health and illness facilitates this transition. “That kind of vulgarity makes me sick. they do help us clarify the distinctions. bacteria (the agent) are more likely to grow and flourish in an unhygienic kitchen (environment).” While these definitions overlap to some extent. the person. The College Network. Figure 3. Now we will discuss the concept of illness.Unlawful to replicate or distribute Ecologic or Epidemiologic Model of Health and Illness We began this chapter discussing health and wellness.0 . It is called an epidemiologic model because it looks at the causes of and influences on disease. Illness A Comparison of Terms: Illness. and Disease The terms illness. Inc. and the environment in which both the agent and the host exist (Leavell and Clark 1965). social. Environment Triad Agent Host Environment In the ecologic model. 1 Examples of Developmentally Related Health Problems Developmental Level Infants Developmentally Related Health Problems • Crying (more than one to two hours of crying or fussiness/day) and/or colic • Failure to thrive • Child abuse. and injury. alcohol. develop a disease.1 presents a list of developmentally related health problems. Inc. Table 3. then those persons are said to be at increased risk.g. including shaken baby syndrome • Sudden infant death syndrome • Respiratory tract infections • Ear infections • Dental caries • Strabismus and amblyopia • Accidents are leading cause of death • Respiratory tract infections • Other communicable diseases • Ear infections • Dental caries • Congenital defects are frequently corrected surgically during this time period • Accidents remain the leading cause of death • Communicable disease. e. Developmental level influences the risk of illness. lice) • Accidents • Substance abuse (drugs. Table 3.. nicotine) • Homicide/violence • Motor vehicle crashes • Nonmotor accidents. sports • Dental caries • Malalignment of teeth requiring orthodontics • Increasing incidence of obesity and hypertension • Child abuse • Prolonged or unresolved grief • Depression • Suicide attempts. This list is not exhaustive. including impetigo • Dental caries • Infestations (scabies. The College Network. disease. thoughts • Homicide/violence • Substance abuse Toddlers Preschoolers School-aged children Adolescents Copyright © 2008. but demonstrates the fact that groups of people are more or less vulnerable to various health problems as a function of their developmental and age categories. NXP 070106 v1. roller blades.0 . or have an accident is greater than what would be expected in the population as a whole.Unlawful to replicate or distribute The Effects of Age on Illness and Injury When the probability or chance that people in certain groups will become ill. swimming. Financial threat may loom. Other psychological issues may be anxiety. or discomfort. loneliness. need for increase in time to complete tasks. sickness. Illness of a family member impacts the family as a whole. cognitive dysfunctions. 2008) Illness Effects In addition to the physical effects of illness. sports related. NXP 070106 v1.0 . psychological functioning. work.Unlawful to replicate or distribute Table 3. prolonged illness. Tasks increase. A sense of separation. decrease in earning ability. Spiritual issues may arise.. understanding of the self.g. inability to recover. Customs and routines are interrupted. isolation. According to Parsons. carries with it responsibilities that include a search for the health care needed to Copyright © 2008. school. or loss may occur. battered woman syndrome) Testicular cancer Accidents (motor vehicle. boating) Homicide/violence Suicide attempts or thoughts Obesity Alcoholism Cardiovascular disease Cancer Accidents Mental health difficulties Chronic illness/disease (e. a sociologist. including questioning the meaning of suffering.g. Roles change. arthritis. Inc. illness causes varying degrees of change in role performance. Sickness at least partially excuses a person from ordinary role functions within home. e. The College Network. mild to severe hearing and vision impairment. spiritual integrity. family relationships. The Sick Role Talcott Parsons (1972). including fear of decreased functional ability. osteoporosis. and loss of autonomy or control. which begins with the experience of signs or symptoms of illness and the assumption of the sick role. self-concept. cardiovascular disease. or other social settings.. Psychological and spiritual issues may arise. chronic obstructive pulmonary disease. Alterations in the way a person relates to his or her own self may be expressed in changes in body image.. irritability. or death. and depression. pain.g. Alterations in role performance may include self-care deficit. such as fatigue. dementia) Middle-aged adults Older adults (Berman et al. and finances.1 Examples of Developmentally Related Health Problems Developmental Level Young adults Developmentally Related Health Problems • • • • • • • • • • • • • • • Hypertension Sexually transmitted diseases Substance abuse Domestic violence (e. or self-esteem. described the role a person assumes when feeling sick. and participation in recovery and/or rehabilitation behaviors.0 . NXP 070106 v1. The College Network. the patient is expected to assume responsibility for getting well as quickly as possible. In other words. Copyright © 2008.Unlawful to replicate or distribute 44 Fundamentals of Nursing recover. dependence on health-care providers for recovery. Inc. Explain informed consent. NXP 070106 v1. 13.Unlawful to replicate or distribute Chapter 4: The Law and Nurse and Patient Rights and Responsibilities Objectives Upon completion of this chapter. Describe what is included in a state’s nurse practice act. Explain the need-to-know aspect of patient confidentiality. 15. Explain why it is important for nurses to have a basic understanding of the law. Discuss the five basic rights used to protect human research subjects. 5. Discuss the purpose and focus of the ANA Code of Ethics for Nurses with Interpretive Statements. Discuss the central ethical issue in the Cruzan case. Define torts and provide examples of intentional and unintentional torts.0 . 3. Differentiate between criminal and common law. 6. 12. The College Network. Explain the two types of restraints and provide nursing-specific examples for each type. List and define the four specific elements that must exist beyond a reasonable doubt and in a court of law to prove that a nurse committed malpractice. 4. you should be able to do the following: 1. 2. 10. 7. Explain the purpose of advance directives and describe the various types. Inc. 11. Copyright © 2008. 14. Define at least four implications of the Health Insurance Portability and Accountability Act (HIPAA). Explain the difference between civil and criminal law. Identify clients’ legal rights guaranteed by the Patient’s Bill of Rights. 9. 8. We also consider clients’ rights when they are involved in human subject research and the issues of informed consent. We then build on these legal issues related to nursing by identifying and discussing basic legal rights of clients in the health care system. gross negligence. This chapter explains why it is important for nurses to understand specific aspects of the law. The Code Copyright © 2008. Inc. themselves. we investigate the different types of legal advance directive documents that can be prepared by people when they are mentally competent. In addition. we explore nurses’ responsibilities to their patients. and their profession. NXP 070106 v1. The critical nursing role of an advocate is discussed and specific examples of advocacy are identified. We also discuss the definition of a “do not resuscitate” order and its usual location in a client’s chart. We then investigate the definitions of intentional and unintentional torts and provide nursing-specific examples for each type of violation.Unlawful to replicate or distribute 46 Fundamentals of Nursing Key Terms abandonment advance directive advocate American Nurses Association Code of Ethics for Nurses with Interpretive Statements assault battery breach of duty character defamation chemical restraints civil law common law criminal law do not resuscitate order durable power of attorney false imprisonment felony fraud gross negligence health care proxy Health Insurance Portability and Accountability Act of 1996 informed consent invasion of privacy law libel living will malpractice misdemeanor Nancy Cruzan case negligence nurse practice act Patient Self-Determination Act Patient’s Bill of Rights physical restraints power of attorney PRN professional liability right to anonymity and confidentiality right to fair treatment right to privacy right to protection from harm and discomfort right to self-determination slander statutory restriction tort Introduction Law refers to the principles and regulations established by authorities in a community and applied to its people. We also consider unintentional torts and issues of nursing negligence. The College Network. we look at particularly sensitive nursing areas such as the use of restraints and the issue of patient confidentiality.0 . Finally. The chapter concludes by defining the elements of the American Nurses Association Code of Ethics for Nurses with Interpretive Statements. and malpractice. It can be in the form of legislation or customs and policies enforced by judicial decisions. In the section on intentional torts. We begin by comparing and contrasting the two primary subdivisions of law that directly relate to nursing: civil law and criminal law. is concerned with issues that arise between individuals or businesses. Inc. Primary Types of Laws There are two primary subdivisions of law that directly apply to nurses: civil law and criminal law. including the revocation of a nursing license. A violation of law can result in severe penalties. Criminal law is a type of public law that is designed to protect society (the public) from harmful and criminal acts of individuals. legal action (also known as a lawsuit) can be brought against another person. Copyright © 2008. It is important for nurses to have a basic understanding of the subject of law because law governs most actions in nursing. This includes the accumulated decisions made by various courts. Nursing and the Law Law is the branch of knowledge that deals with rules and regulations. Civil Law If one’s person or property has been violated in some way. this includes the community of the nation. Civil law is also considered private law.0 . colleagues. and national). A violation of ethical principles related to nursing can make nurses legally liable for their actions as well.” Law is all the rules of conduct established and enforced by various governing bodies and authorities (local. a basic understanding of law makes the nurse a more informed citizen. NXP 070106 v1. One specific example of law governing nursing practice is the nurse practice act from the state that the nurse works in.Unlawful to replicate or distribute provides detailed guidelines to govern nurses’ responsibilities and obligations to patients. which generally involves the protection of both the person and personal property. People or businesses are considered guilty in a civil court of law if there is a preponderance of evidence against them. The College Network. or a business for breaking a civil law. Nurses are morally and ethically responsible for their actions. employers. Penalties for violations of civil law might include compensation in the form of monetary remuneration and repair of any damages incurred. but it is important for nurses to have a working knowledge and understanding of some basic concepts in order to better understand their own legal responsibilities to patients and to ensure that patients are protected from injury or harm. state. like the health care community in general and the nursing community in particular. and society. a group of people. state. The language of law may seem foreign. Civil law. Laws are generally based on community needs. The word “law” literally means “laid down” or “settled. and locality where one lives and the various communities to which one belongs. In a more general sense. Both assault and battery violate one’s right to personal safety and security. but depending on the circumstances. Torts can be classified as intentional (willful with the intent to cause injury or harm) or unintentional. or some other type of damage affecting another person or a group of people.1 Torts Intentional torts • Assault • Battery • Abandonment • Character defamation (libel and slander) • False imprisonment • Fraud • Invasion of privacy Unintentional torts • Negligence • Malpractice Intentional Torts In the legal sense.0 . Even if the person did not intend to shoot the gun or would not be able to injure anyone with the gun because it was not loaded. Table 4. physical damage or injury. or it can occur without assault having taken place.Unlawful to replicate or distribute A violation of a civil law that results in personal injury or personal property damage is called a tort. An example of assault is threatening another person with a gun (loaded or unloaded).1 lists common torts that have occurred or could occur in nursing. Threatening and physically abusing a patient is an example of assault and battery that could be tried in a criminal court rather than a civil court. an assault is an intentional verbal threat or an attempt to inflict physical harm on someone that results in a reasonable and present fear of immediate physical danger. Battery implies that there was no verbal or implied consent to the physical contact that occurred. This can include verbal damage that results in psychological trauma. The College Network. NXP 070106 v1. Table 4. Inc. or even economic damage or loss. an injury. they may also be considered violations of criminal law. The use of force to defend oneself or others is usually not considered battery. It can be the completion of an assault. Physically restraining a resident and forcing the resident to eat or drink could be considered battery. Copyright © 2008. Battery is any unjustified and intentional application of force. An example of battery would be slapping another person’s face or physically forcing someone into a chair. A tort can be a wrongful act. the person threatened would have no way of knowing that. A tort generally involves a violation of a personal right and is the most common violation of law in nursing practice. Assault and battery are usually considered violations of civil law. Unlawful to replicate or distribute In health care, the most common case of abandonment is leaving a patient unattended. A patient admitted to a busy emergency room, placed on a stretcher, moved to the end of the hall, and forgotten by the ER staff could charge the hospital as well as an individual health care worker with abandonment. Abandonment can also be charged if a health care professional begins emergency first aid at the scene of an accident and then leaves the scene before another competent health care worker arrives to take over. Character defamation means attacking or injuring the reputation of another person by making false and malicious statements. Two specific types of character defamation are libel and slander. Libel is defamation of character that occurs through printed statements, including written words, photos, or some other representation of the person (for example, a cartoon). Slander is verbal defamation of a person’s character. Character defamation violates the right to maintain and enjoy a good reputation. There are frequent examples of character defamation in the media today, especially in relation to celebrities who sue tabloid newspapers for libelous statements about them. People running for political office may experience character defamation in the form of slander. Examples of libel in nursing might involve false statements written about a patient in a chart. Slanderous statements might also be made about a patient by one nurse to another nurse and overheard by the patient or the patient’s relative. Verbal character defamation of a coworker can also constitute slander. False imprisonment, or unlawful detention, is another common tort. To imprison means to restrict, limit, or confine in any way. To detain means to keep from going on or to hold back. With this tort, imprisonment or detention must have occurred against the person’s will. The detention or imprisonment also must have prevented the person from moving about freely and must have been accomplished by threat, force, or command. False imprisonment violates a person’s right to personal liberty or freedom. In health care settings, it is usually considered a violation of civil law. In nursing, an example of false imprisonment is applying some type of restraint (for example, a wrist or waist restraint) on a patient without a physician’s order and for the convenience of the nursing staff. There are two types of restraints: physical restraints and chemical restraints. Physical restraints include cloth devices that limit movement of one’s hands, extremities, or torso. Side rails are considered a physical restraint if they are used for reasons other than mobility; half side rails may be considered an assistive device rather than a restraint but must be specifically ordered as such. Chemical restraints are medications given to prevent or moderate certain behaviors like agitation or physical violence. These are usually psychotropic medications. There must be a medical reason for a chemical restraint, like a diagnosis of dementia with severe agitation. Restraints might be ordered if there is a reasonable fear that patients might harm themselves by pulling out an intravenous line or a feeding tube, for example. In rare instances, a patient might be restrained for striking other patients or staff; for example, a patient in an emergency room who exhibits violent behavior might be restrained. The general rule for restraints is that all possible alternatives must be explored. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Most nursing homes and hospitals now have restraint-free environments or are working toward this goal. If physical restraints must be used, the only valid and legal reason for their use is to protect patients from harming themselves. A physician’s order is always needed for a restraint, and the order must include the type of restraint, the reason for the restraint, the length of time the restraint is to be applied, and criteria for restraint removal. Restraints cannot be ordered PRN. (PRN means on an as-needed basis; a PRN order for a restraint would mean that the nurse could decide whether to use the restraint.) Only in an emergency situation would a nurse be justified in using a restraint without a physician’s order. Research has shown that restraints have contributed to falls and other injuries that might have been more severe than injuries that could have occurred if the patient had fallen without being restrained. Improper use of restraints can result in health professionals and institutions being charged with negligence if injury to a patient occurred and also with assault or false imprisonment if evidence indicates that a restraint was not needed. Regulatory agencies look carefully at reasons for any types of restraints ordered for hospital patients or nursing home residents and may cite facilities with violations if surveyors believe that a restraint was ordered or applied unnecessarily. Fraud is an intentionally false statement made by one person to another with the intent to deceive the other person (usually for financial gain). There are numerous instances of this in society in the form of insurance fraud, which often involves fraudulent claims made to vulnerable people like the elderly. Historically, health care institutions have been convicted of specific types of fraud, such as Medicare or Medicaid fraud, which usually involves falsifying records for financial gain. Fraud can be a violation of either civil law or criminal law. Invasion of privacy, or breach of confidentiality, is another tort. In general, the right to privacy prohibits the use of one’s name, picture, or even likeness for commercial or advertising purposes without specific written consent. This also prohibits unauthorized release of any data about patients’ diagnoses and treatments. Personal privacy can also be violated when nurses or other health care personnel fail to take steps to ensure privacy (for example, not closing a door not when giving a bath or not pulling a curtain around a patient’s bed when doing a treatment). The issue of confidentiality specifically related to patient information frequently surfaces in nursing practice. The law is clear that any information about a patient can only be given to other health care workers who are involved in the patient’s care and need to know the information. Information can be given to other people only with the patient’s permission or the permission of a legal guardian of the patient. Visitors might stop at nursing stations and ask how a patient is doing or friends of a patient might even call nursing stations. Without permission, nurses are not allowed to divulge information; otherwise, a patient can sue for invasion of privacy. Patient records are also considered confidential and are to be viewed and used only by people involved in diagnosis, treatment, and general care of the patient. There might be times when confidential information can be disclosed without fear of litigation, such as when a patient threatens to commit suicide or to injure someone else. Reporting child or adult abuse or suspected abuse may also necessitate revealing confidential information. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Unintentional Torts Negligence means failure to do the required thing or to exercise the reasonable amount of care that a person of ordinary prudence in a similar circumstance would. Negligent acts may result in injury to another person or in damage to property owned by another person. Negligence is an example of an unintentional tort that can be committed by anyone, irrespective of training. The person who commits negligence is usually unaware that he or she has failed to exercise a reasonable amount of care until an accident occurs, causing damage, injury, or even death of another person. Investigations are often conducted following plane crashes, for example, to determine if negligence on the part of anyone who serviced or flew the plane may have occurred. In nursing, an example of negligence might be the following scenario: A call bell on a patient’s bed is broken. The patient knows not to get out of bed unassisted. The patient reports that the call bell is broken when the nursing assistant comes in to administer a bath. The nursing assistant fails to notify the maintenance department. The patient needs to use the bathroom and is unable to summon help. The patient gets up unassisted, falls, and fractures a hip. Another example of negligence is failure to assess that a patient has developed a serious medical condition because symptoms leading up to the condition that should have been obvious to the nurse and reported to a physician are ignored. (This example might also be considered malpractice, depending on patient outcomes.) Gross negligence has been defined in Missouri as “a deviation from the professional standards so egregious that it demonstrates a conscious indifference to a professional duty” (Duncan v. Missouri Board for Architects, Professional Engineers, and Land Surveyors 1988). Texas law defines gross negligence as “more than momentary thoughtlessness, inadvertence, or error in judgment” but “an entire want of care as to establish that the act or omission was the result of actual conscious indifference to the rights, safety, or welfare of the person affected” (Convalescent Services v. Schultz 1996). An example of gross negligence occurred in the case of a nursing home resident who was admitted from a hospital with an initial stage I or II decubitus ulcer. Nursing care was deemed to be substandard in many respects. The nursing home staff’s failure to turn the resident every two hours, to notify the resident’s physician of his deteriorating condition, to give the resident whirlpool baths and a special mattress as ordered, to attend to the resident’s nutritional needs, and to start a separate nursing skin-care flow sheet was cited during the hearing. The primary evidence against the nursing home was lack of any nursing documentation, specifically in respect to turning the resident. The nursing home was sued for both negligence and gross negligence following the resident’s readmission to the hospital with a stage IV decubitus ulcer with bone exposure (Legal Eagle Eye Newsletter 1996). Malpractice is a special type of negligence and also an unintentional tort that can involve omissions as well as commissions. Malpractice means misconduct or improper practice by any professional or official (though in the public mind, it is usually associated with physicians) that results in injury or harm. Nurses have also been found guilty of malpractice when carrying out professional duties. Malpractice may cause a patient to experience physical injury, emotional suffering, or even death due to poor professional judgment, lack of knowledge and skill in treatment and care, or lack of fidelity or Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute faithfulness to carrying out the practices of the profession. Malpractice lawsuits are frequently brought against health care professionals who have knowingly or unknowingly engaged in unprofessional behavior. Often in malpractice suits, more than one professional as well as the employing institution will be sued. In nursing, malpractice could occur if nursing practice fails to coincide with acceptable standards of nursing care. One example of acceptable standards of care would be the nurse practice act of the state in which the nurse is licensed and practices nursing. Each nurse practice act includes information about the boundaries of the scope of nursing practice, types of nursing licenses, licensure requirements, and grounds for disciplinary action and revocation as well as a definition of nursing. If a nurse engages in an activity not identified as a nursing function by the nurse practice act, this could be considered a breach of standards of care or a breach of duty. Breach of duty has been defined as a “failure to act as a prudent professional, according to the standard of care for the profession in a particular situation” (Fiesta 1988). Malpractice suits have been brought against nurses for failing to carry out a physician’s order and for carrying out orders that were not correct (for example, giving the wrong dosage of a drug). Improperly identifying a patient could lead to a malpractice suit if the patient receives the wrong treatment, such as an incompatible blood transfusion. There have also been cases in which the wrong patient was operated on or the wrong organ or limb was removed because of faulty identification. Proof of malpractice in nursing is dependent on the existence of four specific elements, all of which must be proven beyond a reasonable doubt in a court of law: 1. 2. 3. 4. Duty: The nurse who is being sued must have been responsible in some capacity for the care of the patient. Breach of duty: The nurse failed to provide acceptable care according to nursing standards of care. Causation: The failure to provide acceptable nursing care caused the injury. Injury: Harm must have occurred and be proved. Negligence and malpractice, as stated previously, are considered unintentional torts; with an unintentional tort, the court would consider there to have been no deliberate attempt to harm a person. All of the other torts are generally considered intentional torts. Criminal Law Criminal law is law that is designed to protect the public from harmful and criminal acts of individuals. It is concerned with the peace, order, and protection of all members of society. The public welfare can be threatened or disturbed when certain types of crimes (for example, theft or murder) are committed. Depending on the nature of the crime and other factors such as the age, the number of prior offenses, and the perceived motive of the perpetrator, punishment for violations of criminal law varies. The court process is designed to ensure that the person accused of a crime has a fair trial and is not unjustly accused. In a trial, the accused party is called the defendant. In criminal cases, guilt Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute must be proved beyond a reasonable doubt in order for the defendant to be convicted of a crime. Nurses and other health care workers can be guilty of the same things that individuals in society are guilty of, though the location of the crime may be a health care venue. Three specific examples of violations of criminal law in nursing could be negligence, physical or psychological patient abuse, and assisted suicide. Criminal acts of nurses could also include violations of specific laws governing nursing practice such as the nurse practice act of the state where the nurse practices. Even if no injury is incurred by a patient, a nurse who is accused of violating a specific law could be found guilty of a crime. This highlights the need for nurses to be aware of the content of their states’ nurse practice acts. Various places of employment also have institutional standards of practice. Adhering to acceptable standards of practice can help protect health care workers from litigation (lawsuits) or allegations of professional liability. To be liable means to be legally bound, obligated, or responsible for one’s actions. Professional liability means that professionals are under obligation to practice according to the standards of their profession. There are two classifications of crimes: misdemeanors and felonies. Misdemeanors are less serious crimes. Punishment for a misdemeanor is often a fine. Examples of misdemeanors in nursing are theft of a patient’s possessions and pushing or striking a patient. Felonies are considered more serious crimes. Punishment for a felony might include fines, incarceration in a prison, loss of some privilege such as a driver’s license or a license to practice one’s profession, or a probationary period, which frequently involves some type of public service. Examples of felonies that have occurred in nursing include falsification of narcotic records or of research study information, withholding life support from a terminally ill patient, and administering a drug to hasten death. For example, two clinical research nurses were convicted of felony charges in California for falsifying information for a drug-related study on patients. One of the nurses who acted as a study coordinator was being paid for providing specimens of her own urine, which routinely tested positive for protein; patients who did not meet study eligibility criteria were also enrolled in the study by these nurses. They were subsequently debarred by the Food and Drug Administration (FDA) from working in a clinical research capacity (PharmSource Information Services 2003). Common Law Common law can be defined as the law of a country or a state based on common customs and the various accumulated judicial decisions and opinions of law courts. Common laws may change over time and may not apply to every individual. One example of the application of common law in society can be seen when a business like a topless bar tries to locate in a neighborhood; typically there are people in the community who protest. The court would examine the standards of the community as a whole, and a ruling could be based on the prevailing customs of the community. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Clients’ Rights Nurses often are in positions of advocacy and need a clear understanding of clients’ rights in relation to health care and the health care system. Health care facilities post a Patient’s Bill of Rights in public places and give copies to each new client on admission. The following are considered some important legal rights of clients: • The right to choose a provider. Clients should be able to choose a specific physician or nurse practitioner for their care, though external limiting factors often occur, for example, in family practice settings, physicians may state they are unable to take on any more new clients. The right to treatment in an emergency. Even if they are unable to pay and are without insurance, people have a right to emergency medical care, including transportation to the hospital via a local emergency transportation system. This does not exempt them from future payment obligations, however. The right to receive treatment in a hospital of their choice. This is generally a right, though sometimes hospitals may need to divert patients coming in for emergency treatment to other hospitals due to issues like lack of beds or lack of appropriate personnel to handle particular cases. The right to receive an acceptable standard of care without discrimination. Health care agencies are regulated by a variety of governmental or voluntary agencies that provide guidelines for acceptable standards of care for people of all ages. The right to privacy. National standards have been set to protect patient privacy and the privacy of personal health information. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that gives people rights to privacy over their health information. All health care facilities are mandated to have patients read and sign an information sheet concerning this law. The law sets limits and rules on who can access private health information. Health information cannot be shared without a patient’s written permission unless the law allows it. All health care employees receive mandated training on privacy rules and regulations. The right to informed consent. Prior to receiving any treatments, including diagnostic tests and surgery, clients must be fully informed of the purpose of the treatment or procedure and voluntarily make a decision to receive or reject the test or treatment. Issues of informed consent are also applicable in research situations. The right to make their own choices concerning quality-of-life and end-oflife issues. This includes the right to refuse certain treatments to maintain or extend life. The criterion of mental competency is considered with respect to this right. • • • • • • Statutory restrictions may apply to some of the foregoing rights. A statutory restriction is a legally binding or lawful restriction. An organization like a Health Maintenance Organization (HMO), for example, may legally restrict an enrollee’s or subscriber’s choice of a primary physician or other provider to those in a preselected group, specified Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 the parents may be restricted from seeing the child’s health records. and prisoners who are confined to institutions. Researchers are obligated to fully inform potential research subjects of the purpose of any study and allow them to make an informed decision about agreeing to participate in the study. this is accomplished through some type of coding system for quantitative research. for example. minor children. the mentally and cognitively impaired. There are five basic rights that are based on ethical principles of research. A right to selfdetermination and the ethical principle of personal respect would be violated if a patient was entered into a study without his or her knowledge or consent. Articles are often written for publication keeping this principle in mind. 5. free of coercion. Special care must be taken with human subjects considered especially vulnerable to coercion. Generally. no one should be able to link any aspect of the study results to a specific subject. NXP 070106 v1. Information should not be shared outside the study without the human subject’s permission. These include the following: 1. 4. friends. Rights about Human Subjects in Research Human research subjects are protected by a special set of rights. for example. They are also free to withdraw from a study at anytime. researchers should not share any identifying information about human subjects in conversations with other health care personnel. The HIPAA law generally allows a parent to have access to the medical records about his or her child as his or her minor child’s personal representative. If a minor child received medical care under court order. 3.Unlawful to replicate or distribute in its evidence of coverage. the frail and elderly. Right to self-determination Right to privacy Right to anonymity and confidentiality Right to fair treatment Right to protection from harm and discomfort The right to self-determination is predicated on the assumption that people have the right to autonomous decisions. 2. the terminally ill. in qualitative research. The right to anonymity and confidentiality means that once a study is completed. Inc.0 . researchers must respect this right. names and some identifying information are generally changed to ensure anonymity. Copyright © 2008. when such access is not inconsistent with state or other statutory restrictions. The College Network. There should be no external pressure placed on a person to agree to participate in a study. this is a right related to informed consent. The right to privacy for research subjects means they alone have a right to share information about themselves with the researcher. During the study there may be times when the study participant would prefer privacy to being interviewed or observed. or family. Subjects must also be informed that refusal or withdrawal from a study will not adversely affect their care in any way. Confidentiality means the researcher can only share study information as indicated by the terms of the study. people with advanced dementia. should be in writing. The College Network. this right has been violated in research. such as those involving patient participation in nursing research studies. and risks of surgery or special procedures as well as the potential side effects from medications that might be used for treatments. Informed Consent for Treatment or Research Consent forms for various treatments and procedures. but this should fall under the category of minimal risk. minors may or may not be able to consent to certain procedures. or the signed consent will not be legally valid in a court of law. The legal age for consent varies from state to state. Inc. such as changing a dressing or giving an injection. there may be times when temporary discomfort occurs. and witnessed. The person responsible for obtaining informed consent depends on the situation. If the patient does elevate his leg. NXP 070106 v1. doing a diagnostic test. or conducting research. In an emergency situation two physicians are required to sign a consent form for surgery. child. All consent forms should be signed with informed consent (i. patients should be aware of all the procedures. There should be clear and compelling reasons for choosing certain subjects for a research study. A person must be mentally competent to sign an informed consent form. proposed benefits. In these cases. for example during World War II when many life-threatening medical experiments were conducted in Germany in concentration camps. for example women who might agree to participate in a study and share their personal stories of abuse. Consent should also be solicited for all nursing activities. This may include emotional risks when highly personal information might be shared. An example of behavioral or implied informed consent occurs when a nurse asks a patient to elevate his leg so that she can change a dressing. Copyright © 2008. consent can be verbal or behavioral (which is called implied informed consent) rather than written or signed (which is called expressed informed consent). and people with a developmental disability). For people who are not considered competent to legally sign a consent form (for example. and study subjects must be ensured they will receive fair and safe treatments.Unlawful to replicate or distribute The right to fair treatment and the right to protection from harm and discomfort are related to the principle of justice. including surgery. consent must be voluntary. consent is implied. people who have suffered a stroke that results in cognitive impairment. and whenever vulnerable subjects are included. Patients must be able to fully understand the information and the implications of the consent form that they sign. Historically.e. Benefits for human subjects should outweigh risks. If there is any doubt about a nurse’s role in obtaining informed consent. Human subjects must be made aware through the informed consent process of any potential risks from study participation. the nurse should clarify the correct procedure with a supervisor. Nurses may also be responsible for some consent forms. depending on state laws. informed consent can be obtained from their legal guardians. or parent) may be able to sign a consent form for emergency treatment or surgery.0 . it is usually the responsibility of the person who will be providing a treatment. In both cases. In emergency situations in which a person is unconscious. signed.. others (such as a spouse. Usually surgeons are responsible for surgery consent forms and anesthesiologists are responsible for anesthesia consent forms. usually these are put in writing). This can be particularly important in the case of randomized clinical drug trials. Cruzan. Inc. their daughter had indicated to friends that she would not want to be kept alive if she ever had to live in a vegetative state. Cruzan’s physician and the hospital refused to remove the feeding tube. The most well-known case that publicized this issue was the Nancy Cruzan case. Physicians are also required to include specific DNR (do not resuscitate) Copyright © 2008. Cruzan Case Withholding nutrition or hydration is one ethical issue related to the quality and extension of life that nurses are often faced with in hospitals. In 1990. NXP 070106 v1. Initially. but the Missouri court appealed the decision. End-of-Life and Quality-of-Life Issues and Rights Ethical dilemmas often arise surrounding issues of technological advances and end of life and quality of life. nor did she appear to be suffering. nursing homes. the Patient Self-Determination Act was passed and became effective in December 1991. refuse surgery. the patient could conceivably file a lawsuit for battery. Missouri Department of Health [MDH] 1990).Unlawful to replicate or distribute Patients have the right to change their minds after consent is given. Months after the accident. a judge ruled that the tube could be removed at the parents’ request. and home care situations. As a result of the Cruzan decision. the court claimed that there was no clear and convincing evidence that she would want the tube removed. or drop out of a research project overrides the original consent. was resuscitated at the accident scene but never regained consciousness. One question that new technology has raised is: Should life be preserved at any or all costs? One argument raised in ethical discussions about end-oflife procedures is often related to the economic costs to individuals. The court claimed that it was in the state’s best interest to preserve life and that Nancy Cruzan was not terminally ill. Following a car accident in 1983. Director. The patient’s right to stop a treatment.0 . families. The Cruzan case was highly significant. and society. A statement indicating this is generally included in a consent form. a gastrostomy tube was instituted to maintain nutrition and hydration. the parents again appealed to a local court. The tube was removed. Other arguments might focus on the emotional costs for individuals and families who are struggling to make end-of-life and quality-of-life decisions. and the case went to court. The Supreme Court upheld this decision after an appeal by the parents. saying that prior to the accident. and Cruzan died two weeks later (Cruzan v. Cruzan’s physician also agreed that it was no longer in her best interests to continue artificial nutrition. Facilities are also required to ask patients if they want to prepare an advance directive like a living will or a durable power of attorney for health care and to specifically indicate in writing their wishes concerning such things as resuscitative efforts and the institution and withdrawal of supportive and life-sustaining therapies like artificial nutrition and hydration. The College Network. This act stipulated that any facility receiving federal Medicare reimbursement must inform patients about their right to refuse treatments like artificial hydration and nutrition. then age twenty-five. her parents made a request to the hospital and their daughter’s physician that the feeding tube be removed. If a patient believes that he or she was not adequately informed about a treatment or procedure or that he or she was coerced in any way. Unlawful to replicate or distribute orders in charts if patients choose that option. prior to the Cruzan ruling. or nutrition Antibiotic use in a terminal stage of illness Intubation and ventilation Manual cardiopulmonary resuscitation and defibrillation (electric shock to the heart) in case of cardiac arrest A living will may also include information about whom patients desire to be their power of attorney or health care proxy should they be unable to make their own decisions in the future.0 . Living Will A living will is a written legal document that a person prepares and signs when he or she is mentally competent. it is important for nurses to acknowledge their own beliefs and values in emotionally charged practice situations and to seek appropriate support and counsel. and a living will are all examples of advance directives. an heir to the patient’s estate. This can include the person’s wishes regarding the following: • • • • • Tube feeding institution and maintenance The use of intravenous fluids for treatments. procedures. Copies of advance directives are placed in patients’ charts and are also generally kept at home and often given to family physicians as well. Nurses might be asked questions by patients and their family members about their right to treatment or their right to refuse treatment. There Copyright © 2008. A nurse might also care for a patient who has made an end-of-life decision that the nurse may be uncomfortable with or may disagree with. A durable power of attorney. hydration. Advance Directives Advance directive is the umbrella term for various types of written legal documents that are prepared by people when they are mentally competent and preferably in good health. or an employee of a health care institution. Power of Attorney A power of attorney is a written statement and legal document that authorizes one person to act as a proxy or surrogate for another person under certain conditions. These documents are prepared in advance of any need for them and include specific instructions or directives for family members and health care workers about the use of various medications. As a result of the Omnibus Budget Reconciliation Act (OBRA) of 1990. Some also need to be notarized by a notary public. there was no universal formal mechanism for this in patients’ charts (Pence 1995). A living will includes specific instructions about various measures that may prolong and affect the quality of one’s life. NXP 070106 v1. All advance directives need to be signed by the person desiring the directive and by another person (known as a witness) who is not a relative. all states are required to provide patients with the option of preparing advance directives. Inc. and treatments for the person if he or she is faced with a chronic or terminal illness or a life-threatening situation in which the patient’s physical and mental condition may render him or her incapable of making autonomous decisions. a healthy care proxy. The College Network. 0 . Because this document obligates the person designated to abide by the wishes of the person preparing it.Unlawful to replicate or distribute are various types of powers of attorney. Like a living will. Whoever acts as one’s durable power of attorney is able to make financial decisions for the person. The power of attorney can act only if the person becomes incapable of making decisions concerning his or her health and well-being. a general durable power of attorney (compared with a limited power of attorney) can also make the person’s personal decisions. hospitals and nursing homes generally have a separate DNR form or order as well. and discontinuing various life extension and life support measures. no attempt should be made to revive the patient. The DNR order is usually placed in the front of the chart. a durable power of attorney should be prepared and signed when a person is mentally competent or it will not be honored in a court of law. A do not resuscitate order in a chart means that if a patient has a cardiac or respiratory arrest. Do Not Resuscitate Orders DNR is the abbreviation for “do not resuscitate. In health care facilities. the designated person must understand future responsibilities and agree to take on this role if needed. When a person signs a durable power of attorney. The College Network. pain management. a power of attorney may also contain specific information about procedures that the person may or may not wish to have instituted or maintained if he or she becomes incapacitated. that person is essentially relinquishing his or her decision-making capabilities about health care decisions to another person in the event that he or she becomes mentally or terminally ill or physically or mentally incapacitated and unable to make autonomous decisions. Inc. This is often the responsibility of the nurse in charge of a unit. intravenous medications. and comfort care measures. Every place of employment has its own procedure manual that details what health care staff should do when patients with or without DNR orders arrest. the most comprehensive is the durable power of attorney. The person designated verbally or in writing by a patient as his or her health care proxy would be able to make autonomous decisions about health care issues in the event that the patient becomes unable to do so and has not indicated in writing any advance directives with respect to end-of-life decisions. Preferences about organ donation are also usually included in this document. nurses should be familiar with these procedures. Powers of attorney and health care proxies must be considered competent of making decisions. Health Care Proxy A health care proxy is similar in some ways to a durable power of attorney. NXP 070106 v1. resuscitation. such as tube feedings.” Although the patient’s desires about resuscitation may be noted in a living will. from a nursing home to a hospital) need to remember that a copy of the DNR order is usually transferred with the patient. Copyright © 2008. Nurses working in environments in which patients are frequently transferred (for example. but it does not involve financial decision making and is generally less formal in nature. These include beginning. intubation and ventilator support. maintaining. to exercise professional competence in accordance with the standards of professional nursing. A nurse believes that a serious nursing shortage in the hospital is contributing to increased death rates on the intensive care unit. nurses have a responsibility to themselves to identify and know their own personal and practice limitations.0 . The ANA Code of Ethics for Nurses with Interpretive Statements The American Nurses Association Code of Ethics for Nurses with Interpretive Statements (2001) does not address specific ethical dilemmas in nursing but is designed Copyright © 2008. Inc. Ethical Codes for Nurses Ethics in nursing always relates in some way to professional judgment and professional practice. • • In each of the previous cases. Nurses have the responsibility. A nurse believes that he or she has been falsely accused of unethical behavior by a colleague. Accepting an assignment that a nurse does not feel personally or professionally equipped to handle could be considered an ethical violation and could result in legal action if harm comes to a patient. Codes of ethics. like nursing practice standards. Two of these codes are the American Nurses Association Code of Ethics for Nurses with Interpretive Statements (2001) and the ICN Code of Ethics for Nurses (2000).Unlawful to replicate or distribute Nurse’s Rights and Responsibilities Nursing Responsibilities Because of patient or consumer rights. Nursing codes “make explicit the primary goals. for example. nurses have certain responsibilities. Nurses may also act as a patient’s advocate in situations in which the patient’s rights are violated or in danger of being violated. many of which are identified in the various nursing codes. NXP 070106 v1. They have a duty to participate in the growth of the profession as well as to actively seek continuing education to further their own knowledge and keep abreast of current practices. Examples of situations in which a nurse might act as an advocate include the following: • A hospitalized patient believes that he or she signed a consent form to be in a randomized clinical trial research project without full knowledge and understanding of the possible side effects of a medication that he or she might receive. are considered part of the regulatory criteria for professional nursing. nurses may need to advocate for themselves if they believe that their own rights are being violated or may need to advocate for their profession as a whole. ideally through the appropriate chain of command in the health care facility. A number of ethical codes have been developed for the nursing profession by nurses. In some cases. The College Network. and obligations of the nursing profession” (American Nurses Association 2001). values. the nurse can act as an advocate by voicing concerns. In addition to responsibilities to their patients. ) • • • • • • Respect for human dignity and the uniqueness of all patients or clients The patient’s or client’s right to privacy and the need to maintain confidentiality The responsibility to practice in a safe. benefiting others. One aspect of professional accountability requires reporting unethical conduct of other health care personnel. competent. which is a difficult ethical dilemma that nurses may be faced with. employers. Kevin Hook and Gladys White. trace the evolution of nursing’s code of ethics beginning with the “Nightingale Pledge” of 1893. ethical. it was revised and renamed in 2001. both nurses and authors of the module. They note that the primary concerns of many ethical codes for nursing include doing no harm. Originally drafted in 1985 as the American Nurses Association Code for Nurses with Interpretive Statements. NXP 070106 v1. (Interpretive statements flesh out the general statements of the code and make them more practical.org/mods/mod580/code.0 . and society as a whole. The College Network. Nurses are personally and professionally accountable to this code.org/books. and legal manner Responsibility and accountability for nursing judgments and actions The need to be involved in upgrading professional standards of nursing The right to safeguard the patient and the public from any unethical or unsafe behavior The focus of the code is both broad with respect to the welfare of the general public and specific with respect to the individual patient or client. colleagues. A copy of the complete ANA Code of Ethics for Nurses with Interpretive Statements can be ordered online through http://nursingworld. Copyright © 2008.Unlawful to replicate or distribute Fundamentals of Nursing 61 to provide detailed guidelines that can govern nurses’ responsibilities and obligations to patients. Inc. An excellent independent study module on the ANA code can be found at http://nursingworld. The ANA Code of Ethics for Nurses with Interpretive Statements focuses on some of the following key ethical issues for nurses. and practicing with loyalty and justice.pdf. Explain the gate control theory and discuss the various pain management measures based on gate control theory. 4. NXP 070106 v1. 14. Discuss the significant assessment areas related to comfort and pain. Describe the various concepts associated with pain. Discuss common myths held by providers and clients related to pain and pain management. Explain the harmful effects of acute and chronic pain. goals of treatment. Differentiate between the traditional pro re nata (PRN) approach and a preventive approach to pain control. and discuss nursing guidelines related to their use. 20. you should be able to do the following: 1. Describe the various nonpharmacologic interventions for pain control. 13. Explain the body’s response to pain and the psychology of pain. 21.Unlawful to replicate or distribute UNIT II: PRINCIPLES OF BASIC CARE AND COMFORT Chapter 5: Pain and Pain Management Objectives Upon completion of this chapter. the delivery routes that use PCAs. 10.0 . 18. and common side effects for each category. and the patient’s emotional response. 6. Explain the World Health Organization’s ladder approach to cancer pain management. 8. 16. Describe the various origins and locations of pain. and pain perception. and the three categories of pain. Apply each phase of the nursing process to pain management. 12. Define placebo and placebo effect. the patient’s use of coping strategies. The College Network. 17. 2. the two principles supporting the definition. 11. Provide an overview of the physiology of pain including peripheral mechanisms. central mechanisms. Inc. 15. and the resulting implications for education of the patient and family. Describe the seven standard pain related assessment areas used to develop intervention strategies. Explain patient controlled analgesia (PCA). 7. Discuss the importance of understanding the effects of pain on ADLs. 5. Copyright © 2008. 19. Describe the behavioral and physiologic responses indicating pain. Discuss the major nursing roles in pain management. Identify and define the three general categories of analgesia agents and identify the routes. Explain the nursing definition of pain. 3. Discuss special considerations related to management of pain in children. 9. The purpose of this chapter is to provide an overview of the types and characteristics of pain. and the nurse’s role in pain management and control. We begin our discussion by looking at the nursing definition of pain (i. whenever the client reports it hurts). we also consider the psychology of pain and some common psychological reactions of patients who are experiencing pain. We also look at the types of pain and discuss the origins and locations of the ten most common categories of pain.e. We also consider the essential characteristics of pain and effective nursing-assessment strategies. We also discuss the gate control theory and its implications on pain management..Unlawful to replicate or distribute Key Terms acute pain biofeedback bradykinin breakthrough pain chronic pain cutaneous pain deep somatic pain drug tolerance endorphins enkephalins gate control theory guided imagery intractable pain multimodal (balanced) analgesia myelinated A-delta fibers narcotic addiction neuromodulation neuropathic pain nociceptors non-nociceptors non-noxious stimuli noxious stimuli pain pain reaction pain syndromes pain threshold pain tolerance patient controlled analgesia (PCA) phantom pain phantom sensation physical dependence placebo placebo effect radiating pain referred pain substance P transcutaneous electrical nerve stimulator (TENS) unit unmyelinated C fibers visceral pain Introduction Historically. NXP 070106 v1. plays a critical role in pain management and control. whatever bodily hurt the client says exists. effective pain management. the goal of pain management was reducing discomfort to a “tolerable” level. With the advent of evidence-based research that illustrates the harmful effects of uncontrolled pain. the goal of making the pain tolerable has been replaced by the goal of relieving the pain. We discuss pain misconceptions and the importance of the nurse’s awareness of pain- Copyright © 2008. Inc. We look at the physiology of pain. because of this. In addition to these physiological responses to pain. We then discuss the two important nursing principles upon which this statement is based. The College Network. After this. we define the three pain-related subjective concepts that only the patient can identify and define. The nurse spends more time with the patient in pain than any other health professional and. including information on peripheral and central nervous system factors involved in pain perception and response. Our discussion then turns to the harmful effects of uncontrolled acute and chronic pain and the effects of pain on activities of daily living.0 . we investigate the misconceptions about placebos and the placebo effect.0 . The College Network. Our discussion then shifts to pharmacologic pain interventions and we look at the current standard of practice for balanced pain management. In addition. the pain usually resolves with healing. Perception is reality: The nurse is ethically obligated to record the pain intensity just as it is reported by the client. NXP 070106 v1. Copyright © 2008. but it generally disappears after one month. If the client has suffered no permanent damage. Not believing the client’s assessment jeopardizes the therapeutic relationship and prevents fulfillment of the advocacy role called for in the American Nurses Association’s Pain Management in Nursing: Scope and Standards of Practice (2005). Sometimes. the cardinal rule for pain management is that all pain is real. The chapter concludes with a discussion of the nursing process as it applies to the nurse’s role in effective pain management. The Definitions of Pain The nursing definition of pain is whatever bodily hurt the client says exists. Inc. The pain indicates that tissue injury or damage has occurred. acute pain lasts less than six months. In nursing. We then investigate nonpharmacologic interventions and eight basic factors that influence a person’s response to both comfort and pain. whenever the client reports it hurts. so that appropriate pain management can be achieved. 2. These categories are defined in the following sections. even if its cause is unknown. 3.Unlawful to replicate or distribute related myths. pain-related cues is essential to quality care. This awareness allows the nurse to be both an educator for the patient and family. Validation of the fact that pain exists is based simply on the client’s statement that it is there. The client is always believed: Assessing pain involves collecting information from the client on both the physical causes of pain and any mental or emotional stimuli that influence the individual’s perception of pain. We also consider the different analgesia agents used to attain and maintain good pain control. We take a special look at the issue of pain management among children and the World Health Organization’s ladder approach to cancer pain management. three basic categories of pain are recognized: acute. Nursing interventions are geared to meet both of these areas. This definition is founded on two important principles: 1. By definition. Acute Pain Acute pain is of recent onset and is usually associated with a specific illness or injury. A nurse who suspects pain when a client denies it explores the concern with the client: Knowledge of nonverbal. and cancerrelated pain. chronic. clients are hesitant to admit pain even in situations in which it is expected to occur. as well as a patient advocate. Types of Pain Generally. 1 further compares the characteristics of acute and chronic pain. Six months is an arbitrary period for differentiating acute from chronic pain. and the pain would decrease as the bone healed. dilated pupils Mild to severe Sympathetic Related to tissue injury. rubbing or holding affected area) Client reports pain Chronic pain Normal vital signs Intensity Nervous system response Etiology Client behavior Mild to severe Parasympathetic Continues beyond healing Pain behavior often absent Client response Client often fails to mention pain unless asked Copyright © 2008. but that pain would rapidly subside. and pupils that are normal or dilated. the client appears restless and anxious and generally reports that the pain exists. elevated blood pressure. The College Network. on the other hand.. diaphoresis. Table 5. Clients with chronic pain may appear depressed and withdrawn. or nerve endings that normally transmit only noxious (painful) stimuli may transmit previously non-noxious (nonpainful) stimuli as painful stimuli. Often. the overt painrelated behavior seen with acute pain is often absent. rubbing the injured site. In acute pain. He or she may also exhibit behaviors that are indicative of pain. and blood pressure. Some of these include increased pulse and respiratory rates. these clients will not mention their pain unless directly asked by the provider. A prick of the finger with a needle. or holding the area. Indeed. a fracture would require medical treatment.Unlawful to replicate or distribute Injuries or diseases that cause acute pain may require treatment or may resolve spontaneously. while some may remain primarily acute in nature for longer than six months. and dilated pupils. would result in pain. Some pain experts believe that the pain may result in nerve-related changes. resolves with healing Client’s behavior is indicative of pain (e.0 . For example. Additionally. Many clinicians use the interval of six months’ duration to define pain as chronic. Chronic (Nonmalignant) Pain Chronic pain is constant or intermittent pain that persists over a period of time. Physiological changes are also apparent with acute pain. diaphoresis. as are the physiological responses. Table 5. The reason why some people develop chronic pain after an injury or disease is not known. NXP 070106 v1. crying. some pain may have chronic characteristics long before six months. Parasympathetic nervous system responses to chronic pain include normal vital signs. respirations. For example. warm skin.g. Inc.1 Comparison of Acute and Chronic Pain Area Vital signs Acute pain Increased pulse. dry. nerve endings that normally do not transmit pain may develop the ability to evoke painful sensations. Some of these behaviors include crying. burns. It is a painful sensation perceived in a body part that is missing or paralyzed by a spinal cord injury.g. • • • • Furthermore. where the client feels that the missing body part is still present. tendons.g. is the direct result of tumor involvement.. abdominal cavity. surgery or radiation). Origins and Locations of Pain Pain can also be categorized according to its point of origin. or from pain that is not directly associated with the cancer (e. Tissue stretching. from cancer treatment (e. Most cancer-related pain. and nerves. NXP 070106 v1. muscle spasms. and about 50 percent of these individuals experience severe neuropathic pain.. for example.0 . Examples of this include gallbladder pain in the right shoulder. Cardiac pain. Deep somatic pain comes from injured ligaments. or cranium. An example of deep somatic pain could be an ankle sprain.g. The fear of cancerrelated pain is so pervasive that in newly diagnosed cancer clients.. Referred pain is felt in a part of the body that is considerably removed from the tissues causing the pain. bones. nerve compression or infiltration of cancer cells into the bone). Phantom pain is another example of neuropathic pain. Visceral pain results from the stimulation of pain receptors in the thorax. blood vessels. or gives the sense of pressure). pain can be additionally described based on its relationship to various treatment approaches. or ischemia frequently cause this type of pain. may be felt in the chest and then down the left shoulder and arm. it is second only to the fear of death. This type of pain is described by clients as shooting or stabbing and is often severe. The College Network. It may or may not be associated with ongoing tissue damage. The incidence of phantom pain can be decreased when analgesics are administered via epidural catheter prior to an amputation. injuries). Inc. A paper cut that causes a sharp pain is an example of cutaneous pain. Phantom pain is not the same as phantom sensation. This type of pain lasts longer than cutaneous pain.. Some of the more common categories are as follows: • • • Cutaneous pain originates in the subcutaneous tissue or skin. Visceral pain sometimes feels like deep somatic pain (i. cardiac pain in the center of the back. Neuropathic pain is the result of disturbances in the peripheral or central nervous system that result in pain. and kidney pain on the lateral aspect of the thigh. however. The vast majority (estimated at 95 percent) of people with AIDS have evidence of peripheral nerve disease.e.Unlawful to replicate or distribute Fundamentals of Nursing 67 Cancer-Related Pain The nature of cancer-related pain can either be acute or chronic. aches. This method of classification yields the following categories of pain: Copyright © 2008. Radiating pain is initially perceived at the source of the pain and extends to nearby tissues. Cancer-associated pain can result directly from the cancer (e. Inc. only the client can identify and define their levels. a client with a specific type of burn may be medicated at a dose generally considered therapeutic for pain control. Concepts Associated with Pain A number of concepts are also commonly discussed in relation to pain. trigeminal neuralgia).g. central pain syndromes (e. At that time. Examples of pain syndromes include peripheral pain syndromes (e. Either additional analgesic medications or other analgesic medications used to prevent future breakthrough episodes would be administered. Pain syndromes are associated with prolonged or severe pain.. the client may experience a severe. and lower bowel. No matter what the client’s presenting complaint is.0 . This type of pain can be seen in advanced malignancies. This response often protects the individual from further harm. For example. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure. Since these concepts are based on the subjective experience of the client. postherpetic neuralgia). especially cancer of the cervix. These areas describe the characteristics of the client’s experience with pain and are summarized in the following sections. prostate.. most institutions and agencies consider pain assessment a standard component of any history and physical. due to client-specific factors (e. However. For example.g. however. including medications. a low pain threshold). NXP 070106 v1.g. Breakthrough pain is pain that occurs despite continuous analgesic efforts but is relieved with supplemental medications. The behavioral response is the learned response that is used to cope with the pain (e. Copyright © 2008.Unlawful to replicate or distribute • • • Intractable pain is pain that cannot be relieved satisfactorily by the usual approaches. myofacial pain syndrome).g.. Some of these concepts include the following: • • Pain threshold is the least experience of pain that a subject can recognize.. interventions related to pain control would be reassessed. bladder. Pain reaction includes the autonomic nervous system and behavioral responses to pain. It is a central assessment piece for any client problem related to the neurological system and/or the musculoskeletal system. • Characteristics and Assessment of Pain The client’s pain experience is unique and must be assessed within his or her own descriptive framework and developmental level.. and pain with underlying pathology (e. The College Network. putting the hand in cool water). the immediate withdrawal of a hand from boiling water is the autonomic nervous system response.g. unanticipated onset of pain. Seven important standard assessment areas related to pain provide data for use in developing effective intervention strategies. The scale has simple drawings of five faces illustrating varying degrees of distress. These people include nonEnglish-speaking clients. It is helpful to use a drawing of a body and have the client mark the location on the chart.0 . Discussing with the parents the vocabulary a child uses to describe pain and certain body parts can also help with pain location. nonverbal children. This information will ensure that adequate clientdefined pain management will be achieved. Copyright © 2008. Most scales use a zero to five or zero to ten range. Numerous pain rating scales can be used to evaluate pain. Constancy of pain can be ascertained through such questions as “Do you have periods of time with no pain?” and “How long do they last?” For children and many adults who experience chronic pain. the nurse should explain how the pain intensity information will be used. The nurse’s documentation would include further clarification through the use of words such as proximal. NXP 070106 v1. Pattern Evaluating the pattern of pain means documenting the time of onset. having them show where their parent would put a Band-Aid can sometimes help them better identify the pain location. morphine).. it is also important to ask whether they tell others when they are experiencing pain. distal. The client should also be asked what level of comfort is acceptable to his or her lifestyle. and lateral.g. use of the face scale may be appropriate. medial. For these individuals. Quality Nurses need to use direct quotes when documenting how the client describes pain. Examples include pain described as “hot” or “electrical. Inc. It includes a number scale that relates to each expression so that the intensity of the pain can be documented.g. diffuse. It has long been shown that health care providers generally underrate or overrate a client’s pain.Unlawful to replicate or distribute Location The nurse should ask the client for the specific location of the pain. duration. with zero indicating no pain and the highest number indicating the worst pain possible. Exact information is important both for diagnosis of pain etiology and for treatment choices. and recurrence (or intervals without pain).. a parent or a trusted pet) can add valuable information to the pain assessment. Not all clients can relate to numerical pain intensity scales.g.” Pain with these descriptors tends to be neuropathic in origin and will be more responsive to anticonvulsants (e. Tegretol) than opioids (e. For children. cognitively disabled children and adults.. Intensity The client’s report of the severity of the pain is the most accurate way to measure it. finding out who they tell (e. The College Network. Before the client completes the pain-rating scale. For young children. and cognitively impaired older adults. Examples of such questions include the following: • • • “What do you do for yourself when you are hurting?” “What helps the most to take your pain away?” “What do you want others to do (and not do) for you when you are hurting?” Associated Symptoms Any other symptoms that occur with the onset or presence of pain should be documented. and diarrhea. NXP 070106 v1. Asking children nonthreatening questions can elicit good information on their pain-relief strategies. Copyright © 2008. These include environmental factors such as extremes in heat. The College Network. Intense physical exertion can bring on angina. This includes a careful evaluation of culture-specific healing strategies (e. while emotional stressors can precipitate a migraine. cold. distractions. medications.. Inc. specific herbs or compresses). Common symptoms include nausea. or humidity.Unlawful to replicate or distribute Precipitating Factors A number of factors can precipitate pain. prayer.0 . Physical and emotional stress can also precipitate pain. rest. vomiting. Alleviating Factors A comprehensive history includes documentation of anything the client has done to reduce or eliminate the pain. or the application of heat or cold.g. dizziness. The success or failure of each intervention should be noted along with whether the client is currently using the therapy. In addition to the physiological problems. gastrointestinal. and adults. progressive (e. In all age groups. Widespread inflammatory endocrine changes have serious effects that may be tolerated by a young. increased retention of fluids. It is now preferred to the term “narcotic. Some of these complications include problems with the cardiovascular. It has also been found that the term “narcotic” instills an unwarranted fear of addiction in older children.” which is used in a legal context and refers to any substance that causes psychological dependence. chronic pain also produces adverse physiological and psychosocial effects. This response increases the client’s risk for such physiological disorders as thromboembolism. increased metabolic rate.. Copyright © 2008. it has harmful effects that extend beyond the client’s immediate level of discomfort if the pain is inadequately treated. This suppression may promote tumor growth. Harmful Effects of Chronic Pain As with acute pain. and myocardial infarction. Harmful Effects of Acute Pain Researchers have found that frail. impaired insulin response. and pulmonary systems. unrelieved postoperative pain impairs the ability to sleep. or critically ill client. a behavior that that can easily result in postoperative complications. to a complete disability. and increased production of cortisol. While health care providers are sometimes hesitant to prescribe the large quantities of opioid 1 drugs required to control chronic pain. healthy person but can seriously hamper the recovery of an elderly. Disabilities associated with chronic pain can range from mild inconveniences. Chronic pain results in suppression of the immune system. debilitated. This fear is unwarranted when opioids are used for pain control. The stress response generally consists of increased cardiac output.0 . pulmonary infection. In addition. The College Network. like the inability to continue with an infrequent physical activity. when an individual can no longer perform even simple activities of daily living like getting dressed. anger. and disability. older adults respond to postoperative pain by lying absolutely still. These negative effects have both physiological and psychosocial components. parents. the stress response found with trauma also occurs with severe pain.Unlawful to replicate or distribute Harmful Effects of Pain No matter whether pain is acute or chronic. it is critical to use these medications in chronic. prolonged paralytic ileus. such as cocaine (which is not an opioid). cancer-related) pain situations. NXP 070106 v1. Inc. 1 The term “opioid” refers to a natural or synthetic analgesic with morphine-like actions.g. long-term pain can result in depression. there may not be overt behavioral responses since the individual develops a personal coping style for dealing with pain. work/school. and level of emotional stress (e. sleep. and immobilization of the affected body part. and suffering. For some clients. In situations in which there is concern about suicidal behavior. biting the lower lip. irritability. facial grimaces. A rating scale can be used to determine the pain’s effect on such things as concentration. Affective Responses It is very important to assess the client’s emotional response to pain. appetite. and the nurse would observe increased blood pressure. diaphoresis. Early in the body’s response to acute pain. an example of this is tossing and turning in bed. The College Network.Unlawful to replicate or distribute Effects of Pain on Activities of Daily Living Understanding the impact of pain on a client’s activities of daily living (ADLs) will help the nurse understand the client’s evaluation of the pain’s severity. Behavioral and Physiologic Responses A number of behavioral signs can indicate the presence of pain. driving/walking. the sympathetic nervous system is stimulated. such as someone with suicidal thoughts or plans. and understand why certain strategies are employed. Many times. support. or support from significant others. such as decreased blood pressure and pulse rate. when pain is chronic. This is one reason why accurate baseline data for special needs clients is essential for quality care. marital relations. Some of these include moaning. needs a direct. coping responses reflect cultural or religious influences. Asking a child a question like “What helps the most to take the hurt away?” can elicit a wealth of information on coping behaviors. pallor. clenched teeth. Copyright © 2008.g. coping strategies may relate to past pain experiences. and warm. However. prayer. People who suffer from chronic pain. or anxiety). Knowledge of what coping mechanisms the client uses can help the nurse encourage.0 . respiratory rate. Purposeless movements can also represent pain. With visceral pain. concrete interviewing technique that can then lead to immediate crisis-oriented interventions. discomfort. However.. the nurse needs to ask the client such questions as “Do you ever feel so bad you want to die?” and “Do you feel that way now?” These questions may seem direct to the point of being blunt. Some strategies may include withdrawal. pupil constriction. can become severely depressed and suicidal. Individuals with cognitive impairments and developmental delays require astute nursing assessments and observational skills. Coping Strategies For both adults and children. NXP 070106 v1. distraction. depression. Inc. Physiologic responses are most likely to be absent in people with chronic pain because of central nervous system adaptation. dry skin. and pupil dilatation. signs of parasympathetic stimulation may be observed. pain symptoms in these clients will present only as restlessness and slight blood pressure changes. a person in a crisis situation. for example. The College Network. Cognitive processes Copyright © 2008. and the system involved in the transmission and reception of pain is referred to as the nociceptive system. Bradykinin. burning pain. mechanical. resulting in reddened and tender tissues.0 . It is known that the interaction between the body’s analgesia system and the nervous system’s transmission and interpretation of stimuli are major factors in the pain response process. These receptors can be excited by thermal. The exact nature of pain transmission and pain perception is not understood. Within the nervous system. Nociception is conducted on both types of fibers to the spinal cord via both the dorsal and the ventral roots. general overview of pain physiology. The descending control system is a system of fibers that originate in the lower and midportion of the brain (specifically the periaqueductal gray matter) and terminate on the inhibitory interneuronal fibers in the dorsal horn of the spinal cord. This substance also works as a neurotransmitter by enhancing the movement of impulses across the nerve synapse from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal column.Unlawful to replicate or distribute Physiology of Pain This section provides a very broad. a stimulus may result in pain on one occasion and not on another. When there are enough painful stimuli. biochemical mediators are released that sensitize or activate the nociceptors. It also causes vasodilation and increased capillary permeability. pain impulses travel in myelinated A-delta fibers and unmyelinated C fibers. Not all people exposed to the same stimuli will experience the same intensity of pain. such as histamine. NXP 070106 v1. Inc. Next. The physiologic processes related to pain perception are described as nociception. and pressure. cold. The myelinated A-delta fibers have a relatively large diameter and rapidly conduct impulses. directly activates the nociceptors and causes the release of inflammatory chemicals. Peripheral Mechanisms The peripheral nervous system includes primary sensory neurons that are specialized to detect tissue damage and to evoke the sensations of touch. pricking pain. pain. In addition. Bradykinin additionally stimulates the release of prostaglandin. The receptors that transmit pain sensation are called nociceptors. These fibers are associated with the sensation of sharp. a chemical called substance P increases the inflammatory response and acts on blood vessels in the damaged area to release chemicals that contribute to the conduction of nociception. heat. The sensitivity of this system varies among individuals. The smaller-diameter unmyelinated C fibers transmit impulses more slowly and result in long-lasting. one of a group of endogenous peptides that acts on nociceptive nerve endings. which is thought to increase the sensitivity of pain receptors by enhancing the pain-provoking effect of bradykinin. or chemical stimuli. morphine-like neurotransmitter. The term endorphin is a combination of the terms “endogenous” and “morphine.Unlawful to replicate or distribute may stimulate endorphin production (discussed later in more detail) in the descending control system. Mechanical and thermal pain are conducted via the fast A fibers. Copyright © 2008. Morphine and other opioid medications mimic enkephalin and endorphin. It is thought that conscious recognition of the pain probably occurs initially at the brain stem and thalamic level.0 . These substances bind to opiate receptor sites in the central and peripheral nervous systems. the limbic system. Inc. Pain Perception In the central nervous system.” Enkephalin is also an endogenous. and transmitters. age. NXP 070106 v1. They synapse with second-order neurons (long fibers) that cross immediately to the opposite side of the spinal column and enter the neospinothalamic tract and ascend to the brain. where ascending impulses are inhibited at the first synapse in the dorsal horn by the release of endogenous (produced by the body) opioids. and anxiety. From the thalamus. The dorsal horn has various functions. The slower C fibers conduct impulses from chemical. Central Mechanisms The terminals of the A-delta and C fibers end in the dorsal horn of the spinal column. one of which is sensory processing. localization. receptor sites. and monitoring of the sensation take place in the cortex. The College Network. developmental level. signals are sent to the basal area of the brain and to the somatic sensory cortex. past pain experiences. Endorphins and enkephalins are found in heavy concentrations in the central nervous system. This binding results in a decrease or blockage of the pain impulse. pain transmission continues through the reticular formation. These chemicals are thought to stimulate the inhibitory interneuronal fibers. Chemicals that reduce or inhibit pain include endorphins and enkephalins. As the pain impulses stimulate regions of the midbrain. They often pass through one or more additional short neurons before traveling to the brain by the paleospinothalamic tract. descending fibers transmit impulses from the brain to the spinal column. and mechanical stimuli. including such things as culture. Most of these fibers terminate in the thalamus. the thalamus. Research has found that chronic pain results in a number of complex changes in the nociceptive pathways. The perception of pain is modulated by a number of factors. thermal. Interpretation. This mimicking ability allows these drugs to inhibit the transmission of noxious stimuli. which then reduce the transmission of noxious stimuli via the ascending system. and the cortex. Pain management interventions are seriously affected by these changes since they include alterations in nerve cells. 0 . The College Network. which was introduced by Melzack and Wall in 1965. according to this theory. stimulation of the inhibitory interneuronal fibers of the ascending system closes the gates to pain input and prevents the transmission of pain sensations. For example. This theory helps explain how certain behaviors serve to decrease pain. The existence of endorphins and enkephalins helps explain why the same stimuli result in different pain responses from different people. For example. such as anxiety. but so do other factors that influence endorphin levels. these gates close to keep impulses from reaching the brain and open to permit impulses to ascend to it. Because a limited amount of sensory information can reach the brain at any given time. a person’s previous experiences with pain affect how he or she responds to pain. Gate Control Theory One particularly important idea regarding the physiology of pain is gate control theory. which in turn close the gate to back pain. large-diameter fibers close the gates. Copyright © 2008. More specifically. People with more endorphins and enkephalins feel less pain.Unlawful to replicate or distribute Fundamentals of Nursing 75 Inhibitory neuronal fibers are the interconnections between the descending neuronal system and the ascending sensory tract. While gate control theory is not unanimously accepted. back massage stimulates impulses in the large nerves. it does help explain why certain pain management interventions work. The nonnociceptors normally do not transmit painful or noxious stimuli. this theory also postulates that the brain can influence whether the gate is opened or closed. In particular. For example. This theory postulates that synapses in the dorsal horns of the spinal column act as gates. Stimulation of a large number of non-nociceptive fibers (which synapse on inhibitory fibers in the dorsal horn) inhibits to a certain extent the transmission of painful stimuli in the ascending pathways. These fibers contain enkephalins and are primarily activated through the activity of the non-nociceptor peripheral fibers. small-diameter nerve fibers carry pain stimuli through a gate. but large-diameter nerve fibers going through the same gate can inhibit the transmission of those pain impulses. In other words. Not only do endorphin and enkephalin levels vary among people. Inc. a person who strikes a finger with a hammer immediately wants to put the finger under cold water or in the mouth. gate control theory argues that certain cells can interrupt pain impulses. This action stimulates nonpain (nonnociceptive) fibers in the same receptor field as the just-activated pain fiber. In addition to the influence of nerve fibers. while those with fewer endorphins and enkephalins feel more pain. NXP 070106 v1. The Body’s Response to Pain Once a pain impulse is interpreted by the brain. As pain continues. The reduction of anxiety and fear through education and support and the use of relaxation and guided imagery can alter the perception or interpretation of the pain response. Thus. The client Copyright © 2008. and anger are also clinical applications of gate control theory. such as heat. partially through the action of endorphins. or the use of a transcutaneous electrical nerve stimulator (TENS) unit. and the parasympathetic nervous system takes command. a person’s actual pain receptors adapt very little and continue to send the pain message. low-voltage electrical stimulation. The College Network. In addition to the release of endorphins and enkephalins previously described. however. Topical therapies. The cerebral cortex While gate control theory remains incomplete. ice. resulting in a fight-or-flight reaction. heat and cold application. the body adapts. Throughout this period. Enhancing the client’s mood to decrease fear. The TENS unit is a method of suppressing pain by supplying controlled. such as listening to music or watching TV.Unlawful to replicate or distribute Pain Management Measures Based on Gate Control Theory Gate control theory has led to the recognition that pain can be controlled or modulated at four points: 1. The descending control system is probably always somewhat active. nurses can use this theory to stop nociceptors from firing by treating the underlying cause of pain. such as diversions and excessive sleeping. can also modulate and inhibit the pain response. Activities that distract from the pain. reversing many of the body’s initial physiological responses. the person may cope with the pain through cognitive or behavioral strategies. The administration of opioid analgesics will also inhibit pain impulses by binding to the receptor sites within the peripheral and central nervous systems. the body’s initial response involves activation of the sympathetic nervous system. This adaptation occurs after several hours or days of pain. In the clinical setting. and electrical stimulation. The brain stem 4. Ascending modulation of pain can occur with the stimulation of large-diameter sensory fibers through massage. can also be used. The peripheral nerve site of pain 2. descending modulation can occur through the cognitive and affective response to pain. It is believed that TENS achieves pain relief through the blocking of painful stimuli or by stimulating the release of endogenous opioids (endorphins). Inc. or neuromodulation. it is nonetheless used as the basis for many pain management interventions. The spinal cord 3. It prevents continuous transmission of stimuli as painful. NXP 070106 v1.0 . anxiety. Unrelieved cancer pain has a dramatic negative impact on a person’s life. On the other hand. people who see pain as short-term or who associate pain with a positive outcome may accept the discomfort more readily than others. Within the body. and cooperate with the treatment plan. a proprioceptive reflex also occurs with the stimulation of pain receptors. Anxiety often accompanies pain. At this point. get out of bed. For example. The most effective method to treat pain is to direct the intervention at the pain and not at the anxiety surrounding the pain.Unlawful to replicate or distribute also may respond by seeking out physical interventions to manage the pain. when a person hits his or her finger with a hammer. and depression because they cannot see an end to the pain or attach a positive reason to their suffering. It has also been shown that adults who experience medical pain in their childhood are fearful of medical pain as adults and tend to avoid seeking care when it is needed. While each person must be evaluated in terms of individual psychological responses. Psychology of Pain The uniqueness of a pain experience to each client has already been mentioned. knee surgery on a cross-country athlete that will allow him or her to run again or a woman giving birth are pain experiences that should both have positive outcomes. It seems to be related to the major life changes associated with the limiting effects of the pain. Inc. the hand reflexively draws back from the area even before the person is aware of the pain. some general principles can be mentioned. The College Network.0 . The muscles then contract in a protective fashion. and impulses travel back via these motor fibers to the muscles near the site of the pain. Here. There is also scant evidence to support the old belief that antianxiety agents increase the effectiveness of analgesics. In chronic pain. Copyright © 2008. the fibers synapse with motor neurons. Research has shown that children often do not receive adequate pain control interventions. The longer the pain persists. In chronic pain. The routine use of antianxiety agents. the discomfort is many times looked upon not only as a threat to body image but sometimes as a sign of possible impending death. the impulse travels along sensory pain fibers to the spinal cord. Providing pain relief in this type of situation may decrease the depression. depression is a major issue. such as analgesics. is not recommended since it may prevent the client from reporting pain due to excessive sedation. anxiety. For example. Past pain experiences also alter a client’s sensitivity to and interpretation of pain. These agents may also impair the postoperative client’s ability to take deep breaths. massage. NXP 070106 v1. however. such as unemployment. and exercise. the greater the incidence of depression is. individuals who are faced with chronic pain may suffer despair. Typically. Common myths held by providers and clients are listed below. when pain is not appropriately managed because of a lack of provider knowledge. Evidence suggests that only 5 percent of the people seeking relief for pain discomfort are dishonest and in pursuit of Copyright © 2008. Thus. Inc. or a lack of standardized assessment and follow-up procedures. and more pain.Unlawful to replicate or distribute Inability to control the situation and fear of the unknown often accompany pain-related experiences. On the other hand. and management similar to that of younger patients. emotional. When a person is in pain and this pain is managed correctly. Clients who participate in their pain management decisions and who have an attentive listener regarding their pain management needs tend to fare better emotionally. In reality. fatigue. The College Network. or spiritual. and the environmental situation. fatigue and muscle tension also increase the pain. When pain interferes with sleep. and the demands they generate may be so great that they create severe conflicts for a person. disbelief in the client’s reports of pain. suffering deserves special mention. the client’s interpretation of the pain. Pain as Normal Aging Often. people believe that pain is simply a part of normal aging. Suffering is a feeling of severe distress related to events that challenge the basic emotional and physical intactness of a person. affective responses to pain are as individualized as the pain experience. This. an improved quality of life results. Suffering When discussing the psychological effects of pain. They vary according to the type and duration of pain. however. It is important for the nurse to be aware of some of the more common beliefs so that both clients and providers can be educated. diagnosis. Pain Misconceptions There are numerous and interrelated fallacies about pain and pain management. People who feel they have control over their pain experience have a lower level of anxiety.0 . the client will suffer needlessly. The consequences of accepting this myth are dangerous for the patient and can result in needless suffering and undertreatment of both pain and its underlying cause. NXP 070106 v1. resulting in a cycle of pain. Pain Sensitivity and Perception Decrease with Age Another common misconception is that a person’s pain sensitivity and perception decrease with his or her age. and there is widespread belief that many people report pain merely in an attempt to garner attention or some other secondary gain. pain in elderly clients necessitates aggressive assessment. Pain as a Personality Disorder Pain is sometimes also viewed as a personality disorder. These events can be physical. is absolutely not the case. Unlawful to replicate or distribute personal gain. Copyright © 2008. route. even in children. • • • Drug tolerance is a physiologic. it results in undertreatment of pain. especially in children. leading to an overwhelming involvement in the procurement and use of a drug for purposes other than pain relief. 2008). Pain and Surgery Many clients believe that pain only occurs after major surgery. this side effect is a rare occurrence. Clients are unlikely to become addicted to an analgesic provided to treat pain. what diagnostic work will be required. older adults may be experiencing pain but may not complain because of fear. involuntary effect manifested by withdrawal symptoms when chronic use of opioids is abruptly discontinued or an opioid antagonist. these patients may also believe the aforementioned myth that pain is a normal part of aging. most importantly. However. Even minor surgeries can result in intense pain. Signs that Pain Exists There is a common belief that there are always physiologic or behavioral signs that pain exists. voluntary pattern characterized by compulsive drug-seeking behavior. particularly the elderly. Providers confuse three terms related to opioid use and erroneously equate all three with addiction. Physical dependence is a physiologic. For example.0 . is administered. involuntary need for larger doses of opioids to maintain the original effect. The other 95 percent are honestly seeking help and relief (Berman et al. it results in decreased reporting of pain. severe pain. For providers. Narcotic addiction is a behavioral. In addition. These are drug tolerance. and narcotic addiction. what change in lifestyle the pain may necessitate. Inc.g. The College Network. Likelihood of Respiratory Depression Yet another common misconception related to pain medication is the belief that these drugs are likely to produce respiratory depression. even with acute. such as naloxone (Narcan). NXP 070106 v1. For clients. Periods of behavioral and physiologic adaptation occur. In many cases. physical dependence. Likelihood of Addiction A belief in the high likelihood of addiction to pain medication is probably the most common myth held by both the general public and health care providers. with proper opioid administration (e.) and attention to the additive effects of other drugs the client is taking. No Complaint Equals No Pain The belief that an absence of complaints means that a person is not experiencing pain is a misconception when caring for patients of all ages. dose. and. what economic costs the pain will bring.. which can result in the complications mentioned earlier. they may fear what the pain means. etc. Often. this approach can be applied to pain from other causes. a person responds to a medication or treatment because of an expectation that treatment will work. including those established by the World Health Organization and American Nurses Association. World Health Organization’s Ladder Approach to Cancer Pain Management One leader in the establishment of international standards for pain management is the World Health Organization (WHO). this involves the administration of medications.Unlawful to replicate or distribute Pain Management Once. which should be in done in accordance with existing standards and practices. Knowledge of the harmful effects of pain and inadequate pain management. A nonopioid/nonsteroidal anti-inflammatory drug is administered. The nurse should keep the following guidelines in mind: • A placebo effect is a true physiologic response. step 3 is started. an opioid antagonist. step 2 is implemented. 2. Thus. The WHO has developed recommendations for the treatment of pain. The three steps in the WHO ladder approach are as follows: 1. The effect results from the endogenous (natural) production of endorphins in the descending control system. If the client receives the maximum recommended dose of nonopioids and continues to experience pain. Although cancer-specific. A strong opioid is used and gradually increased in strength until relief occurs. however. The College Network. In some instances.0 . It can be reversed by naloxone (Narcan). Copyright © 2008. NXP 070106 v1. 3. rather than because it actually does work. Various opioid and nonopioid medications may be combined with other medications at each step to control the pain. questions regarding the use of placebos often arise. If the client continues to experience pain. the goal of pain management was to reduce the pain to a level the client could tolerate. A placebo is an inert substance used in research or clinical practice to determine the effects attributable to the placebo as compared to the pharmacological effects of a legitimate drug or treatment. Inc. with the placebo effect. It is not an indication that a person does not have pain. A weak opioid is given and increased until the ceiling dose is reached. There are many misconceptions about placebos and placebo effects. The regimes are based on pain ranging from mild (step 1) to severe (step 3). a phenomenon known as the placebo effect occurs. simply receiving a medication or treatment produces a positive effect not attributable to the medication or treatment. has replaced the idea of “tolerable” control with that of relieving the pain. here. Placebo Effect When discussing the administration of pain medication. A client should never be given a placebo (e. In the home setting. clients may report that their pain is relieved or that they feel better simply to avoid disappointing the nurse. and pharmacist. and evaluates the effectiveness of the interventions. using two or three types of agents simultaneously can maximize pain relief while minimizing the potential toxic effects of one drug. Before administering any medications. For example. lower doses can be used. and nurse. it may take fifteen milligrams of morphine to control a certain pain.. a “sugar pill” or saline injection) as a substitute for an analgesic medication.g. However. The physician prescribes a specific medication and a particular route (e. Inc. physician. pain reduction) should never be interpreted as an indication that the person’s pain is not real. NXP 070106 v1. nonsteroidal anti-inflammatory drugs (NSAIDs). it takes higher doses to control the pain. it must be noted that the use of placebos to assess the presence or nature of pain raises serious ethical questions for nurses in relation to the ANA Code of Ethics.Unlawful to replicate or distribute • • • Placebos should never be used to test a person’s truthfulness about pain or as the first line of treatment. The home care nurse reinforces teaching and ensures communication between the client. Medication Administration Medications are most effective when both the dose and the interval between doses are individualized to the client’s needs..g. A positive response to a placebo (i. This includes the intensity of the current pain. After this. When one agent is used alone. physician. Pharmacologic Interventions Pharmacologic pain management requires the close collaboration of the client. but the nurse administers. maintains. it may take only eight milligrams of morphine to control the discomfort. and any side effects. the American Society for Pain Management Nursing and various other professional organizations have strongly opposed the use of placebos without patient consent. The three general categories of analgesia agents are opioids. the nurse must ask about allergies. if morphine is combined with thirty milligrams of ketorolac (an NSAID).e. if one drug is combined with others. and local anesthetics. The College Network. medication history. previous responses to medications.0 . IV or epidural). Furthermore. and the client’s current status. the change in pain intensity after the last dose of medication. it is often the family who manages the client’s pain and evaluates the treatment’s effectiveness. The only safe way to administer analgesics is to observe the client’s response to the medication and have the client rate the pain. Also.. This is unethical and unacceptable pain management. the nurse can turn his or her attention to issues of administration and scheduling. Since each of these agents works through different mechanisms. Although a placebo can produce analgesia. Copyright © 2008. The current accepted method of pain control is called multimodal or balanced analgesia. However. This is especially true in the home setting. the only way to ensure significant periods of analgesia is to give doses large enough that sedation is produced. If the client is sedated or has absolutely no pain. With the first dose. Before the routine dose is administered. just by its method of operation. many clients remain in pain because they do not know to ask for medication or are hesitant to bother a busy staff nurse. subcutaneous (SQ). the PRN approach leaves the client either sedated or in pain. They also experience different levels of pain. Clients can control the administration of their pain medication within predetermined safety limits through the use of patient controlled analgesia (PCA). or epidural catheter by pressing a button. This is because opioids provide pain relief through the maintenance of a therapeutic serum level. the lower the opioid level. NXP 070106 v1. or when the dose is given more frequently. In addition. Family members must understand that they cannot push the button for the client when the client is sleeping. The dose is adjusted depending on the client’s response. Because the client controls the dose. As a result. Education for the client and the family on how the pump functions is critical. It is critical that response to opioids is monitored when the first dose is administered.Unlawful to replicate or distribute Medication Schedules The traditional pro re nata (PRN) approach to pain control counts on the client to inform the nurse of pain. A timing device controls a PCA pump and clients administer small amounts of pain medication directly into their IV. SQ. the more difficult it is to achieve a therapeutic level with the next dose. the drug is below this level. The pump then delivers a preset amount of medication. Clients who use the PCA device require less pain medication than those who use a PRN system. analgesics are administered at set intervals so that the medication acts before the pain becomes severe and the serum opioid level falls to a subtherapeutic level. or epidural routes. The pump can also be programmed to deliver a continuous background infusion of medication or basal rate and still allow the client to administer additional bolus doses as needed. If the pain does not decrease within thirty minutes (or sooner with IV administration). Thus. Not only is pain better controlled in this system. In this approach. periods of severe pain and sedation occur less frequently. People absorb and metabolize medications at different rates. and by the time a client complains of pain. This approach can be used with continuous infusions of opioid analgesics by IV. the nurse needs to record blood pressure and respiratory rate and complete a pain-rating scale based on the client’s answers. Today. a preventive approach to pain control is considered the most effective clinical strategy. some change in analgesia is needed. even if it looks like he or she is uncomfortable. it would not be safe to administer the dose. Also. when a dose is changed. the nurse assesses the client. PCA can be used in the hospital or home setting. Inc. but smaller doses of medications are needed because the pain does not escalate to severe intensity. Copyright © 2008.0 . This adjustment relates to the need for individualized dosing. with the PRN method. The College Network. peripherally inserted central catheters. and local anesthetics. A shoulder bag or holster holds the pump so the client’s mobility is • • Copyright © 2008. Fentanyl (Duragesic) is an opioid currently available as a skin patch with various dosages. Continuous subcutaneous infusion (CSCI) of narcotics is particularly helpful for clients whose pain is poorly controlled by oral medications. and his or her report of pain determine the route. rectal. who are experiencing dysphasia or gastrointestinal obstruction. CSCI involves the use of a batteryoperated pump that administers the drug through a twenty-three or twenty-five gauge butterfly needle. the overall status of the client. intramuscular. The most frequently occurring side effects are respiratory depression and sedation. The goal of opioid medications is to relieve pain and improve the client’s quality of life. The College Network. the subclavicular region. the nurse must anticipate side effects and do anticipatory teaching to help both the client and the client’s family manage them. and continuous subcutaneous infusions. analgesic agents can be categorized as opioids. Transdermal therapy is advantageous because it delivers a relatively stable plasma level and is noninvasive. subcutaneous. the client’s response to analgesics. SQ.0 . These agents are briefly summarized in the following sections. Minimizing side effects increases the likelihood that the client will take the medication as prescribed and receive adequate pain control. including IV. Inc. constipation. A commonly used agent is butorphanol (Stadol) for acute headaches. newer methods are also being used. Peripherally inserted central catheters are placed in the basilic or cephalic vein just above or below the antecubital space of the right arm. the abdominal wall. nausea and vomiting. and transdermal methods. The needle is inserted into the anterior chest. Examples of these include transnasal and transdermal drug therapy. NXP 070106 v1. These medications have traditionally been administered through the oral. rectal. Tricyclic and anticonvulsant medications are also used for difficult-to-control pain syndromes. No matter what route is used for opioids. • • Nasal administration has the advantage of rapid action due to direct absorption through the vascular nasal mucosa. and intravenous routes. The characteristics of the pain. or the outer aspects of the upper arms or thighs. Opioids Various routes. To circumvent problems associated with these traditional routes. These catheters are frequently used for long-term intravenous access when the client will be managing IV therapy at home. or who have a long-term need for the use of parenteral narcotics. can deliver opioids. intraspinal.Unlawful to replicate or distribute Analgesia Agents As previously mentioned. nonsteroidal anti-inflammatory drugs (NSAIDs). and inadequate pain relief. This method provides drug therapy for up to seventy-two hours if the patch remains in place for the prescribed amount of time. These drugs are also effectively combined with opioids to treat severe postoperative pain and other types of severe pain. NSAIDs may also have a central action in pain reduction. medications are applied directly to the injury (e.g. When these pain syndromes are accompanied by dysesthesia (burning or cutting pain). site care. since NSAIDs increase their effects. particularly drugs such as warfarin (Coumadin). since the client or family administers the medication and changes and cares for the injection site. In intraspinal administration. it is not frequently used to treat pain. and changing the injection site – List the signs indicating the injection site needs to be changed – Describe general care of the pump when the client is traveling.Unlawful to replicate or distribute not impaired. The nurse needs to provide comprehensive education on the use of CSCI. This can be done through topical administration or intraspinal administration. Attention must also be paid to other medications the clients are using. or sleeping – Identify actions to take when the alarm signals Nonsteroidal Anti-Inflammatory Drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) are very helpful in the treatment of arthritis and cancer-related bone pain.. NSAIDs are thought to decrease pain by inhibiting the production of prostaglandin from traumatized tissue. This inhibition prevents pain receptors from becoming sensitive to previously non-noxious stimuli. but because of its frequent and severe side effects. change the medication. The College Network. NSAIDs are well tolerated by most clients. The client needs to be alerted to the fact that the therapeutic effect of an antidepressant may not occur for up to three weeks since the dose prescribed is much smaller than that given for clinical depression.g. the drug is administered directly to nerve fibers by injection at the time of surgery. Ibuprofen (Advil. Intermittent or continuous administration of local anesthetics through an epidural or spinal catheter has been used for years to produce anesthesia during labor. and stop and start the pump – Demonstrate tubing care. NXP 070106 v1. In topical applications. Local Anesthetics Local anesthetics block nerve conductions when applied directly to the nerve fibers. in some cases. tumor impingement on a nerve) can be very difficult to treat and may be unresponsive to opioid therapy. Tricyclic Antidepressants and Anticonvulsant Agents Pain of neurologic origin (e. they may be responsive to tricyclic antidepressants or anticonvulsant agents. Caregivers need to be able to do the following: – Describe the parts and symbols on the pump – Explain how to tell whether the pump is working – Demonstrate how to change the battery. However. Motrin) is a commonly used NSAID that is effective in relieving pain and has a low incidence of adverse side effects. High or prolonged doses can irritate the stomach and. The Copyright © 2008.. have resulted in gastrointestinal bleeds. people with impaired renal function may need smaller doses and must be closely monitored.0 . bathing. a topical anesthetic for a cut). The oldest NSAID is aspirin. Inc. g. The College Network. Nonpharmacologic Interventions While medication-induced pain relief is the most powerful relief measure possible. For greatest effect.Unlawful to replicate or distribute anticonvulsants (e. It is an expression of concern and empathy. other nursing interventions can reduce pain and are usually associated with low client risk. phenytoin or carbamazepine) are also used in lower doses than those used for seizure control. Massage also promotes comfort by producing muscle relaxation and decreasing stress. Such activities as warm baths. Copyright © 2008. Massage. the nurse must be aware of the adverse side effects of these drugs and educate the client and the family. application of cold after exercise or during periods of exacerbation decreases pain and swelling to the area. moist heat is recommended. often focuses on the back and shoulders. Cutaneous Stimulation and Massage Cutaneous stimulation and massage is based on the gate control theory of pain management and includes rubbing the skin to block or decrease the transmission of painful stimuli. heat used before exercise increases blood flow to the muscles and can reduce pain. Both cold and heat therapy must be monitored closely to avoid injuries to the skin. Generally. Also. Heat or Cold When a client is experiencing pain. Therapeutic Touch Therapeutic touch is a technique that may be employed when it is culturally appropriate. Some of the more common interventions are described below. hot or cold compresses. the use of heat or cold can sometimes increase comfort and promote healing of injured tissues. cold should be applied on the injury site immediately after surgery or injury. touching a patient’s arm during a painful procedure conveys understanding and reinforces the nurse’s presence to the person in pain. For ongoing comfort of a chronic condition. For instance.0 . Neither cold nor heat should be applied to areas with impaired circulation. and warm or cold sitz baths can all bring comfort. NXP 070106 v1. cold massage. Heat. Inc. which is generalized cutaneous stimulation of the skin. on the other hand. Because of the variety of medications that may be tried in these difficult cases.. increases blood flow to the area and contributes to pain reduction by speeding the healing process. It does not stimulate the nonpain receptors but may have an effect through the descending control system. watching TV. For example. In postoperative clients. For certain clients. These treatments are based in the Eastern philosophy of qi or life energy. meditation is also an effective tool to help with stress reduction and relaxation. Acupuncture uses needles to stimulate certain points of the body. vibrating. Relaxation Techniques Relaxation techniques aimed at tense muscles can relieve pain. the client may engage in reading books or magazines. crossword puzzles. for example. transcutaneous electrical nerve stimulation (TENS) uses a battery-operated unit with electrodes applied to the skin. or hobbies. music. Biofeedback Biofeedback teaches clients to achieve generalized states of relaxation. card games. Considerable evidence supports relaxation techniques as effective in reducing low back pain. The unit delivers a tingling. Distractions Distractions include visual. abdominal breathing. or buzzing sensation in the area of pain. NXP 070106 v1. This technique brings bodily processes normally thought to be beyond bodily command under conscious control. A simple relaxation technique is slow. humor.Unlawful to replicate or distribute Acupuncture and Acupressure Acupuncture and acupressure are both techniques used to cure certain illnesses. promote wellness. whereas acupressure uses finger pressure. The feedback is usually provided through meters that indicate skin temperature changes or an electromyogram (EMG) that shows the electric potential created by the contraction of muscles. Relaxation techniques require practice before the client can become skilled in using them. and intellectual activities that focus the client’s attention on something other than the chronic or acute pain. but there is not a great deal of evidence that supports its effectiveness in reducing postoperative pain. Almost all people with chronic pain can benefit from relaxation techniques. Inc. the electrodes are placed around the surgical wound. Transcutaneous Electrical Nerve Stimulation As previously mentioned. rhythmic. and activities of daily living for individuals with certain types of dementia. Copyright © 2008. it is consistent with gate control theory and explains the effectiveness of TENS when applied to the same area as the injury. tactile. and relieve pain. guided imagery. auditory. This method is believed to decrease pain by stimulating the non-nociceptor fibers in the same area that transmits the pain. The effectiveness of distraction depends on the client’s ability to receive sensory input other than pain. Reduced EMG activity reflects muscle relaxation. The goal of acupuncture and acupressure wellness care is to recognize and manage changes in the client’s life energy before an illness or a disease occurs. orientation. resulting in fewer painful stimuli being transmitted from the brain. Distraction is thought to reduce pain by stimulating the descending control system. The College Network. slow rhythmic breathing.0 . Again. These techniques have also been shown to improve memory. A number of clinical trials have shown the effectiveness of acupuncture and acupressure for the symptoms of osteoarthritis and low back pain. since regular relaxation periods can help combat the fatigue and muscle tension that occur with and contribute to chronic pain. Aromatherapy Aromatherapy uses the essential oils of plants to illicit an odor. This method has proven effective in relieving pain or decreasing the amount of analgesics required in people suffering from both acute and chronic pain. Each inhaled breath is seen as delivering healing energy into the body. and boost the immune system. Unproven Therapies Finally. clients can be taught self-hypnosis. carrying away pain and leaving behind a relaxed and comfortable body. This therapy must also be used with caution in people who have suffered from prolonged weakness or fatigue. the client imagines muscle tension and discomfort being breathed out. the National Institutes of Health has established an office to examine the effectiveness of alternative therapies. or gas is used to trigger the body’s response to temperature and produce comfort. With each slowly exhaled breath.Unlawful to replicate or distribute Guided Imagery Guided imagery uses a person’s creative thoughts to achieve a positive effect. desperate people with chronic debilitating pain often employ untested. placed in baths. chamomile soothes muscle aches. because these individuals have poor heat regulation. Hydrotherapy must be done with great care in the very young and the very old. Guided imagery requires a great deal of time and explanation for the client to be able to effectively use it. Its effectiveness seems to be related to the susceptibility of the individual. unproven therapies in the quest for comfort. a person trained in hypnosis induces the treatment.0 . Sometimes. They have been shown to calm. hot or cold moisture in the form of solid. Aromatherapy oils can be massaged into the skin. The nurse must weigh the client’s hope of relief with the responsibility to protect the client from costly and potentially dangerous therapies. Hydrotherapy Hydrotherapy uses water as a healing treatment. The nurse instructs the client to close his or her eyes and breathe slowly in and slowly out. NXP 070106 v1. In fact. Specifically. Lavender. and jasmine is uplifting and stimulating. Often. The nurse can help the client and the client’s family understand current scientific information while not diminishing the Copyright © 2008. improve sleep. The College Network. Inc. they will try anything and at any price. How hypnosis works is unclear. but they have not been proven effective. for example. but it is not believed to be mediated by the endorphin system. Usually. The chemicals found in these oils and therefore in the accompanying odors are absorbed into the body and produce specific physiological or psychological effects. is a sedative and can help decrease insomnia. Untested. mixed into ointments. Many of these therapies (with the exception of the macrobiotic diet) are not harmful. liquid. or used as compresses. Hypnosis Hypnosis may decrease pain in difficult pain control situations. as these patients can’t yet verbalize their pain experience. the medical team can work in a collaborative rather than oppositional manner. If the client believes in alternative therapy use. Young infants may show a generalized body response of thrashing or rigidity. in some situations. While the information a nurse receives from the pain assessment discussed earlier helps identify and prioritize goals. Age and Developmental Level Age and developmental level are significant factors in effective pain management. Factors Influencing Comfort and Pain The physiological and psychological complexity of pain and the pain response are apparent. The College Network. This knowledge empowers the client to make an informed decision. This approach is ultimately much safer for the client. Behavioral observations of infant behaviors can help the nurse assess the degree of pain. These areas are discussed in the following sections. Knowledge of age-related pain response is particularly important for effective pain management among children and the elderly. brows lowered and Copyright © 2008. client. biochemical. and family. physician. For example. pain management for young patients can be challenging. Infants Caring for infants can be particularly daunting. respectful relationship between nurse. Children and Pain Because people experience such drastic physical and developmental changes during childhood. the infant shows no association between approaching stimulus and subsequent pain.Unlawful to replicate or distribute positive effects the client may be experiencing. newborns have the anatomic. regardless of their gestational age. Thankfully. Gender Because pain-related behaviors are part of the socialization process.g. the priority is maintaining a trusting.. gender-related differences in pain response are common.0 . It is now understood that. Loud crying and facial expressions of pain (e. a single father supporting two children may ignore pain so he will not lose days at work. The client’s response to pain will be directly related to his or her developmental level. an awareness of other pain-related areas is also important. Inc. and physiologic elements necessary for pain transmission. NXP 070106 v1. If clients feel safe sharing what alternative therapies they are using. girls and women may be expected to express discomfort more than boys or men. Family role can also have an impact on the pain response. and it varies greatly depending on a child’s exact age and characteristics. However. Some American men may be more hesitant to express discomfort because they perceive it as a sign of weakness. knowledge in pain management for infants has grown significantly. Similarly. undermedication occurred across all client care areas studied. and mouth squarish) are indicators of pain. Because a child in this age group may consider pain a punishment. eyes tightly closed. Adolescents Adolescents may be hesitant to acknowledge pain because it may be seen as giving in and not being brave enough to handle the discomfort. NXP 070106 v1. such as music or TV. Providing appropriate distractions. A number of controlled studies have analyzed pain management between matched diagnostic groups of children and adults. An opportunity to discuss pain in private is very important. This reticence to talk about pain may be particularly evident if peers are present. The child also may view pain as punishment for infractions. In some cases. Providing “rehearsals” for this child of what will happen and how it may feel can help the child prepare. Holding the child (if it is acceptable to him or her) can also help ease the discomfort. Inc. the child’s belief in magic can be used to provide comfort. and all studies showed that the nurse provided inadequate pain control. The responsibility for adequate pain control rested solely with the nurse. When caring for patients in this age group. Copyright © 2008. the nurse may use a “magic” blanket to help take the pain away. can also help increase the teenager’s level of comfort. In these studies. all of the children had orders for PRN analgesics. However. the adults received routine medicationrelated pain intervention. The College Network. but they do so because pain is seen as a threat to security. Medicating Children It has consistently been shown that providers undermedicate children for pain.Unlawful to replicate or distribute drawn together. School-Aged Children Unlike their younger counterparts. it is important for the nurse to explore misconceptions about pain with the patient. toddlers and preschool children often respond to pain with crying and anger. Toddlers and Preschoolers Like infants.0 . For example. If the pain becomes chronic. This lack of adequate pain control was even more serious with infants. nurses can benefit from learning how to use age-appropriate pain assessment tools and being sensitive to the idea that children can and do experience significant levels of pain. which may be due to the nurses’ inability to evaluate pain in infants. Children in this age group may perceive pain as being related to body destruction and death. Providing a glucose pacifier can sometimes be an appropriate comfort measure. nurturing interaction is critical. In each of these studies. the child may revert to an earlier developmental level. for the children. A supportive. school-aged children try to be brave when facing pain and can usually describe the location and the type of pain. 2 Agency for Health Care Policy and Research (AHCPR) Publications. This approach is described in Table 5. Physiological responses vary and are related to acute and chronic pain response. use appropriate foreign language words to describe pain as a child would in that language. Box 8527. P.2. Be sure to select a scale that is suitable to the child’s developmental age. the pain with vaso-occulsive crises in sicklecell anemia). When caring for children who are not native English speakers. (800) 358-9295. The pathological condition may give clues to the severity (e. The College Network. To gather this information. blood pressure.gov. temperature. Parents know how their child exhibits pain and are an excellent source of assessment data.g. in the United States.ahcpr.Unlawful to replicate or distribute Assessing Pain in Children One goal for quality care of young patients is for the nurse to assess these patients for pain every time he or she checks for pulse. Copyright © 2008.0 . Pain rating scales provide a quantitative self-reporting measure of pain. MD 20907. and respirations. or anger. For example. Complete pain relief through the use of combined pharmacological and nonpharmacological methods is the goal. For example. as well as anxiety. Evaluation is essential. different assessment strategies should be used to gather information. Use a pain rating scale Evaluate behavioral and physiological changes Secure parents’ involvement Take the cause of pain into account Take action and evaluate results Guidelines for Caring for Children in Pain Attempts have been made to help practitioners effectively manage pain. Silver Spring. Reasons for the child’s discomfort should be taken into account. Table 5. procedure-related. Baker and Wong (1987) have developed an approach to comprehensive pediatric pain assessment called QUESTT. NXP 070106 v1. Behavioral changes are valuable in all children. use age-appropriate words and ask patients to locate the pain. fear. Because pain is both a physical and an emotional experience. trauma. especially those who are nonverbal. Inc. including pain in children. the Agency for Health Care Policy and Research 2 (AHCPR) has published guidelines by pain experts that focus on issues of postoperative. Interviewing parents about a child’s previous pain response is also helpful.O. Family members are excellent assessment partners when evaluating pain-relief measures. and cancer pain. Web site: www..2 QUESTT Approach to Pediatric Pain Assessment Area Question the child Nursing strategy Children’s verbal statements and descriptions of their pain are the most important factor in assessment. it must be based on scientific research. The nurse allays fears and anxieties and provides education on both pain and the rationale for the types of interventions being used (e. For the nurse. with 0 being “no pain” and 10 being the “worst pain possible. as discussed earlier in the chapter. pain may present in atypical fashion. Even when an older patient doesn’t report pain.g. and fatigue that are actually pain-related behaviors. Some adults may use pain for secondary gains or to get attention.Unlawful to replicate or distribute The nurse can obtain copies of the AHCPR guidelines and compare his or her institutional pain practice standards against this agency’s recommendations. the nurse should look for signs of anorexia. This type of behavior is particularly true for elders with dementia who cannot verbalize their discomfort.g. When dealing with older patients. Elders and Pain As previously mentioned. taking time to listen to older patients and develop trusting relationships is very important. etc. Pain Presentation and Assessment Pain presentation varies widely in the elderly population. For example. After all.). lethargy. other scales will need to be used. Also. these scales ask patients to rate their pain on a scale ranging from 0 to 10. The College Network. In some situations. when patients cannot verbalize their pain due to communication impairments or diminished mental capacity. and agitation. pain scales are an easy and relatively reliable way of determining the client’s pain intensity. particularly becoming dependent on someone else for care. boys cannot. This gender-based behavior sometimes results in ignoring pain because admitting the discomfort would be seen as a sign of weakness or failure.g. Copyright © 2008. older adults might not admit to pain because they consider it a normal part of aging. This variation can range from heightened pain related to previously unresolved pain to no pain sensation due to tissue damage. it’s important to note that an older adult’s definition of pain may differ from that used by patients in other age groups. balanced analgesia). cancer). disorientation. girls can cry if they are injured. Providing education that clarifies misconceptions and allays anxieties can also help the older adult both acknowledge pain and agree to appropriate pain-related interventions. However. the nurse may opt to use a faces scale. Inc. Older patients are also particularly likely to withhold complaints of pain because of fear of treatment or the possible lifestyle changes that may be involved. Still other adults refuse to have pain evaluated because of the fear of what it may mean (e. NXP 070106 v1. Some of these may be gender-related behaviors (e. Concern over the cost of medications can be an additional barrier to discussing pain. with symptoms such as confusion.. pain relief is not a matter of personal opinion.. Typically.0 .” The addition of word modifiers can help clients who have difficulty applying a number to their pain. Adults and Pain Adults may exhibit pain-related behaviors that they learned as a child. and words such as “hurt” or “ache” are commonly employed.. especially for the person living with chronic pain. sleep. and physician is central to success. Without adequate pain control. NXP 070106 v1. Thus. Pain Control Pain control is critical in the elderly. Impact of pain on ADLs is a helpful way to determine the physical impact of the pain. Inc. and ability to remain independent. effectiveness of current pain management. all areas of an elder’s life are impacted. family. the goal of pain control is to provide relief while maintaining the highest possible level of functional ability. including mobility. Providing time for clients to express in their own words how they view the pain will help the medical team provide appropriate interventions. For people with chronic pain. For someone with acute pain. the unique nature of pain as the individual’s own experience has been stressed. and any other medications currently used. This information is essential to effective pain management. One reason for this cautious approach is decreased renal function in older patients. Usually. which increases the risk of toxicity. Individual Preferences Throughout this chapter. an older patient’s starting dose is reduced by 25 to 50 percent and then increased based on effect.Unlawful to replicate or distribute Yet another assessment method is to evaluate the extent of the patient’s pain awareness and the degree to which the pain interferes with the patient’s functioning. pharmacist. ability to socialize. the classic dictum of “start low and go slow” is the safest pain control approach. the initial assessment is brief. ADLs. Physical Condition Determining the impact of pain on the client is part of a comprehensive pain assessment. Cultural and Spiritual Beliefs Copyright © 2008. since rapid intervention is needed.0 . and ways in which the pain has affected activities of daily living. The College Network. previous pain treatment and effectiveness. Collaborative care that involves the client. Questions that can help determine this impact include the following: • “How does the pain affect your sleeping patterns?” • “Have your recreational activities changed because of the pain?” • “Does it interfere with your ability to eat?” • “Has your work or social life been affected by the pain?” The nurse would follow each question with additional open-ended statements. when and what analgesics were last taken. It is widely believed that the degree of functional interference caused by pain is a good indicator of its severity. This would allow the interviewer to acquire additional information on what the client has done to self-manage the pain. the nurse would do a comprehensive pain assessment and gather information on coping mechanisms used. The nurse may focus on allergies to medications. When medicating elders. Comorbid conditions can also alter pain medication metabolism and excretion in the elderly. giving complete descriptions of pain. Inc. This is consistent with similar findings over ten years ago that found poor nursing assessment strategies and exaggerated concerns over the use of pain relievers as major “professional” barriers to better pain control. to refuse pain relief measures that do not cure the cause of the pain. they do not affect pain perception. The outdated research that purported these beliefs. and to use words such as “unbearable” when describing pain. however. Given the lack of traditional continuing education methods to change nurses’ beliefs. In fact. In some instances. when dealing with issues of pain control. the culturally competent nurse must be sure to do the following: • • • • Become aware of his or her own cultural expectations and beliefs about pain and pain control Demonstrate knowledge and understanding of the client’s cultural beliefs and behaviors related to pain Accept and respect cultural differences and avoid stereotyping Adapt pain relief measures in a way that is congruent with the client’s cultural values and health care beliefs The nurse must respond to the client’s perception of pain and not react to the pain behavior. the nurse’s cultural values may differ from those of the patient. Individuals learn from early childhood what responses to pain are acceptable and unacceptable. For some. The College Network. new strategies are Copyright © 2008. A client from a different culture may behave in a stoic. The nurse may also believe in seeking immediate relief from pain. The Nurse’s Beliefs As just mentioned. It is often believed that individuals from non-Anglo-Saxon origins have a lower pain tolerance than people with Anglo-Saxon backgrounds. the nurse’s belief system may include the avoidance of loud expressions of pain. Despite the erroneousness of this belief as well as research findings demonstrating that pain perception varies by individual and not ethnicity. research has shown that nurses are still hesitant to believe a person unless there are objective signs of pain (Horbury. NXP 070106 v1. a nurse’s personal beliefs often influence how he or she deals with patients who are experiencing pain. For instance. complain. and Bromley 2005). However. Henderson. A nurse who acknowledges and respects cultural differences in pain behavior will have a greater understanding of a person’s pain and make more effective interventions.0 . people of nonAnglo-Saxon descent are still prescribed and receive significantly less analgesia in emergency rooms. These beliefs influence the meaning given to pain. Thus. quiet manner.Unlawful to replicate or distribute Culture and ethnicity have an impact on how pain is explained and described. is seriously flawed and unacceptable by today’s research standards. despite ethical standards guiding a nurse’s response to a client’s report of pain. rather than expressing the pain loudly. such as crying or moaning. and accepting the relief measures offered. or wail audibly about pain. the cultural expectation may be to moan. can assist in pain relief measures.0 . cold examination rooms. uncertainty about the future. Anxiety over the potential cost of medications is a major barrier to pain relief. intense physical exertion. such as a hospital with its noises. Alterations in the environment. Explaining the range of pain expected for the client’s condition and the Copyright © 2008. Other factors. it is important for clients to have an opportunity to talk about their pain. The nurse acquires information on these areas during assessment and makes appropriate referrals to help the client and family. the client’s use of illegal substances such as marijuana. and fear. and they can amplify the pain. Socioeconomic Factors The financial cost of pain control and its impact on health-seeking behavior cannot be underestimated. Client education can be very helpful in these situations. The College Network. can compound pain. and bright lights. NXP 070106 v1.and long-term effects on clients’ functional abilities. may suffer severe pain rather than seek care. anger. and the underusage of pain-relieving substances for infants. These emotions can be complex and related to such things as unresolved pain in the past. A strange environment. and their perceptions and reactions to it. In addition. can also influence the client’s health-seeking behavior and make adherence to follow-up a problem. no matter what their age. because inadequate pain control can have devastating short. unresolved pain can result in anxiety. and keeping up to date on state-of-theart practices in pain management can all help the nurse work effectively. The stakes are high. Inc. and certain ethnic groups are significant problem areas. children. Psychological Factors Psychologically. In addition. The nurse’s role as a client advocate is central when ethical dilemmas arise. Younger clients without health insurance may also either not seek care or underreport the level of discomfort because of the lack of money to cover a prescription. can cause angina in susceptible people. the use of opioids for pain relief in terminal illness. Thus. Ethical and Legal Factors Effective pain management raises significant issues in terms of ethical nursing practice. An older adult on a fixed income.Unlawful to replicate or distribute needed to help nurses change their behaviors about pain management. use of the hospital or agency’s ethics committee. the fears associated with it. activity. or unmet expectations. such as noise reduction and a comfortable room temperature. Constructive dialogue among the health team members. for example. such as climbing stairs. such as lack of transportation. The use of placebos has already been discussed. This may be particularly true for the person who is alone and has no support network. The client’s home environment and activities that precipitate pain are important assessment areas. Environmental Factors Extreme variations in temperature can have a direct effect on a person’s pain. Collaborate with other team members to determine best pain relief measures.e. It is essential that appropriate follow-up measures are taken if there is any indication of risk. Assess pain within a holistic framework (i.. this is another example of why accurate nursing assessments—including believing the client’s self-reports of pain—are critical to client safety. A question such as “Do you ever feel so bad that you want to die?” can help begin the discussion. If there is a concern about possible suicidal ideation. NXP 070106 v1. Maintain state-of-the-art knowledge on pain management.g. evaluate their effect.1 The Nurse’s Role in Pain Management Nursing role Provider of care Examples of functions • • • Manager of care • • • Educator • • • • • • Assess pain based on the client’s perception and definition of pain. Furthermore. Help clients and families interface with the medical team regarding use of alternative therapies. cultural. Teach the client and family to manage the pain relief regime themselves. Inc.. depression. Identify high-risk clients and refer for needed additional services (e. physical.0 .Unlawful to replicate or distribute types of discomforts that signal the potential for problems will help alleviate the client’s fear and anxiety. emotional. The nursing process is a systematic problem- Copyright © 2008. some people with chronic pain who are severely depressed can become suicidal. and work with the team to alter ineffective interventions.g. or use of placebos). Facilitate understanding of health beliefs and practices among providers. when appropriate. counseling and financial help). The College Network. Develop mutual teaching goals with the client and client’s family. Administer pain relief medications.. Client advocate Application of the Nursing Process Of course. Table 5. and clients’ families.1. Some of these roles and associated functions are listed in Table 5. but also exhaustion. Clients who have chronic. the client should be asked directly. Again. withholding medications from neonates and certain ethnic groups. The Nurse’s Role in Pain Management The nurse plays several active and crucial roles in the management of pain. and a sense of failure. Educate physicians and staff on appropriate pain relief interventions. Intervene with physicians and nurses when care is not acceptable (e. and socioeconomic factors that affect pain control). clients. unresolved pain may experience not only the aforementioned emotions. the nurse’s other major responsibility in pain management comes through proper application of the nursing process. the nursing assessment must analyze all factors influencing the pain experience. For example. his or her behavioral and physiological responses must also be assessed. In addition to the patient’s verbal history. emotional. the nurse relies on the client’s perception of pain. Assessment The first step in a systematic analysis of a client’s pain control is a thorough assessment. after a certain level of trust has developed. This process consists of assessment. diagnosis. intervention. The degree of discomfort felt at the time of the interview should be documented. behavioral. Information associated with the pattern. and evaluating care related to pain relief and comfort measures. Observations of a client’s behavioral and physiological responses are also documented. Intensity can be measured by asking the person to respond on a scale of 0 to 10. Functional questions that identify the pain’s effect on the patient’s ADLs and questions regarding the patient’s past pain history should also be posed. time of onset. Inc. the type of assessment done for a client in the emergency room with a fracture will be different than that done on a client with terminal breast cancer in an oncology clinic. a skilled interview. the nurse must initiate pain assessments. planning. appropriate client care. Those factors include the physiological. The nursing process provides an effective approach for identifying. The depth and frequency of the assessment will vary with each client encounter. the nurse can ask more sensitive questions. and constancy of the pain must also be also collected. The nurse should also document associated symptoms that occur with the pain. These relate to issues such as the emotional and perhaps spiritual meaning of pain to the client. with 0 representing an absence of pain and 10 representing the worst pain possible.0 . and the client’s affective responses.Unlawful to replicate or distribute solving approach used to provide effective. intervening. In a comprehensive pain assessment. or blurred vision. a physical examination. In addition. such as what triggers the pain. Believing the client and conveying that belief to the client is central to establishing a trusting relationship. NXP 070106 v1. For clients who are unable to communicate. dizziness. Comprehensive pain assessments consist of a pain history. are Copyright © 2008. precipitating factors should be considered. The College Network. The nurse should inquire about any strategies the client uses to alleviate the pain and what pain medications he or she is taking. Because it has been found that most people will not voice pain concerns unless asked. Because pain is subjective and experienced only by the individual client. the nurse should ask about the location and quality of the client’s discomfort. and appropriate laboratory work. It is through these types of questions that the nurse will gain insight into the meanings the patient attaches to the pain experience. Toward the end of the history. psychological. available coping resources. and evaluation. As has already been stressed. such as nausea. and sociocultural. duration. open somber eyes. NXP 070106 v1. biting of the lower lip Moaning. absence. resulting in increased blood pressure..g. Analysis After an accurate assessment has been completed.. rocking. continuous back pain.crying. Inc. arm across the chest. the sympathetic nervous system is stimulated.2 identifies some of the observable behaviors associated with a pain response. Examples of the North American Nursing Diagnosis Association’s (NANDA) pain-related diagnoses include the following: • • • • • • • Sleep pattern disturbance related to increased pain perception at night Chronic pain related to reduced blood supply to tissues Risk for injury due to medication side effects Acute pain related to physical injury Altered health maintenance due to chronic pain and fatigue Ineffective airway clearance related to postoperative incisional chest pain Ineffective coping related to prolonged. or severity of pain and should not be used. massaging area of pain Physiological responses vary with the origin and duration of pain.Unlawful to replicate or distribute disoriented. the airway clearance would take priority over the coping problem). ineffective pain management. Table 5. screaming Affected body part is protected (e. or are very young.g. flinging arms about. blood pressure. Since the presence of pain can affect so many other facets of a person’s life. In people with chronic pain. The prioritization is also influenced by the person’s developmental level. tightly shut eyes.2 Observable Behaviors Associated with a Pain Response Indicator Facial expressions Vocalizations Immobilization Purposeless body movements Rhythmic body movements Behaviors Clenched teeth.0 . the client’s autonomic nervous system adapts. pain may be the etiology of other nursing diagnoses. a diagnosis is made that both facilitates individual care and promotes professional accountability for that care. the availability of resources. so measures of physiological response (e. and pupil dilation. pulse) are poor indicators of the presence. Table 5. nonverbal cues may be the nurse’s only indicator of pain. reflexive jerking away from a needle Rubbing. and inadequate support systems The diagnoses are validated with the client and documented in a manner that facilitates an outcome evaluation. diaphoresis. The College Network. the body adapts and makes this response less evident or even absent. After a time. a client may have a Copyright © 2008. In acute pain.g. For example.. and sociocultural considerations. Prioritization of diagnoses is based on the client’s immediate needs (e. pallor. knees and hips flexed) Tossing and turning in bed. groaning . increased pulse rate. Established goals will vary depending on the diagnoses and their defining characteristics. The measures and outcomes described in these resources help identify whether goals have been reached. and representative of unethical treatment. The next step in planning is identification of the rationale for nursing interventions related to pain. has been found to have a number of potential benefits related to symptom management. may dictate that assistance from people outside the family is not acceptable. NXP 070106 v1. The ANA Standards of Practice. Cultural beliefs. The purpose and end product of this step is a holistic plan of care tailored to the client’s problems and strengths. sale and possession of cannabis is generally illegal throughout the United States. the person’s cultural background may indicate not only what pain alternatives are considered viable. particularly in relation to ethical considerations.0 . Similarly. Examples of these include various comfort measures the client has used. nonpharmacological therapies employed by the client. the taxonomy of nursing interventions. Examples of such goals include the following: • • • Patient reports pain level has decreased to a 3 on a 10-point scale Patient describes positive effects of guided imagery as evidenced by decreased need for medication Patient sleeps seven hours each night Established nursing standards and protocols are used to identify measures related to these goals. health maintenance. For example. usually sold as marijuana. the nurse in conjunction with the client and family derives clientcentered goals from the diagnostic statements as well as activities that will meet these goals. Copyright © 2008. however. but also which family members may be key in helping the person comply with the medication regime. Consideration of other factors that influence the client’s response to pain must also be factored into planning. and documentation from the American Society for Pain Management Nursing may all be of assistance in this regard. various state nursing practice acts. and health restoration. the patient’s usual relief measures may provide insight into what interventions he or she would consider valid pain-relief plans. Expected outcomes will relate to health promotion.Unlawful to replicate or distribute dysfunctional family system and need additional social support. fraudulent. another important ethical area in pain management deals with the use of placebos. The American Society for Pain Management Nursing and other professional organizations consider the use of placebos outside the context of an approved research study as deceptive. For example. cannabis. Planning In the planning phase. However. As previously mentioned. and the client’s use of alternative or nonproven pain treatments. Inc. the client’s cultural and spiritual practices. The College Network. noise. implementation of care includes an evaluation of the client and the family’s level of knowledge. it’s also critical that the nurse considers any available evidence-based research. For instance. Basic to all strategies for reducing pain is that nurses convey to the client that they believe the client is having pain. the decision to administer the medication belongs to the nurse..g. Education includes not only the proper administration of analgesics and use of equipment.Unlawful to replicate or distribute When engaging in planning efforts. However. and the family’s willingness to assist with pain management. on the other hand. a nursing assistant may be asked to distract a patient who is in pain. right route. it is important to educate them on the risks of driving or using heavy machinery after taking analgesics. right dose. the nurse could access evidence-based outcome measures for pain-relief interventions such as music therapy. These educational areas are very important when clients are going home with technologies used to moderate pain. After the rationale for various nursing interventions has been identified. For example. can be overcome when using outcome measures that are based in the reality of clinical practice. such as peripherally inserted central catheter (PICC) lines. Basic to all pharmacologic interventions are the five rights: right client. the nurse initiates and completes the nursing plans. self-care abilities for analgesics administration. particularly for infants and children. and the timing of administration. and postoperative analgesia administration. If a client is at home. distraction. The alleviation of pain involves the two basic approaches previously described: pharmacologic and nonpharmacologic. In general. health restoration.0 . right drug. or continuous subcutaneous infusion pumps (CSCI). This phase attempts to move the client and family toward the expected outcomes. Nursing interventions to modify the environment can also help increase comfort. The priority in making such assignments relates to the comfort and safety of the patient. the dose. and health maintenance. administration of analgesic medications requires a physician’s order. and temperature can all be modified to increase the client’s level of comfort. Examples of family issues include such things as positioning a client to maintain an open airway and the use of safety devices (e. It is based on the assessment of the client’s condition. transcutaneous electrical nerve stimulation (TENS). such as the American Chronic Pain Society or the Copyright © 2008. or other team members may be asked to help reposition a patient who is in acute pain. noninvasive measures can be performed as an independent nursing function. Research that shows the nurse’s bias related to the use of pain medications. but also safety-related information. the nurse can then assign care activities to other appropriate members of the health care team. Such things as lighting. Referrals to appropriate community resources can also assist clients and families. Implementation In the implementation phase. Inc. NXP 070106 v1. For clients. These outcomes can be related to activities in health promotion. nonpharmacologic. National resources. and right time. The College Network. side rails) when the client experiences sedation. In this situation. the use of guided imagery may be a useful alternative. the physician and the nurse need to collaboratively reassess the situation with the client. The College Network. is central to determining what kind of change has or has not occurred. the client is again asked to rate the pain. or local support groups and pain clinics must all be considered when helping a client deal with pain. For example. family members as well. Using a systematic method to document this pain. the nurse must also supervise patient care activities assigned to other members of the health care team. NXP 070106 v1. Data on the client’s response to the interventions is also gathered from other members of the health care team and.Unlawful to replicate or distribute 100 Fundamentals of Nursing American Pain Society. These interval evaluations provide the data needed to reassess interventions and make appropriate alterations in care. For example. Inc. when appropriate. Copyright © 2008. it is the supervising nurse’s responsibility to ensure that the staff nurse understands both the purpose and the techniques of relaxation therapy.0 . the nurse needs to consider other strategies. Evaluation It is critical to reassess the client’s pain perception after the interventions have been implemented. Finally. during implementation. The assessments are based on the client’s perception of the pain. such as a pain rating scale. After additional interventions have had a chance to work. if the client does not want to use meditation techniques. The nurse works as the client’s advocate in obtaining pain relief. If these are ineffective. a staff nurse may be asked to assist a client with a relaxation strategy. This role not only involves the delegation of pain-related tasks. If the interventions were not effective. but also the validation that staff members are able to implement these tasks according to established guidelines. Describe the nursing process used to help patients meet basic sleep and rest needs. 7. The College Network. Explain the sleep-wake cycle and the role of the reticular activating system (RAS) in wakefulness. NXP 070106 v1. Differentiate between rest and sleep. 6. Key Terms biorhythm bruxism central apnea circadian rhythms diurnal pattern electroencephalogram (EEG) electromyogram (EMG) electrooculogram (EOG forebrain hypnotic drugs insomnia narcolepsy noctual enuresis non-rapid eye movement sleep (NREM) obstructive apnea paradoxical sleep pulse oximetry rapid eye movement sleep (NREM) rest reticular activating system (RAS) sleep sleep apnea sleep deprivation sleep terrors sleep-wake cycle slow-wave sleep somnambulism sundowning tryptophan white noise Copyright © 2008. 2. 8. Describe the most common disturbances to rest and sleep seen in various health care settings and those disturbances related specifically to age. 4. including the various tests used to assess sleep patterns and oxygenation. Describe the various interventions used to promote sleep and rest.0 . Discuss the major assessment areas related to rest and sleep disturbances. Discuss the diagnostic information gathered when assessing sleep and rest. Describe the two primary stages of sleep. you should be able to do the following: 1. 5. Inc.Unlawful to replicate or distribute Chapter 6: Rest and Sleep Objectives Upon completion of this chapter. 3. the eyes are usually closed and there is little or no conscious thought. depending on the quality of the sleep. sleep. Generally there is little physical movement and no conscious awareness of one’s environment. and problematic social interactions. Stages and Cycles of Sleep There are two primary stages of sleep: non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM). peaceful emotional state. Our discussion then turns to seven basic factors nurses can evaluate related to rest and sleep. analyze.Unlawful to replicate or distribute Introduction A restful night’s sleep is as essential to good health as nutritional food. water. but in an emotional state of unrest. and the stages and cycles of sleep. Defining Rest and Sleep Rest can be thought of as a state of peace. The College Network. Finally. With too little sleep. A state of restfulness can also be conducive to sleep. and exercise. Inc. It can mean physical inactivity or it can be related to emotions. develop a nursing diagnosis. Emotional unrest is usually characterized by anxiety. minds. including medications. environmental factors can affect sleep. we use the nursing process to assess. Nurses work with patients who are at high risk for sleep disturbances—disturbances that can negatively impact the patient’s ability to recover. Sleep can be deep or it can be fitful. People can be physically inactive. Sleep usually contributes to rest. We also discuss diagnostic tests that are helpful in identifying sleep-related disturbances. and evaluate interventions for patients with sleep disturbances. Sleep is an altered state of consciousness or change of awareness of and reactions to one’s environment. poor work performance. good rest combines both less physical activity and a quiet.0 . Copyright © 2008. increased stress. We then investigate specific interventions used to promote rest and sleep. plan. In sleep. We begin by establishing basic definitions of rest. we run the risk of accidents. psychological modifications. We discuss common sleep disturbances and the relationship of some sleep pattern disturbances to age and developmental levels. and emotions to recover. though there may be unconscious dreaming. This chapter helps us look at basic concepts related to rest and sleep. people can awake from a state of sleep feeling rested or tired. however. People of all ages generally require more sleep and rest when they have acute or chronic diseases or have suffered accidents in order for their bodies. a person can be physically active but at rest (at peace) emotionally. or relative quiet. and alternative and complementary therapies. NXP 070106 v1. Normally. ease. REM sleep declines with age and then appears to plateau. though various disease processes like certain types of dementia may adversely affect REM sleeping patterns. REM sleep increases proportionately to how well rested a person is. REM sleep generally follows each NREM sleep cycle. otherwise known as slow-wave sleep. pulse. meaning “about. in the fourth and final stage. Total sleep time for newborns is about six hours in a twenty-four-hour day. and lower than normal heart rate. respirations. Circadian Rhythms A biorhythm can be defined as any biological cycle in the body involving periodic changes in body temperature. it generally makes up ninety to one hundred and twenty minutes of total sleep each night. and blood pressure. though it varies with age. it aids in physical regeneration of the body systems. Defining characteristics throughout the four-stage cycle of NREM sleep include the following: • • • • Some rolling of the eyes Skeletal muscle relaxation Slow metabolism. meaning that it occurs each day. People normally go through four to six cycles of NREM sleep per night. The defining characteristics of REM sleep include the following: • • • • • • Rapid brain metabolism Active and remembered dreaming Decreased muscle tone Rapid eye movement Increased gastric secretions Irregular heart and respiratory rates REM sleep is believed to relate more to psychological well-being and improved memory. generally ranges from 20 to 50 percent of all sleep. allowing more opportunity for physiological repair of body tissues NREM sleep is progressive and can be characterized by restlessness and light sleep in the early stages with a deep sleep. This is also called a diurnal pattern. A night is considered approximately eight hours.” and dies. the sleep-wake activity Copyright © 2008. twenty-four hours. is thought of as a sleep-wake cycle. also called paradoxical sleep. Inc. lowered blood pressure. The College Network. The sleep cycle and circadian rhythm are two others. While all people have the same twenty-four hours available to them for each cycle.Unlawful to replicate or distribute Fundamentals of Nursing 103 Non-rapid eye movement sleep (NREM) makes up about 80 percent of sleep. NXP 070106 v1.” A day. including a slow pulse. If effective.0 . and body temperature Energy expenditure is less due to the slower metabolism. depending on a person’s age. In adults. The menstrual cycle is a common example of a biorhythm. The phrase circadian rhythm is derived from the Latin words circa. meaning “day. REM occurs about every sixty to ninety minutes and can last to up to thirty minutes. Rapid eye movement (REM) sleep. A number of things can affect the normal sleep-wake cycle. Hospitalization can contribute to insomnia because it is a strange environment. When someone sleeps. the medication lithium appears to offer a corrective. Some patients may experience fears and anxieties associated with illness. Travelers may experience “jet lag” if they change time zones and can have symptoms of disorientation. is often situational. Nurses experience this when they alternate shifts during a week. Sleep Regulation Wakefulness is regulated by the central nervous system and by a structure in the brain stem called the reticular activating system (RAS). Chronic use of hypnotics can result in a significant decrease in REM sleep. the very medication people take to induce sleep. fatigue. narcolepsy. Rest and Sleep Disturbances Alterations in normal patterns of rest and sleep can have deleterious effects all systems of the body even though they may not directly contribute to acute or chronic disease. when stressful circumstances change or problems are resolved. The RAS releases norepinephrine. Insomnia Insomnia is the most common sleep disorder. NXP 070106 v1. a stimulant. and sleep deprivation. and urinary system in particular can affect level of rest and sleep. working days and then nights and then back to the day shift. They also may wake up very early (terminal insomnia). sleep apnea. The College Network. Insomnia. Inc. People with insomnia may have difficulty initially falling asleep (initial insomnia) or getting back to sleep with frequent periods of wakefulness if they wake up (intermittent insomnia). during waking hours that keeps the mind alert. and insomnia. Older adults especially may become more wakeful and sometimes confused after taking hypnotic drugs. meaning “sleepless. Overuse of hypnotics that normally depress the central nervous system can cause insomnia. Recent research related to bipolar disorder indicates circadian rhythm disturbances.” This disorder is characterized by a prolonged inability to sleep. and they can include drowsiness and general fatigue if the insomnia is a chronic problem. and the term is derived from the Latin insomnis. The defining characteristics of nighttime insomnia are seen during the day. they feel as if they hadn’t slept or their sleep was insufficient. the RAS seems to shut down. musculoskeletal. Diseases of the respiratory. however. Common disturbances of rest and sleep that nurses are most likely to see in various health care settings include insomnia. Sleep may be enhanced by a hormone and neurotransmitter called serotonin from the parts of the brain called the pons and the forebrain. sleep patterns may return to normal. Copyright © 2008. Often insomnia is related to hypnotic drugs.Unlawful to replicate or distribute within the cycle can vary from person to person and between different ages and developmental levels.0 . When they wake up. may experience this type of apnea.g.. The exact cause is unknown. The College Network. Defining characteristics include a complete stoppage of gas exchange and absence of chest wall movement. Muscular dystrophy also can prompt central apnea. but it appears to be related to a central nervous system abnormality related to REM sleep.” Narcolepsy occurs during the waking hours of the day. Narcolepsy Narcolepsy is an uncontrollable and frequent desire for sleep. while at work or when driving a car. severe hypertension. Obstructive Apnea Obstructive apnea can be the result of a mechanical problem. The following are defining characteristics of sleep deprivation in relation to body systems and structures: • • • Central nervous system (CNS): Tremors of the hands. it can lead to cardiac dysrhythmias. decreased reflexes. decreased hearing. usually at inappropriate times and in inappropriate places. memory. as the regular cycles become disrupted. especially when a hospital stay is frequently interrupted (e. visual or auditory hallucinations Copyright © 2008.Unlawful to replicate or distribute Sleep Apnea Apnea means “without wind. Obese patients. and even death. especially older men. The word is derived from the Greek word narkoun. Specific diseases and conditions that trigger this type of apnea are brain stem injuries and brain infections like encephalitis. Sleep deprivation means being deprived of sleep. general irritability. particularly just before the usual time of waking. If apnea is prolonged. Sleep Deprivation Hospitalization. for example. it can be caused by enlarged tonsils. meaning “to benumb.0 . and ability to reason. a loud snorting sound occurs. impaired judgment. specifically REM and NREM sleep. people with sleep apnea may complain of fatigue and morning headaches. polyps (mucous membrane growth) in the nares.” Sleep apnea is a temporary cessation of breathing that occurs during sleep. The person may wake up suddenly after a period of sleep apnea due to increased carbon dioxide levels in the blood. and exaggerated reactions to pain Cardiac: Cardiac dysrhythmias Eyes and ears: Decreased or blurred vision. Central Apnea Central apnea is triggered by an abnormality in the respiratory center that controls breathing. or a deviated septum. for patients in intensive care or on units that are very busy and noisy). The defining characteristics during sleep include snoring followed by an apneic period when snoring ceases. can result in sleep deprivation. When breathing resumes. NXP 070106 v1. During the day. Inc. A person’s breathing can stop for ten seconds up to two minutes. This sleep deprivation can put them at risk for accidents on the job and on the road. and then they may sleep in short naps. Nurses and others engaged in shift work may sleep very few hours because of the difficulty for the body to adjust to time changes. and some newborns sleep several hours more.Unlawful to replicate or distribute Rest and Sleep Pattern Disturbances Some sleep pattern disturbances are related specifically to age and developmental level. Infants still require at least twelve to fourteen hours a day of sleep. Age. Adolescent boys may also experience nocturnal erections during REM sleep. sleeping or dozing lightly throughout the day for short periods of time. may be awake much of the night. As children grow. Preferences and Dietary Habits Employment habits can influence a person’s rest and sleep habits. This pattern can continue through the preschool years. a period of extreme restlessness and agitation that occurs in the late afternoon. Nightmares (frightening dreams) or sleep terrors can also be common to children. Copyright © 2008. but it is also based on age. The need for sleep varies greatly from individual to individual. Approximately 50 percent of a newborn’s sleep is REM sleep. older men who are also obese may experience obstructive apnea just prior to waking. Sleep terrors are characterized by a partial arousal from sleep. Assessment of Rest and Sleep A number of factors can influence a person’s rest and sleep patterns in the hospital. especially older adults with dementia. Toddlers also may require twelve hours of sleep a night. Gender. there is no dreaming. sleep requirements range from eight to ten hours for adolescents.0 . Somnambulism (sleepwalking) is characteristic of some children. The College Network. And. The newborn infant requires a minimum of sixteen hours of sleep per day. or home care settings. the older adult may sleep about six hours a night. as noted. nursing home. Alzheimer’s disease is characterized by sundowning. Babies sleep through the night generally at age three to four months. Older adults. Sleep needs decrease through adulthood. Age-related changes often create sleep disturbances in older adults. The following are major categories to consider while formulating nursing diagnoses and planning interventions related to the factors that most frequently influence a patient’s rest and sleep. they seem to lose the sense of time. Inc. Other sleep disturbances seen in children are nocturnal enuresis (bed-wetting) and bruxism (grinding of teeth when asleep). and Developmental Level A number of physiological differences based on age and developmental level can affect rest and sleep. but they may also waken during the night for a variety of reasons including nightmares or frightening dreams. NXP 070106 v1. more advanced stage NREM sleep accounts for the other 50 percent. Alcohol causes people to become drowsy and initially go to sleep because it is a hypnotic drug and a CNS (central nervous system) depressant. Pseudoephedrine has been known to cause cardiac problems and hypertension. Nightmares are a symptom of drug withdrawal. If diuretics like Lasix are given in the late afternoon. NXP 070106 v1. a good exercise program early in the day. plenty of fluids. Tylenol for fever control. Sedatives (opiates or narcotics). Normal physical activity.Unlawful to replicate or distribute Some people drink excessive amounts of caffeine in coffee. frequent nighttime urination. they can cause nocturia. Caffeine stimulates nerve receptors and can also cause restlessness and irritability. Physicians generally discourage cold (decongestant) and cough suppressant medications containing these drugs. Pseudoepinephrine. The nicotine in cigarettes also has a stimulant effect that can keep people from falling asleep. comfort care. but it adversely affects the quality of sleep.0 . encouraging instead the use of saline nose drops. Inc. including the drug alcohol. New laws are in effect now governing the sale of medications that include these ingredients and they are not as readily available now over the counter. this can add to central nervous system stimulation. and older people may often doze off during the day. and soda as a stimulant to keep them awake. and this condition can cause wakefulness. The College Network. tea. one of the most common disorders of the gastrointestinal tract. Vigorous exercise late in the evening often has a stimulating effect. Gastric acid is regurgitated into the esophagus. three infants and toddlers who died in 2005 were found to have high levels of pseudoepinephrine in their bloodstreams. people who are obese tend to sleep more. Some cold and allergy medications contain ephedrine or pseudoephedrine. or urinary incontinency. Copyright © 2008. and moderate exercise in the evening generally contribute to nighttime sleep. and many over-the-counter cold medications may induce drowsiness. Conditions like anorexia contribute to sleep deprivation. also found in cold and allergy medications. has been known to have harmful effects. In general. this is a side effect of many cardiac medications. Other medication effects include insomnia or a prolonged inability to sleep. Physical Condition How well are all the systems of the patient’s body functioning? An admission assessment by the nurse may uncover physical problems that can affect normal patterns of rest and sleep or put the person at risk for developing sleep disturbances. especially for infants and toddlers. particularly REM sleep. and rest. when combined with caffeine. People who are overweight or obese may also suffer from heartburn or esophageal reflux. Caffeine intake can also stimulate urine production. and a full bladder can waken people in the night several times. common side effects are restlessness and irritability. Medication History Many medications have side effects that can affect sleep patterns and the quality and quantity of both NREM and REM sleep. pain relievers. others are used to noise and can sleep well. Endocrine disorders can also disrupt sleep. from air conditioners or fans) or too much light can inhibit sleep. in some cultures. Some people are unable to sleep even with night-lights on. as is often true with arthritis. Socioeconomic and Environmental Factors What socioeconomic and environmental factors might influence sleeping patterns? Does the patient live in a crowded and noisy environment? Noise affects people in different ways. ethical. practices. can contribute to nocturia. or spiritual/religious beliefs. Sleep rituals are also important. Some people are unable to initiate sleep in a noisy environment.g. Excessive amounts of air (e. especially in the older adult. Temperature extremes can also affect sleep. and the anxiety and panic associated with this can further inhibit a desire to sleep. both very hot and very cold environments inhibit sleep.Unlawful to replicate or distribute Many chronic illnesses contribute to ineffective sleep because of associated pain. NXP 070106 v1.. or preferences that might influence the patient’s rest and sleep? For example. Ulcer formation in the stomach or duodenum can disrupt REM sleep and this type of sleep increases the secretions causing pain in the abdomen. Untreated urinary tract infections can also lead to confusion and restlessness in older people that can keep them awake at night. and events like hospitalization can disrupt these. noise from other restless patients can create adverse conditions for rest and sleep. when hospitalized. Patients with various forms of lung disease may have difficulty sleeping if they are short of breath. parents and children sleep together. Cultural Practices and Religious Beliefs Are there any cultural. In nursing homes. Impaired renal (kidney) function. The hospital environment of the intensive care unit and noise from the nursing unit or nursing stations may also affect rest and sleep. Even the common cold can affect sleep if people have difficulty breathing or experience much nasal drainage. Inc. the need to sleep alone for either the child or the adult can cause stress and wakefulness if the patient was used to sleeping with another person at home. The College Network.0 . Copyright © 2008. some rituals are of a religious nature. such as prayer or reading from the Bible or other religious literature. as is assessment information about any bedtime rituals used at home that may enhance sleep. One that might be done by nurses on the unit is pulse oximetry. Any other factors that may influence the needs for rest and sleep should also be assessed. an electromyogram (EMG). certain social and psychological factors may influence rest and sleep. and noting rest patterns and sleep patterns during the day. and an electrooculogram (EOG). so the patient may be referred to a special sleep disorder unit or clinic within the hospital. NXP 070106 v1. assess the patient’s prescription and over-the-counter medications for sleep or other physiologic conditions. General observations about facial appearance can be important. The College Network. Diagnostic Information Related to Rest and Sleep Diagnostic information includes any data that can influence a person’s rest and sleep status. this can include subjective information based on a patient’s health history and any other data that can be objectively measured.. The following are some questions to consider: • • • • Does the patient have dark circles around the eyes? Does he or she appear anxious and restless? Is he or she constantly dozing off during the day? Does he or she have any tremors of the hands? Observations specific to the central nervous and cardiovascular systems. for example. comments about being tired or fatigued. The nurse should obtain a history from the patient or the patient’s significant others on admission to the health care facility related to such things as recent changes in sleep patterns and sleep history. Other tests are generally not done by nurses on the nursing unit.g. Assessment of routine sleep patterns for children and older adults with Alzheimer’s dementia are especially important.0 . A number of diagnostic tests can be done to assess sleep patterns. Also be aware of statements the patient might make indicating a need for sleep. Objective nursing assessment data in hospital and nursing home settings includes checking for any alteration in vital signs. Copyright © 2008. that might impact sleep and rest. The quality and stages of REM and NREM sleep are often evaluated by tests including an electroencephalogram (EEG). observing sleep patterns at night. Depression can also lead to sleeplessness if the person is anxious and worried about his or her situation. (e. Emotions like loneliness and depression can contribute to a more sedentary lifestyle and more time spent sleeping and napping. such as renal impairment or respiratory distress. dysrhythmias) may indicate disturbances in sleep. for example. Inc.Unlawful to replicate or distribute Psychological Factors At various stages of the life cycle. The nurse can explore with patients the position they normally sleep in at home and the number of pillows they normally use. If possible. dietary management. Earplugs can be used if needed. Call lights should always be available to patients so they will feel less anxious should they require assistance from nursing personnel.0 . For instance. Electromyogram (EMG) readings measure muscle tone that is affected with REM sleep. A machine called a pulse oximeter is used. Physical and Environmental Modifications The most common interventions for facilitating sleep include physical and environmental modifications. noise should be reduced for patients with sleep disturbances. and the use of complementary therapies and psychological modifications. If at all possible. An electrooculogram (EOG) measures eye movements that are also specific to REM or NREM sleep patterns. proper positioning by placing the body in good alignment can be conducive to sleep. Some patients might benefit from back rubs to induce a state of relaxation. NXP 070106 v1. since it seems to increase sensitivity. this position can be encouraged in the hospital if it has been conducive to sleep. maintain. Elevating the head of the bed can help patients breathe more effectively if they have respiratory disease. Anything less than 70 percent would indicate a respiratory emergency. Nurses should be aware of all the various noises. Interventions to Promote Rest and Sleep A number of common nursing interventions can be used to promote. for example. The knowledge that help is instantly Copyright © 2008. If a patient is hypoxic. The machine will calibrate the percentage of oxygen saturation in the body. A nurse may provide uninterrupted times for sleep during the day if the patient is unable to sleep well at night. These treatments range from basic physical and environmental modifications to medication. brain waves are recorded through electrodes placed on the scalp. and seek to minimize them. the underlying cause of the sleep disturbance should be eliminated. Normally a sensor with an infrared light is clipped to a patient’s middle finger (or foot in the case of infants). Pulse oximetry may be done by nurses or in the sleep disorder clinic to determine adequacy of oxygenation. Noise can be particularly distressing for patients in pain. including voices that are associated with giving care. and restore rest and sleep and treat disturbances of rest and sleep across the life span. this may mean relocation to a room that is quieter. Values between 70 and 95 percent would indicate the need for oxygen and further evaluation. Pulse oximetry measures oxygen saturation in the capillaries.Unlawful to replicate or distribute • • • An electroencephalogram (EEG) measures the level of activity in the cerebral cortex of the brain. This noninvasive test is often done on patients with nocturnal or sleep apnea. Inc. The College Network. a reading might be 88 percent. The College Network. and it is thought to induce sleep. restless leg syndrome (RLS) is a common disorder that can cause people difficulty in falling asleep and remaining asleep because of repeated leg jerking. Other patients may not be able to sleep at all if there is any light in the room. Ideally they should not disrupt the normal cycles and stages of sleep but enhance them. blood clots. NXP 070106 v1. and temazepam (Restoril). especially. Obese patients may experience more sleep apnea if sedative-hypnotics are used to induce sleep. (Note: Leg massage may be contraindicated for some patients. If there is a fracture or skin infection on the leg. The increased blood flow from leg massage is not recommended for people with hematomas. benzodiazepines have been prescribed. and the young child may require extra blankets for warmth. not manage behavior. not chocolate milk. is often encouraged for insomnia. diazepam (Valium). The older adult. Vigorous massage should also be avoided for people with osteoporosis. some patients may benefit from short-term treatments of sedatives or hypnotics. Medications should never be used. oxazepam (Serax). Tryptophan is an amino acid found in both milk and cheese. low platelet counts and people Copyright © 2008. Inc. Plain. Beverages containing caffeine should also be avoided at night because of their stimulant effect on the central nervous system and their diuretic effect on the bladder. clonazepam (Klonopin). The primary drugs used to induce sleep are the benzodiazepines: flurazepam (Dalmane). and varicosities. Warm baths and leg massage may also help relieve symptoms. bleeding disorders. For example. crackers and cheese. as a chemical form of restraint. edema. Hot water bottles or heating pads should not be used because of the danger of burning. especially a meal with hot and spicy foods that can cause heartburn. Medications Though many drugs have side effects that adversely affect the need for rest and sleep. for example. doors may need to be shut and blinds pulled to close out the light from hallways and the outside lights surrounding a busy hospital. The primary purpose of sedative-hypnotic drugs is to induce sleep. especially with the older adult. Chronic use can decrease required amounts of REM sleep and increase confusion in older adults. Some patients benefit from a light protein and carbohydrate snack. chocolate can have a stimulating effect to the nervous system. Dietary Management If a person eats a large meal one to three hours prior to sleep. promoting increased urination. people might benefit from flannel or outing sheets for extra warmth. Patients who are chilled because of air conditioning or fans blowing directly on them will not sleep as well. Alcohol also has a diuretic effect. Night-lights can also be comforting to children in the strange environment of the hospital. In home situations. massage would also be contraindicated. Most sedative-hypnotic drugs depress the central nervous system.0 . it is generally counterproductive to sleep. Some patients may need night-lights in their room or in the bathroom if they are ambulatory at night.Unlawful to replicate or distribute available can decrease anxiety and aid patients in falling asleep. Eyeshades can also be used. Attention should also be paid to providing a comfortable room temperature with adequate ventilation. warm milk. however. . The College Network. like a walk. Alternative and Complementary Therapies A number of nursing interventions considered alternative or complementary may be used.0 . These should generally be given early in the morning to ensure the patient will have a restful sleep at night.g. it is important to reduce sensory stimuli as much as possible several hours before sleep. This ritual is particularly important for children and people with various forms of dementia who may be used to bedtime routines like brushing their teeth. People who work or study using computers until just before bedtime may have difficulty “turning off” their minds. as leg massage may be contraindicated during the first three months of pregnancy. Many patients in the hospital. hospitalization.Unlawful to replicate or distribute 112 Fundamentals of Nursing taking heparin or Warfarin. Anti-inflammatories for arthritis like Motrin (ibuprofen) may also be used. White noise is a sound that contains a blending of all the audible frequencies that are distributed equally over the range of a frequency band and is also considered an intervention. For example. Soft music from a bedside radio may induce sleep. The nurse can also provide an opportunity for patients to unwind or talk about any fears or anxieties associated with their illness. often a pain-relieving analgesic like acetaminophen (Tylenol) or extra-strength Tylenol can be more effective to induce sleep than a sedative or hypnotic. or at home are on diuretic therapy to reduce edema and fluid retention (e. quiet activities are preferred. Nurses should be aware of the patient’s underlying worldview or belief system when offering these interventions. all of which may also help induce sleep. Pain can inhibit rest and sleep. nursing home. Some guided imagery exercises may pose ethical or religious concerns for patients. Psychological Modifications A number of psychological modifications can be considered as interventions. or nursing home placement. Deep breathing exercises that may help the patient to relax incorporate contracting and relaxing various muscle groups. There are a variety of touch therapies from both Eastern and Judeo-Christian traditions Copyright © 2008. Lasix and Diuril). and washing the face and hands. Restful. Music can also help block out the distraction of other noise in the environment. Inc. NXP 070106 v1. Warm milk given with these and other hypnotic drugs aids in their absorption. Various forms of relaxation exercises and guided imagery techniques can be taught. Pregnant women should consult their physicians. This might include mild exercise. Over-the-counter pain relievers have minimal side effects and provide the added benefit of pain relief. The process of “getting ready for bed” can also induce sleep.) Common non-benzodiazepine hypnotics include the sedatives chloral hydrate and zolpedim (Ambien). removing dentures. For example: Explore with the mother of a hyperactive toddler who has difficulty sleeping the types of foods the child might be eating before bedtime.0 . For example: Question the patient about any recent changes in ability to sleep. Children and also some older adults may sleep with stuffed animals. Some people pray every night before going to bed. Nurses can provide opportunities for this bedtime ritual by incorporating parents into the bedtime routine of the child or assigning a nurse who is comfortable with that complementary intervention to the patient. Assess other factors that could influence the patient’s ability to rest and sleep. Inc. Assessment To briefly review. Utilize nursing skills for physical assessment. • • • Copyright © 2008. and various forms of guided imagery. This process includes the analysis and synthesis of all data. or ask about environmental factors that might impede sleep. or ask him or her to keep a sleep diary for a week. care planning can be done utilizing the nursing process and other theoretical frameworks. Obtain and review laboratory and other diagnostic data. like therapeutic touch. For example: Review results of pulse oximetry readings over the course of a week for a patient with COPD and insomnia. culminating in one or more nursing diagnoses. The College Network. Some of these therapies. and evaluation follow in logical order. reading a bedtime story or book. For example: Observe the sleep pattern of a patient admitted with sleep apnea. It is important to explore with parents of children and with family members of persons with dementia any other specific bedtime rituals that enhance sleep for them. for example. NXP 070106 v1. such as noise.Unlawful to replicate or distribute that nurses have incorporated into care for patients to aid in relaxation. may pose ethical or religious concerns for patients who do not subscribe to the underlying philosophy or belief system on which they are based. implementation. healing touch. and planning. the following are considerations for a nursing assessment: • Obtain a history from the patient and/or the patient’s significant others related to the patient’s rest and sleep patterns. including children. Applying the Nursing Process to Meet Basic Needs for Rest and Sleep Once the nurse has done a thorough assessment of the patient’s rest and sleep status based on objective and subjective data and is aware of the variety of interventions that can be utilized for related disturbances. Diagnoses are then prioritized. Unlawful to replicate or distribute Analysis Once objective and subjective data have been gathered, the nurse synthesizes the data in order to identify the patient’s actual or potential health problems that are amenable to some type of nursing intervention. Other health team members such as the physician and personnel from a sleep disturbance clinic might also be involved in analysis. Nursing diagnoses are then formulated and prioritized. Nursing Diagnoses The nursing diagnosis will include an actual or potential problem related to sleep and rest, and the etiology of the problem or potential condition of risk. Defining characteristics based on objective and subjective data help define the diagnoses. The general nursing diagnoses based on NANDA-I and criteria related to disturbances in rest and sleep are sleep deprivation and readiness for enhanced sleep. Specific nursing diagnoses that address actual problems or situations of risk can be phrased as follows: • • • • • • Sleep deprivation related to sleep apnea secondary to morbid obesity Sleep deprivation disturbance related to frequency of nocturnal voiding secondary to urinary tract infection At risk for sleep deprivation related to severe pain associated with bone cancer Fatigue and depression related to alteration in sleep patterns following death of spouse Activity intolerance related to disturbed sleep pattern secondary to severe COPD At risk for injury when driving related to narcolepsy Nursing diagnoses that relate to complications associated with inactivity and immobility or to specific needs on Maslow’s hierarchy may also be considered: • • At risk for cardiac dysrhythmias and hypertension related to sleep apnea High risk for falls or injury related to somnambulism Nursing diagnoses that imply a readiness for sustaining a lifestyle that will foster healthy sleep patterns include: • Readiness for enhanced sleep indicated by adherence to recommended sleep routines. This might be applicable to a child or adolescent who had been refusing to go to bed at recommended times but decides to follow the guidelines of his parents in order to feel more rested for school. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Prioritizing, Planning, and Setting Goals Prioritizing Priorities can also be set for various nursing diagnoses based on Maslow’s hierarchy of needs and optimal use of resources. Consider this example: A fifty-three-year-old patient with recent weight gain is admitted to the hospital due to sleep apnea. Laboratory tests reveal borderline hypoxia with pulse oximetry. An EKG reveals a cardiac dysrhythmia. The patient has symptoms of left-sided heart failure, including hypertension. Needs that could be life threatening if unmet or that put the patient at risk for more serious complications would be considered top priority, such as the basic physiological need for adequate gas exchange and prevention of carbon dioxide buildup. If pulse oximetry continues to reveal abnormally low oxygenation values, oxygen can be given by nasal cannula using an oxygen concentrator at night. Blood gases can be monitored. A device called a continuous positive pressure airway (CPAC) can be used at night to relieve sleep apnea. An assessment by a respiratory therapist could help determine what specific treatments might be indicated. Health restoration needs would precede needs for health promotion. Dietary management will also be indicated, and thus a thorough dietary assessment by the hospital dietitian is indicated. The patient might be placed on a low-fat, lowcholesterol, 1,500 calorie diet during the course of hospitalization and given a discharge diet planned with the patient as well as referral to a support group for weight management. Planning Planning includes patient-centered goal setting related to health promotion, maintenance, and restoration with strategies to meet the goals. A goal for a patient who has been admitted for exhaustion related to inability to sleep is that the patient would demonstrate decreased signs of sleep deprivation, including increased alertness, decreased fatigue, and ability to sleep for at least six continuous hours at night. The person might also verbalize feeling refreshed upon awakening. A goal for a morbidly obese patient who is experiencing sleep apnea is that he or she would lose five pounds a month. Planning also needs to include various other influencing factors. The nurse could plan to incorporate teaching concerning alcohol consumption and its effect on sleep patterns with a patient who consumed several beers prior to retiring each night and complained of difficulty sleeping at home. Specific nursing standards and protocols can be used to plan interventions to meet needs. Discharge planning with the wife of a patient with Alzheimer’s dementia who has Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute difficulty sleeping would be that the wife be able to incorporate dietary changes into her husband’s bedtime routine (for example, a carbohydrate snack of a cheese sandwich and warm milk), or that she might play music tapes or the radio to enhance sleep. A patient with severe arthritis could be given Motrin one half hour before bedtime with a glass of warm milk. An occupational therapist could be consulted to provide any splinting devices that might aid in keeping hands and feet in proper alignment when sleeping. The child on the pediatric unit who is afraid of the dark and unable to sleep can be provided with a night-light by the bed and stuffed animals from home. Specific factors that could influence rest and sleep should also be incorporated in planning. Any normal routines a patient engaged in prior to hospital or nursing home placement that enhanced sleep should be encouraged, such as a bedtime story, nightly prayers, readings from a devotional book, or a warm bath. Sleep centers associated with various medical centers like the Mayo Clinic or the Cleveland Clinic is good sources of information to aid in the planning process. Information about different topics related to dysfunctional sleep patterns and habits is also available from the National Sleep Foundation (NSF). The A-to-Z listing on their web site (http://www.sleepfoundation.org) can be helpful to nurses, patients, family members, and other health professionals in planning care. For example, the NSF recommendations to help alleviate bruxism (nocturnal teeth grinding) include reducing stress levels prior to retiring, engaging in soothing bedtime routines, having a cool, comfortable, dark, and quiet room to sleep in, and, if possible, sleeping on the stomach or in a side-lying position rather than on the back. The guidelines also note that sleep deprivation can exacerbate symptoms of bruxism. Some relaxation techniques recommended include progressive muscle relaxation to relieve muscle tension and diaphragmatic breathing and autogenic training to increase blood flow in the extremities. Various relaxation techniques are often part of a specific training program at sleep clinics and in private practices. Setting Goals Goals also require measurement. How will you know if a goal has been met? If a goal is for the person to be able to be less fatigued during the day at work, one measurement of that goal could be verbalization of feeling more alert and the ability to accomplish shortterm goals that are work related. Goal setting also includes assigning patient care activities to others. Nursing assistants could be assigned to give a back rub to a patient prior to sleep, read a bedtime story to a child, or change the patient’s bath to the evening hours to see whether that promotes sleep in a nursing home setting. Implementation Interventions should be targeted to move the patient toward the expected outcomes related to health promotion, maintenance, and restoration with respect to rest and sleep. For example: Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute • • • • • • Promote rest and sleep. Bedtime rituals can be promoted. Voiding can be encouraged immediately prior to bedtime. A back rub can be administered or a protein snack given to the patient. Proper positioning of the patient to maintain good body alignment should be a priority. Give medications to maximize effects and minimize side effects. Diuretics should be given to patients in the morning to avoid nocturnal awakenings. Chronic use of sedatives and hypnotics should be avoided, and these medications should not be used as chemical restraints. Make modifications to the environment. Eliminate as much noise as possible or mask noise with music, close doors, and adjust lighting to suit patient preferences. Provide information and instruction regarding rest and sleep. The patient can be instructed on how to do relaxation exercises and what types of exercise and work activities are appropriate for different times of the day to prevent nighttime overstimulation of the nervous system and sensory overload. Promote continuity of care. Referrals to sleep clinics can be made if needed for people experiencing sleep apnea. Follow-up referrals can be made to community health facilities to monitor a depressed patient who has been experiencing sleeplessness following an amputated limb. Collaborate with the patient on enhancing sleep patterns. A home care nurse might encourage a client to keep a sleep diary that would include number of hours slept, time of day of sleeping, number of times awakened and possible reasons, and types of strategies used to enhance sleep in order to better determine an ongoing plan of care to provide adequate rest. Evaluation Once the care plan has been implemented, it will be important to evaluate the patient’s response on an ongoing basis and any progress made toward the patient-centered goals. The following are general categories for evaluation and questions or aspects of care to consider: • Record and report the patient’s response to any nursing actions. Did changes in sleep patterns occur after dietary and environmental modifications were made? How is the patient responding to the newly ordered sedative for sleep? Is he or she experiencing any side effects? Does the patient indicate that he or she is sleeping better? Reassess and revise the patient’s care plan as needed. If the nursing diagnosis indicates the patient is at risk for developing activity intolerance related to sleep deprivation, attention should be given to ongoing daily patterns of activity tolerance including any shortness of breath, any confusion, and observance of gait. Additional modifications to the care plan might be needed to enhance sleep if activity intolerance increases. • Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute 118 Fundamentals of Nursing • Determine the patient’s response to the care provided by other members of the health care team. LPNs/LVNs can be asked to record and describe a patient’s sleep pattern during their shift report. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Chapter 7: Caring for Patients with Cancer Objectives Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. Define the word “cancer,” and list several factors that can cause genes to malfunction, mutate, and lead to cancer. Differentiate between benign and malignant tumors and between carcinomas and sarcomas. Explain the grading of neoplasms and the staging of neoplastic disease. Discuss the changes in lifestyle and the diet recommended to prevent cancer. Identify three cancer-screening exams and their recommended frequency. Explain tumor markers and identify examples of lab tests used for tumor markers. Describe the four therapies used for cure, control, and palliation of neoplasia. Discuss the major family of pharmacologic agents used for chemotherapy, and list at least eight adverse effects associated with chemotherapeutic drugs. Apply each phase of the nursing process to a patient who is in the following stages: undergoing cancer surgery, receiving antineoplastic agents, receiving radiation therapy, or undergoing rehabilitation or terminal care for cancer. Apply each phase of the nursing process to the family of a patient who is receiving treatment for cancer. Explain how the nursing process can be applied to cancer education and prevention in a community. 10. 11. Key Terms afterloading benign tumors biologic response modifiers brachytherapy cachexia cancer carcinoma chemotherapy computed tomography (CT) debulking endoscopy grading immunotherapy interstitial radiation intracavitary radiation laparoscopy leukemia magnetic resonance imaging (MRI) malignant tumors mammography metastasis neoplasia palliative treatment positron-emission tomography (PET) radiation radioisotope studies remission sarcoma staging systemic radiation teletherapy TNM system tumor tumor lysis syndrome tumor marker Introduction Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 responsibilities. Our discussion then turns to general nursing care for individuals with cancer and for families who have a member diagnosed with cancer. and radiographic procedures that are sometimes used to help in the differential diagnosis of cancer. cancer is the second-leading cause of death in the United States (Garfinkel 1995). Cancer is a group of disorders defined by abnormal cellular differentiation and growth (neoplasia).Unlawful to replicate or distribute Cancer nursing is a dynamic area of practice that covers all health care-delivery settings and all age groups. and goals of cancer nursing are as diverse and complex as any nursing specialty area. Cancer additionally has a significant psychosocial impact on its victims. Individuals with cancer commonly experience pain. and lipid metabolism. and altered protein. laboratory studies. We discuss a variety of patient-level interventions that can help prevent cancer from developing. Inc. body image. and cachexia. Anemia is commonly seen in cancer because of malnutrition. clients might ask “What is the prognosis for this type of cancer?” or “How long do I have to live?” It is not uncommon for the individual with cancer to experience fear. We then discuss screening for neoplasms. Treatment with radiation or surgery also can lead to devastating changes in physical appearance from burns or scars. hostility. The chapter concludes with a discussion of cancer-related preventive care provided to the community as a whole. This results in increased numbers of cells with altered anatomy and function. and radiation. iron deficiency. Infection also is a common complication of the cancer process and its treatment modalities. altered taste. This increase in cells may result in tumors (groups of neoplastic cells clumped together) or leukemias (abnormal proliferation of white blood cells). carbohydrate. hopelessness. and loss of work. fatigue. infection. and classifying neoplasms. identifying factors that can lead to cancer. The patient’s self-esteem may be threatened by changes in role function.0 . in cancer. The specialty area is called oncology nursing and the scope. and loss of control. NXP 070106 v1. The chapter begins by defining cancer. anxiety. The College Network. anemia. We also explore the four general treatment options for individuals diagnosed with cancer and apply the nursing process to each alternative. Basic Concepts of Cancer A dreaded diagnosis today. depression. the affected cells are unresponsive to normal control mechanisms and are less differentiated than the parent cells. weight loss. For example. cell division and proliferation are regulated. helplessness. chemotherapy. anger. Copyright © 2008. The purpose of this chapter is to provide a very general overview of cancer and nursing care for cancer patients and their families. Normally. Cachexia is a severe form of malnutrition that includes anorexia. The life of an individual who has been diagnosed with cancer is full of uncertainties. chronic bleeding. 0 . Likewise. infiltrating and destroying surrounding tissue. grow slowly by expansion. such as nicotine. and management of patients with cancer will be discussed in this chapter. Classification of Neoplasms Tumors are classified as either benign or malignant. For example. a benign tumor in bone tissue is called an osteoma. are encapsulated and localized. Because both benign and malignant tumors may arise from any source. an individual is considered to be cured if he or she has been in remission for anywhere from one to seven years. More males are diagnosed and die from cancer than females. the incidence of cancer is higher in the lower socioeconomic groups. and rarely cause tissue damage or death. pesticides. On the other hand. For example. and cause death if uncontrolled. Copyright © 2008. Malignant tumors are called carcinomas or sarcomas. NXP 070106 v1. Some chromosomal syndromes increase the risk of certain types of cancers. treatment. such as estrogen Drugs. malignant tumors contain undifferentiated cells that grow at the periphery. based on their cells of origin. Once the malignancy has been eradicated. individuals with Down syndrome have an increased incidence of leukemia when compared to the rest of the population. Carcinomas are derived from epithelial cells. and asbestos Obesity and high-fat. low-fiber diets Stress (causes a depressed immune system) Genes have been identified that are associated with certain types of cancer. cause generalized effects. leading to cancer. alcohol. an individual is said to be in remission. The College Network. Inc. whereas sarcomas develop from mesenchymal cells.Unlawful to replicate or distribute Fundamentals of Nursing 121 A number of different factors cause the genes that control cellular growth and differentiation to mutate and malfunction. exhibit a variable rate of growth. such as cytotoxic medications Heredity Environmental and occupational exposures to certain agents. Examples include the following: • • • • • • • • • Viruses Chemical agents. the different types are differentiated by a common nomenclature. metastasize (travel to and proliferate at distant sites causing a secondary tumor). Cancer rates are highest in the elderly. Depending on the type of cancer. such as radiation and UV light Hormones. whereas a malignant tumor is called an osteosarcoma. such as mustard gas. and nitrites Physical agents. pesticides. Benign tumors usually contain well-differentiated cells that resemble the cell of origin. such as anemia. The diagnosis. N codes denote the extent of lymph node involvement. lotions.. • • • • Copyright © 2008. broccoli. they may need referral to smoking cessation programs. such as Nicorette gum or nicotine patches. For example. NXP 070106 v1. Minimize occupational exposure to chemicals by dressing properly and using designated safety equipment. and metastasis.m. T codes depict the size and characteristics of the tumor. excessive sun tanning. use other spices to flavor foods. and high-fiber foods.Unlawful to replicate or distribute Grading Grading is the first step in evaluating a malignant neoplasm.g. carrots) and cruciferous (e. and 3 p.0 . The TNM (tumor-node-metastasis) system is commonly used to describe most neoplastic disease through a process called staging. alcohol. the following changes in lifestyle and diet are recommended: • Decrease consumption of saturated and unsaturated fats. It is also important to inform individuals who use smokeless tobacco that chewing tobacco and snuff are associated with oral cancer.). and sunburns. and they are graded on a scale from G1 to G4. Neoplastic cells are compared with their parent cells to determine the extent to which cellular changes have occurred. Stop using tobacco products. Individuals should be informed about how to dress to decrease their exposure to the sun and about the difference between sun tanning oils. carotene (e. Increase consumption of foods rich in vitamins A and C.m. Avoid exposure to the sun (especially between 10 a. excess calories. Individuals should be informed about the availability of agents designed to stop smoking. nitrite-preserved.. instead of frying chicken. and blocks (and which products are the best to use). Prevention of Neoplasms The first objective of medical management of cancer is to prevent neoplasia. individuals may need information about food items rich in these nutrients. brussels sprouts. Inc. fruits (citrus). while G4 cells are poorly differentiated and determination of parent cells is difficult. The College Network. or cauliflower) vegetables. broil or bake it.g. and smoked. or salt-cured foods. Staging The extent of neoplastic disease is described in terms of the size of the tumor. instead of salt. and M codes relate to the presence of metastasis. Based on factors known to lead to cancer. such as whole grain cereal products and legumes. G1 cells closely resemble their parent cells. The TNM system is a standardized set of codes. Individuals should be taught what is acceptable and how to read the labels on food items. whether or not there is lymph node involvement. Again. Individuals also may need to be instructed in alternative ways to prepare and cook meals. 0 . the sensitivity (ability to detect cancer) and specificity (ability to exclude those without cancer) of the markers vary. ↓ = decreased Test ↑Acid phosphatase ↑ACTH ↑Alkaline phosphatase (ALP) Neoplasia Prostate cancer Lung cancer Bone cancer. Laboratory Studies A number of laboratory studies may be done.).1 Tumor Markers Legend: ↑ = increased. and oncogenes. insulin and diabetes. stomach cancer. breast cancer Breast cancer Pancreatic cancer.. renal cancer. HCG and pregnancy. therefore. including a complete blood count with differential. sigmoidoscopy is recommended every three to five years (American Cancer Society 1995). After the age of fifty. hormones. lymphoma. enzymes. annual physical and oral examinations are important to identify changes and catch neoplasia early when intervention is still possible. liver cancer. pancreatic cancer. as well as other blood and biochemical tests (depending on the type of cancer suspected or the risk factors present). The College Network. leukemia. With age. Inc. etc. are known to be produced by specific types of neoplasia and measurable in an affected individual’s serum. These agents are called tumor markers. Several procedures have been recommended. kidney cancer. lung cancer. Certain agents. colon cancer. Table 7. liver cancer. women should have regular mammograms and breast exams. Table 7. LDH and myocardial infarction. both men and women should have digital rectal exams and fecal occult blood assessments to check for colorectal cancer. lung cancer. It is recommended that women perform breast self-exams monthly and obtain annual pelvic examinations and Pap smears to detect reproductive system cancers.g. Men should perform monthly testicular self-exams. testicular cancer Multiple myeloma. After forty. such as antigens. breast cancer.1 provides an overview of some of the tumor markers that are available. liver cancer. the incidence of cancer increases.Unlawful to replicate or distribute Diagnosis of Neoplasms Screening Early detection provides the best prognosis for most cancers. Unfortunately. metastasis to bone and liver Liver cancer. NXP 070106 v1. metabolites. First. after the age of forty. colorectal ↑Alpha-fetoprotein ↑beta2-microglobulin ↑CA 15−3 ↑CA 19−9 Copyright © 2008. and many are associated with other diseases (e. leukemia. leukemia. neuroblastoma Breast cancer. uterine cancer. ↓ = decreased Test ↑Parathyroid hormone ↑Prostatic specific antigen (PSA) Neoplasia Lung cancer. lung cancer. thyroid cancer. stomach cancer Breast cancer Stomach cancer. liver cancer. bladder cancers. stomach cancer. lung cancer. lung cancer Pancreatic cancer Stomach cancer. pancreatic cancer Pancreatic cancer Gestational trophoblastic tumors. cervical cancer. ↓ = decreased Test ↑CA 27. Inc. ovarian cancer. colorectal cancer Ovarian cancer. liver cancer. thyroid cancer. kidney cancer. breast cancer. breast cancer Bone cancer. kidney cancer. liver cancer. ovarian cancer Prostate cancer Copyright © 2008. The College Network. Ewing’s sarcoma. lung cancer. pancreatic cancer. lymphoma Bone cancer.0 . liver cancer. pancreatic cancer. breast cancer.1 Tumor Markers Legend: ↑ = increased. leukemia. NXP 070106 v1. pancreatic cancer. colorectal cancer. kidney cancer. bladder cancer.Unlawful to replicate or distribute Table 7.1 Tumor Markers Legend: ↑ = increased. pheochromocytoma ↑Carcinoembryonic antigen (CEA) ↑Creatine kinase (BB isoenzyme) ↑DU-PAN-2 ↑Gastrin ↑Glucagon ↑Human chorionic gonadotropin ↑Insulin ↑Lactate dehydrogenase (LDH) ↑Neuron specific enolase (NSE) Table 7. kidney cancer. Wilms’ tumor. pancreatic cancer. kidney cancer Lung cancer Liver cancer. lymphoma. pancreatic cancer. small-cell lung cancer. neuroblastic carcinoma of the testes Neuroblastoma. stomach cancer. testicular cancer. liver cancer Thyroid cancer. pancreatic cancer. ovarian cancer. 29 ↑CA 50 ↑CA 125 ↑Calcitonin ↑Calcium Neoplasia cancer. kidney. thyroid cancer.1 Tumor Markers Legend: ↑ = increased. esophageal cancer. stomach cancer. pheochromocytoma Intestinal cancer ↑Uric acid ↓Uric acid ↑Vanillylmandelic (VMA)/homovanillic acid (HVA) ↑Vasoactive intestinal peptide (VIP) Cellular analysis of suspect cells also may be conducted. Magnetic resonance imaging (MRI) also obtains cross-sectional images. Inc. NXP 070106 v1. spleen. pancreatic cancer. retinoblastoma. head and neck cancer. lung or breast tissue. lung cancer Neuroblastoma. a radioisotope is injected through an IV. colorectal cancer. Cells may be obtained from urine. Positron-emission tomography (PET) is another imaging technique in which radioisotopes are injected. prostate cancer. lung cancer. ↓ = decreased Test ↑SGPT ↑SGOT ↑Squamous cell carcinoma antigen (SCC) ↑Testosterone ↑Tissue polypeptide antigen (TPA) Neoplasia Liver metastasis Liver metastasis Head and neck cancer. Radiographic Procedures Common tests used to diagnose and characterize the size and location of solid tumors include radiographs (with or without contrast). The College Network. In radioisotope studies. cross-sectional images of the body that may be obtained with or without the use of a contrast dye. Mammography uses radiography to view the breasts and visualize tumors. or needle aspiration of bone marrow. ovarian cancer Leukemia Hodgkin’s disease. computed tomography. Copyright © 2008. liver. and uptake by the suspect organ is measured by a scintillation scanner. radioisotope studies. a Pap smear (a slide of sloughed cervical cells). sputum. but a PET scanner is used to obtain cross-sectional images of the organs of interest.Unlawful to replicate or distribute Fundamentals of Nursing 125 Table 7. but with the use of magnetic fields.0 . and magnetic resonance imaging. Computed tomography (CT) is a radiographic technique that produces sequential. cervical cancer Ovarian cancer Breast cancer. lung cancer. positron-emission tomography. For example. Cancer-specific treatments also may be available. as much of the tumor as possible may be removed to reduce the tumor burden (debulking) and to facilitate other forms of treatment. Surgery can also be used to correct damage or complications associated with tumor growth. are sometimes used to prevent recurrence of a tumor after it has been eradicated. and palliation: (1) surgery. Four therapies are used for cure. including additional radiation or chemotherapy. If localized. Treatments for Neoplasms The goal of treatment is a cure. and (4) radiation. undescended testes may be surgically moved to the scrotum in young boys. such as bone marrow transplants for leukemia. as in a mammaplasty. adjuvant therapies. In endoscopy. lighted tube is inserted into the tract of the patient’s orifice to view the internal anatomy. surgery may be used to insert devices needed for treatment (venous access devices. control. palliative treatment modalities are used to control tumor growth and relieve symptoms. etc. In addition.0 . Surgery is also used to cure. because they produce hormones that promote tumor growth. NXP 070106 v1. A diagnostic or exploratory laparoscopy is a surgical procedure in which the contents of the abdomen are inspected. Copyright © 2008. Sometimes. The College Network. Inc. For example. Again. gastrointestinal. a flexible. During these times. It is often used to verify the location and size of tumors. Surgery Surgery may be performed prophylactically to prevent the development of cancer. Tissue biopsies may be obtained at the same time. Some women at high risk for breast cancer may undergo radical mastectomies before cancer is identified. Endocrine glands are sometimes removed as well. in part to decrease the development of testicular cancer later in life. such as chemotherapy or radiotherapy. Additionally. tumors may be eradicated through resection.). Pain management and symptom control are major aspects of therapy. tissue samples may be obtained during the procedure. In this situation. as well as to biopsy and stage tumors. Those with familial polyposis may undergo a subtotal colectomy because of the high association of this condition with colorectal cancer. (2) chemotherapy. Surgery may also be used in the diagnosis of cancer. but sometimes a cure is not possible. and genitourinary tracts may be done through endoscopic procedures or surgery. complete removal of the tumor is not possible. implantable pumps. (3) immunotherapy.Unlawful to replicate or distribute Direct Visualization Direct visualization of the respiratory. obstructions may be relieved or tissues may be reconstructed. or is he or she depressed. Inc. Other concerns include the following: • • • • • • • Activity intolerance related to the fatigue associated with cancer Impaired adjustment due to changes in body image. NXP 070106 v1. role performance. withdrawn. such as tracheostomy care? Will the individual need to learn how to use adaptive equipment. the nurse should evaluate the individual’s reaction by considering the following topics: • • • Is the individual able to view the surgical site? Is the individual open to information and teaching? Is the individual able to meet self-care needs. body functions.Unlawful to replicate or distribute Nursing Care of the Individual with Cancer Who Undergoes Surgery Assessment The needs of an individual with cancer who undergoes surgery are similar to those of any other patient undergoing surgery.0 . it is vital that the nurse ascertain the meaning of the procedure to the patient by asking questions such as the following: • • • • • • • • • Does the individual fully understand what to expect after the surgery? Will the individual have a visible scar or obvious loss of a body part? Will all the hair on the individual’s head need to be shaved? Will the individual need to learn a self-care procedure. and adaptations to equipment Anxiety and fear related to unknown outcomes and change Ineffective coping due to inadequate or ineffective coping mechanisms Grieving for the lost body part and associated functions Ineffective role performance and body image changes related to the surgery Pain (acute or chronic) related to the surgical intervention Planning and Implementation Copyright © 2008. Therefore. the risks for infection and poor wound healing are often heightened due to the immunocompromised state of the individual. However. The College Network. and preoccupied with bodily changes? Analysis When caring for individuals who have had surgery related to cancer. such as an artificial limb or larynx? Will the individual need extensive physical and/or occupational therapy? What anxieties and fears has the individual identified? Are the fears realistic? Are there concerns about role performance or relationships? Can the individual identify coping mechanisms or supports to help him or her adjust following the surgery? After the surgery is performed. there may be significant changes in body image and function because of the invasive nature of cancer. body image.g. Provide the client with information about community resources and programs (e. a psychologist. • • Evaluation Expected outcomes for the patient undergoing surgery for cancer include the following: • • • • Verbalizing an understanding of the surgical procedure and the implications for role and lifestyle changes Accepting body image changes as evidenced by visualization of the affected body part and management of self-care needs Identifying a system of support and using positive coping methods Recuperating without evidence of infection or other complications Chemotherapy Chemotherapy is the use of pharmacologic agents to eradicate or inhibit the growth of neoplastic cells. facilitate understanding. affecting rapidly dividing cells. and self-concept (e. Reach for Recovery. such as those in the gastrointestinal tract. or breast or limb prostheses). and anxieties. As a result. Arrange for visits from prior patients who have adapted well to the changes associated with surgery. etc. pastoral care. Listen with empathy and acceptance. The major family of pharmacologic agents used in chemotherapy consists of antineoplastic (or cytotoxic) drugs. Assist the client with the use of adjuncts. These goals can be accomplished by taking the following nursing actions: • • • • • • • Assess the client’s physical and mental well-being. wear scarves to hide a thyroidectomy scar or tracheostomy. and promote integration of a positive body image. wigs while hair grows back in. Provide the client with plenty of opportunities to verbalize concerns. Unfortunately. NXP 070106 v1..g. promote healing. Inform the individual about ways to disguise scars or otherwise improve appearance. body image. cytotoxic drugs kill normal as well as tumor cells. Administer analgesics. such as crutches or an artificial larynx. or counseling for assistance in adjusting to role and lifestyle changes associated with the surgery. and selfconcept. including the following: Copyright © 2008.. a number of adverse effects are associated with chemotherapeutic agents. Inc. ameliorate pain. and other medications as ordered. fears.0 ..).g. antibiotics. the most. American Cancer Society. Make referrals as needed to social services.Unlawful to replicate or distribute The goals of care for anyone undergoing surgery related to cancer are to prevent complications. Encourage the client to look at the surgical site and assist with the site’s care. The College Network. tracheostomy or ostomy care). Teach the client how to perform self-care activities related to the surgery (e. These agents may also be used to reduce the tumor bulk (palliation) or as an adjuvant to radiation or surgery. renal. Hormones (such as estrogens and androgens) and hormone inhibitors (such as tamoxifen) are also used.2 Antineoplastic Agents Drug class Alkylating agents: • Nitrogen mustard • Busulfan • Carmustine Action on cancer cells Damage DNA. flank pain. acute renal failure and hematuria. and liver tissues. central or peripheral neuropathy. tetany. Extreme caution must be used to avoid extravasation. antitumor antibiotics. pneumonitis and fibrosis.Unlawful to replicate or distribute • • • • • • • • • • Alopecia (hair loss) Anorexia Bone marrow suppression Immunosuppression Gonadal suppression Nausea Vomiting Mucositis (inflammation and ulceration of gastrointestinal mucous membranes) Stomatitis (inflammation and ulceration of the mouth and tongue) Diarrhea Many chemotherapeutic agents administered via IV are highly irritating and may cause extensive tissue damage. Antineoplastic/Cytotoxic Agents Antineoplastic/cytotoxic agents are classified by their modes of action. Table 7. pulmonary. and cirrhosis. Some agents have been found to be toxic to cardiac. hyperphosphatemia. hyperkalemia. hematuria. confusion.0 . neuromuscular cramps. antimetabolites. preventing replication Table 7. The most common categories are alkylating agents. these may respectively result in cardiomyopathy and congestive heart failure. hyperuricemia. cardiac dysrhythmias. Longterm effects of chemotherapy include development of leukemia and other secondary tumors.2 Antineoplastic Agents Drug class Action on cancer cells Copyright © 2008. Tumor lysis syndrome may occur within one to five days after the start of chemotherapy due to the rapid destruction of tumor cells. Table 7. Tumor lysis syndrome is characterized by oliguria. NXP 070106 v1.2 depicts common antineoplastic agents used in the fight against cancer. neural. and hypocalcemia. and plant alkaloids. The College Network. especially for reproductive system tumors. Inc. Because of the potential damage associated with IV administration and the need for repeated administrations.0 . Prior to administration of antineoplastics. interfere with DNA repair. The efficacy of these agents is demonstrated by tumor shrinkage and overall improvement. The College Network. As a result. intrathecal. For example. The nurse should also verify the patency of the vascular access device before administering chemotherapy. Special handling is required to protect the provider as well as the patient. vascular access devices are often inserted. A complete physical exam is usually conducted. most commonly IV.g. Antineoplastic agents are administered through a number of routes. The nurse should also ascertain the patient’s understanding of the therapeutic plan and associated adverse effects. especially the presence of a fever.g. and implantable or peripheral ports (e. inhibit RNA and protein synthesis Prevent or arrest mitosis Cytotoxic drugs are most effective when given in combination.. procarbazine. Oncovin. The nurse should note the presence of any manifestations associated with infection. protocols combining two or more cytotoxic agents have been developed for many types of cancer.Unlawful to replicate or distribute Table 7.. Hickman and Groshong). prednisone) is a protocol used to treat Hodgkin’s lymphoma. the nurse should ascertain the status of the patient. Port-A-Cath or PAS-Port). MOPP (nitrogen mustard. Other routes used for administration of chemotherapeutic agents are per os.2 Antineoplastic Agents Drug class Antimetabolites: • Methotrexate • 5-fluorouracil • 6-mercaptopurine Antitumor antibiotics: • Adriamycin • Bleomycin • Actinomycin D Plant alkaloids: • Vincristine • Vinblastine Action on cancer cells Compete for or replace metabolites. tunneled central venous catheters (e. Nursing Care of the Individual Receiving Antineoplastic Agents Assessment Administration of antineoplastic agents is usually limited to registered nurses or physicians who have specialized training regarding these drugs. and topical. intra-arterial. Inc. Common forms include peripherally inserted central catheters (PICC). NXP 070106 v1. blocking DNA synthesis Damage DNA. This includes consideration of the following: Copyright © 2008. and baseline laboratory studies are obtained to determine the hematologic status and liver and renal function. intracavitary. Perform mouth care regularly with a soft-bristled toothbrush or disposable mouth sponge to prevent irritation and nausea. what was his or her response? Analysis Common diagnoses associated with the administration of chemotherapy include the following: • • • • • • • • • • • Altered comfort related to nausea and vomiting Altered nutrition (less than body requirements) related to anorexia. liver. Administer sedatives. and facilitating emotional adaptation to the effects of chemotherapy. and tissue damage Sexual dysfunction related to gonadal suppression Planning and Implementation The goals of care for someone undergoing chemotherapy are maximizing the therapeutic benefits of the drug. cardiac. The College Network. and vomiting.Unlawful to replicate or distribute • • • • Is the client prepared for the body image changes associated with chemotherapy? Has the client been adequately prepared regarding ways to cope physically and emotionally with treatment? What are the individual’s fears and concerns? If the individual has previously received chemotherapy. Teach relaxation and distraction techniques. Ensure that the site of administration is patent and without evidence of infiltration or thrombophlebitis. Inc. such as guided imagery. and stomatitis Altered oral mucous membranes related to stomatitis Altered urinary elimination related to nephrotoxicity Body image disturbance related to loss of hair Diarrhea related to gastrointestinal cell damage Fatigue related to cellular damage and anemia Peripheral neurovascular dysfunction related to paresthesias secondary to neurotoxicity Risk for infection related to immunosuppression Risk for injury related to myelosuppression and lung. nausea. nausea. as ordered. to relieve anxiety. kidney. Administer antiemetics before nausea and vomiting occur and at regular intervals. NXP 070106 v1. Eliminate odors and unpleasant stimuli that stimulate nausea. CNS. Copyright © 2008. minimizing the associated complications. These goals can be attained by taking the following nursing actions: • • • • • • Administer antineoplastic agents as ordered. vomiting.0 . ovaries. Instruct the client to avoid the use of tampons. vegetables. Provide perianal care following diarrhea. Encourage frequent. The major concern with these medications is precipitation of a generalized inflammatory reaction. and palliate. diarrhea. and sick people. and malaise. Immunotherapy Immunotherapy is the use of pharmacologic agents called biologic response modifiers to stimulate the individual’s own immune system to damage and destroy neoplastic cells. Stress the importance of good hand washing and the avoidance of crowds. Explain ways to disguise hair loss (scarves. and signs of bleeding (petechiae. colonystimulating factors. NXP 070106 v1.Unlawful to replicate or distribute • • • • • • • • • • • • • • Avoid the use of dental floss. unexplained bruises. wigs. and emesis). Commonly used agents include interleukins. Inform the client to minimize handling of hair. and erythropoietin. Avoid foods with strong odors or those known to be irritating to the GI tract (e. spicy foods) to prevent nausea and diarrhea. Explain the importance of protecting the skin from injury and infection by wearing shoes.. nose bleeds. cure. fatty. The College Network. rapidly dividing non-neoplastic cells. Care is supportive. so it also is used to control. and commercial mouthwashes that contain alcohol and may further irritate the oral mucosa. Common signs of a reaction are fever. using an electric razor. caps. leading to an infection. etc. Inc. small meals and high-protein snacks and supplements. enemas. Encourage the use of pH-balanced shampoos and discourage procedures that damage hair. such as blow-drying. monoclonal antibodies.0 . interferon. hair. such as bone marrow. Evaluation Expected outcomes for an individual on chemotherapy include the client verbalizing his or her understanding of the side effects associated with chemotherapy and methods used to minimize complications.). or perms. and rectal thermometers because they may traumatize the tissues. urine. and potted plants out of the patient’s room. bleeding gums. water picks. and avoiding sunburn. Irritating food should also be avoided in the individual with mucositis. Administer viscous Xylocaine as ordered to promote mouth comfort. Instruct the client and family to report the presence of white patches in the mouth. rectal suppositories. warning the client not to swallow the mixture. Administer swishes as ordered. chills. children. Keep fresh flowers. However. tints. Copyright © 2008.g. fruits. and gross or occult blood in stool. Radiation Radiation kills rapidly dividing cells. A radioisotope seed. the radiation source is inserted in a procedure called afterloading. Therapy may involve high-energy radiation administered externally (teletherapy) or radioisotope implants placed internally (brachytherapy). nausea. itching. dryness. Teletherapy uses ionizing forms of radiation to cause cellular damage and death. fatigue. Nursing Care of the Individual Receiving Radiation Therapy Assessment When caring for an individual undergoing radiation therapy. brain. Intracavitary radiation is primarily used for cervical and endometrial cancers. head. cramping. painful intercourse Brachytherapy is usually used as an adjunct to teletherapy. wire. weakness. and bone marrow suppression. alpha particles. and prostate tumors. hematuria. tooth decay Esophagitis. Skin reactions may occur. Common skin reactions include redness. are also affected. and how therapy is to be administered. what type of therapy is being employed. Electrons. It also is important to assess the client’s level of knowledge by exploring the following areas of concern: 1. gold. vaginal dryness. Reactions to radiation may be acute or delayed. Oral radioactive iodine is administered and absorbed by the thyroid gland. as well as local and systemic effects. since reactions are (to some degree) dose-dependent. or needle is placed within the tumor. Examples are listed in Table 7. neck. and photons are all sources of ionizing radiation. or how long an implant will be in place. neutrons. and cobalt. Alopecia also is common. hepatitis Cystitis. The College Network. iridium. or systemic (affecting the body generally). Once the patient is back in his or her hospital room. Administration of radioisotopes may be intracavitary (placed within a hollow organ). desquamation. and anhidrosis. diarrhea.0 . protons.Unlawful to replicate or distribute testes. Inc. proctitis. An applicator is placed within the organ in the operating room. pericarditis Anorexia. interstitial (placed within a solid tumor). Commonly used brachytherapy radioisotopes are radium. it is important to know why radiation is being used. Local reactions are those that occur in the irradiated tissue. dysphagia. Systemic radiation is most often used for thyroid cancer. Interstitial radiation is most commonly used for breast. dry mouth. ribbon.3. iodine. and gastrointestinal and genitourinary mucosal linings. pneumonitis. It is also important to know the dose. Systemic reactions include nausea. Know how often the patient will undergo radiation treatments. hyperpigmentation. vomiting. negative pi-mesons. cesium. Does the client understand why radiation therapy is being used? Copyright © 2008.3 Local Reactions from Radiation Therapy Tissue Head/neck Thorax Abdomen Pelvis Reaction Oral mucositis. NXP 070106 v1. bleeding. Table 7. 0 . and similar items on the affected area unless ordered by the physician − Protecting the affected area from the sun Instruct individuals receiving brain irradiation to avoid the use of electric hair dryers. CBC. fatigue. Encourage the client to pace his or her activities and to plan for periods of rest. dysphagia. altered nutrition. curlers. pain. Instruct the client regarding any restrictions in activity. Arrange the room for minimal exertion of energy. powders. anxiety. 3. hot or cold liquids. diarrhea. Organize care to facilitate rest periods. Is the client aware of the treatment plan? Is the client knowledgeable about possible adverse effects? Is the client aware of any restrictions imposed by the radiation therapy. such as bed rest or room confinement. adverse effects. citrus juices. The College Network. chewing or smoking tobacco. and curling irons. Limit visitors and length of visits. Planning and Implementation The goals of care are to facilitate the patient’s understanding of the procedure and minimize injury and reactions. Encourage the client to avoid exertion.Unlawful to replicate or distribute 2. and hard toothbrushes − Eating soft or pureed foods that are moist − Rinsing or gargling with warm water or using artificial saliva preparations • • • • • Copyright © 2008. Keep the client informed about the treatment plan. mouthwashes. and restrictions Risk for injury related to cellular damage and death However. and impaired skin and tissue integrity also may be pertinent diagnoses. and weight. highly seasoned foods. and mouth dryness by encouraging the following: − Avoiding alcohol. input and output. ineffective individual coping. alterations in body image. and patting to dry − Wearing loose clothing to prevent friction and rubbing − Avoiding the use of tape on or the shaving of the affected area − Avoiding the application of creams. Provide information about the purpose of therapy and what adverse effects to report to the physician. Inc. altered mucous membranes. NXP 070106 v1. vital signs. Tell the client not to remove skin markings. lotions. Provide relief for symptoms of oral mucositis. fear. These goals can be met by taking the following actions: • • Monitor the client’s status. rinsing thoroughly. Encourage the client to minimize skin irritation by doing the following: − Washing the skin gently with lukewarm water. 4. such as bed rest or room confinement? Analysis The primary diagnoses associated with radiation therapy include the following: • • Knowledge deficit related to a lack of understanding about the treatment mode and plan. Instruct individuals in distraction and relaxation techniques to reduce nausea and vomiting. procedures. and terminal care of clients with cancer. NXP 070106 v1. determine whether there is a history or physical evidence of neoplasia. diagnosis. detection. diagnosis. Evaluation Evaluate the physical response of the client to radiation therapy and modify the plan as needed. 7. Also. evaluate the psychosocial response of the client. This involves application of the nursing process as described in the following sections.Unlawful to replicate or distribute • • • − Chewing sugarless gum − Using viscous Xylocaine − Placing a cool mist humidifier in the room − Taking in an adequate amount of fluids Encourage individuals experiencing nausea to avoid spicy or greasy food. 3. 6.0 . The College Network. treatment. 5. Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness Once cancer has been diagnosed. willing. Remove noxious stimuli from the patient’s environment to prevent nausea and vomiting. How is the client’s self-concept and body image? Is the client depressed or coping well with treatment? General Nursing Care for Individuals with Cancer Nurses are actively involved in the prevention. prognosis. The seven common warning signs of cancer are as follows: 1. 2. ascertain the physical and psychosocial impacts on the client and family by considering the following: • • • What is the client’s response to the diagnosis? How well does the client understand the procedures. and treatment plan? Is the individual ready. Is the tumor responding as desired? Is the client experiencing any skin or systemic reactions? Is pain under control? Also. Inc. diet. Assessment Obtain an in-depth history of familial factors. 4. and self-care management? Copyright © 2008. and able to learn about the diagnosis. and lifestyle behaviors to determine individuals at risk for cancer. rehabilitation. is he or she ready to die? Analysis There are numerous diagnoses associated with the care of individuals with cancer. diarrhea. helplessness. dressing/grooming. or the adverse effects of radiation and chemotherapy Constipation related to chemotherapy and immobility Chronic sorrow related to loss of hope Diarrhea related to medications and radiation Deficient fluid volume related to vomiting.0 . and changes in routine? Is there any evidence of fear. and adverse effects of radiation Self-care deficits (bathing/hygiene. vomiting. or despair? What are the individual’s strengths. and altered metabolism Impaired oral mucous membranes related to chemotherapy and radiation effects Ineffective role performance related to diagnosis and treatment Anticipatory grieving related to potential loss of life Anxiety related to diagnosis. surgery. These include the following: • • • • • • • • • • • • • • • • • • • Activity intolerance related to weakness Imbalanced nutrition (less than body requirements) related to nausea. NXP 070106 v1. resources. treatments. anger. altered nutrition. treatments. role relationships. toileting) related to weakness and fatigue Copyright © 2008. Inc. and coping mechanisms? Does the individual have a system of support? What are the individual’s feelings about the isolation procedure? Are there any financial concerns? If the client is terminal. tests. and emotional demands Hopelessness related to deterioration in condition or lack of treatment or cure Deficient knowledge related to lack of understanding about pathophysiology. sorrow. body image. and threat to life Disturbed body image related to tumors. chemotherapy. anxiety. feeding. and self-care needs Pain related to disease process or adverse effects of radiation or chemotherapy Risk for infection related to altered defense mechanisms. or insufficient intake Impaired skin and tissue integrity related to poor nutrition or radiation Ineffective individual coping related to situational crisis presented by diagnosis of cancer Fatigue related to disease process. invasive procedures. The College Network.Unlawful to replicate or distribute • • • • • • • • • • • How does having cancer or cancer treatments affect the client’s body function. procedures. self-concept. guilt. and growth and development? Is the client weak or in pain? Is the individual having difficulty sleeping? Are skin changes present? How is the client coping with the diagnosis. managing discomfort. infection. The College Network. providing information as needed. Provide four to six small. and lymphedema).g. Inc. Monitor the client for signs and symptoms of complications associated with the disease process (e. Schedule and facilitate radiation and other treatments. or chemotherapy Disturbed sleep pattern related to fear. bedpan) in the room. Provide oral care. preventing complications. input and output. rinsing the mouth frequently. smoking cessation. avoiding spicy or fried foods and carbonated beverages. Collaborate with nutritional services to combat anorexia and meet caloric requirements. altered level of consciousness. achieving remission. chemotherapy. take the following nursing actions: • Identify individuals at risk and provide information about ways to prevent cancer (such as diet modification. providing emotional support. and facilitating a dignified..0 . and skin integrity. side effects. specific gravity. Monitor the client’s vital signs. radiation. and alcohol avoidance) and detect cancer early (such as monthly breast self-exams and testicular exams). Encourage family and friends to bring in the client’s • • • • • • • • • Copyright © 2008. surgery. increased intracranial pressure. lung sounds. Manage pain by administering pain medications as ordered around the clock and by using nonpharmacologic methods (such as distraction and massage). antinauseants. Avoid extravasation of chemotherapeutic agents. high-protein meals per day and supplements. treatments. anxiety. Goals include cancer prevention. or dyspnea) or treatment modalities (such as anemia. Minimize nausea by administering antinauseants as needed. nutritional status. and immunotherapy) as ordered. protect with a bed cradle if necessary. peaceful death.g. disease process. Administer blood components and pharmacologic agents (such as analgesics. there are a number of goals and interventions. extravasation. laboratory results. Eliminate odors and unpleasant sights (e. Assist with tests and procedures as needed. or adverse effects of chemotherapy and radiation Spiritual distress related to suffering and questioning the purpose of life Planning and Implementation Because the role of the nurse in caring for clients with cancer is so diverse. Teach the client about manifestations associated with complications and when to notify the physician. To attain these goals. NXP 070106 v1. diagnostic procedures. Ascertain knowledge deficits and provide information about pathology.Unlawful to replicate or distribute • • • Sexual dysfunction related to disease process. Keep irradiated areas clean and dry. high-calorie. and increasing fluid intake. Stomatitis may be relieved by applying viscous Xylocaine. Provide popsicles or hard candy to suck on.. being careful to handle and discard chemotherapeutic agents with caution and according to agency protocols. and resources. and grief in order to facilitate coping and a realistic understanding of the client’s condition. Instruct the client regarding the use of technology (e. The client should be instructed in proper hand washing techniques and advised to avoid exposure to ill or recently vaccinated individuals. Assist the client to make decisions about end-of-life issues (e. Monitor the client’s fluid-electrolyte and acid-base status. and the intake of fluids. hairpiece. If the client is constipated. pH-balanced shampoo.g. Inc. and encourage expressions of fear. quiet. Emollients may be added to bath water or lotion to soothe dry skin. Refer the client to social services. Elevate the head of the bed to promote food retention. and wash hair with a gentle. anxiety. moist compresses may be used to control itching. The client should be advised to avoid sun exposure. counseling. Protectants may be applied to the anal area. teach the client measures to decrease hair loss.0 .Unlawful to replicate or distribute • • • • • • • • • • • • favorite foods. Inform the client that hair loss is temporary and may be disguised with a wig. Arrange personal articles within reach of the client. The College Network. American Cancer Society). and comfortable environment to promote rest and relaxation. or pastoral care. Discuss how to deal with body changes and how to respond to others. Keep anal area clean. Maintain protective isolation. Decrease risk of infection by washing hands well. Facilitate a peaceful and dignified death by respecting the client’s wishes while still meeting comfort and basic needs. Suggest makeup and grooming ideas that will facilitate adaptation to a changing body image. ingestion of high-fiber foods. having visitors wear masks when ill. and local anesthetics may be applied (viscous Xylocaine). such as reading or watching TV. injections. administer antidiarrheal medications as ordered. If diarrhea is present. hospices. colostomy care) as needed. scarf. A soft sponge toothbrush may be used to clean the mouth. minimize handling of the hair. and funeral arrangements). if ordered. Organize care to minimize interruptions so that the client can rest or sleep.g. using an electric razor or soft toothbrush. or invasive procedures.. Encourage relaxation techniques. Also. Evaluate the client’s feelings about death and dying. but irradiated sites should be avoided. frequent mouth rinses with normal saline or baking soda in water are soothing. Determine the client’s readiness to die. hospice. fried. and avoiding rectal temperatures. artificial larynx) or new procedures (e. such as avoid damaging the hair with chemicals or heat. advance directives. Warm soaks may alleviate anal irritation.. Encourage mobility. Tell the client to avoid fatty.. Provide skin and oral care. support groups (e. Provide a calm. moisturizers may be applied to lips. administer stool softeners and laxatives as ordered. Cool. and gas-producing foods and to drink liquids after meals. or hat. Irradiated areas should be exposed to air. Consider tube or IV feedings if PO feedings are not tolerated. Provide emotional support to the client.. loss. do-notresuscitate orders. as needed. NXP 070106 v1. Copyright © 2008.g.g. treatments. including denial and anger. They may seek out unorthodox approaches and try unproven therapies in desperation. prognosis. it is important to assess the family’s response and understanding of the disease process and any related tests. This includes examination of the following: • • • • • • • Is depression present? Does the family feel hopeless and helpless? Does the family have the ability to cope? What are the family’s strengths? Is there a viable support system? Is there a willingness to use support groups? Is the family able to make necessary decisions. Assessment Because the loss of a loved one is a realistic possibility associated with cancer. Also evaluate the psychosocial response of the client to the disease process and treatment modalities. Thus. This may involve asking questions such as the following: • • • • • • Has the client’s pain been reduced to an acceptable level? Is the client getting adequate rest and sleep? Have the client’s nausea and vomiting been controlled? Is the client free from infection? Are positive coping methods being used? Can the individual verbalize understanding of the diagnosis. or accept death if it is pending? Analysis Numerous nursing diagnoses also apply to the family.Unlawful to replicate or distribute Evaluation Evaluate the physical response of the client to therapy.0 . and self-care management practices? Nursing Care for the Cancer Patient’s Family The nurse can also use the steps in the nursing process to provide care to the cancer patient’s family. families often are anxious and distraught. procedures. Inc. NXP 070106 v1. surgeries. and modify the plan of care as needed. procedures. They may respond in a variety of ways. such as the following: • • • • • Impaired parenting related to frequent hospitalization of a child with cancer Anticipatory grieving related to potential loss of loved one and current lifestyle Anxiety related to diagnosis and potential loss of loved one Caregiver role strain related to inability to juggle responsibilities Decisional conflict related to indecision about end-of-life choices Copyright © 2008. The College Network. tests. as detailed in the following sections. honor the client’s wishes. and care needs. g. surgeries. Evaluation Finally. Reassure the family about the temporary nature of alopecia and other side effects related to chemotherapy and radiation. stopping treatment. Teach family members how to meet the client’s comfort or special care needs.. Candlelighters. tests. prognosis. procedures. pastoral care. Help the family plan for the future and make difficult decisions. The College Network. such as choices related to childbearing. Inc. such as hand washing and avoiding individuals who are ill. a psychologist. and care needs Powerlessness related to an inability to control the outcome Planning and Implementation Care of the family is focused on helping family members accept and cope with the client’s diagnosis and related changes in relationships and lifestyle. or making funeral plans.Unlawful to replicate or distribute • • • • • Fear related to the unknown Hopelessness related to lack of available cure Ineffective family coping related to inadequate coping skills or support systems Deficient knowledge related to lack of understanding about diagnosis. Teach preventative measures. determine the effectiveness of interventions and make modifications as needed. Give emotional support and allow the family to verbalize their concerns and fears. American Cancer Society. tests. hospice. Refer the family to social services. procedures. This includes the following nursing actions: • • • • • • • Keep the family informed about the status of the client. Several important questions to consider are as follows: • • • • • Is the family able to verbalize understanding of teaching provided? Is the family able to express feelings and concerns? Is the family able to verbalize the use of effective coping methods? Is the family able to make decisions as needed? Is the family able to provide home care needed? Nursing Care for the Community The nurse can also provide cancer-related care to the community as a whole by applying the specific steps in the nursing process that are outlined below.0 . etc. and treatment modalities. Assessment and Analysis Copyright © 2008.) as needed. NXP 070106 v1. Give the family information related to the diagnosis. and community agencies (e. and other early detection and preventative measures present? Copyright © 2008. Candlelighters. or similar items present in the community? Evaluation It is also critical to evaluate the community’s knowledge level about the causes of cancer and preventative measures. Inc.Unlawful to replicate or distribute Fundamentals of Nursing 141 Based on knowledge about the community. NXP 070106 v1. wigs. determine what services are available: • • • • • • Are there oncologists in the community? Are hospice services present? What community agencies are available for support? Is there a local chapter of the American Cancer Society. Related questions include the following: • • Are screening programs. First. The College Network. or Reach for Recovery? What types of rehabilitative services are available for individuals after an amputation or mastectomy? Are image services that provide breast prostheses. become familiar with the rates of cancer in the community by considering the following: • • What types of cancer are most prevalent? Are there groups within the community at high risk for certain types of cancer? Next. such as hemoccult testing or mobile mammography units. testicular exams.0 . it is important to develop educational and service programs that meet community needs and inform clients and families about available services. available? Are educational programs that provide instruction in breast self-exams. 4. Explain the concepts of metabolism and basal metabolic rate (BMR). Copyright © 2008. Describe the purpose and nutritional focus of Healthy People 2010. Describe at least three benefits of breastfeeding. 13. 7. 3. 2. Differentiate between calories and kilocalories. NXP 070106 v1. including general recommendations for good health and nutrition. 5. describe their composition and purpose in the body. Explain protein’s function in the maintenance of nitrogen balance. Define each of the four macronutrients. The College Network. Describe the groups of the USDA MyPyramid. Define nutrition. 12. 11. Identify nine important minerals for a healthy body. Explain the use of recommended dietary allowance (RDA) tables. 9. and list examples of food sources for each macronutrient. and list the daily requirement for each category.Unlawful to replicate or distribute UNIT III: PRINCIPLES OF NUTRITION Chapter 8: Concepts and Components of Nutrition Objectives Upon completion of this chapter. you should be able to do the following: 1. 14. List the characteristics of water-soluble vitamins and fat-soluble vitamins. Define insulin and explain its function related to glucose transport. Differentiate between macrominerals and microminerals. Inc. 6. 8. and provide examples of food sources for each. 10. and list food sources for each.0 . List the recommended daily intake of water for an adult and identify the two groups of people most affected by inadequate fluid intake. The chapter concludes with information on breastfeeding and a brief overview of the nutritional focus of Healthy People 2010. In this chapter. NXP 070106 v1. The College Network. Our discussion then turns to micronutrients. We discuss the new USDA MyPyramid and explain the meaning of the recommended daily allowance (RDA). we look at the basic principles of nutrition. We investigate minerals—the body’s inorganic micronutrients—which are also essential to good nutrition. Defining Nutrition The phrase “we are what we eat” may sound trite. We also begin to look at some of the problems that can occur with macronutrient problems such as diabetes mellitus. To maintain health. Inc. We build on this information by defining the types of nutrients our bodies need and the types of food sources that contain them. metabolism. including definitions of nutrition. and elevated triglycerides. it is important that the food used enhances rather than endangers a person’s physiological well-being.Unlawful to replicate or distribute Key Terms adipose tissue alpha-linolenic acid amino acids anabolic reactions basal metabolic rate (BMR) calorie carbohydrates catabolic reactions catalytic effect cholesterol complete proteins diabetes mellitus dietary exchanges energy enzymes fiber fruits glucose glycogen grains Healthy People 2010 hydration incomplete proteins insulin kilocalorie (kcal) lactose linoleic acid lipids macrominerals macronutrients meat and beans metabolism microminerals micronutrients milk minerals MyPyramid nutrients nutrition oils peristalsis polyunsaturated fats proteins recommended dietary (or daily) allowance (RDA) satiety saturated fats trans fat triglycerides unsaturated fats vegetables vitamins Introduction Nutrition refers to the body’s ability to take in and utilize food. nutrients. Basic nutritional knowledge is essential to professional nursing practice because good nutrition is central to both the promotion and maintenance of health and its restoration after illness.0 . where we discuss the organic compounds of water-soluble and fat-soluble vitamins. and basic metabolic rate (BMR). The link between the foods and fluids we ingest daily and the maintenance of good health and Copyright © 2008. nitrogen imbalance. but it is quite accurate. will vary at different stages of the life cycle. Inc. The process of digestion that breaks down foods begins as they are chewed. maintaining the integrity of tissues. A person’s energy. planning. and combined with ingested fluids into forms capable of being absorbed by the small and large intestines. meaning “to nourish. and elimination are the four basic processes related to metabolism. and to cells and tissues. This research can be incorporated into nursing assessments and care plans for all age groups. The products of digestion are circulated through the blood. yet this amount will not exceed the body’s ability to digest and absorb those calories. and implementation of various nutritional strategies often involves dietitians with specialized nutritional knowledge. swallowed. Energy can be simply defined as strength or power. Metabolism encompasses all the chemical and physical processes that are constantly going on in all cells of the body. tissue maintenance.” Both definitions remind us of how foundational good nutrition is for attaining. through the lymphatic system. It might be thought of as the minimum energy requirements of the body to function.0 . Basic Principles of Nutrition Metabolism Ingestion. Foods that are not absorbed and utilized for growth. or in other words. or use food for promoting growth and development. but it is the role of nurses to integrate basic principles of good nutrition into all of their patient care. Nutritional or diet therapy has always been a concept foundational to nursing. and sometimes through the pores of the skin as sweat. the basic energy required by a person who is in a state of wakefulness but at rest. A body in health will have its basic energy requirements met by ingesting enough calories to meet its needs. Nutrition can be generally defined as a series of processes by which human beings take in. chemical compounds known as enzymes act as catalysts to break down the more complex substances in the foods into simple substances. and strengthening and replacing tissues that have been injured by trauma or acute and chronic diseases. Nutritional assessment is the foundation of the maintenance and promotion of overall health.” and nutrire. maintaining. absorption. digestion. but it is sometimes not given the attention it should in practice. Foods are normally ingested (taken into the body) through the mouth. assimilate. meaning “nurse. through the rectum as stool or feces. and Copyright © 2008. or basal metabolic and nutritional requirements. and restoring health. The word “nutrition” is derived from the Latin root words nutrix. The basal metabolic rate (BMR) is the energy required by a person to function at the lowest or most basic level of cellular function. and everyday bodily activities are eliminated as waste products through the bladder in the form of urine. NXP 070106 v1. Assessment. In order for digestion and absorption through intestinal mucosa to occur.Unlawful to replicate or distribute prevention of illness is the subject of considerable health-related research. The College Network. especially in relation to vulnerable populations like infants and the elderly. growth. water. such as aerobic or other forms of exercise. fiber. or Calorie (also called a large calorie). Other influences on a person’s metabolic requirements include weight and sex. Inc. vitamins. While these foods can be thought of as interventions. another good reminder of the foundational importance of nutrition to basic nursing care. and certain abnormal physical conditions. Decreased activity below the body’s metabolic needs accompanied by increased food intake generally results in weight gain in the absence of any disease.” A calorie is the amount of heat needed to raise the temperature of one gram of water by one degree Celsius. more specifically defined as anything ingested or taken into the body that provides the body with the energy needed to keep it alive. A healthy body uses calories for all its normal daily internal and external activities. When we say we count calories for a diet. Both macronutrients and micronutrients are essential to metabolism. or large calories. A term that is often used in relation to water is hydration. A kilocalorie (kcal). such as fever. Fluids Fluid. and water quite literally provides the solution. and lipids are more commonly known as macronutrients. and able to repair itself. carbohydrates. Not all foods have the same value nutritionally. more specifically. what we are actually counting is kilocalories. growing. and repair are called nutrients. absorption. proteins. When food is metabolized after eating. This allows our bodies to grow and repair themselves and otherwise carry out all the normal activities of daily living. The primary source of energy is food. meaning “heat. for practical purposes they are included early in our discussion of nutrition as the basis for good nutritional care. Carbohydrates. Vitamins and minerals are micronutrients. Copyright © 2008. which creates a need for more calories to maintain weight and optimal tissue function. is needed by the body because all other nutrients are dependent on water to carry out their functions. The word “nutrient” is also based on the Latin words for nurse and nourish. Increased activity. and minerals. A nutrient is a food that nourishes. Some nutrients serve as catalysts for the metabolic process to occur.0 . and elimination require that nutrients be in solutions. Types of Nutrients Everyone has a basic understanding of what constitutes food. but not necessarily of what constitutes good food.Unlawful to replicate or distribute it can be affected by many things in addition to age. fiber. is the amount of heat needed to raise the temperature of one kilogram of water by one degree Celsius. The categories include fluids. A number of common food sources can supply a person with all the essential nutrients in the absence of disease. The processes of ingestion. energy or heat is freed to enable us to move and breathe. can increase the BMR. proteins. Food energy is often measured in terms of calories. NXP 070106 v1. Foods that are of value and supply the energy the body requires for maintenance. Seven primary categories of nutrients are essential for building and maintaining a healthy body at any age. The word “calorie” is derived from the Latin calor. lipids (fats). The College Network. digestion. Simple sugars are frequently ingested in the form of fruit. There may also be a need to limit fluid intake related to circulatory overload for patients with compromised cardiac statuses (e.. Inc. Excess carbohydrates are stored as glycogen in the liver and in muscle. enabling glucose to be used as an energy source. and blood level maintenance can be stored by the body as fat or adipose tissue. The recommended daily intake of water for an adult is eight to ten 8-oz. Copyright © 2008. The metabolism of glucose for conversion into energy is controlled by insulin secretion. Infants’ body weights have a greater percentage of water. extra energy requirements. and soft drinks. winter squash. Their primary purpose is to provide the body with energy in much the same fashion and for the same reasons that gas provides fuel for a car. The process of digestion breaks down carbohydrates into glucose for the body’s immediate energy requirements. children’s cereals. potatoes. whole grain breads. vary depending on age. but they are also added in processed foods and fluids like cookies. glasses per day. Water also is present in certain foods. If insufficient insulin is present.g. NXP 070106 v1. When these foods are eaten.Unlawful to replicate or distribute Hydration requirements. and oxygen. specifically fresh fruits and vegetables. fruit-flavored drinks. These two groups of people are most adversely affected by an inadequate intake of water. or water requirements in relation to total body weight. The recommended range for carbohydrates is 50 to 60 percent of an adult person’s total caloric intake. the water is released into the body. and fortified cereals. and the percentage is less in older adults. corn.0 . Insulin is an endocrine hormone produced by the beta cells of the islets of Langerhans in the pancreas. such as beans and peas. older people with congestive heart failure). Food sources of carbohydrates are commonly available and relatively inexpensive as compared to foods supplying the other basic nutrients. hydrogen. glycogen can be readily converted to glucose when needed for energy or to maintain blood levels. candy. The primary source of the more complex and nutritive-rich carbohydrates to meet energy requirements comes from plant foods including vegetables (especially starchy vegetables like corn) and various grains and legumes. Macronutrients Carbohydrates Carbohydrates are organic chemical compounds made up of carbon. The specific disease associated with hyperglycemia is diabetes mellitus. The following vegetables and processed foods are high in complex carbohydrates: brussels sprouts. This amount will vary when a person is acutely or chronically ill. The College Network. glucose can also accumulate in the blood. since greater demands are placed on the body for fluid replacement. Sixty to 70 percent of normal body weight consists of water in a normal adult. Insulin promotes glucose transport into cells through cell membranes. Excess glucose over and above that which is needed for normal activities of daily living. Carbohydrates come in two basic forms: simple carbohydrates (sugars) and complex carbohydrates (starches and fiber). causing hyperglycemia. the rhythmic. Whole grain versus processed foods. and many fruits and vegetables. they can assist in eliminating other waste products from the body. Carbohydrates in the form of rice cereal are generally introduced to babies at around six months of age. and unpeeled fruits and vegetables are higher in fiber than cooked fruits and vegetables. or milk sugar. Fiber is then eliminated out of the body through the rectum. prunes. but fiber does play a significant role in nutrition. Once ingested. Foods high in fiber also are thought of as foods high in bulk or high in volume. phytochemicals found in some vegetables may interfere with the process of cancer growth. and dark. five or more servings of fruits and vegetables are still recommended. Total fiber recommendations for people age 50 and younger are 38 grams (males) and 25 grams (females). Inc. into the stomach. vegetables with seeds and/or peels (cucumbers. according to the American Academy of Pediatrics (AAP). such as lettuce. Lactose. wavelike motions that help move food through the large intestine. vegetables in the cabbage family. Fibercontaining foods are high in roughage and are not digestible. leafy green vegetables like spinach. Note: Introducing solids to infants before four months of age may cause food allergies. Dieters are often encouraged to eat plenty of foods high in fiber since these foods give the person a sense of fullness. raw. raw berries. rhubarb. raw fruits. complex carbohydrates. so fiber gram counts are also lower. squash. whole grain breads. and then into the small and large intestines to aid in the process of peristalsis. and vegetables are all high in fiber (and low in fat). Females generally require fewer overall calories. unless there is a strong history of allergies in the family. The organization therefore recommends increasing food intake from fibrous plant sources. Researchers at the Harvard School of Public Health reviewed 14 studies that tracked over 750. legumes. The researchers did not find a strong association for lower colon cancer risk. cucumbers.0 . Common direct food sources of fiber can be found in breakfast cereals (especially those that contain bran). Ranges for carbohydrates and other nutrients are revised periodically based on the latest research. Fiber has little nutritional value in the traditional sense of directly supplying the body with energy. but there was some indication that there might be a lower risk of cancer of the distal (left side) colon among the largest consumers of fruits and vegetables (2007). Fruits and vegetables recommended for higher-fiber diets include raw fruits with seeds and/or skins. contain trace or few carbohydrates.Unlawful to replicate or distribute 148 Fundamentals of Nursing Other vegetables. over age 50. peas). The College Network. the recommendations are 30 grams (males) and 21 grams (females). is a type of simple carbohydrate. dried Copyright © 2008. raw pineapple.000 participants for 6 to 20 years and analyzed the association between fruit and vegetable intake and colon cancer. Furthermore. According to the American Cancer Society. Uncooked. nuts. The recommended range for carbohydrate is 45 to 65 percent of an adult’s total caloric intake. a long-term diet high in saturated fats from animal sources like red meats and processed meats can increase risk of colorectal cancer. Though research to date is inconclusive. they move down the esophagus. NXP 070106 v1. Fiber Fiber is a nutrient that is an important nutritional subcategory of starchy. these are the most recent ranges cited by the Food and Nutrition Board of the Institute of Medicine (2006). and replacement of body tissue. meaning “rising up. is a characteristic of pregnancy when women require additional protein. canned vegetables without seeds or peels). People who are immobile due to paralysis. severe burns. can result in the body losing more nitrogen that it retains. maintenance. Protein is contained in foods that are often less readily available in many diets than carbohydrate or fiber because the foods with high amino acid content are usually more expensive. strained fruit juice. or other injuries. derived from the Greek word anabole. lettuce. like carbohydrate. Protein is said to be spared for this building-up process. Proteins are often called the building blocks of the body. and oxygen. resulting in a negative nitrogen balance. it can be utilized to meet the metabolic need for tissue growth and repair. Anabolic reactions. lentils. To spare means to refrain from using. such as prolonged states of infection or fever. Protein metabolism is a special type of metabolism that involves primarily anabolic reactions. repair. Inc. Nitrogen builds and repairs tissues.” include all the processes that turn or convert protein into living tissue. as in negative states of nitrogen balance. cooked vegetables (mashed potatoes.0 . melon. and vegetable juice. The essential amino acids the body requires can be obtained through various food sources. which involves the conversion of complex substances into simpler substances for energy. Some foods are known as complete proteins since they provide the body Copyright © 2008. Another important function of protein is the maintenance of nitrogen balance in the body. or a physically debilitated state are also prone to negative nitrogen balance and its associated tissue breakdown due to catabolic reactions. proteins also contain nitrogen. However. The College Network. Catabolic reactions can also involve the destruction of tissue. Protein. fruit cocktail. Under normal conditions. and they are able to carry out this task of construction very well if enough carbohydrates are available to meet the body’s needs. In contrast. cooked fruits without peels. catabolic reactions (the Greek word kata means “throwing down”) more commonly characterize carbohydrate and fat metabolism. these anabolic states are considered to be periods of positive nitrogen balance. and it occurs during periods of rapid growth (infancy and adolescence). bananas. but its chief role is to aid in the growth. One gram of protein equals four kilocalories. Certain conditions. One regular work duty of metabolism is to provide an energy supply for the body. protein is not needed for this regular work duty. instead. hydrogen. or to not be taken up by regular work duties. cooked spinach.Unlawful to replicate or distribute cooked beans. Proteins Proteins. Wounds heal more slowly when protein is depleted or there is inadequate dietary intake. coma. corn. Fruits and vegetables recommended for lowerfiber diets include applesauce. also consist of three primary elements: carbon. starvation. for example. The atoms of these four primary elements form nine essential amino acids. like carbohydrates. Anabolism. and legumes. When carbohydrates are burned to meet the body’s needs for energy. NXP 070106 v1. is also an energy source. This is possible when nitrogen (protein) intake and protein anabolism are equal to or exceed nitrogen (protein) output or protein catabolism. Inc. These macronutrients are saturated with hydrogen or contain as much hydrogen as they are capable of containing. higher protein diets are generally recommended for people who are critically ill.2 kg/lb.0 g/kg of body weight. a complete protein is formed. A common term associated with saturated fats is cholesterol.Unlawful to replicate or distribute with all the essential amino acids needed by the body. milk. and other dairy products. Eggs.0 . milk.. Complete protein foods include all varieties of meat and poultry. a person weighing 150 lbs. Margarine and butter are examples of saturated fats. or oatmeal Nuts and seeds of all types: almonds. or two starchy 3 vegetables). incomplete proteins make up a complete protein.” High cholesterol intake or inadequate utilization of cholesterol has been associated with atherosclerosis and cerebral vascular accidents (strokes). Saturated fats or lipids come in solid form. combine 1 with 2. This is an important consideration for nutritional planning for persons with low or fixed incomes or for people on vegetarian diets. known as triglycerides (lipids containing three fatty acids). in both unprocessed and nonartificial forms. including all forms of unprocessed cheese. A kilogram equals 2. divided by 2.8 g/kg. Most fish are considered complete proteins. cashews. have been implicated in the development of diseases such as coronary artery diseases (CAD).g. or dried/split peas If any two of these incomplete proteins are combined (e. these patients may have protein requirements of up to 2. The following are examples of incomplete plant proteins: 1. would require 150 lbs. When combined with each other in the same meal or when combined with a complete protein food such as meat. 2 with 3. The literal meaning of cholesterol is “solid” or “stiff. so. lentils. though the percentages of carbon. Unsaturated and polyunsaturated fats can take the form of oils and contain the element hydrogen in lesser degrees. and certain cancers when ingested or present in the body in saturated forms. Recommended levels of protein are 0. Eggs. An additional 25 g/day is recommended for pregnant and lactating women and children in their growth years. are also complete protein foods. Animal fats are the primary source of saturated fats. specifically egg yolks. Examples of these kinds of lipids are vegetable oils like safflower and corn oil. examples of such foods are fatty cuts of beef and pork and most organ meats. kidney beans. hydrogen. or cheese. because protein can aid in the repair of tissues damaged by trauma or disease. The general recommended range for adults is 56 g/day (males) and 46 g/day (females).8 grams per kilogram of body weight for adults. specifically atherosclerosis (hardening of the arteries). Olive oil is also unsaturated. The chemical composition of lipids is similar to that of carbohydrates. and oxygen differ. are Copyright © 2008. 2. or sunflower seeds Starchy vegetables and legumes: corn. for example. The College Network.2 pounds. NXP 070106 v1. Various grains: brown rice. and multiplied by 0. The most common form of lipids. Also. Lipids Lipids are also known as fats. whole wheat breads.4 g of protein. 3. or 54. stored body fat can also be converted to energy. a number of micronutrients are required for optimum health and well-being. mackerel). The College Network. cookies. shrimp. Inc. Copyright © 2008.6 grams/day (males) and 1. NXP 070106 v1. A well-balanced diet. These take the form of vitamins and minerals. salmon. and other foods made with or fried in partially hydrogenated oils. is high in essential fatty acids. Some fat. wheat germ. the Institute of Medicine recommends 1. this information should be on the nutrition label directly under the line for saturated fat. Food manufacturers may add hydrogen to vegetable oil to increase its shelf life and maintain its flavor. Note: women who are pregnant or nursing and also young children should limit their intake of low-mercury fish (canned light tuna. more active and underweight people will require more fat intake. Fats add flavor to foods and increase the length of time food remains in the stomach. vitamins have a catalytic effect⎯they act as a stimulus to help release energy from the macronutrients of carbohydrate and fat. Vitamins Vitamins are micronutrients and organic compounds essential to normal metabolic processes. It can be found in some margarines. for example. Sources of linoleic acid are corn. flaxseed. for alpha-linolenic acids. Two types of essential fatty acids are linoleic acid (an omega-6. which gives people a feeling of fullness. Recommended intake for linoleic acids is 17 grams/day (males) and 12 grams/day (females). Sources of alpha-linolenic acid include canola. however. vegetable shortenings. snack foods like crackers. Breast milk.Unlawful to replicate or distribute also high in cholesterol. If a product contains trans fat. but in fact. or n-6. can usually provide what the body requires. and nuts. fatty acid) and alpha-linolenic acid (an n-3 fatty acid). It is recommended that only 20–35% of daily calories be fat calories. wheat germ. Fats are stored in the body and can be converted into energy in the form of glucose when needed. pollock) to two meals a week maximum and should avoid fish higher in mercury (swordfish. Mercury is a heavy metal and research continues on its adverse effects on various organs of the body and the neurological system with high concentrations. safflower. While not direct suppliers of energy.1 grams/day (females). the end result is a solid fat that can elevate LDL cholesterol and increase risks for CAD. is essential to maintaining good health. cottonseed.0 . During periods of starvation. A common misconception is that most vitamins come in bottles. halibut) are also high in n-3 fatty acid. however. One gram of fat provides the body with nine kilocalories. Polyunsaturated oils may actually decrease cholesterol. and soybean oils. Fish (salmon. canned tuna. and walnuts. and soybean oils. many foods are excellent sources of vitamins. Micronutrients In addition to macronutrients. A diet with no fat can result in poor growth and development in childhood and adolescence. although they tend to be high in calories. as is whole milk. Trans fat is another category of fat. in the absence of disease or a developmental change such as pregnancy. light. accumulates in the epidermal (outermost) layer of the skin.1 lists these vitamins and some common food sources. carrots. liver. etc. strawberries. green beans. and wheat germ B1 (thiamine) Table 8. poultry. liver. poultry. etc. Ultraviolet light from the sun activates vitamin D for use in the body by transforming this precursor. cheese. and meats Egg yolks. Inc. Table 8.2. yellow fruits (apricots). nuts. oranges. potatoes. potatoes. liver.) and vegetables (broccoli. kidney. etc. milk. Water-soluble vitamins include vitamin C (ascorbic acid) and a number of vitamins categorized as B complex vitamins. fish.Unlawful to replicate or distribute Vitamins can be categorized as either water-soluble substances that cannot be stored in the body or fat-soluble substances that can be stored. and whole grains Fish. leafy green vegetables. whole milk and whole milk products. Table 8. tuna. a precursor or source of vitamin D. eggs. liver. 7dehydrocholesterol. dairy products. spinach. greens. meat (beef. The College Network. cereal (oatmeal). organ meats (liver). meat. whole grains. liver.0 . For example. green beans. and exposure to air and water. and dark green vegetables Water-soluble vitamins can be adversely affected by various environmental factors such as heat.1 Water-Soluble Vitamins and Their Sources Vitamin B2 (riboflavin) Niacin B6 (pyridoxine) Folic acid or folate B12 (cobalamin) Pantothenic acid Biotin Food source Milk. grapefruit.). and green leafy or yellow vegetables (broccoli. and green vegetables (broccoli and spinach) Cereals. cabbage. and whole grains Fish.1 Water-Soluble Vitamins and Their Sources Vitamin C (ascorbic acid) Food source Citrus and other fruits (cantaloupe. Fat-soluble vitamins that may not require daily intake and their common food and environmental sources are included in Table 8. green peppers. and meat Whole grain cereals. pork. and winter squash) Copyright © 2008. Fresh foods are generally the highest in vitamin content. and whole grains Eggs. The final synthesis of vitamin D occurs in the epidermis. Table 8. NXP 070106 v1. legumes. meat. tomatoes. legumes. special storage and cooking processes can help retain vitamin content.) Whole grain bread. Fat-soluble vitamins are less sensitive to environmental conditions than their watersoluble counterparts. saltwater fish.2 Fat-Soluble Vitamins and Their Sources Vitamin A Food source Eggs (yolks). have nothing to do with the importance of the minerals⎯they simply note the amount of the mineral required by the body for optimum health. cheese. Vitamins and minerals are also listed. NXP 070106 v1. pineapple. etc.). yogurt. pork. sodium.). bananas. beans. eggs. nuts. collard greens. is 1000 mg (ages 19–50) and 1200 mg (over age 51). fluoride.). and all milk products Eggs. The College Network. for example. and zinc. and green vegetables Legumes (dried peas.) Whole grains. facilitate the transfer of chemical substances across cell membranes. ice cream.or macro. in particular the microminerals: cobalt. and green. legumes. carrots. fruit (oranges. One of the easiest ways to gain a better understanding of vitamins and minerals is get out a cereal box and look at the label. meats (beef. some Magnesium Phosphorus Potassium Sodium Copyright © 2008. chloride. salmon. and vegetable oils Egg yolks. and play an important role in maintaining the health of nerves and muscles. apricots. Note that some of the minerals are considered trace elements. tomatoes.). milk. meat. milk and all dairy products (cheese.). etc. The recommended daily allowance (RDA) for calcium. or orange vegetables (broccoli. etc. etc. Table 8. These micronutrients help regulate enzyme metabolism. phosphorus. The prefixes micro. liver.). There are two basic categories of minerals: macrominerals and microminerals. chromium. Inc. fish oils. copper. often by percentage per serving in comparison with minimum daily requirements. and whole grains Smoked or salted luncheon meats. manganese. The RDA for iron. Functions and some food sources for some of the most common macrominerals and microminerals are outlined in Table 8. etc. iron is considered a micromineral. vegetables (green and leafy). milk.3 Important Minerals and Their Sources Mineral Calcium Food source Fish (sardines. oranges. iron. Macrominerals include calcium. canned and frozen vegetables. and sunlight Cereals (wheat germ). selenium. etc. fresh and dried fruits (grapefruit. is only 10 mg (males) and 15 mg (females). The minimum daily requirement for macrominerals is over 100 mg. fortified milk.3. Included on most labels is the amount of calories or energy for a single serving of that food. milk. the minimum daily requirement is less than 100 mg. etc. for microminerals. an equally important mineral. potassium. Macronutrients are also listed in grams. and sulfur. iodine. rhubarb. fortified margarine.Unlawful to replicate or distribute Table 8.2 Fat-Soluble Vitamins and Their Sources D E K Egg yolks.0 . and leafy green vegetables Minerals Minerals are inorganic micronutrients that also play a catalytic role in nutrition. calcium would be considered a macromineral. juices. liver. leafy. magnesium. gov/. unprocessed red meats and organ meats (liver.). and oysters Zinc MyPyramid and Dietary Guidelines The original Food Guide Pyramid and logo was introduced in 1992 by the United States Department of Agriculture (USDA) to serve as an identifiable and easy-to-use guide to help people plan meals and purchase food that would meet the minimum daily requirements of good nutrition. poultry. You can also see the new pyramid in Figure 1. there are also differences for the population in general and also for people with special dietary needs.3. Copyright © 2008. The MyPyramid has replaced the older Food Guide Pyramid. shrimp. enriched bread. Inc. it was formulated by the Center for Nutrition Policy and Promotion. celery. and dark green vegetables (spinach) Legumes.Unlawful to replicate or distribute 154 Fundamentals of Nursing Table 8. raisins. kidneys. liver. an organization of the United States Department of Agriculture (USDA). dried fruits (dates. NXP 070106 v1. in 2005. etc. etc. whole grain cereals.). nuts.mypyramid. The new food guide pyramid can be viewed on the official government web site. While there are many similarities to the Food Guide Pyramid. prunes. etc.). etc. and table salt Fluoridated water. toothpaste. The College Network. shellfish (oysters. and seafood Seafood or table salt (iodized) Egg yolks.0 .). http://www.3 Important Minerals and Their Sources Mineral Fluoride Iodine Iron Food source fresh vegetables (beets. “Steps to a Healthier You” is the new motivational slogan. cardiovascular disease. Current nutritional requirements expand on the original concept of basic food groups and can be found in the Dietary Guidelines for Americans 2005.S. type 2 diabetes. The College Network. Department of Health and Human Services. and low-fat milk products. Copyright © 2008. NXP 070106 v1.Unlawful to replicate or distribute Figure 1. colon cancer).0 . there is an overconsumption of saturated fats and refined white sugars.3 The USDA’s Food Guidelines and MyPyramid Sources: U. The current focus on dietary guidelines is based on scientific evidence about health promotion and risk reduction for chronic conditions as well as evidence relating certain diseases to an inadequate diet coupled with a sedentary lifestyle. dark green and orange vegetables. The logo itself is a visual reminder of the five daily food groups and exercise recommendations. Inc.S. legumes. and osteoporosis. The logo retains the look of a pyramid but in a more simplified format. steps running up the side of the pyramid are a reminder to consumers to be physically active. whole grains. U. and U. Department of Agriculture. high cholesterol. Department of Agriculture 2005. The typical American diet is deficient in the following: fruits. hypertension. In contrast.S. The MyPyramid guidelines are appropriate for those over two years of age. Certain types of cancers may also be related to diet (for example. Examples of these conditions include obesity. tomatoes. Refining removes essential nutrients like iron. mushrooms. peas. dietary fiber. 4. body size/height. Fruits as well as vegetables can be fresh.Unlawful to replicate or distribute One basic premise of the Dietary Guidelines is that food. Food and caloric requirements can be individually calculated using the MyPyramid web site. 2. and Dairy Substitutes Milk is a category that includes yogurt and cheese and is generally high in calcium. or fat-free Copyright © 2008. Dairy. Milk. and white rice. 5. NXP 070106 v1. pasta. thiamin. fruits contain carbohydrates and are good sources of vitamin A and vitamin C. breads. this level will vary based on gender. rather than dietary supplements. lima beans). is high in potassium. and brown rice. romaine lettuce). and pasta made from whole-wheat flour. Broccoli. Food labels should be read carefully. Nutrient-dense food and beverages are encouraged for consumption among all basic food groups. and a miscellaneous category of general lower-calorie vegetables (iceberg lettuce. dry peas and beans (lentils. The College Network. corn. starchy (white potatoes. 3. Raw vegetables are good sources of fiber. Raw fruits are generally high in fiber. Fruits Fruits and 100-percent fruit juice comprise this category that includes melons. cucumbers). berries. canned. riboflavin.0 . Examples of whole grains are oatmeal. for example. greens. Dark green and orange vegetables have the highest nutrient content. Grains Vegetables Fruits Milk Meat and beans Oils Grains Grains consist of whole grains and refined grains. and age. Inc. 6. and all other varieties of fruit. orange (winter squashes. frozen. kidney beans). or dried. should be the primary means of meeting nutrient needs for all age groups. folic acid). and certain B vitamins (niacin. Vegetables Vegetables and 100-percent vegetable juice comprise this category. Food in this category may be high-fat (whole milk). low-fat (1% milk). Examples of refined grains are breads. The USDA reference level for recommended caloric intake is based on a 2000-calorie diet. carrots. The five subgroups of vegetables are the following: dark green (broccoli. sweet potatoes). although some products are enriched with B vitamins and iron. The five food groups (and one additional group for oils and fats) in MyPyramid include: 1. and other food made from white flour. physical activity level. Meat also supplies iron. abdominal cramping. However. which breaks lactose down into simple sugars for absorption. black. and nuts. Symptoms of lactose intolerance generally appear 30 minutes to two hours after ingesting foods or fluids containing lactose and can include diarrhea. corn) are preferred over oils high in saturated fats (coconut. eggs. and stick margarine.0 . The College Network. herring). fat. and Native American populations. Lactose intolerance is most common in Asian. nausea. trout. vitamin D. Oils Oils are a liquid form of fat. zinc. fish. keep in mind that all processed meats are high in sodium. and rice milk are lactose-free.to high-fat. NXP 070106 v1. Nuts (almonds) and seeds (sunflower. phosphorus. Milk supplies protein. olive. The food in this group is generally high in protein and ranges from low. Foods that do not contain lactose should have one of the following indications on the label: • • • • • Lactose-free Pareve (neither meat or dairy) Lactic acid Lactate Lactoalbumin Enzyme replacements before eating or drinking a lactose-containing food are often recommended. Research indicates that up to 75% of the world’s population is at some risk for lactose intolerance related to a deficiency of the digestive enzyme lactase in the small intestine. and organ meats (liver) and egg yolks are high in cholesterol. and vitamin A (when fortified). Meat and Beans The meat and beans category also includes poultry. and B-complex vitamins (niacin. Inc. Oils high in polyunsaturated or monounsaturated fats (canola. gas. Lactose-free products are available in most regular grocery or health food stores and should be labeled as such.com. Copyright © 2008.mayoclinic. Some common food containing oil may also be high in trans fat (such as some margarines). Solid fats include butter. Several lactose-free products are available for the lactose intolerant/lactase deficient. Hispanic. riboflavin. Soymilk.Unlawful to replicate or distribute Fundamentals of Nursing 157 (fat-free yogurt). Further information on causes and risk factors can be found online from The Mayo Clinic at http://www. oat milk. thiamine). nut milks. and bloating. shortening. sesame) are high in vitamin E. calcium. Some fish is rich in healthy omega-3 fatty acids (salmon. palm kernel). Saturated fats and trans fats should make up less than 10 percent of calories. cycling) Stretching exercises to increase and maintain flexibility Resistance exercises to increase and maintain muscle strength and endurance Recommendations for daily consumption based on a 2000-calorie diet are: • • • • • • • • • • Fruit: 2 cups. food high in cholesterol.. The College Network.g. Alcohol is not recommended for women of childbearing age who may become pregnant.Unlawful to replicate or distribute General MyPyramid Recommendations The following is a summary of recommendations based on the food groups in MyPyramid: • • Limit intake of the following: saturated and trans fats. alcohol is also included in this category. and lentils can also be considered part of this category. • Copyright © 2008. 60 minutes of moderate to vigorous activity can help maintain normal weight. Discretionary calories should be limited to 100–300 calories a day. The three primary types of activity recommended are: Cardiovascular conditioning (e. orange. NXP 070106 v1. sweetened cereals. low fat. fish. Inc. pregnant and lactating women. brisk walking. or fat free. vegetables. and starchy vegetables. At least 30 minutes of moderate to intense physical activity can reduce risk of chronic disease. Gradual weight loss comes from balancing calories taken in from food and beverages with calories expended. Discretionary calories are extra calories over and above the minimum daily requirements and might include solid fats and sugar that is added to some food and beverages. candy. or butter added to a potato. 60–90 minutes of moderate-intensity activity can sustain weight loss. Fiber-rich fruits. Food high in potassium includes fruits and vegetables. and people who may be taking medications that could interact with alcohol. beans. Examples are sodas. Meats and poultry should be lean. especially if physical activity is low. salt. daily exercise is encouraged.0 . and vegetable oils). Legumes such as peas. Whole-grain products: at least 3 ounce-equivalents in addition to any enriched products. food and beverages containing sugars and starches should be consumed less to prevent weight gain and dental caries. running. Alcoholic beverage recommendations include up to one drink/day for women and up to two drinks/day for men. added sugars. and whole grains are the recommended source for carbohydrates. and alcohol. with a variety of dark green. Sodium consumption should not exceed 2. Vegetables: 2 ½ cups.300 mg (1 teaspoon) per day. The majority should be from polyunsaturated and monounsaturated fats (nuts. children and adolescents. Fat-free or low-fat milk or milk products: 3 cups Fats and oils: 20–35 percent of daily calories. To lose a pound a week. A deficit of 7000 calories would result in a two-pound loss over two weeks. In one week.. Determine current weight and multiply by 10 (women) or 11(men) B. This can best be done through a combination of calorie counting and exercise. low-intensity activities daily (add 300 to above result) Moderately active. Making choices from the food pyramid based on recommended food groups and servings is not a guarantee that a person’s complete nutritional requirements will be met. To lose a pound a week. One common formula for calculating weight loss is the following: A. 30-minute brisk walk (add 500 to above result) Very active.0 . gradual weight loss comes from balancing calories taken in from food and beverages with calories expended. the recommended number of calories needed by the body to maintain that weight is (175 × 10) + 300 = 2050 calories. daily exercise is encouraged. Inc. there are also weight charts made available by the federal government based on gender. The College Network. In order to lose one pound a week. and height. a recommendation would be to take in 500 fewer calories a day than what your body needs. This averages 500 calories a day × 7 days. Add results of A and B. so a visual aid like the food pyramid can be helpful to people when planning menus and purchasing foods. walking at work. For example: For a generally inactive female weighing 175 pounds. e. A calorie deficit forces the body to draw on its fat reserves for energy. NXP 070106 v1. Determine general activity level: • • • Generally inactive. a simple calculation for use in a gradual weight loss plan is presented in this section. To check ideal weight. but it does provide recommendations for a Copyright © 2008.g. engaging in physical sports or labor-intense occupation (add 700 to above result) C. age. Planning Menus Based on MyPyramid We live in a visual society. this would be a difference of 3500 calories and a loss of one pound. This number is the total number of calories you need daily to maintain your current weight. the basic formula for weight loss would be the same no matter what one’s current weight.g. Based on these guidelines.. or 1550 calories a day. e. In one pound of stored body fat there are 3500 calories. housework.Unlawful to replicate or distribute Calculating Weight Loss Based on MyPyramid As MyPyramid advises. plans might include consuming a diet of 2050 – 500 calories a day. However. or 500 calories a day × 14 days. a person must create a 3500-calorie deficit based on their required number of calories. see the American Diabetes Association web site at https://www. This information can be used for purchasing foods that are low in fats and simple sugars and high in the essential nutrients like protein and complex carbohydrates. fluid comes primarily in the form of milk. and an 8-oz. and pregnant or lactating women in particular. and protein allowances are calculated. Diabetic food exchanges can be made within exchange groups based on recommended amounts. In addition to its fluid content. For example. two tablespoons of peanut butter can be exchanged for one egg.org. and they can be found online or in any nursing or nutrition textbook. Various dietary exchanges can also be made if serving sizes are known. it contains all the essential nutrients needed by the growing infant to at least six months of age. although environmental factors (for example. Special Developmental Issues Involving Nutrition For infants. or weights. children. measurements. It provides what is known as satiety. Vitamin. (These are not charts that require memorization. Recommended Daily Allowances Recommended dietary (or daily) allowance (RDA) tables are also readily available for the following groups of people: infants.diabetes.0 . Both overnourishment and undernourishment are associated with fast-food cultures.) In health care settings. one slice of bread can be exchanged for one-half cup of cooked rice. Breast milk is especially recommended for infants. NXP 070106 v1. A person using the Food Guide Pyramid to plan meals should be able to avoid the extremes of both overnourishment and undernourishment. For more information on diabetic diets. as is recommended daily caloric intake based on weight and height. very high environmental temperatures) may necessitate a need for more fluid. diets planned by dietitians generally adhere to RDA requirements.Unlawful to replicate or distribute well-rounded diet that includes ingestion of essential nutrients. The majority of processed and unprocessed foods are now labeled with percentages of nutrient content. men. Breast milk has a higher lipid and cholesterol content than bottled milk. Inc. slice of processed cheese. These charts are revised every five years based on the most current research. women in general. with the exception of water. a feeling of fullness. Infants do not need added water under normal circumstances. which are often associated with either excessive intake of fats and simple carbohydrates or a deficiency of vitaminrich fruits and vegetables. These categories are further broken down into age groups. Copyright © 2008. Diabetic diets are based on the concept of food exchanges. The College Network. This higher fat content is believed to function in infants in a similar fashion as with dieters who eat high-fiber foods. glass of milk can be exchanged for a 2-oz. since these requirements are more stringent than the Food Guide Pyramid guidelines. mineral. on a daily basis. NXP 070106 v1. Limiting but not necessarily eliminating consumption of egg yolks and organ meats is also encouraged because of their high fat and cholesterol content. Newborns.0 .Unlawful to replicate or distribute Fundamentals of Nursing 161 Recent research indicates that breast-fed babies are less obese when older. they should not lose more than 10 percent of their birth weight. that can be combined with other incomplete proteins to make a complete protein. Healthy People 2010 Healthy People 2010 is a national health promotion program that includes goals and objectives for better nutrition. Copyright © 2008. diabetes. will lose some weight during the first few days of life. the focus is on choosing foods from the five primary groups of nutrients and specifically adopting a diet that will prevent chronic diseases like heart disease. and they should regain any weight lost within two weeks. even those who are breast-fed. Breast milk also contains antibodies that serve a protective function in relation to food allergies. sometimes classified in the legume group. Additional guidelines include decreasing the percentage of fat in the diet. The bonding between mother and baby due to breast-feeding is well-known. Published by the United States Department of Health and Human Services (HHS) and the Public Health Service (PHS). Inc. such as by eating lean meats and poultry or substituting dried legumes such as beans and peas for protein. The College Network. however. and obesity. Tofu is also a high-protein food. 0 . The College Network.Unlawful to replicate or distribute Copyright © 2008. NXP 070106 v1. Inc. List the effects. Provide an overview of the various types of routine and special diets used as nutrition interventions.0 . The College Network.Unlawful to replicate or distribute Fundamentals of Nursing 163 Chapter 9: Common Nutritional Disturbances Objectives Upon completion of this chapter. 7. Provide an overview of undernutrition and overnutrition. including associated disorders. Because of this. Discuss the benefits of vitamin and mineral supplementation for various client populations. 4. Copyright © 2008. absorb. Describe the effects of the various micronutrient and macronutrient deficiencies and excesses on the body. 3. signs. List the effects. and metabolize nutrients—are commonly found among patients suffering from catastrophic health events. NXP 070106 v1. Key Terms altered-consistency diets amenorrhea anorexia anorexia nervosa beriberi bulimia clear liquid diets cretinism diabetic diets dysphagia full liquid diets glycemic index (GI) healthy heart diets hemolysis high-carbohydrate diets high-fiber/high-residue diets high-protein diets hyperbilirubinemia hypocalcemia hypoglycemia hypokalemia hypothyroidism ideal body weight (IBW) low-fat diets low-fiber/low-residue diets macrocytic anemia malnutrition morbid obesity nothing by mouth (NPO) obesity osteomalacia osteoporosis overnutrition pellagra protein-calorie malnutrition (PCM) prothrombin pureed diet regular/house diet rickets scurvy soft diet tetany undernutrition xerophthalmia Introduction Nutritional disturbances—including alternations in the body’s ability to ingest. and symptoms of macromineral deficiencies and excesses. digest. signs. you should be able to do the following: 1. 2. nurses need to understand the signs and symptoms of common nutritional disturbances and some of the special diets used to support the nutritional needs of people when they are ill. and chronic illnesses. 6. acute diseases. and symptoms of micromineral deficiencies and excesses. Identify the four common physiological alterations that can occur with nutritional disturbances. Inc. 5. Related to that discussion. Some gastrointestinal disturbances cause disturbances in elimination that. can cause nausea and problems with absorption. such as radiation. It can affect all age groups and populations in both developed and underdeveloped countries. in turn. we also discuss the signs and symptoms of macromineral and micromineral deficiencies and excesses. This type of malnutrition. and altered consistency diets are described. and weight loss characterize chronically malnourished people experiencing PCM. muscle wasting. while endemic in underdeveloped countries among children. Some chronic and acute diseases may make it difficult for the body to absorb nutrients. An undernourished person’s caloric intake is less than what is required for normal daily functioning and weight loss. Disease processes and treatments for disease.” Many conditions of anorexia are related to various Copyright © 2008. Undernutrition may be related to problems with ingestion or dysphagia⎯difficulty chewing or swallowing foods. can also occur in developed countries in other age groups. Malnutrition Malnutrition is a term usually associated with pictures of starving children with distended abdomens and spindly extremities who live in countries where there is drought and famine. and the treatment of hypoglycemia.Unlawful to replicate or distribute This chapter begins by discussing the concept of malnutrition and some of the clinical nursing issues surrounding the problems of undernutrition and overnutrition. Undernutrition Undernutrition of a general nature is a common nutritional problem. The College Network. For example. can contribute to a state of undernourishment. Anorexia simply means “without a desire for food. Inc. the use of the glycemic index. Anorexia and Bulimia Anorexia is a condition commonly associated with undernutrition. Inadequate fat deposits beneath the skin. These diets are generally used when the patient suffers from metabolic issues related to ingestion or digestion. older people suffer more from chronic and malignant diseases that deplete protein due to catabolic reactions. We pay special attention to diabetic diets. A variety of conditions causing nausea and/or vomiting can also result in undernutrition and problems with digestion. chemotherapy. We conclude the chapter by discussing certain situations where the use of vitamin and mineral supplementations are appropriate. We then begin a more detailed look at factors related to macronutrient and micronutrient deficiencies and excesses. a number of common. specialized.0 . In addition to the regular diet. NXP 070106 v1. The most common form of severe undernutrition is protein-calorie malnutrition (PCM). is actually an umbrella term for a wide variety of conditions that can include overnourishment as well as undernourishment. Malnutrition. and antibiotics. Difficulty chewing might be related to facial trauma or poor dentition. Our discussion then turns to situations where patients have nutritional disturbances that require special diets. however. As with anorexia.” Food is consumed.g. Chemotherapy and radiation therapy to treat malignancies affecting various parts of the gastrointestinal tract often cause side effects that negatively impact nutritional intake (e. enabling the person to remain slim. Copyright © 2008. Signs of this disorder are related to the effects of starvation on various systems of the body. a girl may use laxatives and diet pills that contain diuretics to prompt increased urinary secretion. generally in very large amounts.0 .Unlawful to replicate or distribute disease processes. the lack of nutrients on the endocrine system can result in amenorrhea (absence of menses) and delayed sexual development. Inc. Teenagers. and then vomited prior to digestion. Adolescent girls in particular may also experience bulimia. General weight loss can be marked. rather than being used to build up and maintain body tissues or normally expended in activities such as exercise. Laxatives and enemas are also often used to frustrate the absorption of nutrients by the body.” and purging means “getting rid of. Overnutrition Overnutrition is a type of malnutrition that occurs when a person’s intake of calories exceeds that which is required for normal daily functioning. for example. otherwise known as the binge and purge disease. especially teenage girls. Malignancies of the head and neck may also require radiation therapy. People with cancer may be anorexic since the malignant cancer cells feed on nutrients at the expense of nonmalignant cells. The College Network. Increased susceptibility to infection can occur related to a compromised immune system. Over time. which results in a fluid volume deficit. The irritation from daily vomiting can affect the teeth. the majority of which are related to what is perceived as the cultural norm of slimness. the patient may have a deficiency of the mineral potassium (a condition called hypokalemia) that may be accompanied by cardiac symptoms or even lead to death. body systems can be adversely affected. resulting in dental caries.. Serious deficiencies of a number of electrolytes can occur. vomiting. nausea. and diminished sense of taste). A person can be bulimic but not anorexic. however. Anorexia can be associated with age and immobility. a process that speeds up metabolism. resulting in dysphagia. Acid from undigested stomach contents can irritate the esophagus. and fatigued. Bulimia alone is not as easy to detect as anorexia because the bingeing and purging usually occur when the person is alone. bulimia frequently accompanies anorexia. The energy provided by calories. Anorexia can also be a side effect of some medications. weakened. Many factors underlie this condition. people who continue to take in more calories than they need develop an excess of adipose tissue. are prone to a condition known as anorexia nervosa. for example. Bingeing means “unrestrained imbibing or eating. Dangerous cardiac arrhythmias can also occur related to electrolyte imbalances that are sometimes self-induced by vomiting. Electrolyte imbalance is further complicated if the teen resorts to over-the-counter products to speed up weight loss. is stored in the tissues in the form of fat or adipose tissue. The ability to salivate can also be diminished or destroyed by these treatments and swallowing can be affected. For example. and esophageal lesions can form. leaving these patients emaciated. such treatments may compromise patients’ nutrition due to the loss of sense of smell as well as taste. NXP 070106 v1. . A number of acute and chronic conditions can contribute to this loss (e. and excessive weight loss. people maintain their weight.Unlawful to replicate or distribute If a person’s body weight is 20 percent or more above his or her ideal or normal body weight. the primary action of nitrogen is to build up body tissue. Inc. and starvation). NXP 070106 v1.” and people who are morbidly obese often have difficulty carrying out routine activities of daily living because their condition affects their ability to breathe and to walk. fat. cancer. low-fat. a major component of protein. Copyright © 2008. he or she is considered obese. but results are inconclusive to date. recently there has been an emphasis on high-protein. and it is a major risk factor for a variety of chronic conditions including diabetes. Protein excess can contribute to the development of kidney damage. hypertension. This loss of nitrogen. prolonged immobilization. Macronutrient Deficiencies and Excesses Protein deficiencies over a long period of time can result in negative nitrogen balance in the body if the body is losing more nitrogen than it is taking in for optimum health. Obesity is a growing concern among grade-schoolers and teenagers. fat deposits that diminish beneath the skin. Older adults with impaired renal function and pregnant women are particularly at risk if protein intake is unreasonably high. and stroke. There is also a condition known as morbid obesity. Protein excess is less common but can occur. There has been considerable research on various types of weight loss diets emphasizing protein. injury/trauma to the body. prolonged fever or infection. The Latin word morbidus means “sickly or diseased.g. Obesity is considered to be one of the primary diseases of our highly industrialized Western civilization. Many people have difficulty maintaining or attaining their ideal body weight for various reasons and require assistance from others in the health care professions to do so.0 . The defining characteristics of low nitrogen levels include muscles that appear wasted. The College Network. Destruction of body tissues depletes nitrogen. and low-carbohydrate diets. When that balance is maintained. thereby reducing calorie intake and increasing weight loss. There are standardized tables of normal weight ranges correlated with age and height available in all health care facilities and textbooks of nursing and nutrition. One theory is that eating more protein and fat and fewer carbohydrates makes a person feel fuller so they eat less. heart and blood vessel diseases. Formulas can be used to calculate morbidity and obesity in relation to ideal body weight. contributes to the destruction of tissue. obesity is related to a more sedentary lifestyle and the abundance of fast foods that are high in calories. and simple carbohydrates. According to recent research. These symptoms are similar to the defining characteristics of PCM. Ideal Body Weight The concept of ideal body weight (IBW) is based on the belief that there should be a balance between nutritional intake and energy expenditure. or a softening of the bones. skin (epithelial) tissue. K. a disease characterized by the softening or bending of the bones. is a bone disorder characterized by a decrease in bone density with an increase in bone brittleness and porosity. or destruction of red blood cells. Osteoporosis. Triglycerides also compose 98 percent of the fat content in foods. serving of chicken (no skin) contains 77 mg of cholesterol. Postmenopausal women with vitamin D deficiency coupled with inadequate calcium intake may develop osteoporosis. Elevated triglyceride and blood cholesterol levels may also contribute to cerebral vascular accidents (CVAs or stokes) and myocardial infarctions (MIs). and immune function. In adults. in adults and macrocytic anemia. In children.0 . is evidenced in children with this deficiency. related to corneal drying. Inc.5-oz. In children. or anemia characterized by large red blood cells. or night blindness. E. People who are lactose intolerant may develop this deficiency due to the inability to drink milk or ingest other dairy products. Vitamin E synthesizes heme. Ninety percent of the fat stored in the human body is composed of a chemical compound called triglyceride. A 3. Vitamin A deficiency can result in the condition known as xerophthalmia. D. Vitamin K forms prothrombin in the blood. The American Heart Association (AHA) recommends a dietary intake of cholesterol no greater than 300 mg/day. serving of lean ground beef contains 107 mg of cholesterol. scaly skin and decreased resistance to infection is also a result of too little vitamin A. a 3. insufficient vitamin A intake can adversely affect the development of teeth and bones. or builds up red blood cells. and C can all occur with detrimental effects. from the Greek osteon and the Latin porosis (meaning “a porous condition”).5-oz. NXP 070106 v1. Breast-fed infants need more of this vitamin coupled with vitamin C. Abnormally high triglyceride levels may be a precursor to atherosclerosis. • • • Copyright © 2008. Micronutrient Deficiencies and Excesses Vitamin and mineral deficiencies and excesses can also result in nutritional imbalances with accompanying signs and symptoms. Rickets. The College Network. • Vitamin A maintains visual acuity (especially in dim light). dry. a deficiency of this vitamin can delay tooth formation and bone development. which aids in blood clotting. Vitamin Deficiencies Deficiencies in vitamins A. Vitamin K deficiency can contribute to prolonged clotting/bleeding times in adults and hemorrhagic disease in newborns. Vitamin D deficiency in older adults can lead to osteomalacia. in premature infants.Unlawful to replicate or distribute Lipid excesses have been implicated in nutritional imbalances. Vitamin D is responsible for the deposit of calcium salts and the absorption of calcium in teeth and bones. Higher than normal triglyceride levels have been linked to elevated blood cholesterol levels. Vitamin E deficiency can result in increased hemolysis. and pallor. especially the fat-soluble vitamins. and described below: • Vitamin B1 (thiamine) is necessary for the normal function of nerves. Vitamin B6 (pyridoxine) is necessary for healthy blood and nerve cells. anemia. Excesses do not generally occur from food intake but from megadoses of vitamins. It stimulates production of heme. Pregnant women may develop this anemia.Unlawful to replicate or distribute • Vitamin C builds strong capillary walls and red blood cells and aids in the metabolism of amino acids and in wound healing.0 . a chronic disease characterized by anorexia and generalized weakness if mild. Breast-fed infants need more of this vitamin. including herbal products and vitamins. Children who are deficient in vitamin C may experience growth retardation. but many people take over-the-counter medications. bruising. and tachycardia can occur in children and adults. muscles. that can be toxic in sufficient dosages or in combination with Copyright © 2008. vitamin B1 deficiency can lead to a condition known as beriberi. Symptoms of scurvy include weakness. Infants with deficiencies may experience diarrhea. and wounds that do not heal. Vitamin C deficiency can lead to bleeding gums. and deficiency can also result in enlarged heart and cardiac failure. Beriberi is a disease that affects the cardiac and nervous systems. cry when they are picked up. and other nutrients are dependent on it for their metabolism. and the heart. vomiting. cracks at the corners of the mouth. Deficiency can result in macrocytic anemia. and neurological and gastrointestinal disorders and skin eruptions if severe. Inc. NXP 070106 v1. Mental confusion. which are often reduced in older adults. and irritability. facial edema. The College Network. Deficiency can result in pernicious anemia that includes neurological and gastrointestinal symptoms. aid in B12 absorption. and other skin lesions. Deficiency of folic acid in pregnant women can also result in neural tube defects in their children. Deficiency can result in pellagra. Physicians and nurses usually do general assessments upon admission to a health care facility for prescription medications. Deficiency of vitamin B6 manifests itself in anemia. Megadoses of vitamin A can cause abnormal fetal development. muscle weakness. since gastric secretions. and bleeding from mucous membranes. In less developed countries. Deficiencies of B Vitamins A number of vitamin B deficiencies are also common. causing spinal deformities. Folic acid aids in the maturation of red blood cells. spongy gums. in part. scurvy. especially the peripheral nerves. Purple spots under the skin of elderly people are common due to a tendency to easily bruise related. and move less. This is seen especially in the elderly. Vitamin B12 (cobalamin) is necessary for red blood cell production. to this deficiency. Pronounced signs of vitamin B1 deficiency in infants are pallor. • • • • Vitamin Excesses Vitamin excesses can also occur but are more rare. Niacin synthesizes fat and contributes to the utilization of protein. • Fluoride aids in tooth formation and cavity prevention. and formation of bones. and failure to grow. Fluoride deficiency has been implicated in poor overall dental health. weakness. The College Network. Excess fluoride can cause discoloration of tooth enamel. They may be related to an insufficiency or excess of nutrients ingested by the patient. and abdominal cramps. vomiting. Children may experience stunted growth. abnormally slow pulse. Tetany. decreased level of consciousness. Nausea and vomiting are two of the most common symptoms of vitamin excess. or hypocalcemia. and older people may experience bone loss. a condition called hyperbilirubinemia. These over-the-counter drugs are rarely selfreported. Deficiencies are characterized by hypotension.Unlawful to replicate or distribute other prescription or nonprescription drugs. especially in relation to fluoride. is not uncommon. Potassium is important to both cardiac impulse transmission and muscle contraction. difficulty breathing. In infants. iodine. Sodium excess can manifest itself in skin edema (swelling). NXP 070106 v1. Allergic reactions include hives. muscle twitching. Copyright © 2008. muscle weakness. especially in older people. Pathological fractures can occur. hallucinations. Magnesium deficiencies may manifest in confusion. or the patient may experience side effects if these minerals are taken in pill form. Sodium is important to the maintenance of acid-base and fluid balance. • Calcium facilitates the body’s nerve impulse transmission. Convulsions can occur if hypocalcemia is severe. • • • Micromineral Deficiencies and Excesses Micromineral deficiencies can also occur. shortness of breath. characterized by an excessive amount of bilirubin in the blood and resulting jaundice. thirst. Calcium deficiency. is a side effect. Breast-fed infants need additional fluoride. Magnesium helps the body maintain electrical activity in nerves and muscles and enables calcium and protein utilization. including weak and rapid pulse. Macromineral Deficiencies and Excesses Both deficiencies and excesses in the macrominerals are nutritional imbalances that will occur more frequently in the various health care settings nurses work in. as are muscle cramping and spasms of the toes or thumb. cardiac function. and restlessness. zinc. Tingling sensations around the mouth and of the fingers are common. irritability of the nervous system. and iron. Potassium excess can cause confusion. Deficits result in muscle weakness. nausea. which is marked by involuntary muscle spasms. Calcium excess can cause cardiac irregularities and a state of overrelaxation of the skeletal muscles. can develop related to an excess of vitamin K.0 . muscle contraction. Excess vitamin D can also dangerously increase blood levels of calcium. fatigue. and decreased urinary output. and various cardiac irregularities. Inc. dry tongue. and itching. and they need ironfortified cereals. Iron deficiency bears special mention because it is probably the most common mineral deficiency. gender. this might also be known as the house diet. and the soft diet. Zinc helps the body maintain connective tissue. Lack of meat in a diet. characterized by fatigue.0 . The theoretical basis for their use relates to issues of metabolism (e. cold intolerance. and activity level. nutritional disturbances require special diets. NXP 070106 v1. acute or chronic intestinal infections).Unlawful to replicate or distribute 170 Fundamentals of Nursing • • Iodine regulates thyroid hormones. Copyright © 2008. Inc. Zinc deficiency may result in impaired wound healing and skin lesions and a decreased sense of smell and taste. weight. in adults. Iodine excess can produce toxic goiters. and sluggishness. however. Altered-Consistency Diets Altered-consistency diets may be used for a variety of reasons to aid in nutritional promotion. a number of common specialized and altered-consistency diets might be used in certain situations. The College Network. In hospital and nursing home settings. Children who drink large amounts of milk in lieu of solid foods can be iron deficient⎯the phosphate in whole milk combines with iron and removes it from the body. Infants ages six to eighteen months are especially vulnerable to deficiencies. Iron forms hemoglobin and aids in the formation of antibodies. the full liquid diet. like skin. The bulk may interfere with iron absorption from other foods. Sometimes. Persons with anemia are also subject to infections related to an impaired immune system. related to vegetarianism or the inability to chew. People with arthritis who regularly consume aspirin may be iron deficient related to some internal bleeding that is a side effect of aspirin given in high or frequent doses. Iodine deficiency can result in cretinism. or low thyroid function producing arrested physical and mental development. Lethargy. It contains all the basic nutrients from the Food Guide Pyramid based on a person’s height. and sometimes dyspnea (shortness of breath) on exertion can occur. Routine and Special Diets A number of diets are considered interventions. In addition to the regular diet. The most common diet to meet all basic nutritional needs and prevent the various deficiencies is called a regular diet.. Older people may have low hemoglobin levels if they are overconsuming foods high in bulk. The three most typical are the clear liquid diet.. Adolescent girls with menstrual blood loss may be anemic. Oxygen is carried to the cells by iron for energy release. difficulty with ingestion or digestion). such as bran cereals. can result in iron deficiency. Children may exhibit irritability and a decreased attention span. in infants and hypothyroidism.g. These diets are often used in relation to physically limiting conditions (e.g. fatigue. resulting in iron-deficiency anemia. All types of fruits and vegetables in addition to meat and poultry can be cooked without skins and blended or pureed.g. clear broths. The College Network. tea. Clear liquids are usually given at room temperature with enough fluid intake to prevent dehydration.g. including coffee. accident victims with facial injuries or the elderly with dental concerns). Foods can be combined to increase protein intake—for instance. Milk and foods containing milk are typical of this diet.. Carbonated beverages are considered clear liquids. nurses should be familiar with a number of common special diets. or boiled poultry and meats are included if they are minced or ground. Juices of all kinds are included. with less need for additional vitamin and mineral supplementation. iron. broiled. including custards. The thicker the consistency of the diet. Soft diets cause less irritation to the lining of the gastrointestinal tract. diabetic diets. Foods are not highly seasoned on this diet. Inc. Smaller. and creamed soups. Although the risk is relatively small. including NPO diets. Full Liquid Diets Full liquid diets may include any type of food that melts into liquid at room temperature (e. any infection from these bacteria can be especially dangerous to the elderly. Soft Diets Soft diets are used for patients who may have difficulty chewing and swallowing more solid foods (e. and this diet may be used prior to surgery to prevent any aspiration from vomiting. instant breakfast drinks or egg substitutes can be added to milk shakes. and several other variations. the more variety there can be in the types of foods. A version of the soft diet that is thinner in consistency is the pureed diet. and clear gelatin.Unlawful to replicate or distribute Clear Liquid Diets Clear liquid diets are generally short-term in nature. this diet lacks other essential nutrients. Special Diets In addition to the aforementioned diets. infants.0 . Dietary supplementation is usually needed to ensure adequate protein. more frequent intake of fluids with a variety of tastes to stimulate taste buds generally helps the palatability of this diet because it tends to be quite bland in nature. ice cream). foods are mixed (pureed) in a blender with liquids. They consist of no solid food⎯only liquids or semisolids that are clear or transparent. One primary rationale for a clear liquid diet is to provide rest for the gastrointestinal tract following intestinal surgery. Various types of baked. Copyright © 2008. and others compromised by illness.. and calories if the diet is used on a long-term basis. fiber diets. children. NXP 070106 v1. puddings. as are strained juices that are transparent. but nutritionally. Raw eggs should not be used because of the risk of contamination with salmonella. This can be given in the form of liquid dietary supplements and oral vitamin supplements that can be in liquid form. There may be some calories in a clear liquid diet in the form of simple carbohydrates (sugars) in liquids such as apple or white grape juice. the American Diabetes Association classifies based on a food's carbohydrate and protein gram count. and corn are considered part of the mostly carbohydrate bread. This makes it easy to determine the amount of insulin coverage needed for a meal for a person with type-I or insulin-dependent diabetes. rice. The College Network. Carbohydrate foods are foods from the carbohydrate exchange group. Low-residue or low-fiber diets may be ordered for these cases. Fiber Diets While fiber is a required nutrient and important to peristalsis. NXP 070106 v1. and pasta grouping of foods in the diabetic food plan. when extra roughage is needed to increase peristalsis and the movement of the products of digestion through the intestines. and they are usually ordered before and after surgery. they begin with clear liquids and progress to a regular diet. For example. On this diet. the USDA classifies according to type of food. no oral intake is allowed in any form. though there are some differences. The primary rationale for such a diet is to prevent the patient from aspirating gastric contents. depending on the number of calories they contain. and carbohydrates. (NPO stands for nothing by mouth in Latin: non per os. potatoes are grouped with vegetables in the USDA plan. one slice of whole grain bread could be exchanged for one-third cup of rice or one-half cup of oatmeal or cream of wheat. not strictly diets. is considered part of the meat and meat substitutes group for the Diabetic Pyramid. Diabetic Diets Diabetic diets are also common and recommended for both diabetics and general weight loss. General anesthesia used during surgery can cause nausea and vomiting. For example. High-residue or high-fiber diets are recommended for conditions like chronic diverticulosis. Inc. Cheese. A serving of fruit juice is one-half cup in the Diabetes Pyramid but three-fourths cup in the USDA Pyramid. Generally.Unlawful to replicate or distribute Nothing by Mouth In addition to the three traditional diets. fat. a serving of pasta or rice in the Diabetes Food Pyramid is onethird cup.) NPO diets are. This difference in serving sizes reflects the higher carbohydrate count of pasta and fruit juice. Once bowel sounds return. For instance. People with diabetes generally follow a specific diet recommended by their physician with different percentages of protein. This method may allow the person to consume more Copyright © 2008. The American Diabetes Association (ADA) has guidelines for diabetic diets for people of all ages based on the USDA MyPyramid guidelines (and the former Food Guide Pyramid). Starchy and high-carbohydrate vegetables like potatoes. These diets are also recommended for simple constipation. cereal. cheese is a low-carbohydrate and high-protein food. it may cause excessive irritation if a patient is suffering from a disease like ulcerative colitis or Crohn’s disease or if he or she has had surgery on the lower bowel. A popular alternative to the diabetic food exchange is calculating carbohydrate grams.0 . dry beans. a diet commonly called nothing by mouth (NPO) may be ordered. Exchanges can be made between the two pyramids as long as quantities are consistent with the diabetic plan. a part of the milk product group in the USDA Pyramid. people can begin to take fluids by mouth (PO) as ordered by the physician. of course. which increases the risk of aspiration during and after surgery as well as the development of aspiration pneumonia. compared to one-half cup in the USDA MyPyramid. peas. 1 vegetable. and a glass of low-fat milk or cup of yogurt (exchanges include 3 meat. and general malnutrition. Hypoglycemia. Carbohydrate foods that break down quickly during digestion have the highest glycemic indexes. one mixed salad. and 1 milk). binge drinking of alcohol. 1 bread/starch.0 . Healthy heart diets that address the growing number of people at risk for heart and blood vessel disease are generally low in saturated fat. white potatoes have a high glycemic index. can occur in diabetics. although like people with diabetes. a cup of green beans or a roll. such as excess secretion of insulin from the pancreas. one teaspoon salad dressing. perspiration. Inc. A person with diabetes who might be experiencing very low blood sugar may drink fruit juice to quickly increase blood glucose levels. or low blood sugar. but it can also occur in people who do not have diabetes because of different causes. they may also need to consume high glycemic foods or beverages to increase blood sugar quickly if they experience adverse symptoms. and Copyright © 2008. releasing glucose gradually into the bloodstream. People with chronic hypoglycemia may also need a diet with foods with a lower GI to help stabilize blood sugars. 1 fruit. 2 starch/bread. One concept diabetic patients and health care workers should understand is that of the glycemic index. and an eight-ounce glass of skim milk for breakfast (exchanges include 1 fruit. Lunch might include a three-ounce luncheon meat sandwich with two slices of wheat bread. Orange juice is generally recommended to bring very low blood sugar up quickly for diabetics and people with hypoglycemia who may be experiencing adverse symptoms like shakiness. Other recommendations for chronic hypoglycemia include more complex carbohydrates and high-fiber. and oats. The College Network. 2 starch/bread. and levels rise immediately after eating or drinking. and a cup of lettuce salad with tomato and fruit (exchanges include 3 meat. protein-rich meals with a variety of fruits and vegetables. 1 fat. and pasta and rice in place of potatoes. as long as there is sufficient insulin coverage. Examples of foods appropriate with these diets are breakfast cereals with wheat bran. have lower glycemic indexes. wounds. 2 vegetable. since juice has a higher GI than actual fruit.Unlawful to replicate or distribute Fundamentals of Nursing 173 ~ carbohydrates than the basic exchange plan. blood sugar response is fast. NXP 070106 v1. and 1 fruit). and 1 fat). A typical diabetic diet for an average-weight adult might consist of a one cup of melon. cholesterol. a banana. Highprotein and high-carbohydrate diets are used in cases of severe burns. a half of a bagel with a teaspoon of butter. Lower glycemic index diets can help improve sensitivity to insulin and stabilize blood sugar and are recommended for long-term management of diabetes. sometimes as a side effect of a diabetic medication like insulin. The glycemic index (GI) is a ranking of foods based on their immediate effect on blood glucose (blood sugar) levels. Dinner might include three ounces of chicken or beef. weakness. Other Diets Low-fat diets are recommended for people with difficulty absorbing fats and people with gallbladder disease. Carbohydrates that break down slowly. or tumors. Skim milk and low-fat dairy products are part of this diet. 1 milk. barley. and confusion. Sodium in this diet may also be restricted. The thyroid gland also increases its activity during pregnancy and iodine needs may increase. increases the body’s need for these elements. Vitamin and Mineral Supplementation While vitamins and minerals can be ingested naturally through foods. A middle-aged adult may also need calcium in pill form along with vitamin D for the prevention of osteoporosis. Inc.200 mg/day. Iron needs also increase to 30 mg/day and can best be met by supplemental iron or a multivitamin with iron. for example. since deficiencies can affect both mother and growing fetus. NXP 070106 v1. Certain conditions may also increase the need for vitamins and minerals above and beyond what food will supply. sometimes vitamin and mineral supplements are necessary to maintain nutrition if people are on any of these special diets for long periods of time. food) form for pregnant women are vitamin A and B vitamins (especially folic acid). Copyright © 2008.Unlawful to replicate or distribute simple sugars. Calcium needs increase to approximately 1. The College Network. Pregnancy. The specific vitamins needed in supplemental (vs. and higher in complex carbohydrates. moderate in protein.0 . Provide several examples of factors and variables nurses need to know about related to a patient’s nutritional status. Key Terms anthropometric data antioxidants blood urea nitrogen (BUN) celiac disease complete blood count (CBC) free radical gluten hematocrit (Hct) hemoglobin level lacto-ovo-vegetarians lactovegetarians midarm circumference (MAC) serum albumin serum cholesterol serum transferrin skin turgor thrush total lymphocyte count (TLC) triceps skin fold thickness (TSF) triglyceride counts twenty-four-hour urine collection urea urinary creatinine excretion vegans/pure vegetarians vegetarians white blood cell count (WBC) Copyright © 2008. Inc.0 . you should be able to do the following: 1. 3. Explain the importance of investigating an individual’s medication history and physical condition when completing a nutrition assessment. 7. Explain how socioeconomic. Discuss the impact of gender on nutritional requirements.Unlawful to replicate or distribute Chapter 10: Assessment of and Diagnostic Tests for Nutritional Health Objectives Upon completion of this chapter. 5. 2. NXP 070106 v1. Explain how religious beliefs and cultural practices can impact nutrition. 10. 4. Define six noninvasive anthropometric measures that the nurse can use to track a patient’s nutritional status. Discuss the impact of various serious medical conditions on the body’s nutritional status. Explain the role of antioxidants and the impact of free radicals. Explain what serum readings measure. Describe various dietary habits and preferences and their impact on nutritional status. Explain a complete blood count (CBC) and describe the three specific tests included in a CBC that give a picture of a person’s nutritional status. 9. and environmental factors can influence nutrition. Describe the most common effects of age and developmental level on metabolism and nutritional needs. 12. Explain the nutritional implications of both low and high blood urea nitrogen (BUN) levels. The College Network. and provide examples of their implications for a patient’s nutritional status. 8. psychological. 6. 13. 11. a medication may interfere with the absorption of nutrients. Not only does nutritional information help us plan for immediate nursing interventions. Admission assessments can uncover potential situations of risk. In nursing home settings. food intolerances and allergies. in other cases. The chapter concludes with an investigation of the importance of specific lab results and lists reasons these lab values are directly related to a person’s nutritional status. however. while. food types. The following are more specific considerations for nursing assessment that can aid in formulating nursing diagnoses and planning interventions related to the categories that most frequently influence a person’s nutritional status across the life span. NXP 070106 v1. and food preferences. Nutritional Assessments A dietitian in a hospital setting will generally do an in-depth nutritional assessment of a patient. Inc. including anthropometric data and laboratory data. We also discuss the importance of a comprehensive medication history as it relates to nutritional status. We look at specific metabolic and nutritional needs across the life span and analyze special dietary preferences and lifestyle choices that directly impact a person’s nutritional status. we must practice a comprehensive approach to nutritional assessments. Copyright © 2008. quality nursing care. Our discussion then turns to the types of nutrition-related assessment data we can use. The College Network. including amounts. For example. nurses should be aware of the patient’s daily intake patterns.Unlawful to replicate or distribute Introduction Our knowledge of a patient’s nutritional status allows us to provide holistic. Nurses should note any health factors that might compromise nutritional status. as well as for maintaining health for all ages. specific nutrients may interfere with the absorption of a drug. In many cases. We analyze the fact that. dysphagia (difficulty swallowing). Many of these influencing factors can also directly or indirectly affect the patient’s BMR.0 . such as pressure sores in the elderly and physically debilitated. Good nutrition is essential for preventing adverse conditions. In order to reach this level. extensive nutritional evaluation and planning is done by dietitians for every resident. it also allows us to develop preventive health interventions for both patients and their families. in some cases. or mechanical difficulties with chewing. including anorexia (lack of desire for food). nurses should be knowledgeable about the factors and variables relative to the patient’s nutritional status in any setting. an initial nutritional assessment on admission might indicate the need for a more comprehensive nutritional screening by a dietitian. nausea and/or vomiting. This chapter helps us understand how to do that by first identifying eight critical assessment areas. Unlawful to replicate or distribute Gender The basic rule of thumb is that men require more calories than women due to their increased metabolism both at rest and when active. Caloric needs overall are generally greater for men due to increased height and weight. Protein needs are also greater for men related to increased muscle mass. Different physiological changes related to stages of the life cycle based on gender should also be considered; for example, blood loss during menstruation can trigger an increased need for iron in women. Similarly, pregnant women have increased needs for protein, calcium, iron, folic acid, and vitamins C and D. Age and Developmental Level Age and developmental level also affect a patient’s nutritional status. Table 10.1 lists the most common effects of age and developmental level in relation to metabolism and nutritional needs. Table 10.1 Metabolic and Nutritional Needs across the Life Span Life stage Infants Developmental needs Metabolic requirements and energy consumption increase due to rapid growth and higher metabolic rate; extra iron needed from four to six months; water accounts for a high percentage of total body weight in infants; water loss and hydration needs can be high Metabolic/caloric requirements decrease as growth stabilizes; protein needs remain high for muscle tissue growth Calcium needs are high to ensure tooth formation Need for protein is high, especially for breakfast; 2,400 kcal per day needed for adequate nutrition Metabolic/caloric requirements increase due to growth and activity, especially in boys; needs for the following nutrients increase: protein, calcium, iron, zinc, vitamins B and C Women may need more vitamin C and iron Postmenopausal women need additional calcium and vitamin D to maintain or increase bone density and prevent osteoporosis Increased needs for protein, iron, folic acid, calcium, vitamin C, and vitamin D Metabolic/caloric requirements decrease due to decreased metabolism; decreased gastric secretion and diminished taste buds and sense of smell; increased need for calcium, iron, vitamins C, B1, B12, and fiber; decreased need for calories, fat, and sodium Toddlers Preschoolers School-age children Adolescents Young adults Middle-aged adults Pregnant and/or lactating women Older adults Many different variables, including gender and age, can contribute to dietary habits and regular and irregular eating patterns. Adolescent teenage girls, for example, are more prone to undernutrition. This can be related to a desire to remain slim or to attain slimness; anorexia and bulimia can then be contributing factors that impact metabolic and nutritional needs. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Dietary Habits and Preferences The patient’s cooking and work habits should be explored. Busy work schedules may force people to resort to dining out at fast-food restaurants or eating more microwavable processed foods that can be high in sodium. If patients are on a sodium-restricted diet, do they know how to cook tasty meals using herbs and spices? Methods of cooking should also be explored. Do they bake, broil, boil, or fry most foods? Individual preferences and dietary habit patterns can influence nutrition across the life span. Food allergies and intolerances can be assessed. Many people are lactose intolerant and require lactose-free milk substitutes, like LACTAID® Milk, or medications, like a lactase enzyme tablet (e.g., Lactaid tablets), available in drug stores without a prescription. Lactase enzyme is also available in liquid form that can be added to foods or beverages to make lactose more digestible. Many supermarkets also carry lactose-free breads and other products. Soymilk is one of the post popular alternatives to dairy milk and is carried in many supermarkets as well as health food stores. Soy milk is made from ground soybeans and is a good source of magnesium and thiamine, though it does not naturally contain calcium and vitamin D. Other options are almond, rice, and nut milks. The word parve or pareve on a product means it contains neither meat nor any dairy-based ingredients; these products adhere to Jewish dietary laws requiring the separation of meats and milk at the same meal and thus may be used in a lactose-free diet. Whole milk may cause gastrointestinal bleeding and iron-deficiency anemia in infants. A protein known as gluten, found in wheat, rye, barley, and oats, can also contribute to celiac disease in children with muscle wasting, anorexia, and abdominal distention. Most supermarkets also contain gluten-free products like breads made from alternative flours, such as rice, soya, sorghum, or potato flour. People often have preferences for the type of foods they eat, the texture of foods, and modes of cooking. All of these preferences can be capitalized on at different stages in life to ensure good nutrition. Well-loved foods from childhood might appeal to people with end-stage illnesses (terminal cancer or dementia) and can be incorporated into their diet; for example, patients may be served milk shakes with powdered protein supplements or with an egg for added protein and iron. Flavored yogurts that are high in calcium and iron provide older people with a sweet taste, which is more appealing to diminished taste buds. Yogurt can often be combined with cereals for added fiber. Children gravitate to fast foods and finger foods like peanut butter sandwiches, which are good sources of protein. Vegetarianism Many people are vegetarians, often prompted by concerns that are religious or ethical in nature. The primary source of food for vegetarians is plant foods. All vegetarians avoid meat, poultry, and fish. Actually, the vegetarian diet is classified by three primary variations: pure vegetarians, or vegans, consume plant foods and plant foods only; lacto-ovo-vegetarians eat eggs and milk in addition to plant foods; and lactovegetarians consume milk but not eggs in addition to plant foods. Assessment of a vegetarian diet should consider whether patients adequately combine foods to ensure that complete Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute proteins are part of the diet and that they eat other food groups in a balanced fashion. Vitamin and mineral supplements may also be needed. Table 10.2 indicates vitamins and minerals and food sources that vegetarians would especially need to consider for adequate nourishment; many are normally plentiful in foods that are not in a vegetarian diet, for example meat and eggs. If it is not possible to obtain these through food sources, vitamin and mineral supplements can be taken. Table 10.2 Vitamins and Minerals for Vegetarian Diets Vitamin or mineral Calcium Iron B12 Vitamin D Vitamin C Food source Soy products (e.g., soybean milk, tofu) and leafy vegetables (important for pure vegetarians) Leafy and green vegetables, whole grains, and iron-fortified breads and cereals Brewer’s yeast, fortified breads, and cereals Fortified milk Citrus and other fruits (cantaloupe, grapefruit, oranges, strawberries, tomatoes, etc.); vegetables (broccoli, cabbage, potatoes, etc.); extra vitamin C is needed to aid in the absorption of iron from plant sources Alcohol and Drugs Excessive alcohol consumption has been implicated in the development of both liver disease and dementia. Nutritionally, people who consume excessive amounts of alcohol are frequently malnourished due to the substitution of alcohol for food and/or the adverse effect of alcohol on the liver and internal organs of digestion, which results in decreased absorption of essential nutrients. The primary vitamin deficiency associated with excessive alcohol consumption is a B vitamin deficiency. If people are dependent on drugs like cocaine, they may be neglecting their nutritional needs. Cigarette smoking can also decrease desire for food. Heart Disease, Diabetes, and Obesity Do work habits influence the patient’s nutrition? Is he or she dependent on high-calorie, high-fat fast foods? An excessive intake of sweets and carbohydrates can contribute to diseases like diabetes and obesity. Excessive animal fat intake can contribute to obesity and heart disease. Diabetes, a chronic disease involving inadequate utilization of glucose, can often be controlled by diet alone if it is adult-onset. A diabetic diet generally includes limiting the intake of simple carbohydrates (refined sugars) and taking in more complex carbohydrates and protein. Acid indigestion, more commonly known as heartburn, can be a problem in the latter part of middle age; it is often related to obesity but is also related to decreased levels of gastric juice in the stomach. Foods high in fat content can precipitate this, especially when patients lie flat. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Caffeine Excessive caffeine intake has not been associated with breast cancer, but it has been associated with fibrocystic disease of the breast. Persons with cardiac disease are often advised to avoid the stimulating effects of caffeine in tea, coffee, or colas. Chocolate is also high in caffeine. Sodium-Restricted Diets Sodium, a chemical element foundational to good nutrition, is contained in many natural foods. However, salt is often prohibited due to health concerns. People who are forced to eliminate salt from their diet may consume fewer calories because food has little flavor. Additional sodium in the form of table salt, however, is often contraindicated for people with vascular diseases like hypertension or congestive heart failure. Many canned, packaged, frozen, and other processed foods have high sodium content that people may not be aware of. Antioxidants Patients should be knowledgeable about the role of antioxidants in relation to good nutrition. Antioxidants appear to reduce or eliminate damage caused by molecules known as free radicals. Free radicals contain oxygen and are generally important to a well-functioning immune system, unless present in excessive amounts. People who are exposed to pollution or radiation, experience stress, smoke, or overexercise may evidence an excess of free radicals. Free radicals have been implicated in heart and blood vessel disease, Alzheimer’s dementia, and cancer. Vitamins E and C are considered antioxidant vitamins, as is beta-carotene, a precursor of vitamin A. Medication History A medication history is an important component of a comprehensive nutritional assessment. Here, the nurse should consider the following questions: • • Is the person using over-the-counter vitamin and mineral supplements and/or herbal products? Is he or she taking prescription or over-the-counter medications that might have side effects like nausea, vomiting, or anorexia, which can affect nutrition? A nurse’s drug book is helpful to identify the many food and medication interactions that can occur. In some cases, specific nutrients may interfere with the absorption of a drug; in other cases, a medication may interfere with the absorption of nutrients. Milk and other dairy products, for example, can interfere with the absorption of some antibiotics; thus, tetracycline and dairy products should not be taken concurrently. Antibiotics sometimes cause gastrointestinal upset, nausea, and vomiting; people may neglect to eat as a result. Antibiotic therapy can also cause thrush, a disease that affects the tongue that makes chewing and swallowing of food very painful. Patients with arthritis who take many doses of aspirin daily may have iron deficiencies; a side effect of aspirin can be internal bleeding. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Physical Condition A head-to-toe assessment by the nurse on admission may uncover physical problems that can affect normal nutrition or put the person at risk for becoming malnourished. Often people with dementia are unable to chew, or chewing is painful due to tooth abscesses that are not assessed. Meat may be avoided because it is painful to chew. Confused people are often unable to communicate discomfort verbally and may simply fail to eat. Are elderly patients eating foods that are extremely sweet or salty to compensate for loss of taste buds? Are they not eating at all because all food tastes bland to them? As people age, taste acuity diminishes, particularly those taste buds responsible for detecting sweet and salty tastes. People with Alzheimer’s disease or other chronic illnesses who live alone may neglect to feed themselves properly. They may forget not only what they ate, but whether they ate. They may be unable to meet their nutritional needs adequately because they can no longer drive themselves to the grocery store, or they may not be able to prepare foods due to conditions such as arthritis. As people become increasingly dependent on others or on mechanical aides, they may become less inclined to eat. Chronic diseases like arthritis that cause pain with muscle motion may make people less able to feed themselves and reluctant to ask for help. Older people as a rule will have a lower metabolism due to decreased physical activity, and their caloric requirements will be less than that for younger or even middle-aged adults. Older and younger people confined to beds or wheelchairs are more prone to kidney stones; increased fluid intake may help prevent this. What is the status of the patient’s circulatory system? Fluids may need to be limited if the person has or is at risk for congestive heart failure. What is the status of the patient’s urinary system? Impaired renal (kidney) function, especially in older adults, compromises the ability to process protein. What is the status of the patient’s gastrointestinal tract, especially with regard to peristalsis? Is the patient drinking enough fluids and eating foods high in fiber content to ensure adequate elimination? This is especially important for older adults. Does the patient take over-the-counter laxatives? People with gastrointestinal conditions such as ulcerative colitis will require low-roughage foods that cause minimal irritation to the lining of the intestines. Celiac disease, related to a sensitivity to gluten found in rye, wheat, or barley, can cause children to be undernourished though they may appear to be eating adequate amounts of food. Nurses should be alert to symptoms related to delayed growth and should observe for or question parents about any skin rashes (blistering, usually located on the elbows, knees, and buttocks). Symptoms may also include digestive problems related to the small intestine that can manifest in nausea, stomach pain, and mouth sores. Anemia can also develop related to this disease. Signs that too few nutrients are being absorbed to meet developmental needs may include paleness, thin extremities, and a protuberant stomach; Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute all of these symptoms are marked in developing countries where children are malnourished. Celiac disease in adults can also occur; an adult with celiac disease might complain of feeling tired and depressed or may manifest irritability. Blood tests might reveal anemia, and an assessment of bone density could indicate osteoporosis. Children with undiagnosed type-I diabetes may exhibit weight loss. Children, especially ages six to twelve, may also have intestinal bowel disorder (IBD), which causes the bowel wall to become inflamed. Ulcers can develop on the intestinal lining and the intestines can narrow. The two primary diseases classified as IBD are Crohn’s disease and ulcerative colitis. A primary symptom is failure to grow with marked weight loss. Puberty may be delayed. If undetected, IBD can result in overall stunted growth as an adult. Ulcerative colitis and Crohn’s disease are two major diseases classified as IBD. Crohn’s disease (CD) usually develops between ages fifteen and forty and is more prevalent in people of Jewish heritage. The innermost layer of the digestive tract, particularly in the small intestine, develops inflamed patchy areas and ulcers. Nurses should be alert to symptoms of mild to severe diarrhea (with or without blood), abdominal pain and bloating. Weight loss, poor appetite and fatigue may be present as well as nausea and vomiting. An assessment might include stool samples to test for occult blood or any infection and blood tests for anemia and white blood cell count. An elevated WBC could indicate infection. Serious Medical Conditions and Nutrition Two treatments for malignancies, chemotherapy and radiation, can compromise and debilitate the body’s ability to salivate, swallow, digest, or absorb nutrients, depending on the part of the body treated. These treatments often cause nausea, vomiting, and anorexia. Diseases that affect the gastrointestinal tract can cause problems at any stage of the metabolic cycle, from ingestion to elimination. Severe back pain after eating a meal high in fat content can indicate gallbladder disease (contractions of the gallbladder) and a related inability to absorb fats. Gastric secretions diminish with age, compromising digestion. Older people may also experience a very dry mouth related to decreased production of saliva, adversely affecting nutrition. Chronic conditions such as arthritis can affect a person’s mobility and ability to purchase and prepare their own food. Preparing and eating food can be difficult with severe arthritis, including activities like opening cans and boxes. Cultural Practices and Religious Beliefs What role do culture and religion play in patients’ nutrition? Are there any religious practices, preferences, restrictions, or taboos that might influence their diet in positive or negative ways that affect essential nutrients? Patients’ maintenance of religious ties and a sense of their ethnicity, for example, is an important value for many older adults and younger people who are recent immigrants (e.g., college students). A diet with liberal amounts of meat and potatoes might suit someone whose ethnic origins are from Eastern Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Pork is traditionally considered a taboo food for Jews and 7th Day Adventists based on Biblical injunctions found in the Old Testament books of Leviticus and Deuteronomy. Some people observe certain days for special feasting or. meat is generally treated by salting. High-protein foods are generally more expensive. Many Hindus are vegetarian. milk products and meat products cannot be eaten at the same time or at the same meal. According to kosher laws. Only fish with fins and scales should be eaten. On certain religious holy days like the Passover. kosher meats are high in sodium content.0 . how meat is slaughtered).Unlawful to replicate or distribute Europe. fasting. Socioeconomic and Psychological Influences on Nutrition Socioeconomic factors can influence the choice and availability of foods. and some more conservative Christian denominations. thus. These preferences may also impact nutrition. and what foods and beverages can be eaten in combination with what other foods and beverages. NXP 070106 v1. Factors can include the person’s weekly income and how much he or she chooses to budget for food. For example. The cow is considered sacred in Hindu society and is generally considered a taboo food for all Hindus. meat from any animal with a cloven (split) hoof or an animal that does not chew its cud. Copyright © 2008. tea. Kosher law also prohibits the eating of animal blood. only unleavened bread can be eaten. either absolute or partial. however. e. 7th Day Adventists are one group that generally adheres to this belief. often in accordance with a belief system related to a specific religion or culture/ethnicity. a belief that a vegetarian diet is generally a more healthful diet. even those who might eat other types of meat or fish. alternatively. and any other beverages containing caffeine... and people on fixed or low incomes need to make sure they are getting enough protein from less expensive sources. Are these foods readily available and affordable? Some people may also consider particular foods and beverages taboo. for example. Cow’s milk and milk products are generally not considered taboo. a nurse should assess these preferences and not make assumptions.g. however. they would constitute a complete protein. (Note: If rice and starchy vegetables are eaten at the same meal. Mormonism (Church of Jesus Christ of the Latter-day Saints). but if eaten at different meals. they would not. called kosher laws. Strict rules and regulations may govern what is eaten and when. Increasingly people are choosing a vegetarian lifestyle related to personal beliefs about the way animals are treated or health-related issues. Orthodox and Conservative Jews in particular might adhere to all these dietary laws. These laws. Inc.g.) When people are ill. but someone from an Asian country like China or Korea might prefer a diet rich in rice and vegetables. Alcohol is a taboo beverage according to the traditions of Islam. they may respond more favorably to foods that were part of their cultural and religious patterns. The College Network. based on a belief that these foods can inflame baser emotions. how the food is prepared (e. Food with very strong flavors like onions and garlic may be taboo for some who practice Buddhism or Hinduism. Mormons also may abstain from coffee. indicate that certain foods are taboo. TV and magazine advertisements are a powerful influence on food habits. anxiety.g. and condition of the body. Environment and Nutrition What role does the person’s environment play in his or her nutritional health? From either what the person tells you or what you are able to observe on a home visit. Adolescent females may suffer from bulimia. Loneliness has been implicated in both overeating (especially with younger adults and teenagers) and underconsumption of calories (with older adults). shape. NXP 070106 v1. An adolescent might experience peer pressure to eat or drink a certain type of food that might be injurious to health if eaten or drunk in excess (e. These assessments are measurements related to the size. Physiologically. But. Inc. Other important categories of diagnostic information include anthropometric data and laboratory data.” include various assessments that can be made by the nurse that are noninvasive in nature. depending on the person’s coping patterns. and eating and cooking facilities? Is the eating environment conducive to good nutrition? If not. food storage and refrigeration. what do you know about the means of food procurement. the focus of the ads is on high-fat. for example. in an attempt to stay slim if they are influenced by the pressure of peers and media messages that slender is better. A person with minimal social supports may be malnourished. certain social and psychological factors may influence nutrition. it is also vital for the nurse to consider diagnostic data. specifically those areas of the body that reflect a person’s nutritional status. could be recorded by the patient and then evaluated by the nurse.Unlawful to replicate or distribute At various stages of the life cycle. and depression can contribute to both malnutrition and overnutrition. a cycle of bingeing and purging. Sometimes this influence is positive if it encourages people to exercise and eat nutritious food that is lower in fat content. Loneliness. high-calorie fast food. Diagnostic information for a basic nutritional assessment includes the primary factors that influence a patient’s nutritional state and any other data that can be objectively measured and observed by the nurse. Copyright © 2008.0 . depression and anxiety are believed to trigger or inhibit the release of hormones that regulate digestive juices or digestive secretions that enable enzymes to be released in the process of metabolism. who can use the MyPyramid guidelines to discern whether the patient enjoys adequate nutrition. beer). The College Network. Anthropometric Data Anthropometric data. A twenty-four-hour food diary over the course of several days. how could it be modified? Assessment Data When assessing a patient’s nutritional health. A person’s mental state can also affect his or her nutritional status. more often. from the root words anthropos meaning “man” and morphe meaning “shape.. Normal skin fold values on average are approximately twelve millimeters for men and eighteen millimeters for women. in the case of a bed-bound patient. MAC is a measurement of muscle wasting. such as cancer. If the person is right-handed. NXP 070106 v1. The skin on the back of the upper arm is grasped at midpoint between the nurse’s thumb and forefingers and calipers are then placed one centimeter below the nurse’s grasp to measure the skin fold thickness in millimeters. Inc. intentional weight loss related to attendance at a weight loss clinic. for example. and the condition of the hair and nails. type. If the nurse pinches and elevates the patient’s skin between fingers (usually over the abdomen). Dry hair and split nails might also indicate dehydration.0 . The midarm circumference (MAC) can also be measured by the nurse using a tape measure at the midpoint of the upper arm that is hanging relaxed by the patient’s side. Normal elastic skin in a well-hydrated person will return to normal immediately when released. or.Unlawful to replicate or distribute Fundamentals of Nursing 185 Anthropometric Measurements A head-to-toe assessment involves the following general observations that can reflect nutritional status: the condition of the skin. Skin turgor refers to the elasticity of the skin. it will form a peak. specifically skin turgor. Any accompanying illness or disability should be noted to better determine what is considered normal weight for the individual. It should also be noted that weight is a primary defining characteristic of fluid overload related to interventions like total parenteral nutrition. preferably at the same time of day and with similar articles of clothing on. In a dehydrated person. Height and weight are the most common anthropometric measures. Subsequent weights after the baseline weight has been determined should be measured on the same scale. Nurses should obtain accurate measurements on admission of each patient and not simply rely on patients’ subjective appraisal of their own height and weight. This is the most common measure of the fat content of subcutaneous tissues. One important objective measurement of body fat includes a measurement of the triceps skin fold thickness (TSF). The admission data can be compared to normal weight and height charts for different age groups. the left arm is generally measured. Amount. the skin may remain peaked and wrinkled. since false readings related to increased musculature in the dominant arm can occur. with the patient’s arm across his or her chest. Assessment of body fat is a primary category for noninvasive assessment. Abdominal skin fold measurements over abdominal muscles may also be done and are often used in fitness centers for determining lean muscle mass. This is especially evident in the elderly. Weight loss that has not been intentional may indicate an underlying and undiagnosed disease process. and level of physical activity will also affect weight. The College Network. Any weight changes should be explored as to their rationale. Copyright © 2008. which generally includes the number of red blood cells. Complete Blood Count A complete blood count (CBC) will indicate levels of circulating red blood cells (RBCs). Nutritionally. A hematocrit (Hct) is the volume of red blood cells compared to the volume of the whole blood.” More specifically. Hematocrits are higher at higher altitudes due to low oxygen tension. A white blood cell count (WBC) count is the number of white blood cells in a volume of blood. This may also be referred to as a total lymphocyte count (TLC). The word anemia literally means “without blood. These are ranges for persons who live at sea level. One blood test that is included in the complete blood count is a hemoglobin level. the number of white blood cells. low hemoglobin levels can be related to iron-deficiency anemia and/or fluid retention. Inc. The range for children varies with age but it is generally between 35 to 49 percent with newborns ranging from 49 to 54 percent. and creatinine and blood urea nitrogen (BUN) levels. The most common laboratory values based on blood or urine samples are part of the complete blood count (CBC). or vitamin B6. RBCs can be depleted in cases of nutritional anemia. Additional laboratory values related to nutrition are triglyceride counts and blood cholesterol. Hemoglobin (Hb) is the protein molecule in RBCs that carries oxygen and gives blood its color. Low numbers of RBCs can indicate malnutrition with related deficiencies of folate.0 . vitamin B12. The range is slightly less for children. NXP 070106 v1. The College Network. RBC range varies with altitude and gender. or protein-calorie malnutrition (PCM). The average range of hematocrit values for women is 37 to 47 percent and. The normal range for a lymphocyte count is between 4. A lowered lymphocyte count is reflective of a depressed immune system. hemoglobin and hematocrit values.2 to 5.800 cells per cubic millimeter (cmm). which may result from conditions like diarrhea as well as inadequate fluid intake.4 million cells/mcL. for men. a finding similar in high hemoglobin levels. Normal range for males at sea level is 4. The nurse’s primary role is to know which laboratory tests are most useful to identify any nutritional deficiencies or conditions of risk and what the normal ranges are for these values. Normal hemoglobin values for women range from 12 to 16 g/100 ml and from 14 to 18 g/100 ml in men. and high hemoglobin levels can be related to dehydration. 40 to 54 percent. serum albumin and serum transferrin values. High hematocrits may indicate dehydration. it is a measure of cell volume and iron status. the blood suffers from a deficit of the mineral iron. when anemia is present. various types of anemia. and mean corpuscular volume. Low hematocrits can indicate the presence of excess fluid.7 to 6. A Copyright © 2008.1 million cells/mcL. so it is important to assess the causative factors for the anemia and not assume it is nutritionally related. Hemoglobin levels can also be lower if there has been blood loss through some type of external or internal trauma or chronic disease process. Normal range for females is 4.Unlawful to replicate or distribute Laboratory Data Laboratory values are an example of objective data that should be used in making both baseline and ongoing nutritional assessments in conjunction with other assessments.300 and 10. high range is from 200 to 499 mg/dL. malnutrition.g. High-fat diets and uncontrolled diabetes can contribute to elevations in cholesterol. and over-hydration. A person is said to be in negative nitrogen balance if nitrogen excretion exceeds nitrogen intake in the form of protein. General malnutrition and malabsorption syndromes like Crohn’s disease. Normal triglyceride value should be less than 150 mg/dL (milligrams per deciliter). Copyright © 2008. Normal range is 60 to 170 mcg/dl (micrograms per deciliter). and Whipple’s disease may also cause low levels of albumin. and they are also more susceptible to infections. familial hyperlipidemia (increased lipids/fat in the blood).. it may be a better indicator of protein-calorie depletion than serum albumin. Inc. NXP 070106 v1. circulates through the blood and is excreted in urine after traveling through the kidneys. a measure of iron transport. Normal range for BUN is 7 to 20 mg/dl. Low serum cholesterol could be an indicator of malnutrition or malabsorption.g. malnutrition. High triglyceride values may be due to a diet low in protein and high in carbohydrates or to poorly controlled diabetes.4 g/dL (grams per deciliter). Persons with malignancies or other depressed immune disorders (e. Normal range is 3. Urea. and very high range is 500 mg/dL or above.Unlawful to replicate or distribute depressed immune system can be related to inadequate intake of essential nutrients. Blood Urea Nitrogen and Creatinine Low blood urea nitrogen (BUN) levels can indicate insufficient protein intake.0 . sprue. formed as a result of the metabolism of amino acids. AIDS) may exhibit low lymphocyte counts related to inadequate protein intake or protein metabolism.4 to 5. Borderline high range is from 150 to 199 mg/dL. a twenty-four-hour urine collection may be ordered to determine a person’s balance of nitrogen. Higher than normal levels related to nutrition include deficiencies of vitamin B12 and vitamin B6. The College Network. Serum Readings Serum albumin readings measure serum protein levels in the blood.. e. Pregnancy also can lower this value. Abnormally low serum transferrin (sometimes called serum iron) levels can also reflect iron-deficiency anemia related to inadequate dietary iron and/or poor absorption of iron. In addition to this blood test. Elevated triglyceride counts and blood or serum cholesterol levels have been associated with heart disease and susceptibility to stroke and heart attack. Serum transferrin. Low triglyceride levels (below normal) may relate to malabsorption syndrome (inadequate absorption of nutrients from the intestinal tract). as can heredity. can also indicate insufficient dietary protein intake when low. and high BUN levels can indicate that too much protein has been ingested. Pregnant women will normally have lower albumin levels. and a very low-fat diet. Too much protein adversely affects kidney function and can contribute to kidney diseases and even kidney failure. Borderline high levels are considered to be in the range of 200 to 239 mg/dL and high risk is 240 mg/dL and over. specifically protein and PCM. Normal serum cholesterol values should be under 200 mg/dL. Low levels can indicate protein depletion. generally of a long-term nature. related to PCM. 0 . Age can also influence values. Values in this chapter are based on information from the National Institutes of Health. Inc. Diets high in meat can also lower values. Note: Laboratory value ranges may differ slightly from laboratory to laboratory. NXP 070106 v1. The College Network.Unlawful to replicate or distribute 188 Fundamentals of Nursing Urinary creatinine excretion can also be measured in a twenty-four-hour urine collection. which results in decreased excretion of creatinine. This value is related to skeletal muscle mass that atrophies or shrinks if a patient is severely malnourished. Normal values can range from 500 mg/day to 2000 mg/day. Copyright © 2008. Unlawful to replicate or distribute Chapter 11: Interventions for Promoting, Maintaining, and Restoring Nutritional Health Objectives Upon completion of this chapter, you should be able to do the following: 1. Explain the impact of proper dental care, positioning and eating atmosphere on good nutrition. 2. Describe enteral nutrition and the various types of tubes used for enteral feeding. 3. Explain the three most common methods for administering enteral tube feedings. 4. Discuss important nursing techniques for correct nasogastric tube placement. 5. Identify nursing strategies for the safe administration of bolus intermittent feedings. 6. Explain the nursing techniques used to check for proper feeding tube placement and identify objective findings for each technique that indicate it is safe to administer the feeding. 7. Identify eight side effects of tube feedings and describe the appropriate nursing assessments and nursing actions for each. 8. Define total parenteral nutrition (TPN) and explain how it is delivered. 9. Define lipid emulsions and total nutrient admixtures, and give the rationales for their use. 10. Describe the side effects of hypertonic solutions, the resulting symptoms and required nursing actions. 11. List the side effects of lipid emulsions and identify the nursing assessment and nursing action appropriate for these problems. 12. Identify two ethical and legal issues that are appropriate to consider before initiating enteral feedings. Key Terms bolus intermittent feedings continuous feedings cyclic feedings dumping syndrome enteral/tube feeding enteral nutrition (EN) gastrostomy tubes hyperalimentation hyperosmotic reactions jejunostomy tubes lipid/fat emulsions nasoenteric/nasointestinal tubes nasogastric tube percutaneous endoscopic gastrostomy (PEG) tube percutaneous endoscopic jejunostomy (PEJ) tube stoma total nutrient admixture (three-in-one) total parenteral nutrition (TPN) Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Introduction As we have seen, a patient’s nutritional status can be compromised by numerous factors. An important area of nursing knowledge related to the promotion, maintenance, and restoration of a compromised patient’s nutritional health is the safe use of artificial feeding techniques. This chapter investigates nutritional interventions that are appropriate for the hospital, nursing home, or home care setting. We begin by looking at very basic physiological and environmental strategies that can enhance good nutrition— specifically oral care, proper patient positioning, and a pleasant eating environment. Our discussion then turns to nutritional interventions used when oral nutrition is not possible. We define enteral nutrition (EN) and describe the different substitute nutritional interventions that can be used as either temporary or permanent feeding methods. We also discuss the different ways enteral feedings can be administered and the critical nursing skills needed to correctly place a nasogastric tube. In addition, we describe the appropriate technique for the administration of bolus intermittent feedings and the responsibility of the nurse to be certain a feeding tube is in the correct location before any tube feeding is administered. Finally, we explore the side effects of tube feedings, lipid emulsions, and total nutrient admixtures. We also discuss the side effects of hypertonic solutions. The chapter then concludes with a discussion of the ethical and legal issues surrounding enteral feedings. Physiological and Environmental Considerations A number of physiological and environmental variables can enhance good nutrition when health and the ability to exercise self-care are compromised. These include proper dental care, positioning, and eating atmosphere. Dental Care Oral care is especially important for people in hospitals and nursing homes who are unable to carry out activities of daily living independently, including brushing teeth and cleaning dentures. Though mouth care is generally part of bedtime care for all ages, giving mouth care prior to eating can perk up taste buds and improve appetite; however, it is generally neglected. Increased activity can also enhance nutritional intake since it increases the metabolic rate. Positioning Patients Proper positioning of patients is important to good nutrition and to prevent complications such as food aspiration. If the patient is in bed, the head should be elevated to approximate a sitting position (if possible) both during and following the meal, for at least half an hour. Patients should be sitting in a chair for meals whenever possible. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Eating Atmosphere Nurses should try to reduce patients’ stress and create and maintain a pleasant environment, all of which are crucial to patients’ nutrition. In nursing home, hospital, and home care settings, equipment like a bedside commode and its associated odors should be considered potential hindrances to good nutrition. Quiet atmospheres generally enhance nutrition. This is true for children who are easily distracted at mealtime and for older adults who have dementia. Enteral Nutrition Even with attention to basic nursing measures, there may be times when oral nutrition is not possible, such as when people can no longer independently feed themselves due to age or disability or they are not able to receive oral nutrition from others. Special nutritional methods may also be needed because of acute or chronic illness that interferes with the body’s normal means of ingesting or digesting foods. Enteral nutrition (EN) includes any form of nutrition that involves nutrients that are directly digested and absorbed through the gastrointestinal tract. The word enteral means “intestine.” The normal access route for foods and fluids to be initially ingested is the oral route, but various acute and chronic disease processes and other conditions, like facial trauma or other head and neck injuries following an accident, can make it difficult for people to chew or swallow. Several types of catheters or tubes inserted through the nose or the mouth and then into the stomach or intestine (or inserted directly into the stomach or the small intestine) can serve either as a temporary or permanent alternative to the traditional oral route of ingestion. These substitute interventions include nasogastric, nasoenteric or nasointestinal, and gastrostomy and jejunostomy tubes. The supplementary or substitutional nutritional treatment associated with enteral nutrition is called a tube feeding or enteral feeding. Feeding Tubes The tube, or enteral, feedings themselves are liquid solutions mixed in plastic bags in the hospital pharmacy or dietary department or solutions in cans that can be poured into bags and hung on a special device next to the patient’s bed or chair. They contain all the essential nutrients, including carbohydrates, protein, fat, water, vitamins, and minerals. Percentages of each nutrient will vary based on the person’s age and nutritional need. Specific orders will be written by the physician indicating the type and amount of feeding. Nasogastric Tubes The nasogastric route for enteral feeding involves the insertion of a flexible catheter or nasogastric tube through one nostril, down the back of the throat into the nasopharynx, and then into the stomach. This is a normal route for adults. In both premature and older infants, the tubes may be inserted through the mouth and pharynx. Nasogastric tubes are generally used to meet short-term nutritional needs. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute 192 Fundamentals of Nursing Nasoenteric or Nasointestinal Tubes Nasoenteric or nasointestinal tubes are inserted through one nostril and empty into the small intestine. There is less risk of aspiration of stomach contents with these longer tubes since the tubes do not terminate in the stomach. Gastrostomy Tubes Gastrostomy tubes are very common methods for the administration of nutrients enterally, especially in nursing home settings and any time a person requires long-term substitutionary or supplemental nutrition. In addition to regular gastrostomy tubes, a special and commonly used type of gastrostomy tube is the percutaneous endoscopic gastrostomy (PEG) tube. For both types of devices, an incision is made through the skin over the upper left quadrant of the abdomen, then a catheter is inserted through the abdominal opening (also called a stoma) into the stomach. Gastrostomy tubes may be removed and reinserted by the nurse between feedings after the surgical site is well healed. An inflatable balloon keeps the PEG tube in place between feedings in much the same way as the balloon on a urinary catheter keeps the catheter in the bladder. In many settings, it is the nurse’s responsibility to insert a new PEG tube if the old tube falls out; it is important to do so as soon as possible, because the opening into the stomach will quickly seal over. Jejunostomy Tubes Jejunostomy tubes are similar in theory to gastrostomy tubes. These tubes or catheters are inserted through the skin directly into the jejunum. A common type of jejunostomy tube is the percutaneous endoscopic (PEJ) jejunostomy tube. Administering Feedings Through Tubes Enteral feedings can be administered several ways. The following are the three most common methods: 1. Bolus intermittent feedings: The word bolus means “small, round lump or mass.” Bolus intermittent feedings are given using a syringe directly through a tube into the stomach. Continuous feedings: Continuous feedings usually consist of a hanging plastic bag filled with the enteral feeding solution that the nurse attaches to a feeding pump or infusion pump that is plugged into an electrical outlet. The pump, when calibrated, delivers the patient’s feeding at a prescribed rate over a twentyfour-hour period. Cyclic feedings: Cyclic feedings are also administered using an infusion pump, usually at night. The patient might be able to ingest and swallow foods and fluids by the oral route during the day, but the oral feedings themselves are not sufficient to provide all the daily nutrient requirements. Cyclic feedings are considered supplemental feedings. 2. 3. Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Feeding Tube Placement The nurse’s role may involve placement of the feeding tube. Nasogastric, or NG, tubes are the most common tubes nurses will independently insert at the bedside. Procedures for tube insertions may vary depending on the health care facility, and procedure manuals should be available. The nurse should check for tube placement prior to tube feedings and prior to medication administration through the tube. The following are tips for nasogastric tube placement: • • • If not premeasured, measure the length of the tube from the tip of the nose, to the earlobe, and to the xiphoid process at the tip of the sternum. Mark the tube with tape prior to insertion. Lubricate the tube prior to insertion with water or a water-based lubricant; oilbased lubricants like petroleum jelly can adversely affect the lungs if the tube is accidentally inserted into the lungs. Place adult patients in a high-Fowler’s position (90° angle) for tube placement. Check nares (nostrils) prior to tube placement for any deformities like a deviated septum. When placing the tube, ask the patient to hyperextend his or her neck as you advance the tube through the nose and back toward the ear into the nasopharynx. Once the tube enters the back of the throat, the client should tilt his or her head forward, drink sips of water, and swallow. Never force a tube; if resistance is met, evaluate the problem (e.g., coiling in the back of the throat). • The following are tips for administration of bolus intermittent feedings: • • • Correctly position the patient to prevent aspiration and ensure good flow of the feeding solution, e.g., a high-Fowler’s position (a 90° angle) or lying on the right side with the head elevated to at least a 30° angle. Assess tube placement as noted in “feeding tube checks” section. Check for any residual (remaining) feeding using a syringe to aspirate gastric contents. A general rule is if more than one hundred milliliters of undigested tube feeding is withdrawn, the next feeding may be held (or a smaller amount of feeding given, depending on the physician’s orders and agency policy). Always reinsert any undigested tube feeding back into the stomach to maintain electrolyte balance. When giving tube feeding by syringe as opposed to a continuous drip, let feeding flow into the tube by gravity instead of using a plunger. The syringe can be raised or lowered to adjust rate. If the tubing is clogged, a small amount of pressure with a syringe and tap water can be used to ensure patency. Coca-Cola is sometimes used to clear feeding tubes, depending on agency policy. The patient should remain in a Fowler’s or an elevated, right-lateral position for at least thirty minutes after the feeding to prevent potential aspiration into the lungs if the patient vomits. • • Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 Unlawful to replicate or distribute Feeding Tube Checks Tube placement should be initially checked by radiography or X ray prior to any feeding being instituted. This is the only reliable method for ensuring a tube is correctly positioned. The American Association of Critical Care Nurses recommends this type of confirmation prior to administering feedings or medications for critically ill patients, but it should apply to any patient. There is a risk for tracheobronchial aspiration of gastric contents, a serious complication, if the tube is not correctly placed or does not remain in place for each feeding. Once a tube is in place, and prior to feedings if given on an intermittent basis, the nurse should attempt to verify that the tube is in the stomach or the intestine by doing the following: • Observe for signs of any displacement of the tube by observing the external length; there should be a note made on the chart about the original length of the tube. Research studies of critically ill patients who were tube fed have indicated external tube length increases of up to 32 cm. A nasal tube might have moved from the stomach into the esophagus, for example, to cause this. Aspirate approximately 20 cc of stomach or intestinal contents with a syringe and check color and pH. Gastric contents are usually green or clear and colorless with off-white or tan mucus shreds; intestinal contents are a bright goldenrod or brownish darker green; fluid is usually thicker and more translucent than gastric fluid. The pH of normal gastric juice ranges between 4 and 5; tube feedings, antacids, and some other medications can increase this range to 6. Intestinal/small bowel contents normally have a pH of 6 or 7. Respiratory contents are 6 or greater and more alkaline; contents can vary in color depending on what part of the respiratory tract it is in, from straw-colored to blood-tinged if the tube has perforated the pleura. For aspirations with pH greater than 6, notify the physician, who may order X rays to check tube placement. A tube initially placed in the small bowel could become displaced to the stomach, resulting in a lower pH; this should also be reported. The nurse should know where the tube originates in order to better evaluate pH results. Note: Medications can alter pH. Wait one hour after medications are given by tube to check pH for feedings; also check tube placement prior to giving medications. It is not always possible to tell when tubes are misplaced from patient symptoms (e.g., coughing). pH tests are not often done with patients on continual feedings as pH levels will register nearly neutral. Accurate pH measurement requires that feedings be stopped one hour or more prior to pH testing. Auscultate with a stethoscope over the left upper quadrant of the stomach or epigastric area while at the same time quickly and forcefully inserting 5 to10 cc of air with a syringe into the tip of the feeding tube. Signs that the tube is in the stomach rather than the lungs should be bubbling, gurgling, or whooshing sounds. This method to determine tube placement is not as safe or accurate as testing stomach or intestinal contents for pH. According to more recent research • • Copyright © 2008, The College Network, Inc. NXP 070106 v1.0 There is a sudden movement of body fluids from the circulatory system across intestinal cell membranes in an attempt to compensate for the sudden dumping of highly concentrated enteral solution into the jejunum. NXP 070106 v1. Inc. pallor. and the nurse should be aware of those effects and their accompanying signs and symptoms. A nurse’s knowledge of reasons that side effects occur is often a key to prevention. Side Effects of Tube Feedings Serious side effects can result from tube feeding administration. and sometimes fainting or loss of consciousness immediately following a tube feeding. and how frequently this information should be documented. nausea and vomiting. Information should also be included on policies for checking placement and administering the feedings.0 . In each case. headache.Unlawful to replicate or distribute and supporting evidence summarized by the AACN. Older adults may be particularly susceptible to too-rapid infusion. immediate nursing action can be taken if symptoms occur. This information on tube feeding placement and evaluation is based on the guidelines and current health care research of the American Association of Critical Care Nurses. procedures. cramping and diarrhea. Copyright © 2008. • Hyperglycemia Hyperglycemia may occur if the glucose concentration in the enteral feeding is too high or the tube feeding is given at too rapid a rate. methods for marking feeding tubes. Dumping Syndrome Dumping syndrome can occur in patients with jejunostomies. though it is still used. • Nursing assessment: Monitor glucose and acetone levels in urine at least once per shift. Review your agency’s policy. This should include information about when and how initial X rays are obtained. auscultation is the most unreliable method for determining placement. Symptoms may include nausea. The following is a summary of their most important guidelines for practice: • • Make sure an X ray is done/has been done to visualize a newly inserted tube prior to the first administration of any tube feeding solution or medication. The College Network. and standards for care. generalized weakness. and dehydration. Nursing action: Immediately stop tube feeding and treat symptoms. heart palpitations and tachycardia. • Nursing assessment: Symptoms can include diaphoresis (sweating). how to document exit sites. High protein content in enteral feedings combined with dehydration may also prevent a patient’s kidneys from excreting nitrogen wastes. Insulin may be ordered to facilitate the metabolism of glucose. • • Nursing assessment: Watch for cold and clammy skin. Serum BUN and sodium levels may increase. including misplacement of the tube and failure to elevate the head of the bed during and after feedings. The College Network. Nursing action: Extra water may be ordered between feedings. which can happen if a feeding tubes becomes clogged. were four times more likely to develop pneumonia (Metheny. Shaking chills and a fever twenty-four hours after an episode of aspiration can occur. lightheadedness or dizziness. Tube placement should always be checked prior to feedings. even in small amounts. headache (occipital region). including due to a clogged feeding tube. • • Nursing assessment: Monitor lab values. NXP 070106 v1. Head should be elevated at least at a 30° angle Copyright © 2008.0 . and tachycardia. Inc. Following discontinuation of tube feedings. confusion. patients who aspirated gastric contents more frequently. The high glucose content of the tube feeding stimulates the release of insulin from the pancreas. Dehydration Dehydration can occur if enteral feeding is too highly concentrated. Infusion rates should be accurately monitored. Nursing action: Prevention is the key. Hypoglycemia Hypoglycemia can occur if a tube feeding is suddenly discontinued for any reason. Hematocrit and the specific gravity of urine can be high due to dehydration. Preventing and lowering the risk for aspiration is a vital part of nursing care. Aspiration of tube feeding products into the lungs can occur for a number of reasons. solutions of glucose and water (5 or 10 percent) may be ordered for a twentyfour-hour period to stabilize blood sugar levels.Unlawful to replicate or distribute • Nursing action: Never increase the rate of a tube feeding to make up for lost time. Nursing action: If a tube feeding is to be discontinued. not suddenly. the rate of the tubefeeding infusion is usually decreased gradually. • • Nursing assessment: The patient may be coughing. Aspiration One research study indicated that 30 of 40 critically ill patients who were mechanically ventilated and also received gastric feedings had at least one microaspiration (defined by the presence of pepsin in tracheal secretions) during the early course of their tube feedings. Sometimes people on continuous tube feedings are also on routine insulin injections. 2006). In a similar study with a larger sample. and a sudden discontinuation of the feeding can result in high levels of circulating insulin. Constipation may also be a problem since tube feedings are low in roughage and bulk. Examples of chronic diseases that might indicate a need for TPN are Crohn’s disease or severe ulcerative colitis. Identify any food allergies on admission (e. • • Nursing assessment: Take a baseline measurement of the abdomen at the level of the umbilicus and subsequent measurements prior to feedings if the abdomen appears distended. Glucose supplies the greatest percentage of nutrients. Bowel Disturbances Bowel disturbances can occur related to the liquid and highly concentrated nature of the tube-feeding solution.Unlawful to replicate or distribute (unless contraindicated) during the feeding and for thirty minutes following the feeding. Abdominal Distention Abdominal distention can occur if the stomach is not emptying between tube feedings.0 . Allergic Reactions Allergic reactions can occur with tube feedings in the same way they can occur with oral feedings. Parenteral Nutrition Parenteral nutrition is an intravenous method of nutrition. Copyright © 2008. Check the contents of a tube feeding to make sure it is the correct one. itching. hypertonic intravenous (IV) solution that contains a variety of nutrients in different amounts. Another term often associated with TPN is hyperalimentation. or difficulty breathing.g. eggs and milk) prior to feeding. depending on the person’s daily nutritional needs. and electrolytes. Note that a liquid stool may indicate constipation. NXP 070106 v1. lipids. TPN solutions include protein (amino acids). TPN is indicated when digestion and absorption of nutrients is a problem and there is a need to bypass the gastrointestinal system. vitamins and minerals. Be prepared to administer antihistamines. Inc. glucose (dextrose). • • Nursing assessment: Diarrhea can occur. The College Network. Total parenteral nutrition (TPN) involves administration of a highly concentrated. adjustments to the concentration of the feeding formula may be needed. abdominal measurements can be taken and compared to baseline measurements. Nursing action: If distention is suspected. water.. Nursing action: Stop tube feeding and notify the physician. Nursing action: Notify the physician. • • Nursing assessment: The patient may experience hives. not diarrhea. thus. They can be given in addition to TPN through a separate intravenous line or through the same site as the TPN using Y-connector tubing. TPN is done in the patient’s home. Side Effects of Hypertonic Solutions Most solutions involved in parenteral feeding are highly concentrated and therefore hypertonic. teaching a patient and family members how to administer TPN is an important nursing task prior to the patient’s discharge from the hospital. and urinary systems as extracellular fluid increases above the body’s ability to adjust to the extra fluid volume. Symptoms of overload primarily affect the respiratory.g. Fluid overload can precipitate pulmonary edema and congestive heart failure. conditions affecting the intestines. shortness of breath.0 . and treat the symptoms. Three-inone solutions combine amino acids. and other nutrients into a single admixture. NXP 070106 v1. and some types of malignancies. however. cardiac. More and more frequently. Listen and watch for the following: confusion. so the nurse must be alert. Lipid Emulsions Lipid or fat emulsions are another form of parenteral nutrition. severe trauma or burns. notify the physician immediately. dextrose.Unlawful to replicate or distribute TPN infusion occurs through either an indwelling peripheral or central venous catheter that feeds into the superior vena cava by means of an infusion pump to ensure accurate regulation of flow. Copyright © 2008. if infused too rapidly. Assess for a weak and rapid pulse (tachycardia). Sometimes fat emulsions are also added to the TPN solution. Large veins rather than small veins are used to accommodate the solution. Total Nutrient Admixture A total nutrient admixture (three-in-one) is another type of TPN solution. concentration levels of dextrose will be less for infants and children. Conditions that indicate TPN include very severe malnutrition. Hypertonic solutions. People of all ages can receive TPN. Fluid Overload Fluid overload is a complication that can occur with any IV solution (not just hypertonic solutions) if the flow rate is too rapid. IV fat emulsions. The nurse might also monitor central venous pressure (CVP). Inc. and decreased urinary output. febrile conditions. pitting edema. Stop infusion if symptoms appear. which is highly concentrated compared to a traditional intravenous solution like normal saline or a blood transfusion. The theoretical rationale for a lipid emulsion is a patient’s need for extra calories and supplemental fatty acids. crackles in the lungs).. hypotension or hypertension. can cause serious side effects. meaning they have higher osmotic pressure than normal body fluids. and adventitious breath sounds (e. Preventive measures include monitoring and maintaining the flow rate. The College Network. the glucose in the solution has been stimulating the pancreas to secrete more insulin naturally to maintain blood levels.. Monitor glucose and acetone levels in urine during each shift. NXP 070106 v1. While the patient is on TPN. Insulin may also have been given by injection.Unlawful to replicate or distribute Hyperglycemia Hyperglycemia can occur during the course of infusion with hypertonic solution because of the high glucose concentration of the solution. • Hyperosmotic Reactions Hyperosmotic reactions related to imbalanced osmotic rates can also result from toorapid infusion rates and electrolyte imbalances. usually 1 liter per 24 hours initially. Monitor glucose levels and report changes to the physician. Administer insulin if ordered. but nurses should visually check equipment every hour. and dehydration. Nursing action: TPN should not be stopped suddenly. The College Network. • • Nursing assessment: Watch for signs and symptoms including nausea. generalized weakness. generally up to 3 liters per 24 hours. Allow time (twelve to twenty-four hours) for the patient’s glucose levels to return to normal.0 . Such reactions include osmotic diuresis. tenting of the skin). Make sure tubing is patent. with orders to increase the drop rate over a period of several days if tolerated. Nursing action: Assessments should be made hourly. The flow rate should be reduced gradually and in accordance with the physician’s orders. Nursing action: Infuse TPN gradually. Never increase the flow rate without an order. Parenterally administer carbohydrates if ordered in the form of a dextrose and water solution. • • Nursing assessment: Closely monitor people receiving TPN for signs and symptoms of dehydration (e. dehydration. lightheadedness or dizziness. infusion pumps generally signal if the tubing becomes clogged or twisted. headache. confusion. • Nursing assessment: Watch for signs and symptoms of hypoglycemia that include cold and clammy skin. Hypoglycemia Hypoglycemia can occur following a course of TPN due to sudden discontinuation of the concentrated glucose solution. and tachycardia. Copyright © 2008. and even death.g. Monitor blood glucose levels every six hours. headache (occipital region). numbness and tingling of the extremities. Inc. NXP 070106 v1. Air Embolism Air embolism is another complication of TPN. Nursing action: Follow protocol for a respiratory emergency. These orders should include not only information about cardiopulmonary resuscitation and mechanical ventilators/respirators but also the person’s wishes regarding artificial feedings in an emergency or.Unlawful to replicate or distribute Infection Infection can occur related to contamination of the intravenous infusion site. headache or pressure over the eyes. Prevention includes ensuring no air is in the intravenous line. do not infuse any other solutions or medications in the same line unless specifically ordered. • Ethical and Legal Issues There are often ethical and legal issues to consider before initiating enteral feedings.0 . Inc. on a long-term basis for nutritional support. As a rule. and redness and swelling around the infusion site. In most facilities. complaints of dizziness. dyspnea. Nursing action: Immediately turn off the flow of the emulsion and notify the physician. cyanosis. Flow rates are slow and generally set at 1 mL/min. The College Network. do not resuscitate (DNR) orders are given by the patient or the patient’s family on admission. especially with persons who have terminal conditions. If no side effects occur. • • Nursing assessment: Watch for sudden onset of rapid respirations (tachypnea) and possible chest pain. • Nursing assessment: Watch for sudden onset of symptoms including allergic reactions (swelling or difficulty breathing). if needed. however. These reactions can suddenly occur as a result of too-rapid infusion rates. back or chest pain. Emulsion reactions are the most important side effect of this form of parenteral feeding. the physician may increase the flow rate gradually. but the flow rate should never be increased without an order. Nursing action: TPN tubing should be changed every twenty-four hours using sterile technique. Side Effects of Lipid Emulsions Side effects and safety tips for lipid or fat emulsions are similar to those for hypertonic solutions with respect to hyperglycemia and hypoglycemia. • • Nursing assessment: Symptoms of a septic condition include shaking chills. a fever. Strict aseptic technique should be used if changing dressings or handling any components of the infusion apparatus. nausea and vomiting. The desire of the Copyright © 2008. Temperature should be monitored at least once every eight hours. Individual hospices may have their own guidelines and recommendations as to what is considered comfort care and what is considered a heroic measure. In many nursing homes and hospitals and also in the home. Recommendations are based on current research evidence.0 . The College Network. including pediatric hospitalization and long term care facilities for older adults.Unlawful to replicate or distribute Fundamentals of Nursing 201 patient and/or his or her family should be ascertained upon admission to the hospital or nursing home. NXP 070106 v1. hospice care is available.nutritioncare.org. The standards are defined as benchmarks and are discipline-specific. For more information you can register without charge on their web site and view various documents. Copyright © 2008. See http://www. The American Society for Parenteral and Enteral Nutrition publishes standards of practice and clinical guidelines to help practitioners provide safe and efficacious nutritional care in a variety of settings. Their enteral nutrition standards are currently under development. Inc. Patients and families need to find out this information from the hospice personnel as they plan for end-of-life care that is congruent with the beliefs and feelings of the patient and family. The College Network.0 .Unlawful to replicate or distribute Copyright © 2008. NXP 070106 v1. Inc. Introduction This chapter synthesizes the information in the previous discussions. 3. such as Maslow’s hierarchy of needs. Explain reasons why health restoration and health maintenance needs generally take priority over health promotion needs in a hospitalized patient. as well as any immediate concerns that threaten the patient’s health. Inc. List the considerations for nursing assessment related to a patient’s nutritional status. Discuss the general categories and questions to consider when evaluating implemented care plans. We then consider the range of nutritional issues a patient may have and discuss criteria to help prioritize. The College Network. 6.Unlawful to replicate or distribute Chapter 12: Applying the Nursing Process to Meet Basic Nutritional Needs Objectives Upon completion of this chapter. Describe the type of information included in a nursing diagnosis related to nutritional needs. We conclude by looking at evaluation—the last phase of the nursing process—and providing examples of general categories. Through specific examples. culminating in one or more Copyright © 2008. 5.0 . we investigate how the nursing process can be used as a clinical problemsolving framework in the identification and implementation of effective nutrition-related care planning. you should be able to do the following: 1. This process includes the analysis and synthesis of all data. care planning can be done utilizing the nursing process and other theoretical frameworks. Finally. We investigate how this data is analyzed and synthesized to include actual or potential problems through the development of nursing diagnoses. 4. questions. plan. NXP 070106 v1. Applying the Nursing Process Once the nurse has performed a thorough assessment of a patient’s nutritional status based on objective and subjective data and is aware of the variety of interventions that can be utilized for nutritional disturbances. and aspects of nutrition-related care that can be used in evaluation strategies. 2. we explore implementation of the plans and discuss how nursing strategies should be targeted to address any underlying causative or associated factors. Identify several factors to consider when planning a nutrition-related nursing intervention. We begin by reviewing the initial subjective and objective data necessary for a comprehensive nursing assessment. and set nursing goals. Identify two target areas of nursing interventions related to nutritional deficits and provide examples of each. serum transferrin. and planning. the nurse synthesizes it in order to identify the patient’s actual or potential health problems that are amenable to some type of nursing intervention. the following are considerations for nursing assessment related to a patient’s nutritional status: • Obtain a history from the patient and/or the patient’s significant others related to the patient’s nutritional health status in a specific area. For example: Evaluate skin turgor and any weight changes over time. Assess various factors that could influence the patient’s health status. Inc. Defining characteristics based on objective and subjective data help define diagnoses.0 . NXP 070106 v1. • • • • Analysis Once objective and subjective nutritional data have been gathered. Utilize nursing skills for physical assessment of the patient. For example: Read the dietitian’s consultation or admission notes. implementation. Nursing Diagnoses The general nursing diagnosis based on NANDA-I terminology and criteria related to nutritional disturbances is imbalanced nutrition. and evaluation follow in logical order. Obtain objective laboratory and other diagnostic report data such as laboratory values. for example. and hematocrit values and compare them to normal ranges to assess for protein and iron deficiencies. this might include imbalanced nutrition: less than body requirements or imbalanced nutrition: more than body requirements. hemoglobin. Nursing diagnoses are then formulated and prioritized. Both diagnoses can be dependent on other factors. and specimens. Nutritional Assessment To briefly review. For example: Interview the patient and/or significant others about daily nutritional intake over the past two weeks and compare it with the Food Guide Pyramid for adequacy. The nursing diagnosis will include an actual or potential nutritional problem and the etiology of the problem or potential condition of risk. imbalanced nutrition: less than body requirements could be related to impaired mobility for an elderly person Copyright © 2008. Obtain any relevant health status information from the patient chart and other health professionals. radiography.Unlawful to replicate or distribute nursing diagnoses. Other health team members such as the physician and dietitian and friends and family members of the patient may also be involved in analysis. Diagnoses are prioritized. The College Network. serum albumin. For example: Explore with the patient the effect of reduced income or religious/ ethical beliefs on nutritional status. For example: Check the patient’s BUN. total lymphocyte count. for example. development of a stage III or IV pressure ulcer) related to immobility and insufficient intake of calories and protein Impaired urinary elimination with frequency related to insufficient intake of fluids and urinary tract infection At risk for constipation related to abdominal muscle weakness Copyright © 2008. can be developed with respect to fluid volume excess or fluid volume deficit. who have a history of congestive heart failure might be at risk for excess fluid volume.0 . Inc. A nursing diagnosis in this category might read as follows: • Ineffective health maintenance related to insufficient knowledge of one’s own nutritional needs Related diagnoses that specifically focus on essential nutrients.Unlawful to replicate or distribute with severe arthritis or to a hectic schedule for a middle-aged accountant who rarely takes time to eat well balanced meals. The associated diagnosis might be as follows: • Imbalanced nutrition more than body requirements related to caloric intake consistently over and above daily requirements related to poor self-image Another diagnostic category could be an alteration in health maintenance related to nutrition. NXP 070106 v1. and the following diagnosis could apply: • At risk for excess fluid volume related to TPN therapy and history of congestive heart failure Nursing diagnoses that relate to other concepts like activity and mobility or elimination may also be considered because of their relationship to nutrition: • • • At risk for impaired tissue integrity (i. The College Network. including water.e. Nursing diagnoses could be phrased as follows: • • Imbalanced nutrition less than body requirements related to impaired mobility from arthritis with inability to purchase food Imbalanced nutrition less than body requirements related to hectic schedule resulting in frequently missed meals Imbalanced nutrition: more than body requirements might be related to a poor self-image for a teenage girl who is five feet tall but weighs 180 pounds. Patients receiving TPN. one goal for patients with arthritis who are able to do their own shopping would be to identify foods from the Food Guide Pyramid that are accessible and easy to prepare. and Setting Goals Prioritizing Priorities can be set for various nursing diagnoses based on Maslow’s hierarchy of needs and optimal use of resources. The nurse might also assess the need for occupational and physical therapy consults to evaluate and improve mobility while the patient is hospitalized. For example. nursing home. The University of Copyright © 2008. the nurse’s attention can turn to long-term planning. There may be several diagnoses related to nutrition that need to be prioritized. or home care agency.Unlawful to replicate or distribute Prioritizing. Planning Planning includes patient-centered goal setting and nutritional strategies to meet those goals. Health restoration needs and health maintenance needs would take precedence over health promotion needs. for example. A community health referral to assess the patient in her home situation could also be part of discharge planning. a goal for an overworked and overweight office worker who frequents fast-food restaurants for lunch every day might be that he or she learns to select low-calorie foods from the menus. Planning also needs to include various influencing factors. however. A nurse would plan to teach that patient about inexpensive high-protein food and food combinations. Important but not urgent needs can be addressed after the urgent needs are met. patients with arthritis may also be subsisting on a fixed income. The College Network. the ANA Standards of Practice. Planning. Inc. Immediate needs for this patient might be a blood transfusion or iron supplementation.0 . The patient’s lab values for hemoglobin and hematocrit are abnormally low. acute problems of health restoration might be recurring. and standards and protocols drafted by nursing specialty associations. which can impact choice of food in addition to their problems with immobility. NXP 070106 v1. The patient’s presenting symptoms in the hospital emergency room following a fall at home are consistent with iron-deficiency anemia. if health promotion needs are not addressed. specific standards and practices (often called protocol) where one works. like the American Association of Critical Care Nurses. Planning can include drawing on a number of outside resources: standards and protocols from state nursing practice acts. a hospital. Or. For example. Once the patient is stabilized and nutritional needs for health restoration have been met. Consider this example: A patient with arthritis and impaired mobility is unable to go to the grocery store independently and purchase food. In the long run. such as religious or ethical beliefs and specific socioeconomic factors. and specific health care settings. The Center for Nursing Classification and Clinical Effectiveness facilitates ongoing research of these classifications and also nursing outcomes. The American Society for Parenteral and Enteral Nutrition (ASPEN) and The American Dietetic Association (ADA) also have guidelines. Interventions suggested throughout this text are consistent with NIC classifications. Evaluation methods should also be included when care is planned. There is currently no one single nomenclature or language for nursing interventions. How will a nurse know whether a goal has been met? If a goal is for the patient to attain a certain weight.Unlawful to replicate or distribute Iowa has also developed a taxonomy of nursing interventions known as NIC (Nursing Interventions Classification). Specialty organizations in health care strive to keep up to date and draw from current research to help ensure an evidence-based practice. Nursing assistants. commonly referred to as NOC (Nursing Outcomes Classification). Weight is one of the best anthropometric measures related to a number of diagnoses. Adaptive feeding devices for Copyright © 2008. The following are some examples: • • Assist the patient with food selection. Goal setting also includes assigning patient-care activities to others. can be assigned to feed patients. or monitoring TPN on an hourly basis (health restoration). For example: A patient with dementia might need assistance filling out and choosing appropriate foods from a menu to provide a nutritionally balanced meal (health maintenance or restoration). but often the nurse must directly intervene to ensure a goal is met in the areas of health promotion. Inc. such as by monitoring and recording accurate intake of foods and fluids. Setting Goals Goals also require measurement. The College Network.0 . administering medications and feedings at ordered times. then the nurse should record the actual weight on a daily basis and at the same time each day. so there may be some variation in terminology between NIC. maintenance. Use appropriate nursing measures to promote nutritional intake. Most of the standards and protocols are available online at no charge. including fluid excess or deficit as well as caloric excess or deficit. for example. and restoration. NXP 070106 v1. Implementation Interventions should be targeted to address any underlying causative or associated factors as well as any immediate concerns that threaten health. Patients themselves may be directly responsible for goal achievement. nursing texts. An evaluation of the patient’s age and physical condition might lead to measures such as assistive feeding devices for infants born prematurely or older people with arthritis (health maintenance and promotion). For example: Specific interventions would include checking tube placement prior to giving medications or feedings. for example. Inc. Provide information and instruction about nutrition. A new mother might not be able to follow a written teaching plan for a child who is lactose intolerant because she finds it too complicated and has difficulty with reading comprehension. Nurses can also provide patients with information about community support groups for weight loss and other community resources related to nutrition. A revised plan • Copyright © 2008. questions. This includes progress made toward the patientcentered goals. For example: Iron is frequently given as a supplement in liquid or pill form. A nurse might teach a vegetarian patient about combining incomplete plant proteins to make complete proteins. NXP 070106 v1. low-fat diet at home? Did the patient keep a daily food diary for a month? Reassess and revise the patient’s nutritional care plan as needed.0 . The College Network. If the patient is already receiving a supplement such as iron. Plate guards might be helpful for a person with dementia to prevent food spills while allowing the person to eat independently. but he or she might be able to tolerate six small feedings throughout the day. it is important to evaluate the patient’s response on an ongoing basis. or the nurse might teach lactose-intolerant patients about alternative food sources to meet their needs for increased calcium. For example: A patient with anorexia might not be able to eat three meals a day according to the initial care plan. the nurse’s knowledge that vitamin C aids in iron absorption could lead to giving the iron supplement with a glass of orange juice. diabetic diet? How much weight was lost? Was this weight loss appropriate? Did skin turgor and laboratory values improve following three days of TPN? Was the patient compliant or noncompliant with a 1. include utensils with wider handles and built up spoons. For example: Were there any weight changes following the patient’s first week on a 1.200 calorie. In addition to teaching.Unlawful to replicate or distribute • • • • older adults. Evaluation Once the nutritional care plan has been implemented. nurses can give patients referrals to community health agencies for follow-up home care after hospitalization. Use nursing measures specific to any nutritional supplements ordered by the physician.500 calorie. Provide nursing supervision and direction to certified nursing assistants for all patient care activities. For example: The nurse might instruct a patient on how to read food labels utilizing a cereal box or other types of packaging. such as Meals on Wheels or other community-based lunch programs (health maintenance and promotion). the nurse would also check laboratory hemoglobin and hematocrit values weekly (health restoration). or aspects of care to consider for evaluation: • Record and report the patient’s response to any nursing actions. A nurse might instruct the patient’s family members prior to hospital discharge about tube-feeding administration and provide an opportunity for them to demonstrate their knowledge (health promotion). Use nursing measures to promote continuity of care. The following are general categories. NXP 070106 v1. or perhaps the nurse could teach her using pictures or a video. This would be important information if the patient were diabetic. the nurse could check the intake records of the nursing assistant assigned to the dining room. for example.0 .Unlawful to replicate or distribute Fundamentals of Nursing 209 • • could be written simplifying the instructions. The College Network. since the patient might have an insulin reaction at night if he or she has had insufficient caloric intake during the evening meal. For example: To determine whether the patient in the nursing home had adequate nutrition for supper. Determine the patient’s response to the care provided by other members of the health care team. Review the plan of care for ambulation of a newly discharged home-care client following a fractured hip. confer with the certified home health aide on a weekly basis to determine the patient’s progress and any need for change based on client response and discussion with the home care agency’s physical therapist. Copyright © 2008. For example: Review the care plan and daily menus with the personal care aide for a homebound client with severe arthritis. Review the nutritional care plan with other health care personnel. Inc. 4. 9. NXP 070106 v1. Identify the major categories of interventions designed to produce a safe environment and provide examples of each. 11. Explain the seven factors that influence a patient’s environmental safety and identify at least four examples of each factor. Describe the various types of restraints and their application. Explain the seven basic terms related to environmental safety. Identify resistance-avoidance strategies and provide examples for each. Discuss research findings related to restraint use and fall prevention. 8. Explain the principles and government regulations to abide by in all cases where restraints are used. List the principles of restraint use a nurse needs to follow in order to preserve patients’ rights and minimize the chance of a lawsuit. The College Network. List the critical documentation pieces the nurse must provide when restraints are used. Inc. 6.0 . 5. Describe the most common types of environmental hazards and preventive techniques for each. 7. Identify the five criteria used to select an appropriate restraint and use it in the safest manner possible. you should be able to do the following: 1. 10.Unlawful to replicate or distribute UNIT IV: SAFETY AND INFECTION CONTROL Chapter 13: Theoretical Frameworks Used as the Basis of Care to Ensure Environmental Safety Objectives Upon completion of this chapter. Copyright © 2008. 2. 3. We begin by defining the terminology of environmental safety and explaining the common safety hazards found in the environment. We also examine the basic principles governing the use of restraints. We also discuss interventions designed to produce a safe environment.Unlawful to replicate or distribute 210 Fundamentals of Nursing Key Terms adaptive equipment chemical hazards ecological hazards elbow restraints environment hazard Hendrich II Fall Risk Model injury internal risk factors limb restraints mechanical hazard mitts/hand restraints mummy restraint para-aminobenzoic acid (PABA) physical/mechanical hazards RACE radiation risk of injury safe environment safety safety straps/belts sun protection factor (SPF) thermal hazards ultraviolet light vest restraints Introduction One of the unique aspects of professional nursing is the comprehensive nature of our approach to patient needs.1. Our attention to environmental safety is an example of this comprehensiveness. Finally. In addition. including correcting the underlying problem and individualizing the nursing approach. Before beginning. Our discussion then turns to the serious nursing-related issues surrounding the use of patient restraints. including critical government regulations about their use. The Terminology of Environmental Safety Principles of environmental safety and the terms commonly associated with this topic are woven throughout this unit.0 . We conclude the chapter by analyzing research related to patient outcomes when restraints are used and the effectiveness of fall prevention interventions with vulnerable populations. and the possible need for restraints. This chapter takes an in-depth look at the theoretical frameworks nurses use to assess safety. We take a detailed look at restraint alternatives. and nasogastric tubes) and strategies than can be used to avoid patient agitation. some basic terms need to be defined. The chapter then turns to the types of documentation needed when restraints are used and how to select an appropriate restraint and use it in the safest manner possible. we look at seven basic factors that influence patients’ environmental safety. Copyright © 2008. gastrostomy tubes. NXP 070106 v1. The College Network. however. discomfort. These terms are explained in Table 13. we discuss specific clinical situations (such as the use of IV infusions. Inc. we explore nine basic steps the nurse needs to follow to ensure a patient’s dignity and protect the nurse when restraints are used. From there. fractures. May be categorized as physical (e. and controlling and reducing workplace hazards. chemical (e. Copyright © 2008.. environmental conditions) to the individual. radiation-related (e. The College Network. thermal (e. encouraging use of grab bars). it is important to keep the injured person flat and warm.0 . thermal. NXP 070106 v1. or loss.2. Basic principles related to these types of hazards are outlined in the following sections. An increased probability or chance of injury due to factors internal (e. such as decreasing obstacles in pathways. The safety of an environment is relative to a person’s vulnerability.. excess heat or cold). The most common categories of hazards are physical/mechanical. A condition or phenomenon that increases the risk of injury. spills on a floor). damage. Physical and Mechanical Hazards Physical and mechanical hazards relate to the application of force on the body.. ammonia fumes)..g. driving safely on streets and highways. each of which can cause specific types of damage.. hazards are conditions or phenomena that increase a person’s risk of injury. chemical. Inc. Hazard Injury Internal risk factors Risk of injury Safe environment Safety Common Safety Hazards in the Environment As described in Table 13. Also refers to the sum of the factors external and internal to a person that influence life and survival. and ecological. The number of physical and mechanical hazards in an environment can be reduced by proper lighting and by instituting common-sense accident-prevention measures. An environment in which the kind and number of hazards are reduced and accidents are prevented.1 Terms Related to Environmental Safety Environment The sum of the physical and psychological factors that influence life and survival.g.g. a home environment that is safe for an adult is not necessarily safe for a toddler. especially in the first trimester). mechanical (e..g.g. controlling bathroom hazards (e. friction.g. sprains.g. A sustained hurt. For example. and examples of specific hazards in each category are provided in Table 13. exposure of a fetus to maternal chest X ray.1.. There are many types of common safety hazards in the environment. and internal damage to the abdominal and thoracic organs. Therefore. Immobilize any extremities in which a fracture is suspected. shearing. Internal variables that increase a person’s vulnerability to injury. Injuries arising from these hazards include contusions. Severe injuries cause shock. exposure of a fetus to maternal smoking). head injuries. radiation. and ecological (e.. Never move a patient with a suspected spine or neck injury until a spinal board is obtained and the patient can be correctly immobilized.Unlawful to replicate or distribute Table 13.g.g. Freedom from the risk of injury. health status) and external (e. and pressure forces).. Unlawful to replicate or distribute Thermal Hazards Thermal hazards involve exposure to extremes in temperature. Copyright © 2008. were not intended for ingestion. the esophagus is burned again when regurgitation occurs during vomiting.9°C (65–75°F). The College Network. Other measures include fire and burn precautions and extreme-cold precautions (e. Inc. and alkalies. Chemical Hazards Chemical hazards are related to internal or external exposure to substances that. and the resultant oil-related pneumonitis is serious. Cold can produce hypothermia. it can result in frostbite. adequate clothing and covering. it can produce burns. The amount of damage and appropriate steps for treatment depend on the type and amount of exposure. (Burned once when the acid is ingested. Therefore. If the dose is sufficiently high. NXP 070106 v1.3–23. Radiation Hazards Radiation by means of exposure to x-ray or any other source damages fetal development. and when applied directly to the skin. Ecological Hazards Ecological hazards are several and include secondary smoke. Prevention measures include maintaining an environmental temperature within the usual comfort zone of 18. and when applied directly to the skin. Vomiting acid increases esophageal damage. Vomiting is never recommended when these substances are ingested because: • • • Vomiting oil-based substances carries with it an extremely high risk of aspiration. and noise pollution.0 . Other chemical substances that people may accidentally ingest include oil. Heat can produce heat exhaustion and heat stroke.g. especially during the first trimester. air and water pollution. If the patient survives the initial exposure. in kind or in amount. especially for the digits and nose). acids. overexposure to radiation in adults may immediately result (within hours or days) in radiation sickness. Vomiting is sometimes suggested by a physician or by a poison control center when medicine is wrongly ingested. Radiation exposure may also result in skin burns..) Vomiting alkalies increases esophageal damage for the same reason associated with vomiting acid. medication errors or medication interactions may result in chemical injuries. he or she is at increased risk of developing cancer in subsequent years. injuries secondary to improper use of restraints. recall of Mattel and Fisher-Price toys. and environmental conditions. Copyright © 2008. radon. and preschoolers. health status/physical condition.2 Examples of Various Kinds of Hazards Type of hazard Physical/ mechanical Common examples Crib suffocation. individual preferences and patterns. cultural and spiritual/religious factors. NXP 070106 v1. other clutter on floor.S. These may be categorized as age/developmental factors. exposure of fetus to chemicals. poisoning. especially in newborns and infants. bumps. motor vehicle or other vehicular crashes. strangulation threat posed by non-childproofed cords on window blinds. The College Network. aspiration of liquids. frostbite Exposure of fetus to maternal consumption of alcohol and/or additive or teratogenic drugs. pedestrian injuries.Unlawful to replicate or distribute Table 13. medication errors. other forms of air pollution. noise pollution Thermal Chemical Radiation Ecological Factors Influencing Patients’ Environmental Safety There are several factors that influence patients’ environmental safety. Inc. sunburn (all ages). or fallen electrical lines. injuries secondary to defective equipment or incorrect placement of equipment Newborn/infant burns from hot bath water or hot liquid spills. especially in infants. aspiration of foreign objects. obstruction of ear canal with foreign objects. especially with failure to use infant/child safety seats or seat belts. drowning. due to wet floors. Common sources of lead exposure are lead paint. electrical shock secondary to defective wiring. newborn/infant crib or playpen injuries. and preschoolers. toys on floor. toddlers. lightning strikes. especially in infants. Each of these factors is elaborated upon in the sections that follow. water pollution. secondary smoke (all ages). Lead paint exposure occurs primarily by living in old homes built before the removal of lead paint from the market. Please note that sun exposure is also a threat for people of all age groups and developmental levels. or poor lighting). scatter rugs.. With the 2007 U.g. socioeconomic factors.0 . carbon monoxide. traffic/playground injuries. Age and Developmental Level Age and developmental level influence a person’s vulnerability to an accident or injury. especially in preschoolers. abrasions. falls (e. Today. psychological factors. overexposure to radiation therapy Exposure of fetus to maternal smoking. lead exposure occurs by children consuming chips of wall or plaster containing lead paint. heat lamps. Examples of safety risks across the life span are presented in Table 13. the public has been made aware that lead paint has been used in the production of toys manufactured and imported from China. and discarded automobile batteries that contain lead. Exposure of fetus to X ray. contaminated surface dirt. especially certain pesticides. tanning booths.3. firearm injuries. especially in first trimester. equipment. fires/burns (all ages). lacerations. and lead poisoning. and puncture wounds. toddlers. The content validity of the tool was established by a literature review. however. altered elimination (1 point). which is a fall risk assessment for older adults. The Hendrich II Fall Risk Model. Just as medical practice uses the electrocardiogram to assess for or confirm the diagnosis of myocardial infarction. harm from other people Vehicular accidents. pedestrian and motor vehicle injuries Best Practices: A Diagnostic Test for Fall Risks Any one of the previously mentioned hazards may be turned into nursing diagnoses by identifying each hazard as a risk. head injuries.org/publications/trythis/issue08. valid and reliable diagnostic tests are needed. firearm injuries. Its interrater reliability is 100%. substance abuse. burns. administered/prescribed anticonvulsants (1 point). drowning Traffic and playground injuries. falling. poisoning. male gender (1 point). fire Falls. pushes up successfully in one attempt (1 point).pdf. To develop a sound evidence-based nursing practice. The College Network.9%. X ray. is described online at http://www. recreational injuries. electric shock. It is currently being validated for use with pediatric and obstetric populations. dizziness/vertigo (1 point). harm from other people Vehicular accidents. recreational injuries. crib/playpen accidents Falls. burns. Copyright © 2008. A total score above 5 indicates the patient is at high risk for falling. choking. especially in the first trimester. multiple attempts but successful (3 points). The Hendrich II Fall Risk Model targets adults at risk of falling within an acute care environment. strangulation.Unlawful to replicate or distribute Table 13. Inc. fire/burns. administered/prescribed benzodiazepines (1 point). electric shock. The probability that the score is negative given a fall not occurring (specificity) is 73. sports injuries. The probability that the score is positive given a fall occurring (sensitivity) is 74. Risk for falls is already listed as a nursing diagnosis. There is a statistically significant relationship between the risk factors incorporated within the tool and patient falls.hartfordign. motor vehicle crashes. is an example of a diagnostic test. Later cross-validation revealed a sensitivity of 83% and a specificity of 66%. developed by Hendrich and colleagues. suffocation. firearm injuries Home-related injuries. choking. depression (2 points). falls. pesticides Suffocation. lacerations and abrasions. This tool. fire/burns.9%. poisoning. and unable to rise without assistance (4 points).0 . teratogenic medications. ability to rise in one attempt (0 points). The Hendrich II Fall Risk Model assigns points to the risk factors of confusion/ disorientation (4 points). NXP 070106 v1. for example. sports injuries.3 Examples of Safety Hazards Across the Life Span Stage of life Developing fetus Newborns and infants Toddlers Preschoolers Adolescents Young adults Middle-aged adults Older adults Common safety hazards Maternal nicotine and alcohol/illicit drug consumption. risk for fire/burns or risk for vehicular accidents. drowning. lawn mower injuries. nursing will someday have tests to assess for or confirm the diagnoses of risk of falling. This tool is an important advance in nursing. However. It is based on the work of the renowned NIH National Institute of Nursing Research investigator. Therefore. displacement of the tube can occur without an increase in the external length of the tube. The items in this section summarize years of research and provide added insight into evidence-based nursing practice. NXP 070106 v1. If the volume of gastric fluid aspirated from a tube increases. It is known. the registered nurse is responsible for being reasonably assured that a feeding tube is correctly placed before giving a tube feeding. continuing gastric feeding in the presence of delayed gastric emptying is likely to increase the risk for reflux and hence risk for aspiration.Unlawful to replicate or distribute Best Practices: Testing the Placement of Feeding Tubes Although neither physicians nor nurses think of themselves as an environmental safety hazard. PH testing of gastric tube aspirate possesses very limited benefit when patients are receiving gastric tube feedings because the feeding will neutralize the pH. the nurse should keep the head of the bed elevated 40° or more to prevent aspiration. Need for Radiography While the registered nurse is not responsible for ordering an X ray. PH may have benefit. This section examines patients at risk for aspiration due to incorrectly placed or dislodged feeding tubes and methods of decreasing that risk by testing for correct placement. and by refusing to administer a feeding without the requisite X rays. The College Network. Radiography is needed to confirm correct placement of any blindly placed feeding tube. Testing the pH of Gastric Tube Aspirate The use of pH testing of gastric aspirate to determine placement of the gastric feeding tube has limited benefits. Norma Metheny. as this may indicate dislodgement. It is also needed to confirm the placement of any feeding tube when a major change in the external length of the tube occurs. Unless contraindicated. Confirm placement with an X ray. Patients aspirate significantly more frequently when the head of the bed is elevated less than 40°. This may occur when the tube is displaced but curls upon itself. nurses are frequently unaware of the importance of this intervention. however. however. in assessing dislodgement of a small Copyright © 2008. Elevation of the Head of the Bed A simple nursing strategy prevents aspiration in patients with feeding tubes. for notifying the responsible physician when an X ray is required. that when gastric emptying is delayed. it is logical to assume that the probability of reflux and hence risk for aspiration is greater. Inc. While a major change in the external length of the tube indicates possible dislodgement of the feeding tube and requires an X ray to confirm or rule out dislodgement.0 . Dr. it may mean that the tube placed in the small bowel has been displaced into the stomach. errors of misjudgments or miscalculations made by health care professionals do place patients at risk. Role of Gastric Emptying and Aspiration The association between delayed gastric emptying and aspiration requires further research. 0 to a pH of 5. Choosing to buy illicit drugs is an unsafe choice for at least three reasons. Nurses need to be aware of this kind of negative attitude in themselves and in others before drawing conclusions about a neighborhood’s safety. Feeding a patient through a gastric tube that is misplaced (usually in the respiratory system or even in the esophagus) can cause death. for example. church pastors. but a person may feel financially constrained to work in such an environment. those who hunt need to wear brightly colored. Furthermore. Berman et al. All too frequently. This is because the pH changes from. using the above mentioned methods. advocating for gun control.0 . For example. NXP 070106 v1. People may be risk takers. certain blocks or portions of neighborhoods may be environmentally unsafe due to criminal activity. a work environment may not be environmentally safe. trusted in the community. neighborhoods are stereotyped or profiled. Inc. and home owners. Risk takers may be tempted to reject the use of seat belts. and state levels. but because of the racial or ethnic character of the neighborhood. (2008) give other examples of environmentally unsafe lifestyles that are beyond a person’s control. Such unsafe choices are decisions made by the individual and are therefore under the individual’s control. 7. store owners. On the other hand. identifying clothing so that they are not mistaken as animal targets. If guns are used for hunting purposes. life jackets when boating. confirm placement with an X ray.0 or less. Nurses. county. The College Network. If multiple signs indicated dislodgement. then all those who use them need to be schooled in safe use in the field and safe storage at home. and other common-sense precautions. is that of an unsafe neighborhood. that the feeding tube is correctly placed before administering feedings. Therefore. The second reason is that they may bring the buyer into close contact with an element of the criminal world and lead to further involvement Copyright © 2008. The first is that the drugs have a high probability of being addictive and physically harmful. and becoming politically active at city. have contributed to such movements by teaching children nonviolent conflict resolution techniques. Other environmentally unsafe lifestyle issues revolve around access to guns and ammunition and access to illicit drugs. who can develop various safetypromotion strategies like neighborhood watches. Individual Preferences and Patterns Individual preferences and patterns influence one’s safety and risk of injury. or risk averse. it may not be beyond the control of an organized group of neighbors. Auscultory Method There is no evidence that supports the accuracy of the auscultory method in confirming correct placement of feeding tubes. While this may be beyond the control of any one person. Another example listed by Berman et al. not because their crime statistics are necessarily higher than other neighborhoods. risk neutral. This method does not differentiate placement accurately within the GI tract or between the GI and respiratory tracts. bicycles helmets. the registered nurse must be reasonably assured.Unlawful to replicate or distribute bowel tube into the stomach. g. income may be insufficient to cover the cost of needed safety repairs. clients may not be able to inform others of an actual injury or threat or point to an area causing pain or pressure. friction. or some older adults) may allow injury to occur because they do not feel it. Impaired emotional responsiveness may increase an individual’s injury risk. those who are afraid of fire may run in the wrong direction when faced with an actual fire. Sensory/perceptual alterations increase risk of injury. 5. 4. Individuals with taste deficits may not know that a food has turned sour. On the other hand.g. thereby allowing environmentally unsafe conditions to continue. In all of these circumstances. Clients with visual problems may not see obstacles (e. sirens.. For example. In some circumstances. depressed people may underreact to threat and fail to move quickly enough to escape from the source of threat. nurse advocacy is needed. Still another issue that affects a person’s or a family’s lifestyle and that is related to environmental safety is that of landlords who refuse to make needed repairs. toys on the floor or electric cords) that might cause a fall. Copyright © 2008. which increases their risk of food poisoning. A number of physical conditions place a person at an increased risk of environmental injury: 1. As a result of auditory aphasia (inability to interpret words correctly). Any decrease in the level of consciousness. smoke. those with paralysis.g. people perceive pain or threat of injury but are unable to move away (either at all or rapidly enough) from the source of pain or the threat. from mild impairments to comatose states. Clients with touch/ pressure/pain disturbances (e.0 . Here. decreases the ability of the person to respond appropriately to risk. Clients who overreact emotionally may be so frightened that their judgment becomes impaired. abrasion.Unlawful to replicate or distribute in the future. diabetes neuropathy. laceration. or they may not perceive an injury that has occurred. Inc. They are especially susceptible to burns and to infection secondary to an unperceived pressure. Cognitive impairments decrease a person’s ability to recognize and/or interpret threats. NXP 070106 v1.. with capture more likely to lead to prison than to enrollment in a treatment program. Impaired mobility or motor dysfunction increases the risk of injury. an individual may not be able to interpret spoken warnings of threats to his or her safety. Clients with olfactory nerve deficits may not smell escaping gas. or embedding of a foreign body in the skin. Health Status/Physical Condition A person’s physical condition and/or health status also influences that person’s safety within his or her environment. For example. sleep deprivation may cause a motor vehicle accident crash. fire alarms.. As a result of motor or expressive aphasia (impairment in speaking and/or writing or pointing at an object of interest). or verbal warnings). Impaired verbal communication may increase risk. 3. An issue that is not a function of lifestyle but rather one that limits and affects lifestyle is a person’s or family’s socioeconomic level. The third reason is that it is illegal. People with hearing deficits may not hear sounds of impending danger or audible warnings (e. 2. The College Network. or burning food. Copyright © 2008. It is conceivable that more serious burns could occur. may lead a patient to leave a home or a facility. Azoque is a mercury-containing substance some Latin American cultures use to treat diarrhea. decrease coordination. NXP 070106 v1. Other cultures (e. associated with confusion. a traditional remedy for Yemenite Jews is the application of topical garlic to the wrist to treat infectious disease. as do other more common sources of exposure. fire safety precautions are needed (Hockenberry 2005). or to wander into unsafe places within an institution. Health care professionals from these same cultures may be needed to explain to the families why these substances need to be avoided (Hockenberry 2005). Hallucinations may so absorb a person that threat is not perceived. Middle Eastern cultures) burn incense when gathered to celebrate. Some also burn “blessed” candles when faced with a severe illness. Greta and azarcon are lead-containing traditional Mexican treatments used for digestive problems. first-degree burns on the back or neck. This may result in the formation of blisters or garlic burns. then exposure to these agents needs to be investigated. Wandering. Family members may need to be instructed on the safe burning of candles within the home and cautioned to never leave a burning candle unattended. hypnotics. The College Network. Other traditional cultural and religious remedies may lead to burns. from narcotics.. Again. There is also a problem of misinterpreting the lesion unless health professionals are informed about the practice (Hockenberry 2005). tranquilizers.g. Other types of traditional treatment may also increase the risk of injury or give the appearance of injury. or illness. Both may create round. or a natural disaster (e.0 . a severe storm or tornado). Inc. or hallucinations may cause a person to behave in an unsafe manner with regard to self or another. crisis. Children raised primarily in the United States may be competent interpreters of the language but not necessarily of the culture of their parents. place. For instance.g. Confusion may cause a person to not remember where objects are located or to think that another’s belongings are his or her own.. or sedatives) may alter a person’s level of consciousness.. When in doubt as to the nature or cause of a lesion. or time may cause a person to become lost. Surma is a leadcontaining cosmetic used in India to improve eyesight. symptom. Traditional Catholic cultures burn “blessed” candles in Advent wreaths as part of their preparation for the feast of Christmas. “Coining” and “cupping” are practices that require the application of a heated coin or the heated mouth of a cup (or glass or jar) to the back or posterior neck. Cultural and Spiritual Factors Cultural and spiritual/religious considerations additionally influence environmental safety. Delusions may lead a person to respond violently to threats that. Other cultural remedies contain mercury. death. A word of caution is needed here about using the children of the family as interpreters for parents. some traditional remedies contain lead. If children from these cultures present with elevated lead or mercury levels. do not exist. Drug-related side effects (e. seek someone to interpret who is a linguistically and culturally competent interpreter. sedating antihistamines.Unlawful to replicate or distribute Disorientation to person. Paylooah is a lead-containing traditional remedy for skin rash in Southeast Asia. For example.g. or cause ataxia. in reality. engages in a certain practice. socioeconomic status does in fact influence safety.). Home safety and workplace and community risks all fall within this category.. NXP 070106 v1. this does not mean that that practice is safe or that it can be practiced without taking safety precautions into consideration. she may not know to whom to complain if the repair is not made. possibly even serious ones. The many subtleties involved and the need for serious reflection on cultural factors and sensitivity should not deter nurses from intervening when necessary. At the same time. Another culture or certain subcultures within the United States may perceive this approach as unnecessarily risky. In addition. However. it is known that these measures reduce but do not eliminate injury severity. The College Network. environmental factors affect environmental safety. At the same time. and appreciating the wealth that diversity offers. she does not feel as if she has actual control over whether the repair is made. if it comes to buying fire extinguishers or food. the dominant culture permits adolescents to engage in a large number of contact sports. Even in less drastic circumstances. Furthermore. rules of the game. Inc. etc. those who lack wealth or income often feel as if they lack power. Families who cannot afford to buy food are not likely to invest in safety equipment. Thus. a family is most likely to choose food. It is as if we have decided to live with a small but known risk of severe injury as a trade-off for the benefits of a game. Environmental Factors Finally. Table 13.Unlawful to replicate or distribute These examples bring up a good point: Just because a culture.g. Copyright © 2008. Socioeconomic Factors Socioeconomic factors also influence environmental safety.0 . ours or another’s. For example. Home Hazards Various factors within a home may increase a person’s risk of injury. teaching when appropriate. where some injuries may occur. In the United States. we need to approach the practices of other cultures with sensitivity. shoulder pads and helmets in football. if a mother lives in public housing and reports that there is no screen or safety device on her sixth-floor apartment window and that her toddler is in danger of falling out. The point is that the notion of what is or is not permitted within the bounds of “being safe” is culturally influenced.4 provides examples of these factors in the form of a home hazard appraisal. the culture minimizes injury by fostering certain safety measures (e. g. an explosion in an area where radioactive material is stored).g.. clean... carbon monoxide detectors. Nurses also face environmental safety Copyright © 2008. thermal (e. farm workers’ exposure to pesticides). gasoline) and corrosives (e.Unlawful to replicate or distribute Table 13. NXP 070106 v1. if needed? Is hospital bed present. rust remover) properly stored? Are emergency telephone numbers (fire. etc. if needed? Are urinals/bedpans present. properly located and in working condition? Medications: Are expired medications present? Is there adequate lighting where medications are prepared? Is the medication storage area adequate and safely located? Is the medication storage area locked if children live in the home? Is there a safe method of disposal of sharp objects. sofas. burns secondary to an explosion in a fireworks factory).g. chemical (e. the nurse should be sure to assess each of the following areas: • • • • • • Indoor and outdoor walkways and stairs: Is the pavement or flooring broken or uneven? Are there loose steps or holes in the steps? Are stairs uncluttered? Is there adequate night lighting on stairs? Handrails: Are handrails present on both sides of all steps or stairs? Are handrails secured? Hallways: Are hallways uncluttered? Is there adequate night lighting? Floors: Are floors uneven.. if needed? If present. clean.g.. and stools too low to sit on with ease? Do they provide adequate support? Bathroom(s): Are there grab bars around tubs and toilets? Is there a nonslip/nonskid surface in tub and/or shower? Is there a handheld showerhead? Is night lighting adequate? Is there a raised toilet seat. such as needles used for injections? Are emergency phone numbers readily accessible? • • • • • • • • Adapted from Berman et al. if needed? Is there a bath/shower chair. industrial belts. radiation-related (e. cluttered.. and fire extinguishers? Does the family have a fire escape plan? Is there a second-floor ladder? Are combustibles (e. Inc. intercoms.4 Home Hazard Appraisal for Adults When conducting a home hazard appraisal for an adult patient. and accessible. injuries secondary to machinery.g. and accessible. or slippery? Are there unanchored floor mats or rugs? Furniture: Are there sharp corners on exposed furniture? Are chairs. and ecological (e.. Workplace Hazards Workplace-related hazards may be categorized as physical/ mechanical (e. police) readily accessible? Toxic substances: Are toxic substances properly labeled and stored? Communication devices: Are telephones. 2008. The College Network. highly polished.. miners’ exposure to coal dust). is it functional? Electrical: Are cords unanchored? Do cords present a fall hazard? Are cords frayed? Are outlets overloaded? Are outlets near water? Fire protection: Are there appropriately located and working smoke detectors.0 .g.g. if needed? Is the water temperature less than 120°F at its maximum? Kitchen: Are pilot lights (gas stove) in need of repair? Is the storage space accessible? Is furniture safely placed? Is area adequately clean for safe eating? Bedrooms: Is lighting adequate? Are night-lights present? Are light switches easily accessible? Is commode present. pulleys). and electric outlets near water. It is also critical to note unanchored light cords over which a patient might trip. Night-lights are particularly important in the bedroom. and earthquakes) Interventions Designed to Produce a Safe Environment Thankfully. sun protection. thermal hazards related to possible electrical shock. Environmental Modifications in Hospital and Home Various types of environmental modifications can be implemented both in the hospital and in the home. wildfires. hazardous intersections. hurricanes. Community Hazards Community safety demands safe water and sewage treatment. a number of interventions can be implemented to help reduce the risk of various environmental hazards. such as those associated with working in a high-stress environment. tornados. radiation hazards including bedside chest x-ray exposure. there should be adequate night lighting for the medicine cabinet. adherence to food selling and buying regulations (e.g. poison precautions. Some of the most common modifications include those related to lighting. vendors selling only state-inspected meat). Lighting Changes in lighting are one type of environmental modification. Copyright © 2008. halls. furniture type and placement. In the home. Rivers and lakes require pollution standards and inspection. and crime. chemical hazards such as latex allergies. and proper use (when necessary) of patient restraints. For example. frayed cords. appropriate street lighting. toxic substance storage. and shelter during natural disasters (floods. there are physical/mechanical hazards related to heavy lifting. In the hospital. Maintenance of air quality requires regulation and monitoring. The College Network. Light cords should also be kept from underfoot so that the patient does not trip over them. Creeks and landfills need to be protected. overloaded electric outlets. Other safety concerns are freedom from excess noise. mechanisms need to be in place to do the following: • • • Provide shelters during episodes of excessive heat to prevent heat-related deaths among those without air-conditioning Prevent deaths from the cold for those who cannot afford heat Provide first aid. Major categories of interventions relate to environmental modifications. adaptive equipment. Inc.0 . safety. safety instructions. and ecological hazards. NXP 070106 v1. the nurse should take steps to reduce lighting and glare. which can cause the patient to squint and interfere with the patient’s view of the room and furniture. and light switches need to be readily accessible. safe sewage disposal.. and bedroom. and food handling regulations. bathroom. traffic congestion. Recreational water safety laws require enforcement.Unlawful to replicate or distribute issues in their workplace. especially in intensive care units. and medication storage. Employers and employees alike should take steps to minimize these risks whenever possible. use of safety devices. dilapidated housing. In addition. Consider handrails.g. The College Network.g. canes.Unlawful to replicate or distribute Furniture Type and Placement Furniture type and placement may pose a hazard to personal safety. Unnecessary furniture and equipment should be stored out of the patient’s way to maintain an adequate walkway. if needed. Make sure nonskid bathmats are available in the tub or shower. restless. crutches. walkers. and wheelchairs are not being moved. In a hospital setting. The nurse should also obtain a commode for patients with diarrhea. weakness. in the hospital setting. Inc. the nurse should orient patients to the layout of the furniture upon admission.0 . All of the above adaptive equipment can also be installed in the home. or fatigue. the nurse can undertake the following actions related to patient use of adaptive equipment: • • • • • • • • • • Make sure the patient’s own adaptive equipment (e. wheelchairs). Thus. mark doorways as needed. Attach side rails to the beds of patients who are confused. While handrails are readily available in hospitals. ataxia. the nurse should note the following in all rooms of a client’s home: • • • • Furniture with sharp corners that may cause injury Hazardous placement of furniture Chairs or stools that are so low that getting in or out of them is difficult Chairs or stools that provide inadequate support Adaptive Equipment Adaptive equipment is intended to assist a person deal with limitation and risk by modifying the environment. Make sure the patient uses ambulatory and mobility devices as prescribed (e. Place a bath chair in the patient’s tub or shower. braces. the nurse should encourage their purchase Copyright © 2008. NXP 070106 v1. the nurse should be sure that they are locked in place. eyeglasses or hearing aids) is functional. sedated. when beds. When and if a home visit is made. Always make sure that the call button is within the patient’s reach.. He or she should be sure to place bedside tables and over-bed tables within the patient’s reach to prevent overextending on the part of the patient and a possible fall.. or unconscious. stretchers. In addition. It is also important to always keep the hospital bed in the low position so that patients may enter and leave the bed without difficulty. If the patient’s vision is impaired. Encourage the use of railings along corridors. When necessary. Encourage the use of grab bars in the bathroom (for ease and safety in rising and lowering to toilet and in entering and exiting the shower or tub). Encourage nonskid footwear. they are not always present in homes. Provide a raised toilet seat if the patient has difficulty with the height of the toilet. for example. increased urinary frequency. Toxic substances that may be ingested include paint thinners. caladium. Toxic Substance Storage Toxic substance storage includes the storage of poisonous substances and medications. narcissus. glycosuria. A complete list may be obtained from the Regional Poison Control Center located at Cardinal Glennon Children’s Hospital in St. holly berries. medications can also be toxic substances. soccer. Safety Instructions Safety instructions represent another important set of environmental interventions. Jerusalem cherry. peony. NXP 070106 v1.org. cleaning fluids/granules. infant car seats. and RACE fire procedures. while other medications become toxic. oleander.0 . disinfectants. They should be stored in their original childproof containers labeled with manufacturer’s information.g. daffodil. poinsettia.Unlawful to replicate or distribute and appropriate placement. Inc. tulip bulb. periwinkle. All should be kept tightly closed. separated from food. azalea. Be sure to reevaluate what is out of reach as a child grows. Some medications (e. dieffenbachia. the overriding principle for safe medicine storage is to dispose of all outdated medications and discard unused prescription drugs. proteinuria. Missouri (314-5775600). outdated and degraded tetracycline has been associated with nausea. elephant ear. Christmas rose. the American Association of Poison Control Centers has a listing of certified regional poison control centers that can be accessed on the Internet at http://www. what is out of reach for the toddler may not be out of reach of the four-year-old who is capable of climbing. It is also vital to discard toxic houseplants or keep them out of the reach of children. Virginia creeper. jonquil. Therefore. Sports Equipment Sports equipment safety instructions involve recommending the use of all appropriate football.. acidosis. Therefore. it is important to keep medicines in their original bottles and to use childproof bottles only. vomiting. These substances should all be placed out of reach on a high shelf. (For example. Although there is no national phone number to call for poison emergencies. hydrangea. and gross aminoaciduria. Examples include instruction in the proper use of sports equipment. poison ivy. aspirin) become less potent with age. A partial list of toxic plants includes arrowhead. English ivy. polydipsia. morning glory. Poisonous plants have become one of the nation’s leading causes of toxic ingestions. philodendrons. mistletoe.) Also note that no medication should be kept beyond its expiration date. handrails need to be securely attached and present on both sides of the stairway. In the home. A listing is also available in each edition of the Physicians Desk Reference. and insecticides. polyuria. and excess substances should be discarded. primrose. infant footwear. For example. and preferably locked.aapcc. Louis. four-o’clocks. bird of paradise. hyacinth. ice hockey and field hockey gear and the appropriate use of hockey Copyright © 2008. mother-in-law plant. When taken improperly. lily of the valley. All medications should be stored out of the reach of children. rhododendron. and wisteria. The College Network. calla lily. dawn and night riding requires special precautions. skateboarding. Children should never ride at dusk or dawn. look both ways for oncoming traffic. Use a bicycle that is correctly sized for you as the rider. These are general recommendations for contact sports. trucks or on the street when riding a bicycle as when walking. Helmets must always be worn.aap. Dusk. Never hitch a ride on a truck or other vehicle. and adults enjoy. Ride with and not against traffic. wear a properly fitted helmet approved by the Consumer Products Safety Association. Bicycle riding. and in-line skating bear special mention because they are sports that a great number of children. and other traffic ordinances. the child must be able to place both feet flatly on the ground with an inch to spare between the center bar and the child’s crotch. Never ride double. Don’t drive off curbs. such as scuba diving and horseback riding. Stop signs mean stop and look both ways. Learn how to interpret traffic lights. If adolescents are permitted to ride at night. Do not obstruct vision with packages or drag an object behind the bicycle. stop first and look for oncoming traffic. At corners or driveways. Use a bicycle light and reflectors. This means always ride on the right side of the road or street. Be as wary of strangers in cars. Hand signals are to be used when turning or stopping. The College Network. and horseback riders require helmet protection to prevent a head injury if thrown. and attach fluorescent material. Abide by the “Rules of the Road” adapted from the American Academy of Pediatrics “Rules of the Road” at http://www. Copyright © 2008. slow down and be careful of not hitting or scaring people. scuba divers need to be certified prior to diving. ride in single file. Be cognizant of miscellaneous admonitions. Inc. There are also safety recommendations for relatively specialized sports.org/family/bicycle. When on the sidewalk. or paint to bicycle for night riding. One well-known set of bicycle safety instructions comes from the American Academy of Pediatrics (1995): • • • • • • • • • • • • • • • • • • • • • • • At all times. When riding with others. For example. NXP 070106 v1. stops. when the child is seated with hands on the handle bar. take the child with you shopping so that the bicycle may be sized to the child before purchase. When straddling the center bar. adolescents. When buying a new bicycle.htm. Balls of the feet must be able to touch the ground. substance. A bicycle needs to be sized for the child.0 .Unlawful to replicate or distribute sticks. stoplights. they must wear light colors and include fluorescent material on clothing. Unlawful to replicate or distribute • • • • • • • Do not encourage or push children into riding two-wheeled bicycles before they are ready. − Avoid games that bring the boards together. − Protect joints (knees. adolescents. participation in the distribution of free or subsidized helmets. Copyright © 2008. beware of loose shoe ties. usually around age five or six. Legislated bicycle helmet use is associated with a reduction in bicycle-related injury and death. since the younger child is not developmentally ready and cannot protect him or herself from injury. traffic patterns. including bicycle injury.” since these games are especially dangerous. Non-legislative means include community-based health education drives.. Young children are only to ride with parental supervision and never in the street. Permission to ride in the street depends on several factors: chronological and maturational age of child. Children need to be taught how to fill bicycle tires and how to change and patch a tire. skateboarding and in-line skating are increasingly popular sports.g.000 emergency room visits. Such visits. 59% are experienced by children age 15 and younger. and elbows) from injury with protective pads. wrist. Wear shoes that fit securely. condition of streets. and helmet education within the schools. which use simple and focused messages. The College Network. Children age 10–14 years account for the highest death rate.0 . Nurses advocate for helmet use through both legislative and non-legislative means. Results indicated modest but sustained behavior change (King. Learning to ride is an important task that parents need to teach children. Bicycle-related injuries present a problem not only to those who are injured and their families but also to the health of the nation.000 bicycle injury visits to the emergency rooms.. The CDC reports that these injuries account for more than 500.” Maintenance of bicycles is another safety factor. e. LeBlanc & Barrowman. Some specific safety guidelines related to these activities are as follows: • • Skateboards and in-line skates are not for children younger than five years of age. − Never skateboard or in-line skate near traffic. Inc. “catching a ride. Males are more than twice as likely as females to be killed while riding a bicycle on any given trip. and adults who ride skateboards or who in-line skate need to observe the following precautions (American Academy of Pediatrics 1995): − Protect the head with a helmet. NXP 070106 v1. et al. 2005). and more than 700 people die annually from bicycle trauma. An innovative approach is that of the home safety visit. Age and maturity of the child and parental directions guide the use of the bicycle. Children are at the highest risk. Skateboards and in-line skates should be prohibited from streets and highways. Of the 500. and adequate knowledge of the “Rules of the Road. As previously mentioned. were made to families of children admitted to emergency departments with various traumas. Children. There are age and weight rules for infants. Inc. If a child weighs 20 pounds prior to age one. the weight limit is model-specific. NXP 070106 v1.) Other indicators that harness limits have been met are that the child’s shoulders are above the harness slots or the ears have reached the top of the seat. Instructions for each model must be read. After harness weight and/or height limits have been met. Weight as well as height limits vary with the model. since they are particularly dangerous.org/family/carseatguide. of which there are several types. o NEVER use a lap belt alone with a booster seat. Once a child is one year old and weighs 20 pounds or more. The College Network. and similar activities on any kind of skate. riding ramps. Keep the child in the rear-facing car seat until the child reaches the highest allowable age and weight recommendations for the particular car safety seat. and place child safety first. The American Academy of Pediatrics web site provides an overview of these types at http://www. Indicators include the following: • • • • • • Copyright © 2008. the seat can be used as a booster seat. These seats use harness straps for children in the 40–65 pound range.aap.htm. Parents need to be encouraged to attend these classes.0 . Booster seats are used until the child reaches 4’9” in height and is between the ages of 8–12 years of age or until the adult seat belts fit properly. (American Academy of Pediatrics 1995) Infant Car Seats − Infant car seat or infant restraint instructions are also important safety measures and are to be accompanied by assurance that the car restraint will be correctly installed and maintained. Rear-facing car safety seats are never to be placed in the front seat of a vehicle that has a passenger airbag. Rear-facing car safety seats are for all infants who are at least one year of age and are 20 pounds. (Again. teaching the proper installation of car seats and testing the adequacy of ones already installed. There is a “never” rule and a “remember” rule as children use booster seats and then transition into adult car safety belts.Unlawful to replicate or distribute Avoid jumping. Some general guidelines for proper use of car seats are as follows: • • The “always use a car safety seat” rule begins with the first trip home with the infant from the hospital. Both age and weight are factored into the rule. a forward-facing car safety seat may be used. The harness is removed and the vehicle’s lap and shoulder seat belts are used with the booster seat. Parameters are established for car safety seat belts and answering the question of when the child is old enough or large enough to wear adult seat belts. Some car safety seats can be used as both a forward-facing seat for the younger child and a booster seat for the older child. You must use both lap and shoulder belts. as serious injury may occur in the event of an accident. o REMEMBER that seat belts are for adults. the child still needs to use a rear-facing car safety seat. Children’s hospitals have classes for the public at regular intervals. Remembering the letters RACE can help nurses remember the proper fire procedure steps (Potter and Perry 2004). has a rounded toe. All children must be buckled in snugly in their car safety seat. Inc. NXP 070106 v1.seatcheck. not the neck or throat.Unlawful to replicate or distribute • • • The shoulder belt lies across the middle of the chest and shoulder. All car safety restraints must be tightly buckled in the vehicle. Check shoe size at three-month intervals between twelve and thirty-six months and buy new shoes accordingly. without slouching. o If needed.0 .) The main purpose of infant footwear is that of protection. and they may aggravate in-toeing or out-toeing. flexible shoes that retain fit. Fire procedures need to be implemented immediately in the event of a fire. These are signs that the shoes have become too small. and can stay in this position comfortably throughout the trip. The following are safety instructions for ensuring that parents understand the importance of proper infant footwear (Hockenberry 2005): • • Instruct mothers on footwear before the baby begins walking. not the stomach. Copyright © 2008. fire safety procedures represent yet another important area of safety instruction. o Be sure to read the car owner’s manual when installing car seats. ask for help when installing a car safety seat. Observe for curled toes or reddened skin on the bottom of toes when removing shoes. (Inflexible shoes do not provide better support and may cause delays in walking and in development of foot musculature. o Infant Footwear Footwear also influences safety. especially in infants. and has plenty of toe space. o Each car seat is different. Adequate infant walking shoes include inexpensive. Read instructions and keep them handy for reference. Buy soft. • • • • • • Fire Safety Finally. Contact a certified Child Passenger Safety (CPS) Technician at a child safety seat inspection station or call toll-free (866) SEATCHECK (866-732-8243). follow the instructions at all times. o The child is tall enough to sit against the vehicle seat back with legs bent. visit www. and have a smooth interior with few construction seams. All car seats must be properly installed. For help or additional information. are durable. o The lap belt is low and snug across the upper thighs. A good shoe conforms to foot shape.org. The College Network. The space between the shoe and the end of the longest toe should be one half of a thumb’s width. well-constructed sneakers or soft leather moccasins. which contain a sun protection factor (SPF). tanning. − Sweep the fire from side to side.” There are certain safety principles to remember regarding UVA and UVB waves: • • • • • Maximum exposure occurs between 10:00 a. and 3:00 p. NXP 070106 v1. Sun Protection Skin safety interventions. Some substances. and windows.” Ultraviolet B (UVB) waves are shorter and are responsible primarily for burning. or 15 × 10 minutes = 150 minutes). A sun protection factor is a number that indicates how long a person may remain in the sun before burning. • Sun blockers (e. (Adapted from Hockenberry 2005) Other substances partially absorb ultraviolet waves. If it normally takes a person 10 minutes of sun exposure to burn. photoallergic. Think of the “A” as representing “allergy. or 8 × 10 minutes = 80 minutes). or phototoxic reactions. Exposure is greater in higher altitudes. Among the most important of these skin-related measures relate to protecting oneself from the effects of the sun. Think of the “B” as representing “burn. To use the fire extinguisher correctly.Unlawful to replicate or distribute • • • • R = Rescue and remove clients who are in immediate danger. reflect ultraviolet waves. represent another critical category of environmental interventions. E = Extinguish the fire..0 . remember the letters PASS: − Pull pin. regular doors. C = Confine the fire. Say that a product has an SPF of 15. then this product will allow the person to remain in the sun for 150 minutes before burning (SPF × 10 minutes. Among these are the sunscreens. − Squeeze handles. and skin cancer. An understanding of sun protection necessitates knowing the difference between UVA and UVB waves. Close all fire doors. Let’s look at some typical sunscreen protection numbers: • Say that a product has an SPF of 8. − Aim. The College Network. then this product will allow the person to remain in the sun for 80 minutes before burning (SPF × 10 minutes. UV stands for ultraviolet light. topical agents. Inc. and treatments for contact dermatitis.m.m. Ultraviolet A (UVA) waves are longer waves responsible primarily for photosensitivity. coating the area involved. Windows screen out UVB but not UVA rays.g. A = Alarm activation. • Copyright © 2008. such as water and some kinds of sand. Haziness may decrease but does not eliminate UVB wave penetration. zinc oxide and titanium dioxide—the “oxides”) reflect ultraviolet waves. If it normally takes a person 10 minutes of sun exposure to burn. along with associated issues of medications. NXP 070106 v1. and they are also susceptible to the carcinogenic effects of the sun. though. For clothing. It should be noted. oak..0 . those with darker pigmentations may also burn. and vesicular weeping that lasts from ten to fourteen days. or sumac causes an allergic (or immune) reaction characterized by erythema. especially when the reaction is detected early and the cream or gel is applied prior to blister formation Administration of oral corticosteroids if the case is severe Copyright © 2008. Inc. Treatment typically consists of the following: • • • • Use of antipruritic lotions (e. Do not apply sunscreen to infants less than six months of age. For example. including the following: • • • Keep infants out of the sun or physically shaded from it. edema.Unlawful to replicate or distribute • Say that a product has an SPF of 30. use tight weave fibers (e. The College Network. Although those who are most susceptible to serious burning are lightly pigmented individuals. cotton) and darker colors. It is vital to follow the manufacturer’s instructions regarding application. or 30 × 10 minutes = 300 minutes). then the product does screen out both UVA and UVB waves. However.. When this substance is added to the sunscreen. regardless of skin pigmentation. such as under halters or under swimming suit straps. It should also be noted that some sunscreens claim they are effective against both UVA and UVB radiation. Special precautions should also be taken to protect infants from sun exposure. vesicular (blister) formation. then this product will allow the person to remain in the sun for 300 minutes before burning (SPF × 10 minutes. Contact dermatitis caused by poison ivy. poisonous plants affect the skin when contact is made. Caladryl lotion) and Aveeno baths Application of diphenhydramine (Benadryl) lotion to the affected skin Use of topical corticosteroid cream or gel.g. If it normally takes a person 10 minutes of sun exposure to burn. it should be applied to all exposed skin areas. Therefore. itching. and by people of all ages (except those under six months of age). Poison Precautions Poison precautions make up an additional class of environmental safety interventions. No matter what type of sunscreen a person uses.g. Poisoning can occur through contact or ingestion. that a small percentage of people are allergic to PABA. this claim is frequently unsubstantiated unless the screen contains a substance called Parson 1789. sunscreen is needed by all people. Para-aminobenzoic acid (PABA) is one substance frequently included in sunscreens that increases their effectiveness. including skin folds and those areas that may become exposed when clothing moves. the antidote and the manufacturer. it may require years of exposure before developing. wild blackberries. more for their sedating effect than for their antipruritic effect Encouraging the patient not to scratch and/or distracting the patient from the itching that is involved Poison ivy may be prevented by wearing a long-sleeved shirt and long pants when walking in the woods. Inc. Never rely on cooking or heating to destroy toxic substances. Because of their increasing popularity. however. Never store toxic liquids in food containers. since the mixed substances may emit poisonous gases. Read and follow instructions on all labels before using any product. This label contains vital information in the event of a poisoning (e. disinfectants. The College Network. they may be eaten safely only after being properly cleaned. People should also learn to identify poisonous plants and avoid them. Never drink teas or “medicines” made from wild plants or trees. Never mix toxic substances.Unlawful to replicate or distribute • • Administration of sedating antihistamines. Keep the label on toxic substance containers. In addition. Teach children to never eat any part of a wild plant or berry and to never put a wild plant or berry or the leaves. and in some cases. In other words. Wild plants and trees may be poisonous. the number of • • • • • • • • • Copyright © 2008. medications. etc. Label toxic substances with poison warning stickers. should they need to be contacted). Never call medicine “candy” or pretend enjoyment. are more popular today than ever. poisonous mushrooms are being accidentally picked and eaten by people who think they know which are poisonous and which are not. or sumac.g. in the case of poison ivy. poison prevention requires observing the following guidelines: • • • Keep all toxic substances (cleaning fluids. It is important to shower and wash clothes immediately upon return. Poisonous plants and other poisonous substances also pose a major safety threat when ingested.0 . Few people know how to correctly identify edible wild mushrooms or distinguish the edible from the poisonous. Here. NXP 070106 v1. such as Benadryl. there is the basic safety principle that no substance should ever be unlabeled or incorrectly labeled.) locked in cabinets or in a storage space above the reach of children. because someone may think that the substance is food because it is in a food container. Mushrooms. Treat the taking of medicine matter-of-factly. do not glamorize medicine taking in front of children. Never place one toxic substance in a container used for storing another toxic substance. oak.. As a result. stems. Toxic gases may form. A reaction may require multiple exposures. Just because a person has never had a poison ivy (or poison oak or poison sumac) reaction does not mean the person will remain nonreactive. Even then. or some other form of edible berry. or bark of wild plants or berries in their mouth unless a parent absolutely knows that the plants are wild blueberries. Smoke detectors should not be disabled in the event of “nuisance” alarms. and motion sensors. and friends of the location of the number. Mushroom poisoning causes hepatic failure. Not all poisonings require vomiting. Keep syrup of ipecac on hand at all times. sometimes not occurring for twenty-four to forty-eight hours. The College Network. NXP 070106 v1. Copyright © 2008. Note that the fire department in many localities will properly install household alarms.Unlawful to replicate or distribute Fundamentals of Nursing 231 • • mushroom poisoning cases is increasing. One good idea is to replace detector batteries with each resetting of the clocks in the fall and spring. due to a smoking fireplace. Instead. In fact. and the battery should be immediately replaced. or family physician. Keep the phone number of the regional poison control center near or on all phones. toilet and shower/tub grab bars have already been discussed. the risk of death from fire is twice as high in homes without detectors. and so on. Smoke detectors should be tested monthly. he or she should not let embarrassment lead him or her to disable the detector.0 . This ensures continued protection. Owner neglect has resulted in unnecessary deaths from smoke and fire. Other safety devices include smoke detectors. family members. or purchasing a smoke detector with a delay switch should be considered. If the fire department responds to a person’s “nuisance” alarm. and some may be worsened by vomiting. and their batteries should be replaced at least once per year. In the event of a poisoning. Safety Devices There are also a range of devices available to increase the safety of the environment. This is because most deaths from smoke inhalation or fire occur during the night. The United States Consumer Product Safety Commission recommends a monthly check. and in some instances. pediatrician. When battery failure begins to occur. Be sure to notify all babysitters. Onset of symptoms may be delayed. Smoke Detectors Smoke detectors save lives if they are properly maintained. contact the regional poison control center immediately to find out how to proceed. which occur during cooking. Inc. the smoke detector will emit a chirping sound. For example. but do not use it unless instructed to do so by a regional poison control center. Never disable a smoke detector! There should be one smoke detector properly placed on every floor in a house. The most important location is near the bedrooms to alert sleeping members of the household. the detector should be relocated. survival depends on receiving a liver transplant. The safest approach is to teach adults and children never to pick and eat wild mushrooms. carbon monoxide detectors. the windows should be opened to rid the house of smoke. A smoke detector that is properly installed and maintained is considered one of the best and least-expensive ways of preventing these deaths. Carbon monoxide detectors alert households to the build up of dangerous carbon monoxide levels in the air. gas water heaters. The most vulnerable victims are infants and elderly individuals. and drowsiness. stoves. Unless intervention occurs. The battery-operated model requires replacement every two to three years. or tool (e.. unconsciousness results. Exposure to very small amounts is asymptomatic. the detectors should be placed near the ceiling. Excessive amounts of carbon monoxide in the home may occur from malfunctioning appliances.. and automobiles) may produce excessively high levels of carbon monoxide. NXP 070106 v1. etc. The commission also recommends that all fuel-burning appliances (e. every person in the home should be checked for symptoms of headache. The College Network. Recovery at this stage is quick with treatment by oxygen or fresh air. The householdcurrent detector is more difficult to install. but once installed. lawn mowers. headache occurs. If the detector sounds. Whether one buys a household-current or a battery-operated detector. everyone in the house should be immediately evacuated. Any fuel-burning appliance.g. woodstoves. toxic gas. fireplaces. nausea. Failure to leave immediately increases carbon monoxide exposure. symptoms will likely Copyright © 2008. Carbon Monoxide Detectors Carbon monoxide detectors also save lives. Both types of carbon monoxide detectors are in the same price range.Unlawful to replicate or distribute The United States Consumer Product Safety Commissions urges all families to have and rehearse a fire escape plan so that if or when the smoke detector sounds. If any one person has symptoms. Check the device for the UL label. gas dryers. vehicle.g. Once evacuated at a distance from the home. nonelectric furnaces.0 . all family members will know how they are to react and do so promptly. charcoal grills. Some companies that install security systems also install householdcurrent carbon monoxide detectors. with two major distinctions: some are operated by household current.) in the home receive regular maintenance checks by qualified personnel. Carbon monoxide is a colorless. or inadequate home ventilation. A number of different brands are on the market. Inc. it will not need replacement for five to ten years. Symptoms of carbon monoxide poisoning increase as blood levels of the gas increase. and others by battery. running fuel-burning equipment in the home or an attached garage. unconsciousness is followed by death. The United States Consumer Product Safety Commission recommends that a carbon monoxide detector be placed on each floor of a residence with an additional detector on the floor on which the major gas-burning appliances are kept. If exposure to carbon monoxide continues. furnaces. The latter detector should be placed at a distance greater than five feet from the appliances. For most effective use. As the gas continues to accumulate in a room or a car. This progresses to severe headache and is accompanied by nausea. gas stoves. it must be approved by the Underwriters Laboratory (UL). odorless. 2008): • • • • • • • • • • • • • • Explain the purpose of the sensor and the device to the client. There are also leg-band sensors that send an activating signal when the leg approaches a near-vertical position (e. which are position sensitive. and assistive personnel. the nurse should intervene in the following manner (Berman et al. Inc. When using these methods.or chair-exit safety monitoring devices. and an alarm is activated. The alarm sounds if the patient attempts to get out of bed without assistance. Obtain the proper sensor and control unit. These devices. with the sensor sending an alarm if the patient attempts to get out of the chair without assistance.Unlawful to replicate or distribute disappear in the fresh air.0 . Document relevant events. In addition to making sure that the call button is within reach. even if it turns out to be false alarm.g. and Kardex. Motion Sensors Motion sensors and alarms are used to detect unassisted movement that is likely to place a patient at risk. Deactivate the alarm when assisting the client to rise. In this situation. For the bed mattress or chair cushion device. Be sure that the call button is placed within reach of the client and that the patient has been instructed on its use. Test the battery and alarm sound. set the time delay for determining attempt-to-rise-without-assistance movement from one to twelve seconds. The sensor on or near the patient sends out a signal to a control box. NXP 070106 v1. Copyright © 2008. Be sure to explain that the device does not limit mobility but is an alerting device for the staff. Even if all are accounted for and no one is symptomatic. These sensors can be placed under the mattress of a bed at the level of the buttocks (preferred position) or at shoulder level (alternative position). The College Network. Instruct the client to call the nurse whenever he or she needs to get up. Activate the alarm after returning the client to the bed or chair. The same kind of device can be used under the cushion of a chair. place monitoring device stickers on the patient’s door. a qualified heating and service contractor can be called to determine the cause for the alarm. All of these systems have a sensor and an alarm or control device. The home should not be reentered until someone calls 911 from a nearby location and firemen arrive to determine the source of the problem. Apply the sensor pad beneath the bed mattress or chair cushion in the proper location or apply the leg pad following the manufacturer’s instructions. Instruct staff to respond promptly to the client’s call. are called bed. Make the necessary sensor-to-control-box connections so that the alarm will sound if triggered.. chart. walking or throwing one’s legs over side rails or the end of the bed). family. the safest procedure is to leave the home when a detector sounds. or Copyright © 2008. material.to twelve-inch edge only. NXP 070106 v1. al 2008) Even when motion sensors are in place.0 . For example. a staff member. (i) A restraint is— (A) Any manual method. the Department of Health and Human Services regulations pertinent to 42 CFR Part 482. Other types of similar protective devices are actual “very low beds” and/or the placement of thick. All patients have the right to be free from restraint or seclusion. interventions. (1) Definitions.13 Condition of Participation: Patient’s Rights (e) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse. (Adapted from Berman et. rubber mats underneath beds to cushion any fall that might occur. if a client “falls” out of bed. When restraints are used. Indeed. patient safety. or head freely. Patients may also be placed in reclining chairs at an angle that maximizes comfort but prevents them from rising without assistance. physical or mechanical device. A summary of the federal legislation includes the following: • • • Does justice to the rights of patients. nursing homes are now using comfortable. and the extent to which the expected outcomes were met.Unlawful to replicate or distribute • Document all assessments. and corporal punishment. it is sometimes necessary to implement other measures to prevent clients from injuring themselves if they do manage to attempt to stand up. the standard of care is federal law. That way. thick mattresses that may be placed on the floor as low beds.13 as reported in the December 8. Inc. These basic human rights demand that any use of restraint be justified ethically and medically. of any form. Table 13. or to the need for registered and advanced practice nurses to know the legislation that governs their practice in any setting in which Medicare or Medicaid funds are received Makes care of patients who require restraints any more transparent or clear Presents more strongly even to students just entering the field the legal responsibilities of the registered and advanced practice nurse Therefore. body. he or she falls or rolls off a ten. 2006 Federal Register are reprinted below. You will find that the terminology is clinically based and readily understood. or others and must be discontinued at the earliest possible time. revised diagnoses. or equipment that immobilizes or reduces the ability of a patient to move his or her arms. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient. the standard of care is not to use restraints. Use of Restraints: The Standard of Care is Federal Law Patients have the human right to freedom of movement and freedom from restraint. The Joint Commission on Accreditation of Healthcare Organizations concurs with these regulations. legs.5 HHS § 482. The College Network. (ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. (7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. such as orthopedically prescribed devices. Seclusion may only be used for the management of violent or self-destructive behavior. or (C) 1 hour for children under 9 years of age.5 HHS § 482. The College Network. or to protect the patient from falling out of bed. protective helmets.Unlawful to replicate or distribute Table 13. (6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as-needed basis (PRN). or others from harm. (2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm. (C) A restraint does not include devices. surgical dressings or bandages. a staff member. and Copyright © 2008. (B) 2 hours for children and adolescents 9 to 17 years of age. and (ii) Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older. Inc. (5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under § 482.0 . (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient. NXP 070106 v1. a staff member. or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). (4) The use of restraint or seclusion must be— (i) In accordance with a written modification to the patient’s plan of care.13 Condition of Participation: Patient’s Rights (B) A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. (8) Unless superseded by State law that is more restrictive— (i) Each order for restraint or seclusion used for the management of violent or selfdestructive behavior that jeopardizes the immediate physical safety of the patient. or (B) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section. regardless of the length of time identified in the order. and (D) The need to continue or terminate the restraint or seclusion. a staff member. (10) The condition of the patient who is restrained or secluded must be monitored by a physician. (ii) To evaluate— (A) The patient’s immediate situation. (C) The patient’s medical and behavioral condition.Unlawful to replicate or distribute Table 13. Inc. the patient must be seen face-to face within 1 hour after the initiation of the intervention— (i) By a— (A) Physician or other licensed independent practitioner. (9) Restraint or seclusion must be discontinued at the earliest possible time. a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under § 482.0 . other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. or others. NXP 070106 v1. (B) The patient’s reaction to the intervention. (13) States are free to have requirements by statute or regulation that are more restrictive than those contained in paragraph (e)(12)(i) of this section.13 Condition of Participation: Patient’s Rights (ii) After 24 hours. physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. At a minimum. (12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient. before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior.5 HHS § 482.12(c) of this part and authorized to order restraint or seclusion by hospital policy in accordance with State law must see and assess the patient. (iii) Each order for restraint used to ensure the physical safety of the nonviolent or nonself-destructive patient may be renewed as authorized by hospital policy. The College Network. (11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. Copyright © 2008. and providing care for a patient in restraint or seclusion— (i) Before performing any of the actions specified in this paragraph. (2) Training content. (ii) As part of orientation. raining. NXP 070106 v1. (iv) The patient’s condition or symptom(s) that warranted the use of the restraint or seclusion. (f) Standard: Restraint or seclusion: Staff training requirements.0 .12(c) as soon as possible after the completion of the 1-hour face-to-face evaluation. Staff must be trained and able to demonstrate competency in the application of restraints. (iii) Choosing the least restrictive intervention based on an individualized assessment of the patient’s medical. and (iii) Subsequently on a periodic basis consistent with hospital policy. The patient has the right to safe implementation of restraint or seclusion by trained staff. (16) When restraint or seclusion is used. (iii) Alternatives or other less restrictive interventions attempted (as applicable).Unlawful to replicate or distribute Table 13. and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors. (ii) The use of nonphysical intervention skills. The College Network.13 Condition of Participation: Patient’s Rights (14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse or physician assistant. monitoring. including training in how to recognize and respond to signs of physical and psychological distress (for example. (v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored— (i) Face-to-face by an assigned. or behavioral status or condition. (1) Training intervals. or (ii) By trained staff using both video and audio equipment. assessment. (ii) A description of the patient’s behavior and the intervention used. positional asphyxia). This monitoring must be in close proximity to the patient. the trained registered nurse or physician assistant must consult the attending physician or other licensed independent practitioner who is responsible for the care of the patient as specified under § 482. (vi) Monitoring the physical and psychological well-being of the patient who is restrained Copyright © 2008. events. Inc. (15) All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion. trained staff member. The hospital must require appropriate staff to have education.5 HHS § 482. implementation of seclusion. (iv) The safe application and use of all types of restraint or seclusion used in the hospital. and (v) The patient’s response to the intervention(s) used. including the rationale for continued use of the intervention. and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. there must be documentation in the patient’s medical record of the following: (i) The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior. Proper Use of Restraints In some instances. Individuals providing staff training must be qualified as evidenced by education. are described in the subsequent sections. alternatives must be sought in all cases before restraints are used. Correcting the Underlying Problem A number of restraint-avoidance strategies are related to correcting a client’s underlying health problem(s). (3) Staff must document in the patient’s medical record the date and time the death was reported to CMS. Restraint-Avoidance Strategies Since restraints should be a last resort. because restraints pose a serious environmental threat. (g) Standard: Death reporting requirements: Hospitals must report deaths associated with the use of seclusion or restraint. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. restriction of breathing or asphyxiation. vital signs. Nursing interventions in this category include the following: Copyright © 2008.13 Condition of Participation: Patient’s Rights or secluded. (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation. The College Network. there are a number of creative alternatives to their use. different types of restraints call for different standards for application. (4) Training documentation. as outlined by Rogers and Bocchino (1999). deaths related to restrictions of movement for prolonged periods of time. “Reasonable to assume” in this context includes. Inc. and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. (2) Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patient’s death. However. Some popular restraint-avoidance or restraint-substitute strategies.5 HHS § 482. (1) The hospital must report the following information to CMS: (i) Each death that occurs while a patient is in restraint or seclusion. In addition.Unlawful to replicate or distribute Table 13. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. but is not limited to. including required periodic recertification. training. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death. including but not limited to. and experience in techniques used to address patients’ behaviors. NXP 070106 v1. skin integrity. or death related to chest compression. The following sections detail different restraint alternatives and guidelines for use. restraints may be necessary.0 . (3) Trainer requirements. respiratory and circulatory status. monitor for temperature.. Document each category that was assessed. Individualizing the Nursing Approach Other restraint-avoidance strategies involve individualizing one’s nursing approach. Inc. psychotropics. Establish simple rituals and structure the day. Determine the patient’s normal sleeping and rising habits. and pulse oximetry readings). Perhaps the patient only retires at 1:00 a. Monitor for acute urinary retention. A bedside commode. with offers of assisting the patient in its use at frequent intervals. Assess for medication toxicity or interactions. check for bladder distention. notify the physician. Allow the patient to sit in a chair near the nurse’s station until drowsiness occurs.g. sedatives.g. symbolic gestures. These strategies are as follows: • Interpret a client’s behavior. crying. obvious signs of pulmonary or urinary tract infection. Again. such as the quinolones). and the interventions initiated. etc. Assess for pain. If a patient pulls on the nasal cannula.g.0 . and it may be necessary to check for an impaction. narcotics.. When present. Assess electrolytes during the last twenty-four hours or request an order for such.). respiratory rate.m. withdrawal. Frequent attempts to get up from bed may indicate that the patient needs to void or evacuate his or her bowel.m. hopelessness/helplessness. the conclusions drawn or diagnoses made. He or she may not be ready to retire at 9:00 or 9:30 p. Be especially concerned about drugs that cross the blood-brain barrier (e.Unlawful to replicate or distribute • • • • • • • • Assess for hypoxemia (e. and sleeps until 8:00 a. diagnose and treat the pain (obtain an analgesic order. verbal indicators of suicide. Symptoms include changes in sleeping and eating patterns. If abnormalities are present. monitor color. if needed) and then evaluate effects of the treatment. Assess for depression. Confusion dissipates when the bladder is drained and comfort is restored. this may indicate that the patient needs the oxygen to be humidified or lubrication applied or that the cannula needs to be taped in place more comfortably. NXP 070106 v1. and some antibiotics. it is also vital to evaluate the patient’s need for all types of tubes. Keep trying new alternatives. Assess for infection (e. • • • • Evaluating the Need for All Tubes To help avoid the use of restraints. may eliminate or significantly reduce the threat of falling. Check the patient’s pulse oximetry when he or she is breathing room air—oxygen administration may not be necessary. Consult with the pharmacist as needed. or suicide plans.m.. anticholinergics. which is uncomfortable. The College Network. Evaluate nursing outcomes. Some general principles include the following: Copyright © 2008. since the presence of tubes can be upsetting. the administration of IV infusions may upset a patient and increase his or her likelihood of needing restraints. discomfort. Sometimes catheters are left in longer than is necessary. a tube is eliminated—tubes distract and may be a source of discomfort to patients. Consider using an arm board or a freedom splint. Move tubing and bags out of the client’s visual field. since they are preferable to tying down the wrist or arm. patients with arm boards or a freedom splint still require frequent full. try the following actions: Copyright © 2008. Provide good and frequent mouth care to maximize comfort. Dealing with Nasogastric Tubes Just as gastronomy tubes are sometimes necessary. since these can cause confusion or be a source of agitation. Suggest preparing the patient for the removal of a urinary catheter. In order to help prevent patient agitation and avoid the use of restraints. so are nasogastric tubes.0 . However. Provide frequent care at the site of insertion to maximize comfort. Inc. Stabilize the tube to prevent unnecessary movement. Feeding tubes may no longer be necessary in some clients. Thus. To help the patient avoid agitation. consider using these strategies: • • • Cover the insertion site with a loose abdominal binder. Restraintavoidance measures related to NG tubes include the following: • • • • Guide the patient’s hands over the tube while gently explaining its use. To help the patient remain calm. Dealing with Urinary Catheters Clients also sometimes require urinary catheters. passive range of motion exercises. If these measures are ineffective. Tuck the client’s shirt or gown into his or her pants so that the tube cannot be seen. which can be upsetting. a client may require a gastronomy tube. Dealing with Gastrostomy Tubes In some cases. NXP 070106 v1. and the possible need for restraints. the following steps are recommended: • • • Wrap IV tubing and the client’s arm in a compression dressing. With this method. This may be all that is necessary. consider using dummy tubes for the client to pull on. assess patients to determine their need. Administering IV Infusions Sometimes. The College Network.Unlawful to replicate or distribute • • • Capped IV lines are a much preferable alternative to “keep open” IVs. Consult with an occupational therapist to increase the client’s number and variety of activities to decrease boredom and engage the mind. Establish eye contact. Instead. even after the aforementioned strategies are attempted. Use catheter leg bags for patients who forget to carry their bag when walking. Place the catheter bag at the foot of the bed and allow the tubing to run comfortably between the patient’s legs. Explain that the doors are closed only to keep a patient from leaving. walk him or her to the bathroom.Unlawful to replicate or distribute • • • • • Cover the catheter with loose underwear or pants. it may be possible to use leg. close exit doors and leave a sign on them indicating that visitors may enter. Talk calmly and the patient may become calm. and the patient may return eye contact. or chair sensors in preference to restraints. Try nurse-initiated or occupational therapy–initiated music therapy. Patients respond favorably to their favorite music and object less to restraints. Adapting Furniture Restraint use can sometimes also be avoided through proper adaptation of furniture. For example. bed. Consider using the following strategies: • • • Consult with a physical therapist to increase the client’s muscle strength and decrease his or her chances of falling. Implementing Security Measures One final restraint-avoidance strategy is to implement security measures. Using Consultations and Therapy Consultations with other staff members and various forms of therapy can also be helpful restraint-avoidance measures. Principles Governing the Use of Restraints In some cases. it may still be necessary to use restraints with a client. These include the following: Copyright © 2008. Distract the patient with an activity gown containing zippers and buttons. The College Network.0 . As previously mentioned. These include the following guidelines: • • • Always explain what you are going to do in anticipation of doing it. It may also be helpful to position the client in a reclining chair or fashion a wedge cushion for a regular chair to keep the client’s legs higher than his or her hips and prevent him or her from rising unattended. Do not try to convince the patient with a catheter that the urge to void is not real. there are several important principles that must be observed in all cases. Minimizing the Probability of Combativeness Other strategies are aimed at minimizing the patient’s probability of combativeness. Since the application of restraints is associated with a number of environmental risks. Never touch a cognitively impaired person before telling the patient your intent. NXP 070106 v1. Inc. If a restraint must be applied. sensors) possible. it is also critical to observe the following government regulations: • • • Restraints may only be applied with a physician’s order. If it is an emergency situation. Consider alternatives to restraints and implement them. 3. Provide emotional support verbally and through touch during and after restraint application. 6. but not enough to remove the tube. Copyright © 2008. Document all steps thoroughly. The client or the client’s guardian must agree to restraint of the client.. Six other vital principles to be observed with regard to restraint use are as follows: 1. Apply all restraints so that they may be released quickly in the event of an emergency. leg bands. The order must specify why the restraint is being used and the length of time it is to be used. they must not be applied so tightly as to impair circulation. Restraints are never to be used punitively or for the convenience of the nurse or staff. If restraints are necessary. The client must be free of restraints not required to treat his or her medical symptoms. While restraints are to be secure.g. In cases in which physical restraints are needed as a last resort. In the process of obtaining consent. keep the following five criteria in mind: 1. if the patient needs wrist restraints to prevent removal of an endotracheal tube.Unlawful to replicate or distribute • • • • • • • Obtain a physician order for restraints. 5. For example. Consider physical restraint only as a last resort and limit the time of its use. Restraints must not interfere with the patient’s treatment or health. assure the patient/guardian that the restraint is temporary and intended to keep him or her safe. 2. The College Network. The restraint must be readily changeable (and with the least possible amount of disturbance to the client). Assess the patient thoroughly for the cause of the agitation or confusion. NXP 070106 v1. 3. 2.0 . The use of restraints does not mean that the patient is not turned or that the restraints are applied so tightly that circulation is impaired. it must be applied safely. then apply the restraints so that the patient is in a comfortable position and has some elbow mobility. If both wrists need to be restrained. Evaluate the results of these alternatives. do not restrain the ankles as well. 4. use the least restrictive ones (e. To select an appropriate restraint and use it in the safest manner possible. Inc. obtain the order within twenty-four hours of application. Apply restraints with the related body part in a normal anatomic position. Restrict the patient’s movement as little as possible. persistent redness.Unlawful to replicate or distribute 4. Here. several different kinds of restraints are available for use with patients. • The nurse should also reassess the patient’s need for restraint. He or she should check the patient’s signs (color and warmth of skin distal to the restraint. Any alternative interventions that were attempted. A child could climb out of a crib and be left hanging by the one-wrist restraint. Finally.. the nurse should log the response. the nurse should remove the restraint but not leave the patient unattended. exercise the limb. The patient’s response to the restraint(s) at thirty-minute intervals. the nurse should remove the restraint. The restraint should not be the means by which the patient self-inflicts injury. the restraint order that was given. The restraint must be discreet.0 . The times at which the patient was given joint mobility exercises and skin care (e. impairment of flexion or extension. change in flexion or extension). The time the physician was notified. inflicting injury. intact. cyanosis. Copyright © 2008. At the first sign. At these times. NXP 070106 v1.g.. On the other hand. tingling. The time the restraint was applied. looking for pathologic signs of pallor. abraded areas).g. and any interventions made.to four-hour intervals). the nurse should loosen the restraint. Inc. coolness) and symptoms (pain. freely movable. limb restraints. Persistent redness or any abraded areas must be reported immediately to the nurse in charge or to the physician. This means it must be the least obvious kind of restraint to others. mitts/hand restraints. These include vest restraints. If necessary.. If necessary. the nurse should document the mobility of the joint (i. Client/guardian permission for restraint and the explanation given. and mummy restraints. After restraint use is discontinued. at two. the condition of the skin (e. he or she should also assess the patient’s skin condition and joint mobility. use a jacket restraint with a child rather than restraining him or her by one wrist. numbness). and note the patient’s response. since restraints cause embarrassment to patients and to their visitors. in all cases in which restraints are applied. but he or she should not leave the patient unattended. The objective is to minimize embarrassment. a child could not climb out of a crib with a jacket restraint. every eight hours. it is vital that the nurse document the following: • • • • • • Nursing assessment and diagnoses. For example. The restraint must be safe for the particular client. 5. elbow restraints.e. safety straps or belts. Any persistent signs or symptoms should be immediately reported to the nurse in charge or to the physician. Various Kinds of Restraints and Their Application As previously mentioned. and the reason for the restraint. including the presence or absence of the behavior that initiated the request for restraint. The College Network. Inc. make sure both sections are functional. Kozier et al. According to FDA regulations. If the patient is in a chair or wheelchair. Do not attach the ties to the top of the bed. in the case of severe poison ivy reactions). manufacturers need to label the front and the back of vest restraints. Leave the patient only after ensuring that he or she is properly positioned and that a call device is within reach.g. NXP 070106 v1. Place the vest on the patient according to the manufacturer’s front and back indications. The tails are tied to the bed frame under the mattress or to the back of a chair. Repeat this step for the other tie. Make sure that the restraint allows for proper and full excursion of air and expansion of the chest wall. Mitts/Hand Restraints Mitts or hand restraints are used to prevent confused patients from scratching and injuring themselves.Unlawful to replicate or distribute Vest Restraints Vest restraints are varied but all are sleeveless jackets with tails. since this applies pressure to the axilla and may result in a brachial plexus injury. the patient will be squeezed by the restraint.0 . Never attach the ties to a side rail or to the fixed frame portion of the bed. They are placed around the client’s waist and secured in the back of the wheelchair or stretcher. ensuring its adequacy. and provide passive exercises. Interventions for proper safety strap use include the following: • • • Check the condition of the safety belt. Pull one tie on one side of the vest and place it in the slit on the opposite side. Copyright © 2008. (2000) suggest the following interventions for proper use of vest restraints: • • • • • • • Make sure the vest is the proper size. wash the patient’s hands. The College Network. place it over the patient’s hips or abdomen. Do attach the ties lateral to the chest on a part of the bed that does not move when the head of the bed is raised or lowered. • • Safety Straps or Belts Safety straps or belts are used to protect a client from falling as he or she is being moved on a stretcher or wheelchair.. because when the head is elevated. remove them every two to four hours. fasten the belt behind the chair. If the belt is being applied to a patient on a stretcher. Use a half-bow knot (quick-release knot) to secure each tie around the movable bed frame or behind the chair. Check the patient frequently. If mitts are used for several days. Mitts are also sometimes recommended for cognitively intact persons during sleep to prevent them from scratching severely itching areas of the body (e. If Velcro ties are used. Make sure circulation is intact.0 . including the ends. Make sure all tongue depressors are securely covered. Never use a tie that will tighten when pulled. Fold back one corner. Attach the tie to the bed.Unlawful to replicate or distribute Limb Restraints Limb restraints in the form of wrist or ankle restraints are mostly used to restrict movement in a patient’s limb during IV infusions. with the material. Associated interventions include the following: • • • • • Obtain a sheet or blanket large enough that the distance between two diagonal ends is about double the length of the child’s body. with the crease at the foldeddown corner slightly above the child’s shoulders. Place the child’s elbow in the center of the restraint. using a quick-release knot. pad the patient’s bony prominences to prevent skin breakdown if the patient is susceptible to such. The restraint is composed of material containing elongated pockets into which tongue depressors are placed to immobilize the limb. Pull the tie through the hole on its opposite side. Wrap the restraint smoothly around the arm. Make sure two fingers can be inserted between the restraint and the wrist or ankle. Place the blanket on a dry. Elbow Restraints Elbow restraints are used in the care of infants or small children to prevent flexing an arm to scratch or touch a skin lesion on the face or head or when a scalp infusion is being administered. Mummy Restraints A mummy restraint is a blanket wrapped in a special way to enclose a child’s body to prevent movement during a procedure such as a gastric lavage or an eye irrigation or to draw a blood sample. Place the child on the blanket in a supine position. but do not cause discomfort or impair circulation. Interventions associated with their use include the following: • • • • • • • Insert tongue depressors after making sure they are unbroken. Copyright © 2008. flat surface. Inc. The College Network. Fold the right side of the blanket over the infant’s body. Apply the padded portion of the restraint around the ankle or wrist. Some principles for their use are as follows: • • • • • Before applying. Secure the restraint by tying the ties. NXP 070106 v1. Remove the restraint and exercise the child’s arm at regular and frequent intervals. leaving the left arm free. material. 483. On June 22. Do not leave the baby alone with a mummy restraint on. this same Copyright © 2008. Fold the left end of the blanket over the baby and tuck it under the body. Bring the point of the blanket below the child’s feet up and over the child’s body.R. unwrap the child and provide comfort as needed. On June 22.6 CMS Definition and Interpretation of Patient Restraint Regulations Issue The Centers for Medicare & Medicaid Services (CMS) is committed to reducing unnecessary physical restraint use in nursing homes and ensuring residents are free of physical restraints unless permitted by regulation. Table 13.Unlawful to replicate or distribute • • • • • Tuck the right side of the blanket under the child. Table 3. Appendix PP as.” Albeit for different functions. Then.F.5 presents the definitions outlined by this document. Proper interpretation of the physical restraint definition is necessary in order to understand whether or not nursing homes are accurately assessing devices as physical restraints and meeting the federal requirement for restraint use. The College Network. Long-Term Care Facilities and Restraint Use One component of the 1987 Omnibus Budget Reconciliation Act (OBRA) states that nursing home residents have the right to be free from physical or chemical restraints that are not required to treat specific medical symptoms. CMS issued a clarification of the December 8. or equipment attached or adjacent to the resident’s body that the individual cannot remove easily which restricts freedom of movement or normal access to one’s body.13(a) provides that “the resident has the right to be free from any physical or chemical restraints imposed for discipline or convenience. but make sure that the right arm is in a natural position. Legal and Ethical Issues Related to Environmental Safety Several important legal and ethical issues revolve around environmental safety.” CMS defines “physical restraints” in the State Operations Manual (SOM). NXP 070106 v1. Background 42 C. the United States Centers for Medicare and Medicaid Services recognized this right as well as the need for clarification. until the procedure is complete. This memorandum from CMS was designed to give the State Survey Agencies clarification on the definition of physical restraints and the implications of these requirements for long term care facilities. Now. “any manual method or physical or mechanical device. and not required to treat the resident’s medical symptom. 2006 federal regulations on human restraint in hospitals to address those rights within longterm facilities. place the left arm of the infant beside the body.0 . Inc. Remain with the child the entire time. Position the arm naturally. 2007. Some issues worth noting include those related to restraint use and safety programs and research. 2007. get to the bathroom in time). and help the resident attain or maintain his or her highest level of physical or psychological well-being. Medical symptoms that warrant the use of restraints must be documented in the resident’s medical record. Definitions • • “Freedom of Movement” means any change in place or position for the body or any part of the body that the person is physically able to control.Unlawful to replicate or distribute Table 13. for residents whose care plans indicate the need for restraints that the facility engages in a systematic and gradual process towards reducing restraints (e. This systematic process also applies to recently admitted residents for whom restraints were used in the previous setting. circumstances. Inc. the MDS and QM do not capture all physical restraints used because of the MDS’s limited categories and the QM’s calculation methods. siderails are put down. physical restraints should not be used without also seeking to identify and address the physical or psychological condition causing the medical symptom.g. Before a resident is restrained. There must be a link between the restraint use and how it benefits the resident by addressing the medical symptom. material. rather. the resident’s medical symptoms should not be viewed in isolation. and care plans. ongoing assessments.g. gradually increasing the time for ambulation and strengthening activities). “Remove Easily” means that the manual method. as a temporary symptomatic intervention while the actual cause of the medical symptom is being evaluated and managed. protect the resident’s safety.6 CMS Definition and Interpretation of Patient Restraint Regulations definition is used in the SOM. physical restraints Copyright © 2008. Discussion The following clarifications are meant to be used in conjunction with the definition of physical restraints.. Therefore. The physician’s order alone is not sufficient to justify restraint use. and environment. whether or not those restraints are captured on the MDS or in the QM. Restraints may be used.. Despite using the same definition. the symptoms should be viewed in the context of the resident’s condition. The College Network. Ultimately. In addition. and in the Quality Measure (QM). buckles are intentionally unbuckled. Objective findings derived from clinical evaluation and the resident’s subjective symptoms should be considered to determine the presence of a medical symptom.) considering the resident’s physical condition and ability to accomplish objective (e. as with other interventions. the Resident Assessment Instrument User’s Manual and subsequently the Minimum Data Set (MDS). etc.0 .. Additionally. transfer to a chair. less restrictive intervention and a restraint is required to treat the medical symptom. The resident’s subjective symptoms may not be used as the sole basis for using a restraint. surveyors should focus on the appropriate use of all physical restraints. CMS will hold the facility ultimately accountable for the appropriateness of that determination. • Physical restraints as an intervention do not treat the underlying causes of medical symptoms. While there must be a physician’s order reflecting the presence of a medical symptom. NXP 070106 v1. “Medical Symptom” is defined as an indication or characteristic of a physical or psychological condition. It is further expected. ties or knots are intentionally untied. not climbed over.g. or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e. device. the facility must determine that the resident has a specific medical symptom that cannot be addressed by another. if warranted. serious drawbacks and can contribute to serious injuries. the FDA lists the following legal considerations regarding restraint use: 1. In addition.10(b)(4) and 483. Restraints limit mobility and increase the risk for a number of adverse outcomes. Physical restraints certainly do not eliminate falls. Staff must document the need to restrain. Although restraints have been traditionally used as a falls prevention approach. falls that occur while a person is physically restrained often result in more severe injuries. There is no evidence that the use of physical restraints. A patient in restraints requires frequent monitoring. will prevent or reduce falls. Additionally. NXP 070106 v1. In fact in some instances reducing the use of physical restraints may actually decrease the risk of falling. 3.Unlawful to replicate or distribute Table 13. If the resident needs emergency care. A resident who is injuring himself/herself or is threatening physical harm to others may be restrained in an emergency to safeguard the resident and others.F. The resident's right to participate in care planning and the right to refuse treatment are addressed at 42 C. Considerations of Restraint Use The Food and Drug Administration (FDA) also indicates that patients have a right to be free from restraint (Rogers and Bocchino 1999). 2. Note: Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Manufacturers need to label restraining devices so that the manufacturer’s brand name and the restraint size may be included when documenting their application. 4.R. Inc. Conclusion Although the requirements describe the narrow instances when physical restraints may be used. they have major. and no other less restrictive or less risky interventions exist. Restraining devices must be appropriately selected and properly applied.0 .6 CMS Definition and Interpretation of Patient Restraint Regulations may be used as a symptomatic intervention when they are immediately necessary to prevent a resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment. 5. The College Network. The use of physical restraints should be limited to preventing the resident from interfering with life-sustaining procedures only and not for routine care.20(k)(2)(ii) respectively. as long as those restraints are used as a last resort to protect the safety of the resident or others and use is limited to the immediate episode. restraints may be used for brief periods to permit medical treatment to proceed. A resident whose unanticipated violent or aggressive behavior places him/her or others in imminent danger does not have the right to refuse the use of restraints. Copyright © 2008. Need for restraint implies that the patient has been assessed and other interventions or methods have been tried so that physical restraint is justified only as a last resort. Health care facilities are obligated to have policies covering the use of restraints. including but not limited to side rails. unless the resident or legal representative has previously made a valid refusal of the treatment in question. growing evidence supports that physical restraints have a limited role in medical care. §§483. which must be documented. then the nurse who represents the agency has the obligation to obtain consent from an appointed guardian or surrogate. but human dignity. in 1992. or under legal age). Individualize restraint. 2. Food and Drug Administration data indicate that. the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends that restraints only be used when clinically necessary and as a last resort. 9. Finally.Unlawful to replicate or distribute A nurse must know a health care agency’s restraint policies. sedated. In some states. Research has additionally shown that restraints double the length of a patient’s hospital stay (Janelli Copyright © 2008. NXP 070106 v1. 4. These recommendations don’t just make sense from a legal point of view. condition. These steps may be considered restraint use principles: 1. The College Network. 8. and this number is likely to be an underestimate of the actual number (Rogers and Bocchino 1999). In citing JCAHO’s concern. there were at least one hundred restraint-related deaths. Inc. obtain a physician order if restraints are the last resort. Berman et al. in the face of a client’s refusal to sign a release from liability statement.. or. In either case. Speak with the family or caregiver and enlist their help in seeking solutions other than restraint. the agency may decide to refuse to continue care. 7. The nursing responsibility for patient safety or remaining with a client cannot be legally delegated to a family member. compromised in terms of mental status for any reason. 5. 6. and respect as well. If a patient is incompetent (e. to prevent serious disruption of treatment.g. Reassess the patient to determine whether alternative measures are successful. In discussing client consent. the interaction and results need to be documented. Note important information in the patient chart. Alert the physician. or to prevent significant property damage. Evaluate the patient’s potential for injury and know your state’s laws. not past. In the case of the former. (2008) rightly distinguish between the competent adult client who has a right to make personal decisions regarding care and treatment and the person who is determined to be legally incompetent. For example. Place a time limit on the use of restraints. value. Base your decision on the patient’s current.0 . They are ethical and common-sense positions that preserve not only the client’s human rights. Issues Related to Safety Programs and Research Several research studies have been conducted on a number of different environmental safety issues. Try alternative measures first. the agency may require the patient’s signature on a release from liability statement. competent individual. recovering from anesthesia. like OBRA and the FDA. DiBartolo (1998) cites nine steps that the nurse needs to follow to minimize the chances of becoming involved in a lawsuit. 3. either because of age or mental status. and of course. restraints may only be applied if there is imminent harm to the patient or to others. those assigned to small group fall-prevention instruction made more changes than those assigned to the one-on-one session. Control subjects received health promotion information but no information specific to fall prevention. 1987). Of these. Kapp 1996). Whether assigned to a small group session or to a one-on-one session. Bedrails can pose a threat. flashlights. the specific knowledge and skills that are used in working with these patients are diagnostic-specific. When the use of restraints decreases.. Restrained patients who fall sustain more serious injury than unrestrained patients (Tinetti et al. Fall-prevention studies have also been conducted. Predictors of restraint use in this study were abnormal mental status exam. and rearranging furniture to maximize safety. purchasing night-lights. For example. and the use of monitoring or support devices. Furthermore. These changes included avoiding use of bath oils in the bathtub/shower. 67 percent were restrained at the time of the fall (Janelli 1995). state. 41 percent had their side rails up. Disaster Preparedness The same standards of nursing practice and of performance apply when working in disaster preparedness. the measures discussed in this chapter) be used. Inc. Eighty-one percent of those patients who remove their endotracheal tubes are restrained at the wrists (Taggert and Lind 1994). eliminating scatter rugs and clutter.g. At the same time. are managing a therapeutic regimen ineffectively. In any professional activity. and agency levels. such as intravenous lines. 1992. The College Network. local. or have diabetes mellitus or depression. The sample consisted of forty-five women aged sixty-five years and older who were randomly assigned to a fall-prevention small group session. regional. relate to process activities. Acquiring this knowledge and skill and applying it successfully may be considered a professional task for which registered nurses are accountable. infection. national. and deconditioning (Evans and Strumpf 1990).0 . a fall-prevention one-on-one session. Restrained patients are eight times more likely to die than unrestrained patients (Robbins et al. Restraints predispose clients to depression. Ryan and Spellbring (1996) conducted a fall-prevention study to evaluate the effectiveness of fall-prevention instruction on changes in fall-prevention behavior. falls increase slightly. dementia diagnosis. These activities are expected whether the patients we are working with possess deficient knowledge. patients have been asphyxiated after becoming entrapped between a bedrail and a mattress (Parker and Miles 1997). This preparedness occurs at the global. anger. subjects who received fall-prevention instruction made more fall-prevention changes than those assigned to the control group. Of those patients who fall from a hospital bed. the standards of nursing practice. which are built on the nursing process. pressure ulcers. or to a control group. NXP 070106 v1. The authors recommended that surveillance be heightened in this group of patients and prevention methods (e.Unlawful to replicate or distribute 1995). and nonskid mats. but serious injuries decrease (Evans and Strumpf 1990). surgery. Copyright © 2008. two factors need to be considered: process and task. and all health professionals. The College Network. Minnesota during the summer of 2007). Inc. “This department provides surveillance. (e. Therefore..g. Another issue needs to be discussed before presenting these competencies. At such times. Regardless of the care settings. Any skill requires practice.g.) Copyright © 2008. all advanced practice nurses. The same holds true for these core competencies. is a public health event that affects health care professionals in all health care settings. rehabilitation. Table 13. etc. the collapse of the bridge over the Mississippi River in Minneapolis. This is incorrect thinking.. and weather emergencies. They are based on a CDC document titled Bioterrorism and Emergency Preparedness: Competencies for All Public Health Workers. fax. or even primary care settings. Before enumerating the core competencies. Some skills are so seldom required that few obtain the practice they need to become proficient. NXP 070106 v1. long-term care. natural disasters.Unlawful to replicate or distribute There are nine competencies associated with both process and task activities in the study of emergency preparedness. because bioterrorism. 5 Demonstrate correct use of all communication equipment used for emergency communication (phone. all health professionals become members of a team that is responding to and sometimes directed by public health authorities. radio.0 . 4 Describe his/her functional role(s) in emergency response and demonstrate his/her role(s) in regular drills. investigation and public information in disease outbreaks and collaborates with other agencies in biological.7 Core Competencies for All Public Health Workers: Process Skills Core Process Competency 1 Describe the public heath role in emergency response in a range of emergencies that might arise. or a disaster of any nature. 3 Identify and locate the agency emergency response plan (or the pertinent portion of the plan). it is important to say that the phrase “for all public health workers” may lead some to think that these competencies are not applicable in acute care. these competencies are for all registered nurses. (e.”) 2 Describe the chain of command in emergency response. The first set of competencies discussed in this section may be considered process competencies. environmental. Given such reasoning. demonstration and return demonstration sessions are developed so that the skills can be practiced even though the skills may never be needed. structures need to be established so that these core competencies may be practiced and tested. This document was developed by the Columbia University School of Nursing Center for Health Policy in 2002. including burns. NXP 070106 v1. and other diseases Mass casualties.Unlawful to replicate or distribute Table 13. neighbors) 7 Identify limits to own knowledge/skill/authority and identify key system resources for referring matters that exceed these limits. the use of the automated external defibrillator.cdc. These are no longer sufficient. including exposure to chlorine. are part of the basic knowledge and skill set of the new generation of professional nurses—today’s nursing students. accessible at http://www. which devastated the coast of New Orleans in the summer of 2005. Because they were not an integral part of curriculum of yesterday.0 .bt. and others Copyright © 2008. and injuries Chemical emergencies. The key is to be prepared to practice should the event occur. including outbreaks of anthrax. Core Bioterrorism and Disaster Preparedness Competencies: Professional Task or Functional Role Nursing Skills At one time.g. Like the above process competencies for emergency situations. These competencies. The requisite knowledge is presented within the CDC Emergency Preparedness and Response site categories. in an age when massive bioterrorism events are a threat and in the wake of huge natural disasters such as Hurricane Katrina. 8 Recognize unusual events that might indicate an emergency and describe appropriate action (e. nerve agents. These categories are the following: • • • Bioterrorism emergencies. explosions/blasts. and. however. however. To learn such skills will require effort on the part of all registered nurses. plague. faculty will need to teach new content and practicing nurses will need to update their knowledge and skills bases.gov. ricin. Q fever.7 Core Competencies for All Public Health Workers: Process Skills Core Process Competency 6 Describe communication role(s) in emergency response: within the agency using established communication systems • With the media • With the general public • Personal (with family..) 9 Apply creative problem solving and flexible thinking to unusual challenges within his/her functional responsibilities and evaluate effectiveness of all actions taken. The College Network. communicate clearly within the chain of command. cardiopulmonary resuscitation. more recently. Inc. emergency preparedness skills for nurses consisted of learning basic and advanced first aid skills. tularemia. these competencies will not be practiced frequently. toxic alcohols. The purpose of this section is to present the basic competencies needed in the face of such realities. on the web page of each of the above CDC categories. In such cases. NXP 070106 v1. The most current field triage decision scheme was prepared in 2006. Its aim is to provide criteria for pre-hospital personnel to use when transporting Copyright © 2008. and other hazards Outbreaks and incidents. Still. and others Radiation emergencies. an epidemic outbreak of salmonella in a community. the knowledge base for nursing is a resource that can be tapped to frame this new bioterrorism and emergency preparedness information. nuclear blasts. the sense of being overwhelmed by the sheer amount of new information is lessened and preparedness is facilitated. and continue the nursing process Once there is a framework for professional development and the acquisition of new competencies. extreme heat. it is useful to be able to place the new information within a known knowledge base. For example. including exposure to salmonella. including floods. There is a randomness to these events that cannot be predicted. wildfires. there is information for professional training and continuing education. Mass Casualty Triage Protocols A bioterrorism event or a major natural disease may result in mass casualties. Furthermore. or botulism and incidents such as bridge collapse It should be obvious from the extent of this list that no one professional is going to be an expert in handling every potential emergency. The above competencies apply whether the event is an earthquake. These protocols are driven by algorithms prepared by the CDC in collaboration with other national agencies. professionals prepare for the unpredictable. Registered nurses will find themselves responsible for keeping up to date on disaster preparedness skills and for planning emergency strategies with supervised staff.Unlawful to replicate or distribute • • • Natural diseases and severe weather. asbestos. including some video presentations.0 . an essential part of bioterrorism and emergency preparedness is staff education. such as the National Highway Traffic Safety Administration. Fortunately. This knowledge base includes the following competencies for the registered nurse: • • • • • • • • Apply the principles needed to protect self so as to be able to assist others Conduct surveillance and report unusual occurrences or clinical findings to proper authorities Triage patients Assess individual patients Diagnose the risk involved Identify expected outcomes in the immediate future Plan emergency strategies individually as well as in collaboration with interprofessional teams Evaluate immediate outcomes of. health professionals rely on mass casualty triage protocols. or the release of a chemical agent in the broader population. necessitating triage. hurricanes. including acute radiation syndrome and exposure to dirty bombs. polonium. The College Network. When learning new content. There is on the CDC web site a wealth of learning tools available. Inc. reassess. as in the treatment of Ebola virus. and total body gear. environments.Unlawful to replicate or distribute trauma victims. lungs (masks.. working in conjunction with the National Institute for Occupational Safety and Heath. For example. or missile. administration. Even preplanning. and decontamination or disinfection. respirators). eyes (goggles). about one-third of the acute casualties are considered critical. the goal of the triage decision scheme is to match the severity of the injury with the given allocation of resources and expertise. require emergency surgery. patient placement. The CDC “Field Triage Decision Scheme” provides the basis for the development of nationally consistent field triage protocols used locally by EMS and trauma systems throughout the United States. Infection Control Practices In the event of a major epidemic. and community and public health groups to coordinate practices and plan for emergency situations Copyright © 2008. NXP 070106 v1. Predictions of injury severity are another factor involved in the development of mass casualty triage protocols. gloves). data indicate that when the weapon is a bomb. head (helmets).g. specific hospital equipment. however. Issues that must be considered include standard precautions. has developed a resource base for Personal Protective Equipment (PPE). These patients are treated and released from the emergency department. or require hospitalization.0 . infection control practices are crucial in the prevention of the infection’s spread. meaning one-third of victims are dead on the scene. Personal Protective Equipment (PPE) The CDC. PPE is body part–specific. Since trauma centers lower trauma-associated mortality and since the clinical needs of the more severely injured are best addressed in trauma center settings. The College Network. which is disease. protection of health workers. rocket. requires considerable use of resources. These steps often include the following: • • • • • Learning how the disease transmits and identifying transmission risks (e.and hazard-specific barrier gear. The task would be overwhelming were measures for such an event not preplanned. Inc. These personnel have the option of transporting trauma victims to a trauma center or to a non-specialized acute care facility. or procedures) Ensuring proper use of Personal Protective Equipment (PPE) by health care workers Training health care personnel in recognition of early signs or symptoms of the infection and in procedures to follow up with symptomatic patients Initiating cleaning and disinfecting procedures in waiting rooms and common areas as well as in rooms and beds occupied by infected patients Collaborating with hospital staff. but most plans comprise a similar set of basic principles and steps. About two-thirds of the casualties are less serious. die at the hospital. Examples of the organs protected by various kinds of PPE follow: skin (gowns. Infection control practices are disease-specific. face (face shields). intrusive thoughts.0 . Signs of acute stress include inability to function. insomnia. and exhaustion. Inc. The College Network.Unlawful to replicate or distribute Fundamentals of Nursing 255 Mental Health and Equilibrium in a Crisis Professionals and patients alike are subject to stress in the midst of a crisis. It is as imperative for professionals to recognize these problems and seek help for psychological reactions to stress as it is for patients. NXP 070106 v1. acute anxiety. Copyright © 2008. withdrawal. Unlawful to replicate or distribute Copyright © 2008.0 . Inc. NXP 070106 v1. The College Network. Explain why laboratory and other diagnostic test results have safety implications for clients. The College Network. We also explain why including the words “related to” in any diagnoses of a patient’s safety needs is so important. you should be able to do the following: 1. In addition.0 . Explain why historical data is important to gather when doing a health history. the last phase of the nursing process. Explain how accumulation of risks affects the prioritization of safety needs when planning nursing interventions. 5. Identify possible North American Nursing Diagnosis Association (NANDA) diagnoses that relate to environmental safety issues. NXP 070106 v1. We investigate why this concept is so important in the prioritization of safety needs for different populations. The chapter then provides detailed examples of outcomes related to environmental safety issues for children and throughout the life span. 4. Introduction As previously discussed. 7. It is here that we discuss an important nursing issue related to safety—the accumulation of risks. factors influencing a patient’s environmental safety. This chapter provides a concrete example of the nursing process “in action” as we apply its components to injury prevention.Unlawful to replicate or distribute Chapter 14: The Nursing Process Related to Injury Prevention Objectives Upon completion of this chapter. We begin the chapter by discussing the assessment phase of the nursing process and the importance of collecting and analyzing a comprehensive health history. Identify possible outcomes related to safety measures in each of the eight life span stages. Inc. Again. and specific laboratory findings that have safety implications. We then look at nursing diagnoses and the North American Nursing Diagnosis Association (NANDA) diagnoses that relate directly to environmental safety. skills. Describe the role of the client during the implementation and evaluation phases of the nursing process. Explain why it is imperative to consider the “related to” factors when the diagnosis is about patient safety. 3. 2. We conclude by looking at evaluation. the nursing process provides the framework for the unique combination of knowledge. and caring that constitutes the art and science of nursing. we look at the implementation phase of the nursing process and the importance of anticipating client needs when discussing intervention strategies. Our discussion then turns to the planning phase of the nursing process. the Copyright © 2008. Identify the key variables that play a role in a client’s safety. 8. 6. ..g. this data includes a health history. Safety Factors Various factors influencing the client’s environmental safety also need to be determined. or gait/ locomotion/coordination difficulties Cultural and spiritual/religious considerations Socioeconomic factors Environmental factors (home. Since these factors were described in detail in the preceding chapter. Assessment Assessment refers to the gathering of health data. along with the goal of an effective evaluation (i. head injuries. or other serious injuries (e. burns) provides insight into a client’s risk-taking behavior and exposure to violent behavior. community. and laboratory findings and other objective health information.g. The College Network. pain. workplace) Psychological factors • • • • Copyright © 2008. NXP 070106 v1. The following are variables that play a role in a client’s safety: • • • Age/developmental level Individual preferences and patterns (risk-taking or risk-avoidance behavior) Physical condition/health status. fractures. Historical data is important. including: − High-risk conditions (e.e. decreased caloric or protein intake) − Impaired emotional responsiveness − Gait or locomotion difficulties − Sensory deficits − Cognitive deficits − Pharmacologic agents that may cause cognition.0 . prolonged bed rest. Prior history of falls.g. neurological conditions) − Debilitating diseases that increase weakness or fatigue − Debilitation (e. disuse syndrome. Inc.Unlawful to replicate or distribute importance of client input is stressed. In relation to environmental safety. factors influencing a patient’s environmental safety.. response time. This data also helps the nurse understand the safety level in prior environments that the client worked or lived in. Health History One of the first things a nurse should consider during assessment related to injury prevention is a patient’s health history.. they will simply be categorized here. the comparison of the expected outcomes versus those actually attained). Are the patient’s hematocrit and hemoglobin levels significantly reduced? If yes.. The nurse should also consult with the physician and a social worker regarding the development of an approach to address the issue of possible alcohol abuse. Diagnosis After collecting the assessment data.0 . do a patient’s X-ray reports indicate multiple prior fractures? If so. and take measures to increase the patient’s food intake. knowledge deficit related to electrical safety in the home) Impaired memory Impaired physical mobility Rape-trauma syndrome (the syndrome itself as well as its compound and silent reactions) Sleep deprivation Impaired social interaction Risk for suffocation • • • • • • • • • Copyright © 2008. and workplace) and within the health care agency (e. dizziness.g. community. fatigue. NXP 070106 v1. the nurse should notify the physician immediately and think of the signs and symptoms that accompany anemia. Is the patient’s serum albumin level below normal? If yes. Is the client’s blood alcohol level significantly elevated? If so. this information needs to be analyzed in order to derive nursing diagnoses. the nurse should take measures to prevent the client from falling if he or she is still under the influence of alcohol. Inc.g. and syncope. North American Nursing Diagnosis Association (NANDA) diagnoses that relate to environmental safety issues include the following: • • • • • • • • Acute confusion Chronic confusion Dysfunctional family processes (e. notify the physician and the nutritionist. For example.Unlawful to replicate or distribute Laboratory Findings Laboratory and other diagnostic test results also have safety implications. The College Network. within the home. alcoholism) Fear (as in fear of falling) Altered home maintenance management Hyperthermia Hypothermia Risk for injury related to factors outside the health care agency (e..g... He or she should also assist the patient in rising from lying or sitting positions and walking. the nurse should consider possible malnutrition. the nurse should consider the possibility of abuse and notify the physician for further assessment.g. procedure-related accidents such as medication errors and equipment-related accidents such as those related to improper grounding of electrical equipment) Risk for falls Risk for perioperative positioning injury Knowledge deficit in a specific area (e. especially protein intake. including weakness. within the home. NXP 070106 v1. or at risk of injury related to impaired mobility. where the client lives. they relate to all age groups and can be developed as such. outcomes are diagnostic-specific and framed within a goal statement. However. a patient may be at risk of injury related to impaired vision. For example. This is because nursing interventions are going to be shaped by the more specific “related to” factors than by the more generic overall diagnoses. It would be better to say that. aspiration. and burn prevention measures Suffocation.” At this point. Inc. After informing the client’s daughter about the client’s safety needs. electrical hazard. Although the “at risk of injury” diagnostic stem is the same in each case. or at risk of injury related to noncompliance with seat belt recommendations.0 . this expected outcome is very difficult to evaluate comprehensively. strangulation. Outcomes Identification According to the ANA Standards of Practice. it is especially imperative that the “related to” or etiologic factors be considered. For example.Unlawful to replicate or distribute • • • • Altered thought processes Impaired tissue integrity Risk for violence directed at others Risk for self-directed violence When a nurse diagnoses a patient’s safety needs. the parents will institute the following proper measures: • • • • • Fire. let’s say a community health nurse followed up on the discharge of the aforementioned seventy-five-year-old client at the home of the client’s daughter. and drowning prevention measures Poison prevention measures (see extended development of these measures in the preceding chapter) Fall prevention measures Other bodily injury prevention measures Copyright © 2008. “My spouse and I would really like more detailed information about home safety for children. the nurse makes a mental note that the daughter’s diagnosis is a knowledge deficit related to home safety measures for children. They may be developed once the diagnoses have been: • • • Identified as specifically as possible Analyzed (especially noting the accumulation of multiple safety risks) Prioritized Expected safety outcomes relate to more than one age group. One way of stating an expected outcome is to say that the parents will establish an environmentally safe home for their children. The College Network. interventions will vary greatly depending upon the cause for the increased risk. as no specific behavior outcomes are stipulated. the daughter says. even these outcomes are not especially helpful for evaluation purposes because they say nothing about what the specific measures are. Matches are kept away from the child. Electrical fuse box and gas outlets are readily accessible so that they can be turned off in an emergency. Upper floors have a fire escape ladder. The family has its own fire escape plan. and coffee pots are away from the reach or grasp of the child. The crib is away from windows. No one wears loose clothing near a stove or fireplace. including the basement. and wires are intact. Each floor. Part of that plan is to keep the emergency and fire telephone number (in most locations 911) as well as the home address and the nearest cross streets posted near the phone at all times. and holiday decorations are away from an open fire or from heated surfaces. Outlets have plastic caps on them to prevent a child from inserting a finger or an object into them. the nurse develops even more specific expected outcomes. fireplace. parents will ensure that: • • • • • • • • • • • • • Smoke detectors are in adequate number. Copyright © 2008. The College Network. and in working condition.0 . Guardrails are around any wood-burning stove. Electrical wires and cords are not frayed or broken and are kept out of reach of the child. Lamps and electrical appliances are away from the crib of an infant or toddler. Burning candles. cigarettes. has a fire extinguisher. tablecloths. Inc. NXP 070106 v1. Detailed and Expected Outcomes Addressing Environmental Safety Issues for Children (Whaley and Wong 2000) To prevent fire. There is easy access to exits in the event of fire.Unlawful to replicate or distribute However. To prevent electrical hazards. Small appliances with cords are disconnected from the wall when not in use and placed out of reach of the child. parents will ensure that: • • • • • All electrical outlets. properly located. or heating appliance. Remember that the basis for evaluation is a comparison of the expected and attained outcomes. So. cords. All exits (windows and doors) are uncluttered and capable of being exited. Hanging curtains. as infants and toddlers may strangle themselves in window blind cords. g. eyes in stuffed animals). or the child may accidentally inhale a small or large piece. dryers. Consumer Product Safety Commission for a list of the regulations). The child may try to swallow all or part of the balloons. To prevent aspiration (inhalation of liquid. They not drink hot liquids while holding a child. Keep hanging toys and mobiles out of reach of the child. parents should padlock them closed or remove their doors. parents will do the following: • • • • • • • • Check that crib design is according to federal regulations (call 1-800-638-CPSC to contact the U. Keep clotheslines above head level. The College Network. The balloon creates a seal over the trachea. discard the bags immediately in a place inaccessible to the child. NXP 070106 v1. Inc. Inspect toys and remove all small parts (e. and refrigerators.S. noncylindrical pieces. Serve food in small.Unlawful to replicate or distribute To prevent burns or scalding from hot water and other liquids. parents will do the following: • • • • • Remove all strings and ties from toys. Copyright © 2008. If any appliances are unused and remain on the property. After tying knots in them the plastic garment bags. When cooking. Be sure that the mattress and pillows are not covered in plastic that could in any conceivable manner become loose and cover the child’s face. Use toy chests without lids or chests with lids that lock securely in an open position. Keep all plastic bags away from the reach of the child. Do not use accordion-style gates. such as washers. To prevent strangulation. as a child can get his or her head caught between the slats. To prevent suffocation.0 . Use only window blind cords that have been childproofed.. Keep belts and ropes out of reach of the child. food. parents will do the following: • • • • Keep all small objects out of the child’s reach. pot handles are turned to the back or to the center of the stove beyond grasp of a child. Never allow a child to play with inflated or uninflamed rubber or latex balloons. parents will ensure that: • • • • The hot water heat is set at no greater than 49° Celsius or 120° Fahrenheit. A cool mist vaporizer is used instead of hot mist. or small objects into the respiratory tree). Keep the doors of stoves and appliances. causing suffocation. closed at all times when not in use. parents will do the following: • • • • Lower the crib mattress level as the child grows. Preferably elect that the child not use a walker. Keep stairs uncluttered. Use nonskid mats. Use guardrails on windows (however. NXP 070106 v1. Keep all buckets and wading pools empty when not in use. first-floor porches. or glass dividers. upper-level porches or balconies.g. windows. boxes. keep the window height less than that needed for the child to climb through. The College Network. For a detailed listing and discussion of measures to prevent poisoning. or surfaces in bathtubs and showers. parents will do the following: • • • • • Keep toilet lids down. strips. Keep hallways well lit and uncluttered. do not completely enclose a window with railing or bars. Keep rooms free of toys. risers. e. refer to the previous chapter. Inc. Keep the top and bottom of stairs gated for all children incapable of climbing them safely. keep restraint in place. Follow Red Cross instructions for pool and swimming safety. To prevent falls. Use safety glass on all doors. Keep treads. Keep gated all elevated areas. Keep stairs well lit with a light switch at the top and the bottom of the stairs. or furniture that obstruct walk areas and could be the cause of bumps or falls. and rugs in good repair. Be sure that all indoor and outdoor stairs or steps have sturdy handrails. Mark glass doors and windows with decals to prevent someone from attempting to walk or place their arm through them. Use high chair restraint at all times when in use.Unlawful to replicate or distribute To prevent drowning. Advocate for lifesaving certification for any family with a swimming pool. Advocate for basic life support (CPR and treatment of choking) training of at least one family member. Do not use stairs for storage space.. the most basic instruction being that no swimming is permitted unless someone certified in lifesaving is in attendance. and the bathroom door closed securely at all times. If used. Fence in the pool and keep the fence locked when not in use. Ensure that scatter rugs are nonskid or secured in place. or fire escapes. Keep crib side rails up at all times when in use. • • • • • • • • • • • • • Copyright © 2008. If window locks are used. as then the window cannot be used for fire escape purposes) or use windows that lock when raised to a certain height. faucets tightly turned off.0 . Have proper poolside safety equipment available. tight fit of mattress to crib. 2008) Clients who are parents of newborns and infants will teach the following regarding: • • • • • • • Federally approved car seats—Use at all times when driving. and poison control. and ammunition are stored safely and locked. Infant’s crib—Check for compliance with federal safety regulations. Be sure pets are properly restrained and under the owner’s control at all times. NXP 070106 v1. Infant’s position during feeding—Upright. Toys—Should be large and soft. In the same way. out-of-reach place. Make sure that garden tools are returned to storage area or racks when not in use. firearms.. are framed as expected outcomes. sofa. popcorn. Secure cement birdbaths and other yard sculptures so that child cannot overturn them. fire. Maintain fences and gates intact. Never hot. Keep swings. and other play-yard equipment in safe condition. adjustable height of crib sides so that sides can be lowered as child grows to prevent rolling or climbing over. slides. and keep the key in a safe. lead-free paint. eyes) that may detach from the toy. Keep yard free of broken glass. The above safety measures. nail-studded boards. Do not use a lock that is easily opened.g. Playpens—Buy only with small-sized netting on sides. To prevent bodily injury from other causes. Never feed peanuts. designed in detail as behaviors needed to prevent injury to children. nails. Be sure pets’ rabies immunizations are current. Fill in any lawn holes. safety measures throughout the life span may be framed as expected outcomes. or countertop) —Never leave an infant unattended. Food—Cut in small pieces. Position of bottle during feeding—Never propped. Inc. to the emergency numbers posted near the telephone: police. Temperature of the infant’s bath water and formula prior to use—Warm only. One expected outcome that crosses all ages is to refer. maximum of two and three eighths inch slat width.0 . Never leave playpen sides down. parents will do the following: • • • • • • • • Make sure that knives. and other litter. Do not allow • • Copyright © 2008. power tools. or raisins. when needed. and driveways in good repair. Expected Outcomes Related to Safety Measures Throughout the Life Span (adapted from Berman et al. Make infant/toddler proof by removing sharp edges and small parts (e.Unlawful to replicate or distribute • Keep walkways. The College Network. Any raised surface (bed. All firearms kept in a home with children must be unloaded. patio areas. The College Network. Fence in pools. Tricycle safety—Keep tricycle away from street. even when traveling short distances. Clients who are parents of preschoolers will teach the following regarding: • • • • • • Small objects—Teach children not to run with candy or any object in their mouths. Safe areas—Teach children to identify safe play areas and unsafe play areas (streets and railroad tracks) and to keep away from the latter. Potential poisons (cleaning solutions. Beds—Obtain a low bed when the child begins to climb. Electric outlets—Cover all outlets at all times. Discard unwrapped or opened candy. and ears. Hot pots and pans—Place on back burners. Halloween treats—Check before allowing children to eat them. Cover sharp edges of furniture or move out of reach. fire. and highchairs—Supervise infant when these are in use. Teach children not to put any object in their mouths (other than food). Matches. Small objects and pills—Teach children not to place such objects in their mouths. Street and corner safety—Teach children to cross streets safely and obey traffic signals. Gasoline—Never store on property. Guard gates on stairs and screens on windows—Use at all times. insecticides. Other water sources—Do not overfill bathtub. and wastebaskets—Place them out of reach. such as refrigerators—Remove all doors. Walkers. Supervise children at all times. If exposure has occurred. Plants. and teach children to stay away from the street.Unlawful to replicate or distribute • • • • • • • any continued exposure to toys on lead paint recall list. household detergents. and heating appliances—Teach preschoolers fire safety and the dangers of the above items. Electric cords—Coil them out of reach. Windows and balconies—Keep securely screened. or cleaners) —Place under lock and key. swings. Objects with sharp edges—Keep knives out of reach. request a serum lead level from the pediatrician.0 . paint. Swimming pools—Teach children to swim. Potential poisons (drugs. Inc. Electrical outlets—Cover all outlets at all times. Protect child from ditches or wells. Clients who are parents of toddlers will teach the following regarding: • • • • • • • • • • • Federally approved car seat or seat belts—Continue to use at all times when driving. Unused equipment. Place children in back seat. Copyright © 2008. noses. medicines) —Keep locked. charcoal. NXP 070106 v1. Turn handles inward toward the center of the stove. Set firm limits on automobile use. • • • • • Copyright © 2008. gunpowder. quarries.). Fireworks.. and out of reach.e. tools. vacant buildings. Drugs. Teach adolescents to obey traffic regulations in all circumstances. Teach children to keep their parent(s) informed of whereabouts. and boating—Encourage adolescents to use the buddy system at all times. Saws. Sports—Teach adolescents to wear proper sports equipment. The College Network. Have adolescents call home for a driver without fear of reprimand if no driver is available who has not used alcohol or drugs. Be alert for mood and behavior changes in the adolescent. jogging. Clients who are parents of adolescents will teach the following regarding: • Automobile driving—Enroll adolescents in a driver’s education course. and roller-skating—Teach children to obey all traffic signals and safety rules. to always wear a life jacket when in a boat. garden tools.0 . Inc. etc. Playgrounds—Teach preschoolers swing safety and playground manners (i. electric appliances. Listen to him or her and communicate openly. and other sports vehicles—Teach adolescents to wear a safety helmet. Contact sports—Supervise children when engaging in contact sports. Practice driving with adolescents under various weather conditions. Swimming. Allow them to drive only after passing the course. Adult example—Set a good example. scooters. Schedule a sports physical each year when participating in sports. Caves. Teach adolescents to adhere to safety rules for each of these activities. NXP 070106 v1. and unprotected sex—Teach the consequences of each. Drugs and alcohol—Teach children effects of drugs and alcohol on judgment and coordination. and to wear a protective helmet and knee and elbow pads when needed. alcohol. and heavy machinery—Teach children not to play in or around such areas. Clients who are parents of school-age children will teach the following regarding: • • • • • • • • • Recreational and sports activities—Teach children never to swim alone. Night walking or cycling—Teach children to wear light or reflective clothing. Stoves. Keep firearms unloaded. locked up. and other potentially dangerous equipment— Supervise children at all times. Check that medical supervision is available for all athletic activities. excavations. or firearms—Teach children not to play with any explosive or gun. Bicycling. Motorcycles. don’t push playmates off of equipment.Unlawful to replicate or distribute • • Strangers—Teach children to avoid strangers. skateboarding. and other equipment—Teach children safe use. Teach them to never drive under the influence of alcohol or drugs and to never ride with a driver who has used alcohol or drugs. and wear sun-blocking agents and protective clothing.0 . and insist on seat and shoulder belts with all passengers. Water safety—Know the pool depth of a pool before diving. and stretching exercises daily. Now that the expected outcomes have been specified within the framework of goal statements. Muscle strength and agility—Perform active. limit total exposure time. Inc. Planning Once nursing diagnoses are identified. Maintain these devices. Skin changes—Assess for changes that may indicate cancer. fire alarms. Activity—Keep as active as possible. and test visual acuity and peripheral vision regularly. Use designated drivers if alcohol is consumed.Unlawful to replicate or distribute Young adults will perform the following regarding: • • • • • • • Motor vehicles—Drive safely and defensively. they are prioritized according to those threats that are most imminent and most life threatening. and expectations of adulthood. drive within the speed limit. Fire hazards—Check for potential hazards and repair promptly if found. responsibilities. For example. Use seat and shoulder belts at all times. Follow safety precautions when using equipment and tools. Home safety—Obtain a home hazard appraisal. Fire safety—Place smoke detectors. and consider hazards when making employment decisions. a twenty-year-old client with Copyright © 2008. and carbon monoxide detectors in appropriate places in home. Sun radiation—Avoid excessive exposure. check brakes and tires routinely. Middle-aged adults will perform the following regarding: • • • • • Automobile driving—Drive car safely and maintain it in good condition. always use seat and shoulder belts. Mental health—Seek counseling when having difficulty coping with the pressures. Adhere to all safety and supervisory precautions regarding backyard pools and other water activities. Older adults will perform the following regarding: • • • • Vision and hearing tests—Obtain these tests regularly. and never perform a deep-water dive in shallow water. Stairways—Keep well lighted and uncluttered. passive. Workplace/occupational safety—Be aware of dangers. Bathrooms—Equip bathrooms with grab bars and nonskid bath mats. One factor that affects the prioritization of safety needs is the accumulation of risks. Machine equipment and tools—Keep them in good working condition at home and work. The College Network. the next step is planning strategies to address the goals. Promote programs aimed at reducing hazards. NXP 070106 v1. fire extinguishers. He or she should ask if there is anything that can be done to help the client meet any unmet goals and whether there are any questions he or she may help answer. The College Network. circulation. Physical needs for air. This is because the seventy-fiveyear-old client has accumulated multiple risks of falling over and above limited mobility due to the torn cartilage. since his risk of injury is greater than that of the twenty-year-old. a balance problem. and so on are more basic and must be met before the higher-order need for safety. The nurse should allow sufficient time to answer the client’s questions either during or after the intervention.g. Once planning takes priorities into account. visual difficulties). Inc. Given a choice as to who is to receive care first. His accumulated risk is much greater than that of the twenty-year-old client. NXP 070106 v1. a sensory deficit of some kind (e. Implementation During the implementation portion of the nursing process.. The older client will also require more resources than the younger one. preference would go to the seventy-five-yearold. Someone will need to be assigned to assist the older client when walking. Copyright © 2008. Is it all right if I phone in a couple of weeks to check on the progress you are making and to see if you have any questions that I may answer?” Evaluation Evaluation arises from patient follow-up. “I will leave this home safety list here for you. the nurse should also determine a convenient time for further follow-up. Therefore. However. whereas the twenty-year-old may do quite well on crutches. If necessary. Thinking in terms of these priorities is consistent with Maslow’s hierarchy of needs.0 . the intervention identified during the planning stage needs only to be put into place. his safety must be ensured before moving on to care for the needs of the twenty-year-old. You may want to post it on your refrigerator. and he or she should establish and maintain rapport. the nurse should schedule a time to meet with the patient. For example. at the aforementioned two-week follow-up phone call. the nurse may say something such as. or an unsteady gait. the nurse could refer to the list of desired outcomes and interventions to determine which goals and outcomes have and have not been met. It is also important to anticipate client needs during the intervention and explain the steps of the intervention as progress is being made in completing it. Explaining what is to be done next is also critical. strategies designed to assist the patient achieve the expected outcome are developed. For example.Unlawful to replicate or distribute 268 Fundamentals of Nursing impaired mobility due to torn cartilage in the right knee is at less risk of falling than a seventy-five-year-old client with the same diagnosis. As with any intervention. Perhaps the seventy-five-year-old has a fear of falling. the client’s safety needs (freedom from risk of injury) must be dealt with before those needs that are of a higher order than safety can be addressed. 3. 8. Describe the types of dressings and the types of wounds each is used on. Differentiate between medical asepsis and surgical asepsis. Provide an overview of the four basic nursing interventions for biological safety.Unlawful to replicate or distribute Chapter 15: Theoretical Frameworks Underlying Principles of Biological Safety Objectives Upon completion of this chapter. 13. Inc. Explain four serious complications of wound healing. NXP 070106 v1. 15. 16. including examples and the theoretical basis for each. The College Network. 14. List ethical and legal nursing implications related to communicable diseases. 6. active immunity. Identify the nine principles governing the maintenance of a sterile field. Differentiate between primary and secondary intention in wound healing. 11. Explain the four stages of the infectious process. Describe the six links in the medical asepsis chain of infection and the medical asepsis methods used at each link to control the spread of infection. 10. Describe ten common skin lesions. 9. autoantigen. and passive immunity. 5. Copyright © 2008. Identify the eight steps used to establish a sterile field. 7. you should be able to do the following: 1. Describe the four stages of decubitus ulcers. 17. Describe the seven factors that influence a client’s biological safety. Explain the four stages of wound healing. List four ethical and legal nursing issues when communicable diseases are involved.0 . Describe nonspecific defense and specific defense as they relate to the body’s shield against infections. Define the following terms related to the body’s specific defense against infections: antigen. 2. 12. 4. Unlawful to replicate or distribute Copyright © 2008. NXP 070106 v1. The College Network.0 . Inc. Unlawful to replicate or distribute Fundamentals of Nursing 271 Key Terms abrasion abscess active immunity airborne transmission antibody-mediated response antigen asepsis autoantigen autoclaves barrier precautions cell-mediated response chain of infection cleaning cohorting contact precautions convalescence stage critical items Davol drainage system decolonization dehiscence destructive phase direct transmission disinfecting entry portals environmental measures evisceration external hemorrhage full thickness skin wound hemorrhage Hemovac drainage system illness stage immunoglobulin incubation period indirect transmission infection infectious agent infectious process inflammatory phase inflammatory response internal hemorrhage Jackson-Pratt drainage system laceration macule maturation phase medical asepsis mode of transmission nodule noncritical items nonspecific defenses papule partial thickness skin wound passive immunity Penrose drain portal of exit pressure ulcer primary intention prodromal stage proliferative phase pustule reservoir secondary intention semicritical items specific defenses sterilizing superficial skin wound surgical asepsis surgical field surgical scrub susceptible host tumor ulcer vesicle wheals Yates drain Introduction Understanding biological safety is central to the provision of quality nursing care since it is part of the nurses’ responsibility to protect patients against biological hazards and pathogenic agents like viruses. and then look at specific defenses against infections through discussions of antibody-mediated responses and cellmediated responses. one of the nonspecific defenses. Our discussion then turns to principles underlying the body’s defense against infection and analyzes the body’s nonspecific and specific defenses. Copyright © 2008. We discuss the stages of the inflammatory responses. We begin by defining the principle of asepsis (maintenance of an environment free to some degree from infectious microorganisms) and the two types of biological asepsis: medical asepsis and surgical asepsis. Inc. The College Network.0 . and fungi. bacteria. The purpose of this chapter is to provide an overview of central concepts related to biological safety. We build on the concept of medical asepsis by analyzing the six links in the chain of infection and describing the medical asepsis methods used to control the spread of infection at each link in the chain. NXP 070106 v1. changing a surgical dressing on a wound. As opposed to medical asepsis. we explain the four stages in the infectious process and the four stages involved in wound healing. wound care. We explain the theoretical bases for each of these different types of interventions. application of heat and cold. as described in the following sections and illustrated in Figure 15. with particular attention to specific issues related to the maintenance of medical and surgical asepsis. starting an intravenous infusion. (2008). We look at four central biological safety interventions including medications. fungus. The College Network. In conjunction with this. which inhibits the growth of organisms. we explore ethical and legal nursing issues related to communicable disease management.Unlawful to replicate or distribute In addition. virus. According to Berman et al. Specific steps toward creating or maintaining medical asepsis can be aimed at each of the six links.0 . Medical asepsis refers to biological safety techniques used during daily routine care to prevent infection or control its spread. Three medical asepsis methods used to control or eliminate infectious agents are cleaning (or cleansing). and sterilizing. This microorganism may be a bacterium. or establishing and maintaining a sterile field. To grasp the full significance of medical asepsis. The First Link The first link in the chain of infection is the infectious agent. we consider the seven critical factors that influence a client’s biological safety. Cleaning Cleaning refers to the removal of all foreign material from objects by cleansing. or the set of six connected factors or “links” that allow for the spread of infectious and communicable disease. Principles of Asepsis There are two categories of biological asepsis with which the nurse must be familiar: medical asepsis and surgical asepsis. a nurse must know the six links in the chain of infection and the medical asepsis methods that apply to control the spread of infection at each link in the chain. protozoan. surgical asepsis refers to those techniques a nurse uses to establish and maintain a field free of all organisms. maintenance of asepsis. Surgical asepsis is used in administering an intramuscular injection. disinfecting. Common skin lesions are discussed along with a description of the four stages of pressure ulcers and complications of wound healing. six steps are involved in the process of cleaning an object: Copyright © 2008. Medical Asepsis and the Chain of Infection At the heart of the concept of medical asepsis is the idea of the chain of infection. Finally. and dietary modifications. including spores (Potter and Perry 2004).1. or rickettsia. NXP 070106 v1. Inc. Once the object is rinsed in cold water. are used to rid inanimate objects and surfaces of pathogenic organisms other than spores. An antiseptic is an agent that inhibits the growth of organisms. When proteins are coagulated. 5. Dry the article using clean cloths or clean material. all objects must be completely submerged in the disinfectant. Rinse the object in warm to hot water. including spores (Potter and Perry 2004). phenol. Be sure to read the manufacturer’s label. Others require longer contact with a disinfectant. The presence of organic materials (e. and surrounding surface. Areas floating above the surface are not disinfected. 6. the equipment must be cleaned. protective eyewear. sink. If a nurse intends to disinfect a surface area. the nurse needs to know the concentration of the disinfectant to use. boiling. Hot water is not used because heat coagulates protein in the same way boiling an egg coagulates the egg white (albumin). Common forms of sterilization are moist heat (autoclave and free steam). In addition to knowing the duration of contact. and waterproof gloves. Disinfectants may be bactericidal or bacteriostatic. Most disinfectants are to be used at room temperature. gas. isopropyl alcohol or sulfadiazine) is a chemical that can be applied to skin. The act of washing removes the dirt brought to the surface by the soap. Before use of such disinfectants.Unlawful to replicate or distribute 1. The friction created by rubbing the brush across the grooves or in the corners helps dislodge foreign material. Inc. the nurse needs to have an understanding of the type and number of infectious agents. In a similar way. NXP 070106 v1. It decreases surface tension and facilitates the removal of dirt. 3. 2. Antiseptic soaps may be used. Sterilizing Sterilizing is a process of destroying all microorganisms. pus. use a mask.. Some infectious agents are readily destroyed on contact. Disinfecting Disinfecting is the process in which chemical solutions.g. When disinfecting.. if a nurse is soaking objects in a disinfectant. When cleansing equipment containing bodily fluids. Clean the grooves and the corners of the object with an abrasive instrument. Some are rendered ineffective in the presence of soap. and sink area used in cleaning equipment. The College Network. Copyright © 2008. Rinse the object in cold water to remove organic material. which readies the object for drying. and when disinfecting the brushes.g. and radiation.0 . the sink. A germicide (e. tissue. Clean or disinfect the brush. The dried article is now considered clean. secretions. you are ready to wash the object with soap and hot water. 4. therefore. such as alcohol. such as a stiff-bristled brush. or objects for disinfectant purposes. saliva) may render the disinfectant inactive. they are harder to remove. or excretions. or chlorine. Soap is an emulsifying agent. blood. These are considered soiled until they are cleaned or disinfected properly. Adding such a disinfectant to soapy water would. be contraindicated. the entire surface area must make contact with the disinfectant. animal. Date bottles when opened. dressing. Its rays do not penetrate deeply. arthropod (e. A disadvantage is its toxicity for humans. First. plant. Several medical asepsis methods are used to control or eliminate infectious disease reservoirs. It is a good method for use in the home. food can be the reservoir for bacterial agents. tissues. Gas sterilization uses ethylene oxide to destroy infectious agents by interfering with their metabolic processes. The intervals are needed to give spores time to return to their vegetative state and become vulnerable to heat. Provide for good oral hygiene. Maintain patency of surgical drainage tubes to prevent stasis and accumulation of drainage under the skin. Protect potential reservoirs from insects and teach families to do likewise. The Second Link The second link in the chain of infection is the reservoir in which the infectious agent lives or exists. NXP 070106 v1. Bathe skin surfaces properly or assist clients in doing so. Gas penetrates well. Ultraviolet radiation is nonionizing and can be used for disinfection. The College Network. and keep them tightly capped when not in use..Unlawful to replicate or distribute • • • • • Moist heat is applied in two ways. Empty drainage bags/bottles according to agency policies and at least once per shift unless ordered otherwise by physician. kills spores and other pathogens. Dispose of contaminated articles (e. or substance where an infectious agent lives and multiplies and on which it depends for survival. Blood is the reservoir for human immunodeficiency virus. Ionizing radiation is used in industry to sterilize foods. Inc. Change dressings or bandages when they become wet or soiled. and other heat-sensitive items. dry table surfaces. Copyright © 2008. tick).g.0 . cap them immediately after use. including the following: • • • • • • • • • • • • Store/handle food and water properly. The gastrointestinal tract is the reservoir for typhoid. soil. Cover or cap all bedside water containers and suction or drainage bottles. Dispose of all contaminated needles appropriately. Boiling objects in water at 212°F for fifteen minutes is an effective method of sterilizing objects contaminated by pathogens other than spores or some viruses. usually for thirty minutes.g. Radiation is another method of sterilizing or disinfecting objects. Free steam of 100°C (212°F) is applied for thirty minutes on three consecutive days. devices called autoclaves supply steam under pressure (usually fifteen to seventeen pounds) at temperatures of 121–123°C (250–254°F). For example. drugs. A reservoir refers to any person. Free steam is another form of moist heat used to sterilize objects that cannot tolerate the higher temperature and pressure of the autoclave. Water is the reservoir for cholera.. soiled linens) properly. and may be used with heat-sensitive objects. Maintain clean. gonorrhea.. Handle all laboratory specimens as if infectious. E coli) exit by means of the urethra or by means of urinary diversion ostomies. brushes. The College Network. Properly dispose of tissues after each use. properly dispose of tissue after each use. These methods include the following: • • • • • • • Cover the mouth with tissue when coughing.0 . Again. such as the male urethra and the female vagina and their respective secretions. Use proper hand-washing technique after use of toilet. pathogens multiply. nose.g. for infection to spread. influenza) exit by the mouth. Infectious agents that invade the reproductive tract (N. streptococcal infections.Unlawful to replicate or distribute • Never raise a drainage bag or bottle above the site being drained unless the tubing is clamped off.. Treponema pallidum. herpes simplex virus type 2) exit by whatever orifice they entered. and talking increases the likelihood that the wound or field will be contaminated. an open wound or sterile field. Infectious urinary tract agents (e. and instruct the patient to do likewise. Sneezing or coughing over a wound or sterile field contaminates it. NXP 070106 v1. and instruct the patient to do likewise. and use a mask and protective eyewear. Pediculi exit by direct contact with another person’s hair or by means of sharing combs. pathogens need a way of exiting the reservoir. Ttubes). Infectious agents that occupy the respiratory tract (e. Several medical asepsis methods help control the spread of infection through control of portals by which microorganisms exit. and never cough or sneeze over. The Third Link The third link in the chain of infection is the portal of exit from the reservoir. salmonella. However. Agents that use blood as a reservoir exit by means of any open wound. The scabies mite exits by direct skin contact. The portal of exit is the microorganism’s exit gate from the reservoir. and drainage tubes (e.g.. or pustule. and endotracheal tubes. Infectious agents harbored in the gastrointestinal tract exit by means of the mouth (vomitus). or other disruption in the skin or mucous membrane. Inc. Examples of these agents are hepatitis A. Handle all excretions or exudate with gloves. Avoid talking over. and remind patients to do likewise. If reservoirs of infection are not adequately controlled. Copyright © 2008. anus (feces).g. Cover the nose with tissue when sneezing. abscess. puncture site. Agents that invade skin and tissue exit by means of drainage at the site of the wound. or hats. and Clostridium dificile. tuberculosis. or droplet transmission (sneezing. wear masks and eye protection gear.. blood. doorknobs) or a vector (e. Dispose properly in an appropriate receptacle. Dust particles transmit disease (e.g. biting. The second mode is indirect transmission. kissing. NXP 070106 v1. They may also exist or become airborne when they are dispersed in the form of a mist as a result of coughing. 2. 3. The latter are called aerosolized droplet nuclei. or the way in which the infectious agent travels between the reservoir and a portal of entry in a new host. Bag all linen appropriately and discard in keeping with agency policies.g. eliminating. they become an important element in its spread. Discard anything that touches the floor. Droplet nuclei are small particles of droplets that are involved in the transmission of airborne infection.. Wear gloves and handle all urine and feces carefully. For example. The third mode is airborne transmission by means of droplet nuclei or by dust particles. When exposed to clients with infections transmitted by droplet. There are three different modes of transmission: 1. touching secretions or any infectious material. IV Copyright © 2008. client contact. which may be by means of a vehicle (e. coughing) within three feet. sexual intercourse.. or talking. Once evaporated. Wear masks and eye protection gear when performing irrigation procedures if a spray of bodily fluids is possible. Entry frequently (but not always) occurs by the same route that the organism exited the other body.Unlawful to replicate or distribute The Fourth Link The fourth link in the chain of infection consists of the mode of transmission. Clean patient equipment properly. disrupted mucous membranes. mosquitoes. broken skin. The Fifth Link The fifth link in the chain of infection is the control of entry portals (e. ticks). They remain in the air for long periods. They may exist in the form of dried residue of excretions coughed or sneezed into the air.. performing invasive procedures. The portal of entry is the gate through which an organism enters the body. The College Network. It can be any orifice in the body or a break in the skin or mucous membranes.. so as to prevent spillage. which refers to touching.g. the spores of Clostridium difficile). Several medical asepsis methods control the mode of transmission: • • • • • • • Wash hands frequently. Discarded soiled material needs to be placed in moisture-proof bags. urinary meatus). handkerchiefs. The first mode is direct transmission. and never allow patients to share equipment. When emitted by a host with tuberculosis.g. a towel that accidentally falls to the floor must be considered soiled and is not to be used in patient care. toys.g. water. Entry portals also include invasive lines (e. Wear gowns if there is danger of soiling clothing with bodily substances. Inc. sneezing.0 . or touching open wounds. they may be carried as dust particles. especially before and after eating. Use universal blood and body fluid precautions with any anticipated contact with blood or body fluids. Prevent accidental needlesticks by placing used disposable needles in punctureresistant containers. injections. such as those for tuberculosis. Use negative pressure isolation rooms to prevent organisms from leaving. Use positive pressure isolation rooms to prevent entry of organisms into a room.0 . A susceptible host is a person whose defenses against infection are weakened or compromised for whatever reason. Allow for sufficient sleep and rest. such as immunosuppression. Ensure a balanced diet. catheterizations). Educate clients and the public about the value of immunization. and advanced age. The main objective of infection control is to prevent the spread of infection to a susceptible host. Inc.Unlawful to replicate or distribute lines. urinary catheters). if needed. diabetes. burns. or handling dressings. and varicella. Use sterile technique when exposing open wounds. Instruct women to clean the perineum and anus by wiping front to back and discarding toilet paper after each swipe. Body substance isolation (BSI) provides generic protection for all clients. This refers to any person at risk for infection. NXP 070106 v1. The Sixth Link The sixth link in the chain of infection is the susceptible host. Obtain PPD at intervals specified by the health care agency or more frequently. Several ways to help do this are as follows: • • • • • • • • • Maintain client hygiene at an optimal level. Copyright © 2008.. central venous catheters. Use sterile technique for invasive procedures (e. cleaning open wounds. This is to avoid contaminating the urethra with gastrointestinal organisms. as in the case of tuberculosis. The following asepsis methods control the portal of entry: • • • • • Ensure that the client’s mucous membranes and skin remain intact to decrease the number of possible entry sites. rubella. The College Network. Adhere to disease-specific isolation (stop-sign) procedures.g. surgery. routine care. Open the surgical drape one corner at a time. Clean and disinfect a flat work surface and allow it to dry. starting an intravenous infusion. surgical asepsis or surgical technique is used in administering an intramuscular injection.0 . Inc. The steps used to establish a sterile field are as follows: 1. 5. Organize the supplies and equipment needed. Place the sterile pack on the work surface. 6. 3. Do not let the drape touch any object. The College Network. Check sterile package expiration dates on equipment and package labels. 4. touching the outside surface of the cover only.Unlawful to replicate or distribute Figure 15. Wash hands thoroughly. Copyright © 2008. NXP 070106 v1. including spores. 2. Do not touch any object within the sterile package.1 The Chain of Infection Surgical Asepsis Surgical asepsis refers to those techniques a nurse uses to establish and maintain a field free of all organisms. or changing a surgical dressing on a wound. In regular. bloody drainage diluted by serous fluid • Copyright © 2008. Exudate may be: − Serous: Clear. Only sterile technique can be used to access and use items from the field. and tears in the eyes. Stage II is the exudative stage. alveolar macrophages (large phagocytes) in the lungs. poisons. mucosal shedding in the oral cavity. Stressors are the stimuli that initiate the response. which causes vasodilation resulting in hyperemia. and if stage I of the inflammatory response is ineffective in keeping the infection localized. microbial inhibition by substances in the saliva. low pH in the vagina. 8. chemicals (e. then systemic signs of infection occur. the initial reaction is vasoconstriction followed by histamine release. gastric hydrochloric acid). Add sterile items to the sterile field by opening covers or lids and allowing the sterile objects to fall at an angle gently onto the field without the wrapper touching the sterile field. causing a leakage of leukocytes into injured tissue. Principles Underlying the Body’s Defense Against Infection The body possesses both nonspecific defenses (anatomic and physiologic barriers and the nonspecific inflammatory response) and specific defenses (immune responses) against infection. Both types of defenses are described in the following paragraphs. serum-like drainage − Purulent: Pus-containing drainage − Sanguinous: Dark or bright red bloody drainage − Serosanguineous: Thin. fatigue. the fluid that seeped through blood vessels. These are local signs of inflammation/infection. Nonspecific Defenses Against Infection Anatomic and physiologic barriers against infection include intact skin and mucous membranes. Additional physiologic barriers include high gastric acidity. heat. which stimulates an increase in the production of leukocytes and results in leukocytosis or an elevated white blood count. cilia in the nasal passages. strong acids or bases.. Inc. Dispose of the wrapper. trauma). In this stage. and microorganisms. Another nonspecific defense is the inflammatory response. and impaired function. which is an adaptive mechanism that destroys or dilutes injurious agents. swelling.g.. dead phagocytes. peristalsis. and anorexia. redness. It is important to document the type of exudate present when documenting the characteristics of a wound and its drainage.Unlawful to replicate or distribute 7. and flushing and bacteriostatic action of urine. redness. resident flora in the GI tract.0 . In this stage. gases). These include leukocytosis. If an infectious agent is the stimulus for the inflammatory response.g. This reaction then alters capillary permeability. such as physical agents (e.g.. fever. or an accumulation of fluid or matter that has penetrated through a vessel wall. malaise. internal agents (e. There are three stages in the inflammatory response: • Stage I consists of vascular and cellular responses. NXP 070106 v1. and dead tissue cells and their products form an exudate. It is characterized by pain. The College Network. and heat. Pick up the next item to be added to the field and repeat the procedure. Occurs when a person receives antibodies naturally (e..0 .g. NXP 070106 v1. Occurs when a person’s own body produces antibodies in response to natural antigens (e. Table 15. This phase occurs either by the regeneration of destroyed tissue with cells that are like or nearly like those destroyed or by fibrous tissue formation (growth of scar tissue). This type of immunity resides in the B lymphocytes. First. this indicates that the client is currently or actively infected. or IgE) in response.” Immunoglobulins are proteins. it is first necessary to be familiar with the various elements of that response that are defined in Table 15. those found in a mother’s breast milk) or artificially (e. When IgM immunoglobulins or antibodies are present.1. those obtained in an injection of immune serum). Table 15. a fragile tissue called granulation tissue is laid down. Specific Defenses Against Infection In order to understand the body’s specific immune response.. “Ig” stands for “immunoglobulin. a firm tissue called cicatrix (scar) tissue develops. This concludes the nonspecific inflammatory response.g. This immune response is the body’s way of defending itself or fighting against specific pathogens. Passive immunity There are two types of specific immune responses: (1) antibody-mediated responses or defenses and (2) cell-mediated responses or defenses. B cells are activated by a foreign antigen (e. and E refer to classes of immunoglobulins. IgD.g. Fibrous tissue formation consists of two stages. the findings indicate the client was infected by this specific pathogen in the past. Inc. The letters M. vaccines). D.g. Antibody-Mediated Responses The antibody-mediated response is sometimes also referred to as humoral or circulating immunity. Copyright © 2008.. G.Unlawful to replicate or distribute 280 Fundamentals of Nursing • Stage III is the reparative phase.2 presents the functions associated with each of these classes. A person’s own protein that elicits an antibody reaction because the body mistakenly identifies that protein as a foreign protein. Another word for antibody is immunoglobulin. a type of plasma protein. a specific pathogen) and yield antibodies or immunoglobulins (IgM.1 Terms Related to the Body’s Specific Defense Mechanisms Antigen Autoantigen Active immunity A foreign protein that elicits an antibody reaction upon being introduced into the body.. IgG. IgA. Next. When IgG immunoglobulins or antibodies are present..g. foreign proteins introduced by bacteria) or artificial antigens (e. The College Network. A. and the antibodies produced in B cells mediate the response. The length of the incubation period varies according to the disease. This series of events. When the body loses this form of immunity—as when it is infected with the human immunodeficiency virus (HIV)—it loses its ability to defend itself against infection and becomes vulnerable to opportunistic infections. which attack and kill invading organisms and sometimes the body’s own cells Suppressor T cells. Immunoglobulins A are located in external secretions (e. IgG crosses the placental membrane and provides passive immunity during the gestational months and the early months of infancy. three types of T cells have been identified: • • • Helper T cells.. a specific series of events occurs as the pathogens affect the body and the body begins to battle back through its immune responses. The incubation period Copyright © 2008. colostrum) and are also found in the respiratory tract and in plasma.0 . These are infections caused by organisms that ordinarily do not cause disease in healthy people. Its production diminishes when IgG comes into play about one week after initial antigenic contact. Currently. For example. which stimulate the action of B cells and other T cells Cytotoxic T cells. consists of four stages (Potter and Perry 2004): 1. tears. Immunoglobulins E produce the typical signs and symptoms of allergy and of anaphylaxis. saliva.2 Classes and Functions of Immunoglobulins Immunoglobulin class IgM Function This is the first immunoglobulin produced during an immune response. The incubation period is the time interval between the invasion of the pathogen into the body and the first signs or symptoms of infection. which suppress helper and cytotoxic T cells T cells play an important part in helping the body fight infection. bile. The function of IgD is unknown. This kind of immune response resides in the T cell system. The Stages in the Infectious Process Once pathogens enter the body. Upon exposure to an antigen. commonly referred to as the infectious process. The College Network. NXP 070106 v1.g. however. the incubation period for varicella or chicken pox is two to three weeks. Cell-Mediated Responses The cell-mediated response also has another name: cellular immunity. these microorganisms cause serious and sometimes overwhelming infections. Inc. lymphoid tissue releases large numbers of T cells. IgG IgA IgD IgE Adapted from McKenry and Salerno 1995. because of the loss of cellular immunity in immunocompromised individuals.Unlawful to replicate or distribute Table 15. This ingestion process is completed by the monocytes. The convalescence stage is the time period between the disappearance of the acute signs and symptoms of the disease and full recovery. NXP 070106 v1. 4. achiness in joints) to more diseasespecific signs and symptoms. edema. proliferative. forming an exudate. which have become macrophages. The blood vessels constrict and platelets accumulate at the wound. This entire inflammatory phase ends within three days of injury. Destructive Phase The destructive phase follows and lasts from two to five days. hemostasis occurs almost immediately. In this phase. During this phase. The prodromal stage is the time interval between the onset of nonspecific signs and symptoms of infection (e. Inc. The macrophages also secrete growth hormone to help with epithelialization. such as illness severity and general health status. As epithelial cells are laid down beneath the eschar (scab). Neutrophils begin to ingest bacteria and debris. the four stages are referred to as the inflammatory. the main ingredient in scar formation. macrophages continue to clean the wound and stimulate fibroblast formation. This vasodilation leads to increased permeability of the vessel wall through which serum and white blood cells pass. The white blood cells that actively participate in the process are neutrophils and monocytes.Unlawful to replicate or distribute 2. Here. Characteristic signs and symptoms are redness. malaise. Next. The disease is communicable during the prodromal stage of an infection. Inflammatory Phase The inflammatory phase is the first stage in wound healing. they form a barrier to bacterial invasion. heat. responsible for the final cleaning of the wound. injured tissue and the mast cells secrete histamine.0 . The length of the convalescence stage depends upon many factors. twelve hours to three days. 3. along with amino acids and oxygen. which is useful in the later process of epithelialization. Fibroblasts synthesize collagen. so does the process of wound healing. The illness stage is the stage during which the disease-specific signs and symptoms are present. and maturation phases. while that of hepatitis A is fifteen to fifty days. for the common cold is much shorter. which causes vasodilation. Proliferative Phase The proliferative phase lasts from three to twenty-four days and is characterized by beginning wound closure and increasing strength of closure between opposing sides of Copyright © 2008. The College Network. To function properly.g. and pain.. Platelets also secrete growth hormone during this phase. Wounds and Wound Healing Phases of Wound Healing Just as the infectious process consists of four stages. yielding a fibrin matrix that provides a foundation for later repair. with a mean of approximately thirty days. destructive. fibroblasts require vitamins B and C. 3 Definitions of Common Skin Lesions Type of Lesion Abrasion Abscess Laceration Macule Description A wound characterized by scraped or excoriated skin tissue and removal of superficial layers of the skin. a shard of glass or a knife. Inc. or bedsore) Copyright © 2008. hypoproteinemia. the risk of wound separation decreases. two other forces are commonly involved: • Friction: A force acting parallel to the skin’s surface. Clean incisions are the best candidates for healing by primary intention. it is necessary to know how to identify or define the various kinds of common skin lesions.. Tissue in healed wounds does not possess the strength of the tissue prior to disruption. Types of Skin Lesions When discussing wounds. Some may cause an elevation of the skin. and smaller than 0.g. Wounds that heal by secondary intention are those in which the sides of the wound are not approximated but are allowed to close by filling with scar tissue. They may be palpated through the skin. small node or aggregation of cells. A macular rash refers to a number of macules that are flat and level with the surrounding skin. such as an elbow friction rub caused by rubbing the skin surface of the elbow against sheets. A small.0 . An ulcer caused by unrelieved pressure over a bony prominence that leads to damage of the underlying tissue. Table 15. It is characterized by increasing strength of closure over a period of several months and perhaps up to a year. red. Primary intention occurs when the sides of the wound are approximated (brought closely together) and held in place by surgical suturing or butterfly sutures. NXP 070106 v1. circumscribed. A saclike accumulation of pus that displaces tissues. Types of Healing Wounds heal by primary or secondary intention. nonraised spot or colored area on the skin. As closure progresses. while Table 15. elevated area on the skin that is solid. The College Network. pressure sore. Maturation Phase The maturation phase is the final stage of healing. especially if found over a bony prominence. A firm. Table 15. e. Besides pressure. frequently subcutaneous and nontender.Unlawful to replicate or distribute the wound. Macules are smaller than one centimeter.5 centimeters.3 presents these definitions. It takes far longer for a wound to heal by secondary intention than by primary intention. • Shearing force: A force resulting from a combination of friction Nodule Papule Pressure ulcer (also called decubitus ulcer.4 presents the three categories these lesions may fall into. Healing during this stage may be impaired by age. A torn or jagged wound usually caused by a sharp object. and zinc deficiency. anemia. A red. The lesion presents as an abrasion. most notably hemorrhage. which displaces tissues. The eruption of wheals is called urticaria. and evisceration. A Stage III pressure ulcer is a full-thickness skin loss. A Stage IV ulcer consists of full-thickness skin loss with damage to or necrosis of muscle. or bedsores) bear special mention because they are common in the hospital environment but can be prevented with proper care. usually elevated lesion of the skin that contains purulent material or pus. Complications of Wound Healing Complications of wound healing can occur in several forms. and surrounding structure. Hemorrhage may manifest itself in two ways: Copyright © 2008. thicker layer of skin). A spontaneous. Vesicles larger than one centimeter are called bullae. Damage to the epidermis and dermis (the inner. or organs. A blister-like elevation of the skin that contains serous fluid. or shallow crater. commonly occurring in a semi-Fowler’s position when the body tends to slide downward in bed.4 Classification of Common Skin Lesions Superficial skin wound Partial thickness skin wound Full thickness skin wound Damage only to the epidermis. In Stage I. Wheals vary in size. which may include any of the following (in descending order): fascia. Pustule Tumor Ulcer Vesicle Wheals Table 15. A saclike. Inc. a slipped ligature. bone. Distinct from an abscess. which transmits force over the sacrum. In lay terms. There are four stages in the formation of a pressure ulcer. They vary in size from a few millimeters to a centimeter. Stage II consists of a partialthickness skin loss that involves the epidermis and may extend into the dermis. The College Network. including damage to or necrosis of subcutaneous tissue but not the fascia.3 Definitions of Common Skin Lesions and pressure. thinner layer of skin. pressure sores. new. or blood vessel tear or erosion. independent. unrestrictive growth of tissue forming an abnormal mass. infection. plus underlying exposure of underlying structures. dehiscence. Stages of Pressure Ulcers Pressure ulcers (also called decubitus ulcers. An open sore that may be associated with deep loss of skin surface. muscle. NXP 070106 v1.Unlawful to replicate or distribute 284 Fundamentals of Nursing Table 15. the skin is intact but a nonblanching erythema is present.0 . which is the outer. This lesion presents as a deep crater that may or may not undermine adjacent tissue. blister. bone. Pale. wheals are called hives. irregularly shaped itching areas of the skin. elevated. • Hemorrhage is an abnormal loss of blood from a wound caused by a dislodged clot. Damage to both layers of the skin. physical condition. have friable skin that may be slow to heal. bright red blood that saturates a dressing. Similarly. failure of suturing. IVdrug-related infections).. a client’s biological safety is affected by a number of factors. They do not possess active immunity until six months of age. − External hemorrhage is characterized by loss of fresh. Factors related to dehiscence are obesity. It may appear as a reddishblue swelling. many internal hemorrhages (e. or postoperatively. spiritual. Dehiscence is the partial or complete rupture of a sutured wound (usually an abdominal wound) and is most frequently accompanied by at least partial separation of the underlying tissue. lack of exercise or smoking) may impair overall responsiveness to infection and prolong convalescence. socioeconomic factors. cultural. during surgery.. With or without chronic disease. Infection slows the healing process. The College Network. and religious considerations. risk-taking behaviors among adolescents may predispose them to injury and open the door to infection or allow them to believe that they do not need condoms because they are “invulnerable to disease. Older adults may be debilitated by chronic disease. which is a collection of blood beneath the skin.” Lower educational levels and depressed socioeconomic Copyright © 2008.g. however. or excessive stress placed on the incision by coughing or vomiting. dehydration. individual preferences and patterns. or pools beneath the client. they may also experience the following conditions that negatively influence their biological safety: • • • • • Vascular changes that impede flow of blood to a wound Less flexible collagen Poorly functioning immune systems Nutritional deficiencies Less elastic skin Individual Preferences and Patterns Lifestyle choices influence exposure to pathogens (e. − Factors Influencing a Client’s Biological Safety Like any other type of safety.Unlawful to replicate or distribute • • • Internal hemorrhage is characterized by the formation of a hematoma.. Inc. NXP 070106 v1. Partial dehiscence places the patient at considerable risk of complete dehiscence and evisceration. environmental factors. including age and developmental level. a retroperitoneal splenic or liver hemorrhage) are not visible but are assessed by the presence of characteristic pain and signs of systemic circulatory collapse. Age and Developmental Factors Healthy children and adults heal well. Infection is the invasion of a wound by pathogenic organisms at the time of injury.0 .g. sexually transmitted diseases. poor nutrition.g. Health habits (e. and psychological factors. Infants. Evisceration is the protrusion of viscera through a dehisced wound. However. escapes under the dressing. Deficiencies in vitamins B and C lead to poor wound healing. For instance. may think of diseases such as St. Any intravenous line. An incomplete trial of therapy is usually ineffective and contributes to the development of resistant organisms. Cultural. For example. increases a person’s chances of infection. The uninsured are more likely to have serious infections or wounds that go untreated. both of which contribute to increased susceptibility to and transmission of infectious disease. which then predispose the respiratory tract to infection. Vitus’ dance (a complication of a streptococcal infection of the throat) as possession by an evil spirit and not seek appropriate medical care. catheter. Secondary smoke is associated with otitis media. opportunistic or otherwise. Immunosuppressive therapy. The availability of pasteurized milk in the United States and the industrial world contributes greatly to the control and elimination of gastrointestinal Copyright © 2008. NXP 070106 v1. Socioeconomic status also influences crowding. Socioeconomic Factors Socioeconomic factors greatly influence peoples’ access to health care in the United States. In the United States. Spiritual. and their children may not be vaccinated. when faced with an inability to pay for an entire prescription. Some cultures or subgroups within cultures rely on a shaman (one who uses magic to cure the sick) for treatment or cure in the event of an infection. The College Network. Any kind of invasive procedure is accompanied by the risk of infection. It influences whether people can buy the antibiotics they are prescribed. Other cultures. Patients living with human immunodeficiency virus (HIV) are more likely to contract opportunistic infections. Environmental Factors Environmental factors additionally influence a patient’s biological safety. and their immobility makes them more vulnerable to pulmonary infections and to pressure ulcers. Illnesses also increase vulnerability to infection. people as a whole are dependent on meat from antibiotic-treated cattle and seek antibiotic treatment at the first sign of infection. and nutritional status. and the treatment of water supplies help control communicable disease. Physical Condition Poor nutritional status predisposes a person to infectious disease. as mentioned. and Religious Considerations Some people subscribe to faith systems that do not believe in medical interventions. or drainage tube increases infection risk.0 . clients with chronic obstructive pulmonary disease and asthma are at increased risk of dying from influenza.Unlawful to replicate or distribute conditions may result in poor hygienic practices and overcrowding. Patients with a decreased level of consciousness are less likely to turn independently. garbage collection. not fully aware of disease processes. used in the treatment of cancer and sometimes in the treatment of autoimmune diseases. buy less than a full course of therapy. Protein-deficient populations are more vulnerable to tuberculosis and other infections. and thus contribute to antibiotic resistance in general. Other environmental factors include pollens that cause seasonal allergies. sewage treatment. Some people. this increases the children’s vulnerability to infectious diseases. Inc. they may predispose to it. and dietary modifications. the client most likely will need prednisone to treat the acute bronchial wall inflammation and antibiotics to treat the sinus infection. DOT may sometimes evoke anger or frustration if a patient feels his or her right to self-determination has been denied. the infecting organism is grown in a culture media and identified. If the sensitivity results indicate that the organism is sensitive to the antibiotic selected. Patients sometimes take corticosteroids as an immunosuppressant for cancer therapy. they are usually not indicated in the treatment of infection.g. it is likely that the prednisone will be continued and an antibiotic added. These are just a few links between the environment and biological safety. This is called empirical therapy.0 . Anti-inflammatory agents include corticosteroid agents. antitubercular agents. antivirals. maintenance of asepsis. Should the patient develop an infection. wound care. Copyright © 2008. in fact. NXP 070106 v1. Corticosteroids are anti-inflammatory agents that also suppress the immune system. Obtaining a culture and sensitivity helps ensure that an appropriate antibiotic is used and decreases the probability that resistance will develop. and the sensitivity of the organism to a variety of antibiotics is evaluated.Unlawful to replicate or distribute Fundamentals of Nursing 287 tuberculosis. antifungals. Theoretical Bases for Biological Safety Interventions Biological safety interventions can take a variety of forms. or even pneumonia). Stress also accompanies news of a diagnosis (e. Inc. application of heat and cold. and aspirin. in an acute exacerbation of asthma precipitated by a sinus infection. For example. Some infectious disease treatment methods have a psychological impact. If the sensitivity results indicate that the organism is resistant. lack of pasteurization in some developing countries of the world places those populations at increased risk of this disease. then the antibiotic is changed. Not infrequently. Another factor that has an impact on a person’s well-being is that of the individual’s right to privacy versus the state’s obligation to protect the public. Medications Anti-infectives are used to treat infection. HIV. For best results. there may be times when both corticosteroids and antibiotics are administered together. gonorrhea. Psychological Factors Stress may predispose a patient to infection by altering the immune system. These include medication. Thus. then treatment is continued. The College Network. directly observed therapy (DOT) safeguards the state’s right to protect the public by ensuring a patient’s compliance with antituberculosis therapy. On the other hand. as in the mandatory reporting of sexually transmitted diseases. The theoretical bases for these different types of interventions are explained in the following sections.. nonsteroidal anti-inflammatory drugs (NSAIDs). For example. These include antibiotics. and antiprotozoal agents. the severity of the infection demands that antibiotics be given on the basis of the physician’s clinical judgment of the nature of the invading organism before receiving the results of a culture and sensitivity. However. the bedside unit. however.g. They must be disinfected or sterilized. intravascular catheters. 2. NSAIDs should be taken with food. and drainage bottles and bags. and thermometers. The first category is that of items entering the vascular system (e. and stethoscopes. cleaning. both classes of drugs are frequently used to control inflammation. and sterilizing are used to maintain medical asepsis. intramuscularly or subcutaneously).. These are called critical items. “Clean” refers to the near absence of microorganisms. It has no anti-inflammatory action. all surgical instruments.. lacerated or abraded skin). These items must be free of all microorganisms except for bacterial spores. they categorized items and equipment that came into contact with patients during the delivery of nursing care on the basis of their degree of sterility or cleanliness: 1. if contaminated. “Dirty” refers to soiled or contaminated objects capable of causing infection. These are called semicritical items. To minimize the probability of gastric irritation. The College Network. Finally. the administration of aspirin to control fever in the treatment of varicella (chicken pox) in children twelve and younger has been associated with Reye syndrome. There are two options available when medical asepsis is considered: clean or dirty. intravenously or through central lines) and tissue (e.Unlawful to replicate or distribute NSAIDs share anti-inflammatory. Maintenance of Medical Asepsis Medical asepsis is another common biological safety intervention. the probability of or risk of infection is very high. blood pressure cuffs. a serious condition that can lead to death or leave the child severely impaired. dressing changes. As previously mentioned. urinary catheters. These items include bedpans. including needles. hepatotoxicity can occur.g.. antipyretic.g. These items must be sterile because. All NSAIDs may precipitate asthma attacks in asthmatic patients who are aspirin sensitive. and needles must be sterile. These are called noncritical items and must be disinfected. and pain associated with infection. Such items include oral and endotracheal suctioning tubes and catheters. endoscopes. More specifically.0 . it is safe for children and adults. Spaulding (1968) and Rutala (1989) identified three principles that nurses can use to maintain medical asepsis. When toxic amounts are ingested or when large doses are given over time to patients with underlying liver disease. and analgesic action with aspirin. Some words of caution are necessary. When taken in the doses prescribed. fever. Therefore. Therefore. NXP 070106 v1. Acetaminophen (Tylenol) is an analgesic and antipyretic. care of contaminated articles. disinfecting. Although hand washing was mentioned above. linens. Aseptic measures or interventions are designed to control and reduce the number of potentially infective agents. Inc. 3. it is important Copyright © 2008. The third category is that of all items that contact intact skin (but not the mucous membranes). The second category is that of all items that contact the mucous membranes or contact skin that is not intact (e. Health care agencies also establish infection control procedures governing hand washing. Do not touch the sink with your hands. length is determined by agency policy. Discard gloves and wash hands after contact with a patient. arms. Apply soap via foot pedal in sufficient quantity to lather thoroughly. and proper protective gear. establishment of a surgical field. The following are the steps in a surgical scrub: • • • • • • • • • • • Control water flow with knee or foot pedals. Maintenance of Surgical Asepsis Surgical asepsis has even stricter standards than medical asepsis. Surgical Scrub A surgical scrub is a much more intensive hand-washing technique than that already described.. infants. however. The College Network. suctioning) Before and after change of any dressing or touching open wounds Between contact with all high-risk patients (e. the elderly. Lather a minimum of ten to fifteen seconds. Hand Washing To prevent the transmission of microorganisms from the nurse to the patient or to prevent the nurse from carrying microorganisms from one patient to another. wearing gloves does not excuse the nurse from hand washing. Garner and Favero (1985) recommend that hand washing be performed for at least ten to fifteen seconds under each of the following circumstances: • • • • • • Prior to contact with newborns or any immunosuppressed patients (e. patients receiving glucocorticoids.Unlawful to replicate or distribute for the nurse to know when hand washing is indicated. or patients with leukemia or HIV) After caring for an infected patient After disposing of or touching any organic material Before administering medications and performing any invasive procedure (e. Turn on the water (avoid splashing and regulate flow). intramuscular injections. or cancer chemotherapy. Copyright © 2008. Inspect your hands and report lesions or breaks in the skin.. It is also important to know the distinction between hand washing (a medical asepsis method) and surgical scrub (a surgical asepsis method). including rings (safeguard them).g. catheterization. NXP 070106 v1. Clean under and scrub your nails. or uniform. During washing. or immunosuppressed patients) In addition. Remove watches and jewelry.. Be sure your nail beds are short and filed.g. Inc. Wet your hands and arms to the elbow.0 . intensive care patients. especially in relation to surgical scrubs. keep your hands below your elbows.g. Inc. NXP 070106 v1. and allow soap and water to be rinsed in the direction of hand to elbow. then elbows. Use knee or foot pedal to turn off water. anything sterile touching anything clean. The Surgical Field Establishing a surgical field is another aseptic method that has been discussed previously. Repeat soap wash for one to three minutes (length of time is determined by the agency).Unlawful to replicate or distribute • • • • • Rinse. then wrists. an object below the waist) is considered contaminated. The College Network. Sterile objects must be removed from packages sterilely (for example. and proper techniques to maintain the sterile field. a sterile drape is first opened. “The field is contaminated.0 . Outside of surgery.” Under such circumstances. or sterile objects may be dropped onto the field without touching the edges of the container or package from which they came. establishment of a sterile field requires sterile gloves and proper techniques to maintain a sterile field. The sterile field is established within the center of the sterile drape. or questionably contaminated is no longer sterile and is considered contaminated. • • • • Copyright © 2008. In surgery. sterile gloves. This is because inadvertent contamination of the field could conceivably occur and the nurse would not see it occur. Unless a field or an object is known to be sterile. holding your hands above your elbows. Any sterile field or object is considered contaminated in the following circumstances: − Upon prolonged exposure to air − When subjected to strong air currents or winds − When coughed or sneezed upon (nurses with respiratory infections should not perform surgical procedures unless double masked) Because a 2. it is not sterile. sterile gown. A sterile field from which the nurse has turned his or her back is considered contaminated. Discard towel. establishment of a sterile field requires a mask. This drape must not touch anything but air. Any object out of the nurse’s vision (e. Only sterile objects may go into a sterile field. Fields can be inadvertently contaminated and go unnoticed unless the health care professional speaks out to say..5 centimeter (1 inch) edge of a sterile field is considered contaminated. Ease in its establishment and maintenance comes with practice. Therefore. Principles governing the maintenance of a sterile field are as follows (Potter and Perry 2004): • • • • Sterile touching sterile remains sterile. a sterilely gloved nurse can use sterile forceps to remove sterile dressings from a package being held and having been just opened by another nurse using sterile technique). contaminated. Dry your hands first. a new sterile field needs to be established. Sterile touching anything less than sterile becomes contaminated.g. Whether in surgery or on a nursing unit. pour the sterile liquid into a sterile bowl without touching the bottle or its neck to the bowl. barrier methods (to be used in care of patients with MDROs or with persons who colonize and carry such organisms). multi-drug resistant organisms (MDROs) are an increasing threat to the biological safety of patients within health care settings. such as surgery. and protective eyewear are worn under various circumstances. pour a small portion out of the bottle into a receptacle for discarding. Now. According to CDC guidelines. Inc. Despite conflicting evidence. Caps are not worn when performing sterile procedures on the nursing unit. Protective eyewear is worn any time there is a danger that bodily fluids may splash into the eye. In isolation. and protective eyewear are used in performing procedures within isolation rooms. (Potter and Perry 2004) Protective Gear Caps. Contact precautions include placement in a private room with gown and glove precautions. Even so. masks. cohorting. and decolonization. These organisms are found in all health care settings. other strategies are usually used alongside cohorting. The most common organisms are MRSA.Unlawful to replicate or distribute • When pouring a liquid. VRE. This cleanses the lip exposed to air. Decisions regarding the duration of contact precautions vary. masks. prudence and logic lead to the conclusion to continue contact precautions on all patients with MDRO until three negative cultures have been obtained or the patient is discharged from the facility. duration of contact precautions. The College Network. The multi-drug resistant strategies discussed here are designed to limit exposure and decrease communication to other patients or staff within health care settings. these six strategies include contact precautions. environmental measures. clean gloves are used wherever there is risk of exposure to bodily fluids. a relatively high recurrence rate of VRE was found among these patients. masks are to be changed when they become moist or upon completing a procedure. NXP 070106 v1. Note that clean caps. In routine care. In surgery. sterile gowns and sterile gloves are used. Copyright © 2008. clean gowns and gloves are used. These organisms are usually bacteria and are resistant to one or more classes of antimicrobials. MRSA stands for methicillin-resistant Staphylococci Aureus. Gowns and gloves are worn under various circumstances.0 . Cohorting is another strategy in which MDRO patients and staff are assigned to a particular unit or set of rooms. GNB stands for gram-negative bacteria. Multi-drug Resistant Organisms and Related Interventions According to the CDC Multi-Drug Resistant Guidelines. VRE stands for Vancomycin-resistant enterococci. Guidelines formed in 1995 for VRE management required weekly negative stool cultures for three weeks before discontinuing contact precautions. Wearing clean gloves in patient care does not eliminate the need for hand washing for medical asepsis purposes. and GNB. They are considered contaminated once they become moist. Without drug therapy. Patients infected with these strains are resistant to treatment for four or five of the available antituberculosis agents. Educational programs targeting housekeeping personnel have been helpful in infection control. and less quantity and quality of care. and other small spaces. The second method is to simply dilute the contaminate air and facilitate its exit by general ventilation methods such as opening windows and avoiding closed. Because of these observations. cohorting. NXP 070106 v1. This prevents bacteria from exiting the room. for example. Studies report varying results as to the effectiveness of barrier methods. some strains of mycobacterium tuberculosis. This is because isolation often involves decreased surveillance. The air pressure in these rooms is less than ambient air pressure. The latter is a relatively new system used to improve the quality of indoor air and control disease. Contact measures can isolate patients and place them at risk for preventable adverse events. Copyright © 2008. resuscitation masks. In these patients. Within hospital environments. Combined with special ventilation and filters. The College Network. including biodefense applications. greater patient dissatisfaction because of decreased contact with staff. these rooms not only allow the patient to be separated from the public but also control the airborne flow of tuberculosis organisms. however. monitoring staff adherence is required. removing the infected lung or portions thereof.0 . nursing care strategies need to be planned to address these problems. Again. the only treatment strategy is that of surgery. environmental control of air is mandatory. are associated with side effects. Inc. Environmental measures refer to actions taken to disinfect all surfaces and equipment in the environment to decrease reservoirs of bacteria. crowded spaces. Barrier precautions refer to the use of barrier methods such as gloves (with gowns or without).Unlawful to replicate or distribute Contact precautions. and duration of contact precautions. There are also what are termed very multi-drug resistant organisms. Primary environmental controls consist of controlling the source of infection by using exhaust ventilation methods to facilitate the exit of airborne organisms from hoods. Decolonization refers to attempts to decrease the colonization in persons carrying the bacteria. booths. Secondary environmental controls consist of controlling the airflow itself to prevent recirculation of contaminated air or to attempt to remove bacteria from contaminated air by the use of high efficiency particulate air (HEPA) filtration or UVGI (ultraviolet germicidal irradiation). Environmental Control of Air Environmental control may be used to prevent the spread and reduce the concentration of infectious droplet nuclei in ambient air. patients with tuberculosis are placed in Airborne Infection Isolation Rooms (AIIRs). This is perhaps because adherence to barrier methods among staff is often low. as in the days prior to the discovery of streptomycin. Infectious disease experts need to prescribe and manage therapy if this strategy is chosen. and goggles to prevent spread of infection. NXP 070106 v1. Remember. should do everything in his or her power to obtain admission for the client to an AIIR within a hospital. and insuring that all health care workers are instructed on use.Unlawful to replicate or distribute Respiratory Protection Controls The control measures previously mentioned decrease the amount of air or air space that contains mycobacterium tuberculosis. The complacency period is now over. The CDC also teaches that when in an AIIR. Between the advent of antitubercular drugs in the late 1940s and early 1950s and the development of mycobacterium resistant to many of those same drugs. they may not actually do this. they are still in the room before they exit. While community-based patients who are infectious to others should wear a surgical mask inside and out of the home. Respiratory protective controls or personal respirators use equipment to limit exposure in high-risk environments. If compliance remains a problem. A relatively small but growing number of patients with multi-drug and very multidrug resistant tuberculosis are being ordered to isolation units within hospitals or to specialized respiratory disease hospitals by judges to protect the public. All tuberculosis patients infectious to others need to be taught proper respiratory hygiene and best cough practices to help decrease exposure to others. but the health care worker should wear a personal respirator. DOT may be also mandated by the court with the threat of mandated admission to a hospital should compliance remain an issue. Community-based patients with tuberculosis who are not compliant with therapy may have directly observed therapy (DOT) prescribed by the prescribing practitioner. of which respiratory protective control measures are a part. Public health law has again come to the forefront of the news. The rationale underlying this approach is that non-compliance leads to drug and multi-drug resistance to an organism that has the potential for infecting others in the society. Officials talked of tuberculosis eradication programs. in conjunction with the public health department. The provider.0 . Inc. The CDC teaches that when interviewing patients with infectious or suspected infectious tuberculosis in non-AIIR settings. Ethics and Legal Issues: Persons with Multi-drug Resistant Tuberculosis Tuberculosis is a deadly disease that is capable of being communicated to others. Integral to the successful use of respiratory protective control equipment is the establishment of an overall program. Patients with tuberculosis who are infectious or suspected to be infectious to others are instructed to wear a surgical mask to limit the exposure of others to the organisms if they are not hospitalized in an AIIR. The College Network. while the organisms are exiting the AIIR safely. a degree of complacency occurred. Such equipment also prevents droplet nuclei exposure. they are mandated Copyright © 2008. Surgical masks are by no means foolproof but do help decrease exposure. health care workers should wear a personal respirator and patients should wear a surgical mask. the patient need not wear a mask. This means that when physicians or nurse practitioners diagnose a case of tuberculosis. Tuberculosis is mandated by law as a notifiable communicable disease. too.Unlawful to replicate or distribute to report the case to the public health department. At the same time. NXP 070106 v1. This is an important distinction. The General Requirements on PPE follow. Protection of the patient does not mean that proper public health procedures are overlooked.0 . at times. foremost of which is human respect. Occupational Safety and Health Administration and Personal Protective Equipment The U. Copyright © 2008. There are ethical issues involved in the care of persons with tuberculosis that concern the providers of services. Protection of self and others means ensuring that all protective procedures are followed. which in turn follows the patient and evaluates all contacts. Occupational Safety and Health Administration (OSHA) is interested in the appropriate use of Personal Protective Equipment (PPE) by all health care workers. that patients who are separated from others in AIIR require special attention to maintain psychological health. and the law.S. others. Tuberculosis is not a crime. they must be accorded the human rights they deserve. including registered nurses. have an obligation to complete the following actions: • • • Adhere to the treatment policies and procedures laid out by the CDC Ensure that instructions provided to patients are understood (Asking for feedback or recall of instructions is a good method. including the instructions given and the patient’s comprehension of those instructions There are ethical considerations as well. This holds true even for those patients who do not comply with public health law and find themselves in situations where they are mandated to receive therapy or enter a hospital. When caring for such persons. In all situations. They often have very real family and financial concerns. public health. Patients with tuberculosis who are infectious to others have an ethical obligation to help in the prevention of its spread to others. People with tuberculosis are human persons who are ill with added concern over the diagnosis and recovery. Remember. Inc. or hospital standards. and the patient. Health care providers and health care workers have an ethical obligation to protect themselves. remember it is the behavior that is disapproved of and not the person. Registered nurses need to be aware of these regulations for their own benefit and for the benefit of assistive personnel for whom they are responsible. the public health department. The College Network. Public health workers.) Document care plans and progress at each encounter. require advocacy in the event that the patient is receiving less care or care that does not meet nursing. the patient. this is unethical and places the self and others at risk. protection of the patient may. Select PPE that properly fits each affected employee. which necessitate the use of personal protective equipment (PPE). All personal protective equipment shall be of safe design and construction for the work to be performed. the date(s) of the hazard assessment. Verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated. and extremities. or are likely to be present. and maintained in a sanitary and reliable condition wherever it is necessary by reason of hazards of processes or environment. Where employees provide their own protective equipment. radiological hazards. and. shall be provided. or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption. inhalation or physical contact. Communicate selection decisions to each affected employee. and protective shields and barriers. The employer shall assess the workplace to determine if hazards are present. the types of PPE that will protect the affected employee from the hazards identified in the hazard assessment.132(a) Topic Application Regulation Protective equipment. Defective or damaged personal protective equipment shall not be used. 1910. or likely to be present. used. including proper maintenance. which identifies the document as a certification of hazard assessment.Unlawful to replicate or distribute Table 15. including personal protective equipment for eyes. protective clothing. chemical hazards. the employer shall be responsible to assure its adequacy. If such hazards are present.132(b) Employee-owned equipment 1910. The College Network. and sanitation of such equipment. respiratory devices. head. Inc. and have each affected employee use. and. the employer shall: • Select. NXP 070106 v1.132(c) 1910.132(d) Design Hazard assessment • • • • Copyright © 2008.0 . face.5 General Requirements on Use of Personal Protective Equipment Standard 1910. the person certifying that the evaluation has been performed. NXP 070106 v1. Each such employee shall be trained to know at least the following: When PPE is necessary. Inc. the date(s) of training. and the ability to use PPE properly. What PPE is necessary. and wear PPE. adjust. maintenance. useful life and disposal of the PPE. but are not limited to.132]. and that identifies the subject of the certification. When the employer has reason to believe that any affected employee who has already been trained does not have the understanding and skill required.0 . before being allowed to perform work requiring the use of PPE. The College Network. Circumstances where retraining is required include.132(d) [cont’d] Topic Training Regulation The employer shall provide training to each employee who is required by this section to use PPE. Copyright © 2008. Each affected employee shall demonstrate an understanding of the training [specified in paragraph (f)(1) of section 1910.5 General Requirements on Use of Personal Protective Equipment Standard 1910. The limitations of the PPE. the employer shall retrain each such employee. or Changes in the types of PPE to be used render previous training obsolete. doff. situations where: • • • Changes in the workplace render previous training obsolete. and. The employer shall verify that each affected employee has received and understood the required training through a written certification that contains the name of each employee trained. How to properly don.Unlawful to replicate or distribute Table 15. The proper care. or Inadequacies in an affected employee's knowledge or use of assigned PPE indicate that the employee has not retained the requisite understanding or skill. as it absorbs moisture very well and may dry the site more than desired. Autolytic debridement uses dressings (e. loosely tuck normal saline saturated gauze that has been fluffed over the wound. absorbent acrylic dressings) to capture the body’s own drainage and uses its own proteolytic products to debride the eschar. is also available. Physicians. and black wounds. Papain is derived from the papaya fruit. which is a dry scablike covering or slough covering all or part of a wound. The rationale for treatment is to protect the affected and surrounding skin. Chemical debridement is a process that relies on the use of proteolytic products such as papain-urea to remove necrotic tissue. Apply absorbent dressing impregnated with alginate. If the dressing is too moist. caked.. or cracked. Inc. maggot debridement therapy (MDT) or larval therapy is an ancient therapy revisited at times during the twentieth Copyright © 2008.or glycerinbased. use less normal saline in changing the dressing. Sharp debridement uses sharp instruments (scalpel or scissors) to remove dead tissue. Avoid dressings with lesser absorbency. The tissue is fragile at this stage. In the pre-antibiotic era. If the gauze is dry or if the wound is dry.g. A newer product.Unlawful to replicate or distribute The RYB Color Code and Wound Dressings The RYB Color Code represents red. moisten the old gauze before removing very gently. Red Wounds Red wounds usually represent granulation tissue developing in the late regenerative stage of healing. NXP 070106 v1. and then change the dressing again. Yellow Wounds Yellow wounds are suppurative. necrotic tissue and eschar. meaning they secrete purulent material along with seropurulent drainage. hydrocolloid and clear. Use a more moist dressing during this change. The nurse removes the old dressing gently and cleanses the wound gently without pressure by using a cleaning agent that will not kill or damage cells. The College Network. If moist dressings are used. advanced practice nurses. a calcium alginate dressing with antimicrobial silver. It is a transparent film. which will also keep the area moist. Hydrogel is either water. making sure all surfaces are covered. The rationale of treatment is to clean the skin of infectious drainage and debris and promote growth of viable tissue. of which there are four kinds. which will absorb fluid and purulent material even as it keeps the area moist. To change the dressing.0 . Take a piece of dry gauze to cover the moist gauze and use tape to secure the dressing. an alginate dressing is not a good choice. so it facilitates assessment of the wound site between dressing changes. Black Wounds Black wounds are characterized by black. yellow. and physical therapists (all with special training in wound care) are the only ones qualified to conduct sharp debridement. wound care nurses. gently remove and discard the old dressing. Black wounds require debridement. Keep in place six hours or as directed. These substances help clean away necrotic tissue or eschar and prepare the wound bed for healing. and urea is a protein denaturant. If the intent is to keep the wound moist. Cleanse the wound of debris by irrigating it with normal saline solution. An alternative dressing is hydrogel. These wounds require gentle care. It contains more extensive antimicrobial activity because of the silver and requires fewer dressing changes. The rationale is that the larvae secrete proteolytic enzymes that debride necrotic tissue. ropes. the wound bed is exposed as either a yellow or red wound. zinc-saline. The dressing can last up to seven days. granules. “C” stands for clear absorbent acrylic. soothe. These dressings are used to cover. adhesive dressings. which also absorbs exudates that help form a hydrogel covering over the wound. powder. The formulation depends on the nature of the wound. Once the eschar is removed. or gels. and protect the skin. “H” represents hydrogels. or antimicrobial ointments. They require a secondary occlusive dressing. “Chi path” is a pneumonic available for use in remembering the types of dressings commonly employed in wound care. Its success led experts to adopt it as a debridement tool earlier in the wound care process. Alginates are highly absorbent substances even as they help retain a moist environment. which is a hydrocolloid used to absorb large amounts of exudates while maintaining a moist environment. Types of Dressings Pneumonics are tools to nudge the memory into recalling words. Secondly. saline. represented by letters.Unlawful to replicate or distribute century. or sheets. The College Network. clear absorbent acrylic can be used to cover alginates to facilitate wound packing. “H” represents hydrocolloids. Alginates come in various formulations: paste. They are used to cover IV lines. Inc.0 . pastes. NXP 070106 v1. and Ireland. which are semipermeable. the occlusive nature of the dressing can promote anaerobic growth. They clear the eschar and leave healthy tissue intact. which are water. and superficial wounds. The inner layer contains an adhesive product. Europe. which are wafers. or powders that contain two layers. nonabsorbent. such as sheets. “T” is for transparent films. when its use was usually a last resort measure in an attempt to prevent amputation. which are products of alginic acid.or glycerin-based substances with various formulations. such as petrolatum. transparent wafer that allows the wound to remain moist and to be seen even as healing occurs. They are permeable to oxygen and are Copyright © 2008. With a deep wound bed. which is a clear. The disadvantages of the dressing are that they are not transparent. It requires the care of surrounding healthy tissue to prevent maceration. central lines. and the condition of the wound cannot be directly assessed. Although they permit the exchange of oxygen. which larvae ingest along with associated bacteria. The outer layer provides an occlusive seal. The dressing lasts 5–7 days and remains permeable to oxygen exchange. a substance found in seaweed off the coasts of the United States. “I” stands for impregnated non-adherent dressings made of woven or nonwoven cotton cloth impregnated with substances. “A” stands for alginates. Edges of the hydrocolloid need to be taped down and the dressing covered with a second occlusive dressing. “P” represents polyurethane foam. granules. they are impermeable to water or bacteria. However. pliable. squeeze the bulb with one hand while closing the port. being careful not to dislodge the drain. facilitating drainage. On the bulb is a port. flat surface and compress the bag with one hand while reinserting the stopper. or serosanguineous material from the surgical site to the exterior surface of the body at the incision line. The bulb is connected to a drain from a surgical site. unless the amount of drainage necessitates more frequent changes. if ordered) for cleansing. which causes a less reactive tissue response. flat drainage bag with springs. Complete the dressing change using the proper prescribed type of dressing. move up the tube by cleaning first the proximal and then the distal surface of the drain. rehydrate the wound bed. the rubber tubing establishes a track through which fluids can continue to flow once the drain is removed and until the track heals. Drains A surgical drain is a soft. The Hemovac is usually emptied through its port twice daily. Special skin barriers are sometimes used around drain sites. Drainage ceases more quickly than in the track made by the Penrose drain..0 . They allow drainage material to flow over the barrier without damaging or irritating the skin. The compressed air will create a vacuum exerting a pull on the fluid to be drained. the track tends to close. Before closing the Hemovac with the stopper. consisting of a series of open capillary tubes. The Yates drain. wafer-like plastic materials applied with an adhesive substance. Copyright © 2008. allowing for emptying of accumulated drainage. Drainage systems are of two types: a drain alone or a drain attached to continuous suction. When the port is opened. Drain dressings are usually changed twice daily. After cleansing the skin.g. Fluid drains through the rubber tubing. Closed Drainage Systems A Hemovac drainage system is a round. Be sure that when changing a dressing. rubber. use sterile technique. These drains are covered with sterile absorbent dressings and changed as frequently as needed to keep the dressing dry. Inc. place the Hemovac on a clean. It comes in varying lengths and sizes for adaptation to various kinds of wounds or surgical incisions. sterile saline or a solution such as Betadine. The Penrose drain is a commonly used soft. This creates a vacuum which exerts a pull on the fluid at the surgical site. sanguinous. Drains and Drainage Evacuators Care of drains and drainage evacuators is an important part of wound care. These skin barriers are small.Unlawful to replicate or distribute used to soften and liquefy necrotic tissue. The College Network. is made of polyethylene. oval shaped bulb that fits readily in the palm of the hand. pliable tube used to facilitate passage of suppurative. The Jackson-Pratt drainage system consists of an elongated. and draining the bulb. and function as a filler within wound craters. the Hemovac bag expands and all accumulated fluid may be poured through the port and measured. NXP 070106 v1. open tubing with a gauze wick in its center. drains are not dislodged. After opening the port. Begin at the surface of the surrounding skin and gently remove and discard the dressing. When changing dressings where drains are located. Once the drain is removed. The Hemovac is fed by tubing connected to the surgical wound being drained. Use sterile solution (e. frostbite). Avoid cold in the treatment of open wounds. but only if the patient is monitored during the application. When warm baths are recommended. when pumped with the port of the drainage bottle open.. which drains fluid from the surgical site to the drainage bottle. neuromotor. because it decreases blood flow and consequently. Exposure to excessive heat causes burns. As the balloon inside the sealed drainage bottle gradually deflates. instruct patients not to use excessively warm water or remain in the bath more than the recommended amount of time. traumatic injury such as a sprained ankle. Copyright © 2008.g. Exposure of a large part of the body surface to heat causes vasodilation. If present. NXP 070106 v1. the resulting vasodilation will increase edema at the site and continue extravasation. Heat or cold may be applied in patients who have impaired mental status. Shivering may occur. Provide patients with the assistance they need during and after the bath to prevent weakness and/or falling.0 . When a large surface of the body is exposed to cold. Above the site where the tube inserts itself into the bottle is a rubber bulb. to the affected part.Unlawful to replicate or distribute The Davol drainage system consists of a port. immediately seal the port. Cold is often used for sports-related injuries and for joint injuries. Cold causes vasoconstriction and reduces blood flow to the affected area. Assess for conditions that contraindicate heat therapy. Pumping of the rubber bulb inflates the balloon. Take special precautions when considering the application of heat or cold. in order to prevent burning). reducing edema and inflammation. allowing for emptying of the drainage bottle. with its supply of oxygen and nutrients. If heat is applied too early in the event of a closed. do not apply heat. When the patient stands to emerge from the bath. The Davol system also consists of a tube. Do not apply heat after surgery because heat promotes bleeding. Application of Heat and Cold Heat causes vasodilation and increases blood flow. Avoid heat or cold applications in patients with neurosensory. Weakness or fainting may occur. Inc. and notify the physician. it is also important to do the following: • • Determine the patient’s tolerance to treatment. healing. feeds air into a balloon located within the drainage bottle. the resultant vasoconstriction can result in an increase in blood pressure as blood is shunted from the body’s surface to internal organs. This causes an increase in the amount of bruising. Heat also promotes soft-tissue healing. These patients are at greater risk of heat or cold injury because their ability to sense discomfort or pain may be decreased (neurosensory and/or circulatory impairment) or their ability to move away from the source of pain or discomfort may be decreased (neuromotor impairment). Once inflated. This rubber bulb. Exposure to prolonged cold impairs circulation and may cause tissue damage (e. The College Network. his or her blood pressure may drop dramatically due to orthostasis. drainage of fluid from the surgical site is facilitated. or circulatory impairment. When applying warm heat (not hot. Unless contraindicated. NXP 070106 v1. families. Finally. Return in ten to fifteen minutes and observe the patient’s skin response. and C. the patient needs to have both intake and output measured. or sitz bath. Placing patients in isolation in a hospital also has privacy implications. or visitors. B1. Ask the patient to report any discomfort immediately. Apply the heat source to the affected area. naming the disease or type of organism. The same steps are to be followed when applying cold. including adequate amounts of protein. Dry methods include cold pack. and zinc. aquathermia pad. vitamins A. ice bag. Be sure that both agency and state policies are followed. Evaluate the area to which heat was applied. Again. or disposable heat pack. Moist cold may be applied by compress or by cooling baths. a patient’s right to privacy is weighed against society’s need for protection. Patients need specific nutrients. Ethical and Legal Implications When communicable diseases are involved. is not appropriate. Stop application if any problem occurs. Inc. Stop signs on doors are appropriate. or ice collar. The College Network.500 mL of fluid should be taken. an intake of 2. B2. whereas stating “isolation” or worse. Be sure the patient has a call button within reach. Assess the patient’s skin. Discontinue application at the designated time unless signs indicate that the application needs to be removed prior to the designated time. ice glove. hot pack. Copyright © 2008. A list of communicable diseases that must be reported to the local health department may be obtained from that health department. electric heating pad. Wet heat is applied by hot soak or compress. Dietary Modifications to Improve Wound Healing Wounds heal best in the presence of adequate dietary and fluid intake. If the wound is severe. Each state has its own regulations regarding the reporting of HIV infection. Methods of heat application include hot water bottle. discontinue heat application if a problem occurs.0 . Such reporting may have insurance repercussions.Unlawful to replicate or distribute Fundamentals of Nursing 301 • • • • • • • Explain the procedure to the patient. it is important to make sure that conversations held among health professionals or with auxiliary staff are not overheard by patients. 0 . The College Network. NXP 070106 v1.Unlawful to replicate or distribute Copyright © 2008. Inc. Copyright © 2008. Explain the two criteria used to determine how often outcome evaluations are done. NXP 070106 v1. List the two situations that would have the highest intervention priority in the case of an infection. where we illustrate how data from the nursing assessment results in infection-specific diagnostic labels. involves the collection of infection-related historical data. Describe the role of the nurse in maintaining biological safety during the implementation phase.Unlawful to replicate or distribute Fundamentals of Nursing 303 Chapter 16: The Nursing Process and Biological Safety Objectives Upon completion of this chapter. infection-related nursing assessment areas. Finally. Our discussion then turns to the diagnosis phase of the nursing process. This chapter provides specific examples of how this occurs. physical assessment data for localized and systemic infections. as it relates to the biological safety of the client. We begin by looking at four critical. Inc. We then discuss various implementation strategies aimed at improving the health and well-being of patients with infections. and the meaning of decreased values found in a white blood cell differential count.0 . you should be able to do the following: 1. Explain what must be included in the nursing plan for a patient presenting with an infected wound. 3. 6. their normal count (%). specifically assessments of the patients’ white blood count. Introduction The nursing process is the clinical problem-solving framework used to promote clients’ biological safety. Assessment Nursing assessment. and relevant laboratory data. Explain the four nursing assessment areas needed for a comprehensive assessment related to biological safety. 2. The College Network. we discuss how frequently goals and outcomes need to be evaluated. historical data on factors influencing the client’s biological safety. We look at the evaluation phase and discuss various examples of questions that can be used to determine if the outcomes attained are the same as the expected outcomes. We analyze the planning phase and discuss examples of client-centered goals when infectious processes are involved. We pay particular attention to laboratory data. the meaning of elevated values. Describe the six different types of cells. 5. 4. 3.. or ulcers. History of hygienic practices − Inquire about the patient’s bathing frequency.0 . measles. This data may be categorized in the following manner: 1. History of susceptibility to communicable diseases − Look specifically for a history of significant disease (e. superficial infections. 4. because a high rate of infection frequency may indicate immunosuppression. carinii) and the frequency of communicable diseases. lesions. pertussis). − Ask about travel outside of the United States (recent and past) and any known exposure to unusual pathogens in other countries. Inc. breaks in skin surface. and opportunistic infections like P. − Inquire about prior blood transfusions and record the year(s) in which they were received. hepatitis. − Be sure to record what childhood diseases the patient has had (e. History of exposure (recent and past) to pathogens − Whether or not the patient reports a history of tuberculosis. History of response to the infectious process − Inquire regarding the extent and severity of the infectious diseases reported by the patient and the amount of recovery time necessary. varicella.Unlawful to replicate or distribute Infection-Related Historical Data Infection-related historical data is collected data that relates directly to the patient’s past biological safety issues. − Ask about IV drug use. mumps. and presence of rash. − Ask about condition of skin. and safe-sex practices. − Inquire about history of or fear of exposure to sexually transmitted diseases or HIV. − Obtain a vaccination history..g. oral hygiene practices. Copyright © 2008.g. NXP 070106 v1. tuberculosis. The College Network. 2. inquire about a history of exposure to persons with tuberculosis. 4. NXP 070106 v1. Age/development factors − If the patient is an infant. − Inquire about alternative therapies used. and mental health). − If the patient is an adolescent. Copyright © 2008. record his or her age. − Assess chronic illnesses (immune. inquire about his or her overall health. − Assess immunosuppressive therapy. Individual preferences/patterns − Record lifestyle choices if these issues have not arisen previously (sexually transmitted diseases. − If the patient is an older adult. neurologic. smoking). Socioeconomic factors − Does the patient have health insurance? Does the insurance cover prescription drugs? − Does the patient have access to health care? − Is housing adequate (in terms of heat.g.. cardiovascular. 5. Also. − Inquire about health habits (e. and religious considerations − Inquire about health and religious beliefs regarding vaccinations and drug therapy. or drainage tubes. air conditioning. inquire about his or her behavior. vitamin supplements taken). respiratory. lack of exercise. autoimmune. catheters. Adolescents feel invulnerable to injury and disease and may engage in highrisk sexual behavior.Unlawful to replicate or distribute Historical Data on Factors Influencing Biological Safety Historical data on the factors influencing the client’s biological safety must also be collected. 3. alcohol intake). preschool. nutrition. − Inquire about health care providers (traditional and nontraditional). This information provides a more complete and holistic picture of the client and includes the following: 1. Cultural. and fluid intake as well as illnesses and medications.g. spiritual. Older adults may be debilitated by chronic disease. Physical condition − Assess nutritional status (e. and school settings he or she is exposed to.. gastrointestinal. record any child-care. Infants have friable skin. inquire about his or her history of circulatory changes and noticeable changes in skin. Adults in good health should have relatively few infectious diseases. twenty-four-hour diet recall. metabolic. electricity)? 2.0 . Inc. − Assess fluid intake per day. which may slow skin healing. − Assess sleep habits. they do not possess active immunity until six months of age − If the patient is a child. The College Network. − If the patient is an adult. Children in these settings may come in contact with a large number of pathogens. IV-drug-related infections. − Assess presence or absence of IV lines. sewage treatment. photosensitivity. or sputum production − Malaise − Anorexia. or flank tenderness 2. Here. pain. − Inquire about exposure to secondary smoke. or abdominal tenderness/pain − Urinary frequency. including: − Fever − Blood pressure or hypotension as a sign of sepsis − Tachypnea − Tachycardia − Lymphadenopathy − Sore throat or sinus tenderness/pain − Headache. Examine the patient for: − Localized pain/tenderness − Localized edema − Localized erythema (redness) − Localized heat − Appearance of skin − Lesions/rash − Functional ability/mobility at site of infection − Drainage Assess for signs and symptoms of systemic infection or infection that may become systemic. 7. tenesmus.0 . Environmental factors − Are garbage collection. or nuchal rigidity − Cough. Inc. Perhaps the most important piece of laboratory data for the nurse to assess is the patient’s Copyright © 2008. NXP 070106 v1. Laboratory Data Laboratory data is then gathered and assessed. the nurse should take the following actions: 1. Abnormal results must be reported. The College Network.Unlawful to replicate or distribute 6. Psychological factors − Is the patient under undue stress? − How many major/minor changes have occurred in the patient’s life in the past year? − What stressors does the patient identify? − What are the privacy issues that surround this patient? − What are the confidentiality issues that surround this patient? Physical Assessment Data Health examination or physical assessment data is collected next. Assess for signs and symptoms of local infection. nausea/vomiting. and water treatment services adequate? − Inquire about allergies. hemoptysis. meaning marrow is releasing immature rather than mature neutrophils. inflammation. and tissue necrosis. The white blood count elevates in the presence of infection. Table 16. when the pool of available neutrophils becomes depleted. the production of some types of cells may not be able to keep up with the demand. The College Network. Remember that healing is delayed by infection. the various types of white blood cells should be present in specific percentages in a healthy patient. Decreases occur in the presence of suppurative (purulent) infections. leukocytosis occurs. parasitic infestations.1 provides an overview of typical white blood cell levels in a healthy patient. or when bone marrow damage occurs. rapid removal of large bacteria and cellular debris. In addition. and decreases in cell production may be noted. Specific types of white blood cells also increase in number. Eosinophils 2. when circulating neutrophils are damaged. This is thought to be an early indicator of sepsis.7 These are granulocytes that contain toxic substances used to kill foreign cells. it is critical that the nurse determine the patient’s white blood cell differential count. when the infection is severe or overwhelming. Elevated values Values increase with infection (especially by staphylococci and streptococci). NXP 070106 v1. The differential count allows us to look at the various kinds of white blood cells and track their responses to infection and better grasp their function as a defense against infection. Bands 3 Bands are immature segmented neutrophils. Table 16. When infection occurs. Increases occur with inflammatory and allergic responses. Decreased values Values may decrease in severe infection. The normal white blood count (or leukocyte count) for a healthy individual is between 4. tissue necrosis.0 .1 White Blood Cell Differential Count Type of cell Segmented neutrophils Normal Cell’s action count (%) 56 Neutrophils are phagocytes that provide early. Keeping this information in mind. review Table 16. However.1. Copyright © 2008. An increase in bands causes a shift to the left.Unlawful to replicate or distribute white blood count.500–11. Inc. Severe rise may herald bone marrow malignancy. which indicates the percentage of each type of white blood cell present in the blood. which examines the action of the specific types of white blood cells and the meaning of increases or decreases in the values obtained.000 cells/mm3. Also remember that a wound provides a portal of entry for infectious agents. Thus. and cancer metastases. NXP 070106 v1. All recognize foreign antigens. capable of phagocytosis. Cells release histamine.. The College Network. which are called tissue basophils. Elevated values Increases occur: • During the healing or chronic phases of inflammation • In the presence of hypersensitivity reactions • After radiation • With myeloid leukemia Decreased values Decreases occur during acute infection. and immunologic disorders that attack T cells (e. and serotonin during acute inflammatory/ allergic reactions. and with hyperthyroidism. HIV). and some blood disorders. Decreases occur with bone marrow injury or failure. Monocytes Increases occur with infection.3 These cells modify or moderate (calm) systemic allergic responses and anaphylaxis. Evaluate the culture to determine the organism responsible for the infection. Evaluate the patient’s culture and sensitivity. bone marrow failure. They are similar to mast cells. they mature and become macrophages. 34 These are nongranulocytes that form two classes: B and T cells. T cells are cytotoxic killer cells.g. the nurse’s actions should be as follows: 1. Once released. and other kinds of infection and with lymphocytic leukemia. B cells make antibodies that complex with antigens. 4 These are nongranulocytes that are released by the bone marrow when they are still immature.1 White Blood Cell Differential Count Type of cell Basophils Normal Cell’s action count (%) 0. connective tissue disorders. Inc. Lymphocytes Elevated values occur with bacterial. heparin. viral. Decreased values occur with impaired lymph drainage.0 . Copyright © 2008. After obtaining and analyzing the patient’s white blood cell differential count. and examine the sensitivity results to see to which antibiotics the organism is sensitive and resistant.Unlawful to replicate or distribute Table 16. T cells also help B cells. stress. 4–4. exposure (recent and past) to pathogens. the nurse is collecting data on factors influencing biological safety (age/developmental factors.2–5. The ESR is a nonspecific test that detects the presence of inflammation.5 g/dL − Child: 3. such as rheumatoid arthritis. preschool. and history of hygienic practices.0 . It rises in autoimmune diseases. and nitrogen is needed for tissue growth and healing. past response to the infectious process. The College Network. Albumin is a reservoir for nitrogen. − Child: 0–10 mm/hour − Elevations occur with rheumatic fever. school) High-risk sexual behavior Copyright © 2008. Evaluate the patient’s erythrocyte sedimentation rate (ESR). serum albumin level increases.. and psychologic factors). socioeconomic factors. daycare. and it may rise with the inflammation that accompanies infection. physical condition. Inc. Normal ESRs for various patient groups are as follows: − Adult less than age fifty: 0–15 mm/hour in the male and 0–20 mm/hour in the female.8 g/dL − Adult age eighteen to sixty: 3. NXP 070106 v1. systemic lupus erythematosus. Normal levels are as follows: − Adult over age sixty: 3. cultural/spiritual factors.4 g/dL Diagnosis In the first part of the assessment. Diagnoses that may occur as a result of patient responses in these interview areas include risks of infection secondary (or related) to the following: • • • Infant’s lack of active immunity Exposure in institutional settings (e. preferences/patterns. A low serum albumin level may indicate liver or renal disease or malnutrition.g.Unlawful to replicate or distribute 2. Evaluate the patient’s serum albumin levels by age. An elevated serum albumin level may indicate dehydration. When blood volume decreases.8–4. environmental factors. the nurse is collecting data on the patient’s history of susceptibility to communicable diseases. − Adult greater than age fifty: 0–20 mm/hour in the male and 0–30 mm/hour in the female.4 g/dL − Newborn: 2. Diagnoses that may occur as a result of patient responses in these interview areas include the following: • At risk of infection related to: − Increased susceptibility − Recent exposure − Poor hygiene practices Knowledge deficit related to personal susceptibility Knowledge deficit related to hygienic practices • • In the second part of the assessment. and other inflammatory conditions. It also rises with rheumatic heart disease. 3. abscess-like mass in the upper. Diagnoses that may occur are collaborative in nature and require a notification of the patient’s physician. and heart rate and rhythm regular at 106 beats per minute. NXP 070106 v1. “I did not feel like eating breakfast or lunch. The nurses assesses for signs of systemic infection.” Complains of periumbilical pain with some radiation to the right lower quadrant. In the third part of the assessment.m. sepsis or surgical complications such as a ruptured appendix). the nurse may say that the patient presents with a “two centimeter nondraining. The nurse first assesses for signs and symptoms of localized infectious processes.0 . States. Walks in a hunched position to guard abdomen and lies in bed in left lateral Sims’ position. The exact site must be noted. For example. Anorexic. Inc.” (Note: The left lateral Sims’ position is a semi-prone position in which the client is lying on the left side with the right leg drawn up Copyright © 2008.g. The nurse may write that the patient presents with a particular constellation of signs and symptoms (be sure they are noted).Unlawful to replicate or distribute • • • • • • • • • • • • • • • • Cigarette smoking (primary or secondary smoke) Circulatory changes in the legs Poor nutrition Inadequate sleep Poor stress management Chronic illness Immunosuppressive therapy Invasive lines Refusal of vaccinations due to health/spiritual beliefs Refusal to accept traditional therapy due to nontraditional health beliefs Overcrowding in the home Lack of heat in winter Lack of hot water or running water in the home Rat infestation in neighborhood because of poor garbage collection procedures Inadequately treated chronic or seasonal allergies Fear of loss of privacy/confidentiality Each of these diagnoses may be complicated by a codiagnosis of knowledge deficit in the area of concern. For instance. and one episode of vomiting (approximately one cup).. The College Network. the nurse is collecting health examination data. one report may read as follows: “Fourteen-year-old male admitted with temperature of 100. with onset of nausea this a. outer quadrant of the right buttocks. Respiratory rate of 20 breaths per minute.” The nurse also needs to combine this description of a localized inflammatory or infectious process with any systemic signs or symptoms. Complains of constipation lasting for four days. Abdominal guard present. These are collaborative findings and need to be reported immediately to prevent medication complications (e.6°F with no associated hypotension. Using Maslow’s hierarchy of needs. they threaten the patient’s most basic physical need for life. the results of which are collaborative in nature. the immediate threat is sepsis. fifteen minutes post-admission. The important conclusion or diagnosis that the nurse needs to make is that both cases represent emergencies and that immediate collaboration with a physician is in order. patients seldom present with a single problem—they usually have related problems or diagnoses that need to be addressed. and sputum production. In the fourth part of the assessment. which must be fully described. Another report may read: “Twenty-year-old female in her fifth month of pregnancy admitted to the unit with a 104°F fever and chills with onset about two hours ago. a patient may present with an infected wound. or passage of amniotic fluid. Patient is complaining of a severe right frontal headache but denies photophobia. hemoptysis. diagnoses (or constellations of signs and symptoms) that point to sepsis or to a need for rapid surgical intervention have the highest priority because these are the most life threatening. Fever preceded by two days of sinus pain and low-grade temperature. an elevated white count accompanied by an increase in segmented neutrophils and bands would be expected and would need to be reported. the nurse is collecting laboratory data. In both of the cases presented above. Heart rate of 126 beats per minute. Then. The College Network. Planning Planning is a conscious process in which the nurse establishes patient-centered goals stated in the form of expected outcomes. plans and outcomes related to the wound need to be established and interventions planned. Clients with appendicitis assume this position in an attempt to relieve right lower quadrant pain. Respiratory rate of 24 breaths per minute.” In this case. No nuchal rigidity noted. the patient had acute appendicitis and was operated upon within one hour of admission. Physician phoned stat. In addition. Denies uterine contraction. Denies cough. 96/66. Blood pressure on admission was 104/72.0 .Unlawful to replicate or distribute toward the chest. and now. The life of both the mother and the fetus are at stake.) This constellation of signs and symptoms is derived from the nursing assessment and needs to be reported to the physician immediately. These goals/outcomes are derived from the diagnoses generated from the assessment. When infection is the problem. A systematic assessment allows the nurse to pull together signs and symptoms that form a coherent constellation that may be summarized and presented to the physician. bleeding. Inc. In this case. It is unlikely that a serum albumin or an erythrocyte sedimentation rate would have been ordered in either case. Copyright © 2008. including the type of wound care to be applied. With regard to biological safety. NXP 070106 v1. Even though the patient’s temperature was only 100. Before the patient returns home. the infection will be more difficult to manage. The patient had not changed the dressing for two days and so had not observed the wound. the patient will: • • • • Describe and demonstrate how to change wound dressings using sterile technique. In other words. Relate the gun-safety measures to be instituted immediately to protect the grandchildren as well as the patient. the patient sought medical care for the left upper-arm flesh wound and was discharged after emergency department treatment.6°F and the white count was on the upper limits of normal. Although they have parents with them. making the whole issue of gun safety even more important. take the case of a patient admitted for an accidentally self-inflicted gunshot wound. After conducting the patient’s admission assessment. the grandchildren are at risk of injury. especially since the patient has Type II diabetes mellitus. the nurse discovers while performing the nursing assessment that the patient is noncompliant with the diabetic regimen. Three days later. the physician decided to admit the patient to the hospital for IV antibiotic therapy to make sure the infection was promptly controlled. The nurse. the following outcomes. Gun safety also needs to be addressed. especially medical asepsis. The familial implications of diabetes mellitus also need to be addressed.0 . the patient returns with an infected wound draining a moderate amount of purulent material. Commit to compliance with diabetic therapy.Unlawful to replicate or distribute As an example. the registered nurse knows it is important to address infection control measures. Copyright © 2008. Furthermore. On the basis of this information. The patient also did not comply completely with antibiotic therapy. The nurse decides to teach the patient these same measures to prepare for the discharge home. at least two additional diagnoses need to be addressed: • • Noncompliance with diabetic therapy Risk of future injury related to poor gun-safety procedures Family issues are important. With less than ideal blood glucose control. NXP 070106 v1. and to use sterile technique when changing dressings. Inc. The injury occurred when the patient was hunting deer and could have been prevented had appropriate gun-safety measures been taken. Immediately after the injury. finds out that there are grandchildren staying in the home. The College Network. will need to be obtained. framed as patient goals. in talking with the patient. Discuss with primary relatives the need for regular screening for diabetes mellitus. Consult with a nutritionist. Three examples are listed below: 1. appropriate goals and outcomes are for the patient to do the following: • • • Become afebrile within twenty-four to forty-eight hours. Report on medical asepsis procedures (cleaning. if necessary. For example. the nurse may need to review: • • Vital sign frequency in a stable patient upon admission Agency hand washing policies Copyright © 2008. NXP 070106 v1. 3. disinfecting. the patient is likely to develop hyperglycemia. Obtain sufficient rest/sleep.500 mL per day.) Practice proper skin and oral hygiene measures. Keep the dressing dry and report any soiling.0 . and respiratory rate within normal limits. and definitely wash before and after dressing changes if the patient is assisting with the dressing. Maintain fasting blood glucose at the level specified by the physician (perform blood glucose finger sticks as indicated by the physician). Report signs of increasing hunger. Select appropriate foods that promote healing and that are consistent with a diabetic diet. When a diabetic patient develops an infection. heart rate/rhythm.) Maintain a fluid intake of 2. This planning phase is also the appropriate time for the nurse to gather agency policies and standards that relate to the interventions being implemented. this leads to diabetic coma. and voiding. 2. One way of approaching a subject that varies so greatly from patient to patient is to write overall objectives for a wound-care plan. Maintain blood pressure. Maintain a clean environment. use of sterile technique) that the patient will employ at home upon discharge. For example. Maintain a urine output proportional to intake.Unlawful to replicate or distribute Still remaining is that part of the plan that focuses on wound care in the hospital. The College Network. Wash hands frequently as needed throughout the day. Expected outcomes would be tailored for this particular patient. • • • • • • • • • • • When the goals and expected outcomes are complete for each of these three planning objectives. then the nurse will need to develop goals and objectives for gun-safety instructions and the patient’s diabetic management at home. (Be sure to select appropriate diet according to physician instructions and agency dietary policies/instructions. Increase knowledge of medications and their proper administration. If uncorrected. Maintain and restore defenses (the issue of diabetic blood sugar control would be included within this objective). under maintain and restore defenses. Inc. (These are signs of diabetic coma. Avoid the spread of infection. thirst. Reduce or eliminate problems or other factors associated with infection. NXP 070106 v1.Unlawful to replicate or distribute • • • • Dressing change policies/procedures Maintenance of a sterile field during dressing change Maintenance of a clean environment Diabetic management. disposal of contaminated dressings. For each intervention listed. The reader may want at this point to evaluate the ease with which a rationale is known for each of the above strategies listed.0 . provides skin care. Have available a list of community resources on diabetes and diabetic management. Make sure the patient obtains enough rest and sleep. Enlist the help of a diabetic educator. Review the nursing plan with the LPN. then assign these activities to an LPN. and gun safety. Establish a time for patient teaching each day and outline topics to be covered. the licensed practical nurse assists the patient with bathing. adequate intake. In presenting this section and the preceding section. Provide proper diet. Use sterile technique when changing dressings. not to surrender responsibility for the care. sterile dressing changes. Be sure that. in addition to providing wound care. The College Network. Be sure standard procedures (medical asepsis) are followed. the nurse will also be able to provide a rationale as to the selection of each particular strategy. Provide the patient with teaching and instruction on biological safety and medical asepsis. Copyright © 2008. Build up the patient’s nonspecific defenses. Inc. encourages participation in care. If the agency policy permits licensed practical nurses to perform sterile dressing changes. The LPN will also provide daily routine care for the patient. and measurement of output. the rationales of therapy were presented and integrated throughout the material. Provide assistive and supportive care. assists the patient with oral hygiene. but to enlist LPN support. cleans and trims nails. diabetic management. including: − Diet − Blood glucose monitoring − Educational materials − Patient information sheets on diabetic medications (obtain from pharmacist) The nurse needs to delegate tasks. it is vital to maintain medical asepsis (hand washing. Use standardized hand-washing technique. use of disposable equipment). Practice universal precautions for blood and body fluids. Implementation During implementation. not authority or responsibility. if needed. and assists the patient with walking until the patient is confident and capable of walking alone. the expected outcome list becomes an evaluation tool. Inc. some once a day. patient goals and expected outcomes will be compared with the actual outcomes. Some goals and outcomes are evaluated continuously. Therefore.500 mL/day? Has urine output been proportional to intake? Has the patient’s fasting blood glucose level met the goal specified by the physician? Has the patient maintained fasting blood glucose at the level specified by physician? Has the patient been performing blood glucose checks per finger stick as directed? Has the patient reported any polyphagia. The frequency of outcome evaluation depends on the severity of the patient’s condition as well as the nature of the goal. then the patient or nursing intervention needs to be reassessed. Others are evaluated at two. polydipsia. NXP 070106 v1. To answer this question. In the case presented. and some at even greater intervals. it would be important to ask questions such as the following: Has the patient become afebrile within twenty-four to forty-eight hours? Have the blood pressure. or sixty minutes. When goals or outcomes are achieved. Copyright © 2008. heart rate/rhythm. then the nurse needs to decide if the goal should remain in place or be discontinued. thirty. The College Network.or four-hour intervals.Unlawful to replicate or distribute Fundamentals of Nursing 315 Evaluation Evaluation is a process whereby the outcomes obtained are compared with the expected outcomes. Some goals are evaluated every fifteen. Others are evaluated once every shift. twenty. and respiratory rate been maintained within normal limits? Has the patient selected appropriate foods that promote healing and that are consistent with a diabetic diet? Has the patient’s fluid intake met the goal of 2. such as with telemetry in the coronary care unit. and polyuria? Has the patient been practicing good skin and oral hygiene? Has the patient been washing hands frequently and appropriately? Has the patient kept the wound dressing dry and/or reported any soiling? Has the patient maintained a clean hospital room environment? Has the patient articulated or demonstrated the ways to clean and disinfect the home and the sterile technique to be used when changing the dressing? Does the patient demonstrate knowledge of the daily medications and their proper administration? Is the patient obtaining sufficient rest and sleep? The registered nurse also wants to know whether the teaching strategies were effective. If a goal or outcome is not attained.0 . Weinrich. and L. Pediatrics 95 (4):609–10. Chicago: National Society for the Study of Education/University of Chicago Press. S. Co-family sleeping: Strange bedfellows or culturally acceptable behavior. eds.. Bowers. Bicycle helmets. American Academy of Pediatrics. Sosniak. A. The College Network.. 2001. 1996. Bicycle helmets. Journal of Cultural Diversity 3(4): 109–11. Fundamentals of nursing: Concepts. American Nurses Association. American Nurses Association. Sundown syndrome: Etiology and management. Standards of clinical nursing practice. Erb. American Cancer Society. and S. Nursing 30 (12): 41–48. Anderson. Berman. 1995. & G. 2008.0 . 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