foundations final blueprint

7/31/2019 Foundations FINAL Blueprint

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1 Chapter: 1 Nursing Process Objective: 4 Nurse Practice Acts &Licensure (p 18; 20)Nurse Practice Acts & Licensure- Nurse practice acts are laws established in each state in the united states to regulate the

practice of nursing- Some are common such as:

o Protect the public by defining the legal scope of nursing practice, excluding untrained orunlicensed people from practicing nursing

o Create a state board of nursing or regulatory body having the authority to make andenforce rules and regulations concerning the nursing profession

o Define important terms and activities in nursing, including legal requirements and titles forRNs and LPNs

o Establish criteria for the education and licensure of nurses- The board of nursing for each state has the legal authority to allow grads of approved

schools of nursing to take the licensing exam.- Those who successfully meet the requirements for licensure are then given a license to

practice nursing in the state.- The license, which must be renewed at specified intervals, is valid during the life of the

holder and is registered in the state- Many states have a requirement for a specified # of continuing education units (CEUs) to

renew & maintain licensure.- 2 ways in which nurses can practice in other states:

o Reprocity allows nurse to apply for & be endorsed as a RN by another stateo 23 states are members of the Nurse Licensure Compact allowing a nurse who is licensed

& permanently lives in one of the member states to practice in other member states w/oadditional licensure (National Council of State Boards of Nursing 2008)

- The license and the right to practice nursing can be denied, revoked or suspended forprofessional misconduct

- As nursing roles continue to expand & issues in nursing are resolved, nursing prac acts willreflect those changes.

- All nurses should be knowledgeable about the specific nurse prac act for the state in whichthey prac.

2 Chapter: 5 Nursing ProcessObjective: 4 Protect of Rights of HumanSubj (p 78; 89)Protection of the Rights of Human Subjects- Many nurses work in healthcare institutions in which pts are invited to participate in clinical

research.- W/ their focus on the overall well-being of the pt, nurses play an important role in ensuring

that patient interests are not sacrificed to research interest- Nursing priorities include determining that research studies have met appropriate scientific

and ethical criteria before their implementation, and protecting patient rights- Specific patient rights include informed consent , the patients right to consent

knowledgeably to participate in a study without coercion or to refuse to participate without jeopardizing the care he or she is receiving

- The right to confidentiality- Right to be protected from harm- Federal regulations require that institutions receiving federal funding or conducting studies

of drugs or med devices regulated by the FDA establish IRBs.- Institutional review boards (IRBs) review all studies conducted in the institution to determine

the risk status of all studies and to ensure that ethical principles are followed3 Chapter: 6 Nursing Process Objective: 5 Nursing Standards of Practice (p93, 105)Nursing Standards of Practice


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- When the American Nurses Association (ANA) revised its Standards of Clinical NursingPractice in 1991, it developed standards of professional performance as well as standards forcare

- Standard V of professional performance, Ethics, describes the nurses ethical obligations; thenurses decisions and actions on behalf of patients are determined in an ethical manner

- Standard V:o The nurses practice is guided by the Code of Nurseso The nurse maintains patient confidentiality within legal and regulatory

parameterso The nurse acts as a patient advocate and assists patients in developing skillsso they can advocate for themselveso The nurse delivers care in a non-judgmental and non-discriminatory mannerthat is sensitive to patient deliveryo The nurse delivers care in a manner that preserves or protects patientautonomy, dignity, and rightso The nurse seeks available resources to help formulate ethical decisions

4 Chapter: 11 Comm & Doc Objective: 3 Documenting theNursing Process (p197; 215)Documenting the Nursing Process- The ability to communicate clearly is a critical nursing skill

Accurate, concise, timely, and relevant documentation provides all themembers of the care giving team with a picture of the patient

The pt record is chief means of communication among members of theinterdisciplinary team.

- Legally speaking, a nursing action not documented is a nursing action not performed

5 Chapter: 12 Nursing ProcessObjective: 1 Assessment and CriticalThinking (p224)Assessment & Critical Thinking Entire nursing process rests on initial & ongoing assessment of the patient

o

Need to use excellent critical thinking skills when gathering, validating, analyzing, &communicating data. Critical thinking activities linked to assessment are:

o Assessing systematically & comprehensively, using a nursing framework to identifynursing concerns & a body systems framework to identify medical concerns

o Detecting bias & determining the credibility of info sourceso Distinguishing normal from abnormal & identifying risks for abnormal findingso Making judgments about the significance of data, distinguishing relevant from

irrelevanto Identifying assumptions & inconsistencies, checking accuracy & reliability, and

recognizing missing information Many of these activities are challenging for those new to nursing who most likely lack clinical

experience that aids in expert clinical reasoning. Students are urged to ask qs frequently about data & to test their inferences & judgments

6 Chapter: 17 Comm & Doc Objective: 4 Agency Policies (p328, 357)- Everyone who has access to the record (direct caregivers) is expected to maintain its

confidentiality- Most agencies grant student nurses access to patient records for education purposes

o The student assumes responsibility to hold patient information in confidence- Never use a patients name when preparing written or oral reports for school


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- Agency policies also indicate which personnel are responsible for recording on each form inthe record and such policies might also describe the order in which the forms are to appearin the record

- One of the strategies the JCAHO is using to achieve National Patient Safety Goals is a list of do not use abbreviations, acronyms, and symbols

- The storage of patient records when a patient is no longer receiving treatment is a functionof the health agencys record department

- You will also want to be aware of agency policies regarding the patients right to access

recordso Be sure to check the policy where you work to find out answers to the following FAQs:

Can I take my chart home?How long do you retain records?How long will it take to get a copy of my record?How much does it cost?I dont want some parts of my record released to anyone. What do I do?May I look at my fams med record?Who can look at my record?Who do I tell if my name has been changed?

7 Chapter: 17 Comm & Doc Objective: 1 Guidelines for Effect. Doc

(p324, 353)Guidelines for Effective Documentation- The patient record is the only permanent legal document that details the nurses interaction

with the patient and is the nurses best defense if a patient or patient surrogate allegesnursing negligence

- There are often crucial omissions in the nursing doc, along with repetitious or inaccurateentries.

- Although errors might go undetected & have no effect on the pt, they might also seriouslyaffect the care the pt receives, undermine nursings credibility as a professional discipline &cause legal probs for the nurse responsible.

- In a brief documentation should be consistent with professional and agency standards;complete, accurate, concise, factual, organized, and timely legally prudent and confidential

- Box 17.1 p. 326*Content : complete, accurate, concise, current & factual

Reflects nursing process, pt findings rather than your interpretation,avoid good normal, avoid generalizations of seems comfortable,note probs in a orderly manner, doc all med visits & consultations, avoidstereotypes

Timing : date & military time, never leave unit for break when caring for aseriously ill pt until all sig data are recorded, write a progress note for eachsuch as upon admission, transfer, procedure, any change in pt statusFormat : proper form, dark ink, use standard term, chart nursing interventions& never skip linesAccountability: sign you 1 st initial, last name & title for each entry, be sure ptrecord is complete before sending it to medical recordsConfidentiality: info kept private & confident

- The ANA introduced a new tool to streamline the nursing documentation process in 2003o This guide includes policy statements, principles, and recommendations toassist nurses with documentation and to comply with institutional and regulatoryrequirements

8 Chapter: 21Nursing Process Objective: 3 Using Therapeutic Comm (p444)Using Therapeutic Communication in the Nursing Process


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10 Chapter: 24 Nursing Process Objective: 2 Physiology of BP (p531;571)Physiology of Blood Pressure- Arterial walls contain elastic tissue that allows them to stretch & distend ( compliance ) as

blood enters with each ventricular contractionWhen heart rests btw each beat, the walls of the arteries return to their originalposition, although pressure In them doesnt drop to 0Arterioles offer resistance to the pressure of the blood & keep the bloodentering the capillaries in a continuous flow rather than in spurts.

Therefore, the elasticity of the arterial walls, in addition to the resistance of thearterioles, helps to maintain normal BP.With increased age, the walls of the arterioles become less elastic, whichinterferes with their ability to stretch & dilate.

This can limit right blood flow & contribute to the rising pressure within thevascular system.

- Blood pressure refers to the force of the blood against arterial walls- Max blood pressure is exerted on the walls of the arteries when the left ventricle of the heart

pushes blood through the aortic valve into the aorta at the beginning of systole- Systolic pressure : highest pressure- Diastolic pressure : lowest pressure present on arterial walls- Pulse pressure : difference between the two- Blood pressure regulation is controlled by a variety of mechanisms to maintain adequate

tissue perfusion- The arterial blood pressure has constant minor variations from activities of daily living such

as rising from sitting to a standing position, exercise or emotion

11 Chapter: 24 Nursing Process Objective: 4 Assessing Apical-RadialPulse (p 527, 567)Assessing the Apical-Radial Pulse- When the radial pulse is irregular, counting the pulse at the apex of the heart and at the

radial artery simultaneously is used to assess the apical-radial pulse rate- Pulse deficit : the difference between the apical and radial pulse rates

o Indicates that all the heartbeats are not reaching the peripheral arteries orare too weak to be palpated

12 Chapter: 24 Nursing Process Objective: 5 Normal Blood Pressure(p 532, 574)Normal Blood Pressure- Systole:


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- Any condition causing an increase in CO2 and a decrease in oxygen in the blood also tendsto increase the rate and depth of respiration

14 Chapter: 24Nursing Process Objective: 3 Sites & Methods of AssessingPulse (527; 568)Sites & Methods of Assessing the Pulse- Although peripheral pulses are most commonly assessed, an apical pulse or an apical-radial

pulse should be assessed in certain situation- Radial pulse is used most often in children and adults

- Peripheral pulses are assessed by placing the middle 3 fingers over the artery and lightlycompressing the artery so pulsation can be felt and counted

- Circulation to the legs and feet is assessed at the femoral, popliteal, posterior tibial anddorsalis pedis sites

- Carotid pulse is used in ER situation- Brachial pulse site is used for infants who have had a cardiac arrest

o Peripheral arterial pulses Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalispedisRadial most commonCarotid emergency people in shock or cardiac arrestBrachial infants

o Apical pulseIf peripheral is weak, irregular, very rapidAssessed when giving meds that alter heart rate or rhythm5 th and 6 th intercoastal space, 3inc left of the median line and slightly belownipple

o Apical-radial pulseWhen radial pulse irregular, count pulse at apex and radial artery togetherDifference between the rates pulse deficit indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated

15 Chapter: 25 Comm & Doc Objective: 7 Documentation of Data(607; 649)Documentation of Data- After completing the nursing history and assessment, organize all assessment data to

identify actual and potential health problems, make nursing diagnoses, plan appropriatecare, and evaluate the patients responses to treatment

- Documentation example Box 25-6 (610)

16 Chapter : 26 Nursing Process Objective: 2 Physical HealthState (p618, 662)Physical Health State- Anything that affects the patients health state potentially can affect the safety of the

environment- When a person is chronically ill or in a weakened state, the focus of healthcare includes

preventing accidents as well as promoting wellness and restoring the individual to a healthystate

- Prevention of complications and return to the optimal level of functioning require attention tosafety and become primary concerns in a stroke rehabilitation program

- The nurse strives to maximize the patients potential by considering safety factors in allphases of the illness and recovery experience

17 Chapter: 26 Preventing Falls (p633, 677)Preventing Falls- Preventing falls in the home


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o Major causes of falls in the home include slippery surfaces, poor lighting,clutter, and improperly fitting clothing or slipperso Common traffic pathways in the home, the bathroom and access areas toand from the home are hazardous areas for older adultso Measures as simple as installing hand rails in bathrooms and on stairs,ensuring good lighting and discarding or repairing broken equipment around thehome help prevent accidents

- Hendrich II Fall Model evaluates:Risk factor : confusion/disorientation/impulsivity, depression, alteredelimination, dizziness/vertigo, gender (male), antiepileptics, benzodiapinesGet-up-and-go test rising from chair : rise in single movement, pushes upsuccessful in 1 attempt, multiple attempts but successful, unable to rise w/oassistance

- The Get up and Go test: identifies if a patient is at risk for fallingo A variety of factors such as poor vision, the effects of multiple medication,lower extremity weakness or a gait disorder can reduce the patients mobilityo During this test, assess the patients stability, balance, gait and lower bodystrength any limitations in any of these areas may indicate vulnerability for a fall

- Misunderstandings about fall risk:

Advanced age w/o presence of other risk factors can no longer be viewed as adefinite fall risk factorAdverse effects related to meds are more predictive of falling (antiepileptic)Previous fall is a predictor of future fall

- Preventing falls in the healthcare facilityo Box 26-3 (p.633, 678)

18 Chapter: 27 Comm & Doc Objective: 6 Gloves (p669)Gloves- Gloves, not a substitute for good hygiene, are worn only once and discarded appropriately

according to agency policy- Gloves should always be changed prior to moving from a contaminated task to a clean one

- When care activities do not involve the possibility of soilage of hands with body fluids, glovesare not necessary- While wearing gloves, never do the following:

o Leave the patients room (unless transporting a contaminated item or apatient requiring transmission-based precautions)o Write in the patients charto Use the computer keyboard or telephone in the nurses station

- The warmth and moisture inside gloves create an ideal environment for bacteria to multiply,making it even more important to perform good hand hygiene before and after using gloves

- Double gloving is recommended if the healthcare worker is going to be exposed to blood orbody fluids

- Latex sensitivity reactions ranging from local skin reaction to urticaria (hives) to systemicanaphylaxis, an exaggerated allergic reaction that can result in death

- The National Institute for Occupational Safety and Health (NIOSH) recommends that nonlatexgloves or powder-free low-allergen latex gloves be available for employees

19 Chapter: 27 Nursing ProcessObjective: 6 Performing Hand Hygiene(p661; 708)Performing Hand Hygiene- Hand hygiene is the most effective way to help prevent the spread of organisms- According to CDC guidelines, the term hand hygiene applies to either hand washing with

plain soap and water, use of antiseptic handrubs including alcohol-based products or surgicalhand antisepsis


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- Skills 27-1 (726)

20 Chapter: 27 Comm & Doc Objective: 1 Infectious Agent (p653,704)Infectious Agent- Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi- Bacteria , the most significant and most commonly observed infection-causing agents in

healthcare institutionso Categorized by shape as spherical (cocci), rod shaped (bacilli), or corkscrewshaped (spirochetes)o Can be gram positive (thick wall that resists decolorization and stain violet)or negative (doesnt stain)o Most bacteria require oxygen to live and grow and are therefore referred toas aerobico Those that can live without oxygen are anaerobic bacteria

- Virus is the smallest of all microorganisms, visible only with an electron microscopeo Many infections care caused by viruses, including the common cold and thedeadly disease AIDso Antibiotics have no effect on viruses, however, there are some antiviralmedications available that seem to be effective with some viral infectiono When given in the prodromal stage of certain viruses, these medications canshorten the full stage of the illness

- Fungi , plantlike organisms (molds and yeast) that also can cause infection, are present inthe air, soil, and water

o Athletes foot, ring worm, and yeast infectiono Treated with anti-fungal medication, however, many infections due to fungiare resistant to treatment

- An organisms potential to produce disease in a person depends on a variety of factors:o Number of organismo Virulence of the organism, or its ability to cause diseaseo Competence of the persons immune systemo Length and intimacy of the contact between the person and themicroorganism

21 Chapter: 27 Teaching/Learning Objective: 1 Means of Transmission(p 656, 704)Means of Transmission)- An organism may be transmitted from its reservoir ( natural habitat of the organism) by

various means or routes- Some organisms can be transmitted by more than one route- It can be direct or indirect

o Direct contact involves proximity between the susceptible host and aninfected person or a carrier such as touching, kissing, or sexual intercourseo Indirect route involves personal contact with an inanimate object such astouching a contaminated instrument

- Contaminated blood, food, water or inanimate objects (fomites) are vehicles of transmission- Vectors , such as mosquitoes, ticks, and lice are nonhuman carriers that transmit organisms

from one host to another by injecting salivary fluid with a human bite occurs- Microorganisms can also be spread through the airborne route when an infected host coughs,

sneezes or talks or when the organism becomes attached to dust particles- Droplet transmission is similar to airborne transmission

22 Chapter: 27 Nursing Process Objective: 3 Full Stage of Illness(657, 705)


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Full Stage of Illness- The presence of specific signs and symptoms indicates the full stage of illness- The type of infection determines the length of the illness and the severity of the

manifestations- Localized symptoms : occur in only one body area- Systemic symptoms : symptoms manifested throughout the entire body

23 Chapter: 27 Nursing ProcessObjective: 4 Factors Affecting Risk (658,

705)Factors Affecting Risk for Infection- The susceptibility of the host depends on various factors:

o Integrity of skin and mucous membranes, which protect the body againstmicrobial invasiono pH levels of the GI and genitourinary tracts, as well as the skin, which helpsto ward off microbial invasiono Integrity and number of the bodys white blood cells which provideresistance to certain pathogenso Age, sex, and race and hereditary factors, which influence susceptibilityo Immunization, natural or acquired, which act to resist infectiono Level of fatigue, nutritional and general health status, the presence of preexisting illnesses, previous or current treatments and certain medications whichplay a part in the susceptibility of a potential hosto Stress level: stress may adversely affect the bodys normal defensemechanismo Use of invasive or indwelling medical devices, which provide exposure toand entry for more potential in a patient whose defenses are already weakened bydisease

- Sensible nutrition, adequate rest and exercise, stress-reduction technique and good personalhygiene habits can help maintain optimum bodily function and immune response

24 Chapter: 28 Nursing Process Objective: 4 Botanical (HerbalProducts) (p714, 761)Botanical (Herbal Products) & Nutritional Supplements- Description

o Some consumers and practitioners are attached to herbs because they arenatural plant products, which are perceived as more compatible with the bodythan manufactured pharmaceutical agentso Herbs can be used for treatment of disease and reduction of symptomso Echinacea and goldenseal are frequently used for respiratory infections andginkgo biloba is frequently used to dilate cerebral blood vessels and reducesymptoms of memory loss and mental confusiono Nutritional supplements are chemical compounds that contain ingredientsbelieved to promote health

- Nursing considerationso Nurses adds an aspect of safety to their practiceo Some herbs and/or supplements may interact with prescribed medicationspatients are takingo Ginkgo biloba, the most widely sold herb in Europe and used by many toimprove memory, affects platelet function and thus should be used with warfarin oraspirin

- Teaching to Promote Health at Home 28-1 (761)

25/26Chapter: 29 Nursing Process Objective: 3 Serum Drug Levels(p732, 773)


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Serum Drug Levels- After a drug has been absorbed, its serum level can be monitored by drawing a blood

specimen and measuring the level of the drug in the serum- A drugs therapeutic range is the concentration of drug in the blood serum that produces the

desired effect without causing toxicity- Peak level : highest plasma concentration of the drug should be measured when absorption

is complete- The trough level is the point when the drug is at its lowest concentration, and this

specimen is usually drawn in the 30-min interval before the next dose- A drugs half-life is the amount of time it takes for 50% of the blood concentration of a

drug to be eliminated from the body

27 Chapter: 29 Dosage Calculations (736; 782)Dosage Calculations- Systems of Measurements

o Three systems of measurements are used for administering medication:metric, apothecary and householdo Metric : meter (linear), liter (volume), and the gram (weight)

Weight: 1 kg=1000g 1g=1000mg 1mg=1000microgramsVolume 1 liter = 1 ml

o Apothecary : basic unit of weight is grain. Minim, dram, ounce, pint andquart are used for volume

- Dose on hand/ quantity on hand = dose desired/ X (quantity desired)

28 Chapter: 29 Nursing Process Objective; 7 Checking Med Order (735, 781)Checking the Medication Order- Nurses should be familiar with the system used in the agency where they work and should

implement it correctly to minimize errors- In many institutions, the order is coped onto the patients medication record (MAR) medication administration record

- Increasing numbers of healthcare facilities are computerized medication administrationrecord (CMAR)

- Nurse is responsible for checking that the medication order was transcribed correctly bycomparing it with the original order

- Nurse is also responsible for double-checking the dosage and appropriateness of themedication

29 Chapter: 29 Nursing Process Objective: 1/7 Medication Orders(p732, 778)

Medication Orders- No medication may be given to a patient without a medication order from a licensedpractitioner

- CPOE systems allow the prescriber to enter medication orders in a standard format- The computer sends the order directly to the pharmacy and enter the order into the patients

permanent recordo Prevents guessing handwriting

- Some of the information this system provides includes recommended dosing of medications,drug-specific information, current patient information, laboratory tests that monitor theaction of the drug, and potential interaction that may occur with other medications and foods


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- A computerized entry system can make medication administration safer and reduce adversedrug events

- Usual hospital policy dictates that when a patient is admitted, unless specific orders to thecontrary are written, all drugs that the physician may have ordered while the patient was athome are discontinued

- When a patient has had surgery or is transferred to another clinical service or another healthagency, it is general practice that all orders related to drugs are discontinued and new ordersare written in the new setting

30 Chapter: 29 Nursing Process Objective: 7 Types of Orders (p 733,779)- A standing order is carried out as specified until it is canceled by another order- P.r.n order (as need): patient receives medication when it is requested or required

o P.r.n orders are commonly written for treatment of symptoms- Single or one time order : directive is carried out only once, at a time specified by the

prescribero Medication to be administered immediately before surgery

- Stat order : single order, but it is carried out immediatelyo Bronchodilator or an antihistamine

31 Chapter : 30 Teaching/Learning Objective: 1 General Anesthesia(p822) Involves admin of drugs by the inhalation or IV route to produce CNS depression.

o It is a combo of both IV & inhalation anesthetics.o Desired actions of general anesthesia are loss of consciousness, analgesia, relaxed

skeletal muscles, & depressed reflexes.o Choices of route & type of anesthesia are made primarily by the anesthesia

provider after discussion with the patient.o Many factors influence these choices, including the type & length of surgery & the

physical & psychological status of the patient.o

Inhalation anesthesia is often used b/c it has the advantage of rapid induction,excretion & reversal of effects. 3 phases are induction, maintenance, & emergence.

o Induction admin of agent & continues until the pt is ready for the incision.o Maintenance continues from this pt until near the completion of the procedure.o Emergence starts as the pt begins to awaken from the altered state induced by

the anesthesia & usually ends when the patient is ready to leave the operatingroom; the length of time depends on the depth & length of anesthesia.

New agents allow pts to emerge from anesthesia & wake up in a fraction of the time requiredin the past.

o As these become more commonly used, pts will bypass the PACU.o This allows more surgical procedures to be safely done in drs offices.o It is advantageous b/c it can be used for pts of any age & for any surgical

procedure with the patient unaware of the physical trauma of the surgery &respiratory depression, post-op nausea & vomiting & alterations inthermoregulation.

32 Chapter: 30 Teaching/Learning Objective: 1/3 Assessing (p868) Assessing/interviewing

o Daily/weekly bathing habits Skin

o Rashes, lumps, itching, dryness, lesions


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o How long have you had this problem? Does it bother you? How does it bother you?o Document patients typical hygiene practices and any complaints (use of creams,

soaps) Oral cavity

o History of teeth, tongue, salivary glandso Identify variables that cause oral problems deficient self-care, poor nutrition, or

excess of sugars, family history Eyes, ears, nose

o Glasses, contacts, hearing aids Hair

o Texture, amount of hair, treatments, malnutrition Nails & feet

o Type of footwear worn, foot problems, history of biting nailso Perineal and vaginal areaso Foley cath, childbirth, surgery, UTI, diabetes

Physical assessment Skin

o Cleanliness, color, texture, temperature, turgor, moisture, sensation, lesionso Lesion type, color, size, distribution & grouping, location, and consistencyo Dry skin, acne, rashes

Oral cavityo Odorso Lips: color, moisture, lumps, ulcers, lesions, edemao Buccal mucosa: color, moisture, lesions, nodules, bleeding

Color of gums and surface of gums: lesions, bleeding, edema,exudates

o Teeth: loose, missing, decayed teeth; dentures or other orthodontic deviceso Tongue: color, symmetry, movement, texture, lesionso Hard and soft palates: intactness, color, patches, lesionso Oropharynx: movement of uvula and condition of tonsils if presento Caries: decay of teeth wit the formation of cavitieso Plaque: invisible, destructive, bacterial film that builds up and leads to destruction

of tooth enamelo Gingivitis: inflammation of gingival, the tissue surrounding the teetho Periodontitis: inflammation of gums that also involves degeneration of the dental

periosteum (tissues) and boneo Halitosis: strong mouth odor

Eyes, ears, and noseo Check position, alignment, and appearance of eye

Check eyelashes are equally distributed and curl outward Note lesions nodules, redness, swelling, crusting, flaking, tearing or

discharge of eyelids Check color of conjunctiva and test blink reflex

o Ear: position, alignment and appearance Buildup of wax in canal, dryness, crusting, or presence of any d/c or

foreign bodyo Nose : position and appearance, nostrils, check tenderness, dryness, edema,

bleeding, discharge or secretions Hair

o Texture, cleanliness, and oilinesso Scaling, lesions, infections on scalpo Dandruff, hair loss, infestations


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- Reduced short-term memory- Sensory deficits- thermoregulation ability

environment clear of clutter & using a night light- Allow additional time for teaching- Use appropriate measures to conserve body heat

Renal- ed renal blood flow- Reduced bladder capacity

- Monitor amt & times of voiding- Monitor fluid & electrolyte status- Maintain & record intake & output

Gastrointestinal- ed gastric pH- Prolonged gastric-emptying time- ed hepatic blood flow, liver mass, &

enzyme fxn

- Obtain baseline weight- Monitor nutritional status (wt, lab data)- Observe for prolonged effects of meds

Integumentary- ed vascularity- skin moisture & elasticity- ed subcutaneous fat

- Assess skin status- Monitor fluid status- Pad & protect boney prominences- Monitor skin for pressure areas- Use min amts of tape on dressings & intravenous

sites

34 Chapter: 30 Communication Objective: 2 Physical Assessment(p828)

& DocumentationPhysical Assessment Assessing the patients current physical status provides data for interventions to surgical

risk & potential postop complications. Depending on the situation, the physical assessment is conducted Presurgical screening tests provide objective data of normal body fxn In cases of abnormalities, such tests provide data for medical interventions to improve the

patients physical status & thus the risks for surgical complications Nurses role is to ensure that the tests are explained to the patient, appropriate specimens

are collected, the results are documented in the pts record before surgery, & abnormalfindings are reported.

Usual presurgical screening tests include chest x-ray, electrocardiography, complete bloodcount, electrolyte levels, & urinalysis. Significant abnormal findings include elevated WBC (infection), ed hemoglobin/hematocrit

(bleeding, anemia), hyperkalemia or hypokalemia ( ed risk for cardiac probs), elevated blood urea nitrogen or creatinine (possible renal failure), and abnormal urine constituents (infectionor fluid imbalances)

PREOPERATIVE PHYSICAL ASSESSMENTFACTORS TOASSESS

QS & APPROACHES

General survey - Note general state of health- Note body posture & stature- Take & record vital signs

Skin - Inspect skin for color, characteristics, & location & appearance of lesions

- Assess skin over bony prominence- Palpate skin turgor

Chest & lungs - Observe chest excursion & diameter & shape of thorax- Auscultate breath sounds- Palpate for any pain or tenderness

Cardiovascularsystem

- Inspect for jugular vein distention- Auscultate apical rate, rhythm, & character


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- Auscultate heart sounds- Assess for peripheral edema- Palpate character of peripheral pulses

Abdomen - Ask time of last bowel movement- Inspect abdominal contour- Auscultate bowel sounds

Neurologic System - Note orientation, level of consciousness, awareness, & speech- Assess reflexes- Assess motor & sensory ability- Assess visual & hearing ability

MusculoskeletalSystem

- Inspect & note joint range of motion- Palpate muscle strength- Assess ability to ambulate

35 Chapter: 30 Nursing Process Objective: Elimination (p834)Elimination Emptying the bowel of feces is no longer a routine procedure before surgery, but the nurse

should use preop assessments to determine the need for an order to facilitate bowelelimination

o If the patient has not had a bowel movement for several days or has had preopbarium diagnostic tests, an enema helps prevent postop constipation

If the pt is scheduled for surgery of the GI tract, a prescribed bowel prep & a cleansingenema are usually ordered

o Peristalsis does not return for 24-48 hrs after the bowel is handled, so preopcleansing helps to postop constipation

o An empty bowel also prevents contamination of the surgical area during surgeryo Insertion of an indwelling urinary catheter may be ordered before surgery,

especially in pts having pelvic surgery to prevent bladder distention or accidentalinjury.

o If an indwelling cath is not in place, the pt should void immediately beforereceiving preop meds to ensure an empty bladder during surgery

36 Chapter: 30 Pneumonia Objective: 4/5 Pneumonia (p844)Pneumonia Pneumonia inflammation of the alveoli as the result of an infectious process or the

presence of foreign material.o May occur postop as a result of aspiration, infection, depressed cough reflex,

increased secretions from anesthesia, dehydration, & immobilization.o Manifestations fever, chills, cough that produces a nasty or purulent sputum,

crackles & wheezes, dyspnea, and chest paino Goals of care: treat underlying infection, maintain respiratory fxn, & prevent

spread of microorganismso Nursing interventions incl those used to prevent or monitor for respiratory,

complications & promoting fall aeration of the lungs by positioning the pt in a semi-Fowlers or Fowlers position, administering O2, administering meds (antibiotics,expectorants, analgesics), providing frequent oral hygiene, & ensuring rest/comfort

37 Chaper: 30 Nursing Process Objective: 4/5 Immediate Postop Assess &Care (p839)Immediate Postoperative Assessment & Care Postop divided into 2 stages immediate care (PACU) in both hospital & outpatient/same day

surgery centers & ongoing postop care (lasting from return to the unit thru convalescence). Assessments carried out to maintain function, promote recovery, facilitate coping with

alterations in structure or function.


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Care in PACU assessing postop patient w/ emphasis on preventing complications fromanesthesia or surgery.

o Assessments are continuous, using preop & intraop data as bases for comparison. These include respiratory status, CV status, CNS, fluid, wound, & generalcondition.Made every 10-15 minutes.

Children can quickly lose their airway & go into a crisis.o Emergence delirium, where they wake up thrashing & disoriented is common in

children.o They must be safeguarded from hurting themselves & often reinduced into general

anesthesia to promote a smoother anesthesia emergence. Average PACU is 1 hr but will vary depending on type of surgery, length of anesthesia, &

patient response.o Outpatient/same day surgery pts return home after recovery in the PACU.o PACU nurses vigilant monitoring during emergence from anesthesia & 1 st hours

after surgery, pain management, fluid & electrolyte balance, stabilization of physiologic parameters (heart & RR), & prep for the next level of care.

Respiratory statuso Rate, rhythm, & depth auscultate breath sounds, noting O2 saturation level,

assessing skin color & monitoring CV & mental status.During a surgical procedure with gen. anesthesia, endotracheal tube may beinserted to administer anesthetic gases & maintain patent air passages.Airway is not removed until laryngeal & pharyngeal reflexes return, allowingthe patient to control the tongue, cough, & swallow.Airway is assessed for patency, humidified oxygen is administered & pulseoximetry is initiated.Ineffective respiratory function is indicated by restlessness & anxiety;unequal chest expansion with use of accessory muscle; shallow noisyrespirations; cyanosis; & tachycardia.

o Respiratory obstruction is most common.Occurs as a result of secretion accumulation, obstruction by the tongue,laryngospasm (sudden, violent contraction of the vocal cords), or laryngealedema.Respiratory obstruction is indicated by assessments of ineffectiverespiratory function plus observing for wheezing or crowing sounds withrespiratory effort.Positioning, administering humidified oxygen, encouraging pt to take deepbreaths, & suctioning may be used to maintain a pt airway & tissueoxygenation.

Cardiovascular statuso Take vital signs, monitory electrocardiogram rate & rhythm, & observing skin color

& condition.

BP findings are compared with baseline data from preop period. Transient hypertension can occur as a result of anesthetic effects,respiratory insufficiency, surgical procedure, or excitement phase of recovery from anesthesia.

o Hypotension result of anesthetic agents, preop meds, position changes, bloodloss, respiratory alterations, peripheral blood pooling.

O2 admin, deep breathing, leg exercises, verbal stimulation (to help expelanesthetic gases & facilitate increasing level of consciousness), &maintaining accurate IV flow rates can increase low BP.


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o Pts are at a risk for altered body temp related to surgical procedure, its length,anesthetic agents, a cool surgical environment, age, use of cool irrigating orinfusion fluids.

Inadvertent hypothermia (temp below 96 F) can lead to complication to poorwound healing, hemodynamic stress, cardiac disturbances, coagulopathy,delayed emergence from anesthesia, & shivering & its associateddiscomfort.Measure body temp, usually by temporal or tympanic route, initiateinterventions if pt complains of being cold or is hypothermic.Warmed blankets placed on patients body & head & forced warm airdevices are used for rewarming.

o All pulses are assessed for bilateral equality, rhythm, rate, & character.Of special significance are assessments of abnormal fxn, irregular rhythm,absence of pulses, or tachycardia.

Tachycardia, an early symptom of shock, must be carefully evaluated.Other related assessments for shock are a decreasing BP, cyanosis, a coolskin temp, & a decrease in urine output.

Central Nervous Systemo Pts response to stimuli & orientation.

Consciousness returns in reverse order with 1) unconsciousness 2) responseto touch & sounds 3) drowsiness 4) awake but not oriented and 5) awake &oriented.Nurses in PACU verbally reorient pt by gently touching & calling them by hisor her name.

Fluid statuso Fluid imbalance result from factors such as preop fluid restriction, fluid loss during

surgery, wound drainage, or surgical stress response (w/ retention of Na & H20).Imbalanced fluid volume (deficit or excess) is risk for all surgical pts but isan especially imp consideration in children & older adults.Assessing fluid status includes skin turgor, vital signs, urine output, wounddrainage, & IV fluid intake.IV fluid admin assessments include type of fluid infused, rate location of lines, condition of IV insertion site & security/patency of tubing.

Wound statuso Assess dressing over incision (wound) for amt, consistency, & color of drainage as

well as for any tubes or drains & amt & type of drainage by that route.o Large amts of bright red drainage combined with other abnormal physical status

assessments (restlessness, pallor, cold moist skin, decreasing BP, increasing PR &RR) may indicate hemorrhage & hypovolemic shock.

Pain managemento Assessment of pain using a rating scale.o Scale may be verbal ranging from no pain to worse possible pain (0 10 being

worst), or a faces rating scale ranging from a smiley face to a face that frowns &tears.

o Early admin of analgesia, using nonsteroidal anti-inflammatory drugs & opiates,occurs in the PACU.

o Opiates may be delivered by PCA, allowing pt to control analgesic admin.o Nonpharmacologic methods to decrease pain & improve comfort include

positioning, verbal reassurance, & touch.o Preop assessments of methods that are personally effective for the pt assist in

effective implementation in the PACU.o These should supplement not substitute for pharmacologic pain relief.


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General conditiono Ensure physical & emotional comfort & safety.o Constant reorientation & reassurance that the surgery is completed provide

psychological comfort.o Careful assessments, proper positioning, & use of side rails maintain physical

status & level of consciousness are considered stable.o Family is notified that the pt is being transferred back to the room, & the PACU

nurse gives a verbal report to the unit nurse about the assessments &interventions during the intraoperative & immediate postoperative phases.

38 Chapter: 30 Teaching/Learning Objective: Prov. Outpt/Same-DaySurgery Postop

Care (p846)Providing Outpatient/Same-Day Surgery/Postoperative Care Evaluating pts postop status after outpt/same-day surgery focuses on ensuring that the pt

can be safely cared for at home.o After surgery & recovery from the anesthetic, the pt is asked to sit up & drink

liquidso Pt who is no longer drowsy or dizzy, has stable vital signs, & has voided is allowed

to go home accompanied by a responsible adulto Pt is not allowed to drive a car or go home alone on public transportationo Usual length of time from completion of surgery to discharge is 1-3 hrs, provided

that establish criteria have been meto Written & verbal instructions for home care are given to the pt & family

39 Chapter: 31 Nursing Process Objective: Skin (p870)Skin Assisting pts with basic hygiene measures provides a good opportunity for examining the

pts skin.o Many people dont know that they have skin lesions such as precancerous moles,

that if untreated can be fatal.o Early detection & treatment of skin probs are impt nursing fxns.

When examining the skin, pay attn to cleanliness, color, texture, temp, turgor, moisture,sensation, vascularity & any lesions.

o If a lesion is detected, document the type, color, size, distribution, & grouping,location, and consistency.

To assess skin:o Proceed systematically in a head-to-toe fashion.o Use a good source of light, preferably daylight.o Compare bilateral parts for symmetry.o Use standard terms to report & record findings.o Allow data obtained in nursing hx to direct the skin assessmento ID any variables known to cause skin probs such as deficient self-care abilities,

immobility, malnutrition, decreased hydration, decreased sensation, sun exposure,vascular probs (altered tissue perfusion or venous return), or the presence of irritants (body secretions or excretions on the skin, other chems, mechanicaldevices)

Since lifestyle factors, changes in health state, illness & certain diagnostic measures mayadversely affect the skin, be alert for pts who may be at a high risk for skin probs, & performthe appropriate skin assessment.

o Assessment may reveal dry skin, acne, or skin rashes.


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o Illness affects the hair, esp when endocrine abnormalities, increased body temp,poor nutrition, or anxiety & worry are present.

o Changes in color or condition of the hair shaft are related to changes in hormonalactivity or to changes in the blood supply to hair follicles.

Nails are accessory structure of the skin composed of epithelial tissue.o Healthy nailbeds are pink, convex & evenly curved.o With certain pathologic conditions, and to some extend with aging, nails become

ridged & areas become concave. Hygienic care includes keeping the nails trimmed & clean.

o Persons general health influences the health of his or her mouth and teeth &proper care of the mouth & teeth leads to overall health.

Ex. An established relationship btw healthy teeth & a diet sufficient in Ca &Ph, along with Vit D, which is necessary for the body to make use of theseminerals.

Maintaining good oral hygiene & dental care has several benefits.o Esthetic value in having a clean & healthy mouth.o Having ones teeth contributes to image.o The beginning of the digestive process & gustatory pleasure are enhanced when

the mouth & teeth are in good condition. Perineal area is dark, warm, & often moist, providing conditions that favor bacterial growth.

o Patient who cant clean perineal area needs the nurses assistance for this imptpart of personal hygiene.

o Neglecting perineal cleaning for the pt who cant provide self-care often results inphysical & psychological discomfort of the pt, skin breakdown, & offensive odors.

41 Chapter: 31 Nursing Process Objective: 6 Helping w/ Bathing &Skin Care (p877)Helping with Bathing & Skin Care Bathing purposes:

o Cleansing the skino Acting as a skin conditionero Helping to relax a restless persono Promoting circulation by stimulating the skins peripheral nerve endings &

underlying tissueso Serving as a musculoskeletal exercise thru activity involved with bathing, thereby

improving joint mobility & muscle tonuso Stimulating the rate & depth of respirationso Promoting comfort thru muscle relaxation & skin stimulationo Providing sensory inputo Helping to improve self-imageo Providing an excellent opportunity to strength the nurse-pt relationship, to

thoroughly assess the pts integumentary system, to observe the pts physiologic &

emotional status closely, to teach the pt as indicated, and to demonstrate care &interest in the pts general welfare Simple act of bathing a pt is a vital & caring intervention

o Examples of Nursing Interventions & Nursing Outcomes Classifications (NIC/NOC)lists standardized nursing interventions & corresponding outcomes related tohelping the pt promote cleaning of the body for relaxation, cleanliness, & healing.

o In recent yrs, this basic personal care measures has often been assigned to anunlicensed staff member rather than the professional nurse.

o It has become a task to be accomplished rather than an opportunity for therapeuticindividualized intervention.


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o Altho unlicensed assistive personnel are increasingly performing hygienemeasures, the nurse is responsible for ensuring that hygiene measures wereperformed satisfactorily.

o Nurses whose primary focus is the pt, however, can use the time spent assistingwith bathing to establish a rapport w/ the pt & to further assess the ptsintegumentary system.

Examples of NIC/NOC - BathingNursing Interventions Nursing Outcomes- Monitor functional ability while bathing- Offer handwashing after toileting & before meals- Use fun bathing techniques with children wash

dolls/toys- Bathe in water of a comfortable temp- Monitor skin condition while bathing- Apply lubricating ointment & cream to dry skin

areas

- Self-care: Bathing- Pt Satisfaction: Functional assistance- Oral Hygiene- Motivation- Energy Conservation

Shower & Bath Tubso Shower preferred bathing for hospitalized pts who are ambulatory & able to

tolerate the activityBaths may be an option, particularly in long-term care, depending on thefacility policy.

o For the most part, even though many pts can bathe on their own, the followingresponsibilities apply:

Check to see that the bathroom is available, clean & safe. Showers shouldhave mats or nonskid strips to prevent pts from slipping & fallingEnsure that necessary articles, such as soap, a washcloth, a towel & gownare available for the ptProvide a place for a weak or physically disabled pt to sit in a shower. Mosthealth agencies have a stool or chair that can be used in the shower &handheld showerheasd may facilitiate the process. Some nurses have

reported that a commode chair w/ the pan removed serves effectively as ashower chair & offers the pt more support than a stool or chair.Assist the pt to the shower or bathroom, as indicated. Pts who are beginningambulation often need assistance to help preventing falling or fainting.Check that the water temp is safe & comfortable 110F 115F (43C 46C).

The lower temp is recommended for children & elderly ptsEnsure privacy for those who can shower & bathe independently. Call deviceis handy & make sure pt knows what button is for, so that the pt can obtainhelp if needed.Help pt get in and out of the bathtub. Have pt grasp handrails at the side of the tub or place a chair at the side of the tub. The pt sits on the chair &eases to the edge of the tub. After putting both feet into the tub, it is thenrelatively easy for the pt to reach the opposite side & ease down into thetub. Pt may kneel 1 st in the tub & then sit in it; this process can be reversedwhen leaving the tub. Use a hydraulic lift when available to lower & lift thepts who are unable to maneuver safely or completely bear their wt.Keep bathroom door unlocked. Health personnel should be able to enterwith ease if the pt needs help. Sign hung on the door ensures privacy. Neverleave kids or confused pts alone in the bathroom.Help to wash & dry areas of the body that the pt cant reach back.Make any necessary adaptations. For ex. If pt is confused & becomesagitated as a result of overstimulation when bathing, reduce stimuli. Turn


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They are used to protect skin at risk for damage caused by excessiveexposure to water & irritants, such as urine & feces.

They are also used to prevent skin breakdown around stomas & wounds w/excessive exudates.Applications of 1 of these products forms a thin layer on the surface of theskin to repel potential irritants.

Massaging the Back o Acts as a general body conditioner & can relieve muscle tension & promote

relaxation.Some nurses forgo giving backrubs to patients due to time constraints.However, giving a backrub allows the nurse to observe the skin for signs of breakdown.Backrub improves circulation; can decrease pain, distress, & anxiety; canimprove sleep quality; & provides a means of communication w/ the pt thruthe use of touch.

o Effective backrub 4-6 min & if lotion used warm it before use.o Be aware of medical diagnosis when giving backrub

Backrub contraindicated for ex if pt has had back surgery or has fracturedribs

Position the pt on the abdomen or on the side

42 Chapter: 31 Nursing Process Objective: 6 Skill 31-5: Making an OccupiedBed (p909)Skill 31-5: Making an Occupied Bed Check chart for limitations on patients physical activity Assemble equipment and arrange on bedside chair Perform hand hygiene (put on ppe as indicated) Identity the patient Close the curtains Adjust the bed to a comfortable working height

o

Lower side rails nearest you, leaving the opposite side rail up.o Place the bed in a flat position unless contraindicated Put on gloves.

o Check bed linens for patients personal items.o Disconnect the call bell or tubes/drains from the bed linens

Place a bath blanket over the patient.o Fold linen that is to be reused over the back of the chair.o Discard soiled linen in laundry bag or hamper.o Do not place on floor or furniture.o Do not hold soiled linens against your uniform.

Assist the patient to turn toward opposite side of the bed, and reposition pillow underpatients head.

o Loosen all bottom linens from head, foot, and side bed.o Fan-fold soiled linens as close to patient as possible.o Use clean linen and make the near side of the bed. Place the bottom sheet with the

center fold in the center of the bed.o Open the sheet and fan-fold to the center, positioning it under the old linens.o Pull the bottom sheet over the corners at the head and foot of the mattress.

If using, place the draw sheet with its center fold in the center of the bed positioned so thatit will be located under the patients midsection.

o Open the draw sheet and fan-fold to the center of the mattress.o Tuck the draw sheet securely under the mattress.


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Raise the side rail.o Assist patient to roll over the folded linen in the middle of the bed toward you.o Reposition pillow and bath blanket or top sheet.

Loosen and remove all bottom lines.o Discard soiled linen in laundry bag or hamper.o Do not place on floor or furniture. Do not hold soiled linens against your uniform.

Ease clean linen from under the patient.o Pull the bottom sheet taut and secure at the corners of the head and foot of the

mattress.o Pull drawsheet tight and smooth.o Tuck the drawsheet securely under the mattress.

Assist patient to turn back to the center of bed.o Remove pillow and change pillowcase.

Apply top linen, sheet, and blanket if desired, so that it is centered.o Fold the top linens over the patients shoulders to make a cuff.o Have the patient hold to the top linen and remove the bath blanket fro underneath.

Secure top linens under foot of mattress and miter corners.o Loosen top linens over patients feet by grasping them in the area of the feet and

pulling gently toward foot of the bed.o Return patient to a position of comfort.o Remove your gloves.o Raise side rail and lower bed.o Reattach call bell.

43 Chapter: 32 Nursing ProcessObjective: 1 Intentional & UnintentionalWounds (p922)Intentional & Unintentional Wounds Intentional wound = result of planned invasive therapy or tx.

o These wounds are purposely created for therapeutic purposes.Ex. Are from surgery, IV therapy, & lumbar puncture.

o

These wound edges are clean & bleeding is usually controlled.o B/c wound was made under sterile conditions with sterile supplies & skin prep, the

risk for infection is decreased & healing is facilitated. Unintentional wound = accidental

o From unexpected trauma such as accidents, forcible injury (such as stabbing orgunshot), & burns.

o B/c the wounds occur in an unsterile environment, contamination is likely.o Wound edges are usually jiggered, multiple traumas are common & bleeding is

uncontrolled. These factors create a high risk for infection & a longer healing time.

44 Chapter: 32 Nursing Process Objective: 1 Inflammatory Phase (p924)Inflammatory Phase Follows hemostasis Lasts 4-6 days WBC, leukocytes, and macrophages move to the wound

o Leukocytes arrive 1 st to ingest bacteria and cellular debriso 24 hrs after injury, macrophages enter wound area and remain

They release growth factors that are necessary for the growth of epithelial cells & new blood vessels


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These growth factors also attract fibroblasts that help tofill in the wound which is necessary for the next stage of healing.

Acute inflammation = pain, heat, redness, swelling at the site of the injury During this phase, pt has a generalized body response, including a mild elevated temp,

leukocytosis (inc. # of WBC in the blood), & generalized malaise

45 Chapter: 32 Nursing Process Objective: 2 State of Health (p921)State of Health State of a persons health & therapeutic tx have a direct effect on the condition of the skin Proper nutrition, adequate circulation, & good overall health are imp for healthy skin Very thin & obese ppl tend to be more likely to have skin irritations & injury Fluid loss thru fever, vomiting, or diarrhea reduces the fluid volume of the body aka

dehydration & it makes skin appear loose & flabby Excessive perspiration, often associated with being ill, predisposes the skin to breakdown,

esp in skin folds. Jaundice due to excessive bile pigments in the skin results in a yellowish skin color. Skin is often itchy & dry, & pts with jaundice are more likely to scratch their skin & cause an

open lesion w/ the potential for infection. Diseases of the skin such as eczema & psoriasis may have a genetic predispotition & often

casuse lesions that require special care

46/47 Chapter: 32 Nursing Process Objective: 2 Factors Affecting Skin Integrity(p921)Factors Affecting Skin Integrity Unbroken & healthy skin & mucous membranes serve as the 1 st line of defense against

harmful agents. Resistance to injury of the skin & mucous membranes varies among people. Factors influencing resistance incl persons age, amt of underlying tissues, & illness

conditions Adequately nourished & hydrated body cells are resistant to injury.

o Better nourished cell is, the better able it is to resist injury & disease. Adeqauate circulation is necessary to maintain cell life.

o When circulation is impaired for any reason, cells receive inadequate nourishment& cant remove wastes efficienty.

Developmental Considerations:o


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See State of Health

48 Chapter: 32 Nursing Process Objective: 3/6 Preventing Pressure UlcersPreventing Pressure Ulcers Assess patients skin on a daily basis with special attention to bony prominences Cleanse skin routinely and whenever soiling occurs, using mild cleansing agent, minimal

friction, and not hot water. Maintain humid environment and use skin moisturizers Avoid massage over bony prominences Protect skin from moisture associated with incontinence or wound drainage Minimize shearing and friction by using proper positioning, turning, and transferring. Use

lubricants, dressings, protective films, and padding. Investigate any inadequate dietary intake of protein or calories, administer nutritional

supplements Try to improve or at least maintain level of activity, mobility, and ROM Document measures used and results

49 Chapter: 32 Nursing Process Objective: 4 Pressure Ulcer Staging(p932)

Pressure Ulcer Staging Blanching (pale/white) of skin under pressure ulcer Ischemia makes skin look paler Hyperemia reddening of skin when pressure removed

o Body floods area w/ blood to nourish & remove wastes from cellso Area appears red & feels warm but blanches when slight pressure appliedo Circulation impaired & pressure ulcer developso Deep-tissue injury purple/maroon localized area or blood-filled blister

Stage I pressure ulcer = intact skin w/ nonblanchable redness of a localized area usuallyover a bony prominence

Defined area of persistent redness in lightly pigmented skin and a persistent

red, blue, or purple hue in darker skin. Treated by frequent turning, pressure-relieving devices, and positioning. Stage II partial thickness loss of dermis

Superficial; may be present as a blister or abrasion. Maintain moist healingenvironment w/ saline or occlusive dressing

Stage III ulcer with full thickness tissue losso Subcutaneous fat may be visibleo Undermining and tunneling

Require debridgement by: wet to dry dressing, surgical intervention, orproteolytic enzyme

Stage IV full thickness tissue loss w/ exposed bone, tendon, muscleo Slough or eschar may be present & undermining/tunnelingo Unstageableo Base of ulcer covered by slough (yellow, tan, gray, green, or brown) or eschar (tan,

brown, black) in wound bedo Eschar thick leathery scab or dry crust that is necrotis

Stable (dry, intact) eschar on heel serves as bodys natural biological cover & cant beremoved

50 Chapter: 32 Nursing Process Objective: 7 Cleaning the Wound(p946)Cleaning the Wound


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Perform wound cleaning to remove microorganism debris w/ as little chemical & mechanicalforces as possible & protect healthy granulation tissue.

o Normal saline soln (0.9% NaCl) is used to clean pressure ulcer wounds. Wounds are cleaned 1 st and before applying any new dressing.

o Wound irrigation is a directed flow of soln over tissues.o Sterile equipment & solns are required for irrigating an open wound, even in the

presence of an existing infection.o Sterile 0.9% NaCl or sterile water, an antiseptic, or an antibiotic soln may be used,

depending on the condition of the wound & primary practioners order.o Sterile large-volume syringe is used to direct flow of the soln.o After irrigation, open wounds may be packed w/ approp dressing materials to

absorb additional drainage & allow healing by secondary iintention to take place.o Nonsterile solns used to clean the skin surface if the wound edges are

approximated. Wounds with approx edges: clean top to bottom; work outward from the incision in lines

parallel to it Wounds with unapprox edge: clean in full or half circles; work in the center to outward

51 Chapter: 32 Nursing Process Objective: 8 Changing the Dressing

(p944)Changing the Dressing Explain procedure to pt If wound care uncomfortable, administer a prescribed analgesic 30-45 min before changing

the dressing Plan to change the dressing midway btw meals so that the pts appetite & mealtimes are not

disturbed Provide privacy by properly screening the pt

o Close room door & curtaino Help pt into a position that is comfortable & also convenient for changing the

dressingo Expose only the area necessary to perform the wound care while maintaining

proper draping Use approp aseptic techniques when changing the dressing is crucial

o Perform hand hygiene before & after dressing changeso Surgical wounds = sterile techniqueo Pressure ulcers = nonsterile

52 Chapter: 32Nursing Process Objective: 9 Effects of Applying Cold (p956)Effects of Applying Cold Cold = constricts peripheral blood vessels, reduces muscle spasms, & promotes comfort

o Reduces blood flow to tissues & decreases local release of pain-producingsubstances such as histamine, serotonin, & bradykinin

This in turn reduces formation of edema & inflammationo Decreased metabolic needs & capillary permeability, combined w/ increased coag

of blood at the wound site, facilitate control of bleeding & reduce edema formation Cold reduces muscle spasm, alters tissue sensitivity (producing numbness), & promotes

comfort by slowing transmission of pain stimuli.o Cold is used for direct trauma, dental pain, muscle spasms, after sprains, & to treat

some chronic pain syndromes Exposure to prolonged or extensive environmental cold produces systemic effects of

increased BP, shivering, & goose bumps.o Although shivering is a normal body response to cold, prolonged cold may cause

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53 Chapter: 33 Nursing Process Objective: 2/5 Developmental Considerations(p1006)Developmental Considerations Persons age & degrees of neuromuscular development markedly influence body proportions,

posture, body mass, movements & reflex. To promote neuromuscular development in pts of all ages & to facilitate each pts use of the

body to perform self-care actions, nurses need to be familiar w/ developmental variations inbody proportions & neuromuscular development.

Infant: periods of inactivity & alertness alternate w/ quiet periods & sleepo 3 mths may raise chest & head when proneo 4 mths head control usually achieved

Toddler: gross & fine motor development continue rapidlyo 15 mths most can walk unassistedo 18 mths most can runo 2 yrs can jumpo 3 yrs most can stack blocks, string large beads, work simple puzzles, dress

themselves Child: muscles, bone, & nervous system develop, allowing greater gross & fine motor control

o 4 yrs negotiate stairs, walk backwards, & hop on 1 footo 5 yrs skip, jump rope, & jump off htso Able to manipulate writing materialso Has acquired all basic mechanisms for physical locomotion

Adolescent: size increases, growth spurt, physically fit or inactive Adults: stands & sits erect & capable of balance/coordination; purposeful movement

o Activity levels vary

54 Chapter: 33 Nursing Process Objective: 7 Body Mechanics (p1005)Body Mechanics Body mechanics application of mechanical laws to the human body, specifically in regard

to structure, fxn, & position of the body.o It includes proper body movement in daily activities, prevention & correction of

probs associated / posture, & the enhancement of coordination & enduranceo It is imp to use the principles of body mechanics during activity & during rest

periods, to prevent injury & to prevent sore muscles & jointso Principles of body mechanics are used to assess & maintain alignment of ptso Correct use of body mechanics is part of illness prevention & health promotiono Many activities in which the nurse engages, from as simple an activity as moving a

chair, repositioning the med cart, or reaching to silence a monitor alarm, requireunderstanding & using these principles

o Nurses who consciously develop good habits can demonstrate to others properways of using the musculoskeletal system

55 Chapter: 33 Teaching/Learning Objective: 2 Problem w/ BoneFormation (p1008)Problem with Bone Formation Congenital probs such as achondroplasia in which premature bone ossification leads to

dwarfism, or osteogeneis imperfecta, which is characterized by excessively brittle bones &multiple fractures both at birth & later in life

Nutrition related probs, such as vit D deficiency, which results in deformities of the growingskeleton (rickets)

Disease-related probs such as Pagets disease, in which excessive bone destruction &abnormal regeneration result in skeletal pain, deformities, & pathologic fractures


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Age-related probs such as osteoporosis in which bone destruction exceeds bone formation &in which the resultant thin, porous bones fracture easily

56 Chapter: 33Nursing Process Objective: 4/5 Cardiovascular System (p1013+1014)Cardiovascular System To meet the demand for O2 created by the rhythmic contraction & relaxation of skeletal

muscle groups, the supply of oxygenated blood to skeletal muscle needs to be increased. CVS meets this challenge by increasing the HR, increasing the contractile strength of the

myocardium, & increasing stroke volume (volume of blood ejected), thus increasing cardiacoutput.

Arterial (systolic) BP is increased, blood is shunted from nonexercising tissue to the heart &muscles.

Exercise also improves venous return b/c the contracting muscles compress superficial veins& push blood back to the heart against gravity.

Other time, with cardiovascular conditioning regular exercise produces the followingbenefits:o ed efficiency of the hearto ed HR & BPo blood flow to all body partso ed circulating fibrinolysis (substance that breaks up small clots)

Primary & serious effects of immobility on the CVS include ed cardiac workload orthostatic hypotension, & venous stasis, with resulting venous thrombosis.

o Immobility results in an increased workload for the heart.o With immobility, the skeletal muscles that normally compress valves in the leg

veins & help to pump the blood back to the right side of the heart do notadequately contract

o There is less resistance offered by the blood vessels & blood pools in the veins,thus increasing the venous BP & changing the distribution of blood in the immobileperson.

o As a result, the HR, cardiac output, and stroke volume increase Person who is immobile is more susceptible to developing orthostatic hypotension.

o Normal neurovascular adjustments that occur to maintain systemic BP withposition changes are not used during periods of inactivity & become inoperative.

o A drop in BP may occur as result of a lack of vasoconstriction when changing froma supine to an upright position.

o Person tends to feel weak & faint when this condition occurs.

57 Chapter: 33 Nursing ProcessObjective: 4 Respiratory System (p1013 &1015)Respiratory System Respiratory & CVS work together to make increased oxygen available to the muscles.

o During exercise, the depth of respiration, RR, gas exchange at the alveolar level, &rate of CO2 excretion are increased.

o Over time, regular exercise leads to improved pulmonary functioning. Effects of immobility on the respiratory system are related to decreased ventilatory effort &

increased respiratory secretions.o Immobility causes a decrease in the depth & rate of respirations, in part b/c of a

reduced need for O2 by body cells.


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o When areas of lung tissues are not used over time, atelectasis (incompleteexpansion or collapse of lung tissue) may occur.

o Immobility results in a poor exchange of CO2 & O2, upsets their balance in thebody, & eventually causes an acid-base imbalance.

Person who is immobile, the movement of secretions in the respiratory tract is decreased,causing secretions to pool & leading to respiratory congestion.

o These conditions predispose the person to respiratory tract infections.o Hypostatic pneumonia is a type of pneumonia that results from inactivity &

immobility.o Situation worsens when the person is dehydrated or using pharmacologic agents

that increase the tenacity of secretions, depress the coughing mechanism, and/ordepress respirations.

Decreased movement in the thoracic cage during respirations also occur with immobility.o This decrease may be due to loss of tonus in muscles involved with respirations,

pressure on the chest wall b/c of the pts position in bed, or depression of therespiratory system by various pharmaceutical agents.

58 Chapter: 33 Nursing Process Objective: 8 Additional Equipment (p1029)Additional Equipment

Greatest danger to the feet occurs when they are unsupported in the dorsiflexion position.o The toes drop downward, & the feet are in plantar flexion.o B/c of the pull of gravity, this position of the feet occurs naturally when the body is

at rest.o If maintained for extended periods, plantar flexion can cause an alteration in the

length of muscles, and the pt may develop a complication foot drop.o In this position, the foot is unable to maintain itself in the perpendicular position,

heel-toe gait is impossible, & the pt experiences extreme difficulty in walking.o The use of a foot support, such as a foot boot or high-top sneakers, helps avoid this

complication. If top bedding must be kept off the pts lower extremities, a device called a cradle is used.

o A cradle is usually a metal frame that supports the bed linens away from the ptwhile providing privacy & warmth.

o There are a # of sizes & shapes of cradleso If used, the cradle should be fastened securely to the bed so that it does not slide

or fall on the pt. Sandbags, available in various sizes, can be used to immobilize an extremity & support body

alignment.o When properly filled, they should be pliable enuff to be shpaped to body contours

to provide support.o Avoid hard or firmly packed sandbags.o Position a sandbag to avoid creating pressure on a bony prominence.

Trochanter rolls are used to support the hips & legs to that the femurs to no rotate outward.o

Properly placed pillows can be used to help prevent the thighs from turningoutward, but they tend to slip out of place & require frequent adjustment to beeffective.

o If a pt is paralyzed or unconscious, hand-wrist splints or hand rolls may benecessary to provide a means for keeping the thumb in the correct position,slightly adducted & in apposition to the fingers.

o A hand roll can be created by folding a washcloth, rolling it, & securing it in placewith tape.

o Once placed against the palm of the hand, it can effectively keep the hand in afunctional position.


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o A commercial plastic or aluminum splint also may be used to hold the thumb inplace regardless of the hand position.

o Encourage pts who are moving their fingers to do finger exercises, w/ special attnto having the thumb touch the tip of each finger.

Side rails can assist the pt in rolling from 1 side to other or to sitting up without calling forassistance. Using the side rails can help the pt retain or gain muscle efficiency.

o When using side rails, be sure to explain their use to pts & their families & followthe protocol of the healthcare agency.

o If a pt requests that side rails be raised for additional security, the pt must havethe ability to raise & lower the side rails independently.

59 Chapter: 34 Nursing Process Objective: 1 Circadian Rhythms(p1082)Circadian Rhythms Rhythmic biologic clocks exist in plants, animals, & humans

o Influenced by both internal & external factors, they regulate certain biologic &behavioral functions in humans.

o Some cycles are monthly such as womans menstrual cycle. Circadian rhythms complete a full cycle every 24 hours (1 day)

o

Circa = approximatelyo Diem = day Fluctuations in a persons heart rate, blood pressure, body temperature, hormone secretions,

metabolism, performance & mood depend in part on circadian rhythms. Circadian synchronization is present when an individuals sleep-wake patterns follow the

inner biologic clock.o When physiologic & psychological rhythms are high or most active = person awake;

when rhythms are low = person asleepo Even though light & dark are powerful regulators in sleep-wake circadian rhythms,

they dont exert primary controlo Regulating mechanism is the persons individual biologic clock, which is influenced by

many things such as occupational demands & social pressures.Ex. Nurse works at night may sleep 2pm-8pm and peak physiologic activity maybe between 10pm-6am during work

Problems of desynchronization occur when sleep-wake patterns are frequently altered &person attempts to sleep during high-activity rhythms or to work when the body isphysiologically prepared to rest.

60 Chapter: 34 Nursing ProcessObjective: 1 NREM Sleep (p1082)NREM Sleep NREM = 75% of total sleep

o Parasympathetic nervous system dominate in pulse, respiratory rate, blood pressure, metabolic rate, & body temperature are observed

4 stages:Stage I Stage II Stage III Stage IVPerson is in atransitional stagebetween wakefulness &sleep.Person is in a relaxedstate but stillsomewhat aware of thesurroundings.Involuntary muscle

Person fallsinto a stage of sleep.Can bearoused withrelative ease.50%-55% of sleep

Depth of sleepincreases, &arousalbecomesincreasinglydifficult.10% of sleep

Person reaches greatest depth of sleep= delta sleep (slow-wave sleep)Arousal threshold (intensity of stimulusrequired to awaken) is the greatest &most difficult.Physiologic changes in body include:Sloe brain waves recorded on EEG.Pulse & respiratory rate Blood pressure


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jerking may occur &waken the person.Stage lasts onlyminutes.Person can be arousedeasily.5% of total sleep

Muscles are relaxed.Metabolism slows & body temp is low.10% of sleep

61 Chapter: 34 Teaching/Learning Objective: 2 Physical Activityand Exercise (p1086)Physical Activity & Exercise Activity & exercise fatigue & can promote relaxation followed by sleep.

o Physical activity in REM & NREM sleepo Moderate exercise is a healthy way to promote sleep but exercise that occurs within a

2-hour interval before normal bedtime can hinder sleepo Fatigue that results from normal work activities or exercise is believed to contribute to

a restful sleep, whereas excessive exercise or exhaustion can quality of sleep.

62 Chapter: 35 Nursing Process Objective: 1 The Pain Experience (p1112)63/67 Chapter: 35 Nursing Process Objective: 2 Duration of Pain (p1112)The Pain Experience Bodys defense mechanism

o Definition (Margo McCaffery) pain is whatever the experiencing person says it is,existing whenever he/she says it does only one who can be real authority onwhether/how individual is experiencing pain is that individual

o Health practitioners must rely on pts description of pain b/c its a subjective symptom Types of Pain Duration of Pain

o Acute pain generally rapid in onset, varies in intensity from mild to severe;protective in nature (warns individual of tissue damage/organ disease); disappearsafter underlying cause resolved & should end once healing occurs

Causes: pricked finger, sore throat, surgery, etc.o Chronic pain may be limited, intermittent, or persistent but lasts beyond the

normal healing periodo Most recent definition no longer mentions previous guideline of 3-6 months durationo Commonly ppl experience periods of remission (when disease present but person

doesnt experience symptoms) & exacerbation (symptoms reappear)o Pain associated w/cancer or other progressive disorders termed chronic malignant

pain & pain in ppl whose tissue injury is nonprogressive/healed is termed chronicnonmalignant pain

Pts have difficulty describing b/c may be poorly localizedo Healthcare personnel have difficulty assessing b/c of unique responses of individual

pts to persistent pain often perceived as meaningless & may lead to withdrawal,depression, anger, frustration, & dependency (unlike acute); misconceptions &personal biases of caregivers can adversely affect management of pts w/chronic pain

o Individuals may be viewed by healthcare personnel as hysterical personalities,malingerers, or hypochondriacs nurses need awareness of personal feelings towardpain & factors that affect pain

Source of Pain (location)o Cutaneous pain superficial; usu involves skin or subcutaneous tissue

Ex. Paper cut that produces sharp pain w/burning sensationo Deep somatic pain diffuse/scattered & originates in tendons, ligaments, bones,

blood vessels, nerves


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Caused by strong pressure on a bone or damage to tissue that occursw/a sprain

o Visceral pain poorly localized & originates in body organs in thorax, cranium, &abdomen occurs as organs stretch abnormally & become distended, ischemic, orinflamed

Guarding (reflex contraction/spasm of abdominal wall) may occur asprotective mechanism to prevent addl trauma to underlying structuresindividual automatically tenses abdomen when an acute abdominal paincondition present, which prevents underlying tissues & organs frombeing palpated/touched

Mode of Transmissiono Referred pain originates in 1 part of body but perceived in area distant from point

of origino Ex. Pain assoc w/MI frequently referred to neck, shoulder or arms (esp left)o Transmitted to a cutaneous site different from where it originated b/c travels along

affected nerve root Etiology

o Neuropathic pain results from injury to or abnormal functioning of peripheralnerves or CNS

o

Exact cause unknown & can occur in many formso Can be of short duration or lingering & often described as burning or stabbingo Allodynia pain that occurs after normally weak or nonpainful stimuli, such as light

touch or cold drink (characteristic feature of neuropathic pain)o Pain syndromes that produce neuropathic pain include:

Complex regional pain syndrome (causalgia)Postherpetic neuralgiaPhantom limb pain

Trigeminal neuralgiaDiabetic neuropathy

Often misdiagnosed nursing can play important role in early detectiono Intractable pain resistant to therapy & persists despite variety of interventionso Phantom pain pain thats often referred to an amputated leg where receptors &

nerves are clearly absent; w/o demonstrated physiologic or pathologic substance, butis a real experience for the pt

Theory sensory misrepresentations from missing limb may still remainin brain

o Psychogenic pain physical cause for pain cant be IDed Responses to Pain

o PhysiologicIncreases in VS may occur briefly in acute pain & may be absent inchronic pain states

o BehavioralIntense pain experienced briefly usu results in reflex action to escapecause

o AffectiveAnxietyPhysically & emotionally exhausted, depression, irritabilityChronic fatigue (w/chronic pain)

The Pain Processo Transduction activation of pain receptors; involves conversion of painful stimuli

into electrical impulses that travel from the periphery to the SC at the dorsal horno Nociceptors peripheral nerve fibers that transmit pain


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Believed to produce analgesic effects by binding to specific opioidreceptor sites throughout CNS blocking release/production of pain-transmitting substancesBoth pain & stress capable of activating endogenous opioid system

o Endorphins & enkephalins are opioid neuromodulatorsEndorphins produced at neural synapses at various points along CNSpathway; powerful pain-blocking chemicals that have prolongedanalgesic effects & produce euphoriaMay be released when certain measures used to relieve pain (skinstimulation & relaxation techniques) & when certain pain-relieving drugsusedDynorphin has most potent analgesic effectEnkephalins widespread throughout brain & dorsal horn of SC;considered less potent than endorphins; thought to reduce painsensation by inhibiting release of substance P from terminals of afferentneurons

The Gate Control Theory of Paino Gate control theory describes transmission of painful stimuli & recognizes a

relation btwn pain & emotions; certain nerve fibers (those of small diameter) conduct

excitatory pain stimuli toward the brain, but nerve fibers of a lg diameter appear toinhibit transmission of pain impulses from SC to brainIs a gating mechanism thats believed to be located in substantiagelatinosa cells in dorsal horn of SCExciting & inhibiting signals at gate in SC determine impulses thateventually reach brain only limited amt sensory info can be processed byNS at any given moment when too much info sent through, certain cellsin spinal column interrupt signal as if closing a gate

o Brain can also influence gating mechanism past experiences & learned behaviors(interpreted by brain) regulate/adjust eventual behavioral responses to pain gatingmechanism appears to be influenced by amt of activity in lg & small afferent fibers inaddition to nerve impulses that descend from brain

Helps explain why similar painful stimuli interpreted differently bydifferent pplAppears to explain why mechanical & electrical interventions or heat &pressure may provide effective pain relief (ex. Nursing measures likemassage or warm compress stimulate lg nerve fibers to close the gate,thus blocking pain impulses from that area)

64/65Chapter: 35 Nursing Process Objective: 4 Components of a PainAssessment (p1121)Components of a Pain Assessment Use guides to eliminate guesswork & biases when dealing w/pts pain to understand what pt

experiencing, to analyze findings that will help prepare appropriate nursing response to ptspain, & to facilitate improved outcomes (fewer complications, shorter hospital stays,improved quality of life)

Characteristics of pain generally assessed include:o Pts verbalization & description of paino Duration of paino Location of paino Quantity & intensity of paino Quality of the paino Chronology of paino Aggravating factors


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o Alleviating factorso Physiologic indicators of paino Behavioral responseso Effect of pain experience on activities & lifestyle

Comprehensive pain assessment must also include discussion of pts expectations for painrelief pt &a

foundations final blueprint

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