NUR 242 Exam 5

Home oxygen therapy

- Indications - Arterial partial pressure (PaO2) of 55 mm Hg or less -or- - Arterial oxgen saturation (SaO2) of 88% or less on room air at rest, on exertion, or with exercise - Administered via nasal cannula or face mask - T tube or tracheostomy collar used if patient has a permanent tracheostomy - Beneficial effects for patients with chronic cardiopulmonary disease •Home oxygen therapy improves patients' exercise tolerance and fatigue levels and in some situations assists in the management of dyspnea. •[Review Skill 41-4, Using Home Oxygen Equipment, •Three types of oxygen delivery systems are used: compressed gas cylinders, liquid oxygen, and oxygen concentrators. Before placing a certain delivery system in a home, assess the advantages and disadvantages of each type, along with the patient's needs and community resources. •[Review Table 41-8, Home Oxygen Systems, •In the home, the major consideration is the oxygen delivery source. •Patients and their family caregivers need extensive teaching to be able to manage oxygen therapy efficiently and safely. Teach the patient and family about home oxygen delivery (i.e., oxygen safety, regulation of the amount of oxygen, and how to use the prescribed home oxygen delivery system) to ensure their ability to maintain the oxygen delivery system. •The home health nurse coordinates the efforts of the patient and family, home respiratory therapist, and home oxygen equipment vendor. The social worker usually assists initially with arranging for the home care nurse and oxygen vendor.

Nursing Diagnosis (o2)

-Activity intolerance -Decreased cardiac output -Fatigue -Impaired gas exchange -Impaired verbal communication -Ineffective airway clearance -Risk for aspiration -Ineffective breathing pattern -Ineffective health maintenance •Based upon your assessment, you develop nursing diagnoses for patients with oxygenation alterations by clustering specific defining characteristics and identifying the related etiology. •[Review Box 41-5, Nursing Diagnostic Process: Impaired Gas Exchange Related to Decreased Lung Expansion, •The defining characteristics for diagnoses related to oxygenation can be similar. •A closer review of assessment findings as well as an analysis of the patient's history will help you clarify and select the correct diagnosis. •The clustered defining characteristics and related factor must support the nursing diagnosis.

Assessment cont.

-Ask about patient's priorities and expectations -Establish realistic, short-term outcomes that build to a larger goal -Educate the patient on the opportunities for individual, group, or telephone counseling and identifying a social support system •Identifying their expectations involves patients in the decision-making process and helps them participate in their care. •Educating the patient on the opportunities for individual, group, or telephone counseling and identifying a social support system give more individual choices when developing the cessation plan. After this is determined, the various nicotine and nonnicotine medications for treatment of tobacco dependence can be discussed to find one that may fit the patient's lifestyle. A combination of counseling and medication is more effective than either alone. •Remember that your goals and expectations do not always coincide with those of your patient. By addressing a patient's concerns and expectations, you establish a relationship that addresses other health care goals and expected outcomes. Knowing your patients' mindsets and respecting their wishes goes a long way in helping them make significant beneficial lifestyle changes.

Assistive devices

-Assess the client for actual/potential difficulty with communication and speech/vision/hearing problems -Assess the client's use of assistive devices -Assist client to compensate for physical and sensory impairment -Manage the client who uses assistive devices or prostheses -Evaluate the correct use of assistive devices by the client

Nursing Process: Assessment (cont)

-Body alignment *Sitting •Characteristics of correct body alignment for the sitting patient include the following: •The head is erect, and the neck and vertebral column are in straight alignment. •Body weight is distributed evenly on the buttocks and thighs. •The thighs are parallel and in a horizontal plane. •Both feet are supported on the floor, and the ankles are flexed comfortably. With patients of short stature, use a footstool to ensure that ankles are flexed comfortably. •A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee. This space ensures that no pressure is present on the popliteal artery or nerve to decrease circulation or impair nerve function. •The patient's forearms are supported on the armrest, in the lap, or on a table in front of the chair. •It is particularly important to assess alignment when sitting if the patient has muscle weakness, muscle paralysis, or nerve damage. Patients who have these problems have diminished sensation in the affected area and are unable to perceive pressure or decreased circulation. Proper alignment while sitting reduces the risk of musculoskeletal system damage in such a patient. The patient with severe respiratory disease sometimes assumes a posture of leaning on the table in front of the chair in an attempt to breathe more easily. This is called orthopnea.

Nursing Process: Assessment continued

-Body alignment *standing •Characteristics of correct body alignment for the standing patient include the following: •The head is erect and midline. •When observed posteriorly, the shoulders and hips are straight and parallel. •When observed posteriorly, the vertebral column is straight. •When observed laterally, the head is erect, and the spinal curves are aligned in a reversed S pattern. The cervical vertebrae are anteriorly convex, the thoracic vertebrae are posteriorly convex, and the lumbar vertebrae are anteriorly convex. •When observed laterally, the abdomen is comfortably tucked in, and the knees and ankles are slightly flexed. The person appears comfortable and does not seem conscious of the flexion of knees or ankles. •The arms hang comfortably at the sides. •The feet are slightly apart to achieve a base of support, and the toes are pointed forward. •When viewing the patient from behind, the center of gravity is at the midline, and the line of gravity extends from the middle of the forehead to a midpoint between the feet. Laterally, the line of gravity runs vertically from the middle of the skull to the posterior third of the foot.

Assistive Devices for Walking

-Canes -Keep cane on stronger side of the body -Place cane forward 6 to 10 inches, keeping body weight on both legs -Weaker leg is moved forward, divide weight between cane and stronger leg -Stronger leg is advanced past cane; divide weight between cane and weaker leg •Canes are lightweight, easily movable devices made of wood or metal. They provide less support than a walker and are less stable. A person's cane length is equal to the distance between the greater trochanter and the floor. •Two common types of canes are the single straight-legged cane and the quad cane. •The single straight-legged cane is more common and is used to support and balance a patient with decreased leg strength. •The quad cane provides the most support and is used when there is partial or complete leg paralysis or some hemiplegia. •Have the patient keep the cane on the stronger side of the body. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is moved forward to the cane so body weight is divided between the cane and the stronger leg. The stronger leg is then advanced past the cane so the weaker leg and the body weight are supported by the cane and weaker leg. During walking the patient continually repeats these three steps. •The patient needs to learn that two points of support such as both feet or one foot and the cane are on the floor at all times.

Cardiovascular physiology

-Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in carbon dioxide and low in oxygen) to the right side of the heart and then to the lungs, where it is oxygenated. -Oxygenated blood (blood high in oxygen and low in carbon dioxide) then travels from the lungs to the left side of the heart and the tissues. •The cardiac system delivers oxygen, nutrients, and other substances to the tissues and facilitates the removal of cellular metabolism waste products by way of blood flow through other body systems such as respiratory, digestive, and renal.

Restorative and Continuing Care

-Cardiopulmonary rehabilitation -Controlled physical exercise; nutrition counseling; relaxation and stress management; medications; oxygen; compliance; systemic hydration -Respiratory muscle training -Breathing exercises -Pursed-lip breathing -Diaphragmatic breathing •Cardiopulmonary rehabilitation helps patients achieve and maintain an optimal level of health through controlled physical exercise, nutrition counseling, relaxation and stress-management techniques, and prescribed medications and oxygen. •As physical reconditioning occurs, a patient's complaints of dyspnea, chest pain, fatigue, and activity intolerance decrease. In addition, the patient's anxiety, depression, or somatic concerns often decrease. •The patient and the rehabilitation team define the goals of rehabilitation. •Respiratory muscle training improves muscle strength and endurance, resulting in improved activity tolerance. •Respiratory muscle training prevents respiratory failure in patients with COPD. •One method for respiratory muscle training is the incentive spirometer resistive breathing device (ISRBD). •Patients achieve resistive breathing by placing a resistive breathing device into a volume-dependent incentive spirometer. •Patients achieve muscle training when they use the ISRBD on a scheduled routine. •Breathing exercises include techniques to improve ventilation and oxygenation. The three basic techniques are deep-breathing and coughing exercises, pursed-lip breathing, and diaphragmatic breathing. Deep-breathing and coughing exercises, previously discussed, are routine interventions used by postoperative patients. •Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. While sitting up, instruct the patient to take a deep breath and exhale slowly through pursed lips as if blowing through a straw. Have him or her blow through a straw into a glass of water to learn the technique. •Diaphragmatic breathing is useful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control. The exercise improves efficiency of breathing by decreasing air trapping and reducing the WOB.

Restoration of cardiopulmonary functioning

-Cardiopulmonary resuscitation (CPR) 1. Circulation 2. Airway 3. Breathing -Defibrillation (automatic external defibrillator [AED]) •If a patient's hypoxia is severe and prolonged, cardiac arrest results. A cardiac arrest is a sudden cessation of cardiac output and circulation. When this occurs, oxygen is not delivered to tissues, carbon dioxide is not transported from tissues, tissue metabolism becomes anaerobic, and metabolic and respiratory acidosis occurs. Permanent heart, brain, and other tissue damage occur within 4 to 6 minutes. •The previous ABC (establish an Airway, initiate Breathing, and maintain Circulation) of cardiopulmonary resuscitation (CPR) is changed to CAB (Chest compression, Airway, Breathing) for adults and pediatric patients (excluding newborns). •In adults (the majority of cardiac arrests) the critical initial elements found to be essential for survival were chest compressions and early defibrillation. •Ventilation is done after the first cycle of 30 chest compressions. In addition, the American Heart Association (AHA) (2014) has set a goal for hospitals to deliver the first electrical shock to patients in ventricular fibrillation in less than 2 minutes. •Defibrillation by automatic external defibrillator (AED) is needed to stop an abnormal heart rhythm, and AEDs are now available in public places such as schools, airports, and workplaces.

Maintenance and Promotion of Lung Expansion (cont)

-Chest tube -Pneumothorax -Hemothorax -Special considerations •A catheter inserted through the thorax to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures. •Chest tubes are common after chest surgery and chest trauma and are used for treatment of pneumothorax or hemothorax to promote lung reexpansion. •[Review Skill 41-3, Care of Patients with Chest Tubes, with students.] •A pneumothorax is a collection of air in the pleural space. The loss of negative intrapleural pressure causes the lung to collapse. There are a variety of causes for a pneumothorax. A secondary pneumothorax can occur as a result of chest trauma. •Spontaneous (primary) pneumothorax is a genetic condition that occurs unexpectedly in healthy individuals who develop blisterlike formations (blebs) on the visceral pleura, usually on the apex of the lungs. The blebs can rupture during sleep or exercise. •A hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleura, usually as a result of trauma. It produces a counter pressure and prevents the lung from full expansion. A rupture of small blood vessels from inflammatory processes such as pneumonia or TB can cause a hemothorax. In addition to pain and dyspnea, signs and symptoms of shock develop if blood loss is severe. •A variety of chest tubes are available to drain air or excess fluid from the pleural space to relieve respiratory distress. A small-bore chest tube (12 to 20 Fr) is used to remove a small amount of air, and a larger-bore chest tube is used to remove large amounts of fluid or blood and large amounts of air. •After a chest tube is inserted, it is attached to a drainage system. A traditional chest drainage unit (CDU) has three chambers for collection, water seal, and suction control. This unit can drain a large amount of both fluid and air. •The simplest closed drainage system is the single chamber unit. The chamber serves as a fluid collector and a water seal. •The use of two chambers permits any fluid to flow into the collection chamber as air flows into the water-seal chamber. Fluctuations in the water-seal tube are still anticipated. Two chambers allow for more accurate measurement of chest drainage and are used when larger amounts of drainage are expected. •When a volume of air or fluid needs to be evacuated with controlled suction, all three chambers are used. Mark the suction control with centimeter readings to adjust the amount of suction. Usually 15 to 20 cm of water is used for adults (Carroll, 2015). This means that the chamber is filled with sterile water to the 15- or 20-cm water level. •Keep a chest tube system closed and below the chest. •The tube should be secured to the chest wall. Watch for slow, steady bubbling in the suction-control chamber and keep it filled with sterile water at the prescribed level. Make sure that the water-seal chamber is filled to the manufacturer-specified level and watch for fluctuation (tidaling) of the fluid level to ensure that the chest tube and system are working. •A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. •Report any unexpected cloudy or bloody drainage. Do not let the tubing kink or loop, and ideally it should lie horizontally across the bed or chair before dropping vertically into the drainage device. •Make sure that he or she is frequently repositioned and ambulated if not contraindicated. Routinely assess respiratory rate, breath sounds, SpO2 levels, and the insertion site for subcutaneous emphysema. •Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. •Chest tubes are not routinely stripped or milked to move clots or increase chest tube drainage. •Handle the chest drainage unit carefully and maintain the drainage device below the patient's chest. •Removal of chest tubes requires patient preparation. The most frequent sensations reported by patients during chest tube removal include burning, pain, and a pulling sensation.

Nursing knowledge base

-Comprehensive safe patient-handling programs -Ergonomics assessment protocol -Patient assessment criteria -Algorithms for patient handling and movement -Special equipment -Back injury resource nurses -After-action reviews -No-lift policy -Safe patient handling -Transfer techniques

Factors influencing activity and exercise

-Developmental changes -Infants through school-age children *Infants spine is flexed and lacks anteroposterior curves *Toddler's posture is awkward because of the slight swayback and protruding abdomen *By the third year, the body is slimmer, taller, and better balanced *Adolescence begins with a big growth spurt *Changes in the adulthood occur mainly in pregnant women *Older adult loses total bone mass -Adolescence -Young to middle-age adults -Older adults -Behavioral aspects -Patients are more likely to incorporate an exercise program if those around them are supportive

Alterations in cardiac functioning

-Disturbances in conduction -Electrical impulses that do not originate from the SA node cause conduction disturbances -Dysrhythmias -Atrial fibrillation -Paroxysmal supraventricular tachycardia -Ventricular dysrhythmias •Illnesses and conditions that affect cardiac rate and rhythm, strength of contraction, and blood flow through the chamber and peripheral circulation will cause altered cardiac functioning. •Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. •Rhythm disturbances are called dysrhythmias, meaning a deviation from the normal sinus heart rhythm. •Dysrhythmias occur as a primary conduction disturbance such as in response to ischemia; valvular abnormality; anxiety; drug toxicity; caffeine, alcohol, or tobacco use; or as a complication of acid-base or electrolyte imbalance. •Dysrhythmias are classified by cardiac response and site of impulse origin. •Cardiac response is tachycardia (greater than 100 beats/min), bradycardia (less than 60 beats/min), a premature (early) beat, or a blocked (delayed or absent) beat. •Tachydysrhythmias and bradydysrhythmias lower cardiac output and blood pressure. Tachydysrhythmias reduce cardiac output by decreasing diastolic filling time. •Bradydysrhythmias lower cardiac output because of the decreased heart rate. •Atrial fibrillation is a common dysrhythmia in older adults. •Abnormal impulses originating above the ventricles are supraventricular dysrhythmias. The abnormality on the waveform is the configuration and placement of the P wave. Ventricular conduction usually remains normal, and there is a normal QRS complex. •Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. •It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. •Ventricular dysrhythmias represent an ectopic site of impulse formation within the ventricles. •It is ectopic in that the impulse originates in the ventricle, not the SA node. •The configuration of the QRS complex is usually widened and bizarre. P waves are not always present; often they are buried in the QRS complex. •Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death.

Planning (o2)

-During planning, use critical thinking skills to synthesize information from multiple sources -Goals and outcomes -Realistic expectations, goals, and measurable outcomes -Setting priorities -Teamwork and collaboration •Critical thinking ensures that your plan of care integrates individualized patient needs. Professional standards are especially important to consider when developing a plan of care. These standards often establish scientifically proven guidelines for selecting effective nursing interventions. •Patients with impaired oxygenation require a nursing care plan directed toward meeting actual or potential oxygenation needs. Allow patients to collaborate in setting relevant goals of care. Develop individual outcomes based on patient-centered goals. •Often a patient with cardiopulmonary disease has multiple nursing diagnoses. In this case, identify when goals or outcomes apply to more than one diagnosis. The presence of multiple diagnoses also makes priority setting a critical activity. •A patient's level of health, age, lifestyle, and environmental risks affect the level of tissue oxygenation. Patients with severe impairments in oxygenation frequently require nursing interventions in multiple areas. Consider which goal is the most important to achieve while the patient is in the hospital or primary care setting. •Both you and the patient need to focus on the same goal and expected outcomes. •Be sure to respect the patient's preferences for his or her degree of active engagement in the care process. •The time spent with a patient in any setting is limited. Therefore collaborate with family members, colleagues, and other specialists to achieve the established goals and expected outcomes. •Communicating among everyone on the patient's health care team and recognizing everyone's contributions in achieving the health care goals for the patient are imperative.

Implementation: Acute Care

-Dyspnea management -Airway maintenance -Mobilization of pulmonary secretions -Hydration -Humidification -Nebulization -Coughing and deep-breathing techniques •Dyspnea is difficult to measure and treat. Treatments are individualized, and more than one therapy can be implemented. •Oxygen therapy reduces dyspnea associated with exercise and hypoxemia. •Airway maintenance requires adequate hydration to prevent thick, tenacious secretions. Proper coughing techniques remove secretions and keep the airway open. A variety of interventions, such as suctioning, chest physiotherapy, and nebulizer therapy, assist patients in managing alterations in airway clearance. •Nursing interventions promoting removal of pulmonary secretions assist in achieving and maintaining a clear airway and help to promote lung expansion and gas exchange. •Maintenance of adequate systemic hydration keeps mucociliary clearance normal. •Humidification is the process of adding water to gas. Humidification is necessary for patients receiving oxygen therapy at greater than 4 L/min (check agency protocol). It might be necessary to add humidification at lower oxygen concentrations if the environment is dry and arid. Bubbling oxygen through water adds humidity to the oxygen delivered to the upper airways. •[Review Skill 41-4, Using Home Oxygen Equipment, with students.] •Nebulization adds moisture or medications to inspired air by mixing particles of varying sizes with the air. •Coughing is effective for maintaining a patent airway. Directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate. •With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then the patient opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. •The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice the patient inhales more air and is able to progress to the cascade cough. •The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. •Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs. •Chest physiotherapy is a group of therapies used to mobilize pulmonary secretions. These include postural drainage, chest percussion, and vibration. You will want to work collaboratively with respiratory therapists when using these techniques.

Artificial Airways cont.

-Endotracheal and tracheal airways -Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions -Tracheostomy -Long-term assistance, surgical incision made into trachea •A physician or specially trained clinician inserts the ET tube. The tube is passed through the patient's mouth, past the pharynx, and into the trachea. It is generally removed within 14 days; however, it is sometimes used for a longer period of time if the patient is still showing progress toward weaning from invasive mechanical ventilation and extubation. •If a patient requires long-term assistance from an artificial airway, a tracheostomy is considered. •A surgical incision is made into the trachea, and a short artificial airway (a tracheostomy tube) is inserted. •Most tracheostomies have a small plastic inner tube that fits inside a larger one (the inner cannula). •The most common complication of a tracheostomy tube is partial or total airway obstruction caused by buildup of respiratory secretions. If this occurs, the inner tube can be removed and cleaned or replaced with a temporary spare inner tube that should be kept at the patient's bedside. •Keep tracheal dilators at the bedside to have available for emergency tube replacement or reinsertion. •Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. •Tracheostomy suctioning should be done as often as necessary to clear secretions.

Structure and Function (o2)

-Gases move into and out of the lungs through pressure changes. -The diaphragm and external intercostal muscles contract to create a negative pleural pressure and increase the size of the thorax for inspiration. •Conditions or diseases that change the structure and function of the pulmonary system alter respiration. •The respiratory muscles, pleural space, lungs, and alveoli are essential for ventilation, perfusion, and exchange of respiratory gases. •Intrapleural pressure is negative, or less than atmospheric pressure, which is 760 mm Hg at sea level. For air to flow into the lungs, intrapleural pressure becomes more negative, setting up a pressure gradient between the atmosphere and the alveoli. •Relaxation of the diaphragm and contraction of the internal intercostal muscles allow air to escape from the lungs.

Implementation (activity)

-Health promotion -Teach patients to calculate maximum heart rate. -Body mechanics -Acute care -Musculoskeletal system -Joint mobility -Walking •Health promotion •Before starting an exercise program, teach patients to calculate their maximum heart rate by subtracting their current age in years from 220 and then to obtain their target heart rate by taking 60% to 90% of the maximum, depending on their health care provider's recommendation. •The U.S. Occupational Safety and Health Administration released federal ergonomic guidelines to prevent musculoskeletal injuries in the workplace. Half of all back pain is associated with manual lifting tasks. •Coordinated musculoskeletal activity is necessary when positioning and transferring patients. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. •Before lifting, assess the weight to be lifted, determine the assistance needed, and evaluate available resources. Use safe patient-handling equipment when the patient is unable to assist in transfer. •Acute care •Encourage patients who are hospitalized to do stretching and isometric exercises, active range-of-motion (ROM) exercises, or low-intensity walking, depending on their condition. When patients cannot participate in active ROM, maintain joint mobility and prevent contractures by implementing passive ROM into the plan of care. •Help maintain the musculoskeletal system during acute care by encouraging the use of stretching and isometric exercises. •The easiest intervention to maintain or improve joint mobility for patients and one that can be coordinated with other activities is the use of ROM exercises. Joints that are not moved periodically are at risk for contractures, a permanent shortening of a muscle followed by the eventual shortening of associated ligaments and tendons. Walking increases joint mobility. Measure distances walked in feet or yards. Illness or trauma usually reduces activity tolerance, resulting in the need for assistance with walking or the use of mechanical devices such as crutches, canes, or walkers. Patients who increase their walking distance prior to discharge have improvement in their ability to independently perform basic activities of daily living, increase activity tolerance, and have a faster recovery after surgery

Implementation cont (activity)

-Helping a patient to walk -Assess patient's ability to walk safely -Evaluate environment for safety -Assist patient to sitting position, dangle patient's legs over the side of the bed 1 to 2 minutes before standing -Provide support at the waist so the patient's center of gravity remains midline (gait belt) -Restorative and continuing care -Implement strategies to assist patient with ADLs •Assess the patient's activity tolerance, strength, coordination, baseline vital signs, and balance to determine the type of assistance needed. Also assess the patient's orientation and determine if there are any signs of distress. Postpone walking if you determine the patient cannot safely walk. Evaluate the environment for safety before ambulation; this includes the removal of obstacles, a clean and dry floor, and the identification of rest points in case the patient's activity tolerance becomes less than expected or if the patient becomes dizzy. Also have the patient wear supportive, nonskid shoes. •Help the patient to a position of sitting at the side of the bed and dangling the legs over the side of the bed for 1 to 2 minutes before standing. Some patients experience orthostatic hypotension, a drop in blood pressure that occurs when they change from a horizontal to a vertical position. Dangling a patient's legs before standing is an intermediate step that allows assessment of the patient before changing positions to maintain safety and prevent injury to the patient. •Several methods are used to assist a patient with ambulation. Provide support at the waist so the patient's center of gravity remains midline. This is achieved with the use of a gait belt. A gait belt encircles the patient's waist and may have handles attached for the nurse to hold while the patient ambulates. Restorative and continuing care involves implementing activity and exercise strategies to assist the patient with ADLs after acute care is no longer needed. Restorative and continuing care also includes activities and exercises that restore and promote optimal functioning in patients with specific chronic illnesses such as coronary heart disease (CHD), hypertension, chronic obstructive pulmonary disease (COPD), and diabetes mellitus •If the patient has a fainting (syncope) episode or begins to fall, assume a wide base of support with one foot in front of the other, thus supporting the patient's body weight (A). Extend one leg, let the patient slide against the leg, and gently lower the patient to the floor, protecting the head (B and C). Practice this technique with a friend or classmate before attempting it in a clinical setting. When the patient attempts to ambulate again, proceed more slowly, monitoring for reports of dizziness, and take the patient's blood pressure before, during, and after ambulation.

Nursing Diagnosis

-Impaired physical mobility -Risk for disuse syndrome -Ineffective airway clearance -Ineffective coping -Impaired urinary elimination -Risk for impaired skin integrity -Social isolation •The two diagnoses most directly related to mobility problems are impaired physical mobility and risk for disuse syndrome. The diagnosis of impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. •Assessment reveals clusters of data that indicate whether a patient is at risk or if an actual problem exists. The clusters of data include defining characteristics that support the diagnostic label and probable cause of the diagnosis. Locating the probable cause of the diagnosis (based on assessment data) is important to planning patient-centered goals and subsequent nursing interventions that will best help the patient. •It is critical that nursing assessment activities identify and cluster defining characteristics that ultimately support the nursing diagnosis selected. •During immobilization some patients experience decreased social interaction and stimuli. These patients frequently use the nurse's call bell to request minor physical attention when their real need is greater socialization. Nursing diagnoses for health needs in developmental areas reflect changes from the patient's normal activities. •Immobility also leads to multiple complications (e.g., renal calculi, DVT, pulmonary emboli, or pneumonia). If these conditions develop, collaborate with the health care provider or nurse practitioner for prescribed therapy to intervene

Assessment (o2)

-In-depth history of a patient's normal and present cardiopulmonary function -Past impairments in circulatory or respiratory functioning -Methods that a patient uses to optimize oxygenation -Review of drug, food, and other allergies -Physical examination -Laboratory and diagnostic tests •Nursing assessment of cardiopulmonary functioning includes an in-depth history of a patient's normal and present cardiopulmonary function, past impairments in circulatory or respiratory functioning, and methods that a patient uses to optimize oxygenation. •The nursing history includes a review of drug, food, and other allergies. •Physical examination of a patient's cardiopulmonary status reveals the extent of existing signs and symptoms. •Utilizing assessment values of pulse oximetry and capnography aide in the assessment of patients with spontaneous breathing, intubated patients, and those patients requiring oxygen therapy or mechanical ventilation. •Pulse oximetry provides an instant feedback about the patient's level of oxygenation. •Capnography, also known as end title CO2 monitoring, provides instant information about the patient's ventilation (how effectively CO2 is being eliminated by the pulmonary system), perfusion (how effectively CO2 is being transport through the vascular system), as well as how effectively CO2 is produced by cellular metabolism. Capnography is measured near the end of exhalation. Finally, a review of laboratory and diagnostic test results provides valuable assessment data.

Diagnostic Tests (o2)

-Many tests used for cardiopulmonary functioning -Blood specimens -X-rays -TB skin testing •[Discuss possible findings in altered oxygenation for each test.] •TB skin test is a simple test and is required for health care workers; restaurant employees; students on entry to school, teachers, and other school employees; prisoners and correctional facility employees; and residents of long-term care facilities. •[Review Box 41-3, Tuberculosis Skin Testing, with students.] •[Review Table 41-3, Cardiopulmonary Diagnostic Blood Studies, Table 41-4, Cardiac Function Diagnostic Tests, and Table 41-5, Ventilation and Oxygenation Diagnostic Studies, with students.] •When reviewing results of pulmonary function studies, be aware of expected variations in patients from different cultures. These changes are caused by structural variations in chest wall size. •[Review Box 41-4, Cultural Aspects of Care: Cultural Impact on Pulmonary Diseases, with students.] •Invasive diagnostic tests such as a thoracentesis are painful. Reduce the patient's anxiety by explaining the thoracentesis procedure and telling the patient what to expect. Be sure that the patient understands the importance of following instructions such as taking a deep breath and holding it when requested and not coughing during the procedure. Provide appropriate pain management before the procedure to reduce the perception of pain. •After any procedure, monitor the patient for signs of changes in cardiopulmonary functioning, such as sudden shortness of breath, pain, oxygen desaturation, and anxiety.

Regulation of Respiration

-Neural regulation -Central nervous system controls the respiratory rate, depth, and rhythm. -Cerebral cortex regulates the voluntary control of respiration. -Chemical regulation -Maintains the rate and depth of respirations based on changes in the blood concentrations of CO2 and O2, and in hydrogen ion concentration (pH). -Chemoreceptors sense changes in the chemical content and stimulate neural regulators to adjust. •Regulation of respiration is necessary to ensure sufficient oxygen intake and carbon dioxide elimination to meet the demands of the body (e.g., during exercise, infection, or pregnancy). Neural and chemical regulators control the process of respiration. •Neural regulation includes central nervous system control of respiratory rate, depth, and rhythm. The cerebral cortex regulates the voluntary control of respiration by delivering impulses to the respiratory motor neurons by way of the spinal cord. •Chemical regulation maintains the appropriate rate and depth of respirations based on changes in carbon dioxide (CO2), oxygen (O2), and hydrogen ion (H+) concentrations (pH) in the blood. •Changes in levels of O2, CO2, and H (pH) stimulate chemoreceptors located in the medulla, aortic body, and carotid body, which in turn stimulate neural regulators to adjust the rate and depth of ventilation to maintain normal arterial blood gas levels.

Maintenance and Promotion of Lung Expansion cont cont.

-Noninvasive ventilation -Purpose is to maintain a positive airway pressure and improve alveolar ventilation -Continuous positive airway pressure (CPAP) -Bilevel positive airway pressure (BiPAP) •Noninvasive positive-pressure ventilation (NPPV) is used to prevent using invasive artificial airways (ET tube or tracheostomy) in patients with acute respiratory failure, cardiogenic pulmonary edema, or exacerbation of COPD. It has also been used following extubation of an ET tube. •Continuous positive airway pressure (CPAP) treats patients with obstructive sleep apnea, patients with heart failure, and preterm infants with underdeveloped lungs. Equipment includes a mask that fits over the nose or both nose and mouth and a CPAP machine that delivers air to the mask The smallest mask with the proper fit is the most effective. Because straps hold the mask in place, it is important to assess for excess pressure on the patient's face or nose that could cause skin breakdown or necrosis. •The mask should have enough slack to allow one to two fingers between the straps and the face. •The most common mode of support is bilevel positive airway pressure (BiPAP) that provides both inspiratory positive airway pressure (IPAP) and expiratory airway pressure (EPAP), also known as positive end-expiratory pressure (PEEP). The difference between these two pressures indicates the amount of pressure support a patient needs. •During inhalation the positive pressure increases the patient's tidal volume and alveolar ventilation. The pressure support decreases when the patient exhales, allowing for easier exhalation. •Complications of noninvasive ventilation include facial and nasal injury and skin breakdown, dry mucous membranes and thick secretions, and aspiration of gastric contents if vomiting occurs during ventilation. Complications avoided by noninvasive ventilation are VAP, sinusitis, and effects of large-dose sedative agents. Use of noninvasive ventilation results in shorter intensive care unit (ICU) and hospital stays (Soo Hoo, 2014). Perform good oral hygiene every few hours while a patient is on BiPAP to relieve dryness.

Conduction system cont.

-Normal sinus rhythm (NSR) -Originates at the SA node, follows normal sequence through conduction system -P wave -PR interval -QRS complex -QT interval •An electrocardiogram (ECG) reflects the electrical activity of the conduction system. An ECG monitors the regularity and path of the electrical impulse through the conduction system; however, it does not reflect the muscular work of the heart. The normal sequence on the ECG is called the normal sinus rhythm (NSR). •NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system. •The P wave represents the electrical conduction through both atria. Atrial contraction follows the P wave. •The PR interval represents the impulse travel time from the SA node through the AV node, through the bundle of His, and to the Purkinje fibers. The normal length for the PR interval is 0.12 to 0.2 second. An increase in the time greater than 0.2 second indicates a block in the impulse transmission through the AV node; whereas a decrease, less than 0.12 second, indicates the initiation of the electrical impulse from a source other than the SA node. •The QRS complex indicates that the electrical impulse traveled through the ventricles. Normal QRS duration is 0.06 to 0.1 second. An increase in QRS duration indicates a delay in conduction time through the ventricles. Ventricular contraction usually follows the QRS complex. •The QT interval represents the time needed for ventricular depolarization and repolarization. The normal QT interval is 0.12 to 0.42 second. This interval varies inversely with changes in heart rate. Changes in electrolyte values such as hypocalcemia or therapy with drugs such as disopyramide (Norpace) or amiodarone (Cordarone) increase the QT interval. Shortening of the QT interval occurs with digitalis therapy, hyperkalemia, and hypercalcemia.

Artificial Airways

-Oral airway -Prevents obstruction of the trachea by displacement of the tongue into the oropharynx •Airway maintenance may require use of artificial airways and suctioning. •An artificial airway is used for a patient with a decreased level of consciousness or an airway obstruction and aids in removal of tracheobronchial secretions. •The presence of an artificial airway places a patient at high risk for infection and airway injury. Use clean technique for oral airways, but use sterile technique in caring for and maintaining endotracheal and tracheal airways to prevent health care-associated infections (HAIs). Artificial airways need to stay in the correct position to prevent airway damage. •[Review Skill 41-2, Care of an Artificial Airway, •The oral airway, the simplest type of artificial airway, prevents obstruction of the trachea by displacement of the tongue into the oropharynx. •The oral airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position. Use the correct-size airway. Determine the proper oral airway size by measuring the distance from the corner of the mouth to the angle of the jaw just below the ear. The length is equal to the distance from the flange of the airway to the tip. If the airway is too small, the tongue does not stay in the anterior portion of the mouth; if the airway is too large, it forces the tongue toward the epiglottis and obstructs the airway. •Insert the airway by turning the curve of the airway toward the cheek and placing it over the tongue. When the airway is in the oropharynx, turn it so the opening points downward. Correctly placed, the airway moves the tongue forward away from the oropharynx, and the flange (e.g., the flat portion of the airway) rests against the patient's teeth. Incorrect insertion merely forces the tongue back into the oropharynx.

Implementation: Suctioning Techniques

-Oropharyngeal and nasopharyngeal -Used when the patient can cough effectively but is not able to clear secretions -Orotracheal and nasotracheal -Used when the patient is unable to manage secretions by coughing and does not have an artificial airway -Tracheal -Used with an artificial airway •Suctioning is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures. Suctioning techniques include oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and suctioning of an artificial airway (discussed on a later slide). •Each type of suctioning requires the use of a round-tipped, flexible catheter with holes on the sides and end of the catheter. When suctioning, you apply negative pressures (not greater than 150 mm Hg) during withdrawal of the catheter, never on insertion. •Oropharyngeal and Nasopharyngeal Suctioning •Apply suction after a patient has coughed. •Once the pulmonary secretions decrease and a patient is less fatigued, he or she is then able to expectorate or swallow the mucus, and suctioning is no longer necessary. •Orotracheal and Nasotracheal Suctioning •You pass a sterile catheter through the mouth or nose into the trachea. The nose is the preferred route because stimulation of the gag reflex is minimal. •The entire procedure from catheter passage to its removal is done quickly, lasting no longer than 10 seconds. •Tracheal Suctioning •The size of a catheter should be as small as possible but large enough to remove secretions. Recommendation is about half the internal diameter of the endotracheal (ET) tube (AARC, 2010a). Never apply suction pressure while inserting the catheter to avoid traumatizing the lung mucosa. Once you insert a catheter the necessary distance, maintain suction pressure between 120 and 150 mm Hg (AARC, 2010a) as you withdraw. Apply suction intermittently only while withdrawing the catheter. Rotating the catheter enhances removal of secretions that have adhered to the sides of the ET tube. •You will learn various suctioning techniques in the nursing skills lab. •You will differentiate between when to use sterile and when to use clean techniques. If you suction the patient too much, he or she can be at risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs.

Scientific Knowledge base (oxygenation)

-Oxygen is needed to sustain life. -Blood is oxygenated through the mechanisms of ventilation, perfusion, and transport of respiratory gases. -Neural and chemical regulators control the rate and depth of respiration in response to changing tissue oxygen demands. -The cardiovascular system provides the transport mechanisms to distribute oxygen to cells and tissues of the body.

Safety guidelines

-Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound hypoxia. -Perform tracheal suctioning before pharyngeal suctioning whenever possible. -Use caution when suctioning patients with a head injury. -The routine use of normal saline instillation into the airway before ET and tracheostomy suctioning is not recommended. -Check your institutional policy before stripping or milking chest tubes. -The most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. -Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy. •Note that the most serious tracheostomy complication is airway obstruction, which can result in cardiac arrest. •Patients with COPD who are breathing spontaneously should never receive high levels of oxygen therapy because this may result in a decreased stimulus to breathe. Do not administer oxygen at more than 2 L/min unless a health care provider's order is obtained.

Factors affecting oxygenation

-Physiological factors -Decreased oxygen-carrying capacity -Hypovolemia -Decreased inspired oxygen concentration -Increased metabolic rate -Conditions affecting chest wall movement -Pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities, trauma, neuromuscular disease, CNS alterations -Influences of chronic diseases •Any condition that affects cardiopulmonary functioning directly affects the body's ability to meet oxygen demands. •Hemoglobin carries the majority of oxygen to tissues. Anemia and inhalation of toxic substances decrease the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. Anemia (e.g., a lower-than-normal hemoglobin level) is a result of decreased hemoglobin production, increased red blood cell destruction, and/or blood loss. •Oxygenation decreases as a secondary effect with anemia. The physiological response to chronic hypoxemia is the development of increased red blood cells (polycythemia). This is the adaptive response of the body to increase the amount of hemoglobin and the available oxygen-binding sites. •Carbon monoxide (CO) is the most common toxic inhalant decreasing the oxygen-carrying capacity of blood. In CO toxicity hemoglobin strongly binds with CO, creating a functional anemia. Because of the strength of the bond, CO does not easily dissociate from hemoglobin, making hemoglobin unavailable for oxygen transport. •Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume, or hypovolemia. Decreased circulating blood volume results in hypoxia to body tissues. With significant fluid loss, the body tries to adapt by peripheral vasoconstriction and increasing the heart rate to increase the volume of blood returned to the heart, thus increasing the cardiac output. •With the decline of the concentration of inspired oxygen, the oxygen-carrying capacity of the blood decreases. Decreases in the fraction of inspired oxygen concentration (FiO2) are caused by upper or lower airway obstruction, which limits delivery of inspired oxygen to alveoli; decreased environmental oxygen (at high altitudes); or hypoventilation (occurs in drug overdoses). •Increased metabolic activity increases oxygen demand. The level of oxygenation declines when body systems are unable to meet this demand. •When fever persists, the metabolic rate remains high, and the body begins to break down protein stores. This causes muscle wasting and decreased muscle mass, including respiratory muscles such as the diaphragm and intercostal muscles. •The body attempts to adapt to the increased carbon dioxide levels by increasing the rate and depth of respiration. The patient's WOB increases, and the patient eventually displays signs and symptoms of hypoxemia. Patients with pulmonary diseases are at greater risk for hypoxemia. •Oxygenation decreases as a direct consequence of chronic lung disease. Changes in the anteroposterior diameter of the chest wall (barrel chest) occur because of overuse of accessory muscles and air trapping in emphysema. The diaphragm is flattened, and the lung fields are over distended, resulting in varying degrees of hypoxemia and/or hypercapnia. •name some nervous system diseases that may affect breathing. Answers may include myasthenia gravis, Guillain-Barré, and polio.

Integumentary changes

-Pressure ulcers Inflammation Ischemia -Older adults at greater risk •The changes in metabolism that accompany immobility add to the harmful effect of pressure on the skin in the immobilized patient. This makes immobility a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative. •A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) in tissues. •The ulcer is characterized initially by inflammation and usually forms over a bony prominence. •Ischemia develops when pressure on the skin is greater than pressure inside the small peripheral blood vessels supplying blood to the skin. •Tissue metabolism depends on the supply of oxygen and nutrients to and the elimination of metabolic wastes from the blood. Pressure affects cellular metabolism by decreasing or totally eliminating tissue circulation. •When a patient lies in bed or sits in a chair, the weight of the body is on bony prominences. The longer the pressure is applied, the longer the period of ischemia and therefore the greater the risk of skin breakdown. •The prevalence of pressure ulcers is highest in long-term care facilities with facility-acquired being the highest in adult intensive care units.

Assessment cont. cont. cont. (activity)

-Recumbent position *Place the pt in a lateral position, removing all positioning supports and all but one pillow -Vertebrae: in straight alignment without observable curves -Mobility *Helps determine the patient's coordination and balance while walking, the pt's ability to carry out ADLs, and the pt's ability to participate in an exercise program -Gait *Manner or style of walking, including rhythm, cadence, and speed -Exercise *Exercise conditions the body, improves health, maintains fitness, and provides therapy for correcting a deformity or restoring the overall body to a maximal state of health. -Activity tolerance *necessary when planning physical activity for health promotion and for patients with acute or chronic illness. This assessment provides baseline data about the patient's activity patterns and helps determine which factors (physical, psychological, or motivational) affect activity tolerance.

Structure and function cont. cont. cont.

-Respiratory gas exchange -Diffusion is the process for the exchange of respiratory gases in the alveoli of the lungs and the capillaries of the body tissues •Diffusion of respiratory gases occurs at the alveolar capillary membrane. •The thickness of the membrane affects the rate of diffusion. •Increased thickness of the membrane impedes diffusion because gases take longer to transfer across the membrane. Patients with pulmonary edema, pulmonary infiltrates, or pulmonary effusion have a thickened membrane; resulting in slow diffusion, slow exchange of respiratory gases, and decreased delivery of oxygen to tissues. •Chronic diseases (e.g., emphysema), acute diseases (e.g., pneumothorax), and surgical processes (e.g., lobectomy) often alter the amount of alveolar capillary membrane surface area.

Implementation cont cont. (activity)

-Restoration of activity and chronic illness -Coronary heart disease -Hypertension -Chronic obstructive pulmonary disease -Diabetes mellitus •Nurses design care plans to increase activity and exercise in patients with specific disease conditions and chronic illnesses such as coronary heart disease (CHD), hypertension, COPD, and diabetes mellitus. •Research shows that activity and exercise play a role in secondary prevention or recurrence of CHD. Patients with CHD benefit from exercise and activity in terms of reduced mortality and morbidity, improved quality of life, improved left ventricular function, increased functional capacity, decreased blood lipids and apolipoproteins (protein components of lipoprotein complexes), and psychological well-being. •Exercise reduces systolic and diastolic blood pressure readings. Research shows low- to moderate-intensity aerobic exercise is most effective in lowering blood pressure. •Some patients are fearful of participating in exercise because of the potential for worsening dyspnea. This aversion to physical activity sets up a progressive deconditioning in which minimal physical exertion results in dyspnea. Pulmonary rehabilitation provides a safe environment for monitoring patients' progress. In addition, they receive encouragement and support to increase activity and exercise. •Along with diet, glucose monitoring, and medication, exercise is an important component in the care of patients with diabetes mellitus. Individuals with type 1 diabetes need to exercise because it leads to improved glucose control, cardiovascular fitness, and psychological well-being. Exercise must occur on a regular basis to have the desired continued benefits in the management of blood glucose levels, lipids, and overall quality of life.

Oxygen Masks

-Simple face mask -Used for short-term therapy -Plastic face mask with reservoir bag -Used for higher concentrations of oxygen -Venturi mask •The simple face mask (Fig. 41-16) is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 6 to 12 L/min (35% to 50% oxygen). The mask is contraindicated for patients with carbon dioxide retention because retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask. Be alert to skin breakdown under the mask with long-term use. •A plastic face mask with a reservoir bag is capable of delivering higher concentrations of oxygen. A partial rebreather or nonrebreather mask is a simple mask with a reservoir bag that should be at least one-third to one-half full on inspiration and delivers a flow rate of 10 to 15 L/minute (60-90% oxygen). Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified. •The Venturi mask delivers higher oxygen concentrations of 24% to 60% and usually requires oxygen flow rates of 4 to 12 L/min, depending on the flow-control meter selected.

Assessment cont. (activity)

-Standing -Head: erect, midline -Body: symmetrical -Spine: straight with normal curvatures -Abdomen: tucked -Knees: slightly flexed -Feet: pointed forward and slightly apart -Arms: at sides •The patient's center of gravity is in the midline, and the line of gravity is from the middle of the forehead to a midpoint between the feet. Laterally, the line of gravity runs vertically from the middle of the skull to the posterior third of the foot.

Respiratory Physiology

-The exchange of respiratory gases occurs between the environment and the blood. -Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. -The airways of the lung transfer oxygen from the atmosphere to the alveoli, where the oxygen is exchanged for carbon dioxide. -Through the alveolar capillary membrane, oxygen transfers to the blood, and carbon dioxide transfers from the blood to the alveoli. There are three steps in the process of oxygenation: ventilation, perfusion, and diffusion

Assessment (activity)

-Thoroughly assess: -Body alignment and posture with the patient standing, sitting, or lying down -Normal physiological changes -Deviations related to poor posture, trauma, muscle damage, or nerve dysfunction -Patients' learning needs -Through the patient's eyes -Assess patient expectations concerning activity and exercise

Evaluation (activity)

-Through the patient's eyes -Are the patient's expectations being met? -Patient outcomes -Reassess the patient for signs of improved activity and exercise tolerance. -Make comparisons with baseline measures -Compare actual outcomes with expected outcomes. •For activity and exercise you measure the effectiveness of nursing interventions by the success of meeting the patient's expected outcomes and goals of care. The patient is the only one who knows the effectiveness and benefits of activity and exercise. Continuous evaluation helps to determine whether new or revised therapies are needed and if new nursing diagnoses have developed. •To evaluate the effectiveness of nursing interventions to enhance activity and exercise, make comparisons with baseline measures that include pulse, blood pressure, strength, endurance, and psychological well-being. •Compare actual outcomes with expected outcomes to determine the patient's health status and progression.

Conduction system

-Transmits electrical impulses -Generates impulses needed to initiate the electrical chain of events for a normal heartbeat •The rhythmic relaxation and contraction of the atria and ventricles depend on continuous, organized transmission of electrical impulses. The cardiac conduction system generates and transmits these impulses. •The autonomic nervous system influences the rate of impulse generation and the speed of transmission through the conductive pathway and the strength of atrial and ventricular contractions. •Sympathetic and parasympathetic nerve fibers innervate all parts of the atria and ventricles and the sinoatrial (SA) and atrioventricular (AV) nodes. Sympathetic fibers increase the rate of impulse generation and speed of transmission. The parasympathetic fibers originating from the vagus nerve decrease the rate. •The conduction system originates with the SA node, the "pacemaker" of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate of 60 to 100 cardiac action potentials per minute in an adult at rest. •The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. The AV node mediates impulses between the atria and the ventricles. It assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network.

Blood flow regulation

Cardiac output Amount of blood ejected from the left ventricle each minute Stroke volume Amount of blood ejected from the left ventricle with each contraction Cardiac output (CO) = Stroke volume (SV) × Heart rate (HR) Preload End-diastolic pressure Afterload Resistance to left ventricular ejection •Normal cardiac output is 4 to 6 L/min in the healthy adult at rest. •The circulating volume of blood changes according to the oxygen and metabolic needs of the body. •Stroke volume is affected by preload, afterload, and myocardial contractility all affect stroke volume. •Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. •The ventricles stretch when filling with blood. The more stretch on the ventricular muscle, the greater the contraction and the greater the stroke volume (Starling's law). •In certain clinical situations, medical treatment alters preload and subsequent stroke volumes by changing the amount of circulating blood volume. •If volume is not replaced, preload, stroke volume and the subsequent cardiac output decreases. •Afterload is the resistance to left ventricular ejection. •The heart works harder to overcome the resistance so blood can be fully ejected from the left ventricle. •The diastolic aortic pressure is a good clinical measure of afterload. •In hypertension the afterload increases, making cardiac workload also increase. •Myocardial contractility also affects stroke volume and cardiac output. Poor ventricular contraction decreases the amount of blood ejected. Injury to the myocardial muscle such as an acute MI causes a decrease in myocardial contractility. The myocardium of the older adult is stiffer with a slower ventricular filling rate and prolonged contraction time. •Heart rate affects blood flow because of the relationship between rate and diastolic filling time. With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The heart rate of the older adult is slow to increase under stress, but studies have found that this may be caused more by lack of conditioning than age. Exercise is beneficial in maintaining function at any age.

Implementation: acute care cont.

Chest percussion •Postural drainage is a component of pulmonary hygiene; it consists of drainage, positioning, and turning and is sometimes accompanied by chest percussion and vibration. It improves secretion clearance and oxygenation. Positioning includes most lung segments and helps to drain secretions from specific segments of the lungs and bronchi into the trachea. •[Review Table 41-6, Positions for Postural Drainage, •Chest percussion involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration. Position the hand so the fingers and thumb touch and the hands are cupped. The cupping makes the hand conform to the chest wall while trapping a cushion of air to soften the intensity of the clapping. The procedure should produce a hollow sound and should not be painful. Perform chest percussion by vigorously striking the chest wall alternately with cupped hands. •Percussion is contraindicated in patients with bleeding disorders, osteoporosis, or fractured ribs. •Vibration is a gentle, shaking pressure applied to the chest wall to shake secretions into larger airways. Place a flattened hand or two hands (pressing top and bottom hand into each other to vibrate) firmly on the chest wall over the appropriate segment and tense the muscles of the arm to provide a shaking motion. Have the patient exhale as slowly as possible during the vibration. This technique increases the velocity and turbulence of exhaled air, facilitating secretion removal. Vibration increases the exhalation of trapped air, shakes mucus loose, and induces a cough.

Preoperative Surgical Phase: Nursing Diagnosis

Common nursing diagnoses relevant to the patient having surgery include: •Ineffective airway clearance •Anxiety •Ineffective Coping •Impaired skin integrity •Risk for aspiration •Risk for perioperative positioning injury •Risk for infection •Deficient knowledge (specify) •Impaired physical mobility •Ineffective thermoregulation •Nausea •Acute pain •Delayed surgical recovery •Cluster the patterns of defining characteristics from your assessment to identify nursing diagnoses relevant for a surgical patient. A patient with preexisting health problems is likely to have a variety of risk diagnoses. The nature of the surgery and assessment of the patient's health status provide defining characteristics and risk factors for a number of nursing diagnoses. •[Review Box 50-4, Nursing Diagnostic Process: Fear Related to Knowledge Deficit and Previous Surgical Experience.] •The related factors for each diagnosis establish directions for nursing care that is provided during one or all surgical phases. Preoperative nursing diagnoses allows nursing staff to take precautions and actions so care provided during the intraoperative and postoperative phases is consistent with the patient's needs. •Nursing diagnoses made before surgery also focus on the potential risks a patient may face after surgery. Preventive care is essential to manage the surgical patient effectively.

Assistive Devices for walking (cont.)

Crutches -Measuring for crutches •The axillary crutch is the more common crutch used. •Measurements include the patient's height, the angle of elbow flexion, and the distance between the crutch pad and the axilla. •When crutches are fitted, ensure the length of the crutch is two to three finger widths from the axilla and position the tips approximately 2 inches lateral and 4 to 6 inches anterior to the front of the patient's shoes.

Psychosocial effects

Emotional and behavioral responses -Hostility, giddiness, fear, anxiety Sensory alterations -Altered sleep patterns Changes in coping -Depression, sadness, dejection •Illnesses that result in limited or impaired mobility can cause social isolation and loneliness. •Patients with restricted mobility may have some depression. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. It results from worrying about present and future levels of health, finances, and family needs. •Because immobilization removes the patient from a daily routine, he or she has more time to worry about disability. Worrying quickly increases the patient's depression, causing withdrawal. Withdrawn patients often do not want to participate in their own care.

Diffusion

Exchange of respiratory gases in the alveoli and capillaries •Diffusion is responsible for moving the respiratory gases from one area to another by concentration gradients. For the exchange of respiratory gases to occur, the organs, nerves, and muscles of respiration need to be intact; and the central nervous system needs to be able to regulate the respiratory cycle.

Nursing Knowledge Base (o2)

Factors influencing oxygenation: -Developmental -Lifestyle -Environmental •In addition to physiological factors, multiple developmental, lifestyle, and environmental factors affect patients' oxygenation status. •It is important to recognize these as possible risks or factors that impact health care goals. •Infants and toddlers are at risk for upper respiratory tract infections as a result of frequent exposure to other children, an immature immune system, and exposure to secondhand smoke. •School-age children and adolescents are exposed to respiratory infections and respiratory risk factors such as cigarette smoking or secondhand smoke. •Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. •The cardiac and respiratory systems undergo changes throughout the aging process. The changes are associated with calcification of the heart valves, SA node, and costal cartilages. The arterial system develops atherosclerotic plaques. Osteoporosis leads to changes in the size and shape of the thorax. The trachea and large bronchi become enlarged from calcification of the airways. The alveoli enlarge, decreasing the surface area available for gas exchange. The number of functional cilia is reduced, causing a decrease in the effectiveness of the cough mechanism, putting the older adult at increased risk for respiratory infections •[Review Box 41-1, Focus on Older Adults: Cardiopulmonary Implication in Older Adults, with students.] •Lifestyle modifications are difficult for patients because they often have to change an enjoyable habit such as cigarette smoking or eating certain foods. •Nutrition: Severe obesity decreases lung expansion, and increased body weight increases tissue oxygen demands. The malnourished patient experiences respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. •Dietary practices also influence the prevalence of cardiovascular diseases. •Exercise increases the metabolic activity and oxygen demand of the body. The rate and depth of respiration increase, enabling the person to inhale more oxygen and exhale excess carbon dioxide. •Cigarette smoking and secondhand smoke are associated with a number of diseases, including heart disease, COPD, and lung cancer. •Excessive use of alcohol and other drugs impairs tissue oxygenation in two ways. First, the person who chronically abuses substances often has a poor nutritional intake. With the resultant decrease in intake of iron-rich foods, hemoglobin production declines. Second, excessive use of alcohol and certain other drugs depresses the respiratory center, reducing the rate and depth of respiration and the amount of inhaled oxygen. •The body responds to anxiety and other stresses with an increased rate and depth of respiration. •The environment influences oxygenation. The incidence of pulmonary disease is higher in smoggy, urban areas than in rural areas. Occupational pollutants include asbestos, talcum powder, dust, and airborne fibers.

Developmental changes

Infants, Toddlers, Preschoolers Prolonged immobility delays gross motor skills, intellectual development, or musculoskeletal development Adolescents Delayed in gaining independence and in accomplishing skills Social isolation can occur Adults Physiological systems are at risk Changes in family and social structures Older Adults Decreased physical activity Hormonal changes Bone reabsorption •Developmental changes tend to be associated with immobility in the very young and older adults. •The newborn infant's spine is flexed and lacks the anteroposterior curves of the adult. As the baby grows, musculoskeletal development permits support of weight for standing and walking. Posture is awkward because the head and upper trunk are carried forward. Because body weight is not distributed evenly along a line of gravity, posture is off balance, and falls occur often. •The infant, toddler, or preschooler is usually immobilized because of trauma or the need to correct a congenital skeletal abnormality. Prolonged immobilization delays the child's gross motor skills, intellectual development, or musculoskeletal development. •The adolescent stage usually begins with a tremendous increase in growth. When the activity level is reduced due to trauma, illness, or surgery the, adolescent are often behind peers in gaining independence and accomplishing certain skills such as obtaining a driver's license. Social isolation is a concern for this age group when immobilization occurs. •When periods of prolonged immobility occur in adults, all physiological systems are at risk. In addition, the role of the adult often changes with regard to the family or social structure. Some adults lose their jobs, which affects their self-concept. •A progressive loss of total bone mass occurs with the older adult. Some of the possible causes of this loss include decreased physical activity, hormonal changes, and bone resorption. The effect of bone loss is weaker bones. •Older adults often walk more slowly, take smaller steps, and appear less coordinated. Prescribed medications alter their sense of balance or affect their blood pressure when they change position too quickly, increasing their risk for falls and injuries. The outcomes of a fall include not only possible injury but also hospitalization, loss of independence, psychological effects, and quite possibly death. •Older adults often experience functional status changes secondary to hospitalization and altered mobility status. •Immobilization of older adults increases their physical dependence on others and accelerates functional losses. When providing nursing care for an older adult, encourage the patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility.

Cardiovascular physiology cont cont.

Myocardial pump Two atria and two ventricles As the myocardium stretches, the strength of the subsequent contraction increases (Starling's law). Myocardial blood flow Unidirectional through four valves S1: mitral and tricuspid close S2: aortic and pulmonic close Coronary artery circulation Coronary arteries supply the myocardium with nutrients and remove wastes. Systemic circulation Arteries and veins deliver nutrients and oxygen and remove waste products. •The pumping action of the heart is essential for oxygen delivery. The ventricles fill with blood during diastole and empty during systole. The volume of blood ejected from the ventricles during systole is the stroke volume. Hemorrhage and dehydration cause a decrease in circulating blood volume and a decrease in stroke volume. •Myocardial fibers have contractile properties that allow them to stretch during filling. •As the myocardium stretches, the strength of the subsequent contraction increases; this is known as the Frank-Starling (Starling's) law of the heart. •In the diseased heart (cardiomyopathy or myocardial infarction [MI]), Starling's law does not apply because the increased stretch of the myocardium is beyond the physiological limits of the heart. The subsequent contractile response results in insufficient stroke volume, and blood begins to "back up" in the pulmonary (left heart failure) or systemic (right heart failure) circulation. •To maintain adequate blood flow to the pulmonary and systemic circulation, myocardial blood flow must supply sufficient oxygen and nutrients to the myocardium itself. Blood flow through the heart is unidirectional. The four heart valves ensure this forward blood flow. During ventricular diastole, the atrioventricular (mitral and tricuspid) valves open, and blood flows from the higher-pressure atria into the relaxed ventricles. As systole begins, ventricular pressure rises and closes the mitral and tricuspid valves. Valve closure causes the first heart sound (S1). •During the systolic phase, the semilunar (aortic and pulmonic) valves open, and blood flows from the ventricles into the aorta and pulmonary artery. The mitral and tricuspid valves stay closed during systole, so all of the blood is moved forward into the pulmonary artery and aorta. As the ventricles empty, ventricular pressures decrease, allowing closure of the aortic and pulmonic valves; this causes the second heart sound (S2). Some patients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation. •The coronary circulation is the branch of the systemic circulation that supplies the myocardium with oxygen and nutrients and removes waste. •The coronary arteries fill during ventricular diastole. The left coronary artery has the most abundant blood supply and feeds the more muscular left ventricular myocardium, which does most of the work of the heart. •[Ask students to trace blood from when it leaves the heart to the systemic circulation, to when it returns to the heart.] •The arteries of the systemic circulation deliver nutrients and oxygen to tissues, and the veins remove waste from tissues. Oxygenated blood flows from the left ventricle through the aorta and into large systemic arteries. These arteries branch into smaller arteries, then arterioles, and finally the smallest vessels, the capillaries. Exchange of respiratory gases occurs at the capillary level, where the tissues are oxygenated. Waste products exit the capillary network through venules that join to form veins. These veins become larger and form the vena cava, which carries deoxygenated blood to the right side of the heart, from which it then returns to the pulmonary circulation.

Pathological Influences of Mobility

postural abnormalities, impaired muscle development, damage to CNS, musculoskeletal trauma •Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system and body alignment, balance, and appearance. During assessment observe body alignment and range of motion (ROM). •Postural abnormalities can cause pain, impair alignment or mobility, or both. Knowledge about the characteristics, causes, and treatment of common postural abnormalities is necessary for lifting, transfer, and positioning. •Injury and disease lead to many alterations in musculoskeletal function. •Damage to any component of the central nervous system that regulates voluntary movement results in impaired body alignment, balance, and mobility. •Trauma from a head injury, ischemia from a stroke or brain attack (cerebrovascular accident [CVA]), or bacterial infection such as meningitis can damage the cerebellum or the motor strip in the cerebral cortex. Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. •Trauma to the spinal cord also impairs mobility. •Direct trauma to the musculoskeletal area can cause bruises, contusions, sprains, or fractures. Treatment often includes positioning the fractured bone in proper alignment and immobilizing it to promote healing and restore function. Even this temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness.

urinary elimination changes

urinary stasis, renal calculi, infection •In the upright position urine flows out of the renal pelvis and into the ureters and bladder because of gravitational forces. •When the patient is recumbent or flat, the kidneys and ureters move toward a more level plane. Urine formed by the kidney needs to enter the bladder unaided by gravity. Because the peristaltic contractions of the ureters are insufficient to overcome gravity, the renal pelvis fills before urine enters the ureters. This condition is called urinary stasis and increases the risk of urinary tract infection and renal calculi. •Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. •As the period of immobility continues, fluid intake often diminishes. When combined with other problems such as fever, the risk for dehydration increases. As a result, urinary output declines on or about the fifth or sixth day after immobilization, and the urine becomes concentrated. This concentrated urine increases the risk for calculi formation and infection. •Inappropriate perineal care after bowel movements, particularly in women, increases the risk of urinary tract contamination by Escherichia coli bacteria. Another cause of urinary tract infections in immobilized patients is the use of an indwelling urinary catheter.

Structure and Function cont. x5

§Oxygen transport §The oxygen transport system consists of the lungs and cardiovascular system §Carbon dioxide transport §Carbon dioxide, a product of cellular metabolism, diffuses into red blood cells and is rapidly hydrated into carbonic acid (H2CO3) §The carbonic acid then dissociates into hydrogen (H) and bicarbonate (HCO3-) ions §Hemoglobin buffers the hydrogen ion, the (HCO3-) diffuses into the plasma •Delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs and tissues (perfusion), rate of diffusion, and oxygen-carrying capacity. •Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the ability of hemoglobin to bind with oxygen. •Hemoglobin, which is a carrier for oxygen and carbon dioxide, transports most oxygen (approximately 97%). •The hemoglobin molecule combines with oxygen to form oxyhemoglobin. •The formation of oxyhemoglobin is easily reversible, allowing hemoglobin and oxygen to dissociate (deoxyhemoglobin), which frees oxygen to enter tissues. •Reduced hemoglobin (deoxyhemoglobin) combines with carbon dioxide, and the venous blood transports the majority of carbon dioxide back to the lungs to be exhaled.

Crutch walking on stairs: descending stairs

•A three-phase sequence is also used to descend the stairs. The patient transfers body weight to the unaffected leg. The crutches are placed on the stairs, and the patient begins to transfer body weight to the crutches, moving the affected leg forward. Finally, the unaffected leg is moved to the stairs with the crutches. The patient repeats the sequence until reaching the bottom of the stairs. •Because in most cases patients need to use crutches for some time, they need to be taught to use them on stairs before discharge. This instruction applies to all patients who are dependent on crutches, not only those who have stairs in their homes. You will frequently collaborate with physical therapists to provide instruction about crutch walking.

Preoperative Surgical Phase: Implementation (Continued.)

•Acute care •Minimize risk for surgical wound infection •Antibiotics •Skin antisepsis •Clipping instead of shaving hair •Maintaining normal fluid and electrolyte balance •Fasting before surgery •IV fluid replacement •Parenteral nutrition •Preventing bowel incontinence and contamination •Bowel preparations •Acute care activities in the preoperative phase focus on the physical preparation of a patient on the morning of surgery or prior to an emergent surgery. •A surgical site infection (SSI) is one of the National Quality Forum-endorsed patient safety measures that hospitals are encouraged to report. Centers for Medicare and Medicaid Services (2010) no longer pays a higher reimbursement for hospitalizations complicated by certain types of surgical site infections if they were not present on admission. As a result, there is great emphasis within hospitals for preventing the occurrence of SSIs. •Antibiotics may be ordered in the preoperative period. A reduction in wound infection rates occurs when an antibiotic is administered 60 minutes before the surgical incision is made and the antibiotics are stopped within 24 hours after surgery. •Preoperative care involves skin antisepsis to reduce the risk of a patient developing a SSI by removing soil and transient micoorganisms at the surgical site. •Current evidence supports leaving hair at the surgical site in place unless the hair interferes with exposure, closure or dressing of the surgical site. When hair removal is required, clipping the hair is likely to result in less SSI than removal with a razor. •A surgical patient is vulnerable to fluid and electrolyte imbalance as a result of the stress of surgery, inadequate preoperative intake, and the potential for excessive fluid losses during surgery. The American Society of Anesthesiologists (ASA) has recommendations on fluid and food intake before non-emergent procedures requiring general and regional anesthesia or sedation/analgesia. These recommendations include fasting from intake of clear liquids for 2 or more hours, breast milk for 4 hours, formula and nonhuman milk for 6 hours, and a light meal of toast and clear liquids for 6 hours. A patient also cannot have any meat or fried foods 8 hours before surgery, unless explicitly specified by the anesthesiologist or surgeon. Despite the ASA standards, many surgeons still have patients maintain nothing by mouth after midnight. Ensure that you follow the healthcare provider's orders. Notify the surgeon and anesthesia provider if the patient eats or drinks during the fasting period. If a patient cannot eat because of gastrointestinal (GI) alterations or impairments in consciousness, you will probably start an IV route for fluid replacement. Patients with severe nutritional imbalances sometimes require supplements with concentrated protein and glucose such as total parenteral nutrition. •Some patients receive a bowel preparation (such as a cathartic or enema) if the surgery involves the lower GI system. An empty bowel reduces risk of injury to the intestines and minimizes contamination of the operative wound if colon surgery is planned or a portion of the bowel is incised or opened accidentally. In addition, cleansing of the bowel reduces postoperative constipation. Too many enemas given over a short time can cause serious fluid and electrolyte imbalances. Most agencies limit the number of enemas (usually three) that a nurse may administer successively.

Intraoperative Surgical Phase: Implementation

•Acute care •Physical preparation •Intraoperative warming •Latex sensitivity/allergy •A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use. •When the patient enters the OR, the patient is usually still awake and notices health care providers in their surgical attire and masks. You transfer a patient to the operating room bed by being sure the stretcher and bed are locked in place. Explain to the patient all the activities you are completing. After safely securing the patient on the OR table with safety straps, you will apply monitoring devices such as continuous electrocardiogram (ECG) electrodes, a pulse oximeter sensor, and blood pressure cuff. For ECG, place electrodes on the chest and extremities correctly to record electrical activity of the heart accurately. The anesthesiologist will use the cuff to monitor the patient's blood pressure. An electronic monitor in the OR will display the patient's heart rate, vital signs, and pulse oximetry continuously. Capnography is also frequently used to measure the patient's ongoing end-tidal CO2 values. Apply an electrical cautery grounding pad to the skin so cauterizing instruments can be used safely. If not applied preoperative, now is the time to apply antiembolism devices. To measure the patient's body temperature continuously, you might assist in insertion of temperature probes via the bladder, esophagus, or rectum. •The unplanned occurrence of perioperative hypothermia is now minimized with the use of active intraoperative warming. Prevention of hypothermia (core temperature <36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and mortality. Evidence suggests that prewarming for a minimum of 30 minutes may reduce occurrence of hypothermia. The nurse in the OR applies warm cotton blankets, forced-air warmers, or circulating water mattresses to patients. Forced air warmers tend to be the most effective when used preoperatively or intraoperatively. •As the incidence and prevalence of latex sensitivity and allergy increase, the need for recognition of potential sources of latex is extremely critical. All medical supplies contain a label notifying the consumer of the latex content. A latex free cart needs to be available at all times in the OR to create a latex safe environment. It is important to know that patients may develop anaphylaxis 30 to 60 minutes after being exposed to latex.

Postoperative Convalescence: Implementation cont.

•Acute care (Cont.) •Maintaining fluid and electrolyte balance •Promoting normal gastrointestinal function and adequate nutrition •Promoting urinary elimination •Skin and wound care •Maintaining/enhancing self-concept •A patient's only source of fluid intake immediately after surgery is IV. You typically will remove an IV catheter once a patient awakens after ambulatory surgery and is able to tolerate water without GI upset. A more seriously ill patient requires an IV to receive fluids and achieve hydration and electrolyte balance. When acute care patients no longer need a continuous IV infusion, the IV line may be saline locked to preserve the site for antibiotics or other use. •Studies show that patients who chew gum after surgery experience a faster return of bowel function (bowel sounds) and pass flatus significantly sooner than those who don't chew gum. A patient likely begins taking ice chips or sips of fluids when arriving on an acute surgical care unit. If fluids are tolerated, the diet progresses with clear liquids next. Interventions for preventing GI complications promote return of normal elimination and faster return of normal nutritional intake. Advance a patient's dietary intake gradually. Promote ambulation and exercise. Physical activity stimulates a return of peristalsis. •Patients without a catheter need to void within 8 to 12 hours after surgery. If the patient has an indwelling urinary catheter, the goal is to remove it as soon as possible because of the high risk for the development of a health care-associated bladder or urinary tract infection (HAI). Help patients assume their normal position to void, assess for bladder distention, and monitor I&O. •Strain on sutures from coughing, vomiting, distention, and movement of body parts can disrupt wound layers. Protect a wound and promote healing. A critical time for wound healing is 24 to 72 hours after surgery, after which a seal is established. If a clean surgical wound becomes infected, it usually occurs in 4 to 5 days after surgery. Monitor patients on an ongoing basis for fever, tenderness at a wound site, and presence of local drainage on dressings: yellow, green, or brown and odorous. A clean surgical wound usually does not regain strength against normal stress for 15 to 20 days after surgery. Surgical dressings (if present) remain in place the first 24 hours after surgery to reduce risk of infection. During this time add an extra layer of gauze on top of the original dressing if drainage develops. After that, use aseptic technique during dressing changes and wound care. Time any dressing change to begin 5 to 30 minutes after giving the patient pain medication. •The appearance of wounds, bulky dressings, and extruding drains and tubes threatens a patient's self-concept. The fear of not being able to return to a functional family role causes some patients to avoid participating in the plan of care. Provide privacy during dressing changes or inspection of the wound. Maintain the patient's hygiene. Prevent drainage devices from overflowing. Maintain a pleasant environment. Offer opportunities for the patient to discuss feelings about appearance. Provide the family with opportunities to discuss ways to promote the patient's self-concept.

Preoperative Surgical Phase: Implementation (Cont)

•Acute care (Cont.) •Preparation on the day of surgery •Hygiene •Preparation of hair and removal of cosmetics •Removal of prostheses •Safeguarding valuables •Preparing the bowel and bladder •Vital signs •Prevention of DVT - Antiembolism devices •Administering preoperative medications •Documentation and hand-off •Eliminating wrong site and wrong procedure surgery •Basic hygiene measures provide patients additional comfort before surgery. •During major surgery an anesthesiologist positions a patient's head to place an endotracheal tube into the airway. •This involves manipulation of the hair and scalp. To avoid injury ask the patient to remove hairpins or clips before leaving for surgery. Electrocautery is frequently used during surgery. Hairpins and clips can become an exit source for the electricity and cause burns. Remove hairpieces or wigs as well. Patients can braid long hair and wear disposable hats to contain hair before entering the OR. When using a pulse oximeter, have patients remove all makeup (lipstick, powder, blush, nail polish) and at least one artificial fingernail to expose normal skin and nail color. Anything in or around the eye irritates or injures the eye during surgery. Have patients remove contact lenses, false eyelashes, and eye makeup. Give the patient's eyeglasses to the family immediately before the patient leaves for the OR. Document all valuables per agency policy. •It is easy for any type of prosthetic device to become lost or damaged during surgery. Have patients remove all removable prosthetics for safekeeping just before leaving for surgery. Place prostheses in a secured area or give them to family members. Document per agency policy. •If a patient has valuables, give them to family members or place in a secure designated location. Prepare a list with a description of items, place a copy with a patient's medical record (see agency policy), and give a copy to a designated family member. Patients are often reluctant to remove wedding rings or religious medals. A wedding band can be taped in place, but this is not the preferred practice. Many hospitals allow patients to pin religious medals to their gowns, although the risk of loss increases. Remove other metal items such as piercings to reduce risk of burns. •Some patients receive an enema or cathartic the morning of surgery. If so, give at least 1 hour before a patient leaves for surgery, allowing time for a patient to defecate without rushing. •The surgeon may order insertion of an indwelling catheter if the surgery is to be long or the incision is in the lower abdomen. •Monitor preoperative vital signs before surgery. The anesthesia provider uses these values as a baseline for intraoperative vital signs. If preoperative vital signs are abnormal, surgery may need to be postponed. Notify the surgeon of any abnormalities before sending the patient to surgery. •Hospitals have made the prevention of deep vein thrombosis (DVT) a priority quality measure. When correctly sized and applied, antiembolism devices such as antiembolism stockings reduce the risk for DVT. •The anesthesia provider or surgeon may order preanesthetic drugs to reduce patient anxiety; the amount of general anesthesia required; respiratory tract secretions; and the risk of nausea, vomiting; and possible aspiration. Complete all nursing care measures before administering these medications. Preoperative drugs can cause dry mouth, drowsiness, and dizziness. If drowsiness or dizziness occurs, keep side rails in the up position, the bed in the low position, and the call bell within easy reach for the patient. Be sure the patient has signed surgical consent before administering drugs that will alter consciousness. •Before the patient goes to the OR, an accurate medical record is essential to ensure safe and appropriate patient care. Check the contents of the medical record for accuracy and completeness. The transfer of information about the patient from one health care provider to another requires an effective hand-off. The Association of perioperative Registered Nurses (AORN) and TJC (2015) recommend time-outs for safe surgery briefings during a pre- to intraoperative hand off. This ensures that the right patient receives the right surgery and at the right surgical site. •[Review Box 50-5, Example of Elements of a Preoperative to Intra-operative Handoff Using SBAR Communication.] •Implement the Universal Protocol whenever an invasive surgical procedure is to be performed, no matter the location. The three principles of the protocol are: (1) a preoperative verification that ensures that all relevant documents and results of laboratory tests and diagnostic studies are available before the start of the procedure and that the type of surgery scheduled is consistent with the patient's expectations; (2) marking the operative site with indelible ink to mark left and right distinction, multiple structures, and levels of the spine; and (3) a "time out" just before starting the procedure for final verification of the correct patient, procedure, site, and any implants. The marking and "time out" most commonly occur in the holding area, just before the patient enters the OR. The individual performing surgery and who is accountable for it, must personally mark the site and the patient must be involved if possible.

Sitting in a chair with crutches

•As with crutch walking and crutch walking up and down stairs, the procedure for sitting in a chair involves phases and requires the patient to transfer weight. •First the patient positions himself or herself at the center front of the chair with the posterior aspect of the legs touching the chair. •Then the patient holds both crutches in the hand opposite the affected leg. If both legs are affected, as with a person with paraplegia who wears weight-supporting braces, the crutches are held in the hand on the patient's stronger side. •With both crutches in one hand, the patient supports body weight on the unaffected leg and the crutches. •While still holding the crutches, the patient grasps the arm of the chair with the remaining hand and lowers his or her body into it. •To stand the procedure is reversed; and the patient, when fully erect, assumes the tripod position before beginning to walk.

Postoperative Convalescence cont

•Assessment (Cont.) •Neurological functions •Skin integrity and condition of the wound •Metabolism •Genitourinary function •Gastrointestinal function •Paralytic ileus •Comfort •In the PACU the patient is often drowsy. As anesthetic agents begin to metabolize, the patient's reflexes return, muscle strength is regained, and a normal level of orientation returns. Continue monitoring neurological status on the nursing unit. Ensure that the patient is oriented to self and the hospital and responds to questions appropriately. Assess pupil and gag reflexes, hand grips, and movement of extremities. Patients with regional anesthesia begin to experience a return in motor function before tactile sensation returns. Check the patient's sensation to touch. Patients remain in the PACU until sensation and voluntary movement of the lower extremities are reestablished. •During recovery and acute postoperative care, assess the condition of the skin, noting pressure areas, rashes, petechiae, abrasions, or burns. After surgery a patient may only have butterfly tape, skin staples, or even glue to close small wounds. Look at the incision carefully and notice any drainage or swelling. Most surgical wounds that are larger have dressings that protect the wound site and collect drainage. Observe the amount, color, odor, and consistency of drainage on dressings. •Nurses should monitor patient blood glucose levels routinely based on surgeon order or hospital policy. •Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. •Normally patients who undergo abdominal or pelvic surgery have decreased peristalsis for at least 24 hours or longer. Paralytic ileus which causes abdominal distention, is always possible after surgery. Auscultate bowel sounds in all four quadrants, noting faint or absent bowel sounds. Inspect the abdomen for distention that may be caused by accumulation of gas. Ask whether a patient is passing flatus, an important sign indicating return of normal bowel function. •As patients awaken from general anesthesia, the sensation of pain becomes prominent. They perceive pain before regaining full consciousness. Ongoing assessment of the patient's discomfort and evaluation of pain-relief therapies are essential throughout the postoperative course. Pain scales are effective for assessing postoperative pain, evaluating the response to analgesics, and objectively documenting pain severity. Using preoperative pain assessments as a baseline, evaluate the effectiveness of interventions throughout the patient's recovery.

Nursing Process: Assessment (continued)

•Body alignment •Lying •People who are conscious have voluntary muscle control and normal perception of pressure. As a result, they usually assume a position of comfort when lying down. Because their ROM, sensation, and circulation are within normal limits, they change positions when they perceive muscle strain and decreased circulation. •Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position. Remove all positioning supports from the bed except for the pillow under the head and support the body with an adequate mattress. •This position allows for full view of the spine and back and helps provide other baseline body alignment data such as whether the patient is able to remain positioned without aid. The vertebrae are aligned, and the position does not cause discomfort. •Patients with impaired mobility (e.g., traction or arthritis), decreased sensation (e.g., hemiparesis following a cerebrovascular accident [CVA]), impaired circulation (e.g., diabetes), and lack of voluntary muscle control (e.g., spinal cord injury) are at risk for damage when lying down.

Implementation: acute care (cont)

•Cardiovascular •Reducing orthostatic hypotension •Reducing cardiac workload •Preventing thrombus formation •SCDs, thromboembolic disease (TED), hose, and leg exercises •When patients who are on bed rest or are immobile move to a sitting or standing position, they often experience orthostatic hypotension. They have an increased pulse rate, a decreased pulse pressure, and a drop in blood pressure. If symptoms become severe enough, the patient can faint. •Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. •Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. When getting an immobile patient up for the first time, assess the situation using a safe patient-handling algorithm. •The nurse designs interventions to reduce cardiac workload, which is increased by immobility. •A primary intervention is to discourage the patient from using the Valsalva maneuver. This increases intrathoracic pressure, which in turn decreases venous return and cardiac output. When the strain is released, venous return and cardiac output immediately increase, and systolic blood pressure and pulse pressure rise. •Teach the patient to breathe out while moving side-to-side or up in bed. •The most cost-effective way to address deep vein thrombosis (DVT) is through an aggressive program of prophylaxis. It begins with identification of patients at risk and continues throughout their immobilization. •Leg, foot, and ankle exercises; regularly providing fluids; position changes; and patient teaching need to begin when the patient becomes immobile. •Common dosage for heparin therapy for DVT prophylaxis is 5000 units given subcutaneously 2 hours before surgery and repeated every 8 to 12 hours until the patient is fully mobile or discharged. •Common dosage of enoxaparin (Lovenox) (a low-molecular-weight heparin) in the prophylaxis of DVTs is 30 to 40 mg subcutaneously 2 hours before surgery and continued every 8 to 12 hours throughout the postoperative period. •Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or GI aspirate, guaiac-positive stools, and bleeding gums. •SCDs and intermittent pneumatic compression (IPC) are used to prevent blot clots in the lower extremities. •Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return. •Proper positioning reduces the patient's risk of thrombus formation because compression of the leg veins is minimized. •ROM exercises reduce the risk of contractures and aid in preventing thrombi.

Metabolic Changes

•Changes in mobility alter •Endocrine metabolism •Calcium resorption •Functioning of the GI system •Endocrine system helps maintain homeostasis •Immobility disrupts normal metabolic functioning •Decreases metabolic rate •Alters metabolism •Causes GI distrubances •The endocrine system, made up of hormone-secreting glands, maintains and regulates vital functions such as (1) response to stress and injury; (2) growth and development; (3) reproduction; (4) maintenance of the internal environment; and (5) energy production, use, and storage. •When injury or stress occurs, the endocrine system triggers a series of responses aimed at maintaining blood pressure and preserving life. It is important in maintaining homeostasis. •Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. •In the presence of an infectious process, immobilized patients often have an increased basal metabolic rate (BMR) as a result of fever or wound healing because these increase cellular oxygen requirements. •When the patient is immobile, his or her body often excretes more nitrogen (the end product of amino acid breakdown) than it ingests in proteins, resulting in negative nitrogen balance. Weight loss, decreased muscle mass, and weakness result from tissue catabolism (tissue breakdown). •Immobility causes the release of calcium into the circulation. Normally the kidneys excrete the excess calcium. However, if the kidneys are unable to respond appropriately, hypercalcemia results. Pathological fractures occur if calcium resorption continues as the patient remains on bed rest or continues to be immobile. •Impairments of gastrointestinal functioning caused by decreased mobility vary. Difficulty in passing stools (constipation) is a common symptom, although pseudodiarrhea often results from a fecal impaction (accumulation of hardened feces). •Over time intestinal function becomes depressed, dehydration occurs, absorption ceases, and fluid and electrolyte disturbances worsen.

Respiratory Changes

•Immobile patients are at high risk for developing pulmonary complications •Atelectasis •Hypostatic pneumonia •Lack of movement and exercise places patients at higher risk for respiratory complications. •Patients who are immobile are at high risk for developing pulmonary complications. •The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Both decreased oxygenation and prolonged recovery add to the patient's discomfort. •In atelectasis secretions block a bronchiole or a bronchus; and the distal lung tissue (alveoli) collapses as the existing air is absorbed, producing hypoventilation. The site of the blockage affects the severity of atelectasis. Sometimes an entire lung lobe or a whole lung collapses. •At some point in the development of these complications, there is a proportional decline in the patient's ability to cough productively. Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position. Mucus accumulates in the dependent regions of the airways. Hypostatic pneumonia frequently results because mucus is an excellent place for bacteria to grow.

Implementation (activity)

•Integumentary system •Reposition every 1 to 2 hours. •Provide skin care. •Elimination system •Provide adequate hydration. Serve a diet rich in fluids, fruits, vegetables, and fiber •The major risk to the skin from restricted mobility is the formation of pressure ulcers. •Repositioning every 2 hours and providing skin care will help to prevent pressure ulcers. •Interventions aimed at prevention include positioning, skin care, and the use of therapeutic devices to relieve pressure. Change the immobilized patient's position according to his or her activity level, perceptual ability, treatment protocols, and daily routines. •Patients need between 2000 and 3000 mL of fluids per day to help prevent renal calculi and urinary tract infection (UTI). Monitor intake and output to ensure that fluid balance is maintained. •Although turning every 1 to 2 hours is recommended for preventing ulcers, it is sometimes necessary to use devices for relieving pressure. Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. •Reposition patients frequently because uninterrupted pressure causes skin breakdown. Teach patients to shift their weight every 15 minutes. Chair-bound patients need to have a device for the chair that reduces pressure. •The nursing interventions for maintaining optimal urinary functioning are directed at keeping the patient well hydrated and preventing urinary stasis, calculi, and infections without causing bladder distention. •Adequate hydration (e.g., at least 1100 to 1400 mL of noncaffeinated fluids daily) helps prevent renal calculi and urinary tract infections. •Record the frequency and consistency of bowel movements. •Provide a diet rich in fluids, fruits, vegetables, and fiber to facilitate normal peristalsis. •Psychosocial changes •Developmental changes •People who have a tendency toward depression or mood swings are at greater risk for developing psychosocial effects during bed rest or immobilization. •Anticipate changes in the patient's psychosocial status, and provide routine and informal socialization. Observe the patient's ability to cope with restricted mobility. •Nurses provide stimuli to maintain a patient's orientation. Plan nursing activities so the patient is able to talk and interact with staff. •Involve patients in their care whenever possible. •Ideally, immobilized patients continue normal development. •Nursing care needs to provide mental and physical stimulation, particularly for a young child. •Older patients who are frail or have chronic illnesses are often at increased risk for the psychosocial hazards of immobility. Maintaining a calendar and clock with a large dial, conversing about current events and family members, and encouraging visits from significant others reduce the risk of social isolation. •Nurses need to encourage older immobilized patients to perform as many ADLs as independently as possible.

Implementation: acute care

•Metabolic •Provide high-protein, high-calorie diet with vitamin B and C supplements. •Respiratory •Cough and deep breathe every 1 to 2 hours. •Provide chest physiotherapy. •Because the body needs protein to repair injured tissue and rebuild depleted protein stores, give the immobilized patient a high-protein, high-calorie diet. A high-calorie intake provides sufficient fuel to meet metabolic needs and replace subcutaneous tissue. Also ensure that the patient is taking vitamin B and C supplements when necessary. Supplementation with vitamin C is needed for skin integrity and wound healing; vitamin B complex assists in energy metabolism. •If the patient is unable to eat, nutrition must be provided parenterally or enterally. •For respiratory patients, they need to frequently fully expand their lungs to maintain their elastic recoil property. In addition, secretions accumulate in the dependent areas of the lungs. Often patients with restricted mobility experience weakness; and, as this progresses, the cough reflex gradually becomes inefficient. All of these factors put the patient at risk of developing pneumonia. The stasis of secretions in the lungs is life threatening for an immobilized patient. •A variety of nursing interventions are available to expand the lungs, dislodge and mobilize stagnant secretions, and clear the lungs. All of these interventions help reduce the risk of pneumonia. •Prevention begins with assessment. •Assess the patient's respiratory status per agency policy. •Assessment findings that indicate pneumonia include productive cough with greenish-yellow sputum; fever; pain on breathing; and crackles, wheezes, and dyspnea. •It is essential to implement pulmonary interventions in all patients, even those who do not have pneumonia. •Encourage the patient to deep breathe and cough every 1 to 2 hours. Teach alert patients to deep breathe or yawn every hour or to use an incentive spirometer. Instruct the patient to take in three deep breaths and cough with the third exhalation. •Chest physiotherapy (CPT) (percussion and positioning) is another effective method for preventing pneumonia and keeping the airway clear. CPT helps the patient drain secretions from specific segments of the bronchi and lungs into the trachea so he or she is able to cough and expel them. •Ensure that patients who are immobile take an adequate fluid intake. Unless there is a medical contraindication, an adult needs to drink at least 1100 to 1400 mL of noncaffeinated fluids daily. This helps keep mucociliary clearance normal.

Nursing Process cont. cont. cont.

•Mobility •Body alignment is used for: •Determining normal physical changes •Identifying deviations in body alignment •Patient awareness of posture •Identifying postural learning needs of patients •Identifying trauma, muscle damage, or nerve dysfunction •Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological problems) •Body alignment is the condition of joints, tendons, ligaments, and muscles in various body positions. •Balance occurs when a wide base of support is present, the center of gravity falls within the base of support, and a vertical line falls from the center of gravity through the base of support. •Perform assessment of body alignment with the patient standing, sitting, or lying down. This assessment has the following objectives: •Determining normal physiological changes in body alignment resulting from growth and development. •Identifying deviations in body alignment caused by incorrect posture. •Providing opportunities for patients to observe their posture. •Identifying learning needs of patients for maintaining correct body alignment. •Identifying trauma, muscle damage, or nerve dysfunction. •Obtaining information concerning other factors that contribute to incorrect alignment such as fatigue, malnutrition, and psychological problems. •The first step in assessing body alignment is to put patients at ease so they do not assume unnatural or rigid positions. When assessing the body alignment of an immobilized or unconscious patient, remove pillows and positioning supports from the bed and place the patient in the supine position.

Nursing Process Assessment cont cont.

•Mobility •Gait (a particular manner or style of walking) •Exercise (physical activity for conditioning the body, improving health, and maintaining fitness) •Activity tolerance •Physiological •Emotional •Developmental •Assessing a patient's gait allows you to draw conclusions about balance, posture, safety, and ability to walk without assistance. The mechanics of human gait involve coordination of the skeletal, neurological, and muscular systems of the human body. •Nurses use exercise as therapy to correct a deformity or restore the overall body to a maximal state of health. •Assessment of the patient's energy level includes the physiological effects of exercise and activity tolerance. •Activity tolerance is the type and amount of exercise or work that a person is able to perform. •Assessment of activity tolerance is necessary when planning activity such as walking, ROM exercises, or ADLs. •Activity tolerance assessment includes data from physiological, emotional, and developmental domains. •As activity begins, monitor patients for symptoms such as dyspnea, fatigue, chest pain, and/or a change in vital signs. A weak or debilitated patient is unable to sustain even slight changes in activity because of the increased demand for energy. •When the patient experiences decreased activity tolerance, carefully assess how much time he or she needs to recover. Decreasing recovery time indicates improving activity tolerance. •People who are depressed, worried, or anxious are frequently unable to tolerate exercise. •Developmental changes also affect activity tolerance. As the infant enters the toddler stage, the activity level increases, and the need for sleep declines. The child entering preschool or primary grades expends mental energy in learning and often requires more rest after school or before strenuous play. The adolescent going through puberty requires more rest because much body energy is expended for growth and hormone changes. •Changes still occur through the adult years, but many of them are related to work and lifestyle choices. •As the person grows older, activity tolerance changes. Muscle mass is reduced, and posture and bone composition change. Changes in the cardiorespiratory system such as decreased maximum heart rate and lung compliance, which affect the intensity of exercise, often occur. As age progresses, some older individuals still exercise but do so at a reduced intensity.

Nursing Knowledge Base: Factors Influencing Mobility-Immobility

•Mobility refers to a person's ability to move about freely, and immobility refers to the inability to do so •Bed rest •Effects of muscular deconditioning •Disuse atrophy •Physiological •Psychological •Social •You need to know how to apply scientific principles in the clinical setting to determine the safest way to move patients and to understand the effect of immobility on the physiological, psychosocial, and developmental aspects of patient care. •To determine how to move patients safely, assess their ability to move. •Think of mobility as a continuum, with mobility on one end, immobility on the other, and varying degrees of partial immobility between the end points. Some patients move back and forth between mobility and immobility, but for others immobility is absolute and continues indefinitely. •Manually lifting and transferring patients contributes to the high incidence of work-related musculoskeletal problems and back injuries in nurses and other health care staff. •Bed rest is an intervention that restricts patients to bed for therapeutic reasons. Nurses and health care providers most often prescribe this intervention. •The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of days. This cluster of symptoms is often referred to as the "hazards of immobility." The individual of average weight and height without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day. •Immobility also is associated with cardiovascular, skeletal, and other organ changes. The term disuse atrophy describes the tendency of cells and tissue to reduce in size and function in response to prolonged inactivity resulting from bed rest, trauma, casting, or local nerve damage. •Periods of immobility or prolonged bed rest cause major physiological, psychological, and social effects. These effects are gradual or immediate and vary from patient to patient. •The patient with complete mobility restrictions is continually at risk for the hazards of immobility. When possible, it is imperative that patients, especially the older adults, have limited bed rest and that their activity is more than bed to chair. •The deconditioning related to reduced walking increases the risk for patient falls.

Musculoskeletal changes

•Muscle effects •Lean body mass loss •Muscle weakness/ atrophy •Skeletal effects •Disuse osteoporosis •Joint contracture •The effects of immobility on the musculoskeletal system include permanent or temporary impairment or permanent disability. Restricted mobility sometimes results in loss of endurance, strength, and muscle mass and decreased stability and balance. Other effects of restricted mobility affecting the skeletal system are impaired calcium metabolism and joint mobility. •Because of protein breakdown, the patient loses lean body mass. The reduced muscle mass is unable to sustain activity without increased fatigue. If immobility continues and the patient does not exercise, there is further loss of muscle mass. Muscle weakness always occurs with immobility, and prolonged immobility often leads to disuse atrophy. Muscle atrophy is a widely observed response to illness, decreased activities of daily living (ADLs), and immobilization. Loss of endurance, decreased muscle mass and strength, and joint instability (see Skeletal Effects) put patients at risk for falls. •Immobilization causes two skeletal changes: impaired calcium metabolism and joint abnormalities. Because immobilization results in bone resorption, the bone tissue is less dense or atrophied, and disuse osteoporosis results. When disuse osteoporosis occurs, the patient is at risk for pathological fractures. •Approximately 80% of people who have osteoporosis are female. Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, it is imperative for nurses to recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis. •A joint contracture is an abnormal and possibly permanent condition characterized by fixation of the joint. It is important to note that flexor muscles for joints are stronger than extensor muscles and therefore contribute to the formation of contractures. •Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot achieve full range of motion (ROM). Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in patients who are permanently curled in a fetal position. Early prevention of contractures is essential. •One common and debilitating contracture is footdrop. When footdrop occurs, the foot is permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position because the patient cannot dorsiflex the foot. The patient with footdrop is unable to lift the toes off the ground.

Nature of movement cont. cont.

•Muscle movement and posture •Skeletal muscles are working elements of movement •Nervous system •Regulates movement and posture •Movement of bones and joints involves active processes that are carefully integrated to achieve coordination. Skeletal muscles, because of their ability to contract and relax, are the working elements of movement. Anatomical structure and attachment to the skeleton enhance contractile elements of the skeletal muscle. •The nervous system regulates movement and posture. •The precentral gyrus, or motor strip, is the major voluntary motor area and is in the cerebral cortex. A majority of motor fibers descend from the motor strip and cross at the level of the medulla. •Movement is impaired by disorders that alter neurotransmitter production, transfer of impulses from the nerve to the muscle, or activation of muscle.

Implementation (cont)

•Musculoskeletal system •Prevent muscle atrophy and joint contractures •Exercises to prevent excessive muscle atrophy and joint contractures help maintain musculoskeletal function. If the patient is unable to move part or all of the body, perform passive ROM exercises for all immobilized joints while bathing the patient and at least two or three more times a day. •If one extremity is paralyzed, teach the patient to put each joint independently through its ROM. Patients on bed rest need to have active ROM exercises incorporated into their daily schedules. Teach patients to integrate exercises during ADLs. •Some orthopedic conditions require more frequent passive ROM exercises to restore the function of the injured joint after surgery. Patients with such conditions need to use automatic equipment (continuous passive motion [CPM]) for passive ROM exercises).

Cardiovascular Changes

•Orthostatic hypotension •Increased cardiac workload •Thrombus formation •Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mmHg in diastolic pressure and symptoms of dizziness, light-headedness, nausea, tachycardia, pallor or fainting when the patient changes from the supine to standing position. •In the immobilized patient decreased circulating fluid volume, pooling of blood in the lower extremities, and decreased autonomic response occur. These are especially evident in the older adult. •As the workload of the heart increases, so does its oxygen consumption. Therefore the heart works harder and less efficiently during periods of prolonged rest. As immobilization increases, cardiac output falls, further decreasing cardiac efficiency and increasing workload. •Patients who are immobile are also at risk for thrombus formation. A thrombus is an accumulation of platelets, fibrin, clotting factors, and the cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel. •Three factors contribute to venous thrombus formation: (1) damage to the vessel wall (e.g., injury during surgical procedures), (2) alterations of blood flow (e.g., slow blood flow in calf veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in clotting factors or increased platelet activity). These three factors are often referred to as Virchow's triad.

Crutch gait

•Patients assume a crutch gait by alternately bearing weight on one or both legs and on the crutches. •Determine the gait by assessing the patient's physical and functional abilities and the disease or injury that resulted in the need for crutches. This section summarizes the basic crutch stance and the four standard gaits: four-point alternating gait, three-point alternating gait, two-point gait, and swing-through gait. •The basic crutch stance is the tripod position, formed when the crutches are placed 15 cm (6 inches) in front of and 15 cm (6 inches) to the side of each foot (shown on left). This position improves the patient's balance by providing a wider base of support. The body alignment of the patient in the tripod position includes an erect head and neck, straight vertebrae, and extended hips and knees. The axillae should not bear any weight. The patient assumes the tripod position before crutch walking. •Four-point alternating, or four-point, gait gives stability to the patient but requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so three points of support are on the floor at all times (shown on right, A). •Three-point alternating, or three-point, gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence (B). The affected leg does not touch the ground during the early phase of the three-point gait. Gradually the patient progresses to touchdown and full weight bearing on the affected leg. •The two-point gait requires at least partial weight bearing on each foot (C). The patient moves a crutch at the same time as the opposing leg so the crutch movements are similar to arm motion during normal walking. Individuals with paraplegia who wear weight-supporting braces on their legs frequently use the swing-through gait. With weight placed on the supported legs, the patient places the crutches one stride in front and then swings to or through them while they support his or her weight

Nursing Knowledge Base (CoSC)

•Perioperative communication •Hand-off communication •Glycemic control and infection prevention •Poor glucose control increases risk for wound infection and mortality •Pressure ulcer prevention •Positioning •Pressure-relieving surfaces •Most commonly different nurses and other health care providers care for a patient during each phase of the surgical experience. A smooth communication "hand-off" between caregivers is needed to ensure continuity of care and reduce risk of medical errors. Transitions from one care provider to another place patients at risk for injuries, missed care, and errors in translating information. A standardized checklist or protocol for hand-off communication between perioperative health care providers minimizes these risks. •Poor control of blood glucose levels (specifically hyperglycemia) during surgery and afterward increases patients' risks for adverse outcomes such as wound infection and mortality. Good perioperative glycemic control has been shown to reduce mortality in general surgery patients with and without diabetes, and in cardiac surgery patients. •Operating room (OR) nurses prevent pressure ulcers intraoperatively by carefully positioning patients and using pressure-relieving surfaces. After surgery, nurses perform careful skin assessment and intervene using appropriate pressure-reduction strategies

Preoperative Surgical Phase: Assessment (Continued)

•Physical Examination •General survey •Head and neck •Integument •Thorax and lungs •Heart and vascular system •Abdomen •Neurological status •Diagnostic screenings •Conduct a partial or complete physical examination, depending on the amount of time available and the patient's preoperative condition. Assessment focuses on findings from the patient's medical history and on body systems that the surgery is likely to affect. •Preoperative vital signs, including blood pressure while sitting and standing, and pulse oximetry provide important baseline data with which to compare alterations that occur during and after surgery, including response to anesthetics and medications and fluid and electrolyte abnormalities. Notify the surgeon immediately if the patient has an elevated temperature. •Assessment of oral mucous membranes reveals the level of dehydration. Dehydration increases the risk for serious fluid and electrolyte imbalances developing during surgery. Identify any loose or capped teeth because they can become dislodged during endotracheal intubation. Note the presence of dentures, prosthetic devices, or piercings so they can be removed before surgery. •Carefully inspect the skin, especially over bony prominences such as the heels, elbows, sacrum, back of head, and scapula. Consider the type of surgery a patient will undergo and the position that is required on the operating room table, to identify areas at risk for pressure ulcer formation. An older adult is at high risk for alteration in skin integrity from decrease in epidermis, positioning (pressure forces), and repositioning on the OR table (shearing forces). •When ventilation is reduced, a patient is at increased risk for respiratory complications (e.g., atelectasis) following surgery. •Screen a patient for one or more of the three primary causative factors of deep vein thrombosis (DVT) formation (Virchow's triad: venous stasis, vessel wall injury, and hypercoagulability [noted in coagulation lab tests]). •Assess preoperatively a patient's usual abdominal anatomy for size, shape, symmetry, and presence of distention. •Preoperative assessment of baseline neurological status is important for all patients. The baseline neurological status assists with the assessment of ascent (awakening) from anesthesia. •Patients undergo diagnostic tests and procedures for preexisting abnormalities before surgery. As a preoperative nurse, you will coordinate the completion of tests and verify that a patient is properly prepared. The patient's medical history, physical assessment findings, and surgical procedure determine the type of tests ordered. Patients undergoing elective surgery and who may need blood products will have a pretransfusion type and screen sample taken 1 to 7 days before surgery. This test ensures blood compatibility (if a transfusion is needed) and avoids antibodies that may emerge in response to exposure through transfusions or a patient's disease. Autotransfusion, the reinfusion of a patient's own blood intraoperatively, is more common today.

Planning

•Planning •Goals and outcomes •Setting priorities •Teamwork and collaboration •Develop goals and expected outcomes to assist the patient in achieving his or her highest level of mobility and reducing the hazards of immobility. •Set priorities when planning care to ensure that immediate needs are met first. This is particularly important when patients have multiple diagnoses. •Plan therapies according to severity of risks to the patient; individualize the plan according to the patient's developmental stage, level of health, and lifestyle. •Do not overlook potential complications. •Care of the patient experiencing alterations in mobility requires a team approach. •Nurses often delegate some interventions to nursing assistive personnel. •Collaborate with other health care team members, such as physical or occupational therapists, when it is essential to consider mobility needs. •In anticipation of the patient's discharge from an institution, make referrals or consult a case manager or a discharge planner to ensure that the patient's needs are met at home.

Implementation: Health Promotion (activity)

•Prevention of work-related musculoskeletal injuries •Exercise •Bone health in patients with osteoporosis •Health promotion activities include a variety of interventions such as education, prevention, and early detection. •[What are some examples of health promotion activities that address mobility? Discuss: Prevention of work-related injury, fall prevention measures, exercise, and early detection of scoliosis.] •The rate of work-related injury in health care settings is on the rise. •Most of these injuries occur as a result of overexertion, which results in back injuries and other musculoskeletal problems. •Back injuries are often the direct result of improper lifting and bending. Get help, if necessary, before starting a lifting task, and follow correct lifting procedures. The most common back injury is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. •Nurses and other health care staff are especially at risk for injury to lumbar muscles when lifting, transferring, or positioning immobilized patients. Therefore be aware of agency policies and protocols that protect staff and patients from injury. Current evidence supports that using mechanical or other ergonomic assistive devices is the safest way to reposition and lift patients who are unable to do these activities themselves. •Exercise programs enhance feelings of well-being and improve endurance, strength, and health. Exercise reduces the risk of many health problems such as cardiovascular disease, diabetes, and osteoporosis. •Exercise has many positive health benefits. Assist patients in overcoming barriers to physical activity, and encourage them to perform activities that are within their ability. Take cultural practices into consideration. •For patients diagnosed with osteoporosis, early evaluation, consultation, and a team approach are important interventions, especially when they become immobilized. ADLs help a patient maintain independence. Assistive ambulatory devices, adaptive clothing, and safety bars help the patient maintain independence. Patient teaching needs to focus on limiting the severity of the disease through diet and activity.

Postoperative Surgical Phase cont

•Recovery in ambulatory surgery (Phase II) •Postanesthesia recovery score (PARS) •Postoperative convalescence •The thoroughness and extent of postoperative recovery depends on the ambulatory patient's condition, type of surgery, and anesthesia. In some cases, the patient goes through both Phase I (PACU) and Phase II recovery. Assess and care for patients in need of close monitoring in the same fashion as inpatients in Phase I. After patients stabilize and no longer require close monitoring, transfer them to Phase II recovery. With new anesthetic agents and minimally invasive surgical techniques, fast-track surgery is becoming more common with patients experiencing a more rapid awakening in the OR, quicker recovery, and reduced morbidity. Many ambulatory surgery patients are able to bypass Phase I. •Phase II recovery is performed in a room equipped with medical recliner chairs, side tables, and foot rests. Kitchen facilities for preparing light snacks and beverages are usually located in the area, along with bathrooms. The Phase II environment promotes the patient's and family's comfort and well-being until discharge. Monitor patients but not at the same intensity as during Phase I. In Phase II recovery, initiate postoperative teaching with patients and family members. •[Review Box 50-8, Initial Postanesthesia Care Assessment.] •Patients are discharged to home following ambulatory surgery after they meet certain criteria. When you are using a tool for assessing a patient's recovery score, such as the PARS, the patient must achieve a certain score before being discharged. •Review written postoperative instructions and prescriptions with the patient and family before releasing the patient and ensure that they verbalize understanding of these instructions. Always discharge the patient to a responsible adult.

Implementation (immobility)

•Restorative and continuing care •IADLs •ROM exercise •Walking •The goal of restorative care for the patient who is immobile is to maximize functional mobility and independence and reduce residual functional deficits such as impaired gait and decreased endurance. •The focus in restorative care is not only on ADLs that relate to physical self-care, but also on instrumental activities of daily living (IADLs). •IADLs are activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting; they include such skills as shopping, preparing meals, banking, and taking medications. •Work collaboratively with patients and other health care professionals. •To ensure adequate joint mobility, teach the patient about ROM exercises. •When performing passive ROM exercises, stand at the side of the bed closest to the joint being exercised. Perform passive ROM exercises using a head-to-toe sequence and moving from larger to smaller joints. If an extremity is to be moved or lifted, place a cupped hand under the joint to support it, support the joint by holding the adjacent distal and proximal areas or support the joint with one hand and cradle the distal portion of the extremity with the remaining arm. •When a patient has a limited ability to walk, assess his or her activity tolerance, tolerance to the upright position (orthostatic hypotension), strength, presence of pain, coordination, and balance to determine the amount of assistance needed. •Explain how far the patient should try to walk, who is going to help, when the walk will take place, and why walking is important. In addition, determine with the patient how much independence he or she can assume. •Check the environment to be sure that there are no obstacles in the patient's path. •Provide support at the waist by using a gait belt so the patient's center of gravity remains midline. •Patients with hemiplegia (one-sided paralysis) or hemiparesis (one-sided weakness) often need assistance with walking.

Preoperative Surgical Phase: Assessment (cont)

•Risk factors •Screen patients carefully •Take necessary precautions •Collaborate with health care provider •Obstructive sleep apnea, malnourishment, and smoking are all risk factors. •Your knowledge of potential surgical risk factors will enable you to focus your assessment and screen patients carefully so that you can take necessary precautions in planning perioperative care. •Collaborate closely with the health care provider when you identify a risk factor that might require therapy. For example, advise patients to consider stopping estrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery to reduce risk of thromboembolism. •Many hospitals are now making obstructive sleep apnea screening mandatory. The STOP-BANG assessment tool, has high sensitivity and validity. •[Review Box 50-2, The STOP BANG Questionnaire.] •If a patient presents with signs of malnourishment, perform your institutions' nutritional screening tool or confer with a clinical dietitian. •If the patient has a smoking history, use the information to plan aggressive postoperative pulmonary hygiene, including more frequent turning, use of incentive spirometry, deep breathing, and coughing. Smoking causes hypercoagulability of the blood and increased risk for clot formation. Provide preventive measures to decrease the risk for clots such as pneumatic compression stockings, leg exercises, and early ambulation.

Nature of Movement cont.

•Skeletal system •Provides attachments for muscles and ligaments, protects vital organs, aids in calcium regulation •Provides leverage for mobility •Bones are long, short, flat, or irregular •Joints •Ligaments, tendons, and cartilage •Bones are important for mobilization because they are firm, rigid, and elastic. The aging process changes the components of bone, which impacts mobility. •Firmness results from inorganic salts such as calcium and phosphate that are in the bone matrix. It is related to the rigidity of the bone, which is necessary to keep long bones straight and enables bones to withstand weight bearing. •Elasticity and skeletal flexibility change with age. •Bones store calcium and release it into the circulation as needed. Patients with decreased calcium regulation and metabolism, and immobility, are at risk for developing osteoporosis and pathological fractures (fractures caused by weakened bone tissue). •[How does the skeletal system protect vital organs? Discuss: The skull around the brain and the ribs around the heart and lungs.] •In addition, the internal structure of long bones contains bone marrow, participates in red blood cell (RBC) production, and acts as a reservoir for blood. Patients with altered bone marrow function or diminished RBC production fatigue easily because of reduced hemoglobin and oxygen-carrying ability. This fatigue decreases their mobility and increases the risk for falling, which impacts a patient's mobility status. •Joints are the connections between bones. Each joint is classified according to its structure and degree of mobility. There are three classifications of joints: cartilaginous, fibrous, and synovial. •Ligaments are white, shiny, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages, and aid joint flexibility and support. Tendons are white, glistening, fibrous bands of tissue that connect muscle to bone and are strong, flexible, and inelastic. Cartilage is nonvascular (without blood vessels) supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear. The characteristics of the cartilage change with the aging process.

Scientific Knowledge Base (CoSC)

•Surgical Risk Factors •Smoking •Age •Nutrition •Obesity •Obstructive sleep apnea (OSA) •Immunosuppression •Fluid and electrolyte imbalance •Postoperative nausea and vomiting (PONV) •Venous thromboembolism (VTE) •There are numerous factors that create risks for patients facing surgery. Risk factors can affect patients at any point in the perioperative experience. Knowledge of the physiology of the stress response and risk factors that affect patients' responses to surgery is necessary to anticipate patient needs and the type of preparation required. •Cigarette smoking by surgical patients is associated with increased perioperative complications, particularly respiratory problems and poor wound healing. •Very young and older patients are at greater surgical risk as a result of an immature or a declining physiological status. •[Review Table 50-3, Physiological Factors That Place the Older Adult at Risk During Surgery.] •Surgery increases the need for nutrients. Thin and obese patients are often protein and vitamin deficient. •Risk of surgical mortality increases as a patient's weight increases primarily due to reduction in ventilatory and cardiac function. •Patients with OSA who are to undergo surgery present a significant risk. Receiving sedatives, opioid analgesics, and general anesthesia causes relaxation of the upper airway and may worsen OSA. The risk is higher when patients are sedated and lying on their back. Patients have experienced severe apnea and hypoxemia leading to death following surgical and diagnostic procedures under conscious sedation. Careful screening of patients for OSA is essential prior to surgery. •Patients with conditions that alter immune function are more at risk for developing infection after surgery. •A patient who is hypovolemic preoperatively or who has serious electrolyte alterations is at significant risk during and after surgery. •PONV affects approximately 30% of patients in recovery rooms after surgery. It can lead to serious complications, including pulmonary aspiration, dehydration, and arrhythmias resulting from fluid and electrolyte imbalance. A patient who vomits frequently after surgery runs the risk of pulling apart surgical sutures. •Patients most at risk for developing VTE are those who undergo surgical procedures with a total anaesthetic and a surgical time of more than 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limb; acute surgical admissions with inflammatory or intraabdominal conditions; and those expected to have significant reduction in mobility after surgery. In addition, patients are at higher risk if they have one or more risk factors. Risk factors include active cancer or cancer treatment, age older than 60 years, critical care admission, dehydration, known clotting disorders, and obesity.

Preoperative Surgical Phase: Nursing Process and Assessment

•Through the patient's eyes •Determine the patient's expectations of surgery and the road to recovery •Nursing history •Include information about advance directives •Medical history •Screen for conditions that increase surgical risks •Surgical history •Check for complications in prior surgeries •The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care. •The goal of the preoperative assessment is to identify a patient's normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. •When there is time to conduct a thorough assessment, begin by determining a patient's expectations of surgery and the road to recovery. Listen to the patient's explanation, be attentive, and begin to explain what surgery will involve. By opening an assessment with these types of questions, the patient will become your partner and share the details you need to learn about his or her health. •As with any admission to a health care facility, include information about advance directives. Ask if a patient has a durable power of attorney for health care or a living will and include a copy in the patient's medical record. •To help ensure a thorough and accurate nursing assessment, electronic health records provide standardized documentation forms for preoperative assessment. Be sure to use all drop-down menus to most clearly portray a patient's history, but also be willing to enter full text descriptions as needed. •A review of a patient's medical history includes past illnesses and surgeries and the primary reason for seeking medical care. A history screens candidates for surgery for major medical conditions that increase the risk for complications during or after surgery. If a patient has any surgical risk from a medical condition, surgery as an outpatient may not be advisable or it will be necessary to take special precautions. Also inquire about a family history for anesthetic complications such as malignant hyperthermia (an inherited disorder). Malignant hyperthermia is a life-threatening condition that can occur during surgery. •[Review Table 50-4, Medical Conditions That Increase Risks of Surgery.] •[Review Box 50-1, Nursing Assessment Questions: Cardiac History.] •A review of a patient's past experience with surgery reveals physical and psychological responses that may occur during the current planned procedure. Complications such as anaphylaxis or malignant hyperthermia during previous surgery alert you to the need for preventive measures and availability of appropriate emergency equipment. Reports of severe anxiety before a previous surgery identify the need for additional emotional support, medications, and preoperative teaching. Inform the surgeon or anesthesiologist of your findings, especially when you believe medications are indicated.

Preoperative Surgical Phase: Evaluation

•Through the patient's eyes •Evaluate whether the patient's expectations were met with respect to surgical preparation •Patient outcomes •Deficient knowledge •Anxiety •The nurse caring for the patient in the preoperative area evaluates initial patient outcomes. Compare the patient's current status with expected outcomes to determine whether new or revised interventions and/or nursing diagnoses need to be implemented intraoperatively. •[Review Figure 50-4, Nursing Diagnostic Process: Fear Related to Knowledge Deficit and Previous Surgical Experience.] •During evaluation, include a discussion of any misunderstandings so patient concerns can be clarified. When patients have expectations about pain control, this is a good time to reinforce how it will be managed after surgery. •Evaluate the patient's response to interventions designed for preoperative nursing diagnoses such as deficient knowledge or anxiety. Observe the patient's behaviors and discuss concerns to see if anxiety has been relieved. Be thorough in your evaluation to determine if further instruction or emotional support is needed after surgery. •Interventions continue during and after surgery; thus the evaluation of many goals and outcomes does not occur until after surgery.

Evaluation (immobility)

•Through the patient's eyes •It is essential to have the patient's evaluation of the plan of care •Patient outcomes •Evaluate effectiveness of specific interventions •Evaluate patient's and family's understanding of all teaching provided •Were the goals met, or is more work required? •You must now determine with the patient and others involved with care if the goals or outcomes established with and for the patient have indeed been met; what still needs to be achieved from the patient's perspective; and the construction of a new plan of care. In other words, how have the patient's expectations changed and in what ways? •From your perspective as the nurse, you are to evaluate outcomes and response to nursing care and compare the patient's actual outcomes with the outcomes selected during planning such as his or her ability to maintain or improve body alignment, joint mobility, walking, moving, or transferring. •When outcomes are not met, consider asking the following questions: •Are there ways we can assist you to increase your activity? •Which activities are you having trouble completing right now? •How do you feel about not being able to dress yourself and make your own meals? •Which exercises do you find most helpful? •What goals for your activity would you like to set now?

Intraoperative Surgical Phase: Evaluation (cont)

•Through the patient's eyes •Keep the family informed •Ask family members if they have questions •Patient outcomes •Evaluate a patient's ongoing clinical status during surgery •The circulating nurse conducts an ongoing evaluation to ensure that interventions such as patient position are implemented correctly during the intraoperative phase of surgery. •While a patient is undergoing surgery, it is important to keep the family informed. Families expect an estimate of when surgery begins and the length of time it will likely last. When you give an update to a family member, ask if he or she has further questions or concerns. •Evaluate a patient's ongoing clinical status during surgery. The anesthesia provider will continuously monitor vital signs. The circulating nurse will monitor and record intake and output (I&O), specimens obtained, medications and irrigations, type of dressing packing, and other treatments. Measure the patient's body temperature during and at completion of the surgery, with the goal of keeping the patient normothermic. Inspect the skin under the grounding pad and at areas where positioning exerts pressure.

Structure and Function cont cont

-Lung volumes Tidal Residual Forced vital capacity Pulmonary circulation Moves blood to and from the alveolar capillary membrane for gas exchange •The normal lung values are determined by age, gender, and height. •Tidal volume is the amount of air exhaled following a normal inspiration. •Residual volume is the amount of air left in the alveoli after a full expiration. •Forced vital capacity is the maximum amount of air that can be removed from the lungs during forced expiration. •Variations in tidal volume and other lung volumes are associated with alterations in patients' health status or activity, such as pregnancy, exercise, obesity, or obstructive and restrictive conditions of the lungs. •Pulmonary circulation begins at the pulmonary artery, which receives poorly oxygenated mixed venous blood from the right ventricle. •Blood flow through this system depends on the pumping ability of the right ventricle. •The flow continues from the pulmonary artery through the pulmonary arterioles to the pulmonary capillaries, where blood comes in contact with the alveolar capillary membrane and the exchange of respiratory gases occurs. •The oxygen-rich blood then circulates through the pulmonary venules and pulmonary veins, returning to the left atrium.

Assessment cont. cont. (activity)

-Sitting -Head: erect -Neck and vertebral column: in straight alignment -Body weight: distributed on buttocks and thighs -Thighs: parallel and in a horizontal plane -Feet: supported on the floor -Forearms: supported on the armrest, in the lap, or on a table in front of the chair

Cardiovascular Physiology cont.

-Structure and function -Right ventricle pumps deoxygenated blood through systemic circulation. -As blood passes through the circulatory system, there is an exchange of respiratory gases, nutrients, and waste products between the blood and the tissues.

Evaluation

-Through the patient's eyes -Focus on evaluating how the disease is affecting day-to-day activities and how the patient believes he or she is responding to treatment -Patient outcomes -Compare the patient's actual progress to the goals and expected outcomes of the nursing care plan to determine his or her health status •Evaluate nursing interventions and therapies by comparing the patient's progress with the goals and expected outcomes of the nursing care plan. Patient expectations evaluate the care from the patient's perspective. •Patients who have chronic lung problems often must be motivated to participate in necessary therapies. •Evaluate the patient's motivation and emotional readiness to adhere to treatments provided. •Be aware of the need to change a treatment plan to be culturally sensitive to improve adherence to it. •Determine if the patient or family/caregiver feels more in control of the health situation after you have provided instruction. •Consider the use of survey tools such as COPD Self Efficacy Scale, Chronic Respiratory Disease Questionnaire, and Pulmonary-Specific Quality of Life for COPD Scale (AARC, 2010b) to evaluate a patient's perception of his or her quality of life. •If the nursing measures used are not successful in improving oxygenation, modify the care plan and reevaluate. Continuous evaluation helps to determine whether new or revised therapies are required and if new nursing diagnoses have developed and require a new plan of care. Do not hesitate to notify the health care provider about a patient's deteriorating oxygenation status. Prompt notification helps avoid an emergency situation or even the need for CPR. •Ask the patient about his or her degree of breathlessness. Observe respiratory rate before, during, and after any activity or procedure. •Ask the patient if the distance ambulated without fatigue has increased. •Ask the patient to rate breathlessness on a scale of 0 to 10, with 0 being no shortness of breath and 10 being severe shortness of breath. •Ask the patient which interventions help reduce dyspnea. •Ask the patient about frequency of cough and sputum production and assess any sputum produced. •Auscultate lung sounds for improvement in adventitious sounds. •Evaluate pulse oximetry changes to decreases in oxygen delivery. •Monitor arterial blood gas levels, pulmonary function tests, chest x-ray films, ECG tracings, and physical assessment data to provide objective measurement of the success of therapies and treatments.

Positioning Techniques

-Trochanter roll -Hand roll -Trapeze bar -Supported Fowler's -Supine -Prone -Side-lying -Sims' •Patients with impaired nervous, skeletal, or muscular system functioning and increased weakness and fatigability often require help from the nurse to attain proper body alignment while in bed or sitting. •Several positioning devices are available for maintaining good body alignment for patients, including pillows, positioning boots, ankle-foot orthoses (AFOs), blankets, sandbags, hand rolls, and splints. •A trochanter roll prevents external rotation of the hips when the patient is in a supine position. To form a trochanter roll, fold a cotton bath blanket lengthwise to a width that extends from the greater trochanter of the femur to the lower border of the popliteal space. Place the blanket under the buttocks and roll it counterclockwise until the thigh is in neutral position or inward rotation. When the hip is aligned correctly, the patella faces directly upward. •Hand rolls maintain the thumb in slight adduction and in opposition to the fingers, which maintain a functional position. •The trapeze bar is a triangular device that hangs down from a securely fastened overhead bar that is attached to the bed frame. It allows the patient to pull with the upper extremities to raise the trunk off the bed, assist in transfer from bed to wheelchair, or perform upper arm exercises. It increases independence, maintains upper body strength, and decreases the shearing action from sliding across or up and down in bed. •Following guidelines reduces the risk of injury to the musculoskeletal system when the patient is sitting or lying. When joints are unsupported, their alignment is impaired. Likewise, if joints are not positioned in a slightly flexed position, their mobility is decreased. During positioning also assess for pressure points. •In the supported Fowler's position, the head of the bed is elevated 45 to 60 degrees, and the patient's knees are slightly elevated without pressure to restrict circulation in the lower legs. The following are common trouble areas for the patient in the supported Fowler's position: •Increased cervical flexion because the pillow at the head is too thick and the head thrusts forward. •Extension of the knees, allowing the patient to slide to the foot of the bed. •Pressure on the posterior aspect of the knees, decreasing circulation to the feet. •External rotation of the hips. •Arms hanging unsupported at the patient's sides. •Unsupported feet or pressure on the heels. •Unprotected pressure points at the sacrum and heels. •Increased shearing force on the back and heels when the head of the bed is raised greater than 60 degrees. •Patients in the supine position rest on their backs. In the supine position the relationship of body parts is essentially the same as in good standing alignment except that the body is in the horizontal plane. The following are some common trouble areas for patients in the supine position: •Pillow at the head that is too thick, increasing cervical flexion. •Head flat on the mattress. •Shoulders unsupported and internally rotated. •Elbows extended. •Thumb not in opposition to the fingers. •Hips externally rotated. •Unsupported feet. •Unprotected pressure points at the occipital region of the head, vertebrae, coccyx, elbows, and heels. •The patient in the prone position lies face or chest down. Often his or her head is turned to the side; but, if a pillow is under the head, it needs to be thin enough to prevent cervical flexion or extension and maintain alignment of the lumbar spine. Assess for and correct any of the following potential trouble points with patients in the prone position: •Neck hyperextension. •Hyperextension of the lumbar spine. •Plantar flexion of the ankles. •Unprotected pressure points at the chin, elbows, female breasts, hips, knees, and toes. •In the side-lying (or lateral) position the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. A 30-degree lateral position is recommended for patients at risk for pressure ulcers. The following trouble points are common in the side-lying position: •Lateral flexion of the neck. •Spinal curves out of normal alignment. •Shoulder and hip joints internally rotated, adducted, or unsupported. •Lack of foot support. •Lack of protection for pressure points at the ear, shoulder, anterior iliac spine, trochanter, and ankles. •Excessive lateral flexion of the spine if the patient has large hips and a pillow is not placed superior to the hips at the waist. •Sims' position differs from the side-lying position in the distribution of the patient's weight. In Sims' position the patient places the weight on the anterior ileum, humerus, and clavicle. Trouble points common in Sims' position include the following: •Lateral flexion of the neck. •Internal rotation, adduction, or lack of support to the shoulders and hips. •Lack of foot support. Lack of protection for pressure points at the ileum, humerus, clavicle, knees, and ankles

Transport to the Operating Room

Notification Transportation Verify patient's identity Two identifiers Family Allowed to visit before patient is transported to OR Directed to waiting area Prepare room for patient's return •Personnel in the OR notify the nursing unit or ambulatory surgery area when it is time for surgery. •In many facilities, a nursing orderly or transporter brings a stretcher for transporting the patient. The transporter checks the patient's identification bracelet for two identifiers (name, birth date, or hospital number) (refer to institutional or agency policy) against the patient's medical record to ensure the correct person is going to surgery. •Because some patients receive preoperative sedatives, the nurses and transporter help the patient transfer from bed to stretcher to prevent falls. •The ambulatory surgery patient ambulates to the OR if able and not medicated. •Provide the family an opportunity to visit before the patient is transported to the OR. •Direct the family to the appropriate waiting area. •If a patient has been hospitalized before surgery and will be returning to the same nursing unit, prepare the bed and room for the patient's return.

Ventilation

The process of moving gases into and out of the lungs •Ventilation requires coordination of the muscular and elastic properties of the lung and thorax. The major inspiratory muscle of respiration is the diaphragm. It is innervated by the phrenic nerve, which exits the spinal cord at the fourth cervical vertebra.

Critical thinking (CoSC)

•A patient's condition is always changing. •During assessment consider all of the elements that build toward making appropriate nursing diagnoses. •Integrate knowledge regarding the patient's specific clinical situation, along with previous experiences in caring for surgical patients. •Use professional perioperative standards. •Successful critical thinking synthesizes knowledge, information gathered from patients, previous experience, critical thinking attitudes, and intellectual and professional standards. Clinical judgments require you to anticipate the necessary information, analyze the data, and make decisions about patient care. •[Review Figure 50-1, Critical thinking model for surgical patient assessment.] •When caring for a perioperative patient, integrate knowledge regarding the patient's specific clinical situation, along with previous experiences in caring for surgical patients. Apply this knowledge using a patient-centered care approach, partnering with the patient in making clinical decisions. •The use of critical thinking attitudes ensures that a plan of care is comprehensive and incorporates evidence-based principles for successful perioperative care. A key attitude for a perioperative nurse is responsibility, being responsible not only for standards of care but being a patient advocate as well. The professional perioperative standards developed by the Agency for Health Care Research and Quality (AHRQ) (http://www.ahrq.gov), Association of periOperative Registered Nurses (AORN) (http://www.aorn.org), and the American Society of PeriAnesthesia Nurses (ASPAN) (http://www.aspan.org), provide valuable guidelines for perioperative management and evaluation of process and outcomes. The Joint Commission's (TJC) 2015 Hospital National Patient Safety Goals include two sets of recommendations for perioperative care: prevent infection and prevent mistakes in surgery (TJC, 2015). Always review these guidelines within the context of new emerging evidence-based practice, agency policies, and the scope of practice of the state in which you practice

Postoperative Convalescence: Implementation

•Acute care •Maintaining respiratory function •Preventing circulatory complications •Achieving rest and comfort •Temperature regulation •Maintaining neurological function •Primary causes for postoperative complications include impaired healing of the surgical wound, the effects of prolonged immobilization during surgery and convalescence, and the influence of anesthesia and analgesics. If a patient has surgical risks before surgery, the likelihood of complications is greater. •[Review Box 50-9, Focus on Older Adults: The Older-Adult Surgical Patient: Concerns and Nursing Interventions.] •Direct your postoperative nursing interventions at preventing complications so the patient returns to the highest level of functioning possible. Failure of the patient to become actively involved in recovery adds to the risk of complications. •[Review Table 50-8, Postoperative Complications.] •To prevent respiratory complications, begin pulmonary interventions early. The benefits of thorough preoperative teaching are reached when patients are able to participate actively in postoperative exercises. •Measures for preventing circulatory complications avert venous stasis and thrombus formation. •[What measures can you take to prevent circulatory complications? Discuss: encourage patients to perform leg exercises, apply compression stockings, encourage ambulation, avoid positions that interrupt blood flow to extremities, administer anticoagulant drugs as ordered, and promote adequate fluid intake.] •[Review Box 50-10, Evidence-Based Practice: Prevention of Venous Thromboembolism in the Postsurgical Patient.] •Pain control is a priority to facilitate a surgical patient's recovery. Without pain control a patient will not move or ambulate as readily or initiate coughing exercises. When a patient requests pain medication or shows signs of discomfort, assess the nature and character of a patient's pain thoroughly. Patients have the most surgical pain the first 24 to 48 hours after surgery. •When the patient comes to the PACU or surgical unit, provide warmed blankets or heated air blankets if no other device is in place. Increasing a patient's body temperature raises metabolism and circulatory and respiratory functions improve. If malignant hyperthermia develops, immediately administer dantrolene sodium as ordered by the health care provider. If a patient becomes febrile, be aggressive in providing routine postoperative nursing interventions. Try to arouse a patient by calling the patient's name, using a moderate tone of voice. If that is not successful, waken the patient by using touch or gently moving a body part. If painful stimulation is needed to arouse a patient, notify anesthesia immediately. Reorient the patient, explain that surgery is completed, and describe procedures and nursing measures

Postoperative Convalescence: Planning

•Goals and outcomes •Goals that continue into the home setting •Goals established during the preoperative surgical phase that are still relevant •Setting priorities •Reestablish priorities as the status of the patient's health problems change •Teamwork and collaboration •Goal: help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care •During the convalescent phase use current physical assessment data and analysis of the preoperative nursing history to plan the patient's care. The surgeon's postoperative orders and surgical team's report of the patient's operative condition also provide valuable data. •Review nursing diagnoses when establishing goals, expected outcomes, and interventions for the individual patient. Measurable outcomes provide specific guidelines for determining a patent's progress toward recovery from surgery. •At times, goals and outcomes must extend from the convalescence period into the home setting. Also consider all goals of care established during the preoperative surgical phase that are still relevant. •During the convalescent phase of recovery from general anesthesia, priorities for the first 24 hours continue to include maintenance of respiratory, circulatory, and neurological status, wound management, and pain control. In addition, most surgeons are aggressive in increasing the patient's activity as soon as possible. As the patient progresses, focus priorities on advancement of patient activity (e.g., mobility, diet tolerance) to return the patient to preoperative functioning or better. The patient generally has multiple nursing diagnoses •[Review Figure 50-5, Concept map for Mrs. Campana.] During recovery collaborate on the plan of care with respiratory therapy, physical therapy, occupational therapy, dietary, social work, home care, and others. Include family members as much as possible, especially if they will be assuming care responsibilities in the home. The goal of an interdisciplinary approach to care is to help the patient return to the best possible level of functioning with a smooth transition to home, rehabilitation, or long-term care. Acute care settings often have a nurse or social worker in a case manager role to coordinate interdisciplinary care so the most appropriate resources are available to patients

Preoperative Surgical Phase: Planning

•Goals and outcomes •Review and modify the plan during the intraoperative and postoperative periods •Setting priorities •Patients requiring emergent surgery often experience changes in their physiological status that require urgent reprioritizations. •Teamwork and collaboration •Preoperative instruction gives patients time to make necessary preparations •During planning synthesize information to establish a plan of care based on the patient's nursing diagnoses. Apply critical thinking in the selection of nursing interventions. •Critical thinking ensures that a patient's plan of care integrates knowledge, previous experiences, critical thinking attitudes, and established standards of practice. •Previous experience in caring for surgical patients helps establish approaches to patient care (e.g., complications to prevent and anticipate and methods to reduce anxiety). •Professional standards are especially important to consider when selecting interventions for the nursing plan of care. These standards often utilize evidence-based guidelines for preferred nursing interventions. •[Review Figure 50-3, Critical thinking model for surgical patient planning.] •Successful planning requires a patient-centered approach involving the surgical patient and family to set realistic expectations for care. Early involvement of the patient and a family caregiver, when developing the surgical care plan, minimizes surgical risks and postoperative complications and improves transition of care through discharge. A patient informed about the planned surgical experience is less likely to be fearful and is better able to participate in the postoperative recovery phase so expected outcomes are met. Establish diagnosis, interventions, and outcomes to ensure recovery or maintenance of the preoperative state. •Base the goals and outcomes of care on the individualized nursing diagnoses. Review and modify the plan during the intraoperative and postoperative periods. Outcomes established for each goal of care provide measurable evidence to gauge the patient's progress toward meeting stated goals. •Use clinical judgment to prioritize nursing diagnoses and interventions based on the unique needs of each patient. Patients requiring emergent surgery often experience changes in their physiological status that require urgent reprioritizations. Ensure that the approach to each patient is thorough and reflects an understanding of the implications of the patient's age, physical and psychological health, educational level, cultural and religious practices, and stated and/or written wishes concerning advance medical directives. •For patients having ambulatory surgery, those admitted the day of their scheduled surgery, and those with special issues (e.g., morbid obesity), the health care team must collaborate to ensure continuity of care. Preoperative planning ideally occurs days before admission to the hospital or surgical center. The collaboration between the health care provider's office and the surgical center is crucial to preparing a patient for a procedure and ensuring the proper equipment/supplies are available. Preoperative instruction gives patients time to think about their surgical experience, make necessary physical preparations (e.g., altering diet or discontinuing medication use), and ask questions about postoperative procedures. The patient having ambulatory surgery usually returns home on the day of surgery. Thus, well-planned preoperative care ensures that the patient is well informed and able to be an active participant during recovery. The family or significant others also play an active supportive role for the patient.

Preoperative Surgical Phase: Implementation (Cont.)

•Health promotion •Preoperative teaching •Reasons for preoperative instructions and exercises •Preoperative routines •Surgical procedure •Time of surgery •Postoperative unit and location of family during surgery and recovery •Anticipated postoperative monitoring and therapies •Sensory preparation •Postoperative activity resumption •Pain-relief measures •Rest •Feelings regarding surgery •Health promotion activities during the preoperative phase focus on health maintenance, patient safety, prevention of complications, and anticipation of continued care needed after surgery. •Patient education is an important aspect of a patient's surgical experience. Patient education reduces patients' preoperative anxiety, which often leads to an increase in postoperative pain, poor outcomes and prolonged hospital stays. Preoperative information and instructions are delivered by telephone calls and home mailings from the health care provider's office or hospital. When a patient is scheduled for surgery (outpatient or inpatient), preadmission nurses call patients up to 1 week before surgery to clarify questions and reinforce explanations. •When given a rationale for preoperative and postoperative procedures, patients are better prepared to participate in care. Patients who undergo ambulatory surgery need to learn how their instructions and exercises will promote healthy recovery, prevent complications, and allow them to return to a normal lifestyle as soon as possible. Patients who undergo inpatient surgery, need to understand what is required to facilitate their recovery, including pain control, anticipated activity level, diet progression, wound care, and the need to be able to perform postoperative exercises, which help to prevent pulmonary and vascular complications. •[Review Skill 50-1, Demonstrating Postoperative Exercises.] •Explain the preoperative routines that a patient will undergo. Knowing which tests and procedures are planned and why increase a patient's sense of control. •After the surgeon explains the basic purpose of a surgical procedure and its steps, some patients ask you additional questions. First, clarify with the patient what was discussed with the surgeon. If a patient has little or no understanding about the surgery, notify the surgeon that the patient requires further explanation. Avoid saying anything that contradicts the surgeon's explanation. You can augment the surgeon's explanations. •Emphasize that the scheduled time is a rough estimate and the actual time can be sooner or later. Make the family aware that delays do not necessarily indicate a problem. Communicate excessive delays when they do occur. •Few patients are admitted to a hospital unit prior to surgery, unless their case is emergent or unless a complication develops during hospitalization. When surgery is elective, patients and families will first come to the surgical center admission area. There, the patient will learn the likely unit he or she will be in following recovery. The family needs to know where the patient will be after surgery. Be sure to explain where the family can wait and where the surgeon will attempt to find family members after surgery. Many institutions have programs where the circulating nurse gives periodic reports to the family in the waiting room for surgeries that are expected to be prolonged. •If patients understand the type and frequency of anticipated monitoring and procedures, they are less apprehensive when nurses perform care activities. •Provide patients with information about the sensations typically experienced after surgery. Preparatory information helps them anticipate the steps of a procedure and thus form realistic images of the surgical experience. Postoperative sensations to describe include blurred vision from ophthalmic ointment in the eyes, expected pain at the surgical site and in areas of the body affected by prolonged positioning, the tightness of dressings, dryness of the mouth, and the sensation of a sore throat resulting from an endotracheal tube. •The type of surgery that patients undergo determines how quickly they can resume normal physical activity and regular eating habits. It is normal in most surgical cases for patients to progress gradually in activity and eating. •Inform the patient and family of the need to manage pain so patients can resume activity and the type of therapies likely to be used for pain relief. Patient-controlled analgesia (PCA) is common and provides patients with control over pain. Explain and demonstrate to a patient how to operate a pump and the importance of administering medication as soon as pain becomes persistent. Pain relief has been shown to be more effective when analgesics are given around-the-clock (ATC) rather than as needed (prn). •Rest is essential for normal healing. Meet each patient's individual needs, giving them time to ask questions so that anxiety can be minimized. If the patient is in the hospital, make the environment quiet and comfortable. •Some patients feel like part of an assembly line before surgery. Frequent visits by staff, diagnostic testing, and physical preparation for surgery consume time; and the patient has few opportunities to reflect on the experience. Recognize the patient as a unique individual.

Postoperative Surgical Phase

•Immediate postoperative recovery (Phase I) •Notification and arrival •Hand-off: OR to PACU •Patient monitoring and assessment •Modified Aldrete score •Modified postanesthesia recovery score (PARS) •DASAIM discharge assessment tool •Discharge and hand-off: PACU to Acute Care •The type of anesthesia, nature of surgery, and the patient's previous condition determine the phases of recovery that the patient undergoes and the length of time spent in convalescence on an acute care nursing unit. For a patient following ambulatory surgery, the immediate recovery period normally lasts only 1 to 2 hours in phase II recovery, and convalescence occurs at home. However, Phase I recovery may be necessary depending on the patient's condition and anesthesia. For a hospitalized patient, the immediate postoperative recovery (Phase I) period often lasts a few hours in the PACU and Phase II recovery occurs on a surgical unit. Convalescence then takes 1 or more days on the surgical unit. •When a patient is admitted to Phase I recovery, personnel notify the nurses on the acute care nursing unit of the patient's arrival. This allows the nursing staff to inform family members. •When the patient enters the PACU, the nurse and members of the surgical team discuss the patient's status. A standardized approach or tool for "hand-off" communications assists in providing accurate information about a patient's care, treatment and services, current condition, and any recent or anticipated changes. •After receiving hand-off communication from the OR, the PACU nurse conducts a complete systems assessment during the first few minutes of PACU care. •[Review Box 50-7, Initial Postanesthesia Care Assessment.] •Evaluate the patient's status and eventual readiness for discharge from the PACU on the basis of vital sign stability compared with the preoperative data. Patients with more extensive surgery requiring anesthesia of longer duration usually recover more slowly. It is common for hospitals and ambulatory care centers to use objective scoring systems to identify when patients are ready for discharge. Standard tools include the Modified Aldrete score, or the modified postanesthesia recovery score (PARS), and the DASAIM discharge assessment tool. •When the patient is discharged from the PACU, another hand-off communication occurs at the patient's bedside between the PACU nurse and the nurse on the acute nursing unit or the ICU. The nurses verify the patient's identification using two identifiers and the type of surgery performed. •The PACU staff transport the patient on a stretcher to the nursing unit. The PACU nurse shows the receiving nurse the recovery room record and reviews the patient's condition and course of care. The PACU nurse also reviews the surgeon's orders that require attention. Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient.

Preoperative Surgical Phase: Implementation

•Informed consent •Surgical procedures require documentation of consent •Report any concerns about the patient's understanding of the surgery to the operating surgeon or anesthesia provider •Privacy and social media •Do not discuss confidential patient information in public areas or use social media to convey patient information; posting patient information and photos on websites is prohibited •Except in emergencies, surgery cannot be legally or ethically performed until a patient fully understands a surgical procedure and all implications. Surgical procedures should not be performed without documentation of the patient's consent in the medical record. Chapter 23 discusses in detail the nurse's responsibilities for informed consent. It is the surgeon's responsibility to explain the procedure, associated risks, benefits, alternatives, and possible complications, before obtaining the patient's oral and documented informed consent. The patient must also be informed about who will perform the procedure. To ensure that a patient understands information about surgery, The Joint Commission (TJC) (2012) recommends consent materials be written at a fifth grade or lower reading level. After the patient or power of attorney signs the consent form, place it in the medical record. The record goes to the OR with the patient. As a nurse, if you have concerns about the adequacy of a patient's understanding of surgery, report any concerns to the operating surgeon or anesthesia provider. •Although patients can now access their medical records electronically, confidentiality risks exist. Inappropriate discussions of a patient and any planned surgery in elevators, in cafeterias, or in social settings after work can end up being communicated "worldwide." You have an obligation to protect each patient's privacy by avoiding inappropriate discussions and not using social media to convey information. Posting patient information and photos on websites is prohibited as 26 state boards of nursing have taken disciplinary action against nurses who practice such behavior. In addition, you might be violating federal and state patient privacy laws.

Intraoperative Surgical Phase: Implementation (cont)

•Introduction of anesthesia •General anesthesia •Regional anesthesia •Moderate (conscious) sedation •Positioning the patient for surgery •Documentation of intraoperative care •The nature and extent of a patient's surgery and current physical status influence the type of anesthesia administered during surgery. Know the complications to anticipate postoperatively for each type. •[Review Table 50-7, Examples of Complications of Anesthesia.] •Under general anesthesia a patient loses all sensation, consciousness, and reflexes, including gag and blink reflexes. There is muscle relaxation and the patient experiences amnesia. Amnesia acts as a protective measure from the unpleasant events of the procedure. An anesthesia provider gives general anesthetics by IV infusion and inhalation routes through the three phases of anesthesia: induction, maintenance, and emergence. During emergence anesthetics are decreased, and the patient begins to awaken. Because of the short half-life of today's medications, emergence often occurs in the OR. The duration of anesthesia depends on the length of surgery. •Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the point of anesthetic injection. Serious complications, such as respiratory paralysis, occur if the level of anesthesia rises, moving upward in the spinal cord. •Local anesthesia involves loss of sensation at the desired site by inhibiting peripheral nerve conduction. It is commonly used in ambulatory surgery. A local can also be used in addition to general or regional anesthesia. The anesthetic agent inhibits nerve conduction until the drug diffuses into the circulation. It is injected locally or applied topically. The patient experiences a loss in pain and touch sensation and motor and autonomic activities. It is necessary to continually monitor patients during a local procedure. •IV moderate sedation or conscious sedation is routinely used for short-term surgical, diagnostic, and therapeutic procedures that do not require complete anesthesia but rather a depressed level of consciousness. The preferred sedative for conscious sedation is short-acting IV sedatives such as midazolam (Versed). •Prevention of positioning injuries requires anticipation of the position and surgical approach to be used during a surgical procedure, the positioning equipment to be used, and whether a patient has conditions creating a risk for injury. Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect skin from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the OR table provide protection to extremities and bony prominences. Positioning should not impede normal movement of the diaphragm or interfere with circulation to body parts. If restraints are necessary, pad the skin to prevent trauma. •Throughout the surgical procedure, the circulating nurse keeps an accurate record of patient care activities and procedures performed by OR personnel. A standardized documentation format assists practitioners in ensuring continuity of information from the OR to the PACU or recovery area. The AORN recommends the use of verbal and standardized forms to transfer patient information between care providers.

Preoperative Surgical Phase: Assessment (cont)

•Medications •Inpatient vs. outpatient •Allergies •Medications, topical agents, latex, food •Smoking habits •Alcohol ingestion and substance abuse and use •Pregnancy •Perceptions and knowledge regarding surgery •Review whether a patient is taking any medications that predispose the patient to surgical complications. •[Review Table 50-5, Medications with Special Implications for the Surgical Patient.] •If a patient regularly uses prescription or over-the-counter (OTC) medications or herbal supplements, some surgeons temporarily discontinue them before surgery or adjust doses. •If a patient is having inpatient surgery, all prescription medications taken before surgery are automatically discontinued after surgery unless reordered. •If you are in an outpatient setting, instruct patients to ask their surgeons whether they should take their usual medications the morning of surgery. •It is important that, as a patient moves through different areas (such as from the holding area to the OR), a complete list of medications is accurately communicated nurse to nurse. •Allergies to medications, topical agents used to prepare the skin for surgery, and latex create significant risks for surgical patients. Patients with an allergy to certain foods, such as bananas, chestnuts, kiwi fruit, avocadoes, potato, strawberries, nectarine, tomatoes and wheat, have shown a cross-sensitivity to latex. List all allergies in the patient's medical record. •In patients who smoke, use information about a patient's smoking habits to plan for aggressive pulmonary hygiene, including more frequent turning, deep breathing, coughing, and use of incentive spirometry postoperatively. •Habitual use of alcohol and illegal drugs predisposes patients to adverse reactions to anesthetic agents. Some patients experience a cross-tolerance to anesthetic agents, necessitating higher-than-normal doses. In addition, the surgeon may need to increase postoperative dosages of analgesics. Patients with a history of excessive alcohol ingestion are often malnourished, which delays wound healing. •Because many women do not know they are pregnant early in the first trimester, many institutions require a pregnancy test when the patient is scheduled for surgery. A pregnant patient has surgery only on an emergent or urgent basis. Because all of the mother's major systems are affected during pregnancy, the risk for intraoperative complications is increased. •Assess a patient's previous experiences with surgery as a foundation for anticipating the patient's needs, providing teaching, addressing fears, and clarifying concerns. Prepare both the patient and the family for the surgical experience. Confer with the surgeon if the patient has an inaccurate perception or knowledge of the surgical procedure before the patient is sent to the surgical suite. When a patient is well prepared and knows what to expect, reinforce the patient's knowledge.

Positioning techniques cont

•Moving patients •Safety is first priority •Ask patient to help as much as possible •Determine if patient comprehends what is expected •Determine patient's comfort level •Determine if you need assistance in moving the patient •Always ask the patient to help to the fullest extent possible. •To determine what the patient is able to do alone and how many people are needed to help move him or her in bed, assess him or her to determine whether the illness contradicts exertion (e.g., cardiovascular disease). Next, determine whether the patient comprehends what is expected. •Then determine his or her comfort level. It is important to evaluate your personal strength and knowledge of the procedure. •Finally, determine whether the patient is too heavy or immobile for you to move alone.

Postoperative Convalescence

•Nursing Process •Assessment •Through the patient's eyes •Airway and respiration •Circulation •Temperature control •Malignant hyperthermia •Fluid and electrolyte balance •Inpatients remain in the PACU until their condition stabilizes; they then return to the postoperative nursing unit. Nursing care in both settings focuses on returning the patient to a relatively functional level of wellness as soon as possible. The speed of convalescence depends on the type or extent of surgery, risk factors, pain management, and postoperative complications. •Once a surgical patient is transferred to an acute care nursing unit, ongoing postoperative care is essential to support recovery. Apply the nursing process and use a critical thinking approach in your care of patients. •When the patient arrives on the acute care unit, monitor vital signs according to institution policy. Generally, the patient is monitored every 15 minutes twice, every 30 minutes twice, hourly for 2 hours, and then every 4 hours or per orders. As the patient's condition stabilizes, the patient usually is monitored once a shift until discharge. Thoroughly document the initial nursing assessment, including vital signs, level of consciousness, airway status, condition of dressings and drains, pulses distal to site of surgery, comfort level, IV fluid status, and urinary output measurements. Document your findings. •When a patient initially returns to the acute care nursing unit, the family and patient have expectations of the patient receiving prompt and attentive care. There is also the expectation that a nurse will explain the patient's immediate status and the plan of care for the next few hours. •The first priority in the care of a postanesthesia patient is to establish a patent airway. •Careful assessment of heart rate and rhythm, along with blood pressure, reveals the patient's cardiovascular status. Compare preoperative vital signs with postoperative values. Also assess circulatory perfusion. A common early circulatory problem is bleeding or hemorrhage. Blood loss may occur externally through a drain or incision or internally. Either type of hemorrhage results in a fall in blood pressure; elevated heart and respiratory rates; thready pulse; cool, clammy, pale skin; and restlessness. Notify the surgeon if these changes occur. •A patient's anesthetically depressed level of body function results in a lowering of metabolism and fall in body temperature. Older adults and pediatric patients are at higher risk for developing problems associated with postoperative hypothermia. In rare instances, a genetic disorder known as malignant hyperthermia, a life-threatening complication of anesthesia, develops. Malignant hyperthermia causes hypercarbia (elevated carbon dioxide), tachypnea, tachycardia, premature ventricular contractions (PVCs), unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. Despite the name, an elevated temperature occurs late. The increased expired carbon dioxide is one of the first signs. Without prompt detection and treatment, it is potentially fatal. Because an elevated temperature may be the first indication of an infection, assess the patient for a potential source of infection, including the IV site (if present), the surgical incision/wound, and the respiratory and urinary tracts. Notify the health care provider because further evaluation is often necessary. •Because of the surgical patient's risk for fluid and electrolyte abnormalities, assess the hydration status and monitor for signs of electrolyte alterations. Accurate recording of I&O assesses renal and circulatory function.

Postoperative Convalescence: Diagnosis

•Nursing diagnoses for postoperative patients include: •Ineffective airway clearance •Anxiety •Risk for infection •Deficient knowledge (specify) •Impaired physical mobility •Impaired skin integrity •Nausea •Acute pain •Determine the status of preoperative nursing diagnoses by clustering new postoperative assessment data. Then either revise or resolve preoperative diagnoses and identify relevant new diagnoses after surgery. •It is common to identify new nursing diagnoses after surgery because of the risks or problems associated with surgery. Also consider the assessed needs of a patient's family when you identify nursing diagnoses. In the formulation of nursing diagnoses, be accurate in identifying a related factor (when appropriate).

Intraoperative Surgical Phase

•Nursing roles during surgery •Circulating nurse •Scrub nurse •Registered nurse first assistant •There are two traditional nursing roles in the OR: circulating nurse and scrub nurse. •The circulating nurse is an RN who remains unscrubbed and uses the nursing process in the management of patient care activities in the OR suite. The circulating nurse also manages patient positioning, antimicrobial skin preparation, medications, implants, placement and function of intermittent pneumatic compression (IPC) devices, specimens, warming devices, and surgical counts of instruments and dressings. •The scrub nurse is either an RN or surgical technologist who is often certified (CST). The scrub nurse must have a thorough knowledge of each step of a surgical procedure and the ability to anticipate each and every instrument and supply needed by the surgeons. •A circulating nurse and scrub nurse partner together to ensure patient safety by minimizing risk of error. The team also works together to ensure cost-efficient use of supplies. A new role in the OR includes the registered nurse first assistant (RNFA). This is an expanded role that requires formal academic education. The RNFA collaborates with the surgeon by handling and cutting tissue, using instruments and medical devices, providing exposure of the surgical area and hemostasis, and suturing

Intraoperative Surgical Phase (Cont)

•Nursing process •Assessment •Nursing diagnosis •Planning •Goals and outcomes •Setting priorities •Teamwork and collaboration •Once a patient enters the OR the circulating nurse thoroughly assesses the patient and critically analyzes findings to make patient-centered clinical decisions required for safe nursing care. The assessment will usually focus on the patient's immediate clinical status, skin integrity (over surgical site and dependent areas where patient will lay on operating table bed), and joint function (when unusual positions on the OR table are required). As the nurse, review the preoperative care plan to establish or revise the intraoperative care plan as indicated. •Review preoperative nursing diagnoses and modify them to individualize the care plan in the OR. •[Ask students: What are some common nursing diagnoses relevant to the patient intraoperatively? Discuss: Ineffective airway clearance, Risk for deficient fluid volume, Risk for perioperative positioning injury, Impaired skin integrity, Risk for Thermal Injury, Risk for injury.] •Patient-centered goals and outcomes of preoperative nursing diagnoses extend into the intraoperative phase. For example, a goal for the nursing diagnosis of risk for thermal injury is "Skin will remain free of burn injury through surgical procedure." An expected outcome for this goal is: Patient will be free of burns from the grounding pad at end of surgery. •The circulating nurse uses judgment to provide a safe operative experience for the patient. Ensuring an aseptic environment, conducting instrument and sponge counts according to policy, managing tissue and specimens correctly, and assuring proper use of equipment and instruments are top priorities. If an unsafe practice begins to occur (e.g., break in sterility, missing sponge in wound), the circulating nurse is integral to ensuring the safety of the patient and operative personnel. •For optimal patient safety the preoperative health care team communicates assessment findings and patient problems via a formal hand-off with the surgical team to ensure a smooth transition in care. For example, alerting the operative team of a latex allergy or risk factors for complications during surgery (smoker) requires collaboration and timely communication among all team members.

Preanesthesia Care Unit

•Preanesthesia care unit (PCU) or presurgical care unit (PSCU) (holding area) •PCU nurse •Inserts IV catheter (if not already present) •Administers preoperative medications •Monitors vital signs •Anesthesia provider •Performs patient assessment •In most hospitals, a patient enters a preanesthesia care unit (PCU) or presurgical care unit (PSCU) (sometimes called the holding area) outside the OR, where preoperative preparations are completed. •Nurses in the PCU are members of the OR staff and wear surgical scrub suits, hats, and footwear in accordance with infection control policies. In some ambulatory surgical settings, a perioperative primary nurse admits the patient, circulates for the operative procedure, and manages the patient's recovery and discharge. •If an IV catheter is not already present, a nurse or anesthesia provider inserts one into a vein to establish a route for fluid replacement, IV drugs, or blood products. •The nurse also administers preoperative medications and/or begins conscious sedation at this time. •The nurse monitors vital signs, including pulse oximetry. •The anesthesia provider usually performs a patient assessment at this time. Because of the preoperative medications, explain to the patient that he or she will begin to feel drowsy. •The temperature in the PCU and adjacent OR suites is usually cool, so offer the patient an extra blanket. The patient will stay in the PCU only briefly.

Postoperative Convalescence: Implementation cont

•Restorative and continuing care •Prepare for discharge •Provide patient education •Help patients adhere to exercise programs •Make referrals to home care as needed •In the postoperative period the nurse, patient, and family work to prepare the patient for discharge. Patients often have to continue wound care, follow activity or diet restrictions, continue medication therapy, and observe for signs and symptoms of complications on returning home. Education regarding these activities is specific to the type of surgery and is an ongoing process throughout hospitalization. It is important that nurses provide specific, culturally appropriate and accurate verbal and written discharge instructions to enhance the ability of patients to care for themselves at home. •With ambulatory surgery patients, focused education within the limited time frame is essential. Including the family or support system provides a resource for the patient once home. With both ambulatory and hospitalized surgical patients, provide a wide variety of written educational materials. For example, offer materials with more pictures and illustrations for patients who do not speak English or have limited reading ability. Ensure that all materials are sensitive to various cultures and religions. Patients receive a copy of signed discharge instructions, and one copy remains in the medical or electronic record. •Surgical recovery is slowed if patients are deconditioned and then fail to exercise regularly. Recent research shows the important of keeping frail older adults active after surgery. A person is considered frail if they have three of the following: unintentional weight loss, low physical activity, slowed motor performance, weakness, and fatigue or exercise intolerance. Aerobic exercise and physical resistance training have promise in improving patients' gait speed and ability to perform activities of daily living (ADLs). Nurses must find strategies to help patients remain adherent to recommended exercise programs and realize the importance of involving family caregivers if patients have dementia or mental alterations. •Some patients need home care assistance in the postoperative period after discharge. For example, nurses make referrals to home care for skilled nursing requirements when patients need wound care, ongoing IV therapy, or drain management. In addition, patients who are more physically dependent may require assistance from nursing assistive personnel to provide bathing and hygiene needs. The case coordinator or social worker at the hospital helps with discharge coordination. Encourage patients to show their discharge instructions to home care providers. •Other patients, especially older adults, may require discharge to a rehabilitation or skilled nursing facility after their hospital recovery. During their convalescence, patients work to gain mobility and recovery of their independent living skills. In addition, nurses provide wound care and other specialized services. A case coordinator or social worker works with the patient, family, and nurse to coordinate transfer to the skilled facility.

Preoperative Surgical Phase: Assessment cont

•Support sources •Occupation •Preoperative pain assessment •Review of emotional health •Self-concept •Body image •Coping resources •Cultural and spiritual factors •Always assess who comprises a patient's family and their level of support. With ambulatory surgery, patients and/or family caregivers assume responsibility for postoperative care. Often a family member becomes the patient's coach, offering valuable support postoperatively when the patient's participation in care is vital. •Assess the patient's occupational history to anticipate the possible effects of surgery on recovery, return to work, and eventual work performance. When a patient is unable to return to a job, refer to a social worker and/or occupational therapist for job-training programs or to seek economic assistance. •Providing patient education about pain reduces preoperative anxiety, which is frequently associated with postoperative pain. Teach patients preoperatively how to use a pain scale so they can be prepared to rate their pain postoperatively. •Surgery is psychologically stressful. Patients are often anxious about surgery and its implications and believe that they are powerless over their situation. Family members may perceive the patient's surgery as a disruption of their lifestyle. Explain that it is normal to have fears and concerns. A patient's ability to share feelings partially depends on your willingness to listen, be supportive, and clarify misconceptions. Assure patients of their right to ask questions and seek information. •Assess self-concept by asking patients to identify personal strengths and weaknesses. Poor self-concept hinders the ability to adapt to the stress of surgery and aggravates feelings of guilt or inadequacy. •Assess patients' perceptions of the potential for body image alterations from surgery. Individuals respond differently, depending on their culture, experience in seeing others with alterations, and their own self-concept and self-esteem. Encourage patients to express concerns about their sexuality. The patient facing even temporary sexual dysfunction requires understanding and support. Hold discussions about the patient's sexuality with the patient's sexual partner so the partner gains a shared understanding of how to cope with limitations in sexual function. •Assessment of patients' feelings and self-concept reveals whether they have the ability to cope with the stress of surgery. The physiological effects of stress are well documented. Activation of the endocrine system results in the release of hormones and catecholamines, which increases blood pressure, heart rate, and respiration. Platelet aggregation also occurs, along with many other physiological responses. Be aware of these responses and assist with stress management by offering relaxation exercises •Patients come from diverse cultural, ethnic, educational, geographic and spiritual backgrounds, which affect the way each patient perceives and reacts to the surgical experience. If you do not acknowledge and plan for cultural and spiritual differences in the perioperative plan of care, you may not achieve desired surgical outcomes. Although it is important to recognize and plan for differences based on culture, it is also necessary to recognize that members of the same culture are individuals and do not always hold these shared beliefs.

Maintenance and Promotion of Lung Expansion

- Ambulation - Positioning - Reduces pulmonary stasis, maintains ventilation and oxygenation - Incentive spirometry - Encourages voluntary deep breathing •Immobility is a major factor in developing atelectasis, ventilator-associated pneumonia (VAP), and functional limitations. Progressive mobilization from dangling the legs to standing and then walking is safe for intubated patients. •Frequent changes of position are simple and cost-effective methods for reducing stasis of pulmonary secretions and decreased chest wall expansion, both of which increase the risk of pneumonia. Research shows that turning critically ill patients every 2 hours is not often enough to prevent pneumonia. •The 45-degree semi-Fowler's is the most effective position for promoting lung expansion and reducing pressure from the abdomen on the diaphragm. In the presence of pulmonary abscess or hemorrhage, position the patient with the affected lung down to prevent drainage toward the healthy lung. For bilateral lung disease, the best position depends on the severity of the disease. •Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient. There is solid evidence to support the use of lung expansion with incentive spirometry in preventing postoperative pulmonary complications following surgery. •Incentive spirometry encourages patients to use visual feedback to maximally inflate their lungs and sustain that inflation.

Nursing diagnosis (activity)

-Activity intolerance -Ineffective coping -Impaired gas exchange -Risk for injury -Impaired bed mobility -Impaired physical mobility -Acute or chronic pain

Alterations in Cardiac functioning cont.

-Altered cardiac output -Left-sided heart failure -Right-sided heart failure -Impaired valvular function -Myocardial ischemia -Angina -Myocardial infarction •Failure of the myocardium to eject sufficient volume to the systemic and pulmonary circulations occurs in heart failure. •Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. •If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, resulting in decreased cardiac output. •Signs and symptoms include fatigue, breathlessness, dizziness, and confusion as a result of tissue hypoxia from the diminished cardiac output. •As the left ventricle continues to fail, blood begins to pool in the pulmonary circulation, causing pulmonary congestion. •Clinical findings include crackles in the bases of the lungs on auscultation, hypoxia, shortness of breath on exertion, cough, and paroxysmal nocturnal dyspnea. •Right-sided heart failure results from impaired functioning of the right ventricle. •It more commonly results from pulmonary disease or as a result of long-term left-sided failure. •The primary pathological factor in right-sided failure is elevated pulmonary vascular resistance (PVR). As the PVR continues to rise, the right ventricle works harder, and the oxygen demand of the heart increases. As the failure continues, the amount of blood ejected from the right ventricle declines, and blood begins to "back up" in the systemic circulation. •Clinically the patient has weight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema. •Valvular heart disease is an acquired or congenital disorder of a cardiac valve that causes either hardening (stenosis) or impaired closure (regurgitation) of the valves. When stenosis occurs, the flow of blood through the valves is obstructed. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. •Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands. •Angina pectoris is a transient imbalance between myocardial oxygen supply and demand. The condition results in chest pain that is aching, sharp, tingling, or burning or that feels like pressure. Typically chest pain is left sided or substernal and often radiates to the left or both arms, the jaw, neck, and back. It is usually relieved with rest and coronary vasodilators, the most common being a nitroglycerin preparation. •Myocardial infarction (MI) or acute coronary syndrome (ACS) results from sudden decreases in coronary blood flow or an increase in myocardial oxygen demand without adequate coronary perfusion. Infarction occurs because ischemia is not reversed. Cellular death occurs after 20 minutes of myocardial ischemia. •Chest pain associated with MI in men is usually described as crushing, squeezing, or stabbing. The pain is often in the left chest and sternal area; may be felt in the back; and radiates down the left arm to the neck, jaws, teeth, epigastric area, and back. It occurs at rest or exertion and lasts more than 20 minutes. Rest, position change, or sublingual nitroglycerin administration does not relieve the pain. There is a significant difference between men and women in relation to coronary artery disease. Women's symptoms differ from those of men. The most common initial symptom in women is angina, but they also present with atypical symptoms such as fatigue, indigestion, shortness of breath, and back or jaw pain. Women have twice the risk of dying within the first year after a heart attack than men

Factors influencing activity and exercise cont.

-Environmental issues -Work site -Schools -Community -Cultural and ethnic influences -Family and social support -common barrier for patients is the lack of time needed to engage in daily exercise

Planning (activity)

-Goals and outcomes -Goal: improve or maintain the patient's motor function and independence -Setting priorities -Take into account the patient's most immediate needs -Teamwork and collaboration -Physical and occupational therapists -Discharge planning

Maintenance and Promotion of Oxygenation

-Oxygen therapy -To prevent or relieve hypoxia -Safety precautions -Supply of oxygen -Tanks or wall-piped system -Methods of oxygen delivery -Nasal cannula -Oxygen mask •Promotion of lung expansion, mobilization of secretions, and maintenance of a patent airway assist patients in meeting their oxygenation needs. •The goal of oxygen therapy is to prevent or relieve hypoxia by delivering oxygen at concentrations greater than ambient air (21%). •Oxygen has dangerous side effects such as oxygen toxicity. The dosage or concentration of oxygen is monitored continuously. Routinely check the health care provider's orders to verify that the patient is receiving the prescribed oxygen concentration. The six rights of medication administration also pertain to oxygen administration. •Supplemental oxygen therapy offers many benefits to patients with chronic cardiopulmonary diseases. This therapy reduces mortality, improved self-reported sleep quality and general comfort, increased exercise tolerance, and reduced polycythemia and pulmonary hypertension. •[Review Box 41-9, Procedural Guidelines: Applying a Nasal Cannula or Oxygen Mask, with students.] •Oxygen is a highly combustible gas. Although it does not burn spontaneously or cause an explosion, it can easily cause a fire in a patient's room if it contacts a spark from an open flame or electrical equipment. •Promote oxygen safety by the following measures: •Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. Distribution must be in accordance with federal, state, and local regulations (AARC, 2007). •Place an "Oxygen in Use" sign on the patient's door and in the patient's room. If using oxygen at home, place a sign on the door of the house. No smoking should be allowed on the premises. •Keep oxygen-delivery systems 10 feet from any open flames. •Determine that all electrical equipment in the room is functioning correctly and properly grounded (see Chapter 27). An electrical spark in the presence of oxygen can result in a serious fire. •When using oxygen cylinders, secure them so they do not fall over. Store them upright and either chained or secured in appropriate holders. •Check the oxygen level of portable tanks before transporting a patient to ensure that there is enough oxygen in the tank. •Ensure that patients have adequate oxygen tubing to safely move around their home environment. Tubing up to 98 feet (30 m) will deliver the prescribed oxygen flow rate. •Oxygen is supplied to a patient's bedside either by oxygen tanks or through a permanent wall-piped system. In the hospital or home, oxygen tanks are delivered with the regulator in place. •The nasal cannula and oxygen masks are the most common devices to deliver oxygen to patients. •A nasal cannula is a simple, comfortable device used for precise oxygen delivery. The two nasal prongs are slightly curved and inserted in a patient's nostrils. •An oxygen mask is a plastic device that fits snugly over the mouth and nose and is secured in place with a strap. It delivers oxygen as the patient breathes through either the mouth or nose by way of a plastic tubing at the base of the mask that is attached to an oxygen source.

Principles of Transfer and Positioning Techniques

-When moving a patient, knowledge of safe transfer and positioning is crucial. -Pathological influences on body alignment mobility, and activity: -Congenital defects *Scoliosis and osteogenesis -Disorders of bones, joints, and muscles *Osteoporosis, osteomalcia, inflammatory joint disease -Central nervous system damage -Musculoskeletal trauma *Bruises, contusions, sprains, fractures

Implementation: Health Promotion

-Vaccinations -Influenza, pneumococcal -Healthy lifestyle -Eliminating risk factors, eating right, regular exercise -Environmental pollutants -Secondhand smoke, work chemicals, and pollutants •Health promotion includes vaccinations against flu and pneumonia, exercise programs, nutrition support, smoking cessation, and environmental assessment for pollutants and air quality. •Maintaining the patient's optimal level of health is important in reducing the number and/or severity of respiratory symptoms. Prevention of respiratory infections is foremost in maintaining optimal health. Providing cardiopulmonary-related health information is an important nursing responsibility. •[Review Box 41-6, Patient Teaching: Prevention of Recurrent Respiratory Infections, with students.] •Flu shot is recommended for children 6 months and older, and for those with chronic illnesses. It is also recommended for those who are in contact with high-risk groups (health care providers) and for immunosuppressed and human immunodeficiency virus (HIV)-positive individuals. •Pneumococcal vaccine is recommended for those older than 65 years of age, those at risk for pneumonia, and those with chronic illnesses or immunosuppression (such as acquired immunodeficiency syndrome [AIDS] or HIV). •Encourage patients to eat a healthy low-fat, high-fiber diet; monitor their cholesterol, triglyceride, high-density lipoprotein (HDL), and low-density lipoprotein (LDL) levels; reduce stress; exercise; and maintain a body weight in proportion to their height. Eliminating cigarettes and other tobacco, reducing pollutants, monitoring air quality, and adequately hydrating are additional healthy behaviors. •Exercise is a key factor in promoting and maintaining a healthy heart and lungs. •Patients with known cardiac disease and those with multiple risk factors are cautioned to avoid exertion in cold weather. •Avoiding exposure to secondhand smoke is essential to maintaining optimal cardiopulmonary function. People who work as farmers, painters, or carpenters might benefit from the use of particulate filter masks to reduce inhalation of particles.

Nature of Movement

Body mechanics Coordinated efforts of the musculoskeletal and nervous systems Alignment and balance Also refers to posture Gravity Weight force exerted on the body Friction Force that occurs in a direction opposite to movement •Movement requires a coordinated effort between the musculoskeletal and nervous systems. Nurses pay attention to body mechanics to avoid injury to self and patients. •Body mechanics are the coordinated efforts of the musculoskeletal and nervous systems. •Today nurses use information about body alignment, balance, gravity, and friction when implementing nursing interventions such as positioning patients, determining the risk of patient falls, and selecting the safest way to move or transfer patients. •Alignment and balance or posture refer to the positioning of joints, tendons, ligaments, and muscles while standing, sitting, or lying. Body alignment means that the individual's center of gravity is stable. Without balance control the center of gravity is displaced. •Individuals require balance for maintaining a static position (e.g., sitting) and moving (e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. •Medications that cause dizziness and prolonged immobility effect balance. •Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions. •Weight is the force exerted by gravity. The force of weight is always directed downward. This is why an unbalanced object falls. •Individuals require balance for maintaining a static position (e.g., sitting) and moving (e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes (e.g., pregnancy) compromise the ability to remain balanced. Medications that cause dizziness and prolonged immobility effect balance. Impaired balance is a major threat to mobility and physical safety and contributes to a fear of falling and self-imposed activity restrictions. •People's centers of gravity are usually at 55% to 57% of standing height and are in the midline, which is why only using principles of body mechanics in lifting patients often leads to injury of the nurse or health care professional •The greater the surface area of the object that is moved, the greater the friction. Large objects produce greater resistance to movement. This is why nurses need to be aware of the friction that can cause a patient's skin to shear or tear. •The force exerted against the skin while the skin remains stationary and the bony structures move is called shear.

Alterations in Respiratory Functioning

Hypoventilation Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide Hyperventilation Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism Hypoxia Inadequate tissue oxygenation at the cellular level Cyanosis Blue discoloration of the skin and mucous membranes •Illnesses or conditions that affect ventilation or oxygen transport cause alterations in respiratory functioning. •The goal of ventilation is to produce a normal arterial carbon dioxide tension (PaCO2) between 35 and 45 mm Hg and a normal arterial oxygen tension (PaO2) between 80 and 100 mm Hg. Hypoventilation and hyperventilation are often determined by arterial blood gas analysis. •Hypoxemia refers to a decrease in the amount of arterial oxygen. Nurses monitor arterial oxygen saturation (SpO2) using a noninvasive oxygen saturation monitor pulse oximeter. Normally SpO2 is greater than or equal to 95%. •Hypoventilation occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. As alveolar ventilation decreases, the body retains carbon dioxide. •Their peripheral chemoreceptors of the aortic arch and carotid bodies are primarily sensitive to lower oxygen levels, causing increased ventilation. Because the stimulus to breathe is a decreased arterial oxygen (PaO2) level, administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. •Signs and symptoms of hypoventilation include mental status changes, dysrhythmias, and potential cardiac arrest. If untreated, the patient's status rapidly declines, leading to convulsions, unconsciousness, and death. •[Ask students to identify signs and symptoms. Answers may include dizziness, headache upon awakening, lethargy, cardiac dysrhythmias, electrolyte imbalances, convulsions, coma, and cardiac arrest.] •Severe anxiety, infection, drugs, or an acid-base imbalance induces hyperventilation. Hyperventilation is sometimes chemically induced. It also occurs as the body tries to compensate for metabolic acidosis. •Signs and symptoms of hyperventilation include rapid respirations, sighing breaths, numbness and tingling of hands/feet, light-headedness, and loss of consciousness. •Why? Answers may include that an increase in respiratory rate causes excessive amounts of carbon dioxide elimination. • Causes of hypoxia include (1) a decreased hemoglobin level and lowered oxygen-carrying capacity of the blood; (2) a diminished concentration of inspired oxygen, which occurs at high altitudes; (3) the inability of the tissues to extract oxygen from the blood, as with cyanide poisoning; (4) decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia; (5) poor tissue perfusion with oxygenated blood, as with shock; and (6) impaired ventilation, as with multiple rib fractures or chest trauma. •The clinical signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. The patient with hypoxia is unable to lie flat and appears both fatigued and agitated. Vital sign changes include an increased pulse rate and rate and depth of respiration. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock. As the hypoxia worsens, the respiratory rate declines as a result of respiratory muscle fatigue. •Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status. •Central cyanosis, observed in the tongue, soft palate, and conjunctiva of the eye where blood flow is high, indicates hypoxemia. •Peripheral cyanosis, seen in the extremities, nail beds, and earlobes, is often a result of vasoconstriction and stagnant blood flow.

Physical Examination (o2)

Inspection Skin and mucous membrane color, level of consciousness (LOC), breathing patterns, chest wall movement, general appearance, circulation Palpation Chest, feet, legs, pulses Percussion Presence of abnormal fluid or air; diaphragmatic excursion Auscultation Normal and abnormal heart and lung sounds •The physical examination includes assessment of the cardiopulmonary system. •When assessing an older adult patient, give special consideration to changes that occur with the aging process. These changes affect the patient's activity tolerance and level of fatigue or cause transient changes in vital signs and are not always associated with a specific cardiopulmonary disease. •[Review Table 41-1, Effects of Aging on Assessment Findings of the Cardiopulmonary System, Inspection: skin and mucous membranes for color, appearance, level of consciousness, adequacy of systemic circulation, breathing patterns, and chest wall movement. Inspection includes observations of the nails for clubbing. •At rest the normal adult rate is 12 to 20 regular breaths/min. Bradypnea is less than 12 breaths/min, and tachypnea is greater than 20 breaths/min. •In some conditions, such as metabolic acidosis, the acidic pH stimulates an increase in rate, usually greater than 35 breaths/min, and depth of respirations (Kussmaul respiration) to compensate by decreasing carbon dioxide levels. •Apnea is the absence of respirations for lasting for 15 seconds or longer. •Cheyne-Stokes respiration occurs when there is decreased blood flow or injury to the brainstem. •Conditions such as emphysema, advancing age, and COPD cause the chest to assume a rounded "barrel" shape. •Palpation: •Palpation of the chest provides assessment data in several areas. It documents the type and amount of thoracic excursion; elicits any areas of tenderness; and helps to identify tactile fremitus, thrills, heaves, and the cardiac point of maximal impulse (PMI). •Palpation of the extremities provides data about the peripheral circulation (e.g., the presence and quality of peripheral pulses, skin temperature, color, and capillary refill) (see Chapter 31). •Palpation of the feet and legs determines the presence or absence of peripheral edema. Patients with alterations in cardiac function, such as those with heart failure or hypertension, often have pedal or lower-extremity edema. Edema is graded from 1+ to 4+ depending on the depth of visible indentation after firm finger pressure. •Palpate the pulses in the neck and extremities to assess arterial blood flow (see Chapter 31). Use a scale of 0 (absent pulse) to 4 (full, bounding pulse) to describe what you feel. The normal pulse is 2; and a weak, thready pulse is 1. •Percussion: detects the presence of abnormal fluid or air in the lungs. It also determines diaphragmatic excursion. •Auscultation: identification of normal and abnormal heart and lung sounds. •Auscultation of the cardiovascular system includes assessment for normal S1 and S2 sounds and the presence of abnormal S3 and S4 sounds (gallops), murmurs, or rubs. Identify the location, radiation, intensity, pitch, and quality of a murmur. Auscultation also identifies any bruit over the carotid, abdominal aorta, and femoral arteries. •Auscultation of lung sounds involves listening for movement of air throughout all lung fields: anterior, posterior, and lateral. Adventitious, or abnormal, breath sounds occur with collapse of a lung segment, fluid in a lung segment, or narrowing or obstruction of an airway.

Maintenance and Promotion of Lung Expansion cont.

Invasive mechanical ventilation -Life-saving technique used with artificial airways (ET or tracheostomy) -Physiological indications -Clinical indications •Physiological indications for invasive mechanical ventilation include supporting cardiopulmonary gas exchange (alveolar ventilation and arterial oxygenation) increasing lung volume, and reducing the work of breathing. •Clinical indications for invasive mechanical ventilation include reversing hypoxia and acute respiratory acidosis, relieving respiratory distress, preventing or reversing atelectasis and respiratory muscle fatigue, allowing for sedation and/or other neuromuscular blockade, decreasing oxygen consumption, reducing intracranial pressure and stabilizing the chest wall. It can be used to either fully or partially replace spontaneous breathing depending on the need of the patient. •Ventilatory support is achieved using a variety of modes; the choice is dependent upon the patient's situation and goals of treatment. •The most commonly used modes: assist-control (AC), synchronized intermittent mandatory ventilation (SIMV) and pressure support ventilation (PSV). •Assist Control delivers a set tidal volume (VT) with each breath, regardless if the breath was triggered by the patient or the ventilator. •Synchronized intermittent mandatory ventilation like AC, delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths are determined by the patient's strength, effort, and lung mechanics. •Pressure Support mode is often combined with SIMV mode, inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient's spontaneous breaths. •Physiological complications associated with invasive mechanical ventilation include: volutrauma, cardiovascular compromise, gastrointestinal disturbances, and ventilator-associate pneumonia. •Volutrauma occurs as a result of alveolar overdistention secondary to the mechanical ventilation. •Ventilator-associated pneumonia (VAP) is a significant potential complication because the artificial airway tube bypasses many of the lung's normal defense mechanisms.

Systemic effects

Metabolic Endocrine, calcium absorption, and GI function Respiratory Atelectasis and hypostatic pneumonia Cardiovascular Orthostatic hypotension Thrombus Musculoskeletal changes Loss of endurance and muscle mass and decreased stability and balance Muscle effects Loss of muscle mass Muscle atrophy Skeletal effects Impaired calcium absorption Joint abnormalities Urinary elimination Urinary stasis Renal calculi Integumentary Pressure ulcer Ischemia

Assessment Nursing History (o2)

Pain Fatigue Dyspnea Cough Wheezing Smoking Respiratory infection Allergies Health risks Medications •The nursing history focuses on the patient's ability to meet oxygen demands. •The nursing history for respiratory function includes the presence of a cough, shortness of breath, dyspnea, wheezing, pain, environmental exposures, frequency of respiratory tract infections, pulmonary risk factors, past respiratory problems, current medication use, and smoking history or secondhand smoke exposure. •The nursing history for cardiac function includes pain and characteristics of pain, fatigue, peripheral circulation, cardiac risk factors, and the presence of past or concurrent cardiac conditions. Ask specific questions related to cardiopulmonary disease. •[Review Box 41-2, Nursing Assessment Questions, with students.] •The presence of chest pain requires an immediate thorough evaluation, including assessment of location, duration, radiation, and frequency. Note any other symptoms associated with chest pain, such as nausea, diaphoresis, extreme fatigue or weakness. •Pleuritic chest pain results from inflammation of the pleural space of the lungs, the pain is peripheral and radiates to the scapular regions. •Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes. •Fatigue in the patient with cardiopulmonary alterations is often an early sign of worsening of the chronic underlying process. •Dyspnea is a clinical sign of hypoxia. It is the subjective sensation of difficult or uncomfortable breathing. •Dyspnea is associated with exaggerated respiratory effort, use of the accessory muscles of respiration, nasal flaring, and marked increases in the rate and depth of respirations. The use of a visual analogue scale (VAS) helps patients objectively assess their dyspnea. •Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. •Patients with a chronic cough tend to deny, underestimate, or minimize their coughing. Often, because they are so accustomed to it, they are unaware of how frequently it occurs. •Patients with chronic sinusitis usually cough only in the early morning or immediately after rising from sleep. •If hemoptysis (bloody sputum) is present, determine whether it is associated with coughing and bleeding from the upper respiratory tract, sinus drainage, or the gastrointestinal tract (hematemesis). •Wheezing is a high-pitched musical sound caused by high-velocity movement of air through a narrowed airway. It is associated with asthma, acute bronchitis, and pneumonia. •Environmental exposure to inhaled substances is closely linked with respiratory disease. •With CO poisoning, the patient will have vague complaints of general malaise, flulike symptoms, and excessive sleepiness. •Radon gas is a radioactive substance from the breakdown of uranium in soil, rock, and water that enters homes through the ground or well water. •It is important to determine patients' direct and secondary exposure to tobacco. Ask about any history of smoking; include the number of years smoked and the number of packs smoked per day. This is recorded as pack-year history. •Obtain information about the patient's frequency and duration of respiratory tract infections. Ask about any known exposure to tuberculosis (TB) and the date and results of the last tuberculin skin test. •Determine the patient's risk for human immunodeficiency virus (HIV) infection. Patients with a history of intravenous (IV) drug use and multiple unprotected sexual partners are at risk of developing HIV infection. •When obtaining information about allergies, ask specific questions about the types of allergens, responses to these allergens, and successful and unsuccessful relief measures. •Determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Documentation includes blood relatives who had cardiopulmonary disease and their present level of health or age at time of death. Other family risk factors include the presence of infectious diseases, particularly TB. •Medications include prescribed medications, over-the-counter medications, folk medicines, herbal medicines, alternative therapies, and illicit drugs (such as opioids, marijuana, cocaine) and substances. •It is important to determine if a patient uses illicit drugs. •Assess the patient's knowledge and ability to self-administer medications correctly.

Critical thinking (o2)

Use professional standards: -Agency for Healthcare Research and Quality (AHRQ) -American Cancer Society (ACS) -American Heart Association (AHA) -American Lung Association (ALA) -American Thoracic Society (ATS) -American Nurses Association (ANA) •To understand how alterations in oxygenation affect patients and the interventions necessary, you need to integrate knowledge from nursing and other disciplines and information gathered from patients. Critical thinking attitudes ensure that you approach patient care in a methodical and logical way.

Assistive Devices for walking

Walkers -The patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and takes another step •In collaboration with other health care professionals such as physical therapists, promote activity and exercise by teaching the proper use of canes, walkers, or crutches, depending on the assistive device most appropriate for the patient's condition. •Walkers are extremely light, movable devices that are about waist high and made of metal tubing. They have four widely placed, sturdy legs. In the home, many patients prefer walkers with wheels or short runners on the legs that allow them to push the walker. Instruct patients on how to use walkers safely and avoid the risk of falling.

Structure and Function cont (o2)

Work of breathing -The effort required to expand and contract the lungs. -Inspiration and expiration -Surfactant -Atelectasis -Compliance and airway resistance •Inspiration is an active process, stimulated by chemical receptors in the aorta. •Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. •Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. •Patients with advanced chronic obstructive pulmonary disease (COPD) lose the elastic recoil of the lungs and thorax. As a result, the patient's work of breathing increases. •Patients with certain pulmonary diseases have decreased surfactant production and sometimes develop atelectasis. •Atelectasis is a collapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide. •Accessory muscles of respiration can increase lung volume during inspiration. •Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. During assessment observe for elevation of the patient's clavicles during inspiration, which can indicate ventilatory fatigue, air hunger, or decreased lung expansion. •Compliance is the ability of the lungs to distend or expand in response to increased intraalveolar pressure. Compliance decreases in diseases such as pulmonary edema, interstitial and pleural fibrosis, and congenital or traumatic structural abnormalities such as kyphosis or fractured ribs. •Airway resistance is the increase in pressure that occurs as the diameter of the airways decreases from mouth/nose to alveoli. Any further decrease in airway diameter by bronchoconstriction can increase airway resistance. Diseases causing airway obstruction such as asthma and tracheal edema increase airway resistance. When airway resistance increases, the amount of oxygen delivered to the alveoli decreases. •Decreased lung compliance, increased airway resistance, and the increased use of accessory muscles increase the work of breathing (WOB), resulting in increased energy expenditure. Therefore the body increases its metabolic rate and the need for more oxygen. The need for elimination of carbon dioxide also increases.

Perfusion

the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Perfusion relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

Measuring for crutches

•Position the handgrips so the axillae are not supporting the patient's body weight. •Pressure on the axillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. •Determine correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20 to 25 degrees. •Elbow flexion may be verified with a goniometer. •When you determine the height and placement of the handgrips, verify that the distance between the crutch pad and the patient's axilla is approximately 2 inches (two to three finger widths).

Nursing Process: Assessment (Cont.)

•Physiologic hazards of mobility •Metabolic •Respiratory •Cardiovascular •Musculoskeletal •Integumentary •Elimination •Psychosocial •Developmental •Assess the patient for hazards of immobility by performing a head-to-toe physical assessment , as well as psychological and developmental dimensions. •When assessing metabolic functioning, use anthropometric measurements (measures of height, weight, and skinfold thickness) to evaluate muscle atrophy. Analyze intake and output records for fluid balance. Dehydration and edema increase the rate of skin breakdown in a patient who is immobilized. Monitoring laboratory data such as levels of electrolytes, serum protein (albumin and total protein), and blood urea nitrogen (BUN) aid the nurse in determining metabolic functioning. •Monitoring food intake and elimination patterns and assessing wound healing help to determine altered gastrointestinal functioning and potential metabolic problems. •Perform a respiratory assessment at least every 2 hours for patients with restricted activity. The respiratory assessment includes inspecting the chest for wall movement and auscultating the lungs for decreased breath sounds, crackles, and wheezes. •Cardiovascular nursing assessment of the patient who is immobilized includes blood pressure monitoring, evaluation of apical and peripheral pulses, and observation for signs of venous stasis. To assess for a deep vein thrombosis (DVT), remove the patient's elastic stockings and/or sequential compression devices (SCDs) every 8 hours (or according to agency policy) and observe the calves for redness, warmth, and tenderness. Measure bilateral calf circumference and record it daily as an alternative assessment for DVT. •Because DVTs also occur in the thigh, take thigh measurements daily if the patient is prone to thrombosis. A dislodged venous thrombus, called an embolus, can travel through the circulatory system to the lungs and impair circulation and oxygenation, resulting in tachycardia and shortness of breath. Venous emboli that travel to the lungs are sometimes life threatening. More than 90% of all pulmonary emboli begin in the deep veins of the lower extremities. •Major musculoskeletal abnormalities to identify during nursing assessment include decreased muscle tone and strength, loss of muscle mass, and contractures. Early assessment of ROM is important because it establishes a baseline against which later measurements can be compared to evaluate whether a loss in joint mobility has occurred. •Continually assess the patient's skin for breakdown and color changes such as pallor or redness. Consistently use a standardized tool such as the Braden Scale. Frequent skin assessment, which can be as often as every hour, are based on patients mobility, hydration, and physiological status is essential to promptly identify changes in patients' skin and underlying tissues. •Evaluate the patient's elimination status on each shift and total intake and output every 24 hours. Inadequate intake and output or fluid and electrolyte imbalances increase the risk for renal system impairment, ranging from recurrent infections to kidney failure. Dehydration also increases the risk for skin breakdown, thrombus formation, respiratory infections, and constipation. •Assessment of bowel elimination status includes the adequacy of dietary choices, bowel sounds, and the frequency and consistency of bowel movements. •During the psychosocial assessment, you will focus on the patient's emotional state, behavior, and sleep-wake cycle. •The developmental assessment looks at how immobility affects the normal development of patients across the life span. Design nursing interventions that maintain normal development, provide physical and psychosocial stimuli after identifying a child's developmental needs, and assure the parents that developmental delays are usually temporary. •Immobilization of a family member changes family functioning. •Immobility has a significant effect on the older adult's levels of health, independence, and functional status. Assessment also includes the patient's home and community to identify factors that are risks to his or her mobility and safety.

Nursing Process: Assessment cont.

•Range of motion •Contractures: develop in joints not moved periodically through their full ROM •Neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes •A flexion contracture of the neck is a serious disability because the patient's neck is permanently flexed with the chin close to or actually touching the chest. Assessment reveals altered body alignment, changes in the visual field, and decreased level of independent functioning. •One feature of the shoulder that sets it apart from other joints in the body is that the strongest muscle controlling it, the deltoid, is in complete elongation in the normal position. No other muscle exerts its full strength when in complete elongation. Patients with limited movement in the shoulder have difficulty moving their arms. •The elbow functions optimally at an angle of approximately 90 degrees. An elbow fixed in full extension is disabling and limits the patient's independence. •Most functions of the hand are best carried out with the forearm in moderate pronation. When the forearm is fixed in a position of full supination, the patient's use of the hand is limited. •The primary function of the wrist is to place the hand in slight dorsiflexion, the position of functioning. When the wrist is fixed in even a slightly flexed position, the grasp is weakened. •The ROM in the fingers and thumb enables the patient to perform ADLs and activities requiring fine-motor skills such as carpentry, needlework, drawing, and painting. The functional position of the fingers and thumb is slight flexion of the thumb in opposition to the fingers. •Because the lower extremities are concerned chiefly with locomotion and weight bearing, stability of the hip joint is more important than its mobility. Excessive abduction makes the affected leg appear too short, whereas excessive adduction makes it appear too long. In either case the patient has limited locomotion and walks with an obvious limp. Internal and external rotation contractures cause an abnormal and unbalanced gait. •A primary function of the knee is stability, which is achieved by ROM, ligaments, and muscles. However, the knees cannot remain stable under weight-bearing conditions unless there is adequate quadriceps power to maintain the knee in full extension. An immobile knee joint results in serious disability. The degree of disability depends on the position in which the knee is stiffened. If it is fixed in full extension, the person needs to sit with the leg out in front. When the knee is flexed, the person limps while walking. The greater the flexion, the greater is the limp. •Without full ROM of the ankle, gait deviations occur. If the joint is not stable, the person falls. When the person relaxes as in sleep or coma, the foot relaxes and assumes a position of plantar flexion. As a result, it becomes fixed in plantar flexion (footdrop), which impairs the ability to walk. Independently and increases the risk for falls. •Excessive flexion of the toes results in clawing. When this is a permanent deformity, the foot is unable to rest flat on the floor, and the patient is unable to walk properly. Flexion contractures are the most common foot deformity associated with reduced joint mobility.

Crutch walking on stairs: ascending stairs

•When ascending stairs on crutches, the patient usually uses a modified three-point gait. The patient stands at the bottom of the stairs and transfers body weight to the crutches. The unaffected leg is advanced between the crutches to the stairs. The patient then shifts weight from the crutches to the unaffected leg. Finally, the patient aligns both crutches on the stairs. The patient repeats this sequence until he or she reaches the top of the stairs.

Nursing Process: Assessment

•See through the patient's eyes •Mobility •Range of motion •Planes of the body •Sagittal •Transverse •Frontal •Apply the nursing process and use a critical thinking approach in your care of patients. The nursing process provides a clinical decision-making approach for you to develop an individualized plan of care. •When unsure of the patient's abilities, begin assessment of mobility with the patient in the most supportive position, and move to higher levels according to his or her tolerance. •Usually the nurse assesses for and asks questions about the patient's degree of both mobility and immobility during physical examination. You convey respect for the patient's preferences, values, and needs when implementing the nursing process and designing a plan of care with the patient. •Assessment of patient mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment. Generally the assessment of movement starts while the patient is lying and proceeds to assessing sitting positions in bed, transfers to chair, and finally walking. This helps to protect the patient's safety. •ROM is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, transverse, or frontal. •The sagittal plane is a line that passes through the body from front to back, dividing it into a left and right side. •The frontal plane passes through the body from side to side and divides it into front and back. •The transverse plane is a horizontal line that divides the body into upper and lower portions. •Ligaments, muscles, and the nature of the joint limit joint mobility in each of the planes. •In the sagittal plane, movements are flexion and extension (e.g., fingers and elbows), dorsiflexion and plantar flexion (feet), and extension (e.g., hip). •In the frontal plane, movements are abduction and adduction (e.g., arms and legs) and eversion and inversion (feet). •In the transverse plane, movements are pronation and supination (hands) and internal and external rotation (hips). •When assessing ROM, ask questions about and physically examine the patient for stiffness, swelling, pain, limited movement, and unequal movement. •ROM exercises may be active, passive, or in between. •Consider the medical plan of care and the patient's ability and need for assistance, teaching, or reinforcement before engaging in active ROM exercises. •Contractures develop in joints not moved periodically through their full ROM. •Assessment data from patients with limited joint movements vary based on the area affected: neck, shoulder, elbow, forearm, wrist, fingers and thumb, hip, knee, ankle and foot, and toes.