Funds final

Impervious

moisture and particle-proof, plastic bags (Figure 17-1).

Long-term goals

often relate to rehabilitation and can take many weeks or months.

Acute radiation sickness

. Acute radiation sickness (ARS) develops when most or all of the body is exposed to a high dose of radiation, usually over a short time. Initial symptoms of ARS are nausea, vomiting, and diarrhea. Loss of appetite, fatigue, fever, skin damage, hair loss, and potentially seizures, coma, and death are possible later effects.

Kinesiology (also called body mechanics) is the study of the movement of body parts. There are two main reasons why the use of good body movement is important for you and your patient. The first reason is that the body functions best when it is in correct anatomic position or alignment (arrangement in a straight line, bringing a line into order). Correct body alignment is generally called "good posture" (Figure 18-2). The second reason for proper body movement is to prevent injuries. One of the most common injuries for health care workers is lower back strain. With proper use of body mechanics, many injuries can be avoided. (See the Evolve website for tips for keeping your back strong.)

Kussmaul

Kussmaul respirations have an increased rate and depth with panting and long, grunting exhalation. Kussmaul respirations are seen in patients with diabetic acidosis and renal failure.

Rickettsia

are small round or rod-shaped microorganisms that are transmitted by the bites of lice, ticks, fleas, and mites that act as vectors. They multiply only in host cells. Examples of rickettsial infection include Rocky Mountain spotted fever and typhus.

Short-term goals

are those that are achievable within 7 to 10 days or before discharge, whereas long-term goals take many weeks or months to achieve.

Fungi

are tiny, primitive organisms of the plant kingdom that contain no chlorophyll. Examples include yeasts and molds. Fungi feed on living plants, animals, and decaying organic material. They thrive in warm, moist environments. Fungi reproduce by means of spores. In humans, fungal infections are called mycoses. When the balance of normal flora is altered by antimicrobial therapy, fungal infections such as vaginal candidiasis may occur.

Fowler position

arranged by elevating the head of the bed 60 to 90 degrees

What are the basic purposes of bathing?

four basic purposes: (1) cleanse the skin, (2) promote comfort, (3) stimulate circulation, and (4) remove waste products secreted through the skin.

Nursing audit

is the examination of a series of patient records to determine whether nursing care for those patients met particular standards and particular outcome

Protazoa

are one-celled microscopic organisms belonging to the animal kingdom. Protozoa that are pathogenic to humans include the Plasmodium species that causes malaria; Entamoeba histolytica, which causes amebic dysentery; and other strains capable of causing diarrhea.

Fall risk assessment

Risk factors to consider, safety measures to provide

Malaise

Not feeling right

Convalescent period

(recovery) period begins when the symptoms begin to subside and extends until the patient has returned to a normal state of health. This can take days to weeks, depending on the microorganism and the person's overall state of health.

Outcome based quality improvement OBQI

) (improvement of the quality of performance) programs are used to evaluate nursing care delivered to patients. The programs' goal is to improve nursing practice. The programs are usually agency-wide, incorporating nursing audits and evaluation regarding compliance with standards for every department

Steps of problem solving

1.Define the problem clearly. 2.Consider all possible alternatives as solutions to the problem. 3.Consider the possible outcomes for each alternative. 4.Predict the likelihood of each outcome occurring. 5.Choose the alternative with the best chance of success that has the fewest undesirable outcomes.

Airborne Infection Isolation Precautions

1.Place the patient in a private room that has negative air pressure: 6 to 12 air exchanges per hour and discharge of air to the outside or a filtration system for the room air. 2.If a private room is not available, place the patient with another patient who is infected with the same microorganism. In select situations, approval from the local health department may be required (e.g., for pulmonary tuberculosis patient). 3.Wear a respiratory device (N95 respirator) when entering the room of a patient who is known to have or suspected of having primary tuberculosis. 4.Susceptible people should not enter the room of a patient who has rubella (measles) or varicella (chickenpox). If they must enter, they should wear an N95 respirator. 5.Limit movement of the patient outside the room to essential purposes. Place a surgical mask on the patient if possible.

Droplet precautions

1.Place the patient in a private room. 2.If a private room is not available, place the patient with another patient who is infected with the same microorganism. 3.Wear a mask if working within 3 feet of the patient. 4.Transport the patient outside of the room only when necessary, and place a surgical mask on the patient if possible.

Contact precautions

1.Place the patient in a private room. 2.If a private room is not available, place the patient with another patient who is infected with the same microorganism. 3.Wear gloves as described in Standard Precautions. a.Change gloves after contact with infectious material. b.Remove gloves before leaving the patient's room. c.Cleanse hands immediately after removing gloves. Use an antimicrobial hand rub agent or soap and running water. d.After hand hygiene, do not touch possibly contaminated surfaces or items in the room. 4.Wear a gown when entering a room if there is a possibility of contact with infected surfaces or items, or if the patient is incontinent or has diarrhea, a colostomy, or wound drainage not contained by a dressing. a.Remove gown in the patient's room. b.Make sure clothing does not contact possible contaminated surfaces. 5.Limit movement of the patient outside the room. 6.Dedicate the use of noncritical patient care equipment to a single patient or to patients with the same infecting microorganisms.

11.Grasp the penis along the shaft with the nondominant hand. Hold the condom sheath at the tip of the penis and smoothly roll the sheath onto the penis, leaving 1 to 2 inches of space between the tip of the penis and the drainage tube of the condom sheath. (Positions the condom catheter on the penis. Allows free passage of urine into the collecting tube and drainage bag. Keeps penis away from collecting urine.)

A bag bath is a variation of the bed bath. Instead of using a basin, use a self-contained bag with several premoistened disposable cloths. The cloths are moistened with a cleansing agent that does not need rinsing. They may be heated or used directly from the bag. The bag contains many cloths, so a different cloth may be used for different body parts. The major disadvantage to this system is that it is more costly. Some facilities are adopting this, however, since bath basins have been found to be reservoirs of bacteria (Johnson, 2009) and a potential infection risk for vulnerable patients.

Types of baths

A bath may be cleansing or therapeutic, and complete or partial. A complete bath is when all areas of the patient's body are washed. The term partial bath has two different meanings depending on your institution. In one case it means only certain parts of the body are bathed, such as the face, hands, axillae, back, and perineal area. In the other case a partial bath means a complete bath is done—partially by the patient (the areas that can be reached) and partially by you (all other areas).

Biohazards

A biohazard is defined as a biologic agent, chemical, or condition (such as unsecure laboratory procedures) that can be harmful to a person's health. The Occupational Safety and Health Administration (OSHA) classifies materials in the work environment according to the degree of hazard to health that they impose. OSHA publishes specific guidelines for labeling, handling, cleaning spills, and disposing of these materials. Mercury is an example of a biohazard, as are blood and most body fluids. A material safety data sheet (MSDS) should be available for each biohazard substance stored or used on the nursing unit. These sheets are consulted for recommended methods of storage, labeling, handling spills, and disposal. Everyone must comply with these guidelines.

A complete bed bath is given when the patient is dependent and unable to provide hygiene self-care. Examples of such instances are patients with severe pain, injuries, or diseases that limit movement, or when the physician has ordered that the patient not expend the energy to self-bathe. In some instances, special perineal care is ordered.

Hyperthermia

A condition in which the patient's temperature is above the normal range (100.2° F [37.9° C]) is called a fever, a 339 340 febrile state, or pyrexia. However, fever is often not considered significant until the temperature reaches 101.3° F (38.5° C). A fever is usually a common symptom of infection in which the heightened temperature helps destroy invading bacteria. Very high fevers, such as those greater than 105.8° F (41° C), cause damage to body cells, particularly those of the central nervous system. Hyperthermia (above-normal body temperature) may also occur after brain injury.

Endotoxin:

A heat-stable toxin associated with the outer membranes of certain gram-negative bacteria that is released when the cells are disrupted

A nursing diagnosis statement indicates the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms

Poison

A poison is a substance that, when ingested, inhaled, absorbed, applied, injected, or developed within the body, may cause functional or structural disturbances. This is possible even if only a small amount of the poison is encountered. Agents used in chemical terrorism fit into this category. Treatments and antidotes for poisoning can be obtained from a poison control center or are listed on some containers. Some poisons do not have antidotes or treatments. When reporting a known or suspected poisoning, have the label handy. Report the following: •Name of the product •Patient's age •Amount you believe is involved •Any symptoms and/or complaints you observe

Mustache and beard care

A patient with a mustache and/or beard needs daily care to these areas. Keep the facial hair clean and free of food particles. Cleanse mustaches and beards with a warm damp washcloth or wash with soap or shampoo. You may not shave off a beard or mustache without a written, informed consent.

Toxin

A poison; a poisonous protein produced by certain bacteria

Skin and pressure ulcers

A pressure ulcer is an ulcer that forms from a local interference with circulation (see Chapter 18). The interference with circulation causes the skin to blanch (turn white or, in darker skin, become pale). If the pressure is relieved at this point, the skin will become red or a darker color because of vasodilation. Reactive hyperemia is the process in which the blood rushes to a place where there was a decrease in circulation.

Planning #3

A series of steps by which the nurse and the patient set priorities and goals to eliminate or diminish the identified problems. The goals are stated as specific expected outcomes. The nurse and the patient collaborate and choose specific interventions for each nursing diagnosis. The interventions assist the patient in meeting the expected outcomes. The expected outcomes and nursing interventions are listed on the patient's nursing care plan.

Lighting

A sunny, cheerful room can improve a patient's spirits. Areas must have adequate lighting for tasks and to prevent accidents and injury. The light should be bright enough to see without glare and to avoid eyestrain, and be soft and diffuse to prevent sharp shadows. Ideally, your patient will be able to control the lights independently. Appropriate interior and exterior lighting in the home helps protect against crime.

A transfer belt or gait belt may be used to ambulate or transfer the weak or unsteady patient. It is made of a tightly webbed canvas material and is very sturdy. Place and buckle the belt around the patient's waist before having the patient stand. Tighten it just enough to allow space for your hand to grasp it from the rear. Insert your hand into the belt from the bottom so that, if the patient falls, you will be able to support the weight. If you hold the belt from the top, it could slip out of your hand from the patient's weight during a fall. Skill 18-6 discusses how to assist a patient in ambulation and how to break a fall.

Sims position

A variation of the side-lying position. It is used for rectal examinations, administering enemas, and inserting suppositories or for an unconscious patient. The distribution of weight is different from in the side-lying position because in the Sims position the weight is distributed over the anterior ileum, humerus, and clavicle. When positioning on the left side, place the patient's left arm behind her, and draw her right knee and thigh up above the left lower leg. Tilt the chest and abdomen forward so the patient is resting on them as well.

Avg pulse rates

AGE-GROUP AVERAGE PULSE RATE AT REST (BPM) Normal pulse range 60-100 Some athletes 45-60 Adult male 72 Adult female 76-80 Child (age 5 yr) 95 Child (age 1 yr) 110 Newborn 120-160

Normal rang of respirations

AGE-GROUP RESPIRATIONS PER MINUTE Elderly 16-20 Healthy adult 12-20 Adolescent 16-20 Child (age 3 yr) 20-30 Infant (age 1 yr) 20-40 Newborn 30-80

Phagocytes

Cells (e.g., macrophages) capable of ingesting particulate matter

Anaerobic

Able to live and grow only in the absence of oxygen

Face sheet

Age, sex, marital status/significant other, religion, occupation, residence, next of kin and address, allergies, insurance status

Physician's orders

Admitting diagnosis, date of admission; current orders regarding diet, activity, frequency of vital signs measurement, daily weight, treatments, medications, diagnostic tests ordered, IV fluids, therapies ordered

Always perform hand hygiene after touching the patient or anything in the patient's room. Methicillin-resistant Staphylococcus aureus (MRSA) and other pathologic organisms can survive for varying periods on almost any surface.

Always use the markings on the cuff to measure the arm-to-cuff width to verify that the cuff is the correct size. If in doubt, use a larger cuff, since it will not alter the readings by being a bit too large. If the sounds are very faint, try using the other arm, or use a Doppler stethoscope to amplify the sounds so that accurate readings occur.

Bactericidal

An agent that is able to kill or destroy bacteria

Disinfectant

An agent that reduces the number of viable microorganism a

Host:

An animal or plant that harbors and provides sustenance for another organism (a parasite)

An expected outcome should be realistic and attainable and should have a defined time line

Community-associated infection

An infection that was present or incubating before the patient came in contact with health care or had a medical procedure performed.

Exotoxins

An unstable, highly toxic by-product of select microorganisms that can be found in both gram-positive and gram-negative bacteria

Vector

Carrier that transports an infective agent from one host to another, such as animals, insects, and rodents

Viruses

Are extremely small and can be seen only with an electron microscope (Figure 16-2). They are composed of particles of nucleic acids, either DNA or RNA, with a protein coat and sometimes a membranous envelope. Viruses can grow and replicate only within a living cell.

Prions

Are protein particles that lack nucleic acids and are not inactivated by usual methods for destroying bacteria or viruses. They do not trigger an immune response, but cause degenerative neurologic disease such as variant Creutzfeldt-Jakob disease (mad cow disease).

Bacteria

Are single-cell microorganisms lacking a nucleus that reproduce from every few minutes up to several

Abdomen

Assess bowel sounds on admission and once per shift for all patients. Bowel sounds are produced by the contractions of the small and large intestine. They are wavelike clicks and gurgles that occur from 5 to 30 times a minute. They are particularly active after eating; between meals it is normal to hear only a few sounds. Bowel sounds are judged to be hyperactive if they are very frequent, hypoactive if there are long periods of silence, and absent if no sound is heard for 2 to 5 minutes in any of the four quadrants. With the patient in a supine position, lightly place the stethoscope over a quadrant (quarter) of the abdomen and listen; if no sound is heard, progress through the other quadrants until sounds are heard or listen for at least 2 minutes (Figure 22-11, p. 380).

Edema and pitting

Assess for generalized edema by checking for weight gain over a short time. Ask about shoe and ring tightness and sock patterns left on the ankles when socks are removed. Look for eye and hand puffiness and abdominal fullness. To check for dependent edema, press the fingers into the tissue over the tibia just above the ankle. If an indentation remains, pitting edema is present (Figure 22-10). To describe edema, you can use the terms taut, tight, puffy, indented, or pitting. If pitting is present, it is classified according to its depth.

Eye care

Assess your patient's eyes for drainage, crusting, or redness. Notify the physician if any abnormalities are found. Routine eye care is described in Skill 19-1. If crusting is noted, soak the eyelid with a warm, damp washcloth for 2 to 3 minutes to soften the crust and ease its removal. Use a different part of the cloth for each eyelid. Perform more frequent eye care for unconscious patients; administer lubricating drops as ordered. Older adults will have the nursing diagnosis Risk for dry eye.

Evaluation #5

Assessing the patient's response to the nursing interventions. The responses are compared with the expected outcomes to determine whether they have been achieved. The entire care plan is reassessed, and any changes needed are made.

Assigning Admission Tasks If assistive personnel are available to help, you may assign the tasks of weighing, measuring, and obtaining a urine specimen for the newly admitted patient. The assistant could open the admission supplies and set up the patient's room. Be certain to alert the assistant of any safety measures needed for the patient.

Interdependent action

Assisting the speech therapist by helping the patient practice speech exercises is an interdependent action. Interdependent actions are those that come from collaborative care planning.

Transporting the patient

Avoid transporting the isolation patient unless absolutely necessary. If transporting is unavoidable, give the patient a standard mask to wear while out of the room. For a patient under Droplet Precautions, take measures to prevent soiling of the environment. Notify the unit or department receiving the patient ahead of time that a patient under this particular type of Transmission-Based Precautions is coming to the area. Share information about any additional precautions required with those receiving the patient.

Gram negative

Bacteria that lose the stain in Gram's method of staining

Gram positive

Bacteria that retain the stain in Gram's method of staining

Positioning

Basically, changing position accomplishes four things: (1) it provides comfort; (2) it relieves pressure on bony prominences and other parts; (3) it helps prevent contractures, deformities, and respiratory problems; and (4) it improves circulation. It is essential to know how to correctly support and position the patient while maintaining good body mechanics.

Chills

Because of chemical reactions in the body, chills (sensations of cold and shaking of the body) may occur. The metabolic rate increases by about 7% for each degree Fahrenheit (10% for each degree Celsius) rise in temperature.

Before carrying out the specific interventions listed on the care plan, identify the reason for the intervention, the rationale for the intervention, the usual standard of care, the expected outcome, and any potential dangers. A danger might be the possibility of introducing microorganisms during an invasive procedure.

Before taking an oral temperature, be certain the patient has not eaten, drunk fluids, or smoked within the previous 15 minutes, since this will cause an erroneous reading. A glass thermometer must remain in the sublingual pocket for 3 to 5 minutes to accurately reflect the body temperature.

Before transferring a patient to a wheelchair, have her dangle her legs over the side of the bed first (Figure 18-12). Dangling is the term used for the patient position of sitting on the side of the bed with the legs and feet over the side. The feet are either on the floor or supported on a footstool. Dangling is often the first step before sitting in a chair or ambulating. The purpose of this is to gradually accustom the body to the position 271 272 change. While the patient is dangling, assess the patient's balance, and monitor for orthostatic hypotension, dizziness, or nausea before getting the patient out of bed. If a patient has been on prolonged bed rest, she may be strong enough to dangle for only a few minutes and then will need to lie down again.

Biotnrespirations

Biot respirations are shallow for two or three breaths with a period of variable apnea (absence of breathing). These respirations occur in patients with increased intracranial pressure. Such changes from the normal respiratory pattern of breathing should be reported to the charge nurse or the physician so that appropriate treatment can be initiated.

Blood Pressure •A sphygmomanometer and stethoscope are used to measure blood pressure. An electronic sphygmomanometer or vital sign monitor may also be used. •The cuff must be the appropriate size for the patient for blood pressure measurement to be accurate. •Errors in technique of blood pressure measurement may cause inaccurate readings. •The phase IV Korotkoff sound (muffling) is used to determine diastolic pressure in children and in some older adults. Generally, the disappearance of sound (silence, phase V) marks the diastolic pressure. •Optimal blood pressure in the healthy adult is less than 120/80 mm Hg; pressure over 140/90 mm Hg or below 90/60 mm Hg is considered abnormal. •A blood pressure consistently over 140/90 mm Hg constitutes hypertension. A symptomatic blood pressure below 90/60 mm Hg is called hypotension. •Signs and symptoms such as cold clammy skin, apprehension, dizziness, blurred vision, and an increase in pulse rate may accompany hypotension and indicate shock. •Vital signs are recorded on the graphic record or the electronic medical record. Abnormalities of vital signs are noted in the nurse's notes along with further assessment data. •Abnormal blood pressures should be reported to the charge nurse or the physician.

Bradypnea

Bradypnea (slow and shallow breathing) results when a limited amount of air is exchanged and less oxygen is taken in. This type of breathing often leads to hypoxemia (decreased levels of oxygen in the blood). It is often seen in patients who are under medical sedation, who are recovering from anesthesia or abdominal surgery, or who are in a weak or debilitated condition.

Bulima

Bulimia is an eating disorder characterized by episodic binge eating, followed by behaviors designed to prevent weight gain, including purging, fasting, using laxatives, and exercising excessively. Women with bulimia are aware of their problem and often feel ashamed of the behavior. Treatment of bulimia is usually easier because of this awareness. Psychological and nutritional counseling is necessary. The treatment plan may include nutritional supplements and monitoring of patients after eating to ensure purging does not occur. Medical conditions such as esophageal and peptic ulcers may accompany bulimia because of the gastric acid exposure during frequently induced vomiting. This condition must be treated along with psychological counseling to stop these practices.

Burns

Burn prevention includes protecting the patient from accidental thermal injury and the threat of fire. Thermal injuries may be caused by either hot or cold materials. A person who has diabetes, impaired circulation, or paralysis or who is taking medications that alter mental awareness is more easily burned than a healthy person. To prevent these injuries, use a barrier between the patient's skin and the thermal application. Check the temperature of oral liquids before giving them to the patient. Warn the patient if a food or drink is hot. Caution the patient to avoid lying on, or sleeping with, heating pads or ice packs. Inspect electrical cords for frayed or broken areas that may cause sparks or fires. The engineering staff must check all electrical appliances brought into the hospital from home before use to ensure safety.

Classification of blood pressur

CLASSIFICATION SYSTOLIC BLOOD PRESSURE (mm Hg) DIASTOLIC BLOOD PRESSURE (mm Hg) Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension ≥160 or ≥100

Time flexible

Can be done at anytime

Cardio vascular disease

Cardiovascular disease includes diseases of blood vessels, hypertension, myocardial infarction (MI) (loss of blood supply to the heart muscle), and congestive heart failure (CHF) (pump failure of the right or left ventricle). Diet therapy is focused on reduction of saturated and trans- fat, cholesterol, and sodium intake. Excessive saturated and trans-fat intake leads to development of atherosclerosis (accumulation of fatty deposits on the walls of blood vessels). This process narrows the vessel diameter, resulting in decreased blood supply to major organs. Narrow blood vessels increase the workload of the heart, resulting in hypertension as the heart attempts to circulate blood. Dietary management includes reduced intake of saturated fats (less than 7% of total calories), trans fats (less than 1% of total calories), and cholesterol (less than 300 mg/day). The blood contains three types of cholesterol. High-density lipoprotein (HDL), known as "good cholesterol," tends to cleanse vessels of fatty deposits. Low-density lipoprotein (LDL) increases fatty deposits on vessel walls. Very-low-density lipoprotein (VLDL) serves as a carrier for triglycerides in the blood (a type of fat linked to atherosclerosis and coronary artery disease); therefore levels should be kept low. Consumption of trans-fats also increases levels of triglycerides. Increased levels of triglycerides can also signal a risk for diabetes or poor control of diabetes. Red meats, eggs, and high-fat dairy products contain large amounts of saturated fat. Convenience foods, such as prepackaged or frozen foods, chips, and fast foods, usually have high levels of trans-fats. Consumption of low-fat dairy products, vegetable oils, poultry, and fish is desirable to lower cholesterol levels (see Low-Fat Diets in Appendix G).

Implementation #4

Carrying out the nursing interventions in a systematic way. The nurse carries out (or appropriately delegates) the interventions. The patient's response to the care given is documented.

Etiologic factors

Causes of the problem

Capillary refill

Check capillary refill time by observing the color of the nail bed and then compressing the nail bed with the thumbnail or the distal end of a capped pen. Release the pressure and note how quickly the color returns to the nail bed. If the color returns slowly, check again and count the seconds ("one-one thousand, two-one thousand," etc.) to estimate the number of seconds it takes for the color to return. Normal refill time is less than 3 seconds. This is not an accurate assessment of circulation, but it can be useful.

Currents diagnostic test

Check for any abnormal findings: CBC, UA, blood chemistries, x-ray films, culture and sensitivity, other tests Nursing admission history and assessment: Reason for hospitalization, average number of cigarettes smoked per day, average amount of alcohol consumed per day, last bowel movement, special diet requirements, use of aids or prostheses (e.g., hearing aid or eyeglasses), medications taken regularly, identification of significant other, previous hospitalizations or surgeries, baseline vital signs, physical abnormalities

Check on the patient every 5 minutes, and inform the patient that the bath should not exceed 15 to 20 minutes.

Cheyne stokes

Cheyne-Stokes respirations consist of a pattern of dyspnea followed by a short period of apnea. Respirations are faster and deeper, then slower, and are followed by a period of no breathing, with continuation 354 355

Measuring body temp

Clinical thermometers are used to measure the body temperature, and a growing number of different types are on the market. The thermometer made of glass with a mercury-filled bulb is not used anymore because, if the thermometer gets broken, it releases mercury and its vapor, which are toxic. Glass thermometers are now filled with nonmercury material. Health facilities often use electronic digital thermometers; tympanic thermometers; temporal artery thermometers; and disposable, single-use thermometers.

Assessment (data collection) #1

Collecting, organizing, documenting, and validating data about a patient's health status. Assessment data are obtained from the patient, the family, the physician, diagnostic tests, and information about the patient from other health professionals.

Concept mapping

Concept mapping helps students learn to synthesize pertinent assessment data, develop comprehensive care plans, link nursing interventions with health problems and nursing diagnoses, and effectively implement the care plan. It can help you see relationships within a concept or relationships between concepts. Concept mapping will help you gather data in a logical manner and then group those data in a meaningful way

Evaluation is a _____ process

Continual

Physician's patient history and physical:

Current complaint, chronic problems, physical finding abnormalities, allergies, impressions

Skin assessment

Risk factors to consider, areas needing inspection and care Nursing care plan or problem list

Subjective data

Data obtained from the patient verbally

Verluance

Degree to which a microorganism can cause infection in the host or invade the host

Diabetes mellitus

Diabetes mellitus is a disturbance of the metabolism of carbohydrates and other nutrients and the use of glucose by the body. There are two main types of diabetes. Type 1 diabetes, or T1DM (formerly called insulin-dependent diabetes mellitus), occurs when the beta cells of the pancreas stop secreting insulin. Insulin is needed to transport glucose across the cell wall. Type 1 diabetes usually develops at an early age. Type 2 diabetes, or T2DM (formerly called non-insulin-dependent diabetes), accounts for 90% to 95% of all cases of diabetes; it occurs when glucose receptors on the cell membrane lose their sensitivity to insulin. Insulin is secreted in normal or excessive amounts; however, the receptor sites do not allow most glucose to enter the cell. Although it usually appears after age 40 years, type 2 diabetes is now appearing more frequently in younger people; even children.

Diagnoses may be actual or related to a risk, syndrome, or to promote wellness.

Critical thinking

Directed, purposeful, mental activity by which you evaluate ideas, construct plans and determine desired outcomes

Legal & Ethical Considerations: Document Preventive Measures

Document all measures taken to prevent pressure ulcers to show that all possible measures were instituted in case the patient develops a pressure ulcer in spite of your care. This can protect you from charges of negligence if the pressure ulcer doesn't heal and the patient brings a lawsuit against you.

Dyspnea

Dyspnea (difficult and labored breathing) is often accompanied by flared nostrils, anxious appearance, and statements such as "I can't get enough air." It is important to know how much activity causes the dysp-nea: Does it occur when walking down the hall, trying to eat a meal, or even when trying to talk?

Each time a procedure is performed, a medication is administered, vital signs are measured, or something is done that is a planned part of nursing care, a notation must be made in the chart. Nurses' notes must indicate that the nursing care plan has been carried out. If an intervention on the care plan is not mentioned in charting, it is considered not done. Review the nursing care plan before beginning care to have a clear idea of all of the areas that need written documentation (recording of pertinent data on the clinical record). Many hospitals require that nurses chart (document) on each patient at least every 2 hours and make some note about each problem or nursing diagnosis at least once every 24 hours. Long-term care facilities require a written note every 7 days or when the patient's condition changes. Care is documented on flow sheets daily

Epnea

Eupnea (a normal, relaxed breathing pattern) is effortless, evenly spaced, regular, and automatic. The inspiratory phase is a bit shorter than the expiratory phase. Changes from this normal pattern are described in a variety of ways.

Prevention of pressure ulcers

Excellent nursing care is the main factor in the prevention of pressure ulcers. It is your responsibility to be aware of any risk factors your patient may have and attempt to lessen them. Prevention is less time-consuming and less costly than pressure ulcer treatment.

Falls

Falls are a safety hazard. The three most common factors that predispose a person to falls are impaired physical mobility, altered mental status, and sensory and/or motor deficits. The Joint Commission 2012 National Patient Safety Goals require that every patient be assessed and periodically reassessed for risk for falling, correlating the patient's medications with increased risk for falls. Action must be taken to mitigate identified risks. An example of a fall risk assessment tool is presented in Figure 20-3. Chapter 40 provides safety tips to prevent the elderly from falling in the home. In most facilities a patient at risk for falls is given a color-coded wrist or leg band to alert the staff of this increased risk. Assistive devices, hip protectors (Figure 20-4), and personal alarms have been shown to decrease fall risk. Personal alarms sense a change in position or pressure and sound an alarm to alert caregivers that patients are attempting to get out of bed or a chair (Figure 20-5). The Quality and Safety

Legal implications of using protective devices

Federal and local laws protect the patient from physical and mental abuse and from physical and chemical restraints except those that are authorized by a physician, in writing, for a specified and limited time, or that are needed in an emergency situation. The devices must be applied by licensed, qualified personnel. The Joint Commission supports the use of protective devices if clinically necessary, but only as a last resort. This text has described the use of the bed's side rails as a way to increase a patient's independence in changing position or getting in or out of bed. However, in some situations and facilities, full side rails are considered restraints because they limit a patient's ability to move, whereas half-rails do not, and are not considered restraints. The evidence demonstrates that using bed rails as a restraint can be harmful.

Physician's progress notes:

Findings from last 2 days; status of problems

Fire

Fire is a possibility in any setting. You must know and be familiar with your institution's fire regulations. This includes knowing the location of the fire extinguishers, fire alarms, and escape routes and how to notify the telephone operator of a fire in your area. There are three basic types of fire extinguishers: A, B, and C. Type A is a water-under-pressure extinguisher that is used for paper, wood, or cloth fires. Type B contains carbon dioxide and is used for gasoline, oil, paint, fat, and flammable liquid fires. Type C is used for electrical fires and contains carbon dioxide. The most commonly seen extinguisher is an ABC combination extinguisher that can be used on any kind of fire. Most agencies use the RACE acronym to respond to a fire because it is easy to remember. Should a fire occur, you must: •Rescue any patients in immediate danger by removing them from the area. •Activate the fire alarm system. •Contain the fire by closing doors and any open windows. •Extinguish the flames with an appropriate extinguisher.

Exudate

Fluid in or on tissue surfaces that has escaped from blood vessels in response to inflammation and that contains protein and cellular debris

Food Allowed on a Clear Liquid Diet •Grape, apple, and cranberry juice •Strained fruit juices •Vegetable broth •Carbonated water (preferably clear) •Clear fruit-flavored drinks •Sweetened gelatin and ices •Clear candies •Popsicles •Tea, coffee •Clear broth

Full diet Milk and milk beverages •Yogurt, eggnog, pudding •Custard and ice cream •Pureed meats and vegetables in cream soups •Strained fruit juices •Vegetable juices •Sweetened plain gelatin •Cooked refined cereals •Strained or blended gruel •All other beverages •Cream, margarine, butter •Sherbet •Popsicles

Full range-of-motion (ROM) exercises should be performed either actively or passively several times a day. Active ROM exercises are used for the patient who independently performs activities of daily living but for some reason is immobilized or limited in activity or is unable to move one extremity due to injury or surgery. Passive ROM exercises are performed on the patient who cannot actively move. This patient cannot contract muscles, so muscle strengthening cannot be accomplished. All muscles over a joint are maximally stretched to achieve or maintain flexibility of the joint. This is accomplished by moving the muscles to the point of slight resistance but not beyond. To prevent joint injury in performing passive ROM exercises, support the limb to be exercised above and below the joint. Principles related to carrying out ROM exercises for patients are listed in Box 18-2. Skill 18-3 describes how to provide passive ROM exercises.

Time fixed

Has to be done at set time

Health care workers must perform hand hygiene before and after giving care to a patient

Ear care

Hearing acuity may be affected if cerumen or foreign material collects in the external ear canal. Remove these materials by gently washing the external ear canal with a warm washcloth. No object, including cotton-tipped applicators, should be inserted into the ear canal. The applicators compact the cerumen, making it more difficult to clean the ear. You may need to irrigate the ear if the wax is dried or excessive. Notify the physician if irrigation is needed.

Humidity

Humidity is the amount of moisture in the air. A range from 30% to 50% is normally comfortable. Very low humidity dries skin and respiratory passages. Most hospitals maintain a low humidity setting to discourage the growth of microorganisms. Vaporizers or humidifiers may be ordered for a patient with a respiratory condition who requires more humidity.

Hyperventilation

Hyperventilation is a pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled, causing the blood level of carbon dioxide to fall. The condition is seen after severe exertion, during high levels of anxiety or fear, and with fever and conditions such as diabetic acidosis.

Hypothermia

Hypothermia (subnormal body temperature) refers to a lowering of the temperature of the entire body, not just a portion of it. The thermal regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94° F (34.4° C). At this level the activity of the cells is reduced, less heat is produced, and sleepiness and coma are apt to develop. Those at risk for hypothermia include postoperative patients who have been cooled during surgery, newborn infants whose skin is exposed to cool room temperatures, elderly or debilitated patients, and those exposed to cold temperatures for prolonged periods.

MAJOR FACTORS of pressure ulcers •

Immobility •Inactivity •Moisture •Malnutrition •Advanced age •Altered sensory perception •Lowered mental awareness •Friction and shear

If the expected outcomes are considered met, the nurses' notes must contain data to support this.

Odor control

Illness changes sensory perceptions. Odors that ordinarily are pleasant may make the patient feel nauseated. Health care facilities may have unpleasant odors from bedpans, urinals, wounds, and other sources. Good ventilation and cleanliness will effectively control odors. Box 20-1 lists odor control measures.

RNS HOPE

In many instances a nursing assessment of the areas of basic need is more appropriate than a total physical assessment. A systematic way to perform such an assessment is to use the acronym RNS HOPE. The acronym stands for: •Rest and activity •Nutrition, fluids, and electrolytes •Safety and security •Hygiene and grooming •Oxygenation and circulation needs •Psychosocial and learning •Elimination

Leukocytosis:

Increase in the number of leukocytes in the blood, resulting from infection or other causes

Temperature

Infants and older adults may need their rooms warmer than other patients because of their poor temperature regulation. Keep room temperature between 68° and 74° F (20° and 23° C). Operating rooms and critical care areas are kept slightly cooler to reduce the patient's metabolic demands.

Health care associated infection

Infection that was not present or incubating on admission to a health care facility; acquired during hospitalization

Objective data

Information obtained through the senses and hands-on physical examination

Quick head to toe assessment

Initial Observation Breathing How patient is feeling Appearance Affect Skin color Head Level of consciousness Ability to communicate Mentation status Appearance of eyes Vital Signs Temperature Pulse: rate, rhythm Respirations: rate, pattern and depth; oxygen saturation Blood pressure: compare with previous readings Heart and Lung Assessment, Neurologic Check Auscultation of heart and lungs done to determine a baseline Neurologic check done now if ordered or indicated Abdomen Shape Soft or hard Bowel sounds Appetite Last bowel movement Voiding status Extremities Normal movement Skin turgor and temperature Peripheral pulses Edema Tubes and Equipment Present Oxygen cannula: liter flow rate; chest tube functioning correctly Nasogastric tube: suction setting, amount and character of drainage; percutaneous endoscopic gastrostomy (PEG) tube; jejunostomy tube Urinary catheter: character and quantity of drainage Intravenous catheters: type; condition of site(s), fluid in progress, rate PEG: intact, skin condition Dressings: location, character and amount of drainage, wound suction device, drains Pulse oximeter: intact probe; readings Traction: correct weight, body alignment, weights hanging free Sequential compression device: correct application, turned on Continuous passive motion: machine set and applied correctly, turned on Cardiac monitor: leads placed correctly, alarm parameters set Pain Status Use a pain scale (e.g., 1 to 10) Assessment in Home Health Care

Infection

Invasion and multiplication in body tissues of microorganisms that cause cellular injury

High priority

Life-threatening problems are of high priority.

Lifting, moving, and positioning patients are integral parts of your workday. To provide the best patient care and prevent self-injury, you must know the principles of body mechanics. Coordinated movement involves using the bones, joints, and skeletal muscles properly. Many institutions are moving toward a "no manual lifting" policy or to the use of a lift team to decrease health care worker back injuries from repetitive lifting. Until equipment or lift teams are in place in all health care institutions, there will be instances when a nurse must lift a patient without assistance or use of a mechanical device. The following principles and practices serve as guides to help prevent injury.

Inflammation

Localized response caused by injury or destruction of tissues that serves to contain the injurious agent and injured tissue

Log rolling

Logrolling is turning the patient as a single unit while maintaining straight body alignment at all times. Logrolling is often used for patients with injuries or surgery to the spine and for those who must avoid twisting. The linens for an occupied bed are often changed by using the logrolling turn. Logrolling can be done either with or without a lift sheet. If a lift sheet is used, two or three people are needed to accomplish the move, depending on the patient's size (Figure 18-10). It takes at least three people to logroll a patient without a lift sheet (Figure 18-11).

Hypotension

Low blood pressure. Some people have blood pressure that is normally below 90/60 mm Hg, and they are healthy with no other symptoms. However, hypotension with symptoms of shock (circulatory collapse) is a dangerous condition that can rapidly progress to death unless treated. Shock is caused by hemorrhage, vomiting, diarrhea, burns, and myocardial infarction, among other conditions.

Low priority

Low-priority problems are ones that do not have a major effect on the person if not attended to that day or even that week.

Therapeutic baths

Means healing or medicinal qualities. Therapeutic baths are performed to achieve a desired effect and include several types. A whirlpool bath is done in a bathtub or special whirlpool tub that has a device that agitates the water. The heat of the water and agitation gently massage the skin. Whirlpools are used to cleanse, stimulate peripheral circulation, and provide comfort. Starch or oatmeal baths, using plain instant oatmeal, are used for patients with dermatitis. Commercial products are also available and are added according to package directions. The skin is patted dry after the bath so the nerve endings are not stimulated by rubbing.

Tympanic artery

Measuring tympanic temperature involves inserting the thermometer probe into the auditory canal. The probe must be pointed at the tympanic membrane for the reading to be accurate. This is another easy and quick method of measuring the temperature. The graduated size of the probe prevents injury to the tympanic membrane. Tympanic membrane temperature is a good indicator of core body temperature. Core temperature is the temperature of the deep tissues of the body. The thermometer measures heat radiated as infrared energy from the tympanic membrane. The same blood vessels serve the hypothalamus and the membrane, so the temperature is close to core temperature at the hypothalamus. Temperatures taken with a tympanic thermometer are not subject to variations caused by eating hot or cold foods or liquids, smoking, or chewing gum. They can be affected by an ear infection or excessive wax blocking the canal.

Two types of aspesis

Medical, surgical

Medication administration record (MAR):

Medications received, frequency of PRN medications, allergies

Colonization

Microorganisms take up residence and grow

Moisture can lead to pressure ulcers in a patient who is incontinent (has lost bowel or bladder control). Skin that is frequently wet leads to maceration (softening of tissue that increases the chance of trauma or infection). Diaphoresis (perspiration), not drying a patient properly after a bath, and the use of incontinence briefs also place a patient at risk due to moisture. A balanced diet is necessary to prevent ulcer development. Without proper calories, protein, fluids, vitamins, and minerals, the body's cells, capillaries, and tissues are easily damaged. Altered sensory perception places a person at risk for pressure ulcers, since he may not receive the body's signals of discomfort reminding him to change position. Lowered mental awareness is another factor because patients who have lost the concept of time may not realize they have been in the same position for a prolonged period. Lowered mental awareness may be caused by medication, anesthesia, or health problems.

Nail care

Most patients can perform nail care for themselves as part of their daily hygiene routine. You may need to provide care for those who are unconscious, blind, confused, unsteady, or in a cast or traction. Nail care includes regular trimming, cleaning under the nails, and cuticle care, and is usually done with the bath. Keep nails clean and trimmed according to the institution's policy and patient preference. Never cut the toenails of a patient with diabetes or circulatory disease of the lower extremities without a physician's order. Check your agency's policy to see if an order is needed to trim the fingernails of the diabetic patient. Use a orangewood stick to clean under nails because a metal nail file can make the nails rough and trap dirt. Push cuticles back gently with the stick to prevent hangnails, which are pieces of skin that are partially detached at the base of the fingernail. Hangnails are painful and a possible source of infection. Soak the nails in warm soapy water for 5 to 10 minutes, especially if they are dirty or thickened. Cut toenails straight across and then smooth the corners.

Oral care

Mouth care removes food particles and secretions, which prevents halitosis (bad breath), feelings of uncleanliness, and dental caries (cavities). Oral hygiene promotes a better appetite and maintains the healthy state of the mouth, gums, teeth, and lips. Fluoride-containing toothpaste, soft or powered toothbrush, and flossing have been shown conclusively to promote oral health. Lack of oral hygiene can have serious consequences, including increased risk of stroke, heart disease, and pneumonia (Stein and Henry, 2009). Provide oral care on a regular basis, ideally, four times a day (see Box 19-3).

Norma flora in the body

NORMAL FLORA Upper respiratory tract (nose, mouth, throat) Corynebacterium species Enterobacter species Haemophilus species Klebsiella species Lactobacillus species Neisseria species Staphylococcus species Streptococcus (viridans group) Streptococcus pyogenes (group A) Various types of anaerobes Skin Acinetobacter species Corynebacterium species Staphylococcus aureus Staphylococcus epidermidis Yeasts Small bowel and colon Anaerobes Bacteroides species Clostridium perfringens Enterobacter species (coliforms) Streptococcus faecalis (enterococci or group D) Vagina Alpha-hemolytic streptococci Enterobacteriaceae Enterococci Lactobacillus sp. Many types of anaerobes Staphylococcus epidermidis

Needles are not to be recapped before disposal. Drop all used needles, scalpel blades, IV cannulas, suture needles, and other sharp items into a puncture-resistant sharps biohazard container. Never put your fingers inside the opening of the sharps container. Shake the container gently to settle the contents and make more room if necessary. Replace sharps containers when they are two-thirds full. Seal the full sharps container and send to the biohazard waste storage area for later removal. Federal policy and state laws require that sharps containers be secured in patient care areas, and that holding areas for biohazards must be accessible by staff only.

Aerobic

Needs oxygen to live and grow

Noise control

Noise is inevitable in health care facilities. The hospital should be a place for rest and quiet, yet a patient may experience sensory overload from all of the noise.

Body temp

Normal body temperature ranges from 97.5° to 99.5° F (36.4° to 37.5° C) and varies considerably among individuals. Two scales are used to measure temperature: Fahrenheit and Celsius. Table 21-1 presents temperature correlations between the two scales. The temperature in a healthy young adult averages 98.6° F (37° C). It varies within the normal range as the body adjusts to changes in the amount of heat produced or the amount of heat lost. Some people run a low-normal or a high-normal temperature consistently; this represents the normal body temperature for them. It is important to know the patient's usual temperature and then compare changes with that measurement.

Nursing activities for treating the patient with a below-normal body temperature should focus on reducing heat loss and supplying additional warmth: (1) provide additional clothing or blankets for warmth (an electric blanket is most effective for raising temperature); (2) give warm fluids, if permitted; (3) adjust the temperature of the room to 72° F (22.2° C) or higher; (4) eliminate drafts; (5) increase the patient's muscle activity; and (6) submerge frostbitten areas in a warm bath, with water temperature no warmer than 107° F (41.7° C).

Nursing= Problem +Etiology+Signs and diagnosis (cause)symptoms Problem Nursing diagnosis label (stem) Etiology Related to (etiologic or causative factors) Signs and symptoms As evidenced by (defining characteristics)

OSHA regulations protect health care workers from occupational exposure to blood-borne pathogens in the workplace. In Canada the Canadian Centre for Occupational Health and Safety addresses worker safety. These two agencies have determined that the three main modes of occupational exposure to blood-borne pathogens are as follows: •Puncture wounds from contaminated needles or other sharps •Skin contact, allowing blood, body fluids, and other potentially infectious materials to enter through damaged or broken skin •Mucous membrane contact, allowing infectious materials to enter through the mucous membranes of the eyes, mouth, and nose

Obesity

Obesity rates continue to rise, and it has now become a national health threat. The Centers for Disease Control and Prevention (2010) estimates that about 26.7%, or 72.5 million, of adult Americans are obese. A poor diet and limited physical activity are two major factors contributing to the epidemic levels of overweight and obese Americans (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 2011). 481 482 Obesity is defined as excessive accumulation of fat, not merely being overweight according to height and weight standards. Many factors contribute to obesity, including genetics, environment, poor eating habits, lack of knowledge about good nutrition, body physiology, age, and gender. Diet therapy to manage obesity must be individualized and incorporate all factors relevant to the patient.

Olfaction is the sense of smell. The nose is used to identify characteristic smells associated with specific problems. A sweetish odor to the breath can indicate diabetic acidosis; alcohol on the breath can provide a clue to the patient's lethargy or irrationality. Mouth odor that is foul may indicate periodontal 371 372

Assessment is an _______ _______

Ongoing process

Spores

Oval bodies formed within bacteria as a resting stage during the life cycle of the cell; characterized by resistance to environmental changes (heat, humidity, or cold)

Pain the fifth vital sign

Triage and treatment

Patients are triaged as they enter the ED. The word "triage" comes from the French word trier ("to sort"), as French physicians in the battlefields of World War I devised a plan to sort patients according to who would be likely to survive. Patients are assessed and labeled according to the priority of care: immediate, delayed, minimal, or expectant. Patients who require lifesaving care are labeled "immediate"; care for those in need of major or prolonged care can be "delayed" briefly; those with minor injuries to be attended to are labeled "minimal"; and "expectant" indicates those with severe life-threatening injuries who probably will not survive even with medical care. Triage priorities are based on the premise that limited medical resources should be used on those patients who will most likely live if they receive treatment. Treatment is based on the type of agent to which the patient was exposed and the degree of exposure. Antibiotics are used for some of the biologic agents, and antidotes may be used for some chemicals and poisonous gases. Otherwise, treatment is directed at supporting organ function while the body tries to recover. Life support measures using drugs, ventilators, and dialysis, if needed, are used.

Patients with acute illness and neurologic disorders may be unable to tolerate oral fluid and food intake. Patients may experience dysphagia (difficulty swallowing) after a stroke or develop an increased risk for malnutrition from the effects of inflammatory bowel disease, HIV/AIDS, or cancer treatment. Some patients may show common signs of swallowing problems such as coughing when drinking, drooling, or having food remaining in the mouth. A physician and a speech-language pathologist may conduct a formal swallowing evaluation and develop a management plan. Nearly 55% of patients who aspirate show no obvious signs or symptoms such as coughing (Garcia and Chambers, 2010). The aspiration may cause a voice change or feeling of food being stuck in their throat. For these patients, it is important to match dietary modifications to their swallowing, motor, and cognitive ability. Liquids can be thickened to help prevent aspiration. Solids can be ordered at four different texture levels: level I, pureed (pudding texture); level II, mechanically altered (moist, minced to ¼ inch maximum); level III, advanced (moist, bite sized; no hard or crunchy foods); and level IV, regular (all foods). Some patients recover and advance to level IV, whereas others may progress in their aging or disease process and may no longer tolerate oral intake of any kind. Once this happens, a feeding tube can be considered.

Denture care

Patients with dentures who are confined to bed, are comatose, are weak, or have trouble with hand and finger dexterity may need assistance to care for their dentures. Dentures should be cleaned to prevent irritation to the gums and infection. A patient may use an adhesive for a better fit. Usually, a patient who uses adhesive does not like to remove the dentures during the day. Care should then be provided in the morning and at bedtime. Do not place dentures on a meal tray because they are often lost when the trays are removed. Dentures should be removed for at least 6 hours daily to relieve pressure on mouth tissues and allow saliva to cleanse the tissues. When not in the mouth, dentures are kept in a labeled denture container filled with water or normal saline. Skill 19-3 details how to clean dentures.

Korotocoff sounds

Phase I: tapping—systolic pressure indicated by faint, clear tapping sounds that gradually grow louder Auscultatory gap: no sound—silence as cuff deflates for 30 to 40 mm Hg; common with hypertension Phase II: swishing—murmur or swishing sounds that increase as the cuff is deflated Phase III: knocking—louder knocking sound that occurs with each heartbeat Phase IV: muffling—a sudden change or muffling of the sound (indicates diastolic pressure in children and some adults) Phase V: silence—disappearance of sound (marks diastolic pressure in adults)

Physiologic needs for basic survival take precedence.

Axillary temp

Place the thermometer in the center of the patient's dry axilla (armpit). A wet axilla will produce a false reading. Ask the patient to hold the arm tightly against the chest. The arm may rest on the chest. Leave the thermometer in place for 3 to 8 minutes or until the thermometer indicates the reading is complete. Remove and wipe the thermometer clean from the stem to the tip.

Pathology report

Presence of malignancy or infection

Pressure Ulcers Pressure ulcers, also known as decubitus ulcers or bedsores, occur from pressure on the skin. This pressure causes a local area of tissue necrosis (local death of tissue from disease or injury). Most often the area of pressure occurs between a bony prominence and an external surface. Besides pressure, the other main factor in the development of pressure ulcers is a shearing force. Shearing is an applied force that causes a downward and forward pressure on the tissues beneath the skin. Shearing forces occur when a patient slides down in a chair, bedclothes are pulled from beneath the patient, or the patient is slid up to the head of the bed without lifting the body. Pressure ulcers are discussed in Chapter 19.

Hypertension

Pressure consistently elevated above the normal range is called hypertension. Hypertension is most often found in people living in urban areas and in those under considerable emotional stress; it affects more men than women and is twice as prevalent in African Americans as in whites. Obesity is another factor contributing to hypertension. Some people may have hypertension without any risk factors. Prolonged hypertension can cause permanent damage to the brain, the kidneys, the heart, and the retina of the eye. It is the cause of many cerebrovascular accidents (strokes)

Priorities constantly change because patient needs and conditions change frequently. To maintain organization with your workload, you must be flexible and you must frequently reorder your tasks. You should reconsider your work organization plan at least every 2 hours during your shift, reprioritizing as needed.

Medium priority

Problems that threaten health or coping ability are of medium priority.

Surgery operative report

Procedure done, organs removed, type of incision, drains or equipment in place, blood loss, problems during surgery

Prone Position •Feet: Position in dorsiflexion. Sustained extension with plantar flexion is undesirable. •Pressure points: Check for pressure on the ear, chin, hips, and knees.

Culture

Propagation of living organisms or tissue in special medica conductive to their growth

Protective devices

Protective devices, formerly called restraints, were overused in the past. Restricting movement on a long-term basis caused problems such as muscle weakness, atrophy, loss of bone mass, joint contractures, constipation, incontinence, pressure ulcers, depression, and cognitive impairment. The patient's self-concept and mood were negatively affected, and both the patient and family were affected emotionally. Some staff used these devices as a way to punish or discipline a patient. This is an illegal, unethical, and totally unacceptable practice that constitutes malpractice. Restraints are used in two types of situations: for behavioral or nonbehavioral indications. A protective device is used for a behavioral health reason if the patient is in a psychiatric setting or has demonstrated a sudden change in mental status or behavior. Nonbehavioral usage is for the continuation of medical treatments. An instance of a nonbehavioral use would be an elderly person with a history of dementia who needs to have her IV site protected from attempts to dislodge the catheter. Health care workers must check patients in a behavioral health protective device more frequently. The array and use of physical and chemical protective devices (i.e., medication) in psychiatric or behavioral health settings are not covered in this text. It is your responsibility to be aware of and follow the regulations in your facility and area.

Mouth care for unconscious patient

Provide full mouth care to an unconscious patient at least once every 8 hours. If the patient is mouth-breathing, perform care every 4 hours. Mouth-breathing causes the tongue to dry and become crusty. Remove any dry secretions, since they cause halitosis and may obstruct airflow. Perform moist swabbing of the mouth every 2 hours or as needed to maintain the integrity of the oral cavity. Mouth care of the unconscious patient is described in Skill 19-2.

Hair care

Provide hair care regularly during illness, during or after the morning bath. Hair care consists of brushing and combing, shampooing, shaving, and mustache and beard care. Morale and body image are improved when the patient is comfortable with his appearance. Brushing and combing the hair stimulates circulation, which helps to promote hair growth, prevent hair loss, distribute oil along hair shafts, and bring nutrients to the roots.

Rectal temp

Provide privacy and ask the patient to turn to the side facing away from you with the knees slightly flexed; drape the patient to reveal only the anal area. Don gloves and lubricate the tip of the rectal thermometer or probe, lift the upper buttock slightly so that the anus can be clearly seen. Insert the lubricated bulb into the rectum directed toward the umbilicus about 0.5 to 1.5 inches. Hold the thermometer in place for 3 to 5 minutes or until the correct temperature is indicated. Wipe the thermometer or probe from the stem toward the bulb or probe tip. Wipe the buttocks to remove lubricant or stool. Correctly dispose of tissues and gloves and perform hand hygiene.

Pull and pivot

Pulling actions require less effort than pushing or lifting. Whenever possible, use pulling motions. When transferring a patient to a stretcher, two nurses should stand on the far side of the stretcher to pull the patient toward them onto the stretcher. This movement is easier than pushing because it brings the patient closer to each nurse's center of gravity. Directly face the object or person to be moved. It is much easier to move an object if you are facing in that direction. For example, place an object on the floor. Stoop down with the object in front of you and move the object forward. This is fairly easy. Now place the same object on the floor, stoop down, only this time with the object to the side. Moving the object forward is not as easy in this instance.

Pulse •The pulse is initiated by contractions of the heart sending blood out into the arteries. •The pulse is normally assessed at the radial artery in the wrist or at the apex of the heart. •Normal pulse rate in the adult ranges from 60 to 100 bpm, with the average being 72 bpm. •A pulse rate greater than 100 bpm is called tachycardia. •A pulse rate lower than 60 bpm is called bradycardia. •When counting a pulse, begin counting with "0"; the next beat is "1." •Pulse measurement includes noting the pulse's rhythm, volume, and rate. •Besides being a measure of cardiovascular status, pulse rates are used to evaluate response to treatment and activity.

Assessments and nursing diagnoses are done by ?

RN

Radiation

Radiation is a form of energy that can come from man-made sources as well as the sun and outer space. Some elements that release radiation, such as uranium, exist naturally in the soil. Plutonium, which is used in nuclear power plants, is also used to make nuclear bomb

Read each clinical scenario and discuss the questions with your classmates. Scenario A Discuss specific ways in which a person with a cold who goes to the movies can transmit the virus to others. Scenario B You are assigned to care for a patient who has viral pneumonia, a disease of the respiratory tract. What precautions would be necessary? Scenario C A parent asks you why her teenage son should be immunized against tetanus when he received the vaccine as a baby. How would you respond? Scenario D An elderly neighbor keeps complaining about getting respiratory tract infections and small infected wounds. He asks you what he could do to prevent this. What would you tell him?

Read each clinical scenario and discuss the questions with your classmates. Scenario A While assisting a female patient during her bath, you notice that she cleanses herself by wiping from the rectum to the pubic area. You remember that she has a history of having recurrent vaginal infections. What will you do? How will you explain perineal care and proper toileting techniques to her? Scenario B Your postoperative patient has a history of a cerebrovascular accident (CVA) with weakness on his left side. In the hospital he has performed most of his hygiene care independently and states that he "likes doing things for himself." What would you tell the family of your patient when they say they always do their father's complete bath at home so that he does not get tired?

Read each clinical scenario and discuss the questions with your classmates. Scenario A You are caring for a 43-year-old man who has an infected leg wound following a hiking accident. He is to keep his leg elevated and is under Contact Precautions. He has recently retired from the military and has just moved to the area. He is bored and restless. How would you help meet his psychosocial needs? Scenario B What would you do if you observed the physician's glove become contaminated during a sterile procedure and the physician appeared unaware that this had occurred? Be specific. Scenario C Your home care patient is an older man with a large abdominal wound that needs daily dressing changes. He lives with his wife, but she has severe arthritis in her hands and is unable to perform the procedure. You are scheduled for three visits per week. How would you solve the problem of getting his daily dressing change done on the days you are not scheduled to visit?

Read each clinical scenario and discuss the questions with your classmates. Scenario A You are to get a patient who has left-sided paresis out of bed and into a chair for the first time. The patient has been in this country only a short time. How would you go about doing this? Would you need assistance? Scenario B You and three other nurses are logrolling a patient. You are 5 feet, 6 inches tall, and the other nurses are all at least 3 inches taller. How high do you position the bed to logroll the patient? Scenario C Your patient became weak while walking, and you broke her fall and assisted her to the floor. What would you do next? What procedures would need to be followed?

Read each clinical scenario and discuss the questions with your classmates. Scenario A Two of your friends and fellow nursing students are talking and laughing loudly at the nursing station. What would you do? Scenario B While giving a bath to your bedridden patient, you notice smoke coming from the bathroom. What is your first action? After that, how would you proceed? Scenario C If, when on a home care visit, you find several hazards to safety in the patient's home, how would you handle the situation? Scenario: You notice a foul odor in your patient's room. How would you proceed?

Restraints

Remove the device at least every 2 hours and perform active or passive range-of-motion exercises for immobilized joints and muscles to prevent complications. Use supportive pillows and pads for positioning. Check circulation and pulses distal to the device every 15 to 30 minutes. Signs that the circulation or nerve function has been impaired include skin coolness, change in color (particularly pallor or a bluish hue), numbness, pain, edema, and loss of sensation or movement. Remove the device immediately and contact the physician if any of these signs occurs.

Respiration •Respiratory rate is always considered in conjunction with other assessment data because many factors can affect it. •The normal range of respirations for the healthy adult is 12 to 20 per minute. •Symptoms of hypoxia include restlessness, confusion, change in level of consciousness, and cyanosis. •Abnormal breathing patterns are dyspnea; tachypnea; bradypnea; hyperventilation; and Cheyne-Stokes, Kussmaul, and Biot respirations. •Respiratory rate is considered along with other data such as breath sounds and arterial oxygen saturation for assessment of the respiratory system. •Measurement of arterial oxygen saturation may be done with a pulse oximeter.

Measuring respirations

Respirations are measured each time a full set of vital signs is taken. A change in respiratory rate may indicate a change in a patient's condition, but is always considered along with the other vital signs and assessment data. Count the respirations for 30 seconds and multiply by 2. In someone who is known to be very ill or who has irregular respirations, count for a full minute (Skill 21-5).

Safety Alert: Lock the Wheels Remember to lock the wheels on the wheelchair and the bed or stretcher before attempting to transfer a patient into a wheelchair or stretcher or onto the bed. Otherwise, the wheelchair or stretcher could roll away from you, and you and the patient could be injured.

Semi fowler low fowler Circulation: Check to see that the lower extremities have palpable pulses, verifying that the popliteal artery is not occluded. •Pressure points: Check for pressure on the scapula, sacrum, elbows, and heels.

Shaving a male patient

Shaving can improve a man's appearance and give him a sense of well-being. Unless he has his own electric razor, you must use a safety razor. Practicing by shaving a family member or friend will increase your confidence in the procedure.

Side-Lying Position •Neck: Avoid lateral flexion. •Pressure points: Check for pressure on the ankles, knees, trochanter, ileum, and ear.

Sims position •Hip and shoulder: Support properly to prevent internal rotation and adduction. •Pressure points: Check for pressure on the clavicle, humerus, ileum, knees, and ankles.

Sitz baths are used to apply moist heat and clean the perineal or anal area (Figure 19-6). The bath promotes healing and relieves pain and discomfort. It is commonly used after birth and vaginal or rectal surgery. Body soaks are usually indicated to cleanse open wounds or apply medicated solutions to an area. Feet and arms are the parts of the body most often soaked. Cooling sponge baths are also known as tepid sponge baths. An order is usually needed before this type of bath can be used to bring down a fever. A cooling sponge bath can be soothing but also may be uncomfortable if the patient's fever is high.

Smoking

Smoking is banned in most health care facilities; however, some long-term care agencies allow smoking in designated areas. Carefully supervise the patient who wants to smoke and is sedated, confused, or irrational. Warn your patient not to smoke in bed. Smoking is never allowed when oxygen is in use because a spark could cause a fire. Any equipment that might cause a spark is also prohibited near oxygen. Inform your patient who uses oxygen at home, and the family, of this risk.

Specific gravity

Specific Gravity Specific gravity is the thinness or thickness of the urine. It may be measured by a urinometer, an instrument that reads the amount of light the urine absorbs, or by a chemical dipstick. The normal range is 1.010 to 1.030, but conditions such as dehydration and fluid excess may extend the range slightly in either direction. 537 538

Stages of Infection Infection occurs when pathogenic microorganisms invade the body and multiply. The infectious process has four stages: the incubation period, the prodromal period, the illness period, and the convalescent period. The length of each period is influenced by many factors, including the organism itself, the host's overall health, and the environment in which infection has occurred.

Nurses notes

Status during the last 24 hours

Sterile equipment and strict aseptic technique must be used to catheterize a patient. Any break in aseptic technique causing contamination must be corrected before continuing with the procedure. One of the National Patient Safety Goals is to follow protocols that protect patients from infection. Catheter kits can be used for males or females. The procedure for male and female catheterization is similar except for variations in the positioning, draping, and cleansing of the urinary meatus. In the male the catheter is inserted farther (about 7 to 8 inches). When inserting a catheter, gently insert until you see the urine flow and then insert 1 to 2 more inches. This will ensure the balloon will not damage the urethra during inflation. Skills 29-3 and 29-4 give the steps for catheterization of the female patient and the male patient, respectively.

Glasses and contacts

Store glasses in a case when not in use. Most glasses today have plastic lenses that are easier to scratch than glass. To clean either type of lens, use clean warm water and a soft cloth to wipe dry. Do not use a paper towel on plastic lenses because it may scratch them. Contact lenses are classified as to whether they are hard or soft. Hard lenses feel like a firm plastic disk, whereas soft lenses have the consistency of a thick plastic food wrap. Many contact lenses may be worn for an extended period.

Supine Position •Feet: Maintain the feet in dorsiflexion; you may need to use a positioning device to decrease the chance of footdrop. •Lower back: If the patient complains of lower back pain, place a small pillow or rolled towel under the patient's lumbar spine. •Pressure points: Check for pressure on the occiput, lumbar vertebrae, elbows, and heels.

Tachypnea

Tachypnea (increased or rapid breathing) results from the presence of fever and a number of diseases. Breathing rate increases about four breaths for each 1° F (0.5° C) increase in temperature.

The different types of Transmission-Based Precautions may be used alone or in combination, but they are always used in addition to Standard Precautions.

Phagocytosis:

The engulfing of microorganisms and foreign particles by phagocytes

Bioterrism

Terrorist activities are designed to cause panic, fear, and chaos and disrupt an area's rescue and medical systems. Bioterrorism is the release of pathogenic microorganisms into a community to achieve political and/or military goals. Common diseases, symptoms, and incubation periods for agents used in bioterrorism are listed in Table 20-1. It is important to know the early signs and symptoms of these agents because many of them initially manifest with vague or flulike symptoms.

The CDC has developed Standard Precautions to facilitate breaking the chain of infection. These precautions protect both the nurse and the patient and are to be used for every patient contact; they include the use of hand hygiene and personal protective equipment (PPE) (Box 16-3). PPE includes gloves, gowns, masks, protective eyewear, shoe covering, and hair covering.

The Postoperative Patient Patients scheduled for surgical procedures may have special dietary needs. Ideally, the surgical patient should be well nourished preoperatively (before surgery) to facilitate postoperative (after surgery) healing and recovery. Preoperative patients are usually NPO (no food or fluids by mouth) 6 to 8 hours before the procedure.

Physical examination

The RN conducts a physical examination. However, parts of this examination may be delegated to the LPN/LVN. To conduct the examination, use techniques of inspection (looking), auscultation (listening), palpation (touching), and percussion (thumping).

Apical pulse

The apical pulse is measured during a physical examination; whenever the radial pulse is irregular; or when the patient has congestive heart failure, has an arrhythmia, has had heart surgery, or is recovering from a myocardial infarction. An apical pulse measurement is required before the patient is given digitalis or beta blocker-type heart medication.

The bathroom should be cleaned daily with standard household cleaning agent or a 1:10 solution of chlorine bleach and water.

The body can be protected from radiation in three basic ways: time (decrease the amount of time near a source), distance (increase your distance from a source), and shielding (use a barrier or shield between you and the source).

3 stages of a fever

The course of a fever can be observed on the recorded graph in the patient's chart. Fever occurs in three distinct stages: onset, febrile, and defervescence (abatement of fever). Onset may occur gradually or suddenly. The body responds to a pyrogen by trying to conserve and manufacture heat to raise the set point for core temperature. The person feels cold and adds clothes or covers, curls up in a ball, and turns up the heat to feel warm. Chills, increased respiratory rate, and increased pulse rate mark this stage. During the febrile stage the body temperature rises to the new set point established by the hypothalamus and remains there until the cause of the fever resolves. If the fever is very high or if it lasts for an extended period, dehydration, delirium, and convulsions may occur. Dehydration occurs as fluid is lost with perspiration and more rapid breathing. Delirium and convulsions may occur because neurologic function is affected when the temperature in the brain rises. The stage of defervescence brings lowering of the body temperature to normal. The person feels warm and the skin may be moist.

The cuff must be the correct size to obtain an accurate blood pressure reading. A narrow cuff is used for small children, and a wider cuff is needed for muscular or obese people. Using the wrong size produces errors as great as 25 mm Hg. The proper width is 21% larger than the diameter of the arm, and the inflatable bladder should go around at least three fourths of the arm. A standard acoustic stethoscope with Y tubing, soft ear tips, and a diaphragm head is satisfactory for taking vital signs (Skill 21-6).

The environment

The environment is the total of all elements and conditions that surround us and influence our development. Caring for the patient's environment is important in providing holistic care. The goal is to ensure safety while making the patient as comfortable as possible. This chapter presents information on the factors that are controllable in a patient's environment, beds and bed making, how to provide a safe environment, and when and how to apply a protective device.

The four rules of surgical asepsis are as follows: 1.Know what is sterile. 2.Know what is not sterile. 3.Separate sterile from unsterile. 4.Remedy contamination immediately.

Normal urinary

The frequency of urination varies. Infants void (excrete urine) from 5 to 40 times a day. The preschool child may void every 2 hours. The adult voids from 5 to 10 times a day. On average, the adult male voids 300 to 500 mL each time, and the adult female voids 250 mL. There should be at least an hourly urine output of 30 mL. This reflects adequate kidney perfusion.

Glass thermometer

The glass thermometer has a bulb containing an alloy of elements called galinstan and a stem in which the substance can rise (Figure 21-6). On the stem is a graduated scale representing degrees of temperature from 94° to 106.8° F. (The range on a Celsius thermometer scale is 34° to 43° C.) A glass thermometer should not be used orally if the patient is unconscious, subject to seizures, confused, or agitated because it might break if the patient bites on it. This thermometer should not be used orally on an infant or toddler who cannot hold it in the mouth properly or who might bite down on it. Rectal and oral thermometers must be kept separated so they are not confused. Glass thermometers are slippery when soapy; be especially careful when washing the thermometer. Glass thermometers may still be used in homes, since not everyone has obtained a new type of thermometer. Nurses should be able to teach parents how to read a glass thermometer (Figure 21-7).

The incidence of diabetes is increasing at an alarming rate in the United States. Of particular concern is the prevalence of type 2 diabetes among children, adolescents, and young adults. Americans of African American and Hispanic ethnic background are at high risk of development of diabetes; Pima Indians have the greatest risk of developing diabetes, with about a 50% risk

The integumentary system contains the skin, hair, nails, and sweat and sebaceous glands. The skin, the largest organ in the body, has two main layers: the epidermis and the dermis

Most common type of bath

The most common type of bath is a cleansing bath. It is generally provided in a bed, tub, or shower. Bed baths are given to patients who are unable to use a tub or shower. Skill 19-1 details how to administer a bed bath.

Clinical judgement

The outcome of clinics reasoning: conclusion or discussion you arrive at as a result of exercising your clinical reasoning skills

Surgical asepsis

The practice of preparing and handling materials in a way that prevents the patient's exposure to living microorganisms. Surgical asepsis is referred to as sterile technique. It involves sterilization of all instruments and inanimate equipment, as well as use of sterile supplies and sterile technique, for procedures that invade the body and for wound care. Most microorganisms are destroyed. Timed hand scrubs may be used by people working in the operating room to reduce the number of microorganisms on the skin, or a hand rub with an alcohol-based product may be used instead. Barrier garments are used to prevent spread of microorganisms between the staff and the patient

Nursing diagnosis #2

The process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified. The factors contributing to the problems are considered, and specific nursing diagnoses are chosen for the patient's care plan.

The purpose of evaluating nursing care is to achieve quality improvement by identifying specific areas that need changes. Evaluation is not performed to blame someone for carelessness, incompetence, or inefficiency. Nurses on a unit often rotate as the quality management person for the unit so that everyone is involved in the process.

Factors affecting the environment

The same environmental factors Florence Nightingale wrote about more than a century and a half ago are still important today. Temperature, ventilation, humidity, lighting, odor, and noise all are factors that must be controlled.

Spine exam

The shoulders should appear to be at equal height. Note whether lordosis (exaggerated lumbar curve), kyphosis (increased curve in the thoracic area), or scoliosis ( pronounced lateral curvature of the spine) is present.

The skin is the largest organ of the body and must be kept clean to prevent skin disorders and pressure ulcers. Hygiene is the proper care of the skin, hair, teeth, and nails to promote good health by protecting the body from infection and disease and to provide a sense of well-being. You are responsible for maintaining safety, privacy, and warmth when providing or assisting patients in hygiene practices. You must also encourage patients to function at their highest level of independence.

Alternative to protected devices

The standard of practice is to consider alternatives to restraints before using them. Many of the actions described in Box 20-3 on p. 322 involve frequent observations of the patient, which help prevent patient injury and decrease the use of the devices. Encourage family and friends of a patient who is confused to sit with the patient to promote safety.

The surgical hand rub is an approved alternate method for removing dirt, skin oil, and microorganisms from the hands and lower arms and reducing the microorganism count to as near zero as possible. Antiseptic residue remains on the skin to prevent the growth of microorganisms for several hours. A surgical hand rub is performed before entering the operating room, the labor and delivery area, the newborn nursery, or the neonatal intensive care unit (NICU). The rub is repeated before the next surgical procedure or delivery or any time that the hands become contaminated. It uses an antimicrobial agent that is at least 60% alcohol.

Surgical scrub

The surgical scrub (Skill 17-1) is more lengthy and vigorous than normal handwashing. Its purpose is to remove as many microorganisms as possible without damaging the skin of the hands. Water, a nail stick, an antiseptic agent, a scrub brush or sponge pad, and friction are used to mechanically cleanse the hands and forearms. The scrub begins at the tips of the fingers, working up the hands, and ends 2 inches above the elbows. All rinsing is done under warm, flowing water (Figure 17-4). The timing for the scrub does not include the rinsing time. Some agencies allow the use of the counted-stroke method of scrubbing rather than by-the-clock timing (Figure 17-5). Current standards regarding the time for the traditional scrub are based on the recommendations of the antiseptic agent manufacturer, and consequently the recommended time varies from one agency to another, depending on the product used. A 2- to 4-minute scrub is average.

Treatment and care of pressure ulcers

The team approach is the most effective method of pressure ulcer treatment. The team should include the patient, the family or caregivers, and health care providers. Some units have developed specialized skin care teams. Treatment options should be explained, and the patient should be encouraged to be an active participant. The plan should be consistent with the individual patient and family preferences, goals, and abilities. Include education on development and prevention of pressure ulcers.

Factors that influence temp

The temperature reading obtained varies according to the site used. Measurement sites are the mouth, rectum, axilla (armpit), ear, and on the skin. Most temperatures are measured orally, rectally, via the tympanic membrane (eardrum), or via the temporal artery. Rectal temperatures are usually about 1° F (0.5° C) higher and axillary temperatures are about 1° F lower than those measured orally. The axillary temperature is the temperature taken in the armpit. The electronic thermometer is switched to the rectal setting and attached to a different probe before taking a rectal temperature, and the reading should be recorded as a rectal temperature. The rectal temperature is usually taken with the patient in the left Sims position so that the rectum is positioned to accept the thermometer probe.

Temporal artery thermometer

The temporal artery thermometer is the most accurate noninvasive way to measure body temperature. It is passed over the temporal artery in the forehead. It captures the naturally emitted heat from the skin over the temporal artery, taking 1000 readings per second and selecting the highest reading. It provides an accurate arterial temperature. The probe is gently stroked across the forehead to the far side (Figure 21-4). The arterial temperature is close to rectal temperature, but almost 1° F (0.5° C) higher than an oral temperature. Ideally the temporal artery thermometer should be slid across the forehead above the brow ridges in a relatively straight line. Temporal artery temperature is unaffected by eating, drinking, smoking, or mouth breathing. If the person has been side-lying with part of the forehead into the pillow, allow the skin to cool to room temperature before using the thermometer.

Tachycardia

The term tachycardia refers to a pulse greater than 100 beats per minute (bpm);

Taking an oral temp

The tip of the thermometer or probe with a plastic sleeve or probe cover should be placed in the sublingual pocket (Figure 21-5). The patient should keep the tongue down, close the mouth, and keep the lips closed. Remove the cover before reading a glass thermometer.

These positions improve cardiac output and respiration and promote urinary and bowel elimination. Do not place a patient who had abdominal surgery in a Fowler position unless ordered. Elevation of the knees above 15 degrees is contraindicated in elderly and postoperative patients because it is associated with decreased circulation of the lower extremities; check the orders. Fowler position may help the patient who had a stroke and has paresis to swallow food and secretions.

Aseptic technique

These principles form the basis of surgical asepsis: 1.A sterile surface touching a sterile surface remains sterile. 2.A sterile surface touching a nonsterile surface becomes contaminated. 3.Sterile materials must be kept dry; moisture transmits microorganisms and contaminates. 4.Only sterile items are used within the sterile field. 5.A sterile barrier must be considered contaminated after it has been penetrated. 6.The edges of a sterile package or container are considered contaminated after it is opened. 7.When there is a doubt about the sterility of any item, it must be considered nonsterile. 8.Avoid reaching across or above a sterile field with bare hands or arms or with other nonsterile items. 9.Avoid coughing, sneezing, or unnecessary talking near or over a sterile field. 10.When wearing sterile gloves, keep hands in sight, away from all unsterile objects, and above waist level. 11.Gowns are considered sterile only in front from shoulder level to table level and the sleeves to 2 inches above the elbow. 12.Open the wrapper of a sterile pack away from the body, the distal flap first, the lateral flaps next, and the proximal flap toward the body last, thus making it unnecessary to reach over the sterile field. 13.Only the horizontal surface of a table is considered sterile. 14.An area of 1 inch surrounding the outer edge of the sterile field must be considered unsterile. 15.The sterile field must be kept in sight at all times. Do not turn away from it or leave it. If this happens, you cannot be certain that it is still sterile. 16.The floor must be recognized as the most grossly contaminated area. Clean or sterile items that fall on to the floor should be discarded or decontaminated.

Removal of lenses

To remove a hard lens, perform hand hygiene and don clean gloves. Cup your nondominant hand below the patient's eye. Move the lens directly over the cornea. Pull the upper eyelid up above the edge of the lens; pull the lower lid down to the lower edge of the lens. Press slightly on the lower lid at the edge of the lens; the lens should slide out between the eyelids. To remove a soft lens, perform hand hygiene and don clean gloves. Place a drop of wetting solution

Mouth care for conscious patient

To assist a patient with mouth care, raise the head of the bed 45 to 90 degrees. Wear gloves when providing or assisting with mouth care. If the patient is unable to sit up, turn the patient to the side facing you. Place a towel under the chin.

Palpate

To feel

To prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA) in your community: •Wash hands frequently; use an alcohol-based rub when soap and running water are unavailable. •Keep cuts and abrasions clean and covered with a bandage until healed. •Avoid sharing personal items such as razors, towels, and make-up. •Avoid contact with other people's bandages or wounds.

Transmission based precautions

are based on interrupting the mode of transmission by identifying the specific secretions, body fluids, tissues, or excretions that might be infective.

Cross contamination

Transmission of infectious microorganisms from one person or object to another

Two premises underlie the current system of isolation. One is that infection may be present before the diagnosis is made. The second is that the greatest risk of transmitting infection for most microorganisms comes from direct contact by the caregiver's hands or equipment and supplies that have been soiled by blood, body fluids, and other potentially infectious materials. It is known that all body substances may harbor microorganisms and be infectious; therefore contact with body substances must be avoided.

Rectal and axillary temps

Tympanic and temporal artery thermometers are more expensive than home electronic thermometers and are not universally used at home. Oral temperatures are convenient for older children and adults. The glass clinical thermometer must be left in place under the tongue for at least 3 minutes to register the temperature accurately, although newer types of electronic, chemical, and infrared thermometers register in much less time. If the patient has recently swallowed hot or cold foods or liquids or has been smoking or chewing gum, wait 15 to 30 minutes for these effects to pass for a more accurate measurement. A glass thermometer is never used orally if the patient is uncooperative or at risk for biting on the thermometer. Rectal temperatures are taken when an accurate temperature cannot be obtained orally and a tympanic or temporal artery thermometer is not available. The rectal route may be used when the patient has nasal congestion, has undergone nasal or oral surgery, is unable to keep the mouth closed, or is at risk for seizures. Rectal temperatures should not be used for cardiac patients or patients who have had rectal surgery. Axillary temperatures are taken when oral or rectal temperatures are contraindicated and a tympanic or temporal artery thermometer is not available. They are a less reliable measure. Factors that may affect body temperature are listed in Box 21-1.

Use Standard Precautions for each contact with every patient, regardless of whether infection is known to be present. Implement Transmission-Based Precautions based on the individual patient's infection status.

Contact precautions

Use in addition to Standard Precautions for patients with known or suspected serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include: •Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant organisms •Enteric infections with a low infectious dose or prolonged environmental survival, including Clostridium difficile •For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus infection •Respiratory syncytial virus (RSV), parainfluenza virus, or enteroviral infections in infants and young children •Skin infections that are highly contagious or that may occur on dry skin, including diphtheria (cutaneous), herpes simplex virus (neonatal or mucocutaneous), impetigo, major (noncontained) abscesses, cellulitis, decubitus ulcers, pediculosis, scabies, staphylococcal furunculosis in infants and young children, and zoster (disseminated or in the immunocompromised host) •Viral or hemorrhagic conjunctivitis •Viral or hemorrhagic infections (Ebola, Lassa, or Marburg virus)

Airborne Infection Isolation Precautions

Use in addition to Standard Precautions for patients with known or suspected serious illnesses transmitted by airborne droplet nuclei. Examples of such diseases are: •Measles (rubella) •Varicella (including disseminated zoster) •Pulmonary tuberculosis

Droplet precautions

Use in addition to Standard Precautions for patients with known or suspected serious illnesses transmitted by large-particle droplets. Examples of such illnesses are: •Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, and epiglottitis •Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis •Other serious bacterial respiratory tract infections spread by droplet transmission, including diphtheria (pharyngeal), Mycoplasma pneumonia, pertussis, and pneumonic plague •Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children •Serious viral infections spread by droplet transmission, including adenovirus, influenza, mumps, parvovirus B19, and rubella

Use smooth, coordinated movements instead of jerking or sudden pulling motions. To coordinate effort, tell the patient and other staff members to move, lift, or pull "on the count of 3." This will help to ensure that everyone is working at the same time to maximize the effort and decrease the individual load.

Perineal care

Usually a patient will accept your assistance with perineal care, although a few try to avoid it because they feel embarrassed. Proper draping helps promote comfort with the procedure (Figure 19-8). You can reduce your feelings of embarrassment by remembering your purpose is to assist the patient. Explain the procedure to reassure the patient and gain cooperation. Maintain a matter-of-fact attitude and be objective; avoid any sexually suggestive conversation or actions. A professional and dignified attitude can help reduce embarrassment.

Ventilation

Ventilation is the process or act of supplying a building or room continuously with fresh air. Most health care facilities have central air-conditioning units that regulate temperature, humidity, and air exchange. Most hospital windows cannot be opened for safety reasons and are not a source of ventilation. Fans are discouraged because air currents spread microorganisms. A table fan may be ordered if the patient has a 313 314 respiratory condition because the patient may find it easier to breathe when air movement is felt. At home, windows may be opened at the top and bottom to encourage air circulation. For certain patients, a negative-airflow room (maintaining air flow into the room) or positive-airflow room (maintaining air flow out of the room) might be indicated.

Water should be warm but should not burn the patient (approximately 105° F [40.6° C], or according to policy). When water cools, replace it. Bed rails must be up when you are away from that side of the bed, since the bed is raised to working height. Fully draw curtains around the bed to maintain privacy. Do not leave any gaps that could expose the patient to others in the room. Place a sign on the outside of the door to indicate that a bath is in progress. Close the patient's door and windows to decrease drafts. Appropriately drape the patient for warmth and comfort. Only the part of the body being bathed should be exposed at any one time. Encourage the patient to be independent, but offer assistance as needed. Depending on the patient's ability and activity level, you may need to give either a partial or complete bath.

Placing protected devices

When applying the protective device, make certain that the patient's movements or tugging will not impair circulation or nerve function. Padding the device with a soft washcloth or gauze pads will prevent skin irritation. The device should fit snugly when applied, but should not compromise the patient's neurovascular status. You should be able to easily fit your index and middle fingers between the patient and the device

Puls characteristica

When counting the pulse, note the rate, the rhythm, and the volume. Begin timing with a beat that is not counted; the next beat is "1." An arrhythmia (irregular pulse) has a period of normal rhythm broken by periods of irregularity or skipped beats. This can occur as a 351 352

Supine position

When patients are resting on their back. It is recommended after spinal surgery and after the administration of some types of spinal anesthetics. The supine position is similar to proper standing alignment except that the body is in the horizontal as opposed to the vertical plane.

When prioritizing such tasks, you must consider what will happen if the task is not done on time. The recovering patient whose vital signs have been stable for the past 24 hours probably will not suffer a bad consequence if you do not take her vital signs right at 8 A.M.

Work at the same level or height as the object to be moved (Figure 18-4). This keeps the workload near your center of gravity. Changing bed linens is a good example of this principle. In most institutions the bed's height is adjustable. When changing linen or moving a patient, temporarily raise the bed to waist level to keep the work near your center of gravity. Injuries are more likely to occur the farther away the work is from the center of gravity.

You must be familiar with your institution's policies and procedures for handling victims of a terrorist attack. Knowing how to respond to terrorist attacks with various agents will help prepare you should a crisis happen in your area. Being prepared will help alleviate your anxiety and increase your confidence in dealing with such unpredictable events. In turn, this will help you manage your patients' fears and give more effective care.

Antiseptic

a chemical compound that is used on skin or tissue to inhibit the growth of or to eliminate microorganisms. Disinfectants and antiseptics have bactericidal or bacteriostatic properties.

Expected outcome

a specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention. An expected outcome for Mrs. Torres' nursing diagnosis of Impaired physical mobility related to left-sided muscular weakness, as evidenced by inability to bear weight on the left leg, might be "Patient uses a walker to ambulate to the nurses' station without assistance by July 10." The expected outcome should also contain measurable criteria that can be evaluated to see whether the outcome has been achieved. For example, for Mrs. Torres' nursing diagnosis of Reflex urinary incontinence related to neurologic impairment as evidenced by inability to retain urine, an appropriate expected outcome might be "Patient voids in bedpan every 2 hours while awake without intervening episodes of incontinence by July 10." If the nurse assists Mrs. Torres with the bedpan every 2 hours and she voids each time, the expected outcome would be met. If Mrs. Torres is wet between voidings, the goal of remaining dry during waking hours would not have been met. An expected outcome should be realistic and attainable and should have a defined time line. Collaboration with the patient regarding the expected outcomes is important. The patient and other health professionals involved in the patient's care must agree on the importance of the expected outcome. Some health facilities use the term discharge criteria in place of expected outcome. Desired outcome is another term often used for expected outcome.

Scientific method

a step-by-step process used by scientists to solve problems

Knee chest position

a variation of the prone position (Figure 18-8). The patient is face down on the bed with the head turned to one side. The chest, elbows, and knees rest on the bed, and the thighs are perpendicular to the bed. The lower legs rest flat on the bed. This is used for rectal examinations and as a method to restore the uterus to a normal position. Do not leave the patient alone in the knee-chest position because the patient may become dizzy, faint, or fall. A patient with arthritis or joint abnormalities may not be able to assume this position.

Nursing process

a way of thinking and acting based on the scientific method

Sign

abnormalities that can be verified by repeat examination and are objective data. A bruise on the arm would be a sign

Crisis

abrupt decline in fever

Classification of bacteria

according to their morphology (shape) places them into one of three main groups: cocci (round), bacilli (rod shaped), and spirochetes (spiral). Some grow in chains (streptococci), some in pairs (diplococci), and some in clusters (staphylococci).

Side lying or lateral

achieved by having patients rest on their side. It alleviates pressure from bony prominences on the back. The major portion of the patients' weight is on the dependent shoulder and hip. Maintain the vertebral column in proper alignment as if they were standing. The oblique side-lying position removes pressure from the dependent shoulder and hip and is easier for patients to maintain.

Dependent nursing action

administering a medication is a dependent nursing action because it requires a physician's order.

Puls pressure

average blood pressure in a healthy young adult is less than 120/80 mm Hg: 120 is the systolic pressure, 80 is the diastolic pressure, and the difference between the two, or 40, is the pulse pressure.

Incubation period

begins when the organism firsts enters the body and lasts until the onset of symptoms. During this period the organism multiplies, and the duration of the period varies depending on the type of microorganism. In many viral diseases the virus is transmitted during the incubation period.

Bradychardia

bradycardia indicates a slow pulse that is less than 60 bpm

Neatness

but not so rigid that the patient may not have possessions from home. Straighten the patient unit after making the bed. Remove old dishes and unused equipment promptly. Clear and wipe the over-the-bed table before serving meals. Obtain the patient's permission before disposing of newspapers or magazines. Check and straighten the unit each time you enter and as time permits.

Asepsis

the practice of making the environment and objects free of microorganisms. Two types of asepsis are practiced within health care agencies

Disinfectant agents

can be used to eliminate some types of organisms that are left after cleansing. Disinfectants are solutions containing chemical compounds such as phenol, alcohol, or chlorine that kill or inactivate nearly all microorganisms. These chemicals can be caustic to the skin and are used only on inanimate objects. A recommended disinfectant is chlorine bleach and water at a ratio of 1:10.

A roller board

consists of several roller bars between fixed end bars. The bars are enclosed in a vinyl covering that allows the bars to turn when something or someone is pulled over the top of the roller board. It works similar to a conveyor belt.

Symptoms

factors the patient has said are occurring that cannot be verified by examination; symptoms are subjective data. A headache would be a symptom. You cannot see or verify that the patient actually has a headache; you must trust what the patient tells you.

Standard precautions

delineate methods for avoiding direct contact with all body secretions except sweat, whether or not visible blood is present. This includes the mucous membranes and all nonintact skin

Bacteriacidal solution

destroys bacteria; a bacteriostatic solution prevents the growth and reproduction of some bacteria. Povidone-iodine is an example of an antiseptic. Items that cannot be sterilized, such as skin, can be disinfected with antiseptic agents.

Pulse deficit

difference between the apical and radial pulse

Independent nursing action

does not require a physician's order, but it does require critical thinking and nursing judgment

Semi fowler

elevation of 30 to 60 degrees

Lysis

gradual return to a normal temperature, when applied to fever

Basal metabolic rate bmr

he rate at which heat is produced when the body is at rest. The average BMR depends on the person's body surface area.

A goal

is a broad idea of what is to be achieved through nursing intervention.

Low fowler

is an elevation of 15 to 30 degrees

Diaphoresis

is excessive sweat production, which attempts to cool the body by evaporation.

Priority

is more important than something else at that time. Prioritizing involves placing nursing diagnoses or nursing interventions in order of importance. Prioritizing patient problems is usually based on the adaptation of Maslow's hierarchy of needs.

Prodominal period

is the short time from the onset of vague, nonspecific symptoms to the beginning of specific symptoms of infection. The patient may be irritable and experience fatigue, malaise and elevated temperature. This period lasts a few hours to a few days. Microorganisms are most likely to be spread during this highly infectious stage. Typically, precautions against spreading the infection are not taken because people do not realize that they are ill until the more specific symptoms of infection appear.

Illness period

localized and systemic signs and symptoms appear. The individual may have fever, headache, and malaise. Other specific signs of infection may be detected, such as rash, swollen lymph nodes, leukocytosis (increased white blood cells), purulent wound exudate, diarrhea, and vomiting. The severity of the symptoms and the duration of the illness depend on the virulence of the pathogen and the person's susceptibility to the microorganism. In this phase people perceive they are ill and may seek professional care.

Ph of urine

pH The acidity or alkalinity of urine is measured in units called pH. The pH of normal urine is slightly acid, ranging from 5.5 to 7.0.

Helminths

parasitic worms or flukes belonging to the animal kingdom. Pinworms, which mostly affect children, are the most common helminths worldwide. Roundworms and tapeworms are other helminths.

Cues

pieces of data or information that influence decisions.

Infection prevention and control

rely on medical and surgical asepsis, Standard Precautions, and Transmission-Based Precautions to prevent or control the spread of microorganisms. The strict use of aseptic technique when performing all diagnostic and therapeutic procedures involving catheters, IV therapy, endotracheal and tracheostomy tubes, drainage tubes, and wound care reduces the incidence of HAIs

Vital signs

temperature, pulse, respiration, blood pressure, and pain level, plus oxygen saturation level—give some indication of a person's state of health. They represent interrelated physiologic systems of the body. Learning to measure vital signs is the beginning step in gathering assessment data for patients. Evaluation of vital sign data requires several readings so that a patient's status can be determined.

Medical asepsis

the practice of reducing the number of organisms present or reducing the risk for transmission of organisms. It prevents reinfection of the patient and the spread of infection from person to person. It involves cleanliness and is accomplished by protecting items in the environment from contamination and by disinfecting items that have been contaminated. Medical asepsis is referred to as clean technique because most, but not all, microorganisms are destroyed.

Dorsal recumbent and dorsal lithotomy positions

ther variations of the supine position. In the dorsal recumbent position, patients are on their back with knees flexed and soles of the feet flat on the bed (Figure 18-6). This is used for a variety of procedures and examinations. The dorsal lithotomy position (Figure 18-7) is used for examining the pelvic organs. It is like the dorsal recumbent position except the feet are usually placed in stirrups and the legs are spread farther apart and abducted. Patients with joint problems or arthritis may have difficulty assuming this position.

Defining characteristics

those characteristics (signs and symptoms) that must be present for a particular nursing diagnosis to be appropriate for that patient.

Prone position

when the patient is lying face down. It provides an alternative for patients who are on prolonged bed rest or are immobilized. Spinal cord-injured patients often use this position. The position is generally not well tolerated because it is boring. In the prone position, for patients who have not had a spinal cord injury, turn the head to one side or the other and support with a small pillow. If the head is not turned or the patient is not on a special bed with a removable piece at the head, the patient will not be able to breathe.

Special circumstances for temp

•A tympanic thermometer should not be used if the patient has an inflammatory condition of the auditory canal or if there is discharge from the ear. •Moving the probe laterally back and forth with small movements assists in positioning the probe so that it seals the canal. •Having a parent hold the child's head against the body helps stabilize the head so that the probe can be placed in the ear. •Approaching the small child or very elderly patient with a slow, smooth movement after explaining what you are going to do decreases reflex "ducking." •A rectal probe attachment and probe cover may be used to take a rectal temperature if that probe is available.

Urinary patterns

•Anuria is present when less than 100 mL of urine is excreted in 24 hours. It may be caused by urinary suppression (the kidneys are not forming urine) or to the retention of urine (all urine is not expelled from the bladder during voiding). •Dysuria (painful or difficult urination) occurs when there is inflammation present in the bladder or urethra and is usually due to infection or trauma. •Incontinence (involuntary release of urine) occurs with a variety of pathologic conditions. When it is due to decreased muscle tone, special exercises (see Patient Teaching, p. 562) may prevent it. •Nocturia occurs when the person must get up to void during the night more than once or twice. •Oliguria (decreased amount of urine output) occurs when urine output falls below 400 mL/24 hr. It may be a sign of kidney failure, blockage of urine outflow somewhere in the system, or retention. •Polyuria (excessive urination) occurs when large amounts of urine are voided, with an output of greater than 1500 mL/24 hr. It is usually associated with either diabetes mellitus, in which there is an absence of insulin, or diabetes insipidus, in which there is decreased production of antidiuretic hormone.

What effects body heat production

•BMR is affected by thyroid hormone. Excessive amounts of thyroid hormone cause an increase in the metabolic rate and the person feels warm; insufficient thyroid hormone results in a decreased metabolic rate and the person may feel cold. •Other hormones that affect metabolic rate are epinephrine, norepinephrine, and testosterone. Because of their levels of testosterone, men have a higher BMR than women. •Voluntary muscle movement of exercise increases the BMR and heat production. •The involuntary muscle action of shivering can increase heat production up to five times normal.

•Because of decreased sweat and sebaceous gland activity, a full bath is not needed every day. Personal preference must be considered. •Because of thinner skin and decreased subcutaneous fat, chilling is more likely during the bath. Prevent this by prewarming the bath area and providing adequate draping. •The elderly have less subcutaneous fat, and their skin is more fragile and drier. Use warm (not hot) water and minimal amounts of mild soap, rinse thoroughly, and thoroughly pat dry to minimize skin irritation. Bath oils may be used, but special care needs to be taken to prevent slips and falls. •Moisturize the skin immediately after the bath with a lotion or cream. Apply this while the skin is still damp to trap additional moisture. •Evaluate the home environment for safety aids such as nonskid tub or shower mats, safety bars, and shower or bench chairs if appropriate.

Blood pressure sp/dp

•Blood pressure is the pressure exerted on the arterial wall. The pressure changes depending on whether the heart is pumping or resting. •Systolic pressure is the maximum pressure exerted on the artery during left ventricular contraction (systole). •Diastolic pressure is the lower pressure exerted on the artery when the heart is at rest between contractions (diastole).

What changes in the system occur with aging?

•Bone strength and mass are lost because of mineral resorption. This may lead to osteoporosis, which is more common in women. •The loss of bone density predisposes the elderly patient to fractures. The fractures do not heal as quickly because of the decreased mineral uptake.

What are the functions of bones for positioning and moving patients?

•Bones provide the scaffolding or framework to the body (Figure 18-1). •The skeleton gives the body shape and supports the internal organs and skin. •The bones provide places for the ligaments and tendons to attach, thereby allowing movement. •The primary function of a joint is to provide movement and flexibility to the skeleton.

Pyrexia

•fever) occurs when normal mechanisms of the body cannot keep up with excessive heat production and body temperature rises. Pyrexia occurs when the body temperature rises above 100.2° F (37.9° C).

How is respiration controlled

•Breathing is an involuntary, automatic function controlled by the respiratory center located in the pons and medulla of the brainstem (see Figure 21-1). •The respiratory center works together with feedback mechanisms. The carotid body receptors in the common carotid arteries and the aortic body receptors lying adjacent to the aortic arch signal the respiratory centers to alter the rate or depth of respiration in response to decreased oxygen levels in the blood. •Increasing levels of carbon dioxide and increasing hydrogen ion (H+) concentration in the blood can activate these receptors also. 337 338 •Messages are sent from the respiratory center to the respiratory muscles controlling the diaphragm and the intercostal muscles, thereby altering the respiratory rate or depth. •The pumping action of the heart brings blood through the lung capillaries, where diffusion of oxygen and carbon dioxide can take place across the alveolar membrane.

Back massage

•Communicates caring •Fosters trust in the nurse-patient relationship •Provides an opportunity to assess the skin on the back •Stimulates circulation of blood to the area •Reduces tension and promotes relaxation

Fever pattern

•Constant: The temperature is continuously elevated with less than 1° F of variation within a 24-hour period. •Intermittent: The temperature alternates rising and falling (e.g., low in the morning and high in the afternoon, or low for 2 to 3 days followed by a high temperature for 2 to 3 days). •Remittent: A high temperature falls, usually in the morning, and again rises later in the day. The temperature never falls to normal in this type of fever until recovery occurs. •Relapsing: The temperature falls to normal and then rises again in a repeating pattern.

Adventitious sounds

•Crackles: Abnormal, nonmusical sound heard on auscultation of the lungs during inspiration; also called rales (sound like hair rubbed between the fingers next to the ear) •Rhonchi: Continuous dry, rattling sounds heard on auscultation of the lungs caused by partial obstruction •Stertor: Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi •Stridor: Crowing sound on inspiration caused by obstruction of the upper air passages, as occurs in croup or laryngitis •Wheeze: Whistling sound of air forced past a partial obstruction, as found in asthma or emphysema

Contributing factors of pressure ulcers

•Dehydration •Obesity •Edema

•Do not massage reddened skin, since it has already suffered temporary damage. Do not massage directly over bony prominences, since this is harmful.

•During the implementation step of the nursing process, the planned nursing interventions are carried out. •Priorities of care are set when developing a well-organized work plan for the shift. •Before carrying out interventions, you need to understand the reason for the intervention, the usual standard of care, the expected outcome, and any potential danger. •An independent nursing action is one that the nurse can perform without a physician's order. •A dependent nursing action requires a physician's order before it can be legally carried out. •An interdependent action is one derived from collaborative planning between two or more health care professionals. •A clinical pathway or interdisciplinary care map contains the actions to be carried out by all of the health professionals involved in the patient's care. It is a managed care tool and is used to speed a patient to recovery as quickly and cost-effectively as possible. •The family and resident are invited to the care planning conference in the long-term care facility. •The care plan for the home health patient encompasses the needs and concerns of the family as well as those of the patient. •Documentation of nursing care is essential and should be done soon after an action has been completed. •Documentation must show the progress toward attainment of outcomes. •Evaluation involves reassessment of data to determine whether the expected outcomes have been achieved. •After evaluation, the nursing care plan is revised. •The goal of a quality improvement program is improvement of nursing practice and patient care. •Construction of a nursing care plan involves assessing the patient, analyzing the data, identifying nursing problems, prioritizing the problems, deciding on goals, writing expected outcomes, and choosing interventions. After the plan is implemented, the outcomes of the interventions are evaluated and the plan is revised as needed.

Nursing interventions to reduce fevers

•Encourage large fluid intake unless contraindicated. •Lower the room temperature by adjusting the thermostat or opening doors or windows. •Increase the rate of circulating air with a fan. •Remove items of clothing or bed covers. •Control or reduce the amount of body activity. •Carry out the physician's orders for cooling measures and supportive treatment: tepid sponge bath, cooling blanket, high-calorie diet and fluids, or medication to lower emperature and combat the disease.

•Formulating a care plan is a collaborative process among the nurse, the patient, and other health team members.

Before measuring BP

•Have the patient lie down or sit and rest for 5 minutes. If sitting, the patient should keep the feet flat on the floor. •Use the brachial artery in the elbow joint of either arm. The arm should be supported on a surface at the level of the heart. •Check the condition of the equipment, and position the manometer gauge so it can be seen at eye level from a distance of 1 to 3 feet. The gauge indicator should be at zero when the cuff is deflated. Use the correct cuff size. •Bare the arm, and place the cuff and stethoscope directly on the skin. Bunched or wrinkled clothing prevents the correct placement of the cuff. •Palpate the brachial or radial artery before taking the blood pressure when the patient is new to you. Inflate the cuff while palpating the artery and note the level at which the pulse disappears. Deflate the cuff. Wait 30 to 60 seconds before reinflating for the auscultated readings. (For repeated measurements on familiar patients, you may forgo the palpated pressure, but inflate to 10 to 20 points above the person's usual systolic reading.) •Make certain the diaphragm of the stethoscope is placed firmly but lightly over the artery, or the bell is placed lightly. All surface edges of the diaphragm should be in contact with the skin. Do not place the thumb over the bell or top of the stethoscope to hold it in place. •Inflate the cuff to 30 mm Hg above where the pulse disappeared on palpation with inflation to prevent missing an auscultatory gap (period when no sound is heard). •Allow the cuff to deflate very slowly at 2 mm Hg/sec. Any faster causes erroneous readings of both systolic and diastolic pressure. •Once the cuff is starting to deflate, continue to deflate slowly all the way to zero. Do not stop midway and begin to inflate again, since this gives a false reading. •Listen for the different sounds while steadily deflating the cuff, and identify the systolic and diastolic pressures. The phase I sound is the systolic pressure; the disappearance, or phase V, sound is the diastolic pressure. If the sound persists down to zero, then indicate the point at which the phase IV sound occurred and record both, as in this example: 30/62/0 (see Skill 21-6).

Gordon's 11 health problems

•Health perception-health management pattern •Nutritional-metabolic pattern •Elimination pattern •Activity-exercise pattern •Cognitive-perceptual pattern •Sleep-rest pattern •Self-perception-self-concept pattern •Role-relationship pattern •Sexuality-reproductive pattern •Coping-stress-tolerance pattern •Value-belief pattern

Dsfunctional

•History of dysfunction •Diagnostic test abnormalities •Risk factors related to medical treatment plan

•Illness progresses through an incubation period, a prodromal period, an illness period, and a convalescent period. •The present system of infection prevention and control consists of two tiers: Standard Precautions, to be used for all patients; and Transmission-Based Precautions, to be used for patients who have an organism that is transmissible. •Transmission-Based Precautions are always used along with Standard Precautions. •PPE is used to protect patients and health care workers. PPE includes head covering, protective eyewear, masks, gowns, gloves, and shoe covers. The mode of transmission of a microorganism determines which PPE is necessary. •Hand hygiene is the best method of preventing HAIs. •A special respirator (N95) mask is necessary to care for a patient under Airborne Infection Isolation Precautions who has or may have pulmonary tuberculosis, varicella, rubeola, or severe acute respiratory syndrome (SARS). •Laboratory specimens are labeled and bagged before removal from an isolation room. •Linens and trash are deposited in specially marked biohazard bags before removal from an isolation room. Sharps are placed in a puncture-resistant container marked "biohazard." •If a patient under Airborne Infection Isolation Precautions must be transported, he wears a mask. •Emphasis in the home environment is on preventing the transmission of microorganisms to others and on containing pathogens. •Protective isolation is used for severely immunocompromised patients. Full use of PPE is required for all people entering the patient's room. •The nurse should oversee appropriate activities and opportunities for contact with friends and family to prevent adverse psychological consequences for the isolation patient. •Nurses must be knowledgeable about and strictly follow the principles of surgical asepsis and the use of sterile technique.

Nursing Diagnoses Commonly Found for Long-Term Care Residents

•Impaired swallowing r/t weakness or paralysis of the swallowing muscles •Risk for aspiration r/t impaired swallowing, depressed gag reflex, or decreased level of consciousness •Impaired verbal communication r/t changes in the cerebral hemispheres •Self-care deficit r/t impaired mobility, disturbed thought processes, or sensory impairment •Disturbed thought processes r/t damage to cerebral tissue •Impaired urinary elimination: incontinence r/t decreased ability to control elimination •Risk for injury r/t falls, weakness, or altered thought processes •Self-esteem, situational low r/t change in appearance, loss of self-control, role changes, or dependence on others to meet basic needs •Imbalanced nutrition: less than body requirements r/t decreased oral intake •Risk for imbalanced fluid volume r/t inadequate fluid intake or excessive fluid loss •Chronic pain r/t chronic disease process •Impaired skin integrity r/t damage to skin associated with friction, pressure, or shearing •Impaired physical mobility r/t loss of muscle mass, tone, or strength, or paralysis •Risk for constipation r/t medication side effects, decreased GI motility, loss of nervous control over defecation reflex, or decreased activity •Impaired social interaction r/t depressed mood, withdrawal, or impaired communication •Disturbed thought processes r/t inaccurate interpretation of environment •Ineffective coping r/t inability to function at previous level, poor problem solving, or poor cognitive function •Wandering r/t decreased cognition, anxiety, and agitation

Safety

•Improve the accuracy of patient identification. •Improve the effectiveness of communication among caregivers. •Improve the safety of using medications. •Reduce the risk of health care-associated infections. •Reduce the risk of patient harm resulting from falls. •Prevent health care-associated pressure ulcers (decubitus ulcers). •The organization identifies safety risks inherent in its patient population.

Hazards of improper alignment and positioning include:

•Interference with circulation, which may lead to pressure ulcers (ulcers that form from local interference with circulation) •Muscle cramps and possible contractures (resistance to stretch in damaged muscle that pulls a joint into a fixed or "frozen" position) •Fluid collection in the lungs

Heath care facility safety

•Keep the bed in the low position if not giving direct care. •Put mattress onto the floor or a low platform if there is a high risk for a fall and the patient does not ask for help when getting out of bed. •Toilet the patient on a regular schedule to decrease the chance the patient will try to get out of bed unassisted. •Lock the bed wheels to prevent the bed from rolling when the patient attempts to get in or out. •Provide a night-light to aid patients in going to the bathroom at night, to decrease disorientation, and to prevent bumping into furniture. •Encourage the use of firm, nonskid slippers to prevent slipping while walking. •Answer call lights quickly so that the patient learns to trust you and does not feel the need to get up without help. •Tell the patient when you will next check in, and be prompt. •Be certain the patient is comfortable and all desired items and call bell are in easy reach before you leave the room. •Encourage use of grab bars for the toilet, tub, and shower. •Place the high-risk or restless patient in a room close to the nurses' station so you can check on the patient often. •Stay with the patient who is confused, agitated, or unsteady whenever the patient is up. •Restrict fluids after 6 P.M. if a patient is up at night frequently to empty the bladder and has a history of injury when out of bed. •Provide diversionary and social activities that confused and restless patients might enjoy. Seating patients confined to a wheelchair close to the nurses' station often provides enough stimulation to occupy their thoughts and reduce their need to wander. •Be certain wheelchair brakes are locked before transferring a patient into or out of it. •Perform change-of-shift safety checks of the unit. •Orient the patient and family when admitted to the room with regard to operation of call bell system, bed, television, and radio. Check to be certain the patient can operate the controls. •On admission, assess the patient's gait and risk for falling. If the patient is considered to be at risk for falls, implement your facility's fall risk prevention program. •Evaluate the patient's drug regimen for side effects that may increase the risk of falling (e.g., those that affect the central nervous system or cause orthostatic hypotension, dizziness, or drowsiness). •Keep the bed in the low position if not giving direct care.

Changes in the system occurring with age

•Loss of elastic fibers and adipose tissue in the dermis and subcutaneous layers causes skin to be thinner and more transparent, with wrinkling and sagging. •Loss of collagen fibers in the dermis makes the skin more fragile and slower to heal. •Decreased sebaceous gland activity causes dry and itchy skin. •Temperature control is altered by the decreased sebaceous gland activity and the loss of skin density. This results in cold intolerance and puts the person at risk for heat exhaustion. •Hair becomes thin and grows more slowly because the number of hair follicles decreases. Hair loses its color from the loss of melanocytes at the hair follicles. •Nail growth decreases and the nails thicken.

Skills of a critical thinker

•Maintain an open mind and a questioning attitude. •Recognize one's own biases and limitations. •Be persistent in seeking solutions. •Separate relevant from irrelevant information. •Recognize inconsistencies in data gathered. •Identify missing information. •Consider all possibilities. •Assume an empathetic attitude. •Use an organized and systematic approach to problems. •Verify accuracy and reliability of data. •Consider all possible solutions before making a decision. •Admit what one does not know. •Reason logically. •Strive for excellence and improvement. •Draw valid conclusions from the evidence or data. •Set priorities and make carefully considered decisions. •Be flexible, realistic, creative, humble, honest, curious, and insightful.

•Many factors can be controlled in the patient's environment. •Bright lighting is needed for performing procedures. •Adequate night lighting is needed to prevent injury when going to the bathroom. •The most common cause of noise pollution in a health care agency is people. •Keep rooms neat and clean, while allowing patients to have personal items close to them. •Privacy is important to a patient's well-being. •A bed should be neat, clean, dry, and free from wrinkles. •Bed making should be done, if possible, while the patient is out of bed. •Safety is a primary concern when caring for patients. •Falls are the most frequent cause of injury for the elderly patient in an acute care facility. •RACE is the acronym for how to proceed in case of a fire. •Know your agency's policy for cleaning up a biohazardous spill and handling bioterrorism or chemical terrorism occurrences. •Protective devices are used only as a last resort. •Use the least restrictive immobilizing device for the situation. •A protective device should be applied snugly but should not impair neurovascular status.

•Microorganisms are abundant in our environment, and many can cause infection if not controlled. •Pathogens include bacteria, viruses, protozoa, rickettsia, fungi, prions, and helminths. •The most effective way to destroy many kinds of microorganisms is to expose them to moist heat at a high temperature for 15 to 20 minutes. •Standard Precautions are used for all patients to prevent the spread of microorganisms. •The spread of infection is prevented by breaking any one of the six links of the infection chain (see Figure 16-3). •The elderly are typically more susceptible to infection due to the effects of natural aging on the body (see Table 16-6). •Body defenses against infection are intact skin, the inflammatory process, and the immune response. •The purposes of the inflammatory process are to neutralize and destroy harmful agents, limit their spread, and prepare damaged tissue for repair. •There are five types of immunity: naturally acquired, passive acquired, naturally acquired passive, artificially acquired, and artificially acquired passive. •Medical asepsis, or clean technique, reduces the number of microorganisms present and decreases the risk of transmission of microorganisms from one person to another. •Surgical asepsis, or sterile technique, is a method of preparing and handling materials or equipment in such a way that microorganisms cannot be transferred from them to a person. •Asepsis is not as stringent in the home environment as in a health care agency, but patients and families must be taught infection prevention and control techniques. •Hand hygiene is the most effective way to prevent the transfer of microorganisms and is performed before and after caring for each patient. •PPE is used to carry out Standard Precautions and includes items such as head cover, gowns, masks, protective eyewear, gloves, and sometimes shoe covers. •Infection prevention and control are the responsibility of all health care workers. •Pathogens can be killed or inactivated by disinfection, by sterilization, or by the use of antimicrobial agents. •There are five methods of sterilization: steam/moist heat, dry heat/hot air, ethylene oxide, low-temperature gas plasma, and radiation.

Range of motion

•Move the body part to stretch the muscles and keep the joint flexible, but avoid movement to the point of discomfort. •Perform ROM exercises of the joints of helpless or immobile patients at least twice a day, or more often if tolerated. •Support the limb above and below the joint when performing passive exercises of arms and legs. •Perform each movement a minimum of three to five times. •Involve patients in planning their exercise program, and encourage active performance of the exercises if allowed and capability returns.

•Nurses are expected to be able to perform a basic physical assessment. •Assessment skill comes with practice over time. •One of nursing's most important roles is to assess ill patients for signs of complications. •Assessment of the home care patient is especially important because you are acting as the physician's "eyes and ears" for the patient who cannot go to the office. •Data collection is a vital part of a physical assessment and requires a comprehensive interview. •A holistic assessment requires psychosocial, spiritual, and cultural data. •Auscultation, percussion, palpation, and olfaction are used as methods of assessment. •Auscultation of the lungs and heart must be done carefully and thoroughly. •While performing a physical assessment, you can teach the patient about preventive health care. •You will assist the examiner with various types of physical examinations by positioning and draping the patient and setting up the required equipment. •You must be able to assist the patient in assuming the supine, lithotomy, prone, Sims, and lateral positions. •Draping protects the patient's privacy and modesty and helps prevent chilling. •Laboratory requisitions must be filled out for all specimens to be sent for analysis. •A neurologic check is often performed by nurses every few hours on patients at risk of increasing intracranial pressure. •The Glasgow Coma Scale is used to score the neurologic examination and to quantify the patient's neurologic condition.

Guidelines for Moving and Lifting: Body Mechanics

•Obtain help whenever possible. •Ask the patient to help if able. •Bend or flex knees. •Use the greatest number of muscles possible. •Use thigh, arm, or leg muscles rather than back muscles. •Use a wide base of support. Keep feet about shoulders' width apart. •Use smooth coordinated movement; avoid jerking or sudden pulling motions. •Keep elbows and work close to your body. •Work at the same level or height as the object to be moved. •Remember that pulling actions require less effort than pushing or lifting. •Directly face the object or person to be moved. •Keep trunk straight; do not twist when lifting or pulling. •Use arms as levers when pulling the patient toward you. Lock the elbows and rock back on your heels, using the weight of your body to move the patient.

Early am care

•Offer bedpan or urinal or provide help to the bathroom or bedside commode. •Wash hands and face. •Clean and clear the over-the-bed table. •Provide oral care. •Prepare for tests or surgery (e.g., enemas, shaves).

Am care usually after breakfast

•Offer bedpan or urinal, etc. •Provide oral care. •Bathe (complete or partial bed bath, shower, or tub bath). •Give back rub. •Shave and provide hair care. •Care for nails. •Dress. •Straighten patient unit.

HS hour of sleep care(bedtime)

•Offer bedpan or urinal, etc. •Wash hands and face. •Provide oral care. •Change to gown if needed. •Give back rub. •Adjust or help patient adjust position in bed. •Straighten patient unit. Linens are straightened or changed as needed throughout the day.

What are the Functions of the Skin and its Structures?

•The skin has four main functions: protection, sensation, temperature regulation, and excretion and secretion. •The skin is the first line of defense in protecting the body from bacteria and other invading organisms. It protects tissues from thermal, chemical, and mechanical injury. •The sebaceous glands produce sebum, which helps make the skin waterproof by preventing water loss from underlying tissues and too much water absorption during bathing and swimming. •Melanin absorbs light and protects against ultraviolet rays. When exposed to ultraviolet light, the skin makes vitamin D, which is needed for absorbing phosphorus and calcium. •The skin has sensory organs for touch, pain, heat, cold, and pressure. •The skin regulates temperature by dilating and constricting blood vessels and activating or inactivating sweat glands. •Sweat glands assist in maintenance of homeostasis of fluid and electrolytes. They serve as excretory organs because sweat contains nitrogenous wastes. As sweat evaporates, it produces a cooling effect. Sweat glands in the axillae and external genitalia also secrete fatty acids and proteins. •Sebum lubricates the skin and hair, keeping these structures softer and more pliable. It also decreases the amount of heat lost and bacterial growth. •Mucous membranes protect against bacterial invasion, secrete mucus, and absorb fluid and electrolytes.

•Once the catheter has touched the patient's skin, it should not be introduced into the urinary meatus because it is contaminated. Anytime the catheter becomes contaminated, the procedure is stopped and begun again with a sterile catheter and kit. •For straight catheterization: There is no balloon to inflate and no drainage bag. The distal end of the catheter is left in the tray so that urine will drain into it. If a specimen is required, prepare the specimen bottle by labeling and opening it; place the lid upside down on a clean surface. After urine has started to flow, pinch off the catheter with the nondominant hand and place the end of the catheter above the specimen container. Allow 1 to 2 oz of urine to flow into the container. Pinch off the flow, replace the catheter in the tray, and drain the remaining urine from the bladder. Pinch off, remove, and discard the catheter. Measure and record the amount of urine on the intake and output record. Place lid on container, label, and send to laboratory.

•Perform hand hygiene before and after caring for the patient, before donning gloves, and after their removal. •Cleanse hands and change gloves between procedures that involve contact with mucous membranes, the perineal area, feces, wound drainage, or other contaminated matter. •Help all patients on bed rest turn, deep breathe, and cough effectively at least every 2 hours. •Use correct aseptic technique for cleansing the skin before performing an invasive procedure. •Assess IV line sites for signs of infection at least once per shift and each time you access the ports. •Use aseptic technique when suctioning the airway. •Keep urinary catheter drainage bag below the level of the bladder at ALL times (even when transferring or transporting a patient). •Clean residual urine off the catheter bag drainage tube after emptying the bag; do not let the tube touch the collection container or floor. •Clean incontinent patients promptly. Carefully cleanse feces from surface of indwelling catheters, the skin, and mucous membranes. •Always cleanse from the urinary meatus toward the rectum (front to back).

In home safety

•Place a nonskid bath mat in the tub and shower. •Use night-lights for moving from the bedroom to the bathroom at night. •Suggest the installation of grab bars for the bathroom by both the toilet and bathtub or shower. •Install door buzzers or bed alarms that sound when the patient leaves the bed or opens an outside door. •Keep the furniture arrangement and position of personal items constant to decrease confusion and eliminate the need to hunt for items. •Maintain sufficient activity during the day to prevent too much napping, which can lead to nighttime wandering. •Encourage removal of extension cords because these may cause a fall. •Caution the patient that items on the floor and animals may also cause falls. Removing a companion animal from the home because of risk of a fall must be carefully weighed against the social and emotional importance of the companionship a pet provides. •Inform the patient and the family that hospital beds may be obtained or rented for home use. Provide appropriate community resources as indicated.

Functional

•Present function •Personal habits •Lifestyle and cultural factors •Age-related factors

Afternoon care

•Provide care after any diagnostic or special test as needed; for example, electroencephalography (EEG) may leave electrode paste in the patient's hair. •Offer bedpan or urinal, etc. •Provide oral care.

•RNs are officially responsible for the initiation of nursing care plans, but LPN/LVNs assist with the care plan, evaluate care, and help revise through collaboration with other health team members.

Common pulse

•Radial artery in the wrist at the base of the thumb •Temporal artery just in front of the ear •Carotid artery on the front side of the neck •Femoral artery in the groin •Apical pulse over the apex, the pointed end of the heart •Popliteal pulse behind the knee •Pedal pulse of the posterior tibial artery on the inside of the ankle behind the malleolus, in the groove between the malleolus and Achilles tendon and dorsalis pedis on the arch of the foot

Helping a patient urinate

•Run water in a nearby sink so the patient hears the sound. •Have the patient deep breathe, relax, and visualize a peaceful place with a bubbling brook. •Help the male stand by the side of the bed (with a physician's order). •Have the female blow through a straw in a glass of water, causing bubbling, while sitting on the toilet or bedpan. •Measure several cups of warm water, then pour the water over the perineum while the patient attempts to void. Subtract the measured amount from the total volume to determine how much the patient voided. •With a physician's order, gently but firmly use Credé maneuver over the bladder (massage from top of bladder to bottom by starting above the pubic bone and rocking the palm of the hand steadily downward).

What are the functions of muscles for positioning and moving patients?

•Skeletal muscle contraction is accomplished through the stimulation of its many muscle fibers. •Contraction of skeletal muscles provides movement, stabilizes joints, produces body heat, and maintains posture.

•Soap is not generally used on the elderly person's skin every day. On alternate days, use soap only on areas visibly soiled. •Elderly women who cannot reach and bend easily need to have the nurse perform perineal care. Rather than giving this patient a choice, say, "I'm going to clean the areas that are difficult to reach." If the patient protests, allow her to wash herself.

What allows expansion

•Surfactant secreted by cells in the walls of the alveoli is necessary for alveoli to remain open; it reduces surface tension on the alveolar wall, allowing expansion.

Stages of pressure ulcers

•Suspected deep tissue injury: Localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from pressure or shearing. The area may be painful, firm, mushy, boggy, warmer, or cooler when compared to adjacent tissue. •Stage I: An area of red, deep pink, or mottled skin that does not blanch with fingertip pressure. In people with darker skin, discoloration of the skin, warmth, edema, or induration (an area that feels hard) may be signs of a stage I pressure ulcer. •Stage II: Partial-thickness skin loss involving epidermis and/or dermis. It may look like an abrasion, a blister, or a shallow crater. The area surrounding the damaged skin may feel warmer. •Stage III: Full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or necrotic. Bacterial infection of the ulcer is common and causes drainage from the ulcer. There may be damage to the surrounding tissue. •Stage IV: Full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present. Infection is usually widespread. The ulcer may appear dry and black, with a buildup of tough, necrotic tissue (eschar), or it can appear wet and oozing. •Unstageable: Loss of full thickness of tissue. The base of the ulcer is covered by eschar (tan, brown, or black) in the wound bed, or the base of the ulcer contains slough (yellow, tan, gray, green, or brown).

Taking temp at home

•Teach the home care patient or family to cleanse the thermometer by using a clean tissue and wiping with a twisting motion from the tip toward the bulb, and then washing it in warm, soapy water and rinsing with cold water. •The thermometer should be disinfected in 70% to 90% isopropyl alcohol or a 1:10 solution of household bleach and water. •The thermometer should be rinsed after disinfection, dried, and stored in a dry container.

•Temperature alterations should be compared with the patient's normal temperature. •Rectal temperatures are about 1° F higher, and axillary temperatures are about 1° F lower, than the oral temperature. •Measurement by tympanic thermometer comes closest to core body temperature. •Temperature is affected by time of day, environment, age, exercise, hormones, emotional stress, disease conditions, and certain drugs. •A temperature over 100.2° F (37.9° C) is abnormal and is termed pyrexia or fever. A temperature of 105.8° F (41° C) or higher may cause damage to body cells. •Hypothermia occurs when the temperature falls below normal range. •The oral route is never used for temperature measurement for the unconscious or uncooperative patient or one who may have a seizure. •Normal body temperature ranges from 97.5° to 99.5° F (36.4° to 37.5° C). Average temperature of a healthy adult is 98.6° F (37° C).

Vital sign that change with age

•Temperature is a less reliable indicator of health in the elderly. Fever is less likely to develop, but heat loss occurs more readily and can lead to hypothermia. The elderly person often has a lower normal temperature than the average adult. This may be due to a lower metabolic rate. •The normal range for the heart rate does not change in the healthy elderly person, but the rhythm may be slightly irregular. •Respiratory rate may rise slightly as decreases in vital capacity and respiratory reserve occur. •The systolic blood pressure rises slightly because the aorta and major arteries tend to harden with age. In many elderly people the diastolic pressure rises also.

•The average temperature in the older adult is 96.5° to 97.5° F (35.8° to 36.4° C). •Body temperature in the very elderly tends to be low in the morning on awakening. This is because the metabolic rate slows during sleep and inactivity. •The lack of subcutaneous fat allows the elder's body to cool more readily than bodies of younger people.

•The elderly are at greater risk for infection because their immune system is not as active as that of a younger person. •An elderly person hospitalized for one infection has an increased risk of developing a second infection (an HAI) because the body's available defenses are already working to fight the first infection.

•The skin is the largest organ of the body. The main functions of the skin are to protect, sense, regulate temperature, excrete, and secrete. •Changes from aging may cause the skin to (1) wrinkle and sag, (2) become dry and itchy, (3) have altered temperature control, and (4) be more fragile and slower to heal. •Hygiene is the practice of cleanliness that helps to preserve health. To determine self-care abilities, assess the patient's physical and cognitive ability. •A pressure ulcer is an ulcer that forms from local interference with circulation. Ulcers are graded according to four stages plus the categories "unstageable" and "suspected deep tissue injury." Ulcer staging may be inhibited in dark-skinned patients, when eschar is present, or in patients with orthopedic devices. •Pay particular attention to assessing areas over bony prominences. •The purposes of bathing are to cleanse the skin, promote comfort, stimulate circulation, and remove waste products from the skin. •When providing perineal care for a female, wipe from the pubic area to the rectal area (front to back) to prevent infection. When providing perineal care for an uncircumcised male, reposition the foreskin after cleansing. •Maintaining oral hygiene prevents halitosis, feelings of uncleanliness, and dental caries. •Hair care improves morale and body image. Hair and beards may not be cut without a written, informed consent. •Shaving with a safety razor is contraindicated in patients who are on anticoagulants, chemotherapy, or aspirin or who are immunocompromised. •Trim toenails straight across. An order is needed to trim the toenails of patients with diabetes or peripheral vascular disease. •To provide eye care, wipe from the inner to the outer part of the eye using a different portion of the washcloth for each eye.

How is body temp regulated

•The hypothalamus, located between the cerebral hemispheres, acts as a thermostat and controls body temperature by a feedback mechanism (Figure 21-1). •The chemical reactions that occur in the body as it fights a pathogen cause the thermostat to reset to a higher level (a new set point). •When the body heat rises above normal, the hypothalamus sends out a signal through the nervous system that causes vasodilation, sweating, and inhibition of heat production. •If the body temperature drops below normal range, the hypothalamus sends messages for vasoconstriction of surface blood vessels to conserve heat and messages to induce shivering to increase heat production. •Heat loss occurs through the skin's exposure to the environment. Heat loss occurs through (1) radiation, (2) conduction, (3) convection, and (4) evaporation. •Blood flow from the internal organs carries heat to the skin. The heat is radiated to cooler objects in the person's vicinity. •When objects in the surroundings are warmer than the body, heat is radiated to the body and absorbed. •When warm skin touches a cool object, heat is lost to the object by conduction. Ice bags applied to the skin increase conductive heat loss. •Air movement causes heat to be transferred from the skin to the air molecules by convection. Fast-moving air from an electric fan cools by convection. Heat loss increases when the skin is moistened and evaporation occurs. •Sweat glands contribute to evaporative loss by secreting sweat in response to a message from the hypothalamus when the body temperature rises too high. •As water evaporates from the skin, heat is transferred to the air. Heat is continuously lost from the body by evaporation, resulting in a daily loss of 800 mL of water from the skin and lungs.

•The kidneys manufacture 1 to 1.5 L of urine on average in 24 hours. Urine output is related to the amount of fluid intake and can vary considerably. •The ureters carry urine from the kidneys to the bladder. •The bladder stores urine and sends a signal to the spinal cord when it becomes full to signal the need for emptying. The signal usually occurs when the bladder contains between 250 and 400 mL of urine. •The bladder can hold 1000 to 1800 mL of urine. Average urine output is 1000 to 1500 mL/day. •The urethra carries urine from the bladder to the outside of the body. •The urinary meatus is the exit point for urination (expelling urine) and the entrance point for a catheter. •The internal sphincter relaxes in response to the micturition (urination) reflex. •Voluntary contraction of the external sphincter stops the expulsion of urine. Relaxing the external sphincter starts the flow of urine for excretion.

•The kidneys, the ureters, the bladder, and the urethra make up the urinary system and function to rid the body of waste and excess fluid. Fluid balance is a primary function of the kidneys. •Infection, severe dehydration, shock, destruction of tissue, blockage, pressure, and lack of neurologic innervation can interfere with proper function of the urinary system. •Kidney function and bladder muscle tone decrease with age. In males, the prostate gland can enlarge and may lead to urethral obstruction. •Urination is under voluntary control. The adult voids 5 to 10 times a day, ridding the body of an average of 1 to 1.5 L of urine a day. •Symptoms of urinary dysfunction are dysuria, urgency, anuria, polyuria, oliguria, retention, and difficulty starting the urinary stream. •Urine specimens are obtained in different ways (e.g., clean catch, catheterization) for a variety of diagnostic tests (e.g., culture and sensitivity). •An indwelling urinary catheter is inserted for a variety of reasons (e.g., urinary stricture, bladder irrigation). The closed urinary catheter and drainage system should be kept sterile. •It is best to perform closed intermittent irrigation, rather than opening the drainage system, to prevent microorganisms from entering the bladder. •There are different types of incontinence: urge, stress, overactive bladder, overflow, functional, mixed, reflex, or transient; interventions must be tailored to the cause. •When the patient has a urinary diversion, the focus is on collection of the urine and care of the skin around the urostomy. •Comparison of daily I & O is part of the evaluation process.

•The musculoskeletal system is involved in positioning and moving patients. •Observing proper body alignment and mechanics helps prevent injuries. Lower back strain is one of the most common injuries for health care workers. •Get help when necessary before moving or positioning a patient. •Observing these principles helps to prevent the hazards of improper positioning: pressure ulcers, muscle contractures, and fluid collection in the lungs. •Pressure and shearing force are the main factors in developing pressure ulcers. •There are three basic positions: supine, side-lying, and prone. Other positions include Fowler, semi-Fowler, low Fowler, and Sims. •Common positioning devices include pillows, boots, splints, high-top sneakers, trochanter rolls, sandbags, trapeze bars, side rails, and bed boards. •Logrolling is a technique in which the patient is turned as a single unit. •A lift sheet supports a patient from the shoulders to below the buttocks and facilitates transfers. •While the patient is dangling, monitor for orthostatic hypotension, dizziness, or nausea before getting the patient out of bed. •Lock the wheels on stretchers and wheelchairs before transferring patients. •Transferring devices include mechanical lifts, roller boards, slide boards, lift or pull sheets, low friction sheets, and transfer (or gait) belts. •Pulling motions are better than pushing motions, except that wheelchairs and stretchers are pushed to maintain alignment.

Organs of respiration

•The nose, the pharynx, the larynx, the trachea, bronchi, and the lungs are the respiratory organs. •There are three lobes in the right lung and two lobes in the left lung. •The bronchial tree, consisting of the bronchi and the bronchioles, carries oxygen to the various parts of the lungs (Figure 21-3). •Movement of the diaphragm controls inhalation and exhalation. The slight negative pressure created in the chest during inspiration draws air into the lungs. •Gas exchange with the blood occurs in the alveoli, tiny thin-walled sacs.

Nursing goals for hygiene might include the following:

•The patient's skin integrity will be maintained. •The patient's hair is clean and neatly styled each day. •The patient's mouth is intact and free from odor.

•The skin of the elderly is less elastic and drier than that of the younger person. Skin begins to sag. Skin turgor is not an accurate measure of hydration in the elderly. Checking the mucous membranes is a better assessment technique. •The elderly are prone to develop lesions related to aging, such as brown spots (lentigines) and actinic keratoses (reddened, flaky areas that are precancerous).

•The use of protective devices must help the patient or be needed for the continuation of medical therapy. •Use the least amount of immobilization needed for the situation. •Obtain a written order for all devices that limit movement or immobilize the patient. Notify the physician as soon as the device is no longer needed. •Apply the device snugly but not so tightly as to interfere with blood circulation or nerve function. •Remove the device and change the patient's position at least every 2 hours. Perform active or passive exercises for immobilized joints and muscles.

Changes occurring with age

•There is a decrease in the number of functioning nephrons and a reduction in the rate of renal filtration with aging. Because of these changes, even minor body stress can cause a decrease in renal function. •The bladder muscle tone decreases and its capacity lessens, causing nocturia (urinating during the night). Decreased muscle tone may interfere with the external urinary sphincter and predispose the person to incontinence. Incontinence is not a normal part of aging. •Decreased bladder and muscle tone may cause incomplete bladder emptying and residual urine (urine left in the bladder after urination). Residual urine becomes stagnant and predisposes the person to infection. •Lower estrogen levels in women can result in tissue atrophy in the urethra, the vagina, and the bladder, which predisposes the person to infection and incontinence.

Factors that affect body temp

•Time of day (circadian rhythm): The body temperature on awakening is generally in the low-normal range because of inactivity of the muscles. Conversely, the afternoon body temperature may be high-normal owing to the body's metabolic processes, the patient's activity, and the temperature of the atmosphere. •Environmental temperature: As might be expected, the body temperature is lower in cold weather and higher in hot weather. •Patient's age: At birth, heat-regulating mechanisms are generally not fully developed, so the infant may have marked ups and downs in body temperature during the first year of life. •Physical exercise: Physical exercise uses large muscles, which create body heat by burning up the glucose and fat in the tissues. Muscle action generates heat, and core temperature rises. •Menstrual cycle and pregnancy: Body temperature drops slightly just before female ovulation (the normal monthly ripening and release of the ovum) and then may rise 1° F above normal during ovulation. Within a day or two preceding the onset of the next menstrual period, the temperature drops again. During pregnancy the body temperature may consistently stay at high-normal because of an increase in the patient's metabolic rate. •Emotional stress: Highly emotional states cause an elevation in body temperature. The emotions increase hormone secretion, and the body activities required for this increase heat production. •Disease conditions: Bacteria, viruses, and toxins from some infective agents and the chemical reactions of the inflammatory response may produce fever. Fever is a protective defense mechanism that the body uses to fight pathogens and their toxins. •Drugs: Certain drugs may cause temperature elevation because of the chemical action they have in the body.

•Use appropriate cuff size with the bladder of the cuff covering two thirds of the arm circumference. Three sizes should be available: pediatric, adult, and large adult. A poorly fitting cuff provides inaccurate measurement. •When using a thigh cuff, wrap the cuff about 2 inches above the knee. Place the stethoscope over the popliteal artery. Turn the patient onto the abdomen if possible. •To palpate a blood pressure when sound cannot be heard, locate the radial pulse, inflate the cuff per usual routine, and let the pressure fall; note the point at which the radial pulse is first felt. This is the systolic pressure; diastolic pressure cannot be determined by this method. This measure will be 2 to 5 mm Hg lower than that obtained by auscultation. •If an ambulatory care patient has "white coat syndrome" (blood pressure rises whenever the patient is approached by a medical person), retake the pressure before the patient leaves the office or clinic. •Teach hypertensive patients the importance of monitoring their blood pressure frequently. •Encourage the purchase of a home blood pressure unit. •If a wrist blood pressure monitor is used, advise that the wrist must be positioned at the level of the right atrium for accuracy. An arm monitor is preferred, since it is more accurate. •Digital blood pressure monitoring systems with large number readouts are available for the elderly with poor vision. •An elderly hypertensive patient's blood pressure should regularly be checked with the patient standing and lying down and on both arms. This method detects hypotensive reactions to blood pressure medication more accurately. •Whenever blood pressure is measured on a patient new to the office or health facility, take the blood pressure on both arms. •If in doubt that an accurate pressure was obtained, ask another nurse to recheck the patient's blood pressure.

•Use good body alignment, a wide base of support, and a proper working height when making the bed. Face the direction of movement and bend at the knees, not the back. •Complete the linen change on one side before moving to the other side to save time and conserve energy. •Avoid contaminating clean linen. Once linens enter a unit, they are exposed to that patient's microorganisms and must not be returned to the clean supply or used elsewhere. •Unfold linens onto the bed. Do not flip or fan linens, to avoid stirring up air currents. Microorganisms travel on air currents and could be carried out of the unit. •Remove linens one piece at a time to avoid wrapping dentures, eyeglasses, religious objects, or other patient belongings in soiled linens. •Do not place used or soiled linen from one patient on the bed, table, or chairs belonging to another patient's unit. •Carry used or soiled linens away from the body and place them in closed linen hampers or bags. Use a pillowcase if a linen bag is not available, and transport it to the linen hamper or chute. Do not place soiled linens on the floor.

Volume and strength of a pulse

•Weak and regular (even beats with poor force), or 1+ •Strong and regular (even beats with moderate force), or 2+ •Full and bounding (even beats with strong force), or 3+ •Feeble (barely palpable) •Irregular (both strong and weak beats occurring within 1 minute) •Thready (generally indicates that it is weak and may be irregular) •Absent (no pulse palpable or heard on auscultation)

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