MCC nursing Block 1 second exam

Perform a nursing assessment of spiritual health, using appropriate interview questions and observation skills.

***LOOK @ FOCUSED ASSESSMENT GUIDE 46-1 **Significant behavioral observations include sudden changes in spiritual practices (rejection, neglect, fanatical devotion), mood changes (frequent crying, depression, apathy, anger), sudden interest in spiritual matters (reading religious books or watching religious programs on television, visits to clergy), and disturbed sleep.

Apply the principles to prepare and safely administer medications via the oral, parenteral, enteral, topical, ophthalmic, otic, vaginal, rectal, and inhalation routes.

**LOOK AT TABLE 29-2**

Distinguish spiritual beliefs and practices of major religions practiced in the United States.

**LOOK AT TABLE 46-1

Identify risk factors for poor nutritional status.

A person's total daily energy expenditure is the sum of all the calories used to perform physical activity, maintain basal metabolism, and digest, absorb, and metabolize food. If a person's daily energy intake is equal to total daily energy expenditure, the person's weight will remain stable. However, if the energy intake is less than the energy expended, the person's weight will decrease. If the energy intake exceeds energy expenditure, weight will increase. basal metabolism: amount of energy required to carry out involuntary activities of the body at rest. Includes actions such as maintaining body temperature and muscle tone, producing and releasing secretions, propelling food through the gastrointestinal (GI) tract, inflating the lungs, and contracting the heart muscle. Because of their larger muscle mass, men have a higher basal metabolic rate (BMR) than women. body mass index (BMI): ratio of height to weight; provides an estimation of relative risk for diseases such as heart disease, diabetes, and hypertension but not for all groups. obesity: weight greater than 20% above ideal body weight waist circumference: a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight **LOOK AT TABLE 36-1** digestion: gastrointestinal system's breakdown process of food into particles small enough to pass into the cells and be used by the cells Adequate Diet Selection: Dietary Reference Intakes provide recommended nutrient intakes for use in a variety of settings. recommended dietary allowance (RDA): recommendations for average daily amounts of essential nutrients that healthy population groups should consume over time MyPlate food guidance graphic is part of a communication initiative based on the Dietary Guidelines for Americans to help consumers make better food choices to follow a healthy heating pattern across the lifespan, using a familiar image, a place setting for a meal. Food labels provide a significant amount of nutritional information for the consumer. Regulations that control food labels have always been controversial. FOOD INTAKE: v Decreased: anorexia (lack of appetite) v Increased: Obesity (BMI ≥30)

Use the nursing process to safely administer drugs.

ASSESS: One component of this is the medication history, which informs the medication reconciliation process. During the interview, the nurse can adapt questions to meet the patient's needs and level of understanding. Additional information to be assessed includes the patient's health status, current and past illnesses, laboratory test results, known drug allergies, and religious beliefs and/or cultural practices. DIAGNOSIS: Each nursing diagnosis statement identifies a patient problem and suggests expected patient outcomes. The etiology of the problem directs nursing interventions. Examples of nursing diagnoses: Ineffective health maintenance related to lack of knowledge about anticoagulant medication regimen Anxiety related to daily self-injection of insulin Disturbed body image related to effects of chemotherapy Constipation related to use of an opioid Risk for aspiration related to impaired swallowing of oral medications Deficient knowledge related to interactions between herbal remedies and prescribed medications Ineffective health management of medication regimen related to adverse drug effects, cost of medications, confusion, lack of motivation, visual impairment, complexity of regimen **LOOK AT GUIDE 29-1** PLANNING and OUTCOMES: Nursing measures for patients receiving medication are directed toward the patient's achievement of the following goals: Expected therapeutic effects will be demonstrated within a specified time frame Expected change in symptoms: for example, the patient's pain will be relieved, or vital signs will return to baseline Maintenance of therapeutic blood levels of medication The patient will demonstrate knowledge regarding his or her medications IMPLEMENT: Remain with the patient and make sure that the medication is taken. If the patient receives several drugs, offer them separately so that if one is refused or dropped, positive identification can be made and the drug can be recorded or replaced. Never leave medications at the bedside for the patient to take later. Record medication administration while or immediately after the patient takes the medication. **LOOK AT NANDA DX**

Explain nursing care necessary to meet needs in each level of Maslow's hierarchy.

As the nurse identifies and carries out interventions to help meet patients' needs, it is important to remember that Maslow's hierarchy is only a framework or guideline, and that, in actuality, each person sets his or her own priorities for needs. ***LOOK AT TABLE 4-1

Describe the influences of spirituality on everyday living, health, and illness.

Aspects of spirituality include the following: Spirituality is experienced as a unifying force, life principle, essence of being. Spirituality is expressed and experienced in and through connectedness with nature, the earth, the environment, and the cosmos. People express and experience spirituality in and through connectedness with other people. Spirituality shapes self-becoming and is reflected in a person's being, knowing, and doing. Spirituality permeates life, providing purpose, meaning, strength, and guidance, and shaping the journey. Meeting Spiritual needs: v Offering a compassionate presence v Assisting in the struggle to find meaning in the face of suffering, illness, and death v Fostering relationships that nurture the spirit v Facilitating patient's expression of religious or spiritual beliefs and practices presencing: standing in the presence of another consciously believing in—and affirming—his or her capacity for wholeness. faith: (1) spiritual dimensions of a person's life regardless of religious affiliation; (2) confident belief in something for which there is no proof or material evidence religion: organized system of beliefs about a higher power; often includes set forms of worship, spiritual practices, and codes of conduct agnostic: person who believes that nothing can be known about the existence of a god atheist: person who denies the existence of a god Hope and Faith: ingredients for positive outlook and connectedness with others hope: ingredient in life responsible for a positive outlook, even in life's bleakest moments

List what steps a nurse should incorporate in their practice to ensure safe medication administration & measures to take to prevent a medication error.

CHECK AND QUESTION MEDICATION ORDER · The patient's medication record, often called an MAR (medication administration record) is a complete list of all medications prescribed for the patient. The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original order, depending on the type of system in use. The nurse is also responsible for double-checking the dosage and appropriateness of the medication. · Nurses are legally responsible for the drugs they administer. When preparing to administer a medication, ask yourself why the patient is receiving the medication—is there a rationale you can provide as to why this medication has been prescribed? Do the therapeutic and pharmacologic classes link with your patient's condition(s)? If not, then ask the provider or pharmacist, and/or use an appropriate resource to further investigate. Positive identification of the patient is essential to safe drug administration. Before administering the drug, check carefully to see that the right drug is being given to the right patient. Handling Controlled Substances Safely: Although methods of recording may differ, the following information usually is required: Name of the patient receiving the controlled substance Amount of the substance used Hour the controlled substance was given Name of the prescribing provider Name of the nurse who administered the substance

Identify five factors that influence spirituality.

Developmental Considerations: Central themes in all the children's descriptions included the following: Notion of a God who works through human intimacy and the interconnectedness of lives Belief that God is involved in self-change and growth and transformations that make the world fresh, alive, and meaningful Attributing to God tremendous and expansive power and then showing considerable anxiety in the face of this power Image of light As the child matures, life experiences usually influence and mature the child's spiritual beliefs. Family: what they explicitly teach a child about spirituality and religion is generally less important than what the child learns about spirituality, life, and self from the parents' behavior. Ethnic Background: A person's culture and formal religion significantly affect whether the person's approach to religion is doing something, being someone, or continually striving for harmony. Formal Religion: Each religion shares several characteristics: Basis of authority or source of power Scripture or sacred word An ethical code that defines right and wrong A psychology and identity, so that its adherents fit into a group, and the world is defined by the religion Aspirations or expectations Ideas about what follows death Life Events: Both positive and negative life experiences can influence spirituality, and they in turn are influenced by the meaning a person's spiritual beliefs attribute to them.

Develop nursing diagnoses that correctly identify spiritual problems.

Diagnoses related specifically to spirituality are: Readiness for Enhanced Hope: A pattern of expectations and desires that is sufficient for mobilizing energy on a person's own behalf and that can be strengthened Hopelessness: Subjective state in which a person sees limited or no alternatives or personal choices available and is unable to mobilize energy on his or her own behalf Readiness for Enhanced Spiritual Well-Being: Ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than self Impaired Religiosity (or Risk for Impaired Religiosity): Impaired ability to exercise reliance on beliefs or participate in rituals of a particular faith tradition Readiness for Enhanced Religiosity: Ability to increase reliance on religious beliefs or participate in rituals of a particular faith tradition Spiritual Distress (or Risk for Spiritual Distress): Impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, or a power greater than oneself

Discuss the components of a nutritional assessment.

History taking Dietary, medical, socioeconomic data § Nutritional Screening: looks for cues associated with nutrition problems to determine if a person is malnourished or at risk for malnutrition. Mini Nutritional Assessment tool (MNA) is an example of a screening tool used to detect older adults at risk for malnutrition. § 24-hour recall method: Easiest way to collect dietary data. 24-hour recall of all food and beverages the patient normally consumes during an average day. This method includes the patient's portion sizes, meal and snack patterns, meal timing, and location where food is eaten. Because this method relies on memory and accurate interpretation of portion sizes, the information may not be reliable. § Food diaries/calorie counts: documentation of actual intake for a specified period of time. All food and beverages consumed in a specified period, usually 3 to 7 days, are recorded. § Food frequency record: A general picture of nutritional consumption. Ask questions to elicit an average number of times certain foods or food groups are consumed in a period of time: per day, per week, or per month. § Diet history: Full history to provide information on past and present food intake and habits. Physical assessments Anthropometric (measurement of body and its parts). These can provide on fat and protein stores. Height and weight are most common measurements, and used to calculate BMI. BMI and waist circumference. Clinical Data: Although signs and symptoms of altered nutrition may be observed during a physical assessment, they usually do not appear until the condition is advanced. In addition, further investigation is necessary to determine whether abnormal findings are actually caused by a nutritional deficiency, are possibly related to a nutritional deficiency, or are unrelated to nutritional status. § dysphagia: difficulty in swallowing or inability to swallow § aspiration: misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract **LOOK AT TABLE 36-2** Laboratory data Protein status, body vitamin, mineral, and trace element status **LOOK AT BOX 36-4**

Develop nursing diagnoses that correctly identify nutritional problems that may be treated by independent nursing interventions.

Imbalanced Nutrition as the Problem: The following nursing diagnoses may be made when imbalanced nutrition is the cause of the patient's disorder: Imbalanced Nutrition: Less Than Body Requirements Obesity Risk for Overweigh Imbalanced Nutrition as the Etiology: The nutritional problem is the cause of another problem. Fatigue Constipation Risk for Impaired Skin Integrity Readiness Diagnosis: Readiness for enhanced nutrition.

Follow guidelines for conducting a health history.

Information is collected during an interview with the patient, who is the primary source of data. The patient's family members and/or caregivers may also be an important source of data. The health records of the patient, if available, can also be used to collect additional information. Nurses should know and be sensitive to cultural differences that influence how both verbal and nonverbal communications are interpreted. Components of the health history include biographical data, the reason the patient is seeking health care, present health or history of present health concern, past health history, family history, functional health, psychosocial and lifestyle factors and review of systems. review of systems: physical examination of all body systems in a systematic manner as part of the nursing assessment v Biographical data: including the patient's name, address, and billing and insurance information. Additional biographical information includes biological sex, age and birth date, marital status, occupation, race, ethnic origin, religious preference, and the patient's primary health care provider. The source of the information is also recorded. v Reason for seeking health care: Ask an open-ended question, such as, "Tell me why you are here today." Try to record whatever the person has to say in the person's exact words. Avoid paraphrasing or interpreting. v History of present illness: Encourage patient to describe symptoms. The description should include information regarding the onset of the problem, location, duration, intensity, quality/description, relieving/exacerbating factors, associated factors, past occurrences, any treatments, and how the problem has affected the patient. v Past health history: A patient's past health history may provide insight into causes of current symptoms. This history should also include accidents or injuries, obstetric history, allergies, and the date of most recent immunizations. Ask about health maintenance screenings and medications taken. v Family history: Certain disorders have genetic links. Opportunities to understand current health, risk factors, teaching, and family counseling. v Functional health: Assess the patient's ability to perform activities of daily living (ADLs) or self-care activities. Eating, bathing, dressing, and toileting are examples of ADLs. Assess the patient's ability to perform instrumental activities of daily living (IADLs) or those needed for independent living. Housekeeping, meal preparation, management of finances, and transportation are examples of IADLs. v Psychosocial and lifestyle factors: May bring out strong, personal reactions so be non-judgmental. v Review of systems: The review of systems is a series of questions about all body systems that helps to reveal concerns or problems as part of the health history. Many times, these questions can be incorporated into the physical examination of each region.

Describe each level of Maslow's hierarchy of basic human needs.

Maslow's hierarchy is useful for understanding relationships among basic human needs and for establishing priorities of care. The hierarchy is based on the theory that something is a basic need if it has the following characteristics: Its lack of fulfillment results in illness. Its fulfillment helps prevent illness or signals health. Meeting it restores health. It takes priority over other desires and needs when unmet. The person feels something is missing when the need is unmet. The person feels satisfaction when the need is met. Physiological: for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. These needs are the most basic in the hierarchy of needs and the most essential to life, and therefore have the highest priority. Safety & Security: Physical and emotional safety. Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as the following: Using proper hand hygiene and sterile techniques to prevent infection Using electrical equipment properly Administering medications knowledgeably Skillfully moving and ambulating patients Teaching parents about household chemicals that are dangerous to children Emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Nurses can help meet such needs by encouraging spiritual practices that provide strength and support, by allowing as much independent decision making and control as possible, and by carefully explaining new and unfamiliar procedures and treatments. safety and security needs: person's need to be protected from actual or potential harm and to have freedom from fear Love & Belonging: understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Included are nursing interventions such as: Including family and friends in the care of the patient Establishing a nurse-patient relationship based on mutual understanding and trust (by demonstrating care, encouraging communication, and respecting privacy) Referring patients to specific support groups (such as a cancer support group or Alcoholics Anonymous) Self-esteem: The need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments. Positive self-esteem facilitates the person's confidence and independence. This is affected by change in role or body image. Nurses can help meet patients' self-esteem needs by respecting their values and beliefs, encouraging patients to set attainable goals, and facilitating support from family or significant others. Self-actualization: The need for people to reach their full potential through development of their unique capabilities. Maslow lists the following qualities that indicate achievement of one's potential: Acceptance of self and others as they are Focus of interest on problems outside oneself Ability to be objective Feelings of happiness and affection for others Respect for all people Ability to discriminate between good and evil Creativity as a guideline for solving problems and pursuing interests

Describe nursing interventions to promote health for middle and older adults.

Middle Adult: The following health-promotion activities are recommended: **Eat a diet low in fat and cholesterol, including fruits, vegetables, and fiber; use sugar, salt, and sodium in moderation. **Make regular exercise a part of life. **Drink alcohol in moderation, if at all. **Do not smoke. **LOOK AT NANDA-I FOR NURSING DX ^Be aware of appropriate health screenings needed. ^Older Adult: The nurse should teach the older adult patient and family general health-promotion activities. This is important because older people often believe themselves "too old" to worry about nutrition, exercise, health screenings, and immunizations. In addition to the recommended screenings, examinations, and immunizations, the following should be emphasized: **Eat a diet that includes all food groups; is low in fat, saturated fat, and cholesterol; balances calories with physical activity; has recommended amounts of fruits, vegetables, and grains; and uses sugar and salt in moderation. **Make exercise a part of daily activities. This will decrease your risk of falls and may improve your strength and focus. **Discuss with your primary provider whether to include a vitamin D supplement as part of your daily routine. Vitamin D may be used to treat or prevent osteoporosis. **Drink alcohol in moderation. **Do not smoke. **LOOK AT NANDA-I FOR NURSING DX **Illness can severely disrupt an older adult's ability to function independently. The ill patient is under increased physical and emotional stress, which increases the risk for complications because of the lack of physiologic reserves.

Develop teaching plans to meet the needs specific to medication administration.

ORAL: Absorption in the stomach and small intestine. The oral route is the most commonly used route of administration. Should not be administered, such as when the patient has difficulty swallowing, is unconscious, is to receive nothing by mouth, or is vomiting. Includes the following: • Solid form: tablets, capsules, pills. Tablets can be cut or crushed but DO NOT do this to Enteric coated, SR (sustained release), ER (extended release), CR or CRT (controlled release), SA (sustained action), or LA (long acting). • Liquid form: elixirs, spirits, suspensions, syrups • Oral route: having patient swallow drug • Enteral route: administering drug through an enteral tube • Sublingual administration: placing drug under tongue (such as nitroglycerin) • Buccal administration: placing drug between tongue and cheek PARENTERAL (outside the intestines or alimentary canal): · Equipment criteria for injections: o Route of administration: A longer needle is required for an intramuscular injection than for an intradermal or a subcutaneous injection. See the discussion related to each individual route for specific guidelines regarding needle length and gauge. o Viscosity of the solution: Some medications are more viscous than others and require a needle with a large lumen to inject the drug. o Quantity to be administered: The larger the amount of medication to be injected, the larger the syringe needs to be. Smaller syringes should be used as needed for precise dosing because they provide smaller increments of measurement—never estimate a dose. For example, a 1-mL syringe provides increments of 0.02 mL, but a 5-mL syringe allows for precise measures only down to 0.2 mL. o Body size: An obese person requires a longer needle to reach muscle tissue than does a thin person. A thin person or an older adult with decreased muscle mass requires a shorter needle. Needle gauges are numbered 18 through 30. As the diameter of the needle increases, the gauge number decreases. For example, an 18-gauge needle is larger in diameter than a 30-gauge needle. o Type of medication: There are special syringes for certain uses. An example is the insulin syringe used only to inject insulin. DO NOT RECAP NEEDLES. o Medications for injection can be removed through ampule (1 dose), removed through vial (several doses, 24 hour time of use), prefilled cartridge or syringe, mixed medications in one syringe (compatibility), mixing insulin, and reconstituting powders (add liquid). · Subcutaneous Injection (subcutaneous tissue): adipose tissue layer just below the epidermis and dermis; slow, sustained rate of absorption due to few blood vessels, includes insulin and heparin. Sited include outer aspect of the upper arm (absorbed slowest), the abdomen (from below the costal margin to the iliac crests; absorbed quickest), the anterior aspects of the thigh, the upper back, and the upper ventral or dorsogluteal area. 25- to 30-gauge, 3/8″ to 1″ needle (3/8" and 5/8" most commonly used). 45-90 degrees (45 for 5/8" and smaller patients, 90 for 3/8"). o Procedure: assess the angle, pinch or bunch skin for administration to lift adipose tissue away from underlying muscle/tissue. If blood or clear fluid appears at the site after withdrawing the needle, apply gentle pressure. Do not massage site. Rotate sights of injection if frequent to prevent buildup of fibrous tissue and permits complete absorption. · Intramuscular Injection (muscle tissue): through skin and subcutaneous tissues into muscles. Faster onset due to larger blood vessels, longer duration of effect. · Sites of administration: If care is not taken, possible complications include abscesses; cellulitis; injury to blood vessels, bones, and nerves; lingering pain; tissue necrosis; and periostitis (inflammation of the membrane covering a bone). Avoid any site that is bruised, tender, hard, swollen, inflamed, or scarred. After using the appropriate landmarks, always palpate the muscle to ensure the location identified is appropriate for each individual patient. Consider the age of the patient, medication type, and medication volume when selecting a site for intramuscular injection. o Ventrogluteal Site (A): involves the gluteus medius and gluteus minimus muscles in the hip area; this is a large muscle mass that is relatively free from major nerves and blood vessels, the area is clean (fecal contamination is rare at this site), and the patient can be on the back, abdomen, or side (preferred) for the injection. o Vastus lateralis Site (B): involves the quadriceps femoris muscle and is located along the anterolateral aspect of the thigh. There are no large nerves or vessels in its proximity, and it does not cover a joint. o Deltoid muscle Site (C): lateral aspect of the upper arm. It is the recommended site for vaccines for adults and may be used for children between 3 and 18 years of age for vaccine administration. o Dorsogluteal site discontinued due to sight having altered drug absorption because of subcutaneous tissue covering, causes tissue irritation, can cause significant injury (pain, partial or full paralysis), and it is near the gluteal artery. · Procedure: The volume of medication that can be administered intramuscularly varies based on the intended site. In general, 1 to 5 mL is the accepted volume range. The less-developed muscles of children and older adults limit the intramuscular injection to 1 to 2 mL. Needle gauge: Aqueous is 20-25 and oil-based 18-25 and done at 90 degree angle. **LOOK AT TABLE 29-5** Z-track technique: technique used to administer medications intramuscularly that ensures that the medication does not leak back along the needle track and into the subcutaneous tissue, reducing pain and discomfort. Suggested for older adults with decreased muscle mass. Attach a clean needle to the syringe after the syringe is filled with the medication to prevent the injection of any residual medication on the needle into superficial tissues. Pull the skin down or to one side about 1″ (2.5 cm) and hold in this position with the nondominant hand. Insert the needle and inject the medication slowly. Withdraw the needle steadily and release the displaced tissue to allow it to return to its normal position. Massage of the site is not recommended because it may cause irritation by forcing the medication to leak back into the needle track. However, gentle pressure may be applied with a dry sponge. · Intradermal Injection (Corium, under epidermis): in dermis below epidermis; longest absorption time of all parenteral routes, used for sensitivity tests. Sites commonly used include inner surface of the forearm and the upper back, under the scapula. 1/4" to ½",25 or 27 gauge needle. Angle of administration 5-15 degrees. · Intravenous: most dangerous route since directly into bloodstream. Used in most emergency situations when immediate onset of action is required, but also nonemergency clinical situations. Aseptic technique required. Done via solution (infusion; over long time period), bolus or push (single injection directly into line), intermittent infusion (drug mixed with solution and administered over time like 50-100 ml per 4 hours and includes Piggyback delivery solutions. TOPICAL: intended for direct action at a particular site, although some can have systemic effects and are given for systemic effect. The action depends on the type of tissue and the nature of the agent. · Skin: creams, lotions, ointments, or pre-medicated patches. Apply directly to the surface of the body or body cavities. Wear gloves, check for other patches if necessary and skin irritation or rash before appliance. **LOOK AT BOX 29-3** · Eyes: instillations, irrigations, ointments, drops, and medication discs. Eye drops or ointments are administered in the lower conjunctival sack of the eye. First assess the patient's eyes prior to administering the drops or ointments. Then apply the medication using clean gloves, and position our patients supine or have them tilt their head back. You can hand them a tissue for excess fluid run off, but don't let them wipe out the drops or ointments. · Ears: instillations, irrigations, and drops. Assessment, then prepare the solution by slightly warming it. For adults to straighten the ear canal you pull up and out. For children you pull down and back. Place them on their side and have them keep the installation in the ear for about 2-3 minutes so it can work. If they get up too quick the solution can run out of their ear. · Nasal: assessment; nasal installation of medications most of the time is easier to teach the patient how to do it, then have the patient do it with your cueing. If it is a certain sinus cavity that needs the medication, position them to reach that area. Teach patients not to abuse over the counter nasal medications like Afrin. Patients can develop a dependency on these and not be able to have clear sinus cavities without them. Make sure the patient's mucous membranes are not getting irritated with the medications, as nosebleeds would be the result of that. Avoid nose blowing 5-10 minutes after. VAGINAL: suppositories, foams, creams, and tablets. The normal mucous membrane is its own best protection. If application is needed, prep the patient by making them comfortable and modest. Put them in a dorsal recumbent position, draped, and nurse will wipe off any excess medication after administration. Insert the plunger 2-3 inches and then push the medication in. For suppositories place them in the whole length of your finger. Have the patient stay in that position for about 5-10 minutes so the medication can get absorbed and not drip out. RECTAL: Normally suppository. Assess for bleeding or hemorrhoids, prep patient by placing them in the Sims position and making sure they are comfortable, and covered up. Use lubricating jelly on the suppository and your finger. It is a natural response to try to close that sphincter when touched, ask them to take a few slow deep breaths and try to relax. Insert the suppository about 2-3 inches and have them lay flat or on their side for 5 minutes. Make sure the call light is in reach, or stay with the patient if expecting a bowel movement from the medication. RESPIRATORY: drugs for inhalation. Drug dosage is difficult to establish. Respiratory Inhalation administration of medications is done by producing a mist, fog or spray from a liquid drug, and then inhaling it. This is also called nebulization. The alveoli absorb the drug through the capillary system, and into the blood stream. Atomizers turn the liquid into droplets. Aerosols turn the liquid into a gas. Metered dose inhalers or MDI delivers a measured dose of fine droplets. Make sure to shake the canister, place the mouth piece in front of the mouth or around it, and inhale slowly and deeply for 3-5 seconds, and possibly have the patient hold the breath for up to 10 seconds to allow the medication to disperse throughout the lung fields. A spacer lets the medication expand prior to being inhaled so it enhances the distribution of the medication. Dry powder medications are also dispensed with a pre-determined amount of medication with each dose, and a certain number of doses in each canister. You want to instruct your patients to wait at least 20-30 seconds between inhalations to allow the medication to disperse and start to enter the bloodstream. You also want to teach your patients to rinse their mouth after administering the medication because these medications if left in the mouth have a tendency to create an environment where candida or thrush can develop. DOCUMENT MEDICATION ADMINISTRATION: this is a legal document. Do not do before the medication has been administered. • Name of the medication • Dosage • Route and time of administration • Name of person administering medication • Site used for an injection • Intentional or inadvertently omitted drugs • Refused drugs • Medication errors TYPE OF MEDICATION ERRORS: Medication errors often occur at points of transition in care: on admission to a hospital, at transfer from one department to another, and at discharge home or to another facility. The principal cause of medication error at these times is the incorrect or incomplete transfer of medication information • Inappropriate prescribing of the drug • Extra, omitted, or wrong doses • Administration of drug to wrong patient • Administration of drug by wrong route or rate • Failure to give medication within prescribed time • Incorrect preparation of drug • Improper technique when administering drug • Giving drug that has deteriorated IF A MEDICATION ERROR OCCURS: • Check patient's condition immediately; observe for adverse effects. • Notify nurse manager and primary care provider. • Write description of error and remedial steps taken on medical record. Complete form used for reporting errors, as dictated by the facility policy PATIENT EDUCATION: • Review techniques of medication administration. • Remind the patient to take the medication as prescribed for as long as prescribed. • Instruct the patient not to alter dosages without consulting a physician. Caution the patient not to share medications. **LOOK OVER MEDICATION CHART**

Conduct a physical assessment in a systematic manner.

POSITIONS USED IN PHYSICAL ASSESSMENT: Refer to box 26-3 v Standing: assessment of posture, balance, and gait v Sitting: allows visualization of upper body v Supine: allows relaxation of abdominal muscles v Dorsal recumbent: used for patients having difficulty maintaining supine position v Sim's: assessment of rectum or vagina v Prone: assessment of hip joint and posterior thorax v Lithotomy: assessment of female genitalia and rectum v Knee-chest: assessment of anus and rectum Equipment Used: v Thermometer and sphygmomanometer v Scale v Penlight v Eyechart v Stethoscope v Metric tape measure and ruler v Watch with sweeping hand Assess Level of Awareness: v Time: What is today's date? What day of the week is it? What season of the year is this? What was the last holiday? v Place: Where are you now? What is the name of this city? What state are we in? v Person: What is your name? How old are you? Who came to visit you this morning? General Survey: v Health History (identify risk factors) · History of changes in weight · History of pain or discomfort · Sleeping patterns, difficulty sleeping v General appearance and behavior · Inspect body build, posture, and gait · Hygiene and grooming · Mood and mental health through speech, facial expressions, ability to relax, eye contact, and behavior v Vital signs · Establish a baseline for the database and to detect actual or potential health problems · PAIN is also considered v Height, weight · Overall health and potential overnutrition or undernutrition. v Calculating BMI, waist circumference · Ratio of weight to height. BMI is used as an initial assessment of nutritional status, and is an indicator of obesity or malnutrition. BMI also provides an estimation of relative risk for some diseases, such as heart disease, high blood pressure, type 2 diabetes, and certain cancers Health Assessment: v Integument: skin, nails, hair, and scalp. Performed by INSPECTION and PALPATION · Assessment for melanoma and skin cancer (Asymmetry, Border, Color, Diameter, Evolving) · Identify Risk Factors: o History of rashes, lesions, change in color, or itching o History of bruising or bleeding in the skin o History of allergies to medications, plants, foods, or other substances o Exposure to the sun and sunburn history o History of bathing routines and products o Presence of lesions (wounds, bruises, abrasions, or burns) o Presence of body piercings and/or tattoos o Change in the color, size, or shape of a mole o Exposure to chemicals that may be harmful to the skin, hair, or nails o Degree of mobility o Types of food eaten and liquids consumed each day o Cultural practices related to skin · Inspect Skin Color: **LOOK AT TABLE 26-1 · Inspect Skin Vascularity and Lesions: Inspect for vascularity, bleeding, or bruising; these signs might relate to a cardiovascular, hematologic, or liver dysfunction. ecchymosis: collection of blood in subcutaneous tissues that causes a purplish discoloration. petechiae: small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure · Palpate Skin for temperature, texture, moisture, and turgor edema: accumulation of fluid in extracellular spaces diaphoresis: an excessive amount of perspiration, such as when the entire skin is moist turgor: tension of the skin determined by its hydration · Inspect the nails for shape, angle, texture, and color. · Inspect hair and scalp: Assess the hair for color, texture, and distribution and the scalp for color, dryness, scaliness, lumps, lesions, or lice. Common skin variations in the older adult include: · Wrinkles, dryness, scaling, decreased turgor · Raised dark areas (senile keratosis) · Flat, brown age spots (senile lentigines) · Small, round red spots (cherry angioma) · Fine, brittle gray or white hair · Hair loss · Coarse facial hair in women, decreased body hair in men and women · Thick, yellow toenails v Head and neck: includes eyes, ears, nose, sinuses, mouth and pharynx, neck · Inspecting and palpating head and face: Inspect the face for color, symmetry, and distribution of facial hair. Edema of the face, especially around the eye (periorbital edema), and involuntary facial movements (e.g., tics, tremors) are abnormal findings. · Inspecting External Eye Structures. Inspect the eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, and iris for position and alignment. · Assessing Visual Acuity, Extraocular Movements, and Peripheral Vision. Assess visual acuity with the Snellen chart. Have the patient stand 20 ft from the chart and ask the patient to read the smallest line of letters possible, first with both eyes and then with one eye at a time (with the opposite eye covered). Test near vision with a handheld vision screen with varying sizes of print. Test extraocular movements by assessing the cardinal fields of vision for coordination and alignment. · Assess the external ear by inspection and palpation: Inspect for shape, size, and lesions and palpate for pain, edema, or presence of lesions. · Assessing Hearing and Sound Conduction: Hearing screening tests that are proven to be useful include the whisper test, audiometer (formal evaluation of hearing that measures hearing at frequencies varying from low pitches to high pitches), and self-report questionnaires. · Inspecting the Nose: Examine the external nose, the nares, and the turbinates. Palpate the sinuses through the frontal and maxillary sinuses, located in the frontal and maxillary bones, respectively, are palpated for pain and edema. · Mouth and Pharynx: include the lips, tongue, teeth, gums, hard and soft palate, salivary gland, tonsillar pillars, and tonsils. · Inspecting and Palpating the Neck: Assessments of the neck include the trachea, lymph nodes, and thyroid gland. Common head and neck variations in the older adult include: · Impaired near vision (presbyopia) · Decreased color vision and peripheral vision · Decreased adaptation to light and dark · A white ring around the cornea (arcus senilis) · Entropion (eyelid turns inward) and ectropion (eyelid turns outward) · Hearing loss (presbycusis) · Elongated ear lobes · Decreased neck ROM · Smaller, more easily palpated lymph glands v Thorax and lungs: lungs, rib cage, cartilage, and intercostal muscles. · Health History and prepare equipment (stethoscope and watch): Techniques used are inspection, palpation, percussion, and auscultation. · Inspect and Palpate thorax: observe chest for color, shape or contour, breathing patterns, and muscle development. Palpate to detect areas of sensitivity, chest expansion during respirations, and vibrations (fremitus). · Auscultating Breath Sounds: Auscultation is used to detect airflow within the respiratory tract. bronchial breath sounds: those heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration bronchovesicular breath sounds: normal breath sounds heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration vesicular breath sounds: normal sound of respirations heard on auscultation over peripheral lung areas adventitious breath sounds: abnormal breath sound heard over the lungs ***LOOK AT TABLE 26-4 Common thorax and lung variations in older adults include: · Increased anteroposterior chest diameter · Increase in the dorsal spinal curve (kyphosis) · Decreased thoracic expansion · Use of accessory muscles to exhale v Cardiovascular and peripheral vascular systems: assessment of the heart and the extremities. Identify signs and symptoms of heart disease and peripheral vascular disease (most often found in the lower extremities). Peripheral vascular assessment includes measuring the blood pressure and assessing the skin and perfusion of the extremities and the peripheral pulses. Assessments are made by inspection and palpation, with the patient sitting or supine. · Neck and Precordium: Observe the neck and precordium (the portion of the body over the heart and lower thorax, encompassing the aortic, pulmonic, tricuspid, and apical areas, and Erb's point) for visible pulsations. Palpate carotid artery. Normal findings include equal pulses bilaterally, with a strength of +2. · Auscultate Carotid Arteries: Using the bell of the stethoscope, auscultate over the carotid arteries for bruits, abnormal "swooshing or blowing" sounds heard over a blood vessel, caused by blood that is swirling in the vessel rather than normal smooth flow. · Auscultating Heart Sounds: beginning at the aortic area, moving to the pulmonic area, then to Erb's point, then to the tricuspid area, and finally to the mitral area. Listen for heart sounds caused by closure of the heart valves. · Inspect Extremities and Palpate Peripheral Pulses and Capillary Refiill: assesses the pulse to the body. Common cardiovascular and peripheral vascular variations in older adults include: · Difficult-to-palpate apical pulse · Difficult-to-palpate distal arteries · More prominent and tortuous blood vessels; varicosities common · Increased systolic and diastolic blood pressure · Widening pulse pressure v Breasts and axillae: Primary focus on female breast but also can be with male · Inspect: Inspect the breasts for size, shape, symmetry, color, texture, and skin lesions. Inspect the areola and nipples for size and shape and the nipples for discharge, crusting, and inversion. · Palpate the breasts/axillae: In each of the four quadrants (the upper outer quadrant, the lower outer quadrant, the upper inner quadrant, and the lower inner quadrant) to detect any abnormal lumps Common breast and axillae variations in older adults include: · Granular, pendulous breasts in women v Abdomen: Includes the stomach, the small intestine, the large intestine, the liver, the gallbladder, the pancreas, the spleen, the kidneys, and the urinary bladder. The abdominal cavity also contains the female reproductive organs. Abdominal assessments are also used to assess for the presence of bowel sounds (e.g., the return of bowel sounds after surgery) and retention of urine in the urinary bladder. Use Stethoscope. v The abdomen can be divided into four quadrants: right upper, right lower, left upper, and left lower. The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. · Inspect: Inspect skin color and surface characteristics, including the umbilicus, contour, symmetry, peristalsis, pulsations, and visible masses. · Auscultate Bowel and Vascular Sounds: Using light pressure, place the flat diaphragm on the right lower quadrant of the abdomen, then move to right upper quadrant, left upper quadrant, and finally to the left lower quadrant. Listen carefully for bowel sounds (gurgles and clicks), and note their frequency and character (usually occur every 5 to 34 seconds). · Palpate: The pads of the fingers are used to palpate with a light, gentle, dipping motion. Watch for nonverbal signs. Common abdominal variations in older adults include: · Decreased bowel sounds · Decreased abdominal tone · Fat accumulation on the abdomen and hips v Musculoskeletal system: bones, muscles, cartilage, ligaments, tendons, and joints. Do in sitting or supine position. · Understand the following risks: o History of trauma, arthritis, or neurologic disorder o History of pain or swelling in the muscles and/or joints o Frequency and type of usual exercise o Dietary intake of calcium o History of any surgery on muscles or joints o History of smoking (how long, how many packs/day) o History of alcohol intake · Inspect and Palpate Muscles: Test muscle tone and strength. Muscle groups are observed for bilateral symmetry and palpated for tenderness. · Palpating Bones: For normal contour and prominence and for bilateral symmetry. · Inspecting and Palpating Joints: Each joint is put through its full ROM to assess the degree of movement. Joint movements include flexion, extension, hyperextension, abduction, adduction, supination, and pronation. Normally, each joint has full ROM, is nontender, and moves smoothly. · Inspect Spinal Curves: inspect the spine from the back and from the side. The spine normally has concave curves at the cervical and lumbar spine and convex curves at the thoracic and sacrococcygeal spine. Kyphosis (an increased thoracic spinal curve) is more often seen in older adults. Common musculoskeletal variations seen in older adults include: · Loss of muscle mass and strength · Decreased ROM · Kyphosis · Decreased height · Osteoarthritic changes in joints v Neurologic system: Includes cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes. · Identify risk factors for altered health during the health history by asking about the following: o History of numbness, tingling, or tremors o History of seizures o History of headaches or dizziness o History of trauma to the head or spine o History of high blood pressure or stroke o Changes in the ability to hear, see, taste, or smell o Loss of ability to control bladder and bowel o History of smoking (how long, how many packs/day) o History of chronic alcohol use o History of diabetes mellitus or cardiovascular disease o Use of prescription and over-the-counter medications · Evaluate cerebral function by observing the patient's behavior throughout the health history interview and physical assessment. · Assess the patient's mental status, memory, emotional status, cognitive abilities, and behavior. · Evaluate cerebellar function by assessing motor skills, coordination, and balance. · Assess the sensory system by having the patient identify various sensory stimuli, and evaluate the reflexes by contraction of specific muscles. · Mental status assessment includes level of consciousness, level of awareness, behavior and appearance, memory, and language. On initial contact, begin to evaluate the patient's orientation to person, place, and time, as well as cognitive abilities and affect (whether the patient knows who he or she is, where he or she is, and the day or month or year). Observe the patient's appearance, general behavior, ability to speak clearly, and their ability to respond to questions. · Assessing Level of Consciousness: o Awake and alert: fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands o Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name o Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements o Comatose: cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma · The Glasgow Coma Scale (GCS) assess eye opening, motor response, verbal response. · Full Outline of Unresponsiveness (FOUR) scale assesses eye response, motor response, brainstem reflexes, respiration. Common neurologic variations for older adults include: · Slower thought processes and verbal responses · Decreased sensory ability (hearing, sight, smell, taste, temperature, pain) · Slower coordination and voluntary movements · Decreased reflex responses · Appearance of confusion in unfamiliar surroundings · Slower gait, with a wider base and flexed hips and knees

Identify different types of medication orders & the components of a medication order/prescription.

PRESCRIPTIONS and ORDERS • Prescription (outpatient) = Order (inpatient); provider communicates information regarding medications (and other procedures and therapies) to the health care team. • Medication administration requires a written order from a licensed practitioner: nurse follows only a written or typed order, or an order entered into a computer order-entry system because these types of orders are less likely to result in error or misunderstanding. The legal implications for dispensing and administering an agent without a written order vary, and nurses must be familiar with the exact facility policy whenever called on to administer therapeutic agents. • Computer provider order-entry (CPOE) system: allow the prescribing provider to enter medication orders in a standard format and guides the prescriber in complete, accurate, and appropriate prescribing. Sends the prescription directly to the pharmacy and enters the prescription into the patient's permanent record. This prevents any guessing when handwriting is illegible or drug names are similar. • For safety send all medications the patient brought from home back with a relative. Usual hospital policy dictates that when a patient is admitted, unless specific orders to the contrary are written, all drugs that may have been prescribed while the patient was at home are discontinued. • Medication reconciliation: a process used by the health care team where the current medication orders are compared to patient report, the patient's medical record, and prescriptions that may have been in place prior to the transition of care. Informs patients of the importance of maintaining an accurate medication list, and comparison of medications taken with the newly prescribed medications to prevent duplications, omission, or interactions. TYPE OF ORDERS · Standing order (routine order): carried out until cancelled by another order · PRN order: as needed, commonly for treatment of symptoms; receives medication when it is requested or required, and when the specifics of the order (particularly clinical parameters or timing between doses) are met. · Single or one-time order: for example, immediately before surgery · Stat order: carried out immediately PARTS OF MEDICATION ORDER The medication order consists of seven parts: Patient's name and a secondary identifier (date of birth, medical record number) Date and time the order is written Name of drug to be administered Dosage of the drug Route by which the drug is to be administered Frequency of administration of the drug Signature of the prescribing provider Medication orders require the drug, dose, rate, route, frequency, and, when appropriate, duration to be explicit and specific to the needs of the patient in order to achieve the desired outcome. MEDICATION SUPPLY SYSTEMS: • Stock supply • Individual unit dose supply • Medication cart • Computerized automated dispensing system • Bar code-enabled medication cart (BCMA)

Describe how nutrition influences growth and development throughout the life cycle.

Physiologic and physical factors: stage of development, state of health, medications Physical, sociocultural, and psychosocial factors influencing food choices: Economics, culture, religion, tradition, education, politics, social status, food ideology Adults: Growth ceases, decline in BMR, become more aware of the preventive role of exercise, or pressures of work and family may lead to a decline in physical activity and exercise, fewer caloric intake and adjustments if weight is gained. Pregnant and Lactating Women: Nutrient needs during pregnancy increase to support growth and maintain maternal homeostasis, particularly during the second and third trimesters. During the second trimester, normal-weight women need approximately 340 extra calories per day and 450 extra calories per day in the third trimester than when not pregnant. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. Caloric needs are higher for lactation than pregnancy, and the nutritional quality of breast milk is maintained at the expense of maternal nutrition if dietary intake is inadequate. Older Adults: energy intake decreases, chewing can be more difficult, decrease in peristalsis leading to constipation, loss of taste, thirst sensation decreases. It is not uncommon for social isolation, poor self-esteem, or loss of independence to affect nutritional intake negatively. CALORIC NEEDS DECREASE and NUTRIENT NEEDS INCREASE Other factors include the following: v Gender: differences in body composition and reproductive function. Men require higher caloric and protein requirements, women require higher iron requirements. v State of health: Dependent on illness (fever) and trauma (surgery) varies with the intensity and duration of the stress. Also includes chronic disorders and mental health problems. v Alcohol abuse: Alcohol can alter the body's use of nutrients, and nutrient requirements by numerous mechanisms. The toxic effect of alcohol on the intestinal mucosa interferes with normal nutrient absorption. B vitamins needed and liver damage. v Medications: Nutrient absorption may be altered by drugs that (1) change the pH of the GI tract, (2) increase GI motility, (3) damage the intestinal mucosa, or (4) bind with nutrients, rendering them unavailable to the body. Nutrient metabolism can be altered by drugs that (1) act as nutrient antagonists, (2) alter the enzyme systems that metabolize nutrients, or (3) alter nutrient degradation. v Megadoses of nutrient supplements: Dietary supplements can have drug-like effects and may interact with other nutrients, food, and medication. Physical, sociocultural, and Psychosocial factors that influence food choices include: Economic Factors, Religion, Meaning of Food, Culture, Illiteracy, Language barriers, Knowledge of nutrition, Lack of caregiver or social support, Social isolation, Limited ability to obtain or purchase food, Lack of or inadequate cooking and/or food preparation arrangements.

Plan, implement, and evaluate nursing care related to select nursing diagnoses involving spiritual problems.

Plan: Enhance Spiritual Health: Show you value spiritual health by being sensitive to the role that spiritual beliefs play in influencing both a person's thoughts about self and the world and his or her interactions with the world. The patient will: Identify spiritual beliefs that meet needs for meaning and purpose, love and relatedness, and forgiveness Derive from these beliefs strength, hope, and comfort when facing the challenge of illness, injury, or other life crisis Develop spiritual practices that nurture communion with inner self, with God or a higher power, and with the world Express satisfaction with the compatibility of spiritual beliefs and everyday living Addressing Spiritual Distress: Goals and expected outcomes for patients in spiritual distress need to be individualized and may include a patient achieving some of the following: Exploring the origin of spiritual beliefs and practices Identifying factors in life that challenge spiritual beliefs Exploring alternatives given these challenges: denying, modifying, or reaffirming beliefs; developing new beliefs Identifying spiritual supports (e.g., spiritual reading, faith, community) Reporting or demonstrating a decrease in spiritual distress after successful intervention Implement: Maintain professional boundaries: Keep the spiritual history patient centered. Recognize pastoral care professionals as experts in this field and consult them appropriately. Proselytizing is never acceptable in professional settings. Addressing spiritual issues should not be coercive. More in-depth spiritual counseling should be under the direction of chaplains and other spiritual leaders. Praying with patients should not be initiated by the nurse unless there is no pastoral care available and the patient requests it, or in situations in which the nurse and patient have a long-standing relationship or share a similar belief system. The nurse can stand in silence as the patient prays in her or his tradition. The nurse can always make a referral to pastoral care for chaplain-led prayer. Evaluate: In general, the nurse evaluates the patient's ability to accomplish the following: Identify some spiritual belief that gives meaning and purpose to everyday life Move toward a healthy acceptance of the current situation: illness, pain, suffering, impending death Develop mutually caring relationships Reconcile any interpersonal differences causing the patient anguish Verbalize satisfaction with his or her relationship with God or a higher being (if important to the patient) Express peaceful acceptance of limitations and failings Express the ability to forgive others and to live in the present Demonstrate an "interior state of peace and joy; freedom from abnormal anxiety, guilt, or a feeling of sinfulness; and a sense of security and direction in the pursuit of one's life goals and activities"

Plan, implement, and evaluate nursing care related to select nursing diagnoses that involve nutritional problems.

Planning and implementation are described through the other questions. Evaluation: The effectiveness of the plan of care is evaluated as the last step in the nursing process. On an ongoing basis, the nurse accomplishes the following: Evaluates the patient's progress toward meeting nutritional outcomes Evaluates the patient's tolerance and adherence to the prescribed diet, when appropriate Assesses the patient's level of understanding of the diet and/or dietary-related interventions and the need for further instruction or reinforcement Communicates findings to other members of the health care team Revises the plan of care, as needed, or terminates nursing care

Prepare the patient and the environment for a health assessment.

Prepare the patient and the environment for a health assessment. v Consider the physiologic and psychological needs of the patient. v Explain the process to the patient. v Explain that physical assessments will not be painful (decrease patient fear and anxiety). v Explain each procedure in detail as it is conducted. v Ask the patient to change into a gown and empty bladder. v Answer patient questions directly and honestly. Lifespan Considerations: comprehensive assessment includes cognitive, psychosocial, and emotional development in addition to physical growth. Cultural Considerations and Sensitivity: Nurses must consider patients within the context of family, culture, and community. Nurses and other health care professionals need to provide health care services in a sensitive, knowledgeable, and nonjudgmental manner with respect for people's health beliefs and practices. Patient Preparation: Consider and remain sensitive to the patient's physiologic needs (e.g., pain or decreased stamina because of age or illness) and psychological needs (e.g., anxiety about having the examination). Explain the first part of the assessment will involve questions about the patient's health concerns, health habits, and lifestyle and that the information will only be shared with the patient's other health care providers. Inform the patient that after the health history is completed, body structures will be examined. Answer questions directly and honestly. Environmental Preparation: Privacy and respect for the patient are primary concerns when conducting a health assessment. In an outpatient setting, such as a clinic or primary care provider office, separate examination rooms provide a quiet, private space for assessment. Prepare the examination room before the health assessment is conducted by preparing the examination table, providing a gown and drape for the patient, and gathering instruments and special supplies needed for the assessment. v Agree on a time for the assessment. o The time should not interfere with meals, daily routines, or visiting hours. v Make sure patient is as free of pain as possible. v Provide a gown and drape for the patient. v Gather the supplies and instruments needed. v Provide a curtain or screen if the area is open to others.

Document health assessment findings in a concise, descriptive, and legally appropriate manner.

Purposes of Documentation: v Identify actual and potential health problems v Make nursing diagnoses v Plan appropriate care v Evaluate patient's responses to treatment If it isn't documented, it didn't happen. Describe nursing responsibilities before, during, and after diagnostic procedures. v Assist before, during, and after diagnostic tests. v Be responsible for other activities associated with diagnostic tests. v Witness the patient's consent. v Schedule the test. v Prepare the patient physically and emotionally for the test. v Provide care and teaching after the test. v Dispose of used equipment. v Transport specimens.

Describe nursing interventions to help patients achieve their nutritional goals.

Teaching nutritional information: For the greatest chance of success, tailor nutrition instructions individually to the patient's lifestyle, culture, intellectual ability, and level of motivation. Simplicity and compromise are often the keys to patient compliance. Include food safety issues. Monitoring nutritional status: Prevention of malnutrition can have a positive effect on patient outcomes. Help advance the patient's diet. Stimulating appetite: Pain, illness, anxiety, and medications can contribute to anorexia and poor intake. The following measures may help to stimulate appetite in any setting: o Serve small, frequent meals to avoid overwhelming the person with large amounts of food. o Solicit food preferences and encourage favorite foods from home or prepared when at home, if possible. o Provide encouragement and a pleasant eating environment. o Be sure that any prepared food looks attractive. o Schedule procedures and medications at times when they are least likely to interfere with appetite. o Control pain, nausea, or depression with medications. o Offer alternatives for items that a person cannot or will not eat. o Encourage or provide good oral hygiene. Ensure that the patient's dentures are well-fitting and in place, if applicable. o Remove clutter from the eating area. o Keep eating area free from irritating odors. o Arrange food tray so that a person can easily reach food. o Provide a comfortable position. · Assisting with eating: The loss of independence with the inability to self-feed can be a severe blow to a person's self-esteem. You can help maintain dignity by: o Involve the person as much as possible. Solicit the patient's preferences regarding the order of items eaten and the eating pace. o Provide appropriate drinks. o Sit at the patient's eye level and make eye contact to create a more relaxed, person-centered atmosphere. o Engage the person in pleasant conversation to ease tension. o Place a napkin, not a bib, over the person's clothes for protection. o Use straws or special eating utensils whenever possible. o Ensure that if a person wears dentures, hearing aids, or glasses, they are in place before mealtime. o Open containers, cut meat, or apply condiments to the prepared food only if the person wishes. When assisting visually impaired patients: o Explain placement of foods on plates and food tray. Relating items on plate to the location on a clock face may be helpful. o Provide special plate guards, utensils, double handles, and compartmentalized plates. o Place foods and dishes in similar locations at each meal. o Use straws for beverages, if not contraindicated by the presence of dysphagia. o Provide supervision as needed Providing oral nutrition: Oral diets may be categorized as regular, modified consistency, or therapeutic. Regular, regular vegetarian, and modified consistency diets are outlined here. o Normal or House Diets: The diet's actual composition and nutritional value varies with the quantity and types of food selected by the patient. No foods are excluded. Portion sizes are not limited. Regular diets are adjusted to meet age-specific needs throughout the life cycle and can be altered accordingly. o Vegetarian Diets: can be for a variety of reasons, such as religious preference, ethical belief that killing animals for food is unjust, fear of contamination with pesticides, or health concerns about the cholesterol and saturated fats found in meats. Different forms of vegetarianism range from avoidance of red meat to complete elimination of all animal products. Consume less saturated fat, cholesterol, and animal protein and greater amounts of carbohydrates, fiber, and other important nutrients. **LOOK AT TABLE 36-3** o Modified Consistency Diets: Liquid diets are used most often as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Because clear liquid diets are inadequate in calories, protein, and most nutrients, progression to more nutritious alternatives is recommended as soon as possible. o Nothing By Mouth: In some cases, such as before surgery to prevent aspiration related to anesthesia and after surgery until bowel sounds return, patients may be given nothing by mouth. Well-nourished patients can easily withstand the stress of NPO for a short period, but being NPO for an extended period of time poses a nutritional challenge for many people. **LOOK AT TABLE 36-4** Providing long-term nutritional support

Demonstrate safe medication administration using the 3 checks & the 6+ rights.

Three Checks: The rights themselves do NOT ensure medication safety. When the nurse reaches for the unit dose package or container After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container Before giving the unit dose medication to the patient, or when replacing the multidose container in the drawer or shelf Rights of Medication Administration: Ensure that the (1) right medication is given to the (2) right patient in the (3) right dosage (in the right form) through the (4) right route at the (5) right time for the (6) right reason based on the (7) right (appropriate) assessment data using the (8) right documentation and monitoring for the (9) right response by the patient. Additional rights have been suggested to include (10) the right to education, ensuring that patients receive accurate and thorough information about the medication, and (11) the right to refuse, acknowledging that patients can and do refuse to take a medication. **LOOK AT TABLE 29-3**

Identify the three spiritual needs believed to be common to all people.

Three spiritual needs underlie all religious traditions and are common to all people: Need for meaning and purpose Need for love and relatedness Need for forgiveness

Summarize the theories that describe how and why aging occurs.

^Genetic Theory: Lifespan depends to a great extent on genetic factors. Genes within the organism control genetic clocks, which determine the occurrence and rate of metabolic processes, including cell division. ^Neuroendocrine and Immunity Theories: The neuroendocrine system contains the pituitary and hypothalamus that serve as control mechanisms for the entire body. As age advances, these control mechanisms fail, which leads to failure of the body's essential pacemaker, and death. **Focuses on the functions of the immune system and immune decline. Age-associated changes in the immune system, also known as immunosenescence, are thought to be responsible for the increase in infections such as pneumonia and septicemia, immune disorders, and cancer as adults age. ^Stochastic Theories: The idea that there is a randomness to cellular damage and errors that makes predicting aging and death impossible. One example is the wear and tear theory in which organisms wear out from increased metabolic functioning, and cells become exhausted from the constant energy depletion that occurs when the body continually adapts to stressors.

Describe major physiologic, cognitive, psychosocial, moral, and spiritual developments and tasks of middle and older adulthood.

^MIDDLE ADULT (40-65) Physiological: Menopause (women) and Andropause (men) **LOOK AT BOX 23-1 ^Cognitive: Cognitive and intellectual abilities of middle-aged adults change little from young adulthood. ^Psychosocial: Time of increased personal freedom, economic stability, and social relationships · Erickson's Theory: generativity versus stagnation. · Havighust's Theory: learned behaviors arising from maturation, personal motives and values, and civic responsibility. · Levinson's Theory: choose either to continue an established lifestyle or to reorganize his or her life in a period of midlife transition. · Gould's Theory: adults accept their lifespan as having definite boundaries, and have a special interest in spouse, friends, and community. ^Moral: Will either remain at the conventional level or move to the postconventional level of moral development. ^Spiritual: Less rigid in their beliefs, and many have increased faith in a supreme being as well as trust in spiritual strength ^OLDER ADULT (Y-old 60-74, M-old 75-84, O-old 85+): American society is aging—dramatically, rapidly, and largely well. With birthrates down and some "baby boomers" already reaching retirement age, we are on the threshold of the first-ever "mass geriatric society." ^Physiological: All organ systems undergo some degree of decline in overall functioning, and the body becomes less efficient. The most commonly encountered chronic disorders are hypertension, arthritis, heart disease, cancer, diabetes, and sinusitis. ^sarcopenia: loss of muscle mass that frequently occurs in older adults as part of the natural aging process. ***LOOK AT BOX 23-3 ^Cognitive: Cognition does not change appreciably with aging. In fact, intelligence increases into the 60s, and learning continues throughout life. Mild short-term (recent) memory loss is common but can be remedied by an older adult using notes, schedules, and calendars. Long-term memory usually remains intact. Dementia, Alzheimer's disease (AD), depression, and delirium may occur and cause cognitive impairment. ^Psychosocial: Sense of self-identity, impacts on loss of driving. · Disengagement Theory: older adults often withdraw from usual roles and become more introspective and self-focused. This withdrawal was theorized as intrinsic and inevitable, necessary for successful aging, and beneficial for both the person and for society. Includes ACTIVITY Theory and CONTINUITY Theory. · Erikson's Theory: integrity versus despair and disgust. Wholeness perspective: Older adults continue to look forward, but now also look back and begin to reflect on their lives. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified worldwide. Reminiscence is a way for older adults to relive and restructure life experiences, often in relation to their current situation, and with the added benefit of the perspective provided by life experience and wisdom. · Havighurst's Theory: the maintenance of social contacts and relationships. Successful aging depends on a person's ability to be flexible and adapt to new age-related roles. ^Moral & Spiritual: Most are at the conventional level, following society's rules in response to others' expectations. Spiritually, an older adult may remain at an earlier level, often at the individuative-reflective level. Many older adults, however, demonstrate conjunctive faith, where they integrate faith and truth to see the reality of their own beliefs, or universalizing faith, where they trust a greater power and believe in the future. ^gerotranscendence: transformation of an older adult's view of reality from a rational, social, individually focused, materialistic perspective to a more transcendent vision manifested by maturity, wisdom, spirituality, and a decreased emphasis on superficial relationships

Discuss physiologic and functional changes that occur with aging.

^Middle Adult: Employment (career change), Spousal Relationships, Relationships with children and aging family members (Generation sandwich and "empty nest syndrome') ^Older Adult: **Physical strength and health: rest, lifestyle, diet, pain, confusion, cognitive impairment, sleep **Retirement and reduced income: Satisfaction with retirement is closely tied to income and the relationships one has outside of work. **Health of spouse: lifestyle changes and need for love and belonging. **Relating to one's age group: affiliation with people their age. **Social roles: the need to feel valued, useful, and productive continues. SOCIAL ISOLATION **Living arrangements: function safely and independently at home, Retirement centers and senior citizens' housing have become common. · Home modifications · Homesharing · Accessory apartments · Elderly cottage housing opportunities · Senior retirement communities · Continuing care retirement communities · Assisted living · Board and care homes; nursing homes · Adult family and group homes · Long-term care facilities **Family and role reversal: Supportive assistance may include providing transportation, food, shelter, social interactions, and even complex medical and nursing treatments. Significant others, such as close friends and neighbors, may also take on tasks formerly assumed to be the responsibilities of the traditional family.

Describe common health problems of middle and older adults.

^Middle Adult: Subject to physical and emotional health problems associated with lifestyle behaviors, developmental or situational crises, family history, and the environment. Both acute and chronic illnesses are more likely to occur, and recovery takes longer. This is a result of slower and more prolonged responses to stressors, more pronounced reactions to an illness, and the possibility of more than one illness being present at a time. **Leading causes of death are malignant neoplasms; cardiovascular disease; unintentional injury, including poisoning, motor vehicle accidents, and falls; liver disease; diabetes mellitus; suicide; chronic lower respiratory disease; cerebrovascular causes; septicemia (infection); and nephritis (kidney disease). **Health problems often depends on a combination of lifestyle factors and aging. Middle age does not automatically result in physical or emotional health problems. Many men and women remain healthy throughout their lives, but knowing preventive health care practices and their special needs at this age can help middle-aged adults have improved quality and quantity of life. ^Older Adult: Nursing care for older adults should be based on two principles: **Most older people are not impaired. They are functional members of the community who benefit from health-oriented interventions. **Older people are more vulnerable to physical, emotional, and socioeconomic problems than people in other age groups. They may require special attention to health promotion and maintenance. ^Chronic Illness: The leading causes of death in adults aged 65 and older are heart disease, cancer, chronic respiratory disease, stroke, AD, and diabetes. ^polypharmacy: the use of many medications at the same time · Heart disease is the leading cause of death for African American men and women · The leading causes of illness and death for Hispanic or Latino Americans are heart disease and cancer. · Cancer is the leading cause of death for Asian Americans; however, heart disease is the leading cause of death among Asian Indian, Filipino, and Japanese men. Stroke is the overall third leading cause of death. · Heart disease, cancer, unintentional injuries, and diabetes are the leading causes of death in American Indians or Alaska Natives. · Native Hawaiian or Other Pacific Islanders (from Guam, Samoa, or other islands) generally have higher reported rates of smoking, alcohol consumption, and obesity when compared to other ethnic or racial groups. This group shares the leading causes of death with the other groups (i.e., cancer, heart disease, unintentional injuries, stroke, and diabetes), but also has an increase in specific risks and diseases including hepatitis B, HIV/AIDS, and tuberculosis. ^Accidental Injury: Increased risk for accidental injury because of changes in vision and hearing, loss of mass and strength of muscles, slower reflexes and reaction time, and decreased sensory ability. **Dementia, Delirium, Depression: **Alzheimer's disease (AD): type of dementia in which discrete patches of brain tissue degenerate; this devastating disease eventually affects all body functions **cascade iatrogenesis: downward spiral or sequence of adverse events often triggered by a medical or surgical intervention during the hospitalization of an older adult **delirium: a temporary state of confusion **dementia: organic impairment of intellectual functioning, gradually leading to interference with social or occupational functioning, memory, and often personality integration **sundowning syndrome: describes a phenomenon when a person habitually becomes confused or disoriented with darkness

Discuss factors in the health care system and in nursing that facilitate or impede culturally competent nursing care.

^The health care system is itself a culture with customs, rules, values, and a language of its own, with nursing as its largest subculture. As you progress through your education, you will be acculturated into the culture of the health care system and will develop values related to health and health care. ^ethnocentrism: belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs. ^Unless nurses are willing to examine carefully and clarify their own attitudes and values and to be sensitive to others who are "different," their use of cultural concepts when providing care will be unsuccessful. The nurse's role is to understand the patient's needs and to adapt care to respectfully meet those needs.

Describe common myths and stereotypes that perpetuate ageism.

^ageism: attitudes that stereotype the older adult on the basis of chronologic age **Fundamental to ageism is the view that older people are different and will remain different; therefore, they do not experience the same desires, needs, and concerns as other adults. Our industrial technologic world places a high priority on productivity, and some may think that older employees or retired people have outlived their usefulness. **LOOK AT BOX 23-1

Identify factors commonly included in a transcultural assessment of health-related beliefs and practices.

^cultural competence: care delivered with an awareness of the aspects of the patient's culture. **The ESFT model (Explanatory model of health and illness, Social and environmental factors, Fears and concerns, Therapeutic contracting) is a cross-cultural communication tool that helps health care professionals strengthen communication and identify potential threats to treatment adherence **People's values and beliefs about health, illness, and health care are influenced by cultural and ethnic groups. People from different cultures may also have different beliefs about the best way to treat an illness or disease. **For example, illnesses are classified as either natural (forces like cold, air, water) or unnatural (God, evil forces), power to heal is thought to be a gift from God, traditional healers, herbs and tea, traditional therapies including the use of cutaneous stimulation, therapeutic touch, acupuncture, and acupressure, and therapeutic touch.

Explain concepts of cultural diversity and respect.

^cultural diversity: (1) coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit; (2) diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. ^cultural respect: enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients; critical to reducing health disparities and improving access to high-quality health care. ^culture: sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group. ****The characteristics of culture include the following: Culture helps shape what is acceptable behavior for people in a specific group. It is shared by, and provides an identity for, members of the same cultural group. Culture is learned by each new generation through both formal and informal life experiences. Language is the primary means of transmitting culture. The practices of a particular culture often arise because of the group's social and physical environment. Cultural practices and beliefs may evolve over time, but they mainly remain constant as long as they satisfy a group's needs. Culture influences the way people of a group view themselves, have expectations, and behave in response to certain situations. Because a culture is made up of people, there are differences both within cultures and among cultures. ^subculture: group of people with different interests or goals than the primary culture. Minority vs. Dominant group. ^cultural assimilation: process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different. ^culture shock: those feelings, usually negative, a person experiences when placed in a different culture. ETHNICITY vs. RACE: ^ethnicity: sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns. ** Sense of identification with a collective cultural group **Largely based on group's common heritage **One can belong to an ethnic group through birth or adoption of characteristics of that group. **Groups share unique cultural and social beliefs and behavior patterns. **Largely develops through day-to-day life with family and friends within the community. ^Race: division of human beings based on distinct physical characteristics. **Typically based on specific characteristics o Skin pigmentation, body stature, facial features, hair texture ** Five major categories: o American Indian or Alaska Native o Asian o Black or African American o Native Hawaiian or Other Pacific Islander o White

Identify the health care needs of older adults in terms of chronic illnesses, accidental injuries, and acute care needs.

^gerontologic nursing: nursing specialty concerned with the care of the older adult. ^gerontology: study of all aspects of the aging process and their consequences. ^functional health: level of health defined by one's ability to carry out usual and desired daily activities. ^Geriatrics is a branch of medicine that focuses on the study of health and disease later in life, while gerontology represents the multidisciplinary, scientific study of the effects of aging and age-related diseases on humans. v S - Sleep disorders v P - Problems with eating or feeding v I - Incontinence v C - Confusion v E - Evidence of falls v S - Skin breakdown

Describe influences that affect culturally respectful health care.

^stereotyping: assigning characteristics to a group of people without considering specific individuality. **May be positive or negative o Negative includes racism, ageism, and sexism ^cultural imposition: tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group. ^cultural blindness: the process of ignoring differences in people and proceeding as though the differences do not exist. ^culture conflict: situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values.

Practice cultural respect when assessing and providing nursing care for patients from diverse cultural groups.

^transcultural nursing: providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society. **When providing care to a person from a culture that is different from your own or the dominant culture, you may use past experiences with members of that culture as a guide but never as the answer to all cultural issues. Learn from your mistakes and do not repeat them. v Developing self-awareness v Demonstrating knowledge and understanding of a patient's culture v Accepting and respecting cultural differences v Not assuming that the health care provider's beliefs and values are the same as the client's v Resisting judgmental attitudes such as "different is not as good" v Being open to and comfortable with cultural encounters v Accepting responsibility for one's own cultural competency

Identify nursing interventions to safely deliver enteral nutrition.

enteral nutrition: alternate form of feeding that involves passing a tube into the gastrointestinal tract to allow instillation of the appropriate formula Involves passing a tube into the GI tract to administer a formula containing adequate nutrients. Gastric feedings have the advantage of allowing the stomach to be used as a natural reservoir, regulating the amount of foods and liquids released into the small intestine. This alternate feeding method may deliver total or supplemental nutrition over a short-term period or for longer intervals. Short-term Nutritional Support (less than 4 weeks): v Using the nasogastric (NG) or nasointestinal (NI) route. o NG tube is inserted through the nose and into the stomach. A patient is at risk for aspirating the tube feeding solution into the lungs, a disadvantage for using this route. Patients with a dysfunctional gag reflex, high risk of aspiration, gastric stasis, gastroesophageal reflux, nasal injuries, and those who are unable to have the head of the bed elevated during feedings are not candidates for nasogastric feeding. Firm and large in diameter such as a Levin Tube. Dobbhoff tube is smaller. o NI tube is passed through the nose and into the upper portion of the small intestine. However, when formula is delivered directly into the intestine, a type of dumping syndrome may develop because the pyloric valve in the stomach, which normally slows transit of food into the intestine, is bypassed. v Confirming NG feeding tube placement o Radiographic examination: the standard procedure to verify placement but exposes patient to radiation. Only confirms position of tube at time it was taken. o Measurement of aspirate pH and visual assessment of aspirate: Observe for a change in the volume of fluid withdrawn from a tube (aspirate) at 4-hour intervals during continuous feedings or before each intermittent feeding. Sharp increase in volume or inability to withdraw fluid from tube can indicate displacement. o Measurement of tube length and tube marking: Measure the length of the exposed tube after insertion and document this measurement and observe for change. o Carbon dioxide monitoring: Indicate tube positioning in the patient's airway. o Confirming nasointestinal tube placement: checking the pH of the aspirate (pH ≥6) and observing the aspirate appearance. Long-term Nutritional Support: v An enterostomal tube may be placed through an opening created into the stomach (gastrostomy) or into the jejunum (jejunostomy). o percutaneous endoscopic gastrostomy (PEG): surgically (open or laparoscopically) placed gastrostomy tube v A gastrostomy is the preferred route to deliver enteral nutrition in the patient who is comatose. v Placement of a tube into the stomach can be accomplished by a surgeon or gastroenterologist via a percutaneous endoscopic gastrostomy (PEG) or a surgically (open or laparoscopically) placed gastrostomy tube. v Continuous feedings allow gradual introduction of the formula into the GI tract, promoting maximal absorption. They require use of an enteral feeding pump, which limits the patient's mobility and increases cost. Continuous feeding into the stomach, however, is controversial because of the risk for reflux and aspiration. Intermittent feedings are the preferred method for gastric feeding. Intermittent feedings are delivered at regular intervals in equal portions, introducing the formula gradually over a set period of time via gravity or a feeding pump. Cyclic feeding involves administering continuous feeding for a portion of the 24-hour period. The usual routine is to feed the patient for 12 to 16 hours, most often overnight. v Feeding Formulas: depends on the feeding route, the patient's ability to digest and absorb nutrients, and the patient's nutrient and fluid requirements. Other considerations include the availability and cost of the formula, medical conditions that require diet modifications, food intolerance, and allergies. The rate of infusion begins at 10 to 40 mL per hour, depending on facility policy. The rate is then advanced by 10 to 20 mL per hour every 8 to 12 hours until the desired rate is achieved. v Pumps and Safety: A pump should be used when slow rates of enteral formula are required. For safety, check tube placement, check gastric residual (feeding remaining in the stomach) before each feeding or every 4 to 6 hours during a continuous feeding (according to institution policy), use sterile water for immunocompromised and ill patients, assess abdomen for abnormalities, make sure patient is as upright as possible during feeding, prevent contamination, and avoid administering medications while feeding. **LOOK AT TABLE 36-5**

Discuss family concepts, including family roles, structures, functions, developmental stages, tasks, and health risk factors.

family: any group of people who live together and depend on one another for physical, emotional, or financial support STRUCTURES: There are no absolute "rights" or "wrongs" about what makes a family, and one person's values must not be imposed on another person. Respect for all kinds of family members and relationships is essential to person-centered, individualized patient care. Nuclear family: family unit, family of marriage, parenthood, or procreation, and their immediate children. There is great variability in nuclear family structure in today's "postmodern families." The parents may be heterosexual or homosexual, and are usually either married or in a committed relationship; family members live together until the children leave home as young adults. The nuclear family may be composed of biologic parents and children, adoptive parents and children, surrogate parents and children, or stepparents and children. blended family: two single-parent families joined together to form a new family unit, children unrelated from previous marriages extended family: nuclear family and other related people (aunts, uncles, grandparents) Single-parent family: Single parents may be separated, divorced, widowed, or never married. Increasing numbers of never-married men and women are choosing to become parents. Other Family Structures: cohabiting adults and single adults are other family structures. Cohabiting families are people who choose to live together for a variety of reasons, including relationships, financial need, or changing values. Cohabiting families include unmarried adults living together and communal or group marriages. Other family structures include binuclear (where divorced parents assume joint custody of children) and dyadic nuclear (in which the couple chooses not to have children). FUNCTIONS: Family functions occur in five major areas. Physically, the family provides a safe, comfortable environment necessary for growth, development, and rest or recuperation. Economically, the family provides financial aid to family members and also helps meet society's needs. The reproductive function of many families is to have and raise children. The affective and coping functions of the family provide emotional comfort to family members and help members establish their identity and maintain it in times of stress. Finally, through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. DEVELOPMENTAL STAGES: Duvall (1984) identified critical family developmental tasks and stages in a family life cycle. Duvall's theory, based on Erikson's theory of psychosocial development, states that all families have certain basic tasks for survival and continuity, as well as specific tasks related to developmental stages throughout the life of the family. ***LOOK AT TABLE 4-2 FAMILY RISK FACTORS: Family patterns of behavior, the environment in which the family lives, and genetic factors can all place family members at risk for health problems. What is the family's structure? What is the family's socioeconomic status? What are family members' cultural background and religious affiliation? Who cares for children if both parents work? What are the family's health practices (e.g., types of foods eaten, meal times, immunizations, bedtime, exercise)? How does the family define health? What habits are present in the family (e.g., do any family members smoke, drink to excess, or use drugs)? How does the family cope with stress? Is any family member the primary caregiver for another family member? Do close friends or family members live nearby and can they help if necessary? ***BOX 4-1

List the six classes of nutrients, explaining the significance of each.

nutrition: study of the nutrients and how they are handled by the body, as well as the impact of human behavior and environment on the process of nourishment. nutrients: specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness or injury. Essential nutrients that supply energy and build tissue are referred to as macronutrients. · Carbohydrates: commonly known as sugars (simple or complex) and starches, are organic compounds composed of carbon, hydrogen, and oxygen. Relatively easy to produce and store, making them the most abundant and least expensive source of calories in the diet worldwide. · Serve as the structural framework of plants; lactose is only animal source · 90% of carbohydrate intake is ingested · Converted to glucose for transport through the blood · Cells oxidize glucose to provide energy, carbon dioxide, and water o Classification & Metabolism: Most easily digested, converted into Glucose for transport in blood. Glucose is transported from the GI tract, through the portal vein, to the liver. The liver stores glucose and regulates its entry into the blood. Hormones, especially insulin and glucagon, are responsible for keeping serum glucose levels fairly constant during both feasting and fasting. o Recommended Dietary Allowance (RDA): It is recommended that carbohydrates provide 45% to 65% of total calories for adults, focusing on complex carbohydrates, such as whole grains. · Protein: Within the human body, more than 1,000 different proteins are made by combining various amounts and proportions of the 22 basic building blocks known as amino acids. Proteins are required for the formation of all body structures, including genes, enzymes, muscle, bone matrix, skin, and blood. · Labeled complete (high quality; sufficient amounts and proportions of all the essential amino acids to support growth) or incomplete (low quality; deficient in one or more essential amino acids), based on their amino acid composition. · Animal proteins are complete; plant proteins are incomplete. · Protein tissues are in a constant state of flux. Tissues are continuously being broken down (catabolism) and replaced (anabolism). o Classification & Metabolism: Protein tissues are in a constant state of flux. Tissues are continuously being broken down (catabolism) and replaced (anabolism). o RDA: for adults is 0.8 g/kg of body weight, 10% to 35% total calorie intake. · Lipids: Fats in the diet, or lipids, are insoluble in water and, therefore, insoluble in blood. Like carbohydrates, they are composed of carbon, hydrogen, and oxygen. Ninety-five percent of the lipids in the diet are in the form of triglycerides, the predominant form of fat in food and the major storage form of fat in the body. Compound lipids (such as phospholipids, in which a lipid is combined with another substance) and derived lipids (such as cholesterol) constitute the remainder of the lipids ingested. o Classification & Metabolism: Digestion occurs largely in the small intestine; most concentrated source of energy in the diet. o RDA: The Dietary Guidelines for Americans 2015-2020 recommends that individuals should limit intake of saturated fats and trans fats, with less than 10 % of calories per day from saturated fats and intake of trans fats to as low as possible. o 95% of lipids in diet are triglycerides o Contain mixtures of saturated (raise cholesterol levels) and unsaturated (lower cholesterol levels) fatty acids o Most animal fats are saturated. o Most vegetable fats are unsaturated. o absorption: process by which drugs are transferred from the site of entry into the body to the bloodstream Micronutrients are required in much smaller amounts to regulate and control body processes. · Vitamins: Organic compounds needed by the body in small amounts, most are active in form as coenzymes o Needed for metabolism of carbohydrates, protein, and fat o Classified as water soluble (C & B-complex vitamins; absorbed through the intestinal wall directly into the bloodstream and not stored) or fat soluble (A, D, E, K; absorbed with fat into the lymphatic circulation and stored) o Vitamins are essential in the diet because most are not synthesized in the body or are made in insufficient quantities. The absence or insufficient use of vitamins in the body causes specific deficiency syndromes. NEVER be a substitute for good nutrition. · Minerals: inorganic elements found in all body fluids and tissues in the form of salts (e.g., sodium chloride) or combined with organic compounds (e.g., iron in hemoglobin). o Needed for metabolism of carbohydrates, protein, and fat o Some minerals function to provide structure within the body, whereas others help to regulate body processes. o Minerals, which are elements, are not broken down or rearranged in the body but, rather, are contained in the ash that remains after digestion. o Macrominerals (bulk minerals), minerals needed by the body in amounts greater than 100 mg/day, include calcium, phosphorus (phosphates), sulfur (sulfate), sodium, chloride, potassium, and magnesium. o Microminerals, or trace elements, are minerals needed by the body in amounts less than 100 mg/day. Microminerals include iron, zinc, manganese, chromium, copper, molybdenum, selenium, fluoride, and iodine. Additional trace elements included arsenic, boron, nickel, silicon, cobalt, and vanadium. · Water: Accounts for between 50% and 60% of adult's total weight. Two-thirds of body water is contained within the cells (intracellular fluid [ICF]). The remainder of body water is extracellular fluid (ECF), body fluids (plasma, interstitial fluid). o Provides fluid medium necessary for all chemical reactions in the body. Acts as a solvent and aids digestion, absorption, circulation, and excretion. o Water intake (an average of 2,200 to 3,000 mL/day for adults) usually equals water output.

Identify nursing interventions to safely deliver parenteral nutrition.

parenteral nutrition (PN): nourishment provided via IV therapy peripheral parenteral nutrition (PPN): prescribed for patients who require nutrient supplementation through a peripheral vein because they have an inadequate intake of oral feedings PN provides calories; restores nitrogen balance; and replaces essential fluids, vitamins, electrolytes, minerals, and trace elements. PN can also promote tissue and wound healing and normal metabolic function. It provides the bowel a chance to heal and reduces activity in the gallbladder, pancreas, and small intestine. PN may be used to improve a patient's response to surgery. PN solutions are hypertonic. PN contains the three primary components necessary to maintain nutrition: proteins, carbohydrates, and fats. Additional components of PN include electrolytes, vitamins, and trace elements. **LOOK AT TABLE 36-6** PPN solutions are isotonic. PPN solutions contain low concentrations of dextrose and amino acids. They provide fewer calories and supplement a patient's inadequate oral intake. These solutions contain 10% glucose or lower or an osmolarity of less than 900 mOsm/L, and thus are suitable for administration into a peripheral vessel. Medications are not added to or co-infused with PN solutions before or during infusion without consultation with a pharmacist regarding compatibility and stability. TPN Complications include the following: v Insertion problems v Infection and sepsis v Metabolic alterations v Fluid, electrolyte, and acid-base imbalances v Phlebitis v Hyperlipidemia v Liver and gallbladder disease

Explain the purposes and types of health assessment.

v Establish the nurse-patient relationship. v Gather data about the patient's general health status. v Identify patient strengths. v Identify actual and potential health problems. v Establish a base for the nursing process. health history: a collection of subjective information that provides information about the patient's health status. physical assessment: systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems. comprehensive health assessment: broad health assessment that includes complete health history and physical assessment; usually conducted when patient first enters health care setting, with information providing baseline for comparing later assessments. ongoing partial health assessment: also known as a follow-up assessment, it is one that is conducted at regular intervals during care of the patient; concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions. focused health assessment: assessment is conducted to assess a specific problem; focuses on pertinent history and body regions but may also be used to address the immediate and highest priority concerns for an individual patient. emergency health assessment: type of rapid focused assessment conducted when addressing a life-threatening or unstable situation. ^A nursing health assessment differs from other types of health assessments in that it is a holistic collection of information about factors that affect or are affected by one's level of health. **LOOK AT BOX 26-1

Use the techniques of inspection, palpation, and auscultation appropriately during a physical assessment.

v Inspection: assessing size, color, shape, position, and symmetry v Palpation: assessing temperature, turgor, texture, moisture, vibrations, and shape v Auscultation: assessing the four characteristics of sound, that is, pitch, loudness, quality, and duration v Pitch: ranging from high to low v Loudness: ranging from soft to loud v Quality: for example, gurgling or swishing v Duration: short, medium, or long v Percussion: assess the location, shape, size, and density of tissues.

Differentiate life-affirming influences of religious beliefs from life-denying influences.

v Life affirming: enhance life, give meaning and purpose to existence, strengthen self, are health giving and life sustaining v Life denying: restrict or enclose life patterns, limit experiences and associations, place burdens of guilt on individuals, are health denying and life inhibiting v Guide to daily living habits v Source of strength and support v Source of conflict spiritual beliefs: practices associated with all aspects of a person's life, including health and illness, that address the invisible "spirit"—a creative, mysterious, guiding power spiritual distress: an alteration in spiritual health (e.g., spiritual pain, alienation, anxiety, guilt, anger, loss, despair) spiritual healing: movement toward integration, from brokenness to wholeness spiritual health: condition that exists when the universal spiritual needs for meaning and purpose, love and belonging, and forgiveness are met spirituality: anything that pertains to a person's relationship with a nonmaterial life force or higher power spiritual needs: lack of anything necessary for spiritual health (e.g., meaning and purpose, love and relatedness, forgiveness)

Discuss examples of how diversity affects health and illness care, including culturally based traditional care.

v Physiologic variations **LOOK AT 5-1 v Reactions to pain **Be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area, avoiding activities that intensify the pain, and uncontrollable, spontaneous expressions of discomfort, such as facial grimacing and moaning. **You also should not consider patients who freely express their discomfort as constant complainers with excessive requests for pain relief. v Mental health **Many ethnic groups have their own norms and acceptable patterns of behavior for psychological well-being, as well as different normal psychological reactions to certain situations. **Hispanic people deal with problems within the family and consider it inappropriate to tell problems to a stranger. **Some traditional Chinese people consider mental illness a stigma and seeking psychiatric help a disgrace to the family. **In times of high stress or anxiety, some Puerto Ricans may demonstrate a hyperkinetic seizure-like activity known as ataques; this behavior is a culturally accepted reaction. v Gender roles **Knowing who is dominant in the family is important when planning nursing care. For example, Muslims being male-dominant. v Language and communication **Slower for people who stay at home, especially if they live in communities of their ethnic and cultural background. Children usually assimilate more rapidly and learn the language of the dominant culture quickly if they leave home each day to go to school and make new friends in the dominant culture. Wage-earners. **linguistic competence: ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter. **Many facilities also have a qualified interpreter, or one can be found in the community. v Orientation to space and time **personal space: external environment surrounding a person that is regarded as being part of that person. **When providing nursing care that involves physical contact, you should know the patient's cultural personal space preferences. For example, people of Arabic and African origin commonly sit and stand close to one another when talking, whereas people of Asian and European descent are more comfortable with more distance between themselves and others. **In some South Asian cultures, being late is considered a sign of respect. v Food and nutrition **Patients in a hospital or long-term care setting often do not have much choice of foods. This means that people with cultural food preferences may not be able to select appealing foods and thus may be at risk for inadequate nutrition. Dietary teaching must be individualized according to cultural values about the social significance and sharing of food. v Family support **Including the family in planning care for any patient is a major component in nursing care to meet individualized needs, especially if those needs can be met only through consideration of all members of the family. v Socioeconomic factors **The lowest income was found in African Americans, Native Americans, and Alaska Natives. In 2014, 21% of all children (15.5 million) lived in poverty—that's about 1 in every 5 children. **At highest risk are children, older people, families headed by single mothers, and the future generations of those now living in poverty. **The number of female-headed households is increasing as a result of divorce, abandonment, unmarried motherhood, and changes in abortion laws. **The increasing population of older people has also raised problems associated with poverty. Many older people live on fixed incomes that often do not keep up with inflation, and many (particularly widows) are on the borderline of poverty or have already slipped below the poverty level. **Socioeconomic status often differs by the cultural group of the older adult. For example, Pacific/Asian, African-American, Native American, and Hispanic elders generally have lower incomes than elders in the majority population. The work history of the cultural group, especially those who have labored all their lives as agricultural workers, often means that a person has no Social Security or Medicare benefits. **Poverty cultures often have the following characteristics: · Feelings of despair, resignation, and fatalism · "Day-to-day" attitude toward life, with no hope for the future · Unemployment and need for financial or government aid · Unstable family structure, possibly characterized by abusiveness and abandonment · Decline in self-respect and retreat from community involvement

Describe nursing strategies to promote spiritual health, and state their rationale.

· Offering supportive presence (Promote the 3 spiritual needs) · Facilitating patient's practice of religion o Familiarize the patient with religious services within the institution. o Respect the patient's need for privacy during prayer. o Assist the patient to obtain devotional objects and protect them from loss or damage. o Arrange for the patient to receive sacraments if desired. o Attempt to meet dietary restrictions. o Arrange for a priest, minister, or rabbi to visit if the patient wishes. · Nurturing spirituality · Praying with a patient · Praying for a patient · Counseling the patient spiritually o Have the patient articulate spiritual beliefs. o Explore the origin of the patient's spiritual beliefs and practices. o Identify life factors that challenge the patient's spiritual beliefs. o Explore alternatives when given these challenges. o Develop spiritual beliefs that meet the need for meaning and purpose, care and relatedness, and forgiveness. · Contacting a spiritual counselor · Resolving conflicts between treatment and spiritual activities