RM

Use of Placebos

A placebo is defined as any medication or procedure, including surgery, which produces an effect in a patient because of its implicit or explicit intent, not because of its specific physical or chemical properties. A saline injection is one example of a placebo. Administration of a medication at a known subtherapeutic dose (e.g., 0.05 mg of morphine in an adult) is also considered a placebo. Placebos are appropriately used as controls in research evaluating the effects of a new medication. Patients or volunteers who participate in placebo-controlled research must be able to give informed consent or have a guardian who can provide informed consent. Unfortunately, occasionally placebos are used clinically in a deceitful manner and without informed consent. This is often done when the clinician does not accept the patient's report of pain. Pain relief resulting from a placebo, should it occur, is mistakenly believed to invalidate a patient's report of pain. This typically results in the patient being deprived of pain-relief measures despite research showing that many patients who have obvious physical stimuli for pain (e.g., abdominal surgery) report pain relief after placebo administration. The use of placebos has both ethical and legal implications, violates the nurse-patient relationship, and deprives patients of more appropriate methods of assessment or treatment. Nursing Safety Priority Drug Alert Deceitful administration of a placebo violates informed consent law and jeopardizes the nurse-patient therapeutic relationship. Never administer a placebo to a patient. Promptly contact your nursing supervisor if you are given an order to do so.

Acute Adrenal Crisis (Addisonian Crisis).

Patients with either primary or secondary adrenal insufficiency are at risk for episodes of acute adrenal crisis, also called addisonian crisis, which is a life-threatening emergency. This usually results from a sudden marked decrease in available adrenal hormones. Precipitating factors are adrenal surgery, pituitary destruction, abrupt withdrawal of steroid therapy (often a result of a patient unwittingly stopping medications), and stress. Any factor that causes stress in the person can initiate a crisis. Examples of stressors include infection, illness, trauma, and emotional or psychiatric disturbances. Manifestations of an addisonian crisis include more severe symptoms of mineralocorticoid and glucocorticoid deficiency: hypotension, tachycardia, dehydration, confusion, hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia. If left untreated, fluid and electrolyte imbalances can lead to circulatory collapse, cardiac dysrhythmias, cardiac arrest, coma, and death. The management of an addisonian crisis is outlined in Table 46-4. Pharmacology Capsule When steroid therapy is discontinued, the drug is tapered gradually. An abrupt decline in adrenal hormones could precipitate acute adrenal crisis. Table 46-4 -- Emergency Medical Care for Acute Adrenal Crisis INTERVENTIONRATIONALE 1. Blood sample collected to determine plasma cortisol level 1. To establish a baseline and obtain data to guide treatment 2. Intravenous (IV) infusion of normal saline with 5% dextrose 2. To provide access for administration of fluids and drugs 3. Initial dose of hydrocortisone (Solu-Cortef) IV push, followed by infusion of saline and dextrose over 8 h 3. To provide a loading dose and maintenance infusion 4. Additional doses of hydrocortisone per infusion at rate of 100 mg every 8 h 4. To ensure continuous source of glucocorticoids

Pedal pulse

Pedal Pulses One of two pedal pulses is assessed by palpating the posterior tibial artery (Figure 20-36), which lies just behind the medial malleolus of the inner ankle. It can be felt by placing the fingertips around the ankle and gently indenting the soft tissues in the space between the medial malleolus and the Achilles tendon. FIGURE 20-36Assessing the posterior tibial pulse. The dorsalis pedis artery (Figure 20-37) is the other pedal pulse assessed. The nurse places the fingertips across the top of the forefoot halfway between the toes and the ankle. The artery lies superficially near the center of the long axis of the foot, between the extensor tendons of the great toe and second toe. In some people, it may be in a slightly different location, necessitating palpation across the dorsum of the foot. FIGURE 20-37Assessing the dorsalis pedis pulse. Obesity, dehydration, vasoconstriction, diminished cardiac output, edema, genetic abnormalities, or peripheral vascular disease may prevent successful detection of pedal pulses. Doppler assessment can be used to detect weak peripheral pulses (Figure 20-38). A Doppler ultrasound device magnifies sound. When performing a Doppler assessment of a peripheral pulse, place water-soluble transmission gel over the pulse area. Applying very light pressure, place the ultrasound transducer over the pulse site at a 45- to 90-degree angle. The pulse is located by listening for a rhythmic, whooshing sound. Ideally, the sound closely parallels the apical heartbeat. FIGURE 20-38Assessing a pulse using a Doppler.

Sputum Collection

Sputum Collection Sputum is the mucus that is found in the lungs, bronchial tubes, and trachea in cases of inflammation or infection. A sputum sample is often ordered when an infectious disease, such as pneumonia or tuberculosis, is suspected. Subsequent sputum specimens can be used to evaluate the effectiveness of antibiotic or antiviral therapy. Sputum analysis can identify abnormal cells that may indicate a tumor or malignancy (Nursing Care Guideline: Sputum Specimen Collection box). The nurse should provide clear instructions to the patient to ensure that the specimen is sputum and not saliva. Normally, the patient is instructed to expectorate the sputum directly into a sterile container. When sputum is being tested for tuberculosis, a special container may be required. Nursing Care Guideline Sputum Specimen Collection Background • A sputum specimen is a sample of mucus used for diagnostic testing to look for specific microorganisms and to determine optimal treatment options. • Unless suctioning techniques are used, obtaining a sputum specimen can be delegated to unlicensed assistive personnel (UAP) who have been educated and trained in the procedure, according to the patient's care plan, the nurse's judgment, or the facility policy and procedure. • UAP education includes appropriate collection and handling of the specimen and reporting of procedural or physiologic difficulties. Procedural Concerns • The specimen cup is sterile so that bacteria from the environment are not introduced into the sample. Do not touch the inside of the cup. Wear clean gloves when handling the sputum cup. • Obtain the sample first thing in the morning if possible. • Provide oral care (see Chapter 27, Skill 27-6). • Instruct the patient to breathe deeply and cough to expectorate sputum into the cup. • If a sample cannot be obtained in this manner, alternative procedures may be used, for which an order from the primary care provider may be needed. The following are alternative methods: • Expectorants • Chest physiotherapy • Aerosols or nebulizers • Suctioning, using tracheostomy suctioning or nasotracheal suctioning (see Skill 38-1) or a sputum trap • Obtain 2 to 10 mL of sputum for routine testing to ensure accurate results. • Provide oral care. • Label the container, place it in a biohazard bag, and transport the sample to the laboratory. Documentation Concerns • Document assessment of the sample for quantity, color, type, odor, and consistency of the sputum. • Document assistance required by the patient or caregiver in obtaining the sample. • Describe the patient's reaction to the procedure. • Note that the order has been completed.

octreotide ()

(ok-tree′-o-tide) Sandostatin, Sandostatin LAR Depot Func. class.: Hormone, antidiarrheal Chem. class.: Octapeptide Pregnancy category B Action: Action similar to somatostatin Therapeutic outcome: Decreased diarrhea; decreased symptoms of acromegaly, carcinoid tumors, vasoactive intestinal peptide tumors (VIPomas) Uses: Sandostatin: acromegaly, carcinoid tumors, VIPomas; LAR Depot: long-term maintenance of acromegaly, carcinoid tumors, VIPomas Unlabeled uses: GI fistula, variceal bleeding, diarrheal conditions, pancreatic fistula, IBS, dumping syndrome Dosage and routes Acromegaly Adult: SUBCUT/IV 50-100 mcg bid-tid, adjust q2wk based on growth hormone levels (Sandostatin) or IM 20 mg q4wk × 3 mo, adjust by growth hormone levels (Sandostatin LAR) VIPomas Adult: SUBCUT/IV 0.2-0.3 mg/day in 2-4 doses for 2 wk, not to exceed 0.45 mg/day (Sandostatin) or IM 20 mg q2wk × 2 mo, adjust dose (Sandostatin LAR) Carcinoid tumors Adult: SUBCUT/IV 0.1-0.6 mg/day in 2-4 doses for 2 wk, titrated to patient response (Sandostatin) or IM 20 mg q4wk × 2 mo, adjust dose (Sandostatin LAR) GI fistula Adult: SUBCUT 50-200 mcg q8hr Irritable bowel syndrome (unlabeled) Adult: SUBCUT 100 mcg single dose to 125 mcg bid Antidiarrheal in AIDS patients Adult: SUBCUT/IV 100-1800 mcg/day Dumping syndrome (unlabeled) Adult: SUBCUT 50-150 mcg/day Variceal bleeding (unlabeled) Adult: IV 25-50 mcg/hr CONT IV INF for 18 hr-5 days Available forms: Sandostatin: inj 0.05, 0.1, 0.2, 0.5, 1 mg/ml; LAR Depot: inj 10 mg, 20, 30 mg/5 ml Adverse effects CNS: Headache, dizziness, fatigue, weakness, depression, anxiety, tremors, seizures, paranoia CV: Sinus bradycardia, conduction abnormalities, dysrhythmias, chest pain, shortness of breath, thrombophlebitis, ischemia, CHF, hypertension, palpitations ENDO: Hypo/hyperglycemia, ketosis, hypothyroidism, galactorrhea, diabetes insipidus GI: Diarrhea, nausea, abdominal pain, vomiting, flatulence, distension, constipa tion, hepatitis, elevated liver function tests, GI bleeding, pancreatitis GU: UTI, cholelithiasis HEMA: Hematoma of inj site, bruise INTEG: Rash, urticaria, pain, inflammation at inj site MS: Joint and muscle pain Contraindications: Hypersensitivity Precautions: Pregnancy B, breastfeeding, children, geriatric, diabetes mellitus, hypothyroidism, renal disease PHARMACOKINETICSAbsorptionRapidly, completelyDistributionUnknownMetabolismLittleExcretionUrine, unchangedHalf-life1.7 hr PHARMACODYNAMICSOnsetUnknownPeak½ hrDuration12 hr Interactions Individual drugs CycloSPORINE: possible increased rejection Drug/food Decreased: absorption of dietary fat, vit B12 levels Drug/lab test Decreased: T4 NURSING CONSIDERATIONS Assessment • Identify growth hormone antibodies, IGF-1, 1-4 hr intervals for 8-12 hr after dose in acromegaly; 5-HIAA, plasma serotonin, plasma substance P in carcinoid; VIP in VIPomas • Fecal fat, serum carotene • Monitor thyroid function tests: T3, T4, T7, TSH to identify hypothyroidism • Assess for allergic reaction: rash, itching, fever, nausea, wheezing • Assess for cardiac status: bradycardia, conduction abnormalities, dysrhythmias; monitor ECG for QT prolongation, low voltage, axis shifts, early repolarization, R/S transition, early wave progression Nursing diagnoses • Body image, disturbed (uses) • Knowledge, deficient (teaching) Implementation • Store unopened amps, vials in refrigerator; or room temperature for 2 wk, protect from light; do not use discolored or cloudy sol SUBCUT route • Rotate inj sites, use hip, thigh, abdomen • Avoid using medication that is cold; allow to reach room temperature IM route • Reconstitute with diluent provided; give into gluteal muscle IV route • May use IV bolus if required; give over 3 min • To use by intermittent infusion, dilute in 50-200 ml D5W, 0.9% NaCl, give over 15-30 min • In an emergency carcinoid crisis, give rapid bolus Patient/family education • Explain reason for medication and expected results • Advise patient that routine follow-up is needed • Instruct parents on procedure for medication preparation and inj use; request demonstration, return demonstration; provide written instructions • Advise patient to change position slowly to prevent orthostatic hypotension Evaluation Positive therapeutic outcome • Decreased symptoms of acromegaly, carcinoid, VIPoma • Decreased diarrhea in AIDS

Assessment

1. Review medical record to assess patient's most recent activity experience, including distance ambulated, tolerance of activity, balance, and gait. Rationale: This facilitates realistic planning and identifies degree of assistance needed. 2. Determine the best time to ambulate, taking into consideration other scheduled activities such as bathing. Rationale: Rest is necessary after activities that require exertion and after meals. Ambulating 30 minutes after analgesic administration improves patient's tolerance. 3. Check the availability of handrails on the walls for patient's safety. 4. Assess patient's physical readiness: a. Assess baseline resting heart rate, blood pressure and respirations before beginning ambulation. Rationale: Comparison of vital signs after ambulation with baseline values determines patient's activity tolerance and whether patient is experiencing orthostatic hypotension. b. If patient's strength and endurance have been affected, assess range of motion (ROM) lower extremities, muscle strength, coordination and whether there is presence of foot deformities. Rationale: Determine if patient has flexibility and muscle strength needed to ambulate safely. c. Assess patient's comfort level (using pain scale 0 to 10). Rationale: Patient may be in pain or fear pain resulting from exercise. If necessary, administer analgesic 30 to 60 minutes before exercise. d. Review health care provider's order for mobility restrictions associated with condition. Also, determine if his or her weight is an issue in ambulation. Rationale: Determines degree of assistance patient needs. For safety, another person may be needed initially to assist with patient ambulation. 5. Assess patient's motivation and ability to understand instructions and cooperate. Rationale: Comparing this activity with patient plans for the home environment often enhances motivation. 6. Assess risk for orthostatic hypotension by identifying medications that may alter stability, including antihypertensive or opioid medications. Check for history of patient falls. Rationale: Drugs may cause hypotension, dizziness, or instability. History of falls is a risk factor for falls.

Physical Assessment

A basic nursing assessment of neurologic function is performed on any patient who is suspected of experiencing a neurologic problem. Nurses often need to assess for the occurrence of cerebrovascular accident (CVA, or stroke) or of a neurologic deficit after a surgical procedure. Basic neurologic assessment includes assessment of the following areas. Vital signs. Assessing and recording temperature, pulse, respirations, and blood pressure are essential. The patient's temperature is important and may be elevated for a number of reasons. Infection or damage to the temperature control mechanisms within the brain from increasing intracranial pressure (ICP) may be present. Changes in blood pressure, particularly a rise in systolic pressure and a widening pulse pressure, may indicate an ICP increase. The pulse may become slow and bounding, and breathing may become irregular and labored as ICP rises. Changes in breathing pattern often indicate a problem with neurologic control of respiration. Any identified change must be reported to the provider promptly. Clinical Cues When the systolic and diastolic pressure readings are farther apart, a widening pulse pressure has occurred. For example, if the blood pressure was 128/78 mm Hg earlier and is now 136/64 mm Hg, there is a widened pulse pressure. Notify the provider when the pulse pressure widens. Current vital signs should be compared with those from the previous several days to determine any changes or trends. Look for changes in blood pressure, pulse rate and quality, and respiratory pattern and for rising temperature. Mental function and level of consciousness. Patients experience varying levels of consciousness and ability to respond. It is necessary to determine where the patient is in relation to level of consciousness (LOC), the extremes being alert wakefulness and deep coma (no responsiveness at all). When observing a patient to determine LOC, the best assessment is based on established criteria or standards that are understood by the observer as well as by others who will be reading the results of the observations. The Glasgow Coma Scale (GCS) is a tool that is universally used in one form or another for this purpose (Table 21-7). The patient's LOC is scored in three different categories. The first category is eye opening, the second is best motor response, and the third is best verbal response. A number is assigned for each category depending on what the assessment reveals. Assessment in the first and last categories determines whether the patient can respond to voice commands or to pain or does not respond at all. Verbal responses are evaluated according to whether the patient is oriented and "making sense," confused, making inappropriate remarks, incomprehensible, or silent. The score in each area is added together, with the optimal score being 15, which indicates a fully alert patient. A score of 3 indicates a totally comatose patient. A score of 8 or less indicates coma level. Some of the criteria for assessing LOC include: Does the patient awaken easily? Is she oriented to person (herself as well as others), place, and time? Is she able to follow commands? Does she fail to respond to any stimulus, even physically painful ones? Is she restless? Combative? Does she respond to pain with abnormal posturing? Table 21-7 -- Glasgow Coma Scale SCORE*Eye OpeningSpontaneous4To sound3To pain2Never1Motor ResponseObeys commands6Localizes pain5Normal flexion (withdrawal)4Abnormal flexion posturing3Extension posturing2None1Verbal ResponseOriented5Confused conversation4Inappropriate words3Incomprehensible sounds2None1 *A score of 8 or less indicates coma. The highest possible score is 15. The FOUR (Full Outline of UnResponsiveness) score developed by Eelco Wijdicks, a neurologist at the Mayo Clinic, is becoming the preferred scale to assess comatose or intubated patients who cannot speak. A score of 0 to 4 is assigned in each of four categories: eye, motor, brainstem, and respiratory function. A score of 0 indicates no function and a score of 4 indicates normal function ( Wijdicks et al, 2011). Think Critically If your patient's blood pressure was 138/84 mm Hg and is now 146/76, what is happening? Is the ICP probably increasing or decreasing? For an alert patient, note changes in mental function by asking questions to determine orientation to person, place, and time: "What day is today? What month is it? Where are you now?" Memory lapses may be assessed by asking when the patient was born, what state she resides in, what the last major holiday was, and so on. Thinking can be evaluated by asking the patient to add three numbers together; to count by sixes; or to solve a simple puzzle, such as "If a man goes to the store and purchases four oranges at 40 cents each, two apples at 60 cents each, and two bananas for 46 cents, how much did he spend?" (Allow pencil and paper to be used.) If the patient can read English, hand her a card with a command written on it, such as "walk to the sink" or "turn on your right side" (assuming she is physically capable of performing such a task). Judgment can be grossly tested by assessing whether the patient has been making rational choices in her day-to-day life and by asking her what she would do in a particular situation. Asking specifically what she would do should there be a fire in the trash can will provide information about her judgment. Neurologic and neuromuscular status. While watching the patient perform morning activities of daily living (ADLs), basic assessment of cranial nerves and motor function can be performed. Assess the following: Does the face move symmetrically when she smiles? Is speech clear when she answers questions? Does she move left and right extremities without noticeable problems? Is there anything abnormal about her gait as she moves across the room or down the hall? Does she have difficulty eating or swallowing? Observe the pupils of the eye for size and equality. Pupils should be equal size and should constrict and dilate readily when the environmental light changes (Figure 21-8). Can the patient hear you if you speak to her when her back is turned? Does she seem as alert as usual? Is she having any trouble with balance? FIGURE 21-8Pupil gauge (mm). Evaluate the extraocular muscle movements. Ask the patient to follow your finger while you move it through the cardinal positions of gaze (Figure 21-9). Note whether both eyes move together (conjugate) or one deviates. If there is deviation, it is important to note the direction of the deviation. Note any quick back-and-forth oscillation ( nystagmus) of the eye at the end points of each direction. Nystagmus can indicate abnormality, such as multiple sclerosis, or can be a side effect of medication, such as phenytoin (Dilantin). FIGURE 21-9Checking the cardinal positions of eye movement. Neuromuscular assessment is concerned with the function of the motor pathways. Test each of the upper and lower extremities. Ask the patient to follow verbal commands such as "raise your left leg," "bend your right knee," "touch your left elbow with your right hand," and "touch your face with your left hand." Have her push against the palms of your hands first with one foot and then the other to test the strength of the leg muscles. To test muscle strength, have the patient extend her arms in front of her, and press down on each arm one at a time, while asking her to try to raise her arm. If the patient has an extremity that is not responding, another stimulus may be necessary to test it. If the patient does not respond to voice commands at all, and deafness is not an issue, test the degree of unconsciousness. First use a louder voice to try to arouse the patient; then, if she does not respond, gently shake her as you would to awaken a child. If that is not successful, painful stimuli are applied for 20 to 30 seconds. First try applying pressure above the eye by placing a thumb under the orbital rim beneath the middle of the eyebrow and pushing upward. If there is no response, pinch the trapezius muscle at the angle of the shoulder and neck; twist the fingers slightly. If there is no response, apply pressure to the angle of the mandible with the index and middle fingers. If there is still no response, the sternum is rubbed with the knuckles in the form of a fist; a twisting motion is used. The sternal rub is performed on subsequent assessments only if there is good reason to believe that the patient's comatose status is changing, as it causes bruising. The levels of response are: • Purposefully withdrawing from the stimulus or an attempt to push it away • Nonpurposeful response, in which the patient may frown or move her arm or leg in a random fashion • Failure to respond at all Nonpurposeful responses to pain occur in two ways. Decorticate (flexor) posturing, which is the extension of the legs and internal rotation and adduction of the arms with the elbows bent upward, occurs with damage to the cortex. In decerebrate (extensor) posturing, the arms are stiffly extended and held close to the body, and the wrists are flexed outward. This response means there is damage to the midbrain or brainstem, which indicates a very serious injury (Figure 21-10). The response may be "lateralization," wherein one side of the body shows typical decorticate or decerebrate posturing. An important aspect of neurologic assessment is to look for changes in the patient from each day to the next. Bilateral flaccidity is usually present when there is no response at all. FIGURE 21-10Decorticate and decerebrate posturing indicating brainstem injury. Pupillary reactions. Changes in pupil size in response to a bright light are commonly used to determine whether the areas of the brainstem that help control consciousness are functioning normally. Cranial nerves II and III control pupil movement. When ICP rises beyond a certain point, pressure on these nerves causes changes in the pupils. If at all possible, find out the normal pupil size for the patient. Although pupils of equal size are considered normal, some people have pupils that are unequal in size. The size of the pupils also may vary from person to person (see Figure 21-8). It is best to measure pupil size rather than estimate it. Examine the pupils in a room with low light, when the pupils would usually be dilated. Direct a bright light into each eye from the side while the other eye is covered. Observe whether the pupil into which the light shines constricts and whether it does so briskly or sluggishly (direct reflex). Finally, shine the light into each eye while watching to see if the pupil constricts in the other eye (consensual reflex) (Table 21-8). When pupils have been previously reactive, changes in pupil size or reactivity may signal an emergency, and the provider must be notified immediately. To test for accommodation (eyes able to focus on both near and far objects), ask the patient to look at an object across the room away from the light source, and then to look at your fingers held about 6 inches from the eyes. The lenses should change shape and the pupils constrict. If a flow sheet is not being used for charting, normal pupil responses often are charted as "PERRLA," meaning "pupils equal, round, and reactive to light with accommodation." Table 21-8 -- Pupillary Abnormalities and Possible Causes ASSESSMENT DATAAPPEARANCEPOSSIBLE CAUSESUnilateral, fixed, dilated pupil.Unreactive to light.May be accompanied by ptosis and deviation to side and downward.Damage to oculomotor nerve related to increased intraocular pressure, compression of oculomotor nerve, head trauma with epidural or subdural hematomaBilateral dilated and fixed pupils that do not react to light.Hypoxia associated with cardiopulmonary arrestPressure on midbrainSevere CNS disorderAnticholinergic drug overdoseBilateral small, fixed pupils that do not react to light.Accompanied by motor deficits, drowsiness, confusion, headache, vomiting, incontinence when caused by damage to diencephalon.Side effect of opiates such as morphineMiotic eyedropsHemorrhage into the ponsDamage to the diencephalonUnequal pupil size; both pupils react to light unless there is underlying pathology.Ocular inflammationCongenital aberrationAdhesion, as of iris to cornea or lensDisturbance of neural pathways CNS, Central nervous system. Pupils that remain dilated and fixed in the presence of a bright light indicate brain damage if there are no drugs in the system that affect the pupils. One pupil that remains fixed and dilated indicates increased ICP. If both pupils remain constricted, there probably is damage to the pons. Safety Alert Report Changes Immediately If changes in data indicate a rise in ICP or a decrease in LOC, it is important to alert the charge nurse and provider. This is even more important when possible intracranial bleeding is suspected, because it may indicate an emergency situation. Although changes in the pupils, such as unequal constriction or decreased rate of constriction, indicate increased ICP, sometimes changes in pupils can be caused by medications. For example, atropine and scopolamine can produce dilated pupils, and opiates, miotics, and street drugs can cause constriction (see Table 21-8). The "neuro" check. Monitoring the neurologic status of a patient with a known neurologic disorder includes a "neuro" check on a set schedule. It is performed to determine whether increased ICP is present or ICP is rising. For example, monitoring is necessary after a traumatic head injury, after ingestion of an overdose of a drug or other chemical, when a stroke has occurred or is suspected, or for any other condition in which the patient has lost or may lose consciousness. A neurologic assessment flow sheet is used to chart assessment data so that the trend in function of each area can be quickly identified. Four areas are monitored: vital signs, LOC, pupil reaction, and motor function. Neuro checks may be ordered as frequently as every 15 minutes or at intervals from 2 to 8 hours. Assignment Considerations The Neuro Check Although the measuring of vital signs can be assigned to assistive personnel, the gathering of data for the neuro check should not be delegated. It is important to compare current data with previous data and to carefully assess neuromuscular and pupillary response. Think Critically You arrive at the home of an older adult woman who has severe heart disease and atherosclerosis and is very weak. Her spouse says she is confused and lethargic and that she would not eat breakfast. He is worried. As her nurse, what specific assessments would you perform in an attempt to determine whether she has suffered a CVA? Diagnostic tests.The major diagnostic tests most commonly used to evaluate the neurologic system are presented in Table 21-6. Basic physiologic testing is also performed to rule out disease in some other system that might be affecting the nervous system. A nerve or muscle biopsy may be performed to determine pathologic changes in these tissues. Figure 21-11 shows the technique used for lumbar puncture. FIGURE 21-11

ENEMAS

An enema is the introduction of fluid into the rectum and colon by means of a tube. Enemas are given to stimulate peristalsis and the urge to defecate or to wash out the waste products or feces. Cleansing enemas are given when the bowel is to be examined by x ray, colonoscopy, or sigmoidoscopy or when the bowel is distended by flatus. The volume of a cleansing enema depends on the patient's age: infant or toddler, 50 to 150 mL (normal saline only); ages 3 to 5 years, 200 to 300 mL; school age, 300 to 500 mL; adult, 500 to 1000 mL. Figure 30-2 shows the equipment used for a cleansing enema. An enema kit contains either a bag or a bucket for the solution. The commercially disposable enema, such as the Fleet enema, is convenient and easy to use when only a small amount of fluid is needed to stimulate a bowel movement. Enemas can be given at any time, but it is best to try to give them before the morning bath and bed linen change. Enema equipment. Types of Enemas The type of enema to be given is prescribed by the physician and varies depending on the patient's age and condition, the purpose of the enema, and the physician's preference (Table 30-1). The commercially packaged enema may require more lubricant on the nozzle; other supplies needed are the same as for any type of enema. When other types of enemas are ordered, consult the hospital's procedure manual for the ingredients and the proportions to use. Table 30-1 -- Types of Enemas and Their Actions TYPES OF ENEMASEXAMPLESACTIONSRetention enemaMineral oilSoftens stool as oil is absorbedCleansing enemaSoapsuds (5 mL castile soap in 1000 mL of water)Tap waterSaline (500-1000 mL normal saline)Stimulates peristalsis through distention and irritation of colon and rectumDistention reduction enemaCarminative (30 g magnesium sulfate, 60 g glycerin, and 90 mL warm water)Relieves discomfort from flatus causing distentionMedicated enemaSodium polystyrene (Kayexalate) (removes potassium)Neomycin (reduces bacteria)Solution with drugs to reduce bacteria or remove potassiumDisposable enema (small volume)Sodium phosphate (Fleet)Stimulates peristalsis by acting as irritant Retention Enema Often an oil-retention enema is ordered for a patient who is constipated. The oil must be retained in the rectum to soften and coat the hardened feces. Between 120 and 180 mL of warm oil is instilled rectally in the same manner as the cleansing enema, except that the oil should be retained for at least 20 minutes. Prepackaged enemas are usually used for this purpose, but mineral oil or olive oil can be used. Amount and Temperature of Solution Disposable enema units contain about 240 mL of solution (Figure 30-3). They may be given at room temperature, but work best when slightly warmed. No special preparation is needed; they are ready for use when taken from the package. With the patient in the left Sims position, the prelubricated nozzle is inserted into the rectum, and the solution is instilled by squeezing the flexible plastic bottle. Rolling the bottle up from the bottom aids in instilling the entire contents. Safety Alert Not Too Hot, Not Too Cold The temperature of the enema solution should be about 105° F (40.5° C). If a bath thermometer is not available, test the temperature of the fluid by pouring a small amount over the inner wrist. It should be warm to the touch but not hot. Solution that is too cool usually cannot be retained; hot solutions may damage the tissues of the rectum. Disposable enema. The amount of solution used for a cleansing enema for adults is between 500 and 1000 mL. Hold the container approximately 12 to 18 inches above the patient's anus and allow the warm solution to run in slowly; a greater height creates too much pressure because the fluid runs in too rapidly and causes painful distention of the rectum and colon. This stimulates the urge to defecate immediately, so that the patient cannot retain the fluid. Safety Alert "Enemas Until Clear" When an order to "give enemas until clear" is written, it means that the return fluid must not have any fecal matter in it; however, no more than three large-volume enemas are given without checking with the physician. Repeated enemas may deplete electrolytes and can be dangerous. Clinical Cues If your elderly patient has trouble holding an enema, take a baby bottle nipple, cut off the tip and insert the enema tube through the nipple. Gently support the outer rim of the nipple with your gloved hand; this provides a temporary "plug" that helps the patient retain the enema. Recommended Position The position of choice when giving an enema is the left Sims position with the hips slightly elevated (Figure 30-4). This allows the fluid, aided by the force of gravity, to flow downward along the natural curve of the rectum and descending colon. If the patient is unable to turn to the side, the supine position can be used (Skill 30-1). FIGURE 30-4

Physical Assessment

Observe the patient for signs of joint pain, such as limping, poor posture, awkward gait, difficulty in arising or walking, and wincing on movement. Watch the patient during performance of activities of daily living (ADLs), noting problems of movement, and changes in facial expression to pick up signs of problems. If the patient is admitted with a fracture, obtain a history of the precipitating event so that an assessment can be made of other areas that may have been injured. Sometimes it is necessary to consult family members or someone who lives with the patient about the patient's true ability to perform the ADLs. A self-care deficit is one of the primary issues for patients who have a problem with mobility. Focused Assessment Physical Assessment of the Musculoskeletal System Note the following points: • Posture: Is there evidence of kyphosis, such as a rounded upper back, also called a dowager's hump? Are the knuckles swollen or deformed, indicating arthritis? • Gait: Is it steady and even? Awkward? • Balance: Is the patient able to sit, stand, and walk with a good center of balance? • Mobility: Is any supportive device being used, such as a cane, brace, splint, or elastic bandage? • Range of motion: Is the patient able to move the neck, shoulders, arms, legs with full range of motion? • Strength: Are grips in hands and push-pull in arms equal bilaterally? Is straight-leg raising against resistance equal bilaterally? • Spine: Any tenderness of the vertebrae on palpation? • Appearance of joints: Is there any redness, deformity, or loss of motion in elbows, hands, knees, ankles, and feet? • Skeletal muscle appearance in arms and legs: Is there any degree of atrophy? • Ability to perform ADLs: Is the patient independent or need assistance to dress, bathe, toilet, eat? Older Adult Care Points Approximately 30% to 40% of inpatient safety incidents are related to falls, and older adults are particularly vulnerable because of changes related to aging, such as decreased strength, unsteady balance, loss of endurance, slow reflexes, gait disturbances and increased postural sway, and chronic diseases such as arthritis. Conduct a fall risk assessment (see Box 9-4) and initiate fall precautions ( Centers for Disease Control, 2014). Nutrition Considerations Vitamin D Associated With Decreased Risk for Falls In a Cochrane review of 41 trials that included 25,422 subjects, higher vitamin D level was associated with a lowered risk for falls among older adult nursing home residents ( Cameron et al, 2010). Think Critically After a hip replacement, can you trust a statement of "I can shop, cook, clean, and do everything I need to do by myself"? If you cannot trust the statement, why not? How would you gather data about an older adult patient's ability to perform self-care activities at home before she is discharged?

Activities of Daily Living

ADLs include the things that most adults do every day, often without special attention or effort. Until something happens to interfere with normal daily routines, little thought may be given to bathing, dressing, eating, or attending to elimination needs. However, with advancing age and changes in health and circumstances, activities that once were accomplished with ease may require modified approaches or the assistance of others. In addition to providing direct assistance with ADLs, nurses assist older adults in the modification of routines and the use of assistive devices that help maintain independence. Nurses also support and advise family members and friends who assist the older adult with ADLs. Instrumental activities of daily living (IADLs) include activities such as driving, shopping, cooking, housekeeping, and using a telephone. Older adults modify their approaches to IADLs because of commonly experienced changes in aging such as reduced strength, impaired vision, or impaired hearing. Assistive devices make the tasks of cooking or housekeeping easier and safer. Driving may be restricted to familiar areas and daylight hours. Family members, friends, or paid caregivers may help with shopping and other tasks. During episodes of acute illness or recovery from hospitalization, additional help may be needed. If sufficient assistance with IADLs is available in the home, relocation to a long-term care facility is not necessary. Basic ADLs include the everyday personal care tasks related to hygiene, nutrition, and elimination. Remaining independent in these activities is highly prized by older adults. Dependency in basic ADLs increases the risk of relocation to a long-term care facility or to the home of a family member. To remain independent in basic ADLs, older adults use assistive devices and modify their care routines. Handheld shower sprays, raised toilet seats, sturdy grab bars in bathrooms, plate guards, and built-up handles on toothbrushes and eating utensils are examples of assistive devices. Clothing with Velcro instead of buttons, ties that can be clipped on rather than tied, and shoes that can be slipped on rather than laced are examples of modifications to help with dressing. However, for some older adults the amount of assistance needed with personal care exceeds their ability to modify routines and the capacity of family members and friends to help. Home care nurses may supplement the care provided by family members and friends, or relocation to a long-term care facility may be necessary. Activities of daily living (ADLs) are usually performed in the course of a normal day; they include ambulation, eating, dressing, bathing, and grooming. A patient's need for assistance with ADLs is temporary, permanent, or rehabilitative. For example, a patient with impaired physical mobility because of bilateral arm casts temporarily needs assistance. After the casts are removed, the patient gradually regains the strength and range of motion needed to perform ADLs. In contrast, a patient with an irreversible cervical spinal cord injury is paralyzed and has a permanent need for assistance. It is unrealistic to plan rehabilitation with a goal of becoming independent with ADLs for this patient. Instead the patient learns new ways to perform ADLs independently through rehabilitation. Occupational and physical therapists play a key role in rehabilitation to restore ADLs function. When a patient is experiencing fatigue, a limitation in mobility, confusion, and/or pain, assistance with ADLs is likely. For example, a patient who experiences shortness of breath avoids eating because of associated fatigue. Help the patient by setting up meals and offering to cut up food and plan for more frequent, small meals to maintain his or her nutrition. Assistance with ADLs ranges from partial assistance to complete care. Remember to always respect a patient's wishes and determine his or her preferences. Patients from some cultures prefer receiving assistance with ADLs from family members. As long as a patient is stable and alert, it is appropriate to allow family to help with care. Most patients want to remain independent in meeting their basic needs. Allow a patient to participate to the level that he or she is able. Involving patients in planning the timing and types of interventions boosts their self-esteem and willingness to become more independent.

Safety Guidelines For Nursing Skills

Ensuring patient safety is an essential role of the professional nurse. To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate the patient's priorities of care and preferences, and use the best evidence when making decisions about your patient's care. When performing the skills in this chapter, remember the following points to ensure safe, individualized patient care: • On the basis of your assessment and knowledge of physiological and behavioral factors, anticipate a patient's fall risks when choosing fall prevention strategies. • Involve patients and families in selection of fall prevention strategies. • Always try restraint alternatives before using a restraint. Involve family in your approach. • Protect patients from injury. Follow assessment guidelines while patients are restrained to avoid injury from inappropriate placement. • Protect patients from falling by implementing fall prevention protocols and providing patient and family education about fall prevention. Skill 27-1Fall Prevention in Health Care Settings Delegation and CollaborationEquipmentThe skill of assessing and communicating a patient's risk for falling cannot be delegated to nursing assistive personnel (NAP). Skills used to prevent falls can be delegated. The nurse instructs NAP to: • Use fall prevention measures that match a patient's mobility limitations. • Use specific environmental safety precautions (e.g., bed locked in low position, call light within reach). • Report to the nurse any patient behaviors (e.g., disorientation, wandering) that are precursors to falls. • Fall risk assessment tool • Hospital bed with side rails; option—low bed • Call light/intercom system • Gait belt • Wheelchair (as needed) • Additional safety devices (e.g., bed alarm pad, wedge cushion) Step/Rationale ASSESSMENT 1. Identify patient using two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2016). 2. Assess patient's fall risks using an agency fall risk assessment tool. Assess patient's age (over 65), number of co-morbidities, impaired memory and cognition, incontinence or urinary frequency/urgency, decreased hearing, decreased vision, orthostatic hypotension, impaired gait, weak lower extremities, poor balance, fatigue, need for transfer assistance, decreased peripheral sensation (Spoelstra, 2011; Viera et al., 2011).A variety of physiological factors predispose patients to fall. 3. Determine if patient has a history of recent falls or other injuries within the home. Assess previous falls, using the acronym SPLATT (Touhy and Jett, 2014). • Symptoms at time of fall • Previous fall • Location of fall • Activity at time of fall • Time of fall • Trauma after fallKey symptoms are helpful in identifying cause for falls. Onset, location, and activity associated with a fall provide further details on causative factors and how to prevent future falls. 4. Review patient's medications (including over-the-counter [OTC] medications and herbal products) for use of antidepressants, anticonvulsants, antipsychotics, hypnotics (especially benzodiazepines), anxiolytics, diuretics, antihypertensives, antihistamines, anti-Parkinson drugs, hypoglycemics, muscle relaxants, analgesics, and laxatives. Also assess for polypharmacy (i.e., over six medications, duplicate medications, drugs inappropriate for condition) (Bushardt et al., 2008).Effects of certain medications and use of multiple medications increase risk for falls and injury (Chang et al., 2011; Gribbin et al., 2010; Kojima et al., 2011).CLINICAL DECISION: If patient takes multiple medications, confer with health care provider on possibility of reducing or adjusting number of medications. 5. Assess patient for fear of falling: those higher at risk are over 75 years of age, female, lower income, or single and have poor perceived general health or history of falling in last 3 months (Boyd and Stevens, 2009).Fear of falling is interrelated with incidence of falls. 6. Perform the "Timed Get-up and Go" (TUG) if patient is able to ambulate. At a minimum observe patient walk in room (with or without assistance). Steps for TUG dual assessment: • Give patient verbal instructions to stand up from a chair, walk 10 feet (3 meters) as quickly and safely as possible (cross a line marked on the floor), turn around, walk back, and sit down. • Have patient rise from straight back chair without using arms for support. • Begin counting. • Look for unsteadiness in patient's gait. • Have patient return to chair and sit down without using arms for support. Check time elapsed.For accuracy, a patient should have one practice trial that is not included in the score. Patient must use the same assistive device each time he or she is tested to be able to compare scores.The Timed Get-up and Go (TUG) is a revision to the original Get-up and Go test (Podsiadlo and Richardson, 1991). It quantifies a patient's functional mobility. Observing a patient walk allows you to determine if gait and posture are normal. The TUG is a measure of physical and cognitive performance. A patient's ability to follow simple instructions measures cognitive function. An older adult who takes 12 seconds or longer to complete the TUG is at high risk for falling (CDC, 2015b). Balance function is scored on a five-point scale: 1 = Normal; 2 = Very slightly abnormal; 3 = Mildly abnormal; 4 = Moderately abnormal; 5 = Severely abnormal (Mathias et al., 1986). A score of 3 or more on the balance scale indicates a patient is at risk for falling (Mathias et al., 1986). Note: The TUG has been found to have limited ability to predict falls in community-dwelling elderly and should not be used in isolation to identify individuals at high risk for falls in this setting (Barry et al., 2014). 7. Assess risk factors for falls in health care facility (e.g., being attached to equipment such as sequential compression hose, intravenous [IV] line, or oxygen tubing; improperly lighted room; clutter; obstructed walkway to bathroom; and frequently needed items that are difficult to reach.Environmental barriers pose risk for falls. 8. Assess condition of equipment (i.e., legs on bedside commode, tips of walker).Equipment in poor repair increases the risk for fall. 9. Assess patient's medical history for osteoporosis, being on anticoagulants, history of previous fracture, cancer, and recent chest or abdominal surgery.Factors increase likelihood of injury from a fall. 10. Use a patient-centered approach. Determine what patient knows about risks for falling and steps that he or she can take to prevent falls.Knowledge of fall risks influences one's ability to take needed precautions in reducing falling. 11. If patient is assessed to be a fall risk, apply color-coded wristband (see illustration). Some agencies institute fall risk signs on doors.STEP 11Arm band alerts nursing staff to patient's risk of falling.Color-coded yellow bands are easily recognizable.PLANNING 1. Gather equipment and perform hand hygiene.Organizes care. Reduces transmission of microorganisms. 2. Explain what you plan to do. Specifically discuss reasons that patient is at risk for falling. Include family caregivers (as appropriate) in discussion. Provide privacy. Be sure that patient is comfortable.Reduces patient anxiety and promotes cooperation. Results in fall prevention measures that are patient centered and not just routine. Younger patients are very independent and often believe that they are not likely to fall.IMPLEMENTATION 1. A adjust bed to low position with wheels locked (see illustration). Option: Place nonslip padded floor mats at exit side of bed.STEP 1Hospital bed should be kept in lowest position with wheels locked and side rails up as appropriate.Height of bed allows ambulatory patient to get in and out of bed easily and safely. Pads provide nonslippery surface on which to stand. 2. Encourage the use of properly fitted skid-proof footwear.Prevents falls from slipping on floor. 3. Orient patient to surroundings, call light, and routines to expect in plan of care.Orientation to room and plan of care provides familiarity with environment and activities to anticipate. a. Provide patient's hearing aid and glasses. Be sure that each is functioning/clean.Enables patient to remain alert to conditions in environment. b. Be sure that call light/bed control system is in an accessible location within patient's reach. Explain and demonstrate how to turn call light/intercom system on and off at bedside and in bathroom (see illustration). Have patient perform a return demonstration.STEP 3bNurse demonstrates use of call light to patient.Knowledge of location and use of call light is essential for patient to be able to call for assistance quickly. Reaching for an object when in bed can lead to an accidental fall. c. Explain to patient/family caregiver when and why to use call system (e.g., report pain, get out of bed, go to bathroom). Provide clear instructions to patient/family caregiver regarding mobility restrictions.Increases likelihood that patient will call for help and of nurse being able to respond to patient's needs in a timely way. 4. Safe use of side rails a. Explain to patient and family members the reason for using side rails: moving and turning self in bed.Promotes cooperation. b. Check agency policy regarding side-rail use. • Dependent, less mobile patients: In a two-side rail bed, keep both rails up. (Note: Rails on newer hospital beds allow for room at foot of bed for patient to safely exit bed.) In a four-side rail bed, leave two upper rails up.Side rails are restraint devices if they immobilize or reduce ability of a patient to move his or her arms, legs, body, or head freely. • Patient able to get out of bed independently: In a four-side rail bed, leave two upper side rails up. In a two-side rail, keep only one rail up.Allows for safe exit from bed. 5. Make the patient's environment safe. a. Remove excess equipment, supplies, and furniture from rooms and halls.Reduces likelihood of falling or tripping over objects. b. Keep floors clutter and obstacle free, particularly the path to the bathroom.Reduces likelihood of falling or tripping over objects. c. Coil and secure excess electrical, telephone, and any other cords or tubing.Reduces the risk of entanglement. d. Clean all spills promptly. Post a sign indicating a wet floor. Remove the sign when the floor is dry (usually done by housekeeping).Reduces the risk of falling on slippery, wet surfaces. e. Ensure adequate glare-free lighting; use a night-light at night.Glare may be a problem for older adults because of vision changes. f. Have assistive devices (e.g., cane, walker, bedside commode) on exit side of bed. Have chair back of commode placed against wall of room if possible.Provides added support when transferring out of bed. Stabilizes commode. g. Arrange personal items (e.g., water pitcher, telephone, reading materials, dentures) within patient's easy reach and in a logical way.Facilitates independence and self-care; prevents falls related to reaching for hard-to-reach items. h. Secure locks on beds, stretchers, and wheelchairs.Prevents accidental movement of devices during patient transfer. 6. Additional interventions for patients at moderate-to-high risk for falling (based on fall risk assessment) a. Prioritize call-light responses to patients at high risk, using a team approach with all staff knowing responsibility to respond.Ensures rapid response by a health care provider when patient calls for assistance. b. Establish elimination schedule, using bedside commode when appropriate.Proactive toileting keeps patients from being unattended with sudden urge to use toilet.CLINICAL DECISION: Getting out of bed for toileting is a common event leading to a patient's fall (Tzeng, 2010), especially during evening or night hours when a room is darkened. c. Stay with patient during toileting (standing outside bathroom door).Patients often try to get up to stand and walk back to their bed from the bathroom without assistance. d. Place patient in a geri chair or wheelchair with wedge cushion. Use wheelchair only for transport, not for sitting an extended time.Maintains alignment and comfort and makes it difficult to exit chair. e. Use a low bed that has low height above floor and apply floor mats.Reduces fall-related injuries. f. Activate a bed alarm for patient.Alarm activates when patient rises off a sensor. Alarm sounds an alert to staff. g. Confer with physical therapy on feasibility of gait training, weight-bearing activities, balance exercise, and strengthening exercises.Exercise can reduce falls, fall-related fractures, and several risk factors for falls in individuals with low bone density and in older adults (deKam et al., 2009; Schubert, 2011). h. Use sitters or restraints only when alternatives are exhausted.A sitter is a nonprofessional staff member or volunteer who stays in a patient room to closely observe patients who are at risk for falling. Restraints should be used only as a final option (see Skill 27-2). 7. When ambulating a patient, have patient wear a gait belt and walk along patient's side (see Chapter 39).Gait belt gives you a secure hold on patient during ambulation. 8. Safe Transport Using a Wheelchair. a. Determine level of assistance needed to transfer patient to wheelchair. Position wheelchair on same side of bed as patient's strong or unaffected side (see Chapter 39).Patient's condition may require more than a one-person assist. Positioning of chair facilitates patient's ability to assist in transfer. b. Place wedge cushion in chair (see illustration.)STEP 8bWheelchair with footplates raised and a wedge cushion in place.Prevents patient from slipping out of chair. c. Securely lock brakes on both wheels when transferring patient into or out of wheelchair.Keeps chair steady and secure. d. Raise footplates before transfer to chair; then lower footplates, placing patient's feet on them after he or she is seated.Prevents tripping over footplate. e. Have patient sit with buttocks well back in seat. Option: Apply a quick-release seat belt.Prevents patient from sliding out of chair. f. Back wheelchair into and out of elevator or door, leading with large rear wheels first (see illustration).STEP 8fNurse backing wheelchair into elevator.Prevents smaller front wheels from catching in crack between elevator and floor, causing chair to tip. 9. Remove unnecessary supplies. Perform hand hygiene.Reduces transmission of microorganisms.EVALUATION 1. Conduct hourly rounds.Hourly rounding programs reduce patient falls, and call light use increases patients' perception of nursing responsiveness. 2. Evaluate patient's ability to use assistive devices such as walker or bedside commode.Adjustments in devices may become necessary. 3. Evaluate for changes in motor, sensory, and cognitive status and review if any falls or injuries have occurred.May require different interventions to be added. Fall outcomes determine success of plan. 4. Use Teach Back: State to the patient and family caregiver, "I want to be sure I explained clearly to you why you are more likely to fall than other patients. Can you tell me some of those reasons?" Evaluate whether patient/caregiver is able to explain fall risks. Revise your instruction now or develop plan for revised patient teaching to be implemented at an appropriate time if patient/caregiver is not able to teach back correctly.Evaluates what patient and family caregiver are able to explain or demonstrate.UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS 1. Patient starts to fall while ambulating with a nurse. • Put both arms around patient's waist or grasp gait belt. • Stand with feet apart to provide a broad base of support (see Figure 39-11, A). • Extend one leg and let patient slide against it to the floor (see Figure 39-11, B). • Bend knees and lower body as patient slides to floor (see Figure 39-11, C). 2. Patient falls. • Call for assistance. Assess patient for injury and stay with patient until assistance arrives to help lift him or her to bed or wheelchair. • Reinforce explanation of identified risks with patient and review safety measures needed to prevent a fall. • Monitor patient closely after the fall since injuries are not always immediately apparent. 3. Patient/family caregiver is unable to explain fall risks. • Offer re-explanation, using plain language, and consider use of printed materials if available.RECORDING AND REPORTING • Record in plan of care specific interventions to prevent falls and promote safety. • Document your evaluation of patient learning. • Report patient's fall risks and measures taken to reduce risks to all health care personnel. • Report immediately to physician or health care provider if the patient sustains a fall or an injury. • Complete an agency safety event or incident report noting objective details of fall (time, location, patient's condition, treatment, treatment response). Do not place report in patient medical record. • Record events related to the fall and treatment in medical record.HOME CARE CONSIDERATIONS • Assess the patient's home environment for hazards and institute safety measures as appropriate, with patient and family partnering on decisions. • Keep personal items in their familiar positions and within easy reach in rooms frequently used. • If patient has a history of falls and lives alone, recommend that he or she wear an electronic Safe Patient Care device. The device is turned on by the wearer to alert a monitoring site to call emergency services for help. Skill 27-2Applying Physical Restraints Delegation and CollaborationEquipmentThe skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. The application and routine checking of a restraint can be delegated to nursing assistive personnel (NAP). TJC (2009) requires training on first aid for anyone who monitors patients in restraints. The nurse instructs the NAP about: • Appropriate restraint to use and correct placement of restraint. • When and how to change patient's position and provide range-of-motion exercises, hydration, toileting, skin care, and time for socialization. • When to report signs and symptoms of patient not tolerating restraint (e.g., agitation, change in skin integrity, circulation of extremities, or patient's breathing) and what to do. • Proper restraint • Padding (if needed) Step/Rationale ASSESSMENT 1. Identify patient using two identifiers (e.g., name and birthday or name and medical record number) according to agency policy.Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2016). 2. Assess patient's behavior (e.g., confusion; disorientation; agitation; restlessness; combativeness; inability to follow directions or repeated removal of tubing, dressing, or other therapeutic devices). Does patient create a risk to other patients?If patient's behavior continues despite treatment or restraint alternatives, use of restraint is indicated. You use the least restrictive type of restraint. 3. Determine failure of restraint alternatives. Review facility policies and state laws regarding restraints. Check for a current health care provider's order. The licensed health care provider assesses the patient in person within 1 hour of initiation of restraints (TJC, 2009). Order must include purpose, type, location, and time or duration of restraint. Determine if signed consent for use of restraint is necessary (long-term care). Orders may be renewed according to time limits for a maximum of 24 consecutive hours (TJC, 2009).A health care provider's order for the least restrictive type of restraint is required. Each original restraint order is limited to 4 hours for adults 18 years old and older, 2 hours for children 9 through 17 years old, and 1 hour for children younger than 9 years (TJC, 2009).CLINICAL DECISION: A licensed independent health care provider responsible for the care of the patient evaluates the patient in person within 1 hour of the initiation of restraint used for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff, or others. A registered nurse or a physician assistant may conduct the in-person evaluation if trained in accordance with the requirements and consultations with the previously mentioned health care provider after the evaluation as determined by hospital policy (TJC, 2016). 4. Review manufacturer's instructions for restraint application before entering patient's room. Determine most appropriate size restraint.You need to be familiar with all devices used for patient care and protection. Incorrect application of restraint device results in patient injury or death.PLANNING 1. Gather equipment and perform hand hygiene.Promotes organization and reduces transmission of microorganisms. 2. Explain what you plan to do. Provide privacy. Be sure that patient is comfortable and in correct anatomical position.Reduces patient anxiety and promotes cooperation; positioning prevents contractures and neurovascular impairment.IMPLEMENTATION 1. Adjust bed to proper height and lower side rail on side of patient contact. Be sure that patient is comfortable and in proper body alignment.Allows you to use proper body mechanics and prevents injury during restraint application. Positioning prevents contractures and neurovascular injury while restraint is in place. 2. Inspect area where restraint is to be placed. Note if there is any nearby tubing or device. Assess condition of skin, sensation, adequacy of circulation, and range of joint motion.Restraints sometimes compress and interfere with functioning of devices or tubes. Assessment provides baseline to monitor patient's response to restraint. 3. Pad skin and bony prominences (as necessary) that will be under restraint.Reduces friction and pressure from restraint to skin and underlying tissue. 4. Apply proper-size restraint.Note: Refer to manufacturer's directions. a. Belt restraint: Have patient in sitting position in bed. Apply belt over clothes, gown, or pajamas. Be sure to place restraint at waist, not chest or abdomen. Remove wrinkles or creases in clothing. Bring ties through slots in belt. Help patient lie down in bed. Have patient roll to side and avoid applying belt too tightly (see illustrations). Option: Apply a belt restraint net.STEP 4aA, Apply belt restraint with patient sitting. B, A properly applied belt restraint allows patient to turn in bed.Restrains center of gravity and prevents patient from rolling off stretcher or sitting up while on stretcher or from falling out of bed. Tight application interferes with ventilation if belt moves up over abdomen or chest. b. Extremity (ankle or wrist) restraint: Restraint made of soft quilted material or sheepskin with foam padding. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly (not tightly) in place by Velcro strap or quick-release buckle. Insert two fingers under secured restraint (see illustration).STEP 4bInsert two fingers under restraint to check for constriction.Restraint designed to immobilize one or all extremities. Maintain immobilization of extremity to protect patient from fall or accidental removal of therapeutic device (e.g., intravenous [IV] tube, Foley catheter). Tight application interferes with circulation and potentially causes neurovascular injury.CLINICAL DECISION: Patient with wrist and ankle restraints is at risk for aspiration if positioned supine. Place patient in lateral position or with head of bed elevated rather than supine. c. Mitten restraint: Thumbless mitten device restrains patient's hands. Place hand in mitten, being sure that Velcro strap is around wrist and not forearm (see illustration).STEP 4cMitten restraint.Prevents patient from dislodging invasive equipment, removing dressings, or scratching but allows greater movement than a wrist restraint. It is considered a restraint alternative if untethered and patient is physically and cognitively able to remove it. d. Elbow restraint (freedom splint): Restraint consists of rigidly padded fabric that wraps around the arm and is closed with Velcro. The upper end has a clamp that hooks to the sleeve of a patient's gown or shirt (see illustration). Insert arm so elbow joint rests against padded area, keeping joint extended.STEP 4dFreedom elbow restraint.Commonly used with infants and children to prevent elbow flexion (e.g., with IV line placed in antecubital fossa). Restraint keeps elbow extended.CLINICAL DECISION: This text does not address application of vest restraints. Many health care agencies ban the use of jacket (vest) restraints because of their association with fatal injuries. 5. Attach restraint straps to portion of bedframe that moves when raising or lowering head of bed (see illustrations). Be sure that straps are secure. Do not attach to side rails. Attach restraint to chair frame for patient in chair or wheelchair, being sure that tie is out of patient's reach.STEP 5Attaching restraint buckle and strap to bedframe.Properly positioned strap does not tighten and restrict circulation when bed is raised or lowered. 6. Secure restraints with quick-release buckle (see illustrations). Do not tie strap in a knot. Be sure that buckle is out of patient reach.STEP 6Connecting the quick-release buckle.Allows for quick release in an emergency. 7. Double-check and insert two fingers under secured restraint. Assess proper placement of restraint, including skin integrity, pulses, skin temperature and color, and sensation of restrained body part.Provides baseline assessment data if injury develops from restraint. 8. Remove restraint at least every 2 hours (TJC, 2016) or more frequently as determined by agency policy. Reposition patient, provide comfort and toileting measures, evaluate patient condition each time. If patient is violent or noncompliant, remove one restraint at a time and/or have staff assist while removing restraints.Provides an opportunity to attend to patient's basic needs and determine need for continuation. 9. Secure call light or intercom system within reach.Allows patient, family, or caregiver to obtain assistance quickly. 10. Leave bed or chair with wheels locked. Keep bed in lowest position.Prevents bed or chair from moving if patient tries to get out. If patient falls with bed in lowest position, this reduces chance of injury. 11. Perform hand hygiene.Reduces transmission of microorganisms.EVALUATION 1. After application, evaluate patient for signs of injury every 15 minutes (e.g., circulation, vital signs, range of motion, physical and psychological status, and readiness for discontinuation. Perform visual checks if patient is too agitated to approach (TJC, 2015).Frequent evaluation prevents injury to patient and ensures removal of restraint at earliest possible time. Frequency of monitoring guides staff in determining appropriate intervals for evaluation on the basis of patient's needs and condition, type of restraint used, risk associated with use of chosen intervention, and other relevant factors. 2. Evaluate patient's need for toileting, nutrition and fluids, hygiene, and elimination and release restraint at least every 2 hours.Prevents injury to patient and attends to basic needs. 3. Evaluate patient for any complications of immobility.Early detection of skin irritation, restricted breathing, or reduction in mobility prevents serious adverse events. 4. The licensed health care provider or registered nurse trained according to CMS requirements needs to evaluate patient within either 1 or 4 hours after initiation of restraints, depending on Medicare status of hospital (see agency policy).Determines patient's immediate situation, reaction to restraints, medical and behavioral condition, and need to continue or terminate restraints (CMS, 2007). 5. After 24 hours, before writing a new order, the health care provider who is responsible for patient's care must see and assess patient.Ensures that restraint application continues to be medically appropriate. 6. Observe IV catheters, urinary catheters, and drainage tubes to determine that they are positioned correctly and that therapy remains uninterrupted.Reinsertion is uncomfortable and increases risk for infection or interrupts therapy. 7. Observe patient's behavior and reaction to presence of restraint.Restraints can increase restlessness and agitation, resulting in harm.UNEXPECTED OUTCOMES AND RELATED INTERVENTIONS 1. Skin underlying restraint becomes reddened or damaged. • Provide appropriate skin/wound care (see Chapter 48). • Notify health care provider and reassess need for continued use of restraint or if you can use alternative measures. • Be sure that restraint is applied correctly and has adequate padding. • Remove restraints more frequently. Change wet or soiled restraints. 2. Patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness. • Remove restraint immediately and notify health care provider. Stay with patient. 3. Patient becomes confused or agitated. • Identify reason for change in behavior and try to eliminate cause. • Use restraint alternatives.RECORDING AND REPORTING • Record nursing interventions, including restraint alternatives tried, in nurses' notes. • Record patient's behavior before restraints were applied, level of orientation, and patient or family's understanding of application. • Document your evaluation of patient/family learning. • Record purpose for restraint, type and location of restraint used, time applied and discontinued, times restraint was released, and routine observations (e.g., skin color, pulses, sensation, vital signs, behavior) in nurses' notes and flow sheets. • Record patient's level of orientation and behavior after restraint application. Record times patient was evaluated, attempts to use alternatives, and patient's response when restraint was removed.HOME CARE CONSIDERATIONS • A physical restraint is a device that requires a physician's order. Do not send a patient home with intent of restraining unless device is necessary to protect patient from injury. If patient's family wishes to use restraint at home, a physician's order is required, and you need to give clear instructions regarding proper application, care needed while in restraints, and complications for which to look. Carefully assess the family for competency and understanding of intent for using restraint.

PUD Meds

Interventions. PUD causes significant discomfort that impacts many aspects of daily living. Interventions to manage pain focus on drug therapy and dietary changes. Drug Therapy. The primary purposes of drug therapy in the treatment of PUD are to (1) provide pain relief, (2) eliminate H. pylori infection, (3) heal ulcerations, and (4) prevent recurrence. Several different regimens can be used. In selecting a therapeutic drug regimen, the health care provider considers the efficacy of the treatment, the anticipated side effects, the ability of the patient to adhere to the regimen, and the cost of the treatment. Although numerous drugs have been evaluated for the treatment of H. pylori infection, no single agent has been used successfully against the organism. A common drug regimen for H. pylori infection is PPI-triple therapy, which includes a proton pump inhibitor (PPI) such as lansoprazole (Prevacid) plus two antibiotics such as metronidazole (Flagyl, Novonidazol ) and tetracycline (Ala-Tet, Panmycin, Nu-Tetra) or clarithromycin (Biaxin, Biaxin XL) and amoxicillin (Amoxil, Amoxi) for 10 to 14 days. Some health care providers may prefer to use quadruple therapy, which contains combination of a proton pump inhibitor (PPI), any two commonly used antibiotics as described above, with the addition of bismuth (Pepto-Bismol). Bismuth therapy is often used in patients who are allergic to penicillin-based medications. Considerations for Older Adults Patient-Centered Care Many older adults have H. pylori infection that is undiagnosed because of vague symptoms associated with physiologic changes of aging and comorbidities that mask dyspepsia. Because the average age of gastric cancer diagnosis is 70 years, it is important to teach older adults about the symptoms of PUD and to consider H. pylori screening. Early detection and aggressive treatment can prevent PUD and gastric cancer. Hyposecretory drugs reduce gastric acid secretions and are therefore used for both peptic ulcer disease (PUD) and gastritis management. The primary prescribed drugs include proton pump inhibitors and H2-receptor antagonists (Chart 55-4). Chart 55-4 Common Examples of Drug Therapy Peptic Ulcer Disease DRUG AND USUAL DOSAGEPURPOSE OF DRUGNURSING INTERVENTIONSRATIONALESAntacidsMagnesium hydroxide with aluminum hydroxide (Maalox, Mylanta) 50-80 mEq orally 1 hr and 3 hr after meals and at bedtimeIncreases pH of gastric contents by deactivating pepsinGive 2 hr after meals and at bedtime.Hydrogen ion load is high after ingestion of foods.Use liquid rather than tablets.Suspensions are more effective than chewable tablets.Do not give other drugs within 1-2 hr of antacids.Antacids interfere with absorption of other drugs.Assess patients for a history of renal disease.Hypermagnesemia may result.These antacids have a high sodium content.These antacids contain magnesium, which cannot be excreted by poorly functioning kidneys, thus causing toxicity.Assess the patient for a history of heart failure.Inadequate renal perfusion from heart failure decreases the ability of the kidneys to excrete magnesium, thus causing toxicity.Observe the patient for the side effect of diarrhea.Magnesium often causes diarrhea.Aluminum hydroxide (Amphojel) 50-80 mEq orally 1 hr and 3 hr after meals and at bedtimeGive 1 hr after meals and at bedtime.Hydrogen ion load is high after ingestion of food.Use liquid rather than tablets if palatable.Suspensions are more effective than chewable tablets.Do not give other drugs within 1-2 hr of antacids.Antacids interfere with absorption of other drugs.Observe patients for the side effect of constipation. If constipation occurs, consider alternating with magnesium antacid.Aluminum causes constipation, and magnesium has a laxative effect.Use for patients with renal failure.Aluminum binds with phosphates in the GI tract.This antacid does not contain magnesium.H2 Antagonists (Blockers)Ranitidine (Zantac) 150 mg orally twice daily or 300 mg orally at bedtime; 50 mg IV every 6 hr or 8 mg/hr IV (continuous)Famotidine (Pepcid) 40 mg orally once daily or in two divided doses; 20 mg IV every 12 hrNizatidine (Axid) 150 mg orally twice daily or 300 mg at bedtimeDecreases gastric acid secretions by blocking histamine receptors in parietal cellsGive single dose at bedtime for treatment of GI ulcers, heartburn, and PUD.Note: IV famotidine or IV ranitidine may also be given to prevent surgical stress ulcers.Bedtime administration suppresses nocturnal acid production.Mucosal Barrier FortifiersSucralfate (Carafate, Sulcrate) 1 g orally four times daily or 2 g twice dailyBinds with bile acids and pepsin to protect stomach mucosaGive 1 hr before and 2 hr after meals and at bedtime.Food may interfere with drug's adherence to mucosa.Do not give within 30 min of giving antacids or other drugs.Antacids may interfere with effect.Bismuth Subsalicylate (Pepto-Bismol) 525 mg (30 mL) orally four times dailyStimulates mucosal protection and prostaglandin productionInhibits H. pylori from binding to mucosal liningPatients cannot take aspirin while on this drug.Note: May cause the stools to be discolored black.Aspirin is a salicylic acid and will lead to overdose of aspirin.Proton Pump InhibitorsOmeprazole (Prilosec, Losec) 20-40 mg orally dailySuppresses H,K-ATPase enzyme system of gastric acid secretionIndications for short-term and long-term use for PUD, symptomatic heartburn, and H. pylori treatmentHave patients take capsule whole; do not crush.Delayed-release capsules allow absorption after granules leave the stomach.Give 30 minutes before the main meal of the day.The proton pump is activated by the presence of food. Therefore the drug needs a chance to work before the patient eats.Lansoprazole (Prevacid) 15-30 mg orally dailyGive 30 min before the main meal of the day.The proton pump is activated by the presence of food. Therefore the drug needs a chance to work before the patient eats.Rabeprazole (Aciphex) 20 mg orally once dailyTake after the morning meal.Drug promotes healing and symptom relief of duodenal ulcers.Do not crush capsule.Drug is a sustained-release capsule.Pantoprazole (Protonix) 40 mg orally or IV daily for 7-10 daysDo not crush.Drug is enteric-coated.IV form must be given on a pump with a filter and in a separate line.Given IV, drug precipitates easily.Do not give Protonix IV with other IV drugs.Note: This medication may have several adverse drug interactions. Be aware of the patient's other medications.The IV form is not compatible with most other drugs.This medication will alter how other drugs are metabolized, either increasing or decreasing their effectiveness.Esomeprazole (Nexium) 20 or 40 mg orally daily (or IV daily for 7-10 days)Assess for hepatic impairment.Patients with severe hepatic problems need a low dose.Do not give Nexium IV with other IV drugs.Note: This medication may have several adverse drug interactions. Be aware of the patient's other medications.The IV form is not compatible with most other drugs.This medication will alter how other drugs are metabolized, either increasing or decreasing the effectiveness.Prostaglandin AnalogsMisoprostol (Cytotec) 200 mcg orally four times dailySynthetic prostaglandin that stimulates mucosal protection and decreases gastric acid secretionsHelps resist mucosal injury in patients taking NSAIDs and/or high-dose corticosteroidsAvoid magnesium-containing antacids.Note: Do not use in pregnant women.Both misoprostol and magnesium-containing antacids can cause diarrhea.Can cause abortion, premature birth, or birth defects.AntimicrobialsClarithromycin (Biaxin) 500 mg orally three times dailyTreats H. pylori infectionBe aware that the drug should be given with caution to patients with renal impairment; monitor renal function lab values.The drug can increase the patient's BUN level and should be monitored.Amoxicillin (Amoxil) 1 g orally twice dailyTreats H. pylori infectionTeach patients to take the drug with food or immediately after a meal.The drug can cause GI disturbances, including nausea, vomiting, and diarrhea.Tetracycline 500 mg orally four times dailyTreats H. pylori infectionTeach patients to take the drug at least 1 hour before meals or 2 hours after meals.Dairy products and other foods may interfere with drug absorption.Teach patients to avoid direct sunlight and wear sunscreen when outdoors.The drug can cause the skin to burn due to photosensitivity.Metronidazole (Flagyl) 250 mg orally three times daily and at bedtimeTreats H. pylori infectionTeach patients to take the drug with food.The drug can cause GI disturbances, especially nausea.Teach patients to avoid alcohol during drug therapy and for at least 3 days after therapy is completed.The patient can experience a drug-alcohol reaction, including severe nausea, vomiting, and headache. Proton pump inhibitors (PPIs) is the drug class of choice for treating patients with acid-related disorders. Examples include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). These drugs suppress the H,K-ATPase enzyme system of gastric acid production, and several of them are available as over-the-counter (OTC) drugs ( Lilley et al., 2014). Omeprazole, lansoprazole, and esomeprazole are each available as delayed-release capsules designed to release their contents after they pass through the stomach. Omeprazole and lansoprazole may be dissolved in a sodium bicarbonate solution and given through any feeding tube. Bicarbonate protects the dissolved omeprazole and lansoprazole granules in gastric acid. Therefore the drugs are still absorbed correctly. These capsules can also be opened. The enteric-coated capsules can be put in apple juice or orange juice and given through a large-bore feeding tube. Rabeprazole (Aciphex) and pantoprazole (Protonix) are enteric-coated tablets that quickly dissolve after the tablet has moved through the stomach and should not be crushed before giving them. Several of the PPIs are also available in an IV form, which may be helpful for patients who are NPO. Some patients use these PPIs for years and perhaps a lifetime. However, these drugs should not be used for a prolonged period because, over time, they may contribute to osteoporotic-related fractures, especially spinal fractures in older women ( Kwok et al., 2010). Omeprazole (Prilosec and Prilosec OTC) reduces the effect of clopidogrel (Plavix), an antiplatelet drug. Teach patients to tell their health care provider if they are taking clopidogrel. PPIs should not be discontinued abruptly to prevent rebound activation of the proton pump. Therefore, a step-down approach over several days is recommended ( Zarowitz, 2011). H2-receptor antagonists are drugs that block histamine-stimulated gastric secretions. These drugs may also be used for indigestion and gastritis. Lower-dose forms are available in over-the-counter (OTC) products. H2-receptor antagonists block the action of the H2 receptors of the parietal cells, thus inhibiting gastric acid secretion. Two of the most common drugs are famotidine (Pepcid) and nizatidine (Axid) and are available as Pepcid OTC and Axid AR in OTC form. These drugs are typically administered in a single dose at bedtime and are used for 4 to 6 weeks in combination with other therapy. Antacids buffer gastric acid and prevent the formation of pepsin. They may help small duodenal ulcers heal but are usually not used alone as drug therapy. Liquid suspensions are the most therapeutic form, but tablets may be more convenient and enhance adherence. The most widely used preparations are mixtures of aluminum hydroxide and magnesium hydroxide. This combination overcomes the unpleasant GI side effects of either of these preparations when used alone. Mylanta and Maalox are examples of this type of combination antacid formulation. The aluminum and magnesium hydroxide combination products neutralize well at small doses. These products must be administered cautiously to patients with renal impairment because elimination is reduced and excessive amounts are retained in the body. Nursing Safety Priority Drug Alert Teach the patient that to achieve a therapeutic effect, sufficient antacid must be ingested to neutralize the hourly production of acid. For optimal effect, take antacids about 2 hours after meals to reduce the hydrogen ion load in the duodenum. Antacids may be effective from 30 minutes to 3 hours after ingestion. If taken on an empty stomach, they are quickly evacuated. Thus the neutralizing effect is reduced ( Lilley et al., 2014). Calcium carbonate (Tums) is a potent antacid, but it triggers gastrin release, causing a rebound acid secretion. Therefore its use in acid inhibition is not recommended. Antacids can interact with certain drugs such as phenytoin (Dilantin), tetracycline (Ala-Tet, Nu-Tetra ), and ketoconazole (Nizoral) and interfere with their effectiveness. Ask what other drugs the patient is using before a specific antacid is prescribed. Other drugs are given 1 to 2 hours before or after the antacid. Inform the patient that flavored antacids, especially wintergreen, should be avoided. The flavoring increases the emptying time of the stomach. Thus the desired effect of the antacid is negated. Teach the patient with past or present heart failure to avoid antacids with high sodium content, such as aluminum hydroxide, magnesium hydroxide, sodium bicarbonate, and simethicone combination products (Gelusil and Mylanta). Magaldrate (Riopan) has the lowest sodium concentration. Sucralfate (Carafate) is a mucosal barrier fortifier (protector) that forms complexes with proteins at the base of a peptic ulcer. This protective coat prevents further digestive action of both acid and pepsin. Sucralfate does not inhibit acid secretion. Rather, it binds bile acids and pepsins, reducing injury from these substances. The drug may be used in conjunction with H2-receptor antagonists and antacids but should not be administered within 1 hour of the antacid. Sucralfate is given on an empty stomach 1 hour before each meal and at bedtime. The main side effect of this drug is constipation. Bismuth subsalicylate (Pepto-Bismol) inhibits H. pylori from binding to the mucosal lining and stimulates mucosal protection and prostaglandin production. Teach patients they cannot take aspirin while on this drug because aspirin is a salicylic acid and could cause an overdose of salicylates. Patients should also be taught that this medication may cause the stools to be discolored black. This discoloration is temporary and harmless. Nutrition Therapy. The role of diet in the management of ulcer disease is controversial. There is no evidence that dietary restriction reduces gastric acid secretion or promotes tissue healing, although a bland diet may assist in relieving symptoms. Food itself acts as an antacid by neutralizing gastric acid for 30 to 60 minutes. An increased rate of gastric acid secretion, called rebound, may follow. Nursing Safety Priority Action Alert Teach the patient with peptic ulcer disease to avoid substances that increase gastric acid secretion. This includes caffeine-containing beverages (coffee, tea, cola). Both caffeinated and decaffeinated coffees should be avoided, because coffee contains peptides that stimulate gastrin release ( McCance et al., 2014). Teach the patient to exclude any foods that cause discomfort. A bland, nonirritating diet is recommended during the acute symptomatic phase. Bedtime snacks are avoided because they may stimulate gastric acid secretion. Eating six smaller meals daily may help, but this regimen is no longer a regular part of therapy. No evidence supports the theory that eating six meals daily promotes healing of the ulcer. This practice may actually stimulate gastric acid secretion. Patients should avoid alcohol and tobacco because of their stimulatory effects on gastric acid secretion. Complementary and Alternative Therapies. Teach patients about complementary and alternative therapies that can reduce stress, including hypnosis and imagery. For example, the use of yoga and meditation techniques has demonstrated a beneficial effect on anxiety disorders. Many have suggested that GI disorders result from the dysfunction of both the GI tract itself and the brain. This means that emotional stress is thought to worsen GI disorders such as peptic ulcer disease. Yoga may alter the activities of the central and autonomic nervous systems. Many herbs, such as powders of slippery elm and marshmallow root, quercetin, and licorice, are used commonly by patients with gastritis and PUD. These herbs may help heal inflamed tissue and increase blood flow to the gastric mucosa. Other substances include zinc, vitamin C, essential fatty acids, acidophilus, vitamin A, and glutamine. Table 55-1 provides a list of therapies that have been used by many patients with gastric disorders. Many of them have been scientifically supported in animal studies but have not been thoroughly studied in humans. Nursing Safety Priority Action Alert Teach the patient who has peptic ulcer disease to seek immediate medical attention if experiencing any of these symptoms: • Sharp, sudden, persistent, and severe epigastric or abdominal pain • Bloody or black stools • Bloody vomit or vomit that looks like coffee grounds

Administering an Enema

An enema is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis. Typically an enema is used to treat constipation or empty the bowel before diagnostic procedures or certain types of abdominal surgery. Preoperative enemas are common for some surgeries. Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through infusion of large volumes of solution. Oil-retention enemas act by lubricating the rectum and colon, allowing feces to absorb oil and become softer and easier to pass. Sometimes these enemas are used before digital removal of stool. Medicated enemas contain pharmacologic therapeutic agents. Some are prescribed to reduce dangerously high serum potassium levels (e.g., sodium polystyrene sulfonate [Kayexalate] enema) or to reduce bacteria in the colon before bowel surgery (e.g., neomycin enema). The volume or type of fluid that breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. Common types of enemas include: • Tap water (hypotonic) enema: It should not be repeated after first installation because water toxicity or circulatory overload can develop. • Physiologic normal saline: It is the safest enema to administer. Infants and children can tolerate only this type because of their predisposition to fluid imbalance. • Hypertonic solution (e.g., commercially prepared Fleet enema): It is useful for patients who cannot tolerate large volumes of fluid. Only 120 to 180 mL (4 to 6 oz) is usually effective. • Harris Flush enema: It is a return-flow enema in which fluid alternately flows into and out of the large intestine. This stimulates peristalsis in the large intestine and helps to expel intestinal gas. • Soapsuds enema (SSE): It is pure castile soap added to either tap water or normal saline, depending on patient's condition and frequency of administration. Use only castile pure soap. Recommended ratio of pure soap to solution is 5 mL (1 teaspoon) to 1000 mL (1 quart) warm water or saline. Add soap to enema bag after water is in place to reduce excessive suds. • Oil-retention enema: It uses an oil-based solution. The colon absorbs a small volume, which allows the oil to soften stool for easier evacuation. • Carminative solution: It provides relief from gaseous distention. An example is MGW solution, which contains 30 mL of magnesium, 60 mL of glycerin, and 90 mL of water. Delegation and Collaboration The skill of enema administration can be delegated to nursing assistive personnel (NAP). The nurse directs the NAP about: • How to properly position patients who have mobility restrictions or therapeutic equipment such as drains, intravenous (IV) catheters, or traction. • Informing the nurse about patient's new abdominal pain (exception: a patient reports cramping) or rectal bleeding. • Informing the nurse immediately about the presence of blood in the stool or around the rectal area or any change in vital signs. STEPRATIONALEASSESSMENT 1 Review health care provider's order for enema and clarify reason for administration.Order by health care provider is usually required for hospitalized patient. 2 Assess last bowel movement, normal versus most recent bowel pattern, presence of hemorrhoids, mobility, and presence of abdominal pain or cramping.Determines need for enema and type of enema used. Also establishes baseline for bowel function. Hemorrhoids may obscure rectal opening and cause discomfort or bleeding during evacuation. 3 Inspect abdomen for presence of distention and auscultate for bowel sounds.Establishes baseline for determining effectiveness of enema. 4 Determine patient's level of understanding of purpose of enema.Allows for planning appropriate teaching measures. Clinical Decision Point "Enemas until clear" order means that you repeat enemas until patient passes fluid that is clear of fecal matter. Check agency policy, but usually patient should receive only three consecutive enemas to avoid disruption of fluid and electrolyte balance. It is essential to observe contents of solution passed. NURSING DIAGNOSES • Acute pain • Constipation • Risk for constipationRelated factors are individualized based on patient's condition or needs.PLANNING 1 Expected outcomes following completion of procedure: • Stool is evacuated.Solution clears rectum and lower colon of stool.• Enema return is clear.Indicates that all solid fecal material in colon has passed.• Abdomen is flat, nontender, with no distention.Gas and feces are expelled.IMPLEMENTATION 1 If enema is medicated, check accuracy and completeness of each medication administration record (MAR) with health care provider's written order. Check patient's name, type of enema, and time for administration. Compare MAR with label of enema solution.The order is most reliable source and only legal record of drugs or procedure that patient is to receive. Ensures that patient receives correct enema.2 Identify patient using two identifiers (i.e., name and birthday or name and account number) according to agency policy. Compare identifiers with information on patient's identification bracelet.Ensures correct patient. Complies with The Joint Commission standards and improves patient safety (TJC, 2012).3 Provide privacy by closing curtains around bed or closing door.Reduces embarrassment for patient.4 Place bedpan or bedside commode in easily accessible position. If patient will be expelling contents in toilet, ensure that toilet is available, and place patient's slippers and bathrobe in easily accessible position.Bedpan is used if patient is unable to get out of bed.5 Perform hand hygiene and apply clean gloves.Reduces transmission of microorganisms.6 Raise bed to appropriate working height; raise side rail on patient's right side.Promotes good body mechanics and patient safety.7 Help patient turn onto left side-lying (Sims') position with right knee flexed. Encourage him or her to remain in position until procedure is complete. Children are placed in dorsal recumbent position.Allows enema solution to flow downward by gravity along natural curve of sigmoid colon and rectum, thus improving retention of solution. Clinical Decision Point Patients with poor sphincter control require placement of a bedpan under the buttocks. Administering enema with patient sitting on toilet is unsafe because curved rectal tubing can abrade rectal wall. 8 Lower side rail on working side and place waterproof pad, absorbent side up, under hips and buttocks. Cover patient with bath blanket, exposing only rectal area, clearly visualizing anus.Pad prevents soiling of linen. Blanket provides warmth, reduces exposure of body parts, and allows patient to feel more relaxed and comfortable.9 Separate buttocks and examine perianal region for abnormalities, including hemorrhoids, anal fissure, and rectal prolapse.Findings influence approach for inserting enema tip. Prolapse contraindicates enema.10 Administer enema.

Assessment of Pulse

Assessing the pulse includes measuring the rate, rhythm, and volume and comparing the findings on both sides of the body. The pulse is assessed by palpation (feeling with the middle three fingertips), auscultation (listening with a stethoscope) (Evidence-Based Practice and Informatics box), or electronic monitoring through specifically placed sensors. Too much pressure of the fingertips can obliterate the pulse, and pressure that is too light may not capture the pulsations. A Doppler ultrasound unit is used to assess pulses that are otherwise difficult to detect, especially pedal pulses (Nursing Care Guideline box). Skill 19-2 reviews the steps for measuring a pulse. Evidence-Based Practice and Informatics Using a Stethoscope A stethoscope is a medical device that is critical in listening to internal sounds of the body. It commonly is used to listen to lung and heart sounds. It also is used to listen to intestinal activity and blood flow in arteries and veins. In combination with a sphygmomanometer, it is used for measurements of blood pressure. It is important that a stethoscope be used and cared for correctly. • The earpieces should fit snugly and point toward the nose. This position follows the path of the ear canal. The chin is dropped toward the chest to determine the position where the earpieces fit the ears the best and room sounds are blocked out. • If the stethoscope has a dual head, with a diaphragm and bell end piece, and if this end piece rotates, it must be rotated to be open to the head in use. The bell is designed to hear low-pitched tones; the diaphragm is designed to hear higher-pitched sounds. • The end piece is placed against the patient's skin with light pressure. • The stethoscope should not be worn against the skin. Tubing made of polyvinyl chloride (PVC) will harden over time from skin oils. • The stethoscope must be kept away from extreme heat or cold. • Infection control issues include the following: • The end piece must be cleaned with an antimicrobial wipe before using it on a patient to prevent infection. • The stethoscope must not be sterilized with steam heat. • The earpieces should be cleaned routinely, as well as whenever shared with anyone else, to prevent infection. Earpieces may be removed for thorough cleaning. • The stethoscope should not be submerged in water; the tubing may be gently wiped with an antimicrobial wipe if needed. • To prevent the spread of infection, decorative coverings should not be placed over the stethoscope tubing. From 3M: Use of your stethoscope, 2014. Retrieved from http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/products/stethoscope. Nursing Care Guideline Using a Doppler Ultrasound Unit to Obtain a Pulse Background • A Doppler ultrasound unit may be used to assess peripheral circulation when a pulse cannot be palpated. • Each pulse wave makes a sound that the Doppler ultrasound unit amplifies. • Pulses may be difficult to palpate for many reasons, including poor circulation, edema, obesity, and other obstructive issues. Procedural Concerns • Apply a small amount of special gel to the skin or the tip of the ultrasound probe. The gel helps to further transmit and amplify the sound waves. • Turn on the machine, and adjust the volume control. • Hold the tip of the ultrasound unit (also called the transducer) at a 45- to 90-degree angle against the skin and directed toward the site of the pulse. • Slide the transducer until the pulse (similar to a "whoosh" sound) can be heard. The pressure used to hold the unit against the skin may need to be varied to obtain the strongest signal. • Ensure presence of a consistent sound at the point where the pulse wave is heard before documenting that a pulse was obtained via Doppler technique. • The transducer should be cleaned with a water-based solution. Documentation Concerns • Note the rate and rhythm of the pulse. • Note the location of the pulse and use of the ultrasound unit for the assessment. Safe Practice Alert If the peripheral pulse is irregular, count an apical pulse for 1 full minute to ensure accurate measurement. Safe Practice Alert In infants and children younger than 2 years of age, the pulse rate is obtained by auscultating the apical pulse. Pulse Rate Pulse rate is an indirect measurement of cardiac output obtained by counting pulse waves over a pulse point. An excessively fast heart rate (>100 bpm in the adult) is termed tachycardia. A slow heart rate (<60 bpm in the adult) is called bradycardia. Tachycardia decreases cardiac filling time, leading to a decreased cardiac output. Factors that lead to tachycardia include a drop in blood pressure; an elevated temperature; conditions such as anemia, which result in poor oxygenation; exercise; prolonged application of heat; pain; strong emotions, such as fear or anxiety; and some medications, including bronchodilators. Bradycardia can occur in athletes, during sleep, in a state of hypothermia, in association with medications such as beta blockers, during tracheal suctioning, in association with increased intracranial pressure, and in myocardial infarction. Bradycardia accompanied by difficulty breathing and decreased blood pressure should be reported immediately, because this is an indication of imminent cardiopulmonary collapse. The radial or apical pulse typically is assessed to measure the pulse rate. The radial pulse is palpated by placing the first two or three fingers of one hand over the radial artery at the groove along the radial, or thumb, side of the patient's inner wrist. The apical pulse is the heart rate measured at the apex of the heart on the anterior chest wall. It is best heard between the left fifth and sixth intercostal spaces, over the midclavicular line (see Skill 19-2 to review apical pulse landmarks). Assessing the apical rate requires auscultation with a stethoscope. The apical site is used if the patient has weak heart contractions, has an irregular rhythm, is taking medications that affect cardiac function, or needs a more accurate assessment. A pulse deficit results when the apical pulse rate exceeds the radial pulse rate. A deficit occurs when the cardiac ejection of a volume of blood is too small to initiate a peripheral pulse wave. To measure this deficit, two people count both pulses simultaneously. Pulse Rhythm Rhythm is the regularity of the heartbeat. An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat, is referred to as a dysrhythmia or an arrhythmia. When an irregular rhythm is detected, the apical pulse is assessed. An electrocardiogram (ECG) is necessary to define the specific dysrhythmia. Pulse Volume The pulse volume, also called amplitude, is the strength of the pulse with each beat. It is described as normal (full and easily palpable), weak (thready and rapid), or strong (bounding). A normal pulse can be felt with moderate pressure of the fingers and obliterated with greater pressure. A forceful volume that is obliterated only with difficulty is a bounding pulse, which may be caused by vasodilation and overhydration. A pulse readily obliterated is described as weak or thready. Causes include vasoconstriction, stiff vessel walls from disease, and shock. A standard pulse-volume scale is used to document findings, with descriptions recorded using a range of 0 to 3+ (Table 19-4). TABLE 19-4 -- Pulse-Volume Scale SCALEDESCRIPTION OF PULSE0Absent pulse1+Weak and thready pulse, difficult to palpate2+Normal pulse, able to palpate with normal pressure3+Bounding pulse, may be able to see pulsation

Foods

Foods containing tryptophan or tyramine • Chicken liver • Pickled herring • Yeast extract • Lima beans • Aged cheeses • Beer and wine Caffeine Sodium chloride Alcohol Licorice

Assessment

History. Review the medical history to determine the possibility of increased metabolic needs or nutrition losses, chronic disease, trauma, recent surgery of the GI tract, drug and alcohol use, and recent significant weight loss. Each of these conditions can contribute to malnutrition. For older adults, explore mental status changes and note poor eyesight, diseases affecting major organs, constipation or incontinence, and slowed reactions. Review prescription and over-the-counter (OTC) drugs, including vitamin, mineral, herbal, and other nutrition supplements. For patients who live independently in the community, the nurse may assess their performance of instrumental activities of daily living (IADLs). Functional status can best be evaluated for institutionalized patients by assessing their ADL performance. Poor nutrition is a major contributing factor to decreased functional ability. In collaboration with the dietitian, obtain information about the patient's usual daily food intake, eating behaviors, change in appetite, and recent weight changes. If the patient is able to communicate, ask him or her to describe the usual foods eaten daily, cultural food preferences, and the times of meals and snacks. If available, ask the family these questions if the patient cannot communicate. If the patient cannot understand the questions due to language differences, locate an interpreter to assist with communication. The dietitian can more thoroughly analyze the diet, if necessary, based on your initial nutrition screening. Ask about changes in eating habits as a result of illness, and document any change in appetite, taste, and weight loss. A weight loss of 5% or more in 30 days, a weight loss of 10% in 6 months, or a weight that is below ideal may indicate malnutrition. Nursing Safety Priority Action Alert When assessing for malnutrition, assess for difficulty or pain in chewing or swallowing. Unrecognized dysphagia is a common problem among nursing home residents and can cause malnutrition, dehydration, and aspiration pneumonia. Ask the patient whether any foods are avoided and why. Ask UAP to report any choking while the patient eats. Record the occurrence of nausea, vomiting, heartburn, or any other symptoms of discomfort with eating. Ask the patient about dental health problems, including the presence of dentures. Dentures or partial plates that do not fit well interfere with food intake. Dental caries (decay) or missing teeth may also cause discomfort while eating. Physical Assessment/Clinical Manifestations. Assess for manifestations of various nutrient deficiencies (Table 60-2). Inspect the patient's hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems. Examine the condition of the skin, including any reddened or open areas. Anthropometric measurements may also be obtained as described on p. 1234. The nurse or UAP monitors all food and fluid intake and notes any mouth pain or difficulty in chewing or swallowing. A 3-day caloric intake may be collected and then calculated by the dietitian. TABLE 60-2 -- Manifestations of Nutrient Deficiencies SIGN/SYMPTOMPOTENTIAL NUTRIENT DEFICIENCYHairAlopeciaZincEasy to removeProteinLackluster hairProtein"Corkscrew" hairVitamin CDecreased pigmentationProteinEyesXerosis of conjunctivaVitamin ACorneal vascularizationRiboflavinKeratomalaciaVitamin ABitot's spotsVitamin AGastrointestinal TractNausea, vomitingPyridoxineDiarrheaZinc, niacinStomatitisPyridoxine, riboflavin, ironCheilosisPyridoxine, ironGlossitisPyridoxine, zinc, niacin, folic acid, vitamin B12Magenta tongueVitamin A, riboflavinSwollen, bleeding gumsVitamin CFissured tongueNiacinHepatomegalyProteinSkinDry and scalingVitamin APetechiae/ecchymosesVitamin CFollicular hyperkeratosisVitamin ANasolabial seborrheaNiacinBilateral dermatitisNiacinExtremitiesSubcutaneous fat lossCaloriesMuscle wastageCalories, proteinEdemaProteinOsteomalacia, bone pain, ricketsVitamin DHematologicAnemiaVitamin B12, iron, folic acid, copper, vitamin ELeukopenia, neutropeniaCopperLow prothrombin time, prolonged clotting timeVitamin K, manganeseNeurologicDisorientationNiacin, thiamineConfabulationThiamineNeuropathyThiamine, pyridoxine, chromiumParesthesiaThiamine, pyridoxine, vitamin B12CardiovascularCongestive heart failure, cardiomegaly, tachycardiaThiamineCardiomyopathySeleniumCardiac dysrhythmiasMagnesium Courtesy of Ross Products Division, Abbott Laboratories, Columbus, OH. Psychosocial Assessment. The psychosocial history provides information about the patient's economic status, occupation, educational level, gender orientation, ethnicity/race, living and cooking arrangements, and mental status. Determine whether financial resources are adequate for providing the necessary food. If resources are inadequate, the social worker or case manager may refer the patient and family to available community services. Chapter 2 discusses nutrition in older adults in more detail. Laboratory Assessment. Laboratory tests supply objective data that can support subjective data and identify deficiencies. Interpret laboratory data carefully with regard to the total patient; focusing on an isolated value may yield an inaccurate conclusion. A low hemoglobin level may indicate anemia, recent hemorrhage, or hemodilution caused by fluid retention. Hemoglobin may also be decreased secondary to conditions such as low serum albumin, infection, catabolism, or chronic disease. High levels may indicate hemoconcentration or dehydration or may be found secondary to liver disease. Low hematocrit levels may reflect anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis. High hematocrit levels may indicate dehydration or hemoconcentration. Serum albumin, thyroxine-binding prealbumin, and transferrin are measures of visceral proteins. Serum albumin is a plasma protein that reflects the nutrition status of the patient a few weeks before testing; therefore it is not considered to be a sensitive test. Patients who are dehydrated often have high levels of albumin, and those with fluid excess have a lowered value. The normal serum albumin level for men and women is 3.5 to 5.0 g/dL or 35 to 50 g/L (SI units) ( Pagana & Pagana, 2014). Thyroxine-binding prealbumin (PAB) is a plasma protein that provides a more sensitive indicator of nutrition deficiency because of its short half-life of 2 days. Depending on the laboratory test used, the normal PAB range is 15 to 36 mg/dL or 150 to 360 mg/L (SI units) ( Pagana & Pagana, 2014). Although not used as commonly, serum transferrin, an iron-transport protein, can be measured directly or calculated as an indirect measurement of total iron-binding capacity (TIBC). It has a short half-life of 8 to 10 days and therefore is also a more sensitive indicator of protein status than albumin. Cholesterol levels normally range between 160 and 200 mg/dL in adult men and women. Values are typically low with malabsorption, liver disease, pernicious anemia, end-stage cancer, or sepsis. A cholesterol level below 160 mg/dL has been identified as a possible indicator of malnutrition. Cholesterol testing is discussed in more detail in Chapter 36. Total lymphocyte count (TLC) can be used to assess immune function. Malnutrition suppresses the immune system and leaves the patient more likely to get an infection. When a patient is malnourished, the TLC is usually decreased to below 1500/mm3.

Musculoskeletal Changes

Immobility affects the musculoskeletal system by causing permanent or temporary impairment or permanent disability. Restricted mobility sometimes results in loss of endurance, strength, and muscle mass and decreased stability and balance. Other effects of restricted mobility affecting the skeletal system are impaired calcium metabolism and joint mobility. Muscle Effects. Because of protein breakdown, a patient loses lean body mass during immobility. The reduced muscle mass makes it difficult for patients to sustain activity without increased fatigue. If immobility continues and the patient does not exercise, there is further loss of muscle mass. Prolonged immobility often leads to disuse atrophy. Loss of endurance, decreased muscle mass and strength, and joint instability (see Skeletal Effects) place patients at risk for falls (see Chapter 39). Skeletal Effects. Immobilization causes two skeletal changes: impaired calcium metabolism and joint abnormalities. Because immobilization results in bone resorption, the bone tissue is less dense or atrophied, and disuse osteoporosis results. When disuse osteoporosis occurs, a patient is at risk for pathological fractures. Osteoporosis is a major health concern in this country. It is predicted that by 2025 it will be responsible for approximately three million fractures and $25.3 billion in costs each year. Furthermore, the National Osteoporosis Foundation (2014) reports that about 54 million Americans have osteoporosis and low bone mass. Studies suggest that approximately one in two women and up to one in four men age 50 and older will break a bone as a result of osteoporosis. Although primary osteoporosis is different in origin from the osteoporosis that results from immobility, it is imperative that nurses recognize that immobilized patients are at high risk for accelerated bone loss if they have primary osteoporosis. Immobility can lead to joint contractures. A joint contracture is an abnormal and possibly permanent condition characterized by fixation of a joint. It is important to note that flexor muscles for joints are stronger than extensor muscles and therefore contribute to the formation of contractures. Disuse, atrophy, and shortening of the muscle fibers cause joint contractures. When a contracture occurs, the joint cannot achieve full ROM. Contractures sometimes leave a joint or joints in a nonfunctional position, as seen in patients who are permanently curled in a fetal position. Early prevention of contractures is essential (Box 28-1) (Clavet et al., 2011). Box 28-1 Evidence-Based Practice Patient Contractures and Treatments to Reduce Future Contractures for At-Risk Patients PICO Question: Can the use of early correct positioning, range-of-motion (ROM) exercises, and mechanical treatment modalities such as dynamic and static splints reduce joint contractures in the lower extremities in patients with at-risk conditions compared with patients who do not have any early intervention? Evidence Summary Joint contractures are common preventable disorders that can result in significant long-term morbidity and reduced patient independence. Contracture is the shortening of the connective tissue and is an abnormal and possibly permanent condition characterized by decreased range of joint motion and/or fixation of the joint. Contractures occur following prolonged joint positioning (immobility), neurological disorders, and surgical joint manipulation (Furia et al., 2013). Evidence shows that early prevention of contractures is essential (Furia et al., 2013; Clavet et al., 2011). A systematic review of contracture reduction by Furia et al (2013) reported on the success of early intervention with splinting procedures. They noted that prompt use of splinting with prescribed range-of-motion exercises reduced contractures and improved active range of joint motion in affected lower extremities. Application to Nursing Practice • In conjunction with an interprofessional health care team, develop an early intervention protocol using prescribed positioning, range-of-motion exercises, and/or splints to reduce the risk for contracture formation (Furia et al., 2013). • Health care agencies need to provide equipment (e.g., splints) and appropriate education for staff to reduce the risk of contractures. • A collaborative plan of care, including a discharge plan, with a contracture prevention and muscle strengthening protocol must be developed on patient admission (Clavet et al., 2011). • Use positioning, ROM exercises, and ROM devices according to the individualized need of the patient and as ordered (Furia et al., 2013). ROM, Range of motion. One common and debilitating contracture is footdrop (Figure 28-3). When footdrop occurs, the foot is permanently fixed in plantar flexion. Ambulation is difficult with the foot in this position because the patient cannot dorsiflex the foot. A patient with footdrop is unable to lift the toes off the ground. Patients who have suffered CVAs with resulting right- or left-sided paralysis (hemiplegia) are at risk for footdrop. FIGURE 28-3Footdrop. Ankle is fixed in plantar flexion. Normally ankle is able to flex (dotted line), which eases walking.

Malnutrition

Pathophysiology Protein-energy malnutrition (PEM), also known as protein-calorie malnutrition (PCM), may present in three forms: marasmus, kwashiorkor, and marasmic-kwashiorkor. Marasmus is generally a calorie malnutrition in which body fat and protein are wasted. Serum proteins are often preserved. Kwashiorkor is a lack of protein quantity and quality in the presence of adequate calories. Body weight is more normal, and serum proteins are low. Marasmic-kwashiorkor is a combined protein and energy malnutrition. This problem often presents clinically when metabolic stress is imposed on a chronically starved patient. The outcome of unrecognized or untreated PEM is often dysfunction or disability and increased morbidity and mortality. Malnutrition (also called undernutrition) is a multinutrient problem because foods that are good sources of calories and protein are also good sources of other nutrients. In the malnourished patient, protein catabolism exceeds protein intake and synthesis, resulting in negative nitrogen balance, weight loss, decreased muscle mass, and weakness. The functions of the liver, heart, lungs, GI tract, and immune system decrease in the patient with malnutrition. A decrease in serum proteins (hypoproteinemia) occurs as protein synthesis in the liver decreases. Vital capacity is also reduced as a result of respiratory muscle atrophy. Cardiac output diminishes. Malabsorption occurs because of atrophy of GI mucosa and the loss of intestinal villi. Common complications of severe malnutrition in adults include: • Leanness and cachexia (muscle wasting with prolonged malnutrition) • Decreased activity tolerance • Lethargy • Intolerance to cold • Edema • Dry, flaking skin and various types of dermatitis • Poor wound healing • Infection, particularly postoperative infection and sepsis • Possible death Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently, particularly in older adults. Infectious diseases, such as tuberculosis and human immune deficiency virus (HIV) infection, can also cause PEM. Diseases that produce diarrhea and infections leading to anorexia result in negative calorie and protein balance. Anorexia then leads to poor food intake. Vomiting causes decreased intestinal absorption with increased nutrient losses. Medical treatments such as chemotherapy can also cause malnutrition. In addition, catabolic processes, such as that caused by prolonged immobility, increase nutrient requirements and metabolic losses. Inadequate nutrient intake can result also when a person is admitted to the hospital or long-term care facility. For example, decreased staffing may not allow time for patients who need to be fed, especially older adults, who may eat slowly. Many diagnostic tests, surgery, trauma, and unexpected medical complications require a period of NPO or cause anorexia (loss of appetite). In a systematic integrative review, Tappenden et al. (2013) reviewed strategies needed to address the needs of hospitalized patients to prevent or treat malnutrition (see the Evidence-Based Practice box). Evidence-Based Practice The Critical Role of Nutrition in Improving Quality of Care Tappenden, K.A., Quatrara, B., Parkhurst, M.L., Malone, A.M., Fanjiang, G., & Ziegler, T.R. (2013). Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition. MEDSURG Nursing, 22(3), 147-165. Health care costs have increased tremendously in the United States over the past decades. With substantial changes coming in health care policy that affect the way that health care is delivered, health care facilities will need to continue searching for ways to deliver the best care at the most reasonable cost. At least one third of patients come to the hospital in a state of malnourishment, and others become malnourished after admission. Therefore ways for addressing adult hospital malnutrition are very important for both quality of care and cost containment. The Alliance to Advance Patient Nutrition (Alliance) reflects combined efforts of the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the American Society for Parenteral and Enteral Nutrition (ASPEN), the Society of Hospital Medicine (SHM), and Abbott Nutrition to help achieve positive patient outcomes and support improving patient nutrition. The Alliance recommends a number of strategies for meeting these outcomes, such as: • Include nutrition as a component of all health care team member conversations and in conversation with patients and family members. • Provide thorough explanations about the patient's nutrition status, nutrition recommendations, nutrition interventions, and post-discharge nutrition care; document these interventions in the electronic health record. • Ensure that the patient and/or family member is given comprehensive follow-up nutrition assessment, education, and follow-up appointment recommendations at the time of discharge. • Provide comprehensive, clear, standardized written instructions for nutrition care at home. • Prioritize nutrition as part of self-management education, taking into consideration dietary intake, weight change, access to food, and other concerns that may affect nutrition status. Level of Evidence: 1 The clinical evidence presented was collected and presented as a result of a systematic integrative review conducted by numerous professional health care organizations. Commentary: Implications for Practice and Research Quality of care, cost implications, and recovery are of primary concern for all patients who are malnourished. Collaborative efforts among the health care team members can (1) provide a more consistent and reliable approach to addressing nutrition needs for hospitalized patients, (2) avoid overlapping charges that may arise from a lack of communication, and (3) create a best practice approach for teaching the patient and family about meeting nutrition needs at the time of discharge. Nurses who work directly with patients are in a key position to provide consistent, comprehensive nutrition education; this can result in better meeting the nutrition needs of patients who are hospitalized, as well as prepare them better for self-management upon discharge. Cultural Considerations Patient-Centered Care In some cases, malnutrition results when the provided meals are different from what the patient usually eats. Be sure to identify specific food preferences that the patient can eat and enjoy that are in keeping with his or her cultural practices. Considerations for Older Adults Patient-Centered Care Older adults in the community or in any health care setting are most at risk for poor nutrition, especially PEM. Risk factors include physiologic changes of aging, environmental factors, and health problems. Chart 60-2 lists some of these major factors. Chapter 2 discusses nutrition for older adults in more detail. Chart 60-2 Nursing Focus on the Older Adult Risk Assessment for Malnutrition Assess for: • Decreased appetite • Weight loss • Poor-fitting or no dentures/poor dental health • Poor eyesight • Dry mouth • Limited income • Lack of transportation • Inability to prepare meals because of functional decline or fatigue • Loneliness and/or depression • Chronic constipation (e.g., in patients with Alzheimer's disease) • Decreased meal enjoyment • Chronic physical illness • "Failure to thrive" (a combination of three of five symptoms, including weakness, slow walking speed, low physical activity, unintentional weight loss, exhaustion) • Prescription and over-the-counter (OTC) drugs (including herbs, vitamins, and minerals) • Acute or chronic pain Acute PEM may develop in patients who were adequately nourished before hospitalization but experience starvation while in a catabolic state from infection, stress, or injury. Chronic PEM can occur in those who have cancer, end-stage kidney or liver disease, or chronic neurologic disease. Eating disorders such as anorexia nervosa and bulimia nervosa, which are seen most often in teens and young adults, also lead to malnutrition. Anorexia nervosa is a self-induced starvation resulting from a fear of fatness, even though the patient is underweight. Bulimia nervosa is characterized by episodes of binge eating in which the patient ingests a large amount of food in a short time. The binge eating is followed by some form of purging behavior, such as self-induced vomiting or excessive use of laxatives and diuretics. If not treated, death can result from starvation, infection, or suicide. Information about eating disorders can be found in textbooks on mental/behavioral health nursing. Patient-Centered Collaborative Care Assessment History. Review the medical history to determine the possibility of increased metabolic needs or nutrition losses, chronic disease, trauma, recent surgery of the GI tract, drug and alcohol use, and recent significant weight loss. Each of these conditions can contribute to malnutrition. For older adults, explore mental status changes and note poor eyesight, diseases affecting major organs, constipation or incontinence, and slowed reactions. Review prescription and over-the-counter (OTC) drugs, including vitamin, mineral, herbal, and other nutrition supplements. For patients who live independently in the community, the nurse may assess their performance of instrumental activities of daily living (IADLs). Functional status can best be evaluated for institutionalized patients by assessing their ADL performance. Poor nutrition is a major contributing factor to decreased functional ability. In collaboration with the dietitian, obtain information about the patient's usual daily food intake, eating behaviors, change in appetite, and recent weight changes. If the patient is able to communicate, ask him or her to describe the usual foods eaten daily, cultural food preferences, and the times of meals and snacks. If available, ask the family these questions if the patient cannot communicate. If the patient cannot understand the questions due to language differences, locate an interpreter to assist with communication. The dietitian can more thoroughly analyze the diet, if necessary, based on your initial nutrition screening. Ask about changes in eating habits as a result of illness, and document any change in appetite, taste, and weight loss. A weight loss of 5% or more in 30 days, a weight loss of 10% in 6 months, or a weight that is below ideal may indicate malnutrition. Nursing Safety Priority Action Alert When assessing for malnutrition, assess for difficulty or pain in chewing or swallowing. Unrecognized dysphagia is a common problem among nursing home residents and can cause malnutrition, dehydration, and aspiration pneumonia. Ask the patient whether any foods are avoided and why. Ask UAP to report any choking while the patient eats. Record the occurrence of nausea, vomiting, heartburn, or any other symptoms of discomfort with eating. Ask the patient about dental health problems, including the presence of dentures. Dentures or partial plates that do not fit well interfere with food intake. Dental caries (decay) or missing teeth may also cause discomfort while eating. Physical Assessment/Clinical Manifestations. Assess for manifestations of various nutrient deficiencies (Table 60-2). Inspect the patient's hair, eyes, oral cavity, nails, and musculoskeletal and neurologic systems. Examine the condition of the skin, including any reddened or open areas. Anthropometric measurements may also be obtained as described on p. 1234. The nurse or UAP monitors all food and fluid intake and notes any mouth pain or difficulty in chewing or swallowing. A 3-day caloric intake may be collected and then calculated by the dietitian. TABLE 60-2 -- Manifestations of Nutrient Deficiencies SIGN/SYMPTOMPOTENTIAL NUTRIENT DEFICIENCYHairAlopeciaZincEasy to removeProteinLackluster hairProtein"Corkscrew" hairVitamin CDecreased pigmentationProteinEyesXerosis of conjunctivaVitamin ACorneal vascularizationRiboflavinKeratomalaciaVitamin ABitot's spotsVitamin AGastrointestinal TractNausea, vomitingPyridoxineDiarrheaZinc, niacinStomatitisPyridoxine, riboflavin, ironCheilosisPyridoxine, ironGlossitisPyridoxine, zinc, niacin, folic acid, vitamin B12Magenta tongueVitamin A, riboflavinSwollen, bleeding gumsVitamin CFissured tongueNiacinHepatomegalyProteinSkinDry and scalingVitamin APetechiae/ecchymosesVitamin CFollicular hyperkeratosisVitamin ANasolabial seborrheaNiacinBilateral dermatitisNiacinExtremitiesSubcutaneous fat lossCaloriesMuscle wastageCalories, proteinEdemaProteinOsteomalacia, bone pain, ricketsVitamin DHematologicAnemiaVitamin B12, iron, folic acid, copper, vitamin ELeukopenia, neutropeniaCopperLow prothrombin time, prolonged clotting timeVitamin K, manganeseNeurologicDisorientationNiacin, thiamineConfabulationThiamineNeuropathyThiamine, pyridoxine, chromiumParesthesiaThiamine, pyridoxine, vitamin B12CardiovascularCongestive heart failure, cardiomegaly, tachycardiaThiamineCardiomyopathySeleniumCardiac dysrhythmiasMagnesium Courtesy of Ross Products Division, Abbott Laboratories, Columbus, OH. Psychosocial Assessment. The psychosocial history provides information about the patient's economic status, occupation, educational level, gender orientation, ethnicity/race, living and cooking arrangements, and mental status. Determine whether financial resources are adequate for providing the necessary food. If resources are inadequate, the social worker or case manager may refer the patient and family to available community services. Chapter 2 discusses nutrition in older adults in more detail. Laboratory Assessment. Laboratory tests supply objective data that can support subjective data and identify deficiencies. Interpret laboratory data carefully with regard to the total patient; focusing on an isolated value may yield an inaccurate conclusion. A low hemoglobin level may indicate anemia, recent hemorrhage, or hemodilution caused by fluid retention. Hemoglobin may also be decreased secondary to conditions such as low serum albumin, infection, catabolism, or chronic disease. High levels may indicate hemoconcentration or dehydration or may be found secondary to liver disease. Low hematocrit levels may reflect anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis. High hematocrit levels may indicate dehydration or hemoconcentration. Serum albumin, thyroxine-binding prealbumin, and transferrin are measures of visceral proteins. Serum albumin is a plasma protein that reflects the nutrition status of the patient a few weeks before testing; therefore it is not considered to be a sensitive test. Patients who are dehydrated often have high levels of albumin, and those with fluid excess have a lowered value. The normal serum albumin level for men and women is 3.5 to 5.0 g/dL or 35 to 50 g/L (SI units) ( Pagana & Pagana, 2014). Thyroxine-binding prealbumin (PAB) is a plasma protein that provides a more sensitive indicator of nutrition deficiency because of its short half-life of 2 days. Depending on the laboratory test used, the normal PAB range is 15 to 36 mg/dL or 150 to 360 mg/L (SI units) ( Pagana & Pagana, 2014). Although not used as commonly, serum transferrin, an iron-transport protein, can be measured directly or calculated as an indirect measurement of total iron-binding capacity (TIBC). It has a short half-life of 8 to 10 days and therefore is also a more sensitive indicator of protein status than albumin. Cholesterol levels normally range between 160 and 200 mg/dL in adult men and women. Values are typically low with malabsorption, liver disease, pernicious anemia, end-stage cancer, or sepsis. A cholesterol level below 160 mg/dL has been identified as a possible indicator of malnutrition. Cholesterol testing is discussed in more detail in Chapter 36. Total lymphocyte count (TLC) can be used to assess immune function. Malnutrition suppresses the immune system and leaves the patient more likely to get an infection. When a patient is malnourished, the TLC is usually decreased to below 1500/mm3. Analysis The priority problem for the patient with malnutrition is Imbalanced Nutrition: Less Than Body Requirements related to inability to ingest or digest food or absorb nutrients (NANDA-I). Planning and Implementation Improving Nutrition Planning: Expected Outcomes. The patient with malnutrition is expected to have nutrients available to meet his or her metabolic needs as evidenced by normal serum proteins and adequate hydration. Interventions. The preferred route for food intake is through the GI tract because it enhances the immune system and is safer, easier, less expensive, and more enjoyable. Meal Management. The dietitian calculates the nutrients required daily and plans the patient's diet. In collaboration with the health care provider and dietitian, provide high-calorie, nutrient-rich foods (e.g., milkshakes, cheese, supplement drinks like Boost or Ensure). Assess the patient's food likes and dislikes. A feeding schedule of six small meals may be tolerated better than three large ones. A pureed or dental soft diet may be easier for those who have problems chewing or are edentulous (toothless). Nursing Safety Priority Action Alert Malnourished ill patients often need to be encouraged to eat. Instruct UAP who are feeding patients to keep food at the appropriate temperature and to provide mouth care before feeding. Assess for other needs, such as pain management, and provide interventions to make the patient comfortable. Pain can prevent patients from enjoying their meals. Remove bedpans, urinals, and emesis basins from sight. Provide a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. Appropriate time should be taken so that the patient does not feel rushed through a meal. Considerations for Older Adults Patient-Centered Care Some patients, especially older adults, may take a long time to eat even small quantities of food because they tend to be less hungry than younger adults. If available, suggest that family members bring in favorite or ethnic foods that the patient might be more likely to eat. Teach them about ways to encourage the patient to increase food intake. Chart 60-3 describes additional interventions to promote food intake in older adults. Restorative feeding programs help nursing home residents who need special assistance. These residents often eat in a separate dining area so that time and attention can be given to them. Some nursing homes have designated food and nutrition nursing assistants and/or trained volunteers who are primarily responsible for promoting and maintaining nutrition and hydration. Delegate appropriate feeding tasks, and supervise these UAPs during resident mealtime. Chart 60-3 Nursing Focus on the Older Adult Promoting Nutrition Intake • Be sure that patient is toileted and receives mouth care before mealtime. • Be sure that patient has glasses and hearing aids in place, if appropriate, during meals. • Be sure that bedpans, urinals, and emesis basins are removed from sight. • Give analgesics to control pain and/or antiemetics for nausea at least 1 hour before mealtime. • Remind unlicensed assistive personnel (UAP) to have patient sit in chair, if possible, at mealtime. • If needed, open cartons and packages and cut up food at the patient's and/or family's request. • Observe the patient during meals for food intake. • Ask the patient about food likes and dislikes and ethnic food preferences. • Encourage self-feeding, or feed the patient slowly; delegate this activity to UAP if desired. • If feeding patient, sit at eye-level if culturally appropriate. • Create an environment that is conducive to eating and socialization and relaxation, if possible. • Decrease distractions, such as environmental noise from television, music, or other people. • Provide adequate, nonglaring lighting. • Keep patient away from offensive or medicinal odors. • Keep eye contact with the patient during the meal if culturally appropriate. • Serve snacks with activities, especially in long-term care settings; delegate this activity to UAP if desired. • Document the percentage of food eaten at each meal and snack; delegate this activity to UAP if appropriate. • Ensure that meals are visually appealing, appetizing, appropriately warm or cold, and properly prepared. • Do not interrupt patients during mealtimes for nonurgent procedures or rounds. • Assess for need for supplements between meals and at bedtime. • Review the patient's drug profile, and discuss with the health care provider the use of drugs that might be suppressing appetite. • If the patient is depressed, be sure that the depression is treated by the health care provider. Nutrition Supplements. If the patient cannot take in enough nutrients in food, fortified medical nutrition supplements (MNSs) (e.g., Ensure, Sustacal, Carnation Instant Breakfast [also available as lactose-free supplement]) may be given, especially to older adults. Many commercial enteral products are available. For patients with medical diagnoses such as liver and renal disease or diabetes, special products that meet those needs are available (e.g., Glucerna for diabetic patients). Nutrition supplements used in acute care, long-term care, and home care can be costly. In addition, patients may refuse them and the supplements are then wasted. In a classic study, Bender et al. (2000) found that a more successful alternative to having the MNS given by nursing assistant staff in the nursing home was to have the supplements delivered by nurses during their usual medication passes. In this study, the nurses gave 60 mL or more of the MNS at least 4 times a day with the residents' medications. As a result, the patients gained weight and had fewer pressure ulcers, thus making the program very cost-effective and providing positive clinical outcomes. Nutrition supplements are supplied as liquid formulas, powders, soups, coffee, and puddings in a variety of flavors. They come in different degrees of sweetness and are also available as modular supplements that provide single nutrients. Examples of modular supplements are Polycose glucose polymers for carbohydrates and Resource Beneprotein for protein, both available in liquid and powder form. Carbohydrate modulars are useful only if additional calories are needed. Protein modulars are indicated when metabolic stress causes a need for higher protein intake. The dietitian may ask the nursing staff to keep a food and fluid intake record for at least 3 consecutive days to help assess the patient's nutrition status. Delegate this activity to UAP under your supervision. UAP also weigh the patient daily, every 3 days, or once a week, depending on the health care setting and severity of malnutrition. Drug Therapy. Multivitamins, zinc, and an iron preparation are often prescribed to treat or prevent anemia. Monitor the patient's hemoglobin and hematocrit levels. Drug therapy can affect nutrition and elimination. For example, iron can cause constipation and zinc can cause nausea and vomiting. If the patient still does not receive enough nutrition by mouth using the interventions just mentioned, request nutrition therapy in the form of specialized nutrition support (SNS). SNS consists of either total enteral nutrition (TEN) or total parenteral nutrition (TPN). Total Enteral Nutrition. Patients often cannot meet the desired outcomes of adequate nutrition via their usual oral intake because of increased metabolic demands or a decreased ability to eat. Therefore TEN using enteral tube feeding may be necessary to supplement oral intake or to provide total nutrition. Patients likely to receive TEN can be divided into three groups: • Those who can eat but cannot maintain adequate nutrition by oral intake of food alone • Those who have permanent neuromuscular impairment and cannot swallow • Those who do not have permanent neuromuscular impairment but cannot eat because of their condition Patients in the first group are often older adults or patients receiving cancer treatment who cannot meet their calorie and protein needs. In some cases, this artificial nutrition and hydration may not be desired. For example, some patients have advance directives stating that they do not want to be kept alive by artificial nutrition and hydration if certain conditions exist. However, legal and ethical questions arise when patients are not able to make their wishes known! For many years it was believed that withholding food and fluids would cause discomfort. Terminally or chronically ill patients who do not eat and drink may not suffer. In fact, they may be more comfortable if food and fluids are withheld. The decision to feed is complex, and there is no clear right or wrong answer. To compound this legal and ethical dilemma, medical complications (e.g., aspiration, pressure ulcers) are common in older adults who are tube-fed. Decisions about these dilemmas are aided by the advice of interdisciplinary ethics committees in health care facilities. When clinicians are making decisions about the desirability of tube feedings in these cases, the focus should be on achieving consensus by: • Reviewing what is known about tube feedings, especially their risks and benefits • Reviewing the medical facts about the patient • Investigating any available evidence that would help understand the patient's wishes • Obtaining the opinions of all stakeholders in the situation • Delaying any action until consensus is achieved Those in the second group of patients likely to receive TEN usually have permanent swallowing problems and require some type of feeding tube for delivery of the enteral product on a long-term basis. Examples of conditions that can cause permanent swallowing problems are strokes, severe head trauma, and advanced multiple sclerosis. Patients in the third group receive enteral nutrition for as long as their illness lasts. The feeding is discontinued when the patient's condition improves and he or she can eat again. TEN is contraindicated for patients in states of significant hemodynamic compromise, such as those with diffuse peritonitis, severe acute or chronic pancreatitis, intestinal obstruction, intractable vomiting or diarrhea, and paralytic ileus ( Bankhead et al., 2009). Many commercially prepared enteral products are available. A therapeutic combination of carbohydrates, fat, vitamins, minerals, and trace elements is available in liquid form. Differences among products allow the dietitian to select the right formula for each patient. A prescription from the health care provider is required for enteral nutrition, but the dietitian usually makes the recommendation and computes the amount and type of product needed for each patient. NCLEX Examination Challenge Health Promotion and Maintenance An older client tells the nurse that he does not have an appetite. His wife states that he refuses to eat the food she cooks. What instructions will the nurse provide for the client and wife? Select all that apply. A. "Place the fork in his hand and leave the room." B. "As long as you drink fluids, you do not need food." C. "Let him choose what foods he might desire." D. "Eat meals together, to make mealtime feel special." E. "Take your time eating, and do not rush through meals." F. "Use nutrition supplements such as Ensure throughout the day." Methods of Administering Total Enteral Nutrition. TEN is administered as "tube feedings" through one of the available GI tubes, either through a nasoenteric or enterostomal tube. It can be used in the patient's home or any health care setting. A nasoenteric tube (NET) is any feeding tube inserted nasally and then advanced into the GI tract, such as a Keofeed, Entriflex, or Dobbhoff tube. Commonly used NETs include the nasogastric (NG) tube and the smaller (small-bore) nasoduodenal tube (NDT) (Fig. 60-3, A). A nasojejunal tube (NJT) is also available but is used less often than the other NETs. FIG. 60-3Feeding tubes used for total enteral nutrition. A, Nasoduodenal tube. B and C, Gastrostomy tubes. The NDTs are used for delivering short-term enteral feedings (usually less than 4 weeks) because they are easy to use and are safer for the patient at risk for aspiration if the tip of the tube is placed below the pyloric sphincter of the stomach and into the duodenum. Small-bore polyurethane or silicone tubes from 8 to 12 Fr external diameter are preferred. The smaller tubes are more comfortable and are less likely to cause complications such as nasal irritation, sinusitis, tissue erosion, and pulmonary compromise. Enterostomal feeding tubes are used for patients who need long-term enteral feeding. The most common types are gastrostomies and jejunostomies. The surgeon directly accesses the GI tract using various surgical, endoscopic, and laparoscopic techniques. A gastrostomy is a stoma created from the abdominal wall into the stomach, through which a short feeding tube is inserted by the surgeon. It may require a small abdominal incision or may be placed endoscopically. This tube is called a percutaneous endoscopic gastrostomy (PEG) or dual-access gastrostomy-jejunostomy (PEG/J) tube. The PEG requires monitored conscious sedation for placement and is secure and durable. An alternative to either device is the low-profile gastrostomy device (LPGD) (Fig. 60-3, B and C). The LPGD is available with a firm or balloon-style internal bumper or retention disk. An anti-reflux valve keeps GI contents from leaking onto the skin. This device is less irritating to the skin, longer lasting, and more cosmetically pleasing. It also allows greater patient independence. However, skin-level devices do not allow easy access for checking residuals (the amount of feeding that remains in the stomach). Jejunostomies are used less often than gastrostomies. A jejunostomy is used for long-term feedings when it is desirable to bypass the stomach, such as with gastric disease, upper GI obstruction, and abnormal gastric or duodenal emptying. Tube feedings are administered by bolus feeding, continuous feeding, and cyclic feeding. Bolus feeding is an intermittent feeding of a specified amount of enteral product at set intervals during a 24-hour period, typically every 4 hours. This method can be accomplished manually or by infusion through a mechanical pump or controller device. Another method of tube feeding is continuous enteral feeding. Continuous feeding is similar to IV therapy in that small amounts are continuously infused (by gravity drip or by a pump or controller device) over a specified time. The most commonly seen method, cyclic feeding, is the same as continuous feeding except the infusion is stopped for a specified time in each 24-hour period, usually 6 hours or longer ("down time"). Down time typically occurs in the morning to allow bathing, treatments, and other activities. Infusion rates for cyclic feedings (and to some extent for intermittent bolus feeding) vary with the total amount of solution to be infused, the specific composition of the product, and the response of the patient to the feeding. The health care provider and dietitian usually decide the type, rate, and method of tube feeding, as well as the amount of additional water ("free water") needed. If the patient can swallow small amounts of food, he or she may also eat orally while the tube is in place. The nurse is responsible for the care and maintenance of the feeding tube and the enteral feeding. Chart 60-4 lists best practices for the patient receiving TEN. Chart 60-4 Best Practice for Patient Safety & Quality Care Tube Feeding Care and Maintenance • If nasogastric or nasoduodenal feeding is prescribed, use a soft, flexible, small-bore feeding tube (smaller than 12 Fr). The initial placement of the tube should be confirmed by x-ray study. Secure the tube with tape or a commercial attachment device after applying a skin protectant; change the tape regularly. • Check tube placement by x-ray study when the correct position of the tube is in question; an x-ray study is the most reliable method. • Per The Joint Commission's National Patient Safety Goals, if a gastrostomy or jejunostomy tube is used, assess the insertion site for signs of infection or excoriation (e.g., excessive redness, drainage). Rotate the tube 360 degrees each day, and check for in-and-out play of aboutinch (0.6 cm). If the tube cannot be moved, notify the health care provider immediately because the retention disk may be embedded in the tissue. Cover the site with a dry, sterile dressing, and change the dressing at least once a day. • Check and record the residual volume every 4 to 6 hours or per facility policy by aspirating stomach contents into a syringe. If residual feeding is obtained, check with the health care provider for the appropriate intervention (usually to slow or stop the feeding for a time) or use the American Society of Parenteral and Enteral Nutrition (ASPEN) best practice recommendations. • Check the feeding pump to ensure proper mechanical operation. • Ensure that the enteral product is infused at the prescribed rate (mL/hr). • Change the feeding bag and tubing every 24 to 48 hours; label the bag with the date and time of the change with your initials. Use an irrigation set for no more than 24 hours. • For continuous or cyclic feeding, add only 4 hours of product to the bag at a time to prevent bacterial growth. A closed system is preferred, and each set should be used no longer than 24 hours. • Wear clean gloves when changing or opening the feeding system or adding product; wipe the lid of the formula can with clean gauze; wear sterile gloves for critically ill or immunocompromised patients. • Label open cans with date and time opened; cover, and keep refrigerated. Discard any unused open cans after 24 hours. • Do not use blue (or any color) food dye in formula because it does not assess aspiration and can cause serious complications. • To prevent aspiration, keep the head of the bed elevated at least 30 degrees during the feeding and for at least 1 hour after the feeding for bolus feeding; continuously maintain semi-Fowler's position for patients receiving cyclic or continuous feeding. • Monitor laboratory values, especially blood urea nitrogen (BUN), serum electrolytes, hematocrit, prealbumin, and glucose. • Monitor for complications of tube feeding, especially diarrhea. • Monitor and carefully record the patient's weight and intake and output as requested by the physician or dietitian. Complications of Total Enteral Nutrition. The nursing priority for care is patient safety, including preventing, assessing, and managing complications associated with tube feeding. Some complications of therapy result from the type of tube used to administer the feeding, and others result from the enteral product itself. The most common problem is the development of an obstructed ("clogged") tube. Use the tips in Chart 60-5 to maintain tube patency. Chart 60-5 Best Practice for Patient Safety & Quality Care Maintaining a Patent Feeding Tube • Flush the tube with 20 to 30 mL of water (or the amount prescribed by the health care provider or dietitian): ▪ At least every 4 hours during a continuous tube feeding ▪ Before and after each intermittent tube feeding ▪ Before and after drug administration (use warm water) ▪ After checking residual volume • If the tube becomes clogged, use 30 mL of water for flushing, applying gentle pressure with a 50-mL piston syringe. • Avoid the use of carbonated beverage, except for existing clogs when water is not effective. Do not use cranberry juice. • Whenever possible, use liquid medications instead of crushed tablets unless liquid forms cause diarrhea; make sure that the drug is compatible with the feeding solution. • Do not mix drugs with the feeding product before giving. Crush tablets as finely as possible, and dissolve in warm water. (Check to see which tablets are safe to crush. For example, do not crush slow-acting [SA] or slow-release [SR] drugs.) • Consider use of automatic flush feeding pump such as Flexiflo or Kangaroo. Patients receiving TEN are at risk for several other complications, including refeeding syndrome, tube misplacement and dislodgement, abdominal distention and nausea/vomiting, and fluid and electrolyte imbalance, often associated with diarrhea. These problems can be prevented if the patient is carefully monitored and complications are detected early. Refeeding Syndrome. Refeeding syndrome is a potentially life-threatening metabolic complication that can occur when nutrition is restarted for a patient who is in a starvation state. When a patient is starved for nutrition, the body breaks down fat and protein, rather than carbohydrates, for energy. Protein catabolism leads to muscle and cell loss, often in major organs like the heart, liver, and lungs. The body's cells lose valuable electrolytes, including potassium and phosphate, into the plasma. Insulin secretion decreases in response to these changes. When refeeding begins, insulin production resumes and the cells take up glucose and electrolytes from the bloodstream, thus depleting serum levels. Nursing Safety Priority Critical Rescue The electrolyte shift of refeeding syndrome can cause cardiovascular, respiratory, and neurologic problems, primarily as a result of hypophosphatemia, according to a classic study by Mehanna et al. (2008). Observe for clinical manifestations of this electrolyte imbalance, including shallow respirations, weakness, acute confusion, seizures, and increased bleeding tendency. Report and document your findings immediately. More information on fluid and electrolyte imbalance can be found in Chapter 11. Refeeding syndrome can be prevented if patients are carefully assessed and managed for nutrition needs. Interventions to supplement or replace nutrition should be implemented early before the patient is in a starvation state. Patients receiving parenteral nutrition (described on pp. 1244-1245 later in this chapter) also may experience refeeding syndrome. Tube Misplacement and Dislodgement. A serious complication is misplacement or dislodgement of the tube, which can cause aspiration and possible death. Immediately remove any tube that you suspect is dislodged! The Joint Commission's National Patient Safety Goals and the Centers for Medicare and Medicaid Services require all health care facilities to establish and implement procedures and systems to prevent patient harm from medical complications. Several techniques should be used to confirm proper placement to prevent harm and to keep the patient safe. An x-ray is the most accurate confirmation method and should always be done upon initial tube insertion. After the initial placement is confirmed, check the placement before each intermittent feeding or at least every 4 to 8 hours during feeding. Also check placement before each drug administration. The traditional auscultatory method for checking tube placement may not be reliable, especially for patients with small-bore tubes. In this method, the nurse instills 20 to 30 mL of air into the tube ("insufflation") while listening over the epigastric area (stomach) with a stethoscope. The resulting "whooshing" sound does not guarantee correct tube placement! Although some patients have respiratory distress if the tube is misplaced into the lungs, others do not. Therefore better methods for ensuring patient safety are being researched. Several safer procedures have been recommended for checking tube placement after the initial placement has been confirmed by x-ray. These methods include: • Testing aspirated contents for pH, bilirubin, trypsin, or pepsin • Assessing for carbon dioxide using capnometry Some hospitals and nursing homes support testing the pH of GI contents at the bedside. To perform this procedure, aspirate a sample of the GI content, observe its color, and test its pH. When aspirating fluid, wait at least 1 hour after drug administration and then flush the tube with 20 mL of air to clear it. Collect the aspirate, and test it with pH paper. The pH of gastric fluid ranges from 0 to 4.0. If the tube has moved down into the intestines, the pH will be between 7.0 and 8.0. If the tube is in the lungs, the pH will be greater than 6.0. The pH may also be as high as 6 if the patient takes certain drugs, such as H2 blockers (e.g., ranitidine [Zantac] and famotidine [Pepcid]). Because these drugs affect pH, bilirubin testing or capnometry may be more reliable and valid methods for predicting tube location. Capnometry can determine if carbon dioxide is emitted from the tube ( Grmec et al., 2011). A device to measure the presence of the gas is attached to the end of the tube after placement. The test is positive for carbon dioxide if the tube is placed into the lungs, rather than the stomach. The tube should be immediately removed if the gas is detected. Nursing Safety Priority Action Alert If enteral tubes are misplaced or become dislodged, the patient is likely to aspirate. Aspiration pneumonia is a life-threatening complication associated with TEN, especially for older adults. Observe for increasing temperature and pulse, as well as for other signs of dehydration such as dry mucous membranes and decreased urinary output. Auscultate lungs every 4 to 8 hours to check for diminishing breath sounds, especially in lower lobes. Patients may become short of breath and report chest discomfort. A chest x-ray confirms this diagnosis, and treatment with antibiotics is started. Abdominal Distention and Nausea/Vomiting. Abdominal distention, nausea, and vomiting during tube feeding are often caused by overfeeding. To prevent overfeeding, check gastric residual volumes every 4 to 6 hours, depending on facility policy and the needs of the patient. The American Society of Parenteral and Enteral Nutrition (ASPEN) (2011) recommends holding a feeding if the gastric residual volumes are more than 200 mL on two consecutive assessments. In some facilities, feedings are temporarily held if the gastric residual is 100 mL or more, depending on the patient. After a period of rest, the feeding can be restarted at a lower flow rate. A problem with frequent residual assessments is that the formula may clog the tube during aspiration, even if flushed with water. If the patient's residual volumes have been low or zero and he or she has no abdominal distention, nausea, or vomiting, consider discontinuing these assessments, depending on facility policy. Fluid and Electrolyte Imbalances. Patients receiving enteral nutrition therapy are at an increased risk for fluid imbalances. They are often older or debilitated and may also have cardiac or renal problems. Fluid imbalances associated with enteral nutrition are usually related to the body's response to increased serum osmolarity, but fluid overload from too much tube feeding can also occur. Osmolarity is the amount or concentration of particles dissolved in solution. This concentration exerts a specific osmotic pressure within the solution. Normal osmolarity of extracellular fluid (ECF) ranges between 270 and 300 mOsm. Enteral feeding products range in osmolarity from isotonic (about 300 mOsm) to extremely hypertonic (600 mOsm). Electrolytes (including sodium) contribute to this hypertonicity, but more of the osmolarity is determined by the concentration of proteins and sugar molecules in the enteral product. Even when the product is isotonic, the ECF can become hyperosmolar unless some hypotonic fluids are also administered to the patient. This situation is most likely to develop in patients who are unconscious, unable to respond to the thirst reflex, on fluid restrictions, or receiving hyperosmotic enteral preparations. Because increased plasma osmolarity is largely a result of extra glucose and proteins (which tend to remain in the plasma rather than move to interstitial spaces), the plasma osmotic pressure (water-pulling pressure) is increased. In this situation, intracellular and interstitial water move into and expand the plasma volume. This volume expansion results in an increased renal excretion of water (in patients with normal renal function) and leads to osmotic dehydration. Considerations for Older Adults Patient-Centered Care If patients do not have normal renal and cardiac function, expansion of the plasma volume can lead to circulatory overload and pulmonary edema, especially in older adults. Therefore early identification of patients at risk for impairment of renal and/or cardiac function is important. Assess for signs and symptoms of circulatory overload, such as peripheral edema, sudden weight gain, crackles, dyspnea, increased blood pressure, and bounding pulse. Collaborate with the dietitian and health care provider to plan the correct amount of fluid to be provided. Excessive diarrhea may develop when hyperosmolar enteral preparations are delivered quickly. This situation can also lead to dehydration through excessive water loss. Collaborate with the health care provider and dietitian for recommendations to prevent diarrhea. The dietitian usually changes the feeding to a more iso-osmolar formula. Most of these formulas can be started full strength but slowly at 15 to 20 mL/hr. The rate is gradually increased as the patient tolerates and as the expected nutrition outcome is achieved. If diarrhea continues, especially if it has a very foul odor, evaluate the patient for Clostridium difficile or other infectious organisms. Contamination can occur because of repeated and often faulty handling of the feeding solution and system. Per The Joint Commission's National Patient Safety Goals, wear clean gloves when changing systems and adding product. Sterile gloves may help prevent infection in critically ill or immunocompromised patients. A closed feeding system is preferred over an open one because the chance of contamination is lessened (see Chart 60-4). Tubes with ports also minimize contamination by eliminating the need to open the feeding system to administer drugs. In some cases, diarrhea may be the result of multiple liquid medications, such as elixirs and suspensions that have a very high osmolarity. Examples include acetaminophen (Tylenol), furosemide (Lasix), and phenytoin (Dilantin). Patients receiving multiple liquid drugs should be evaluated by the health care provider to determine whether their drug regimen can be changed to prevent diarrhea. Diluting these liquids may also be an option. Depending on the patient's state of health, some electrolyte imbalances can be avoided. This is achieved by the use of enteral preparations containing lower concentrations of the electrolytes that the patient cannot handle well. For example, renal patients with high potassium levels receive a special formula that is used for this imbalance. The two most common electrolyte imbalances associated with enteral nutrition therapy are hyperkalemia and hyponatremia. Both of these conditions may be related to hyperglycemia-induced hyperosmolarity of the plasma and the resultant osmotic diuresis. Risk for disturbances in fluid and electrolyte balance are discussed in detail in Chapter 11. Parenteral Nutrition. When a patient cannot effectively use the GI tract for nutrition, either partial or total parenteral nutrition therapy may be needed. This form of IV therapy differs from standard IV therapy in that any or all nutrients (carbohydrates, proteins, fats, vitamins, minerals, and trace elements) can be given. One liter of IV fluid containing 5% dextrose, which is often used as standard therapy, provides only 170 kcal. A hospitalized patient typically receives 3 to 4 L a day, for a total number of calories ranging between 500 and 700 a day. This calorie intake is not sufficient when the patient requires IV therapy for a prolonged period and cannot eat an adequate diet or has increased calorie needs for tissue repair and building. Partial Parenteral Nutrition. Partial, or peripheral, parenteral nutrition (PPN) is usually given through a cannula or catheter in a large distal vein of the arm or through a peripherally inserted central catheter (PICC line). (See Chapter 13 for care of patients with PICC lines.) The alternative is used for some patients who can eat but are not able to take in enough nutrients to meet their needs. The patient must have adequate peripheral vein access and be able to tolerate large volumes of fluid to have PPN. Two types of solutions are commonly used in various combinations for PPN: IV fat (lipid) emulsions (IVFEs) and amino acid-dextrose solutions. IVFEs are usually given using a piggyback method. Nursing Safety Priority Critical Rescue For patients receiving fat emulsions, monitor for manifestations of fat overload syndrome, especially in those who are critically ill. These manifestations include fever, increased triglycerides, clotting problems, and multi-system organ failure. Discontinue the IVFE infusion and report any of these changes to the health care provider immediately if this complication is suspected. Most IVFEs (20% fat emulsion) are isotonic, but the tonicity of commercially prepared amino acid-dextrose solutions ranges from 300 mOsm to nearly 900 mOsm for PPN. Amino acid-dextrose solutions are considered more stable than IVFEs, and therefore additives (e.g., vitamins, minerals, electrolytes, trace elements) tend to be mixed with them. These solutions must be delivered through an in-line filter and are administered by an infusion pump for an accurate and constant delivery rate. Some PPN products are a mixture of lipids (10% or 20% fat emulsion) and an amino acid-dextrose (usually 10%) solution. This mixture of three types of nutrients is referred to as a 3 : 1, total nutrient admixture (TNA), or triple-mix solution. Total Parenteral Nutrition. When the patient requires intensive nutrition support for an extended time, the health care provider prescribes centrally administered total parenteral nutrition (TPN). TPN is delivered through access to central veins, usually through a PICC line or the subclavian or internal jugular veins. Central venous catheters and associated nursing care are described in detail in Chapter 13. Total parenteral nutrition solutions contain higher concentrations of dextrose and proteins, usually in the form of synthetic amino acids or protein hydrolysates (3% to 5%). These solutions are hyperosmotic (3 to 6 times the osmolarity of normal blood). The base solutions are available as commercially prepared solutions. The hospital or community pharmacist adds components (specific electrolytes, minerals, trace elements, and insulin) according to the patient's nutrition needs. This therapy provides needed calories and spares body proteins from catabolism for energy requirements. The TPN solutions are administered with an infusion pump. The osmolarity of the fluid and the concentrations of the specific components make controlled delivery essential. Patients receiving parenteral nutrition fluids are at risk for a wide variety of serious and potentially life-threatening complications. Complications may result from the solutions or from the peripheral or central venous catheter. The following discussion is limited to the complications that involve fluid and electrolyte balance. Complications of IV cannulas and central venous catheters are discussed in Chapter 13, including infection and sepsis. Patients receiving parenteral nutrition therapy are at high risk for fluid imbalance. Not only is fluid delivered directly into the venous system but also the extreme hyperosmolarity of the solutions stimulates fluid shifts between body fluid compartments. The hyperosmolarity is caused by their amino acid and dextrose concentrations. Increased dextrose causes hyperglycemia (increased blood glucose). As a result, some of the dextrose moves into the interstitial and intracellular spaces, where it is metabolized. However, dextrose remains in the plasma volume when the solutions are administered too rapidly, without enough insulin coverage, or in the presence of hyponatremia and hypokalemia. The result is a shift of water from the interstitial and intracellular spaces into the plasma. Expansion of the plasma volume together with hyperglycemia can cause osmotic diuresis and lead to serious dehydration and hypovolemic shock. If the patient also has cardiac or renal dysfunction, he or she may develop fluid overload, congestive heart failure, and pulmonary edema. Monitor the infusion rate of the parenteral fluid, and give insulin as prescribed. Monitor for these complications by taking daily weights and by documenting accurate intake and output while the patient is receiving parenteral nutrition. Serum glucose and electrolyte values are also monitored (Chart 60-6). Report any major changes or abnormalities to the health care provider, and document all assessments and interventions. Chart 60-6 Best Practice for Patient Safety & Quality Care Care and Maintenance of Total Parenteral Nutrition • Check each bag of total parenteral nutrition (TPN) solution for accuracy by comparing it with the physician's or pharmacist's prescription. • Monitor the IV pump for accuracy in delivering the prescribed hourly rate. • If the TPN solution is temporarily unavailable, give 10% dextrose/water (D10W) or 20% dextrose/water (D20W) until the TPN solution can be obtained. • If the TPN administration is not on time ("behind"), do not attempt to "catch up" by increasing the rate. • Monitor the patient's weight daily or according to facility protocol. • Monitor serum electrolytes and glucose daily or per facility protocol. (Many facilities require finger-stick blood sugars [FSBSs] every 4 hours, especially if the patient is receiving insulin. Urine testing for ketones may also be requested.) • Monitor for, report, and document complications, including fluid and electrolyte imbalances. • Monitor and carefully record the patient's intake and output. • Assess the patient's IV site for signs of infection or infiltration (see Chapter 13). • Change the IV tubing every 24 hours or per facility protocol. • Change the dressing around the IV site every 48 to 72 hours or per facility protocol. • Before administering TPN, have a second nurse check the prescription and solution to prevent patient harm. Patients receiving TPN are at an increased risk for many different disturbances of fluid and electrolyte balance, depending on the composition of the solution and whether a fluid imbalance occurs. The health care provider usually requests frequent determinations of serum electrolyte levels to detect these imbalances. The risk for metabolic and electrolyte complications is reduced when the rate of administration is carefully controlled and patients are closely monitored for response to treatment. Potassium and sodium imbalances are common, especially when insulin is also administered as part of the therapy. Calcium imbalances, particularly hypercalcemia, are associated with TPN, although immobility may play more of a role than the actual therapy in developing this imbalance ( National Institutes of Health [NIH], 2013a). Community-Based Care Malnourished patients can be cared for in a variety of settings, including the acute care hospital, transitional care unit, nursing home, or their own home. Malnutrition is often diagnosed when the patient is admitted to the acute care hospital or shortly after hospitalization if complications such as poor wound healing or sepsis occur. If the patient is severely compromised, he or she may require admission to a traditional nursing home for either transitional or long-term care. If adequate home support is available, he or she may be discharged to home in the care of a family member or other caregiver. Home care nurses may be needed to monitor and direct the care. Home Care Management. The malnourished patient needs a variety of resources at home to continue aggressive nutrition support. If he or she can consume food by the oral route, the case manager or other discharge planner determines whether financial resources are available for the necessary nutrition supplements. If the hospital provides ambulatory nutrition counseling services, the patient is scheduled for follow-up after discharge for assessment of weight gain. Self-Management Education. The dietitian teaches the malnourished patient and family about high-calorie, high-protein diet and nutrition supplements. In collaboration with the pharmacist, review specific parenteral solutions with the patient and family or significant others. Reinforce the importance of adhering to the prescribed diet, and review any drugs the patient may be taking. If using an iron preparation, teach the importance of taking the drug immediately before or during meals. Caution the patient that iron tends to cause constipation. For the older adult already susceptible to constipation, emphasize the importance of measures for prevention, including adequate fiber intake, adequate fluids, and exercise. Some patients are discharged to home with enteral or parenteral nutrition. Teach the family or other caregiver how to continue these therapies. Remind caregivers to consider the psychosocial aspects of these alternative methods for nutrition. For example, the caregiver can bring the enteral product and napkin to the patient on a decorative tray to make the feeding experience more elegant and "normal." Moving the feeding equipment out of view of the patient when it is not in use is also helpful. Health Care Resources. The malnourished patient discharged to home on enteral or parenteral nutrition support needs the specialized services of a home nutrition therapy team. This team generally consists of the physician, nurse, dietitian, pharmacist, and case manager or social worker. Several commercial companies supply these services to patients at home in addition to the feeding supplies and formulas and health teaching. Evaluation: Outcomes Evaluate the care of the malnourished patient based on the identified priority patient problem. The primary expected outcome is that he or she has available nutrients to meet the metabolic demands for maintaining weight and total protein and has adequate hydration.

Placebos

There are many different definitions and interpretations of the terms placebo and placebo effect. It is generally accepted that placebos are pharmacologically inactive preparations or procedures that produce no beneficial or therapeutic effect. Professional organizations discourage the use of placebos to treat pain. It is considered unethical and deceitful to administer them. Placebo use jeopardizes the trust between patients and their caregivers. If a placebo is ordered, question the order. Many health care agencies have policies that limit the use of placebos to research only (Pasero and McCaffery, 2011).

Abdominal aneurysm

A pulsatile, nontender mass may be palpated. Acute abdominal pain, often radiating to the back, of sudden onset, and severe in nature, is indicative of aneurysm rupture and must be treated emergently. AAAs occur most often in men and represent approximately 80% of all aneurysms.

Activity Tolerance.

Activity tolerance is the type and amount of exercise or work that a person is able to perform without undue exertion or injury (Box 27-6). Observe patients after ambulation, self-bathing, or sitting in a chair for several hours and assess their verbal report of fatigue and weakness. Assess heart rate and blood pressure response to activity. Box 27-6 Factors Influencing Activity Tolerance Physiological Factors • Skeletal abnormalities • Muscular impairments • Endocrine or metabolic illnesses (e.g., diabetes mellitus, thyroid disease) • Hypoxemia • Decreased cardiac function • Decreased endurance • Impaired physical stability • Pain • Sleep pattern disturbance • Prior exercise patterns • Infectious processes and feverEmotional Factors • Anxiety • Depression • Chemical addictions • MotivationDevelopmental Factors • Age • Sex • Pregnancy • Physical growth and development of muscle and skeletal support

Asepsis

Asepsis Procedural Steps 1 Explain importance that patient coughs and expectorates sputum. Patient cannot imply clear throat and expectorate saliva. 2 Provide opportunity to cleanse or rinse mouth with water. Patient should not use mouthwash or toothpaste because the products may alter culture results. 3 Apply clean gloves. Provide sputum cup and instruct patient not to touch the inside of the container. 4 Have the patient take three to four deep breaths. Emphasize to patient that breaths should include slow, full exhalation. Then after a full exhalation ask patient to cough forcefully, expectorating sputum directly into specimen container. 5 Repeat until 5 to 10 mL (½ to 2 teaspoons) of sputum (not saliva) has been collected. 6 Secure top on container tightly. If any sputum is present on outside of container, wipe it off with disinfectant. 7 Offer patient tissues after patient expectorates, dispose of tissues, and offer mouth care. 8 Remove and dispose of gloves. 9 Securely attach properly completed identification label and laboratory requisition to side of specimen container (not lid). 10 Enclose specimen in a plastic biohazard bag. 11 Send specimen immediately to laboratory.

Evaluation of Arousal

Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection to the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.[5] To stimulate the patient, the nurse should begin with verbal stimuli in a normal tone. If the patient does not respond, the nurse should increase the stimuli by talking very loudly to the patient. If the patient still does not respond, the nurse should further increase the stimuli by shaking the patient. Noxious stimuli, in the form of peripheral and central stimulation, should follow if previous attempts to arouse the patient are unsuccessful (Box 17-3).[2] Box 17-3 Stimulation Techniques in Patient Arousal Central Stimulation • Trapezius pinch: Squeeze trapezius muscle between thumb and first two fingers. • Sternal rub: Apply firm pressure to sternum with knuckles, using a rubbing motion. Peripheral Stimulation • Nail bed pressure: Apply firm pressure, using object such as a pen, to nail bed. • Pinching of inner aspect of arm or leg: Firmly pinch small portion of patient's tissue on sensitive inner aspect of arm or leg.

Muscle Effects

Because of protein breakdown, a patient loses lean body mass during immobility. The reduced muscle mass makes it difficult for patients to sustain activity without increased fatigue. If immobility continues and the patient does not exercise, there is further loss of muscle mass. Prolonged immobility often leads to disuse atrophy. Loss of endurance, decreased muscle mass and strength, and joint instability (see Skeletal Effects) place patients at risk for falls (see Chapter 39).

Hypotension

Hypotension is present when the systolic BP falls to 90 mm Hg or below. Although some adults have a low BP normally, for most people low BP is an abnormal finding associated with illness. Hypotension occurs because of the dilation of the arteries in the vascular bed, the loss of a substantial amount of blood volume (e.g., hemorrhage), or the failure of the heart muscle to pump adequately (e.g., myocardial infarction). Hypotension associated with pallor, skin mottling, clamminess, confusion, increased HR, or decreased urine output is life threatening and is reported to a health care provider immediately. Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 minutes of rising to an upright position (Shibao et al., 2013). When a healthy individual changes from a lying-to sitting-to standing position, the peripheral blood vessels in the legs constrict. When standing, the lower-extremity vessels constrict, preventing the pooling of blood in the legs caused by gravity. Thus an individual normally does not feel any symptoms when standing. In contrast, when patients have a decreased blood volume, their blood vessels are already constricted. When a patient with volume depletion stands, there is a significant drop in BP with an increase in HR to compensate for the drop in cardiac output. Patients who are dehydrated, anemic, or have experienced prolonged bed rest or recent blood loss are at risk for orthostatic hypotension, particularly in the morning (Shibao et al., 2013). Some medications cause orthostatic hypotension if misused, especially in older adults or young patients. Always measure BP before administering such medications. Assess for orthostatic hypotension during measurements of vital signs by obtaining BP and pulse in sequence with the patient supine, sitting, and standing. Obtain BP readings within 3 minutes after the patient changes position. In most cases orthostatic hypotension is detected within a minute of standing. If it occurs, help the patient to a lying position and notify the health care provider or nurse in charge. While obtaining orthostatic measurements, observe for other symptoms of hypotension such as fainting, weakness, blurred vision, or light-headedness. Orthostatic hypotension is a risk factor for falls, especially among elderly patients with hypertension (Angelousi et al., 2014). When recording orthostatic BP measurements, record the patient's position in addition to the BP measurement (e.g., 140/80 mm Hg supine, 132/72 mm Hg sitting, 108/60 mm Hg standing). The skill of orthostatic measurements requires critical thinking and ongoing nursing judgment when determining a patient's response to repositioning. Do not delegate this procedure.

Hypotension

Hypotension occurs when the SBP falls to 90 mm Hg or below. Although some adults normally have a low BP, for the majority of people low BP is an abnormal finding associated with illness (e.g., hemorrhage or myocardial infarction). Orthostatic hypotension, also referred to as postural hypotension, occurs when a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low BP when rising to an upright position. In severe cases, loss of consciousness may occur. Normally, when a healthy individual changes from a lying to sitting or standing position, the peripheral blood vessels in the legs constrict, the heart rate and contractility increase, and BP remains adequate to perfuse the heart and brain. Orthostatic changes in vital signs are good indicators of blood volume depletion. Some medications cause orthostatic hypotension if misused, especially in young patients and older adults.

Imbalanced Nutrition: Less than Body Requirements

Imbalanced Nutrition: Less than Body Requirements Anorexia and nausea are common adverse effects of antitubercular drugs. Monitor the patient's weight at regular intervals. Some measures that may reduce the drug's side effects include taking it at bedtime and taking antinausea drugs. Explain the role of nutrition in recovering from an infectious disease and encourage the patient to eat a balanced diet (see Cultural Considerations box). Five or six small meals may be more acceptable than three large ones to the patient who has a poor appetite. A patient's food preferences should be respected as much as possible. For patients who are homeless or have a low income, ask the social worker to locate services that provide food or prepared meals. Some foods can cause serious reactions if consumed with antitubercular medications. Provide a written list of any foods that the patient should avoid (see Patient Teaching box). Cultural Considerations What Does Culture Have to Do with Patient Teaching? To be effective, the teaching plan for the patient with tuberculosis must consider the patient's native language, vocabulary, lifestyle, and financial resources. Patient Teaching Tuberculosis People with tuberculosis are usually hospitalized for just a short time if at all, so you must implement efficient patient teaching and supplement verbal instructions with written material. Subjects to include in the teaching plan are as follows: • Tuberculosis is spread by airborne droplets. Protect others by covering your mouth when coughing, laughing, or sneezing. Wash your hands often. Use disposable tissues and discard them in bagged trash. • Effective treatment requires taking drugs exactly as prescribed for the full course of therapy to prevent reinfection. Notify your physician of adverse effects of your drugs but do not stop taking them unless advised to do so by the physician. • If you are taking isoniazid (INH), you must avoid foods containing tyramine (e.g., aged cheeses, smoked fish) and histamine (e.g., tuna, sauerkraut). These foods combined with INH can make you very ill. • Good hygiene, nutrition, and hydration can help you to recover. • Rifampin causes body fluids to become red-orange and may stain soft contact lenses.

Implementation for Fall Prevention in a Health Care Setting

Implementation for Fall Prevention in a Health Care Setting STEPSRATIONALE 1. See Standard Protocol (inside front cover). Safe Patient Care Before using any equipment for the first time, know the safety features and proper method of operation. 2. Explain plan of care. Specifically discuss reasons that patient is at risk for falling. Include family caregivers (as appropriate) in discussion. This promotes patient cooperation and results in fall prevention measures that are patient-centered and not just routine. Younger patients are very independent and often believe they are not likely to fall. Safe Patient Care If patient is taking multiple medications, confer with the health care provider on the possibility of reducing or adjusting the medications. 3. Adjust bed to low position with wheels locked (see illustration). Place nonslip padded floor mats at exit side of bed. STEP 3Hospital bed should be kept in the lowest position with wheels locked and side rails up (as appropriate.) Height of bed allows ambulatory patient to get in and out of bed easily and safely. Pads provide nonslippery surface on which to stand. 4. Encourage the use of properly fitted skid-proof footwear. Option: Place nonslip padded floor mat on exit side of bed.Skid-proof footwear or floor mat prevents falls from slipping on floor. 5. Orient patient to surroundings and call light/bed control system.Orientation to room and call system familiarizes patient with environment and the ability to call readily for assistance. a. Provide patient's hearing aid and glasses. Be sure each assistive device is functioning and clean.These assistive devices enable patient to remain alert to conditions in environment. b. Explain and demonstrate how to turn call light/intercom system on and off at bedside and in bathroom (see illustration). Have patient perform a return demonstration.STEP 5bNurse demonstrates use of call light to patient.Knowledge of location and use of call light is essential for patient to be able to call for assistance quickly. c. Explain to patient or family caregiver when and why to use call system (e.g., report pain, get out of bed, go to bathroom). Provide clear instructions to patient or family caregiver regarding mobility restrictions.This instruction increases the likelihood of nurse being able to respond to patient's needs in a timely way. d. Consistently secure call light/bed control system to an accessible location within patient's reach.This ensures that patient is able to reach device immediately when needed. 6. Use side rails safely. a. Explain to patient and family members the reason for using side rails: moving and turning self in bed.This explanation promotes cooperation. b. Check facility policy regarding use of side rails. (1) Dependent patients; less mobile patients: In a two-side rail bed, keep both rails up. (Note: Rails on newer hospital beds allow for room at foot of bed for patient to exit bed safely.) In a four-side rail bed, leave only two upper rails up.Side rails are restraint devices if they immobilize or reduce the ability of a patient to move the arms, legs, body, or head freely. (2) Patient able to get out of bed independently: In a four-side rail bed, leave only one upper side rail up. In a two-side rail, keep only one rail up.This allows for safe exit from bed. 7. Make the patient's environment safe. a. Remove excess equipment, supplies, and furniture from rooms and halls.This reduces likelihood of falling or tripping over objects. b. Keep floors free of clutter and obstacles, particularly the path to the bathroom.This reduces likelihood of falling or tripping over objects. c. Coil and secure excess electrical, telephone, and any other cords or tubing.This reduces the risk of entanglement. d. Clean all spills promptly. Post a sign indicating a wet floor. Remove the sign when the floor is dry (usually done by housekeeping).This reduces the risk of falling on slippery, wet surfaces. e. Ensure adequate glare-free lighting; use a night-light at night.Glare may be a problem for older adults because of vision changes. f. Have assistive devices (e.g., cane, walker, bedside commode) on exit side of bed.Availability of assistive devices provides added support when transferring out of bed. g. Arrange necessary items (e.g., water pitcher, telephone, reading materials, dentures) within patient's easy reach and in a logical way.This facilitates independence and self-care and prevents falls related to reaching for hard-to-reach items. h. Secure locks on beds, stretchers, and wheelchairs.This prevents accidental movement of devices during patient transfer. 8. Additional interventions for patients at moderate to high risk for falling (based on fall risk assessment). a. Institute facility-specific flagging system (e.g., yellow sign on door indicating risk for fall, yellow sticker on chart, yellow dot on assignment board). Apply yellow Fall Risk armband on patient (see illustration).STEP 8aArm band alerts nursing staff to patient's risk of falling.Such a system communicates patients at highest risk for fall to all health care team members. A national effort aimed at standardizing the patient wristband color of yellow for fall risk has gained support in several U.S. states. b. Prioritize call light responses to patients at high risk, using a team approachThis ensures rapid response by a health care provider when patient calls for assistance. c. Establish elimination schedule, using bedside commode when appropriate.Proactive toileting keeps patients from being unattended with sudden urge to use toilet. Safe Patient Care Getting out of bed for toileting is a common event leading to a patient's fall (Tzeng, 2010), especially during evening or night hours when a room is darkened. d. Stay with patient during toileting. Patients often try to get up to stand and walk back to their bed from the bathroom without assistance. e. Place patient in a geri chair or wheelchair with wedge cushion. Use wheelchair only for transport, not for sitting an extended time.A wedge cushion maintains alignment and comfort and makes it difficult to exit chair. f. Use a low bed that has low height above floor, and apply floor mats.This reduces fall-related injuries. g. Activate bed alarm for patient.Alarm activates when patient rises off a sensor and sounds an alert to staff. h. Confer with a physical therapist on feasibility of gait training, weight-bearing activities, balance exercise, and strengthening exercises.Exercise can reduce falls, fall-related fractures, and several risk factors for falls in individuals with low bone density and in older adults (de Kam et al., 2009; Schubert, 2011). i. Accompany patient during transport. Alert receiving area to patient's risk for fall.Safety is provided during transport and transfer. j. Use sitters or restraints only when alternatives are exhausted (see Skill 4.3).A sitter is typically a nonprofessional staff member or volunteer who stays in a patient room to provide close observation of patients who are at risk for falling. Use of sitters can be costly. Restraints should be used only as a final option. 9. When ambulating a patient, have patient wear a gait belt and walk along patient's side (see Chapter 16).A gait belt gives you a secure hold on patient during ambulation. 10. Safe transport using a wheelchair a. Determine level of assistance needed to transfer patient to wheelchair. Position wheelchair on same side of bed as patient's strong or unaffected side (see Chapter 15).Patient's condition may require more than a one-person assist. Positioning of chair facilitates patient's ability to assist in transfer. b. Place wedge cushion in chair (see illustration).STEP 10bWheelchair with footplates raised and wedge cushion in place.A wedge cushion prevents patient from slipping out of chair. c. Securely lock brakes on both wheels when transferring patient into or out of wheelchair.Locking the brakes keeps chair steady and secure. d. Raise footplates before transfer to chair; then lower footplates, placing patient's feet on them after the patient is seated.This prevents patient from tripping over footplate. e. Have patient sit with buttocks well back in seat. Option: Apply a quick-release seat belt.This prevents patient from sliding out of chair. f. Back wheelchair into and out of elevator or door, leading with large rear wheels first (see illustration).STEP 10fNurse backing wheelchair into elevator.

Endocrine Drugs ▼ Patient and Caregiver Teaching

Initially the hypothyroid patient may have difficulty processing complex instructions. It is important to provide written instructions, repeat the information often, and assess the patient's comprehension level. ▪ Stress the need for receiving lifelong drug therapy and avoiding abrupt discontinuation of drugs. Instruct the patient in expected and unexpected side effects. In the teaching plan, include the signs and symptoms of hypothyroidism or hyperthyroidism that indicate hormone imbalance. ▪ Teach the patient to immediately contact an HCP if signs of overdose appear, such as orthopnea, dyspnea, rapid pulse, chest pain, palpitations, nervousness, or insomnia. ▪ The patient with diabetes mellitus should test his or her capillary blood glucose at least daily because a return to the euthyroid state frequently increases insulin requirements. ▪ Thyroid preparations potentiate the effects of other common drugs, such as anticoagulants, antidepressants, and digitalis compounds. Instruct the patient on the toxic signs and symptoms of these medications. ▪ Medication interactions are an important reason for patients to consult their HCP before switching brands of thyroid replacement medication. Switching brands may alter bioavailability of the drug and physiologic response.

Laboratory Assessment

Laboratory tests supply objective data that can support subjective data and identify deficiencies. Interpret laboratory data carefully with regard to the total patient; focusing on an isolated value may yield an inaccurate conclusion. A low hemoglobin level may indicate anemia, recent hemorrhage, or hemodilution caused by fluid retention. Hemoglobin may also be decreased secondary to conditions such as low serum albumin, infection, catabolism, or chronic disease. High levels may indicate hemoconcentration or dehydration or may be found secondary to liver disease. Low hematocrit levels may reflect anemia, hemorrhage, excessive fluid, renal disease, or cirrhosis. High hematocrit levels may indicate dehydration or hemoconcentration. Serum albumin, thyroxine-binding prealbumin, and transferrin are measures of visceral proteins. Serum albumin is a plasma protein that reflects the nutrition status of the patient a few weeks before testing; therefore it is not considered to be a sensitive test. Patients who are dehydrated often have high levels of albumin, and those with fluid excess have a lowered value. The normal serum albumin level for men and women is 3.5 to 5.0 g/dL or 35 to 50 g/L (SI units) ( Pagana & Pagana, 2014). Thyroxine-binding prealbumin (PAB) is a plasma protein that provides a more sensitive indicator of nutrition deficiency because of its short half-life of 2 days. Depending on the laboratory test used, the normal PAB range is 15 to 36 mg/dL or 150 to 360 mg/L (SI units) ( Pagana & Pagana, 2014). Although not used as commonly, serum transferrin, an iron-transport protein, can be measured directly or calculated as an indirect measurement of total iron-binding capacity (TIBC). It has a short half-life of 8 to 10 days and therefore is also a more sensitive indicator of protein status than albumin. Cholesterol levels normally range between 160 and 200 mg/dL in adult men and women. Values are typically low with malabsorption, liver disease, pernicious anemia, end-stage cancer, or sepsis. A cholesterol level below 160 mg/dL has been identified as a possible indicator of malnutrition. Cholesterol testing is discussed in more detail in Chapter 36. Total lymphocyte count (TLC) can be used to assess immune function. Malnutrition suppresses the immune system and leaves the patient more likely to get an infection. When a patient is malnourished, the TLC is usually decreased to below 1500/mm3.

Level of Consciousness

Level of Consciousness Assessment of the level of consciousness is the most important aspect of the neurologic examination. In most situations, a patient's level of consciousness deteriorates before any other neurologic changes are noticed. These deteriorations often are subtle and must be monitored carefully. Nursing priorities in assessment of level of consciousness focus on two areas: 1) evaluation of arousal or alertness and 2) appraisal of content of consciousness or awareness.[2,5] Although universally accepted definitions for various levels of consciousness do not exist, the categories outlined in Box 17-2 are often used to describe the patient's level of consciousness.[2,4,6] Box 17-2 Categories of Consciousness AlertPatient responds immediately to minimal external stimuli.ConfusedPatient is disoriented to time or place but usually oriented to person, with impaired judgment and decision making and decreased attention span.DeliriousPatient is disoriented to time, place, and person, with loss of contact with reality, and often has auditory or visual hallucinations.LethargicPatient displays a state of drowsiness or inaction, in which the patient needs an increased stimulus to be awakened.ObtundedPatient displays dull indifference to external stimuli, and response is minimally maintained.Questions are answered with a minimal response.StuporousPatient can be aroused only by vigorous and continuous external stimuli.Motor response is often withdrawal or localizing to stimulus.ComatoseVigorous stimulation fails to produce any voluntary neural response. From Barker E. Neuroscience Nursing: A Spectrum of Care. 3rd ed. St. Louis: Mosby; 2008. Evaluation of Arousal Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection to the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient's ability to respond to verbal or noxious stimuli in an appropriate manner.[5] To stimulate the patient, the nurse should begin with verbal stimuli in a normal tone. If the patient does not respond, the nurse should increase the stimuli by talking very loudly to the patient. If the patient still does not respond, the nurse should further increase the stimuli by shaking the patient. Noxious stimuli, in the form of peripheral and central stimulation, should follow if previous attempts to arouse the patient are unsuccessful (Box 17-3).[2] Box 17-3 Stimulation Techniques in Patient Arousal Central Stimulation • Trapezius pinch: Squeeze trapezius muscle between thumb and first two fingers. • Sternal rub: Apply firm pressure to sternum with knuckles, using a rubbing motion. Peripheral Stimulation • Nail bed pressure: Apply firm pressure, using object such as a pen, to nail bed. • Pinching of inner aspect of arm or leg: Firmly pinch small portion of patient's tissue on sensitive inner aspect of arm or leg. Appraisal of Awareness Content of consciousness is a higher-level function, and appraisal of awareness is concerned with assessment of the patient's orientation to person, place, time, and situation.[5] Assessment of content of consciousness requires the patient to give appropriate answers to a variety of questions. Changes in the patient's answers that indicate increasing degrees of confusion and disorientation may be the first sign of neurologic deterioration.[1,2] Glasgow Coma Scale The most widely recognized tool for assessing level of consciousness is the Glasgow Coma Scale (GCS).[7] This scored scale is based on evaluation of three categories: 1) eye opening, 2) verbal response, and 3) best motor response (Table 17-1). The highest possible score on the GCS is 15, and the lowest score is 3. A score of 7 or less on the GCS usually indicates coma. The scoring system was developed to assist in general communication concerning the severity of neurologic injury. Recently, however, the usefulness of the GCS has been called into question because of its lack of sensitivity and poor inter-rater reliability.[8] Several points should therefore be kept in mind when the GCS is used for serial assessment. First, the GCS provides data about level of consciousness only and should never be considered a complete neurologic examination. Second, it is not a sensitive tool for evaluation of an altered sensorium. Third, it does not account for possible aphasia or mechanical intubation. Finally, the GCS is a poor indicator of lateralization of neurologic deterioration.[9] Lateralization involves decreasing motor response on one side or unilateral changes in pupillary reaction. TABLE 17-1 -- Glasgow Coma Scale CATEGORYSCORERESPONSEEye Opening4Spontaneous: Eyes open spontaneously without stimulation. 3To speech: Eyes open with verbal stimulation but not necessarily to command. 2To pain: Eyes open with noxious stimuli. 1None: No eye opening regardless of stimulationVerbal Response5Oriented: Accurate information about person, place, time, reason for hospitalization, and personal data 4Confused: Answers not appropriate to question, but use of language is correct 3Inappropriate words: Disorganized, random speech, no sustained conversation 2Incomprehensible sounds: Moans, groans, and incomprehensible mumbles 1None: No verbalization despite stimulationBest Motor Response6Obeys commands: Performs simple tasks on command; able to repeat performance 5Localizes to pain: Organized attempt to localize and remove painful stimuli 4Withdraws from pain: Withdraws extremity from source of painful stimuli 3Abnormal flexion: Decorticate posturing spontaneously or in response to noxious stimuli 2Extension: Decerebrate posturing spontaneously or in response to noxious stimuli 1None: No response to noxious stimuli; flaccid Modified from Teasdale G, Jennett B. Assessment of coma and impaired consciousness—a practical scale, Lancet 2:81,1974.

Endocrine Drugs Clinical Manifestations

Manifestations of hyperthyroidism are related to the effect of excess thyroid hormones. ▪ Inspection or palpation of the thyroid gland may reveal a goiter. Auscultation of the thyroid gland may reveal bruits, a reflection of increased blood supply. ▪ Exophthalmos, or eyeball protrusion, is caused by impaired venous drainage from the orbit, leading to increased deposits of fat and edema fluid in the orbital tissues. This sign is a classic finding in Graves' disease. When the eyelids do not close completely, exposed corneal surfaces become dry and irritated. Serious consequences, such as corneal ulcers and eventual loss of vision, can occur. Ocular muscle changes result in muscle weakness, causing diplopia. ▪ A patient with advanced disease may exhibit many symptoms, whereas a patient in the early stages of hyperthyroidism may only exhibit weight loss and increased nervousness.

Laboratory Values

No single laboratory or biochemical test is diagnostic for malnutrition. Factors that frequently alter test results include fluid balance, liver function, kidney function, and the presence of disease. Laboratory values useful in nutritional assessment include complete blood count (CBC), albumin, prealbumin (transferrin), electrolytes, blood urea nitrogen, 24-hour urine urea nitrogen (UUN), creatinine, glucose, cholesterol, and triglycerides. Individual laboratory measures alone are not specific enough to indicate nutritional risk; therefore they are combined with multiple objective measures to determine malnutrition. A low red blood cell count and depressed hemoglobin value indicate anemia. The hemoglobin, hematocrit, electrolyte, and blood urea nitrogen values also help to reflect the state of hydration. Serum proteins such as prealbumin and albumin levels are affected by inflammatory states and reflect the severity of disease rather than nutritional status (Davis et al., 2012). Nitrogen balance, which is measured through laboratory analysis of a 24-hour UUN, is important to establish adequacy of protein and calorie intake (see the discussion of protein in this chapter).

Aorta

Palpate deeply slightly to the left of the midline, and feel for the aortic pulsation. If the pulsation is prominent, try to determine the direction of pulsation. A prominent lateral pulsation suggests an aortic aneurysm. If you are unable to feel the pulse on deep palpation, an alternate technique may help. Place the palmar surface of your hands with fingers extended on the midline. Press the fingers deeply inward on each side of the aorta, and feel for the pulsation. In thin individuals, you can use one hand, placing the thumb on one side of the aorta and the fingers on the other side (Fig. 17-22). Evidence-Based Practice in Physical Examination Detecting Abdominal Aortic Aneurysms Although health care providers can detect asymptomatic abdominal aortic aneurysms (AAAs) by palpation, the overall sensitivity is somewhat low. A negative examination does not rule out the diagnosis, especially in obese patients and in those who are unable to relax their abdominal musculature during the exam. In general palpation has a moderate sensitivity for detecting aneurysms large enough to be referred for surgery. The United States Preventive Services Task Force (USPSTF) currently recommends a one-time screening ultrasound for AAA in men 65-75 years of age who have ever smoked. From Lederle, 2009; USPSTF, 2005. FIGURE 17-22Palpating the aorta. Place the thumb on one side of the aorta and the fingers on the other side.

aortic pulsation

Palpate with the thumb and forefinger of one hand deeply into the upper abdomen just left of the midline to assess aortic pulsation. Normally a pulsation is transmitted forward. If the aorta is enlarged because of an aneurysm (localized dilation of a vessel wall), the pulsation expands laterally. Do not palpate a pulsating abdominal mass. When enlargement from an aneurysm is present, palpate this area only lightly, referring the finding to the health care provider. In obese patients it is often necessary to palpate with both hands, one on each side of the aorta.

Routine Catheter Care

Patients with indwelling catheters require regular perineal hygiene, especially after a bowel movement, to reduce the risk for catheter-associated UTI (CAUTI) (Gould et al., 2009; Lo et al., 2014). In many institutions patients receive catheter care every 8 hours as the minimal standard of care. See Chapter 40 for routine perineal care and Skill 46-3 on pp. 1140-1142 for catheter care. Empty drainage bags when full (Figure 46-13). An overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra and/or urinary meatus, and increase risk for CAUTI (Cipa-Tatum and Kelly-Signs, 2011; Rassin and Markovski, 2013). Expect continuous drainage of urine into the drainage bag. In the presence of no urine drainage, first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter.

Nutrition

Proper nutrition, as already discussed, is essential for wound healing. Inadequate nutrition is implicated in the development of pressure ulcers. Patients at risk for nutritional deficits include those who are unable or unwilling to feed themselves or to take in enough nutrients to meet their metabolic requirements. When inadequate nutrition results in an unintentional weight loss of 5% or more; a low body mass index (BMI); deficiencies in vitamins A, C, and E and the minerals zinc and copper; and protein-calorie malnutrition, the ability of the tissue to withstand the forces of pressure and shear and to combat infectious agents is compromised (Dorner, Posthauer, and Thomas 2009). A thorough nutritional assessment including an evaluation of weight and recent changes in weight, BMI, diet history, and pertinent laboratory findings (including serum albumin, serum prealbumin, nitrogen balance, and other measures) is an essential first step in preventing the development of pressure ulcers while promoting healing of those already present. Collaboration with a registered dietitian and other members of the health care team, as well as the patient and family members, is needed in the development of a plan to address the nutritional needs of the at-risk patient. This plan must be consistent with the overall plan of care and the wishes of the patient and family. For all of the reasons already discussed, the elderly population is at increased risk for developing pressure ulcers, and such lesions, if they occur, will be slower to heal. The combination of comorbid conditions such as diabetes and peripheral vascular disease, medication use, exposure to sun, and the changes in skin characteristics inherent in aging makes the elder population highly vulnerable to impaired wound healing.

Long-Term Considerations GI DRUGS

Rejection of the transplanted kidney is an ongoing concern for all of these patients. The graft function is monitored closely, and if rejection is suspected, a biopsy is performed. If the biopsy reveals acute rejection, rescue therapy is initiated. This therapy can be in the form of high-dose intravenous steroids for mild rejection or intravenous monoclonal antibody for moderate to severe rejection. If the biopsy reveals chronic rejection, the oral immunosuppressant medications are increased or returned to the higher doses used immediately after transplantation. No two patients' immune systems are exactly alike, and the immunosuppressant medication regimen required to prevent rejection must be tailored to each patient individually. The goal is to create a balance among medications that allows the patient to fight off most infections but avoid rejection of the transplanted organ. Patient adherence to the medical regimen that is required to maintain a transplanted organ is a major concern. Adequate education of the patient and family as to the importance of taking the medications as instructed is of paramount importance. Patients are reluctant to take the medications appropriately if they are experiencing severe side effects. Decreasing the dose of the medications can often alleviate these symptoms but may lead to a rejection episode. Patients often have financial concerns. A 1-month supply of medications can cost more than $1200, and paying for the medications over the long term is a great burden for some patients. The federal government helps to pay for the immunosuppressant medications for 36 months after transplantation.

Albumin and Prealbumin

Serum albumin levels are is used to monitor nutritional status, and liver and kidney disease (Grodner et al., 2004). Albumin levels decrease with age. Low albumin levels (<3.5 grams per deciliter [g/dL]) have been associated with increased mortality in hospitalized patients (Iwata, Kuzuya, Kitagawa, & Iguchi, 2006). Additionally, when albumin is insufficient to sustain sufficient colloid osmotic pressure to counterbalance hydrostatic pressure, edema develops (typically with an albumin level <2.5g/dL). Low albumin levels are also associated with certain medications, including corticosteroids, insulin, and thyroid hormone. Research is conflicting concerning the relationship between serum albumin levels and pressure ulcer or wound healing, with some research indicating little connection (Lizaka, Sanada, Matsui et al., 2011) and other research indicating a relationship between albumin and wound healing in diabetics (Amir, Liu & Chang, 2012). Finally, low levels of albumin are found in patients with burns, HF, acute infection, and thyrotoxicosis. High albumin levels are associated with blood loss and dehydration. Prealbumin is also used to assess nutritional status. It is the measurement of protein status over the short term and is a more accurate measurement of malnutrition because of its short half-life of 2 days (Grodner et al., 2004). Plasma prealbumin level may be useful in evaluating an older adult's response to nutritional supplements (Manning & Shenkin, 1995).

Clinical Manifestations

Signs and symptoms are usually insidious. Affected children usually complain of pain, exhibit a limp on the affected side, and have limited range of motion (ROM). The disease in the affected hip causes the leg to be shorter than that on the unaffected side. The condition is aggravated by activity and improves with rest. Knee pain, thigh and groin pain, hip stiffness, and muscle atrophy in the thigh are also common.

Somatostatin or octreotide

Somatostatin or octreotide (a long-acting somatostatin) is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow and reduce portal pressure, and have minimal adverse effects. Octreotide is given as an IV bolus of 50 to 100 mcg, followed by an infusion of 25 to 50 mcg/hr for up to 3 days. Patients must be monitored for both hypoglycemia and hyperglycemia.[13]

Cytoprotective Drug Therapy.

Sucralfate is used for the short-term treatment of ulcers. It provides cytoprotection for the esophagus, stomach, and duodenum. Sucralfate does not have acid-neutralizing capabilities. Since it is most effective at a low pH, give it at least 60 minutes before or after an antacid. Adverse side effects are minimal. It binds with cimetidine, digoxin, warfarin (Coumadin), phenytoin (Dilantin), and tetracycline, reducing their bioavailability. Misoprostol is a synthetic prostaglandin analog prescribed to prevent gastric ulcers caused by NSAIDs and aspirin. It has protective and some antisecretory effects on gastric mucosa. Misoprostol does not interfere with the therapeutic effects of aspirin and NSAIDs. People who require chronic NSAID therapy, such as those with osteoarthritis, may benefit from its use. Since it is teratogenic, it is used with caution in women of childbearing potential.

Fall Prevention

TJC recommends that hospitals have formal fall-reduction programs (TJC, 2015). A fall-reduction program includes a fall risk assessment of every patient conducted on admission and routinely (see hospital policy) until a patient's discharge. Many health care organizations are implementing hourly rounding to reduce falls (Box 27-12). In addition, most organizations apply yellow color-coded wristbands to patients' wrists to communicate to all health care providers that a patient is a fall risk. In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do- not-resuscitate preferences (American Hospital Association, 2008). This recommendation came after a near-miss incident in which a nurse working in two different hospitals placed a wrong-colored band on a patient. Many state hospital associations and communities are now standardizing colors to reduce confusion both within and across the health care organizations. Box 27-12 Evidence-Based Practice Effects of Nursing Rounds on Patient Safety and Patient Satisfaction PICO Question: In the hospitalized adult patient, will hourly rounding compared with standard practice decrease patient falls and improve patient's perception of nurse responsiveness? Evidence Summary Patient falls are considered a nurse-sensitive indicator. Nurses have the opportunity to reduce this adverse outcome on the basis of evidence-based nursing actions. Hospitalized patients often require assistance with basic activities of daily living such as toileting and mobility. Not meeting patient needs in a timely fashion decreases patient satisfaction and places patients at greater risk for injury when they attempt to move unassisted (Mitchell et al., 2014). Current evidence supports a patient-centered approach to nursing care by implementing purposeful hourly rounding (Ford, 2010). A recent systematic review looked at 16 studies and found moderately strong evidence to support that hourly rounding programs reduce patient falls and call-light use and increase their perception of nursing responsiveness. Most of the programs used every hour or every 2-hour rounds and used the 5 Ps: pain, potty, position, possessions, and plan of care as the focus (Mitchell et al., 2014). Application to Nursing Practice • Implementation of purposeful, hourly nursing rounds with nurses visiting patients improves outcomes by reducing patient falls (Mitchell et al., 2014). • Purposeful rounding includes specific nursing actions such as addressing toileting, assessing pain level, turning, and ensuring that possessions are within reach. • Nurses and nursing assistive personnel often share rounding responsibilities (e.g., alternating every other hour). • Nurse responsiveness to call lights is an important factor in a patient's hospital experience and leads to improved patient satisfaction. Patient-centered care is important, with nurses making patients and families their partners in recognizing fall risks and taking preventive action. Most hospitals and long-term care facilities have fall-prevention protocols for those patients at risk for falling. A patient assessed as being at fall risk receives a fall risk identification bracelet (yellow in color), is given information about personal fall risks, and receives additional individualized nursing interventions (see Skill 27-1 on pp. 395-399). For example, if a patient has postural hypotension, a nurse chooses a low bed and the practice of dangling the patient for 5 minutes on the side of the bed before ambulating. Or a patient with a history of urinary urgency or incontinence benefits from a bedside commode instead of being expected to walk to the bathroom unassisted. Other interventions include established elimination schedules, placement of a fall pad on the floor along the bed, and use of bed safety alarms or motion detectors. A gait belt provides a secure way to steady or guide patients who need assistance with ambulation when transferring or walking. Use additional safety equipment as needed when moving patients (see Chapter 39). When patients use assistive aids such as canes, crutches, or walkers, it is important to routinely check the condition of rubber tips and the integrity of the aid. Also be sure that patients use their devices correctly. Remove excess furniture and equipment and make sure that patients wear rubber-soled shoes or slippers for walking or transferring. Safety bars near toilets (Figure 27-6), locks on beds and wheelchairs (Figure 27-7), and call lights are additional safety features found in health care settings. FIGURE 27-6Safety bars around toilets and showers. FIGURE 27-7Wheelchair with safety locks and anti-tip bars. Another area of fall risk includes wheelchair-related falls involving older adults or patients with disabilities. Patients are at risk for falls during transfer tasks and reaching while seated in a wheelchair. An example of a wheelchair characteristic that increases risk for falls is having smaller and harder front wheels that cause a chair to tip when striking uneven terrain (such as uneven floor surface moving into an elevator). Tripping over the front foot or leg rest and leaning over the back of a wheelchair to engage or disengage the wheel lock are common causes of injury.

Functional Status

The degree of functional ability is of greater concern to older adults and nurses than the incidence and prevalence of chronic disease. Functional ability is defined as the capacity to carry out the basic self-care activities that ensure overall health and well-being. Functional ability is classified in many measurement tools by activities of daily living (ADLs) such as bathing, dressing, eating, transferring, and toileting (Katz, 1963) and instrumental ADLs, which include home-management activities such as shopping, cooking, housekeeping, laundry, and handling money (Lawton & Brody, 1969). These measurement tools were identified more than 45 years ago, but they remain the most used and effective measurements available. The use of such measurement tools or scales to determine the effect of chronic disease and normal aging on physical, psychological, and social function provides objective information about a person's overall degree of health. Assessment of the impact of chronic disease and age-related decreases in functional status enables the nurse to determine needs, plan interventions, and evaluate outcomes. Chronic disease and disability may impair physical and emotional health, self-care ability, and independence. Improving the health and functional status of older adults and preventing complications of chronic disease and disability may avert the onset of physical frailty and cognitive impairment, two conditions that increase the likelihood of institutionalization.

Wheelchair Transfer Techniques

Wheelchair Transfer Techniques Transferring a patient from a bed to a wheelchair encompasses many of the same principles discussed in Skill 15.1. The following procedural guideline focuses on the safety precautions that need to be considered when using a wheelchair. Several additional steps must be taken to maintain safety of the patient and nurse to prevent injury when transferring from or to a wheelchair (Pierson and Fairchild, 2013). Check wheelchair locks, footplates, and wheels for proper functioning before use. Delegation and Collaboration The skill of transferring a patient to or from a wheelchair can be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP by: • Assisting and supervising when moving patients who are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. • Explaining the patient's mobility restrictions, changes in blood pressure, or sensory alterations that may affect safe transfer. • Reminding NAP to back a wheelchair into or out of an elevator to avoid tipping. Equipment • Transfer belt • Nonskid shoes • Wheelchair Procedural Steps 1. See Standard Protocol (inside front cover). 2. Transfer a patient from a bed to a wheelchair (patient is weight bearing and able to cooperate (Pierson and Fairchild, 2013). a. Adjust the height of the bed to the level of the seat of the wheelchair if possible. b. Position the wheelchair at a 45-degree angle next to the same side of the bed as the patient's strong side. c. Face the wheelchair toward the foot of the bed midway between the head and foot of the bed. d. Lock the wheelchair. Locks are located above the rims of the wheels. Push handle forward to lock. Raise the footplates. e. Sit patient up on side of the bed (see Skill 15.1). f. Place transfer belt on patient, and assist patient to move to the edge of the mattress. g. Position yourself slightly in front of patient to guard and protect patient throughout the transfer. h. Coordinate transfer to chair with patient by counting to three (see Skill 15.1, Steps 3c(1-13). i. Lower footplates and place patient's feet on them. j. Unlock wheelchair. Pull lock toward you to release. k. Ensure that patient is positioned well back in the seat and ready to use wheelchair. 3. Transfer a patient from a wheelchair to bed a. Adjust the height of the bed to the level of the seat of the wheelchair if possible. b. Position the wheelchair at a 45-degree angle next to the bed. c. Face the wheelchair toward the foot of the bed midway between the head and foot of the bed. d. Lock the wheelchair. Locks are located above the rims of the wheels. Push handle forward to lock. e. Raise the footplates, and place the transfer belt on patient (if not already in place). f. Assist patient to move to the front of the wheelchair. g. Position yourself slightly in front of patient to guard and protect patient throughout the transfer. If patient has sufficient upper body strength, use a slide board during transfer (see illustration). STEP 3g Transfer from wheelchair to bed using a slide board. h. Coordinate transfer to the bed by having patient stand and then pivot to the side of the bed. Then have patient sit on the side of the mattress (see Skill 15.1). i. With patient sitting on side of the bed, place your arm nearer the head of the bed under the person's shoulders while supporting the head and neck. Take your other arm and place it under the person's knees. Bend your knees and keep your back straight. j. Tell patient to help lift the legs when you begin to move. On a count of three, standing with a wide base of support, raise patient's legs as you pivot his or her body and lower the shoulders onto the bed. Remember to keep your back straight. 4. See Completion Protocol (inside front cover). 5. Monitor vital signs as needed. Ask if patient feels dizzy or fatigued. 6. Note patient's behavioral response to transfer.

Preventing Acute Adrenal Insufficiency.

The patient most at risk for acute adrenal insufficiency is the one who has Cushing's syndrome as a result of glucocorticoid drug therapy. The exogenous drug inhibits the feedback control pathway (see Fig. 61-3 in Chapter 61), preventing the hypothalamus from secreting corticotropin-releasing hormone (CRH). The lack of CRH inhibits secretion of ACTH from the anterior pituitary gland. Without normal levels of ACTH, the adrenal glands atrophy and completely stop production of the corticosteroids. As a result, the patient completely depends on the exogenous drug. If the drug is stopped, even for a day or two, the atrophied adrenal glands cannot produce the glucocorticoids and the patient develops acute adrenal insufficiency, a life-threatening condition. Management of this problem is described on p. 1274. Nursing Safety Priority Drug Alert Teach patients who are taking a corticosteroid for more than a week to not stop the drug suddenly. Gradual drug tapering should be done under the care of the health care provider.

EVIDENCE-BASED PRACTICE TRENDS

There continues to be significant research in the area of fall prevention. In a review of studies designed to reduce the fear of falling in community-living older adults, it appears that multifactorial programs show good success (Zijlstra and others, 2007a). A multifactorial program is one that uses multiple interventions because individuals are at risk for falls for a variety of reasons. Welldesigned research studies show that home-based exercise, fall-related multifactorial programs, and community-based tai chi delivered in a group format are effective in reducing the fear of falling in community-living older adults. Studies also show that tai chi improves body balance and ambulation (Greenspan and others, 2007; Maciaszek and others, 2007). Tai chi is an internal Chinese martial art practiced with the aim of promoting health and longevity. Tinetti (2003) warns that effective home-based exercise programs are only short term, usually lasting 1 year or less. Safety research has focused primarily on ambulatory older adults. However, wheelchair-related falls are a serious problem for persons with disabilities. For a patient who relies on a wheelchair for mobility, a tip or fall will possibly affect morbidity and mortality (Gavin-Dreschnack and others, 2005). Wheelchair-related injuries from falls include factures, concussions, dislocations, amputations, and serious head and spinal injuries. Gavin-Dreschnack and others (2005) developed a model for examining wheelchair-related falls. It proposes that an interaction of the following promotes falls: characteristics of users, wheelchair type and features, health care practices, wheelchair activities, and environmental characteristics. Risks associated with users include younger individuals, males, paraplegia or spina bifida, daily use of wheelchair, and propelling with both hands. An example of a wheelchair characteristic that increases risk for falls is having smaller and harder front wheels, which contribute to forward tips when striking uneven terrain. Caregivers are at risk for injury by not handling patients correctly or not asking for assistance. Injuries occur while caregivers transfer patients who are agitated, fearful, unsteady, or too weak to transfer. Tripping over the front foot or leg rest is a common source of injury, as well as leaning over the back of the wheelchair to engage or disengage the wheel lock. Patients are at risk for falls during transfer tasks and reaching while seated in the wheelchair. Most wheelchair accidents occur outdoors because of uneven terrain, stairs, and wet or icy surfaces.

Thoracic aortic aneurysms

Thoracic aortic aneurysms are usually asymptomatic. When symptoms present, the most common is deep, diffuse chest pain that may extend to the interscapular area. Aneurysms in the ascending aorta and aortic arch can cause (1) angina from decreased blood flow to the coronary arteries; (2) transient ischemic attacks from decreased blood flow to the carotid arteries; and (3) coughing, shortness of breath, hoarseness, and/or dysphagia (difficulty swallowing) from pressure on the laryngeal nerve. Compression of the superior vena cava by the aneurysm can cause distended neck veins and face and arm edema. AAAs are often asymptomatic and found during routine physical examination or on evaluation for an unrelated problem (e.g., abdominal x-ray). A pulsatile mass in the periumbilical area slightly to the left of midline may be present. Bruits may be auscultated over the aneurysm. Physical findings may be more difficult to detect in obese individuals. ▪ AAA symptoms may mimic pain associated with abdominal or back disorders. Compression of nearby anatomic structures and nerves may cause symptoms such as back pain, epigastric discomfort, altered bowel elimination, and intermittent claudication. ▪ Occasionally aneurysms spontaneously embolize plaque, causing "blue toe syndrome," in which patchy mottling of the feet and toes occurs despite the presence of peripheral pulses.

Assessments

To conduct a thorough patient assessment, consider possible threats to the patient's safety, including his or her immediate environment and any individual risk factors (Table 28-1). When you care for patients in the home, perform a home safety assessment to look for factors that are hazards within the home (Box 28-7). A thorough safety assessment covers topics such as adequacy of lighting, presence of safety devices, conditions (e.g., flooring, steps) that pose risks for falls, and safety of the kitchen and bathrooms. To assess a home, walk through the rooms with the patient and discuss how the patient normally conducts daily activities and whether the environment poses problems. For example, when assessing adequacy of lighting, inspect areas where a patient moves and works, particularly outside walkways, steps, interior halls, and doorways. Getting a sense of a patient's routines helps you recognize safety hazards. TABLE 28-1 -- FOCUSED PATIENT ASSESSMENT FACTORS TO ASSESSQUESTIONSPHYSICAL ASSESSMENTEnvironmentDescribe times you have fallen in the past.Where do the falls commonly happen?Have you ever burned yourself?Inspect the home environment both inside and outside for potential hazards: focus on the kitchen and bathroom.SensoryWhen do you wear your glasses?When was the last time you had your eyes checked?Can you hear your phone when it rings?Observe patient's ability to read printed material accurately and ability to move about within the home.Assess ability to hear normal spoken word.Physical mobilityHow does your (arthritis, surgery, impaired gait) affect the way you walk and move around?Do you exercise? Describe how you exercise each day.Are you able to move around safely at home?Observe patient's posture, gait, and balance during activities of daily living. Box 28-7 Home Safety Assessment Look for these factors when assessing the safety of a home: • Proper lighting inside and outside • Storage areas within easy reach • Appliances in good working order • Extension cords placed along walls • Presence of smoke detectors and a fire extinguisher • Presence of carbon monoxide detector • Flammable objects away from stove or heaters • Gas pilot lights lit • Hot water thermostat set to 120° F or less • Handrails or grip bars installed • Nonskid surfaces in bathroom and tub or shower • Floor coverings secured and floors free of clutter • Furniture and assistive devices promote ease of mobility • Medications stored properly and not outdated • Telephone accessible with readily available emergency phone numbers Assessment of patients' risk factors for falling is a priority in health care settings. Many different fall assessment instruments are available such as the Morse Fall Scale (Morse, 2009); use the one chosen by your health care agency. Assess both intrinsic and extrinsic factors that increase a patient's risk. Intrinsic factors include a previous history of falling, being age 65 or over, reduced vision, orthostatic hypotension, gait instability, lower limb weakness, balance problems, urinary incontinence, frequency or need for assisted toileting, use of walking aids, agitation or confusion, and the effects of medications (e.g., sedatives, hypnotics, anticonvulsants, and certain analgesics) (Deandrea et al., 2010). Extrinsic factors include those within the hospital environment. Does the placement of equipment pose barriers when a patient attempts to ambulate? Does positioning of a patient's bed allow him or her to safely reach items on a bedside table? Does a patient need assistance with ambulation? Are self-care items at the bedside and is the call light arranged for accessibility? Another area of risk includes wheelchair-related falls involving older adults and people with disabilities. Patients are at risk for falls during transfer tasks and reaching while seated in a wheelchair (Opalek, Graymire, and Redd, 2009). Finally be sure that equipment is safe to use. Collaborate with the hospital clinical engineering staff if you have any questions about equipment functions. Your nursing history includes data about a patient's level of wellness to determine if any underlying conditions pose a further threat to safety. Patients with conditions such as osteoporosis and bleeding disorders are more at risk for injury from falls. When you believe that a patient is a fall risk, assess for a fear of falling. Signs that a person is fearful of falling include concern or worry during walking, sweating or shaking while walking, clutching people or objects while walking, and reluctance to change position or walk. Other fall risk factors to assess include a patient's activity tolerance, level of cognition, presence of painful conditions, muscle strength in extremities, balance, and vision (see Chapter 16). Consider a patient's developmental level when you analyze your data. Review the type and number of medications that a patient is taking and if the patient is undergoing any procedures that pose risks. Older Adult Considerations. When you assess older adults, recognize the types of physical changes that increase their risk for injury (Box 28-8). Research shows that even minor stride-to-stride variations in a person's gait increase the risk of falls. These gait changes are often too small to notice during normal walking alone but rather appear in combination with an additional task (e.g., walking a dog, carrying a bag of groceries) (Wolf et al., 2012). An assessment approach used within health care facilities is the Timed Get Up and Go Test (Mathias et al., 1986). Have the older adults wear regular footwear, sit back in a comfortable chair with an armrest, and use their normal assist device (if needed). Have a watch with a second hand or a digital second display ready. On the word "GO" time the person as he or she performs the following: 1. Stands up from the arm chair 2. Stands still momentarily 3. Walks 10 feet (3 meters) (in a line) 4. Turns around 5. Walks back to chair 6. Turns around 7. Sits down Time the effort and observe the patient for postural stability, steppage, stride length, and sway. Normally a person completes the task in less than 10 seconds; an abnormal response is more than 20 seconds. Box 28-8 Care of the Older Adult Physical Assessment Findings in Older Adults That Increase the Risk for AccidentsMusculoskeletal Changes • Muscle strength decreased • Joints becoming less mobile • Brittle bones caused by osteoporosis • Posture changes; some kyphosis common • Limited range of motion (ROM) • Change in walking gait Nervous System Changes • Slower voluntary or autonomic reflexes • Decreased ability to respond to multiple stimuli • Decreased sensitivity of touch Sensory Changes • Decreased peripheral vision and lens accommodation • Decreased night vision and ability to adjust to changes in light • Development of opacity (cataracts) in lens • Increased stimuli threshold for light touch and pain • Impaired hearing because high-frequency tones are less perceptible Genitourinary Changes • Increased nocturia • Increased occurrence of incontinence Modified from Touhy TA, Jett K: Ebersole and Hess P: Toward healthy aging, ed 8, St Louis, 2012, Mosby. Patient Expectations. Patients expect to be safe in health care settings and in their homes. However, there are times when their view of what is safe does not agree with that of their health care providers and standards of care. For this reason conduct a patient-centered assessment that includes a patient's own perceptions of his or her risk factors, knowledge of how to adapt to such risks, and previous experience with accidents. Ask what a patient expects from your care. For example, ask, "How can I provide care that will make you feel safe?" or "After we walk through your home, tell me what we need to do to help you feel safe." Patients usually do not purposefully put themselves in danger. When they are uninformed or inexperienced, threats to their safety occur. Always ask patients or family members about their ideas for ways to reduce hazards in their environment.

Wheelchair Transfer Techniques

Transferring a patient from a bed to a wheelchair encompasses many of the same principles discussed in Skill 9-1. The following procedural guideline focuses on the safety precautions that need to be considered when using a wheelchair. Several additional steps must be taken to maintain safety of a patient and nurse to prevent injury when transferring from or to a wheelchair (Pierson and Fairchild, 2008). Check wheelchair locks and footplates for proper functioning before use. Delegation and Collaboration The skill of transferring a patient to or from a wheelchair can be delegated to nursing assistive personnel (NAP). The nurse directs NAP by: • Assisting and supervising when moving patients who are transferring for the first time after prolonged bed rest, extensive surgery, critical illness, or spinal cord trauma. • Explaining the patient's mobility restrictions, changes in blood pressure, or sensory alterations that may affect safe transfer. • Reminding NAP to back a wheelchair into or out of an elevator to avoid tipping forward. Equipment □ Transfer belt, nonskid shoes, wheelchair 1 Transferring patient from a wheelchair to bed (patient is cooperative and weight bearing) a Adjust the height of the bed to the level of the seat of the wheelchair. b Position wheelchair at a 45-degree angle next to the bed. c Face the wheelchair toward the foot of the bed midway between the head and foot of the bed. d Lock the wheelchair. Locks are located above the rims of the wheels. Push handle forward to lock. e Raise the footplates. f Place transfer belt on patient. g Assist patient to move to the front of the wheelchair. h Position yourself slightly in front of patient to guard and protect him or her throughout the transfer. If patient has sufficient upper body strength, use a slide board during transfer (see illustration). STEP 1h Transfer from wheelchair to bed using a slide board. i Coordinate transfer to bed by having patient stand and then pivot to the side of the bed. Then have patient sit on the side of the mattress. j With patient sitting on the side of the bed, place your arm nearest the head of the bed under his or her shoulder while supporting the head and neck. Place your other arm under patient's knees. Bend your knees and keep your back straight. k Tell patient to help lift the legs when you begin to move. On a count of three, standing with a wide base of support, raise patient's legs as you pivot his or her body and lower the shoulders onto the bed. Remember to keep your back straight. 2 Transferring a patient from a bed to a wheelchair a Adjust the height of the bed to the level of the seat of the wheelchair. b Position the wheelchair at a 45-degree angle next to the same side of the bed as patient's strong side. c Face the wheelchair toward the foot of the bed midway between the head and foot of the bed. d Lock the wheelchair. Locks are located above the rims of the wheels. Push handle forward to lock. e Raise the footplates. f Sit patient on the side of the bed (see Skill 9-1). g Place transfer belt on patient. h Assist patient to move to the edge of the mattress. i Position yourself slightly in front of patient to guard and protect him or her throughout the transfer. j Coordinate transfer to chair with patient by counting to three (see Skill 9-1). k Lower the footplates after transfer and place patient's feet on them. l Unlock the wheelchair. Pull lock toward you to release. m Ensure that patient is positioned well back in the seat. 3 Monitor vital signs as needed. Ask if patient feels dizzy or fatigued. 4 Note patient's behavioral response to transfer.

Wheelchairs

Wheelchairs are used for patients who are not able to ambulate either independently or with aids, such as crutches or a walker. Many paraplegics (those without use of the legs), quadriplegics (those without use of both arms and legs), amputees, and individuals with severe hemiparesis or respiratory problems depend on wheelchairs for movement from place to place. Patients who are wheelchair dependent over the long term need chairs that are made specifically to their body measurements. When a patient brings a wheelchair to the hospital, see that it is clearly labeled with the owner's name, and never borrow it for someone else. When moving someone into or out of a wheelchair, always set the brakes. Be certain the person's feet are correctly placed on the footrests and that clothing or lap robes are tucked safely away from the wheels. Shoes, slippers, or bed socks protect the feet from direct contact with the footrests. To prevent accidents, keep patients in wheelchairs well away from stairwells, elevators, and doorways if left to sit stationary. Always lock the brakes when the chair is not in motion.

Soapsuds

You add soapsuds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in a liquid form included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they cause electrolyte imbalance or damage to the intestinal mucosa. The health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid is delivered. High enemas cleanse the entire colon. After the enema is infused, ask the patient to turn from the left lateral to the dorsal recumbent, over to the right lateral position. The position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon.

octreotide ()

octreotide () (ok-tree´oh-tide) Sandostatin, Sandostatin LAR Depot Func. class.: Hormone, antidiarrheal Chem. class.: Octapeptide Action: A potent growth hormone similar to somatostatin Uses: Sandostatin: acromegaly, improves symptoms in carcinoid tumors, vasoactive intestinal peptide tumors (VIPomas); LAR Depot: long-term maintenance of acromegaly, carcinoid tumors, VIPomas Unlabeled uses: GI fistula, variceal bleeding, diarrheal conditions, pancreatic fistula, irritable bowel syndrome, dumping syndrome DOSAGE AND ROUTES Acromegaly • Adult: SUBCUT/IV (Sandostatin) 50-100 mcg bid-tid, adjust q2wk based on growth hormone levels, or IM (Sandostatin LAR) 20 mg q4wk × 3 mo, adjust by growth hormone levels VIPomas • Adult: SUBCUT/IV (Sandostatin) 0.2-0.3 mg/day in 2-4 doses for 2 wk, not to exceed 0.45 mg/day, or IM (Sandostatin LAR) 20 mg q2wk × 2 mo, adjust dose Carcinoid tumors • Adult: SUBCUT/IV (Sandostatin) 0.1-0.6 mg/day in 2-4 doses for 2 wk, titrated to patient response, or IM (Sandostatin LAR) 20 mg q4wk × 2 mo, adjust dose GI fistula • Adult: SUBCUT (Sandostatin) 50-200 mcg q8hr Antidiarrheal in AIDS patients • Adult: SUBCUT/IV (Sandostatin) 100-1800 mcg/day Irritable bowel syndrome (unlabeled) • Adult: SUBCUT (Sandostatin) 100 mcg single dose to 125 mcg bid Dumping syndrome (unlabeled) • Adult: SUBCUT (Sandostatin) 50-150 mcg/day Variceal bleeding (unlabeled) • Adult: IV (Sandostatin) 25-50 mcg/hr CONT IV INF for 18 hr-5 days Available forms: Inj (Sandostatin) 0.05, 0.1, 0.2, 0.5, 1 mg/ml; inj (LAR depot) 10, 20, 30 mg/5 ml SIDE EFFECTS CNS: Headache, dizziness, fatigue, weakness, depression, anxiety, tremors, seizure, paranoia CV: Sinus bradycardia, conduction abnormalities, dysrhythmias, chest pain, SOB, thrombophlebitis, ischemia, CHF, hypertension, palpitations ENDO: Hyperglycemia, ketosis, hypothyroidism, hypoglycemia, galactorrhea, diabetes insipidus GI: Diarrhea, nausea, abdominal pain, vomiting, flatulence, distention, constipation, hepatitis, increased LFTs, GI bleeding, pancreatitis, cholelithiasis GU: UTI HEMA: Hematoma of inj site, bruise INTEG: Rash, urticaria, pain; inflammation at inj site MS: Joint and muscle pain Contraindications: Hypersensitivity Precautions: Pregnancy (B), breastfeeding, diabetes mellitus, hypothyroidism, geriatric patients, children, renal disease PHARMACOKINETICS Absorbed rapidly, completely, peak ½ hr, half-life 1.7 hr, duration 12 hr, excreted unchanged in urine INTERACTIONS Increase: rejection—cycloSPORINE Drug/Food Decrease: absorption of dietary fat, vit B12 levels Drug/Lab Test Decrease: T4 NURSING CONSIDERATIONS Assess: • Growth hormone antibodies, IGF-1, 1-4 hr intervals for 8-12 hr post dose in acromegaly; 5-HIAA, plasma serotonin, plasma substance P in carcinoid; VIP in VIPomas • Thyroid function tests: T3, T4, T7, TSH to identify hypothyroidism • Fecal fat, serum carotene • Allergic reaction: rash, itching, fever, nausea, wheezing • For cardiac status: bradycardia, conduction abnormalities, dysrhythmias; monitor ECG for QT prolongation, low voltage, axis shifts, early repolarization, R/S transition, early wave progression Administer: IM route • Reconstitute with diluent provided; give into gluteal SUBCUT route • Rotate inj site; use hip, thigh, abdomen • Avoid using medication that is cold; allow to reach room temperature IV route • May use IV bolus if required; give over 3 min • To use by intermittent inf, dilute in 50-200 ml D5W, 0.9% NaCl; give 15-30 min • In an emergency carcinoid crisis, give rapid bolus Perform/provide: • Storage in refrigerator for unopened amps, vials; or room temperature for 2 wk, protect from light; do not use discolored or cloudy sol Evaluate: • Therapeutic response: relief of diarrhea in AIDS, improves symptoms in carcinoid or VIP tumors, data is insufficient if products decrease size/rate of tumor growth, decreasing symptoms of acromegaly Teach patient/family: • Regular assessments are required • Regarding SUBCUT inj if patient or other persons will be giving inj • To change position slowly to prevent orthostatic hypotension