exam 1 foundations 192

Medications Affecting Color of Urine

Anticoagulants: red urine Diuretics: pale yellow urine Pyridium: orange to orange-red urine Elavil: green or blue-green urine Levodopa: brown or black urine Know these.......

EYEGLASS CARE Eyeglasses are essential for many people and represent a considerable financial investment. Take special precautions to prevent them from being broken or lost. Encourage patients who need glasses to wear them to avoid eyestrain. Many eyeglasses have plastic lenses, which are considerably lighter in weight than glass lenses but correct vision just as well. Plastic lenses scratch easily. Whenever setting down glasses, make sure they are placed with the lenses up. Clean eyeglasses over a terry towel, so that if they slip they will not become scratched or broken. Use warm water and soap or a special cleansing preparation. Hot water may warp plastic lenses and frames. Rinse the glasses well after cleaning them with soap and water; dry them with a clean, soft cotton cloth, such as a cotton handkerchief or a special eyeglass cleaning cloth. Paper products that are made of wood pulp increase the risk of scratching the lenses, so do not use a dry paper tissue to clean eyeglasses. Do not use silicone tissues to clean plastic lenses. CONTACT LENS CARE A contact lens is a small disc worn directly on the eyeball. It stays in place by surface tension of the eye's tears. Contact lenses are either rigid (hard) or soft. Rigid gas permeable (RGP) lenses are more rigid than soft lenses and therefore more durable for an active user (Cleveland Clinic, 2009a). Soft lenses are made of a plastic material that absorbs water to become soft and pliable. They are brittle when dehydrated and absorb water when placed in a solution, usually normal saline, or when in contact with tears. Soft lenses may be used for daily wear or extended wear. Disposable soft lenses are also available. People who wear contact lenses, and the nurses caring for them, need to take special precautions to keep the lenses free of microorganisms that may lead to eye infections and to avoid injuring or scratching the surface of the eye. When providing contact lens care, always perform meticulous hand hygiene and put on gloves before touching eye surfaces and lenses. Caution lens wearers about eye irritation in the presence of noxious vapors or smoke. Also, remind lens wearers that lenses should not come into contact with cosmetics, soaps, or hair sprays because eye irritation may result. Urge the patient to report immediately to the prescribing physician any adverse reaction related to contact lens use. The cornea, which consists of dense connective tissue, does not have its own blood supply. It is nourished primarily by oxygen from the atmosphere and from tears. In a patient who wears contact lenses, the cornea requires more than its normal supply of oxygen because its metabolic rate increases. To allow the cornea to receive a maximal supply of oxygen, hard lenses should not be worn for more than 12 to 16 hours and should be removed before sleeping. Extended-wear soft lenses can be left in place for 1 to 30 days, depending on the manufacturer. People wearing extended-wear lenses should clean them at least once a week. The time that disposable soft lenses should be worn also varies according to the type and manufacturer. A new type of disposable lens is replaced daily, whereas other options include lenses that can be worn day and night for 7 days or during waking hours only for 14 days. Excessive tearing, pain, and redness signal the need to remove lenses. If a patient wears contact lenses but cannot remove them, the nurse is responsible for removing them. This may occur, for example, when the nurse is caring for an unconscious patient. Whenever an unconscious patient is admitted without any family present, always assess to determine whether the patient wears contact lenses. Leaving contact lenses in place for long periods could result in permanent eye damage. Before removing rigid lenses, use gentle pressure to center the lens on the cornea. When removing soft lenses, use gentle pressure to move the lens down to the sclera and pinch to remove. A small suction device can also be used in an emergency situation to remove gas-permeable or hard lenses. Figure 30-4 demonstrates removal of RGP and soft lenses. Once the lens is removed, identify it as being for the right or left eye, because the two lenses are not necessarily identical. If an eye injury is present, do not try to remove lenses because of the danger of causing an additional injury.

ARTIFICIAL EYE CARE Most patients who wear an artificial eye prefer to care for it themselves if they are able. Encourage them to do so when possible. The necessary equipment includes a small basin, soap and water for washing, and solution for rinsing the prosthesis. Normal saline or tap water can be used for rinsing. Most people have their own method for cleaning the eye socket and the area around it. Ask how the patient does this, and enable the patient to continue with the usual practice. When the nurse is performing the care, the patient should be lying down so that the prosthesis does not accidentally fall to the floor. Flush the socket with normal saline before replacing the prosthesis.

Types of Exercises

Isotonic: muscle shortening and active movement IE., walking, swimming, &ROM Isometric: muscle contraction without shortening IE., contraction of gluteal or quads Isokinetic: muscle contraction with resistance IE., lifting weights

how much distance when irrigating wound?

1 inch

alcohol rub should be rubbed for how long?

15 seconds

how long should u wash ur hands with soap for?

20 seconds, but might be longer if they are more soiled

AXILLARY

97.7°F

ORAL

98.6°F

TEMPORAL ARTERY

98.6°F

RECTAL

99.5°F

CH 3 HEALTH AND WELLNESS CAUSES OF DISEASES.... INHERITED GENETIC DISORDERS DEVELOPING DEFECTS AS A RESULT OF EXPOSURE TO VIRUSES OR CHEMICALS DURING PREGNANCY BIOLOGICAL AGENTS OR TOXINS PHYSICAL AGENTS SUCH AS TEMP CHEMICALS AND RADIATION GENERALIZD TISSUE TRESPONSES TO INJURY OR IRRITATION PHYSIOLOGIC AND EMOTIONAL REACTIONS TO STRESS EXCESSIVE OR INSUFFICIENT PRODUCTION OF BODY SECRETIONS CHRONIC ILLNESS VS ACUTE ILLNESS CH 31.. HOW DO YOU MEASURE A WOUND? L x W x DEPTH 10 PSI WHEN IRRIGATING A WOUND HOW CLSOE DO YOU IRRIGATE A WOUND- from 1 inch above HOW LONG IS IRRIGATION SOLUTION GOOD FOR? 24 HOURS. YOU NEED TO LIP YOUR BOTTLE, CAP SHOULD BE FACING UP, WHEN DO YOU OBTAIN A WOUND CULTURE? AFTER ITS BEEN CLEANED HOW DO YOU OBTAIN A WOUND CULTURE? SWIPE IT ALL OVER DEBUCUTUS ULCERS..KNWO THE STAGES!! STAGE 1: SMALL NO BLANCHING STAGE 2: SMALL STAGE 3: SEE SUBCUTANEOUS TISSUE STAGE 4: SEE THE BONE! BEST DRESSING FOR DECUBITIS ULCERS- saline moistened BEST FOOD SOURCES FOR PEOPLE WITH WOUNDS-protein + vitC TYPES OF DRAINAGE SEROUS CLEAR SANGUINEOUS-BLOODY SEROSANGUINOUS- MIXTURE PURULENT-PUS LIKE TYPES OF DRAINS: PEROSE-OPEN DRAINAGE JACKSON PRATT CLOSED DRAINAGE TYPES OF DRESSING: WET TO DRY STERILE COLLOID- GOOD CHOICE FOR DECUBITIS CH 30 HYGIENE: TEMP FOR SHOWER OR TUB SHOULD BE 110-115 ORAL MUCOUS MEMEBRANCE CONSDIERTAIONS WITH CLIENTS WITH DIABETES: ..SKIN BREAKS DOWN THEY HAVE BACTERIA IN MOUTH PERICARE, DIRECTION OF WASHCLOTH IS ANTICOAGS AND SHAVING- IF THERE INR IS HIGH, DONT USE A RAZOR BUT ELECTRIC RAZOR IF THEY ARE ON ANTICOAGULANTS WHEN DO WE REMOVE TED HOSE? AT THE BATH! REMOVE DURING BATH UNCIRCUMSIZED PENIS, PULL IT BACK IMMEDIATELY AFTER WASHING! POWDER IN GROIN CAUSES BACTERIAL GROWTH CH 32 TECHNIQUES TO REDUCE STRESS: SPEREAD FEET SHOULDER WITDTH APART, KEEP WEIGHT TOWARDS BODY WAYS TO HAVE A CONFUSED PERSON COOPERATE WHEN TRANSFERRING OUT OF BED, USE CLEAR SHORT INSTRUCTIONS AND PHRASE POSITIVE, SAY SIT UP INSTEAD OF DONT SIT DOWN HOW WOULD TOU DESIDE WHEHRE A MECHNAICAL ASSITIVE DEVISE IS NEEDED? THEIR ABILITY TO ASSIST YOUR PT BECOES DIZZZY WHEN AMBULATING: WHAT CACTIONS SHOUD YOU TAKE: SLIDE THEM DOWN THE FRONT OF YOUR BODY AND LET THEM SLIDE DOWN REDUCING SHEARING WHEN RUTNING PULLING UP PTS HAVE THE CROSS ARMS AND LEGS WHY DO WE HAVE PTS PUT HEAD TO CHEST TO SUPPORT HEAD WHEN PULLING UP IN BED? TO REDUCE RISK FOR HYPEREXTENDED NECK WHEN DO WE USE TRANSFER CHAIR? CHAIRS THAT CAN CONVERT INTO STRETCHERS ARE ABAILABLE, USEFUL WITH CLIENTS WHO HAVE NO WEIGHT BEARING CAPACITY! CANNOT FOLLOW DIRECTIONS OR CANNOT COOPERATE, THE BACK OF THE CHAIR BENDS BACK AND LEG SUPPORTS ELEVATE TO FORM A STRETCHER OCNFIGUARION, ELIMINATIING THE NEED FOR LIFTING THE CLIENT. POWERED STAND ASSIST DEVIES AND RESPOSITIONING CH 4. MASLOWS HIERATCHY PHYSIOLOGC IS TH EMOST BASIC NEED , OXYGEN!! SAFETY AND SECURITY SECOND MOST IMPORTANT LOVE AND BELONGING SELF-ESTEEM CH 38. OXYGENATION CONSIDER WAYS TO ASSIT A PERSON WITH COPD TO BREATH BETTER SIT UP IN SEMI TO HIGH FOWLERS POSITION- SO IT ALLOWS MORE ROOM FOR LUNG EXPANSION PURSED LIP BREATHING: HELPS TO CONTROL AND REGULATE DIAPHRAGMATIC BREATHING: KNOW THE DIFF BETWEEN DIAPHRAGMIC BREATHING AND PURSED LIP BREATHING USE OF INCENTIVE SPIROMETER: SHOW THEM HOW TO USE IT , U HAVE TO REALLY INHALE LIKE A CIGARETTED LEAN FORWARD PREVAUTIONS FOR PEOPLE ON OXYGEN: AVOID FLAMES, NO SMOKING SIGNS SHOULD BE UP, ELECTRICAL EQUIP SHOULD BE INTACT AND NO SPARKS, SYNTHETIC FABRICS THAT BUILD OF STATIC, AVOID OILS THAT CAN IGNITE IN THE PRESENCE OF OXYGEN OXYGEN DELIVERY SYSTES NASAL CANNULAS: 2-6 L SIMPLE MASK- HAS NO RESERVOIR PARTIAL REBREATHER MASK: HAS RESERVOIR AND ONE OF THE SIDE HOLES REMAINS COVERED NON BREATHER MASK- pure oxygen VENTURi MASK: PROVIDES THE MOSt Accurate OYGEN DELVIERY, PRECISE....IF BAG IS NOT INFLATING ITS NOT WORKING NASAL PHARYNGEAL: NOT USED MUCH CHANGE TO OTHER NOSTRIL Q 12-24 H FACE MASKS: FIt CAREFULLY TO AVOID AIR LEAKAGE OXYGEN TENT: HIUMIDIFIED AND YOU MUST CHECK PATIENTS REGULARLY SO THEY ARE NOT LAYING IN A WET GOWN OR LININEND TRACHEOSTOMY: POSITION IN SEMIFOWLERS POSITION FOR UNSCONSCIOUS PT? LATERLA POSITION FACING YOU HOW FAR DO YOU GO DOWN WHEN SUCITONING? USE UR ARBITRATOR AND TUBE HOW DO U MEASURE FOR HOW FAR DO U SUCTION? HOW DO U MEASURE FOR HOW FAR U SUCTION HOW MANY PASSES CAN U MAKE BEFORE YOU HAVE TO CHANGE THE CATHERER? 2 OR 3 HOW LONG DO U SUCTION FOR? 15 SECONDS HOW DO YOU KNOW SUCTIONING WAS EFFECTIEV? LUNG SOUNDS ARE MUCH BETTER? WHERNE SHOUDL UR THUMB BE DURING ACTUAL SUCTIONING? THUMB SHOULD BE DOWN!! WHERE SHOULD UR THUMB BE WHEN GOING DOWN INTO THE TRACHEA PRIOR TO SUCTIONING? THUMB SHOULD BE UP!! WHAT SHOULD U HAVE UR SUCTION SET AT? ADULT: 100-120, A LITTLE MORE IF NOT EFFECTIVE WHEN DO WE SUCTION? IF THEY DONT HAVE ANY RONCHI SOUNDS WE DONT NEED TO SUCTION WHEN DO WE KNOW WE NEED TO SUCTION: IF YOU HEAR RONCHII, THEN SUCTION, DONT SUCTION IF U HEAR CRACKLES, BECAUSE THATS FLUID IN THE LUNGS NOT TRACHEA HWO DO U KNOW THE SUCTIONING WAS EFFECT?

AIR POLLUTION page 1404, 1419 (MAINTAINING ADEQUATE FLUID, PROMOTING BREATHING), 1420 (DEEP BREATHING INTSTRUT PATIENT TO BREATH DEEP ENOUGH TO MOVE BOTTOM 2 RIBS), --ok so this is respiratory muscle wasting affects breathing negatively, and 2-3 quarts of water should be consumed daily (1.9-2.9 L) SELECT ALL THAT APPLY: KNOW CLIENTS THAT WOULD BE AT RISK FOR SKIN ALTERATIONS (ATLEAST ONE WRONG OR 2 RIGHT)....ok so heres the list.. thin people, obese people, skin condition ppl (excema, psoriasis), jaundice ppl, excessive perspiration people NEED TO KNOW WHEN A PT NEEDS MORE INFO, AND THEY TELL U SOMETHING THAT WOULD BE WRONG, RECOGNIZE IT AS NOT CORRECT! 2 MATH PROBLEMS: HOW TO CALCULATE A DROP FACTOR AND A DESIRED OVER HAVE (DR ORDERED A DOSE OF 50 AND U HAVE 100, HOW DO U GET THAT?), DROP FACTOR, IF ITS 17.6 WHAT DO U ROUND UP TO? 18! STAGES OF DEBUTIS ULCERS OPEN DRAINAGE SYSTEMS AND CLOSED DRAINAGE SYSTEMS WHEN U R GUNNA USE NEGTIVE PRESSURE FOR WOUND THERAPY P. 992 its for wounds that are not healing well, or healing slowly, or infected....for example, pressure ulceres, diabetic ulcers, dehisced surgical wounds, infected wounds,skin grafts, burns DEHESED A WOUND BEFORE WOUND SMEANS IT STARTS TO OPEN, EVISCERATION MEANS GUT COMES OUT...U NEED TO GIVE SALINE AND STERILE DRESSING CALL A DOCTOR TO GET THEM TO SURGERY PEOPLE OF DARK COLORS, HOW YOU WOULD ASSESS FOR A DEEP TISSUE INJURY IN DARK SKINNED INDIVIDUALS...assess temp!!! KNOW THE FUNCTIONS OF THE SKIN: MORE THAN ONE!! ok here is the list of them...Protection, Body temperature regulation, Psychosocial , Sensation, Vitamin D production, Immunologic,Absorption,Elimination THE EFFECT OF COLD THERAPY AND HOW YOU WOULD EXPLAIN THAT TO A PT WHEN YOU PUT A SALINE MOSTENED DRESSING ON A PATIENT, KNOW THE ACTUAL STEPS (P. 1023) TEACHING ABOUT WAYS TO PREVENT WOUND INFECTIONS: DRAINAGES: SEROUS,ETC WHAT DO U NORMALLY CLEAN A WOUND WITH: DO WE USE JUST WATER? WE USE SALINE! WHAT YOU NEED TO KNOW ABOUT GLOVE USE AND HAND HYGIENE (THE USE OF GLOVES REDUCES NEED FOR HAND HYGIENE, WRONG!! U STILL HAVE TO DO HAND HYGUENE U KNOW ABOUT PATIENTS WITH CDIFF, U MUST WASH HANDS !! WHAT TO DO WITH STANDARD/CONTACT/AIRBORNE PRECAUTIONS! ADDING STERILE ITEMS TO YOUR FIELD! 6 INCHES DROP! WE CAN USE FORCEPS OR STERILE GLOVES IF THEY ARE ALL PACKAGED TYPE OF SOAP THAT SHOULD BE USED WHEN INFECTION IS HIGH DURING FLU SEASON! ANTIBIOTICS DONT WORK ON A COLD (VIRAL) PEOPLE AT GREATESET RISK FOR INJURY TO SKIN AND MUCUS MEMBRANES...ok so here it is..... Resistance to injury is affected by age, amount of underlying tissues, and illness. adequate nutrition and hydrated people are more resistant QUESTION ABOUT PERICARE DIRECTION OF PERICARE ANTICOAG- use electric razor TED HOSE (ANTIEMBOLISM STOCKINGS REMOVED WHEN BATHING) TRUE OR FALSE QUESTION!! UNCIRCUMCISED ADULT (RETURN FORESKIN IMMEDIATELY AFTER WASHING) POWDER ALLOWS GROWTH OF BACTERIA HOW YOU SHOULD POSITION URSELF TO PREVENT BACK INJURY: FEET AT SHOULDER WITH, HOLD OBJECT CLOSE TO BODY WHEN U R MOVING A PATIENT IN BED, HOW TO PREVENT FRICTION REDUCING PROBLEMS (ARMS CROSSED BUT THERE IS MORE TO IT THAN THAT! LOOK IT UP!) WHEN UR PATIENT DOESNT LIFT THEIR HEAD, THEY COULD HYPEREXTEND THEIR NECK, SO THEY HAVE TO DO SOMETHIGN WITH THEIR ARMS (CROSSED), HEAD(TOWARDS CHEST) AND LEGS (?)! WHY ANTIEMBOLISM STOCKINGS ARE GOOD FOR THEM VALSALVA MANEUVAR ACTIVATES VAGAL RESPONSE PULSES AND FEVERS, SOME SCENARIOS OF WHAT TO DO NEXT...SO WHEN A PT HAS DIFFICULTY BREATHING AND COMPLAINING OF CHEST PAIN, SOMETHING U MIGHT WANNA OBTAIN RIGHT AWAY??? atropine? WE ALREADY TALKED ABOTU CORE TEMP! RECTAL! TIMES YOU NEED TO GET VITAL SIGNS, WHEN U SHOULD GET THEM? ok here is the list..Screenings at health fairs and clinics, In the home, Upon admission to any health care agency, Based on agency or institutional policy and procedure, When medications are given that affect cardiac rate & rhythm & or respiratory function, Before and after invasive diagnostic and surgical procedures, Any time there is a change in the client's condition, In emergency situations WHAT YOU MIGHT SEE WITH A PATIENT THAT HAS AN INFECTION TO THE LOWER EXTREMETIES (ITS USUALLY CELLULITIS), SIGNS AND SYMPTOMS OF INFECTION DRY FLAKY SKIN STERILE FIELD WHEN UR TAKING BLOOD PRESSURES U HAV ETO THINK ABOUT MORE THAN ONE THING KNOW HO TO TAKE AN ORAL TEMP, MORE THAN ONE ANSWER PT CANT BREATH THINNING YOUR SECRETIONS READ P.1430, IF YOUR CHEST TUBE BECOMES DISCONNNCTED, WHAT DO YOU DO? WHO BREATHES THE FASTEST? THE TINY CHILD! LIL KIDS IN PRESCHOOL HAVE A LOT OF INFECTION, DID U KNOW KINDERGARDEN AND 1ST GRADE TEAACHERS HAVE MORE SICK DAYS, ITS NOT UNCOMMON FOR TEACHERS TO GET SICK, WHAT YOU WOULD TELL SOMEBODY ABOUT THAT WHAT WOULD U DO IF SOMEONE CANT BREATH, U HAVE TO TAKE CARE OF THE PROBLEM, OR WAIT TIL THEY CATCH THEIR BREATH. WHAT TO DO WITH PEOPLE THAT HAVE SLEEP APNEA KNOW WHERE A CHEST TUBE IS PLACED 24 HOUR URINE EXERCISES THEN U GET MORE URINE AND POOP WHERE U COLLECT URINE, FROM AN INDWELLING CATHETER REMOVING AN INDWELLING CATHETER OPENED A BOTTLE OF SOLUTION TO THE STERILE FIELD, WHAT TO DO WITH THE CAP? CLOSEST TO YOU FURTHER TO YOU? FOLLOWING ACTIVITY IS TERTIERY: ADMINISTERING THE NEB BRONCHILATOR NURSE IS EDUCATING WOMEN ABOUT BONE LOSS: PRIMARY WHICH OF THE FOLLOWING WOULD NURSE BE AT HIGHEST RISK: ADOLESCENT WHO HAD A BABY WHICH OF THE FOLLOWING IS AN EX OF COMMUNITY: AIR AND WATER!!! NURSEING AID PROVIDING PERINEAL AID: MOISTURE BARRIER! PERI CARE ON UNCIRCUMCISED MALE: IMMEDIATELY AFTER WASHING!! HOMELESS PERSON IS WASHING UP IN BATHROOM: SOCIOECONMOIC NURSES CARES FOR OLD PERSON AND ALWAYS IN SEATED POSITION: SACRUM NEEDS TO BE CHECKED!!!!! NURSE HAS COMPLETED BED BATH AND WANTS BABY POWDER! NO POWDER! NURSE IS PROVIDING PERICARE TO FEMALE: FRONT TO BACK GENDER DOESNT AFFECT HYGIENE PRACTICES! PREVENT BACK INJURY, FEET SHOUDL BE SHOULDER WIDTH APART! IF TO USE MECHANIAL DEVISE? DEPENDS IF PT CAN ASSIST! NURSES AMBULATING SOMEONE BEGINS TO FALL: LET THEM FALL GENTLY:

Respiratory Functioning in the Older Adult

Bony landmarks are more prominent due to loss of subcutaneous fat. Kyphosis contributes to appearance of leaning forward. Barrel chest deformity may result in increased anteroposterior diameter. Tissues and airways become more rigid; diaphragm moves less efficiently. Older adults have an increased risk for disease, especially pneumonia.

Developmental Considerations

Children Toilet training 2 to 3 years old, enuresis Effects of aging Nocturia Increased frequency Urine retention and stasis Voluntary control affected by physical problems

However, resistance has developed to this and VRE must be treated with antibiotics other than vancomycin. Risk factors for VRE include:

Compromised immune systems Recent abdominal or chest surgery Presence of urinary or central IV catheter Prolonged antibiotic use, especially with vancomycin Lengthy hospital stay, especially in an ICU (Riley, 2012; CDC, 2010c).

Promoting Proper Breathing

Deep breathing Using incentive spirometry Pursed-lip breathing Diaphragmatic breathing

CHRONIC CONDITIONS AFFECT CARDIOPULMONARY SYSTEM, LIKE MUSCLE WASTING CHRONIC CONDITIONS IMPACT RESPIRATORY MUSCLES AND HEART MUSCLE!

ENVIRONMENTAL FACROS LIKE EXPOSURE TO AIR POLLUTION EXPERIENCE STINGING OF EYES, NASAL PASSAGES, COUGHING, CHOKING, HEADACHE, DIZZINESS, ALSO ASBESTOS, SILICA, OR COAL DUST AND ENVIRONMENTAL POLLUTION CAN CAUSE PULMONARY DISEASE

Postural Reflexes

Labyrinthine sense Proprioceptor or kinesthetic sense Visual or optic reflexes Extensor or stretch reflexes

Physical Health Problems in the musculoskeletal or nervous systems can have a negative influence on body alignment and movement. Similarly, illness or trauma involving other body systems may interfere with movement because of either the underlying pathology or the treatment regimen. Nurses must be sensitive to how both acute and chronic health problems affect a patient's general appearance (posture, body proportions, and movements) and their ability to move purposefully to perform activities of daily living (ADLs). When assessing a patient's response to a mobility deficit, work to: Encourage attempts at behaviors that promote self-care activities despite limitations (e.g., offer supportive suggestions to patients who attempt to feed themselves despite having hemiparesis) Reinforce behaviors that promote healthy functioning (e.g., congratulate a patient who manages transfers well despite left-sided weakness or paralysis) Correct behaviors that compound the mobility deficit over time (e.g., teach successful adaptive strategies that can be shared with other patients and families to a patient with arthritis who severely restricts movement because of joint stiffness and tenderness; or teach energy-conservation measures to patients with emphysema who have greatly decreased activity tolerance) Muscular, Skeletal, or Nervous System Problems Problems with the musculoskeletal or nervous systems may involve one or more of the following health issues. CONGENITAL OR ACQUIRED POSTURAL ABNORMALITIES A newborn with developmental hip dysplasia, torticollis (inclining of head to affected side) or a clubfoot; a teenager with lordosis (exaggerated anterior convex curvature of the spine) or scoliosis (lateral curvature of the spine); and an older person with kyphosis (increased convexity in the curvature of the thoracic spine) are all experiencing postural abnormalities that affect their appearance and mobility. Nursing responsibilities may include the following: Early detection of and referral for these problems Exploration and selection of patient education, counseling, and support as treatment options Careful attention to positioning, transfers, and exercise Education of the patient and family regarding safe self-care activities PROBLEMS WITH BONE FORMATION OR MUSCLE DEVELOPMENT Problems with bone formation may include any of the following: Congenital problems, such as achondroplasia, in which premature bone ossification (bone tissue formation) leads to dwarfism, or osteogenesis imperfecta, which is characterized by excessively brittle bones and multiple fractures both at birth and later in life Nutrition-related problems, such as vitamin D deficiency, which results in deformities of the growing skeleton (rickets) Disease-related problems, such as Paget disease, in which excessive bone destruction and abnormal regeneration result in skeletal pain, deformities, and pathologic fractures Age-related problems, such as osteoporosis, in which bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily The muscular dystrophies are a group of genetically transmitted disorders that share a common progressive degeneration and weakness of skeletal muscles. They vary in terms of the muscle groups involved and their clinical course. Myasthenia gravis is a weakness of the skeletal muscles caused by an abnormality at the neuromuscular junction that prevents muscle fibers from contracting. Myotonic muscular dystrophy involves prolonged muscle spasms or stiffening after use. Duchenne muscular dystrophy involves a muscle decrease in size, as well as weakening of muscles over time. Nursing responsibilities for patients with problems of bone formation and muscle development and functioning include the following: Careful collaboration with the physician and health care team to determine the motor capacities of the person Patient and family education aimed at developing optimal mobility Having a solid knowledge base about the underlying disease process The ability to position, transfer, and exercise the patient safely, with attention to patient comfort PROBLEMS AFFECTING JOINT MOBILITY Inflammation, degeneration, and trauma can all interfere with joint mobility. The term arthritis describes more than 100 different diseases that affect areas in or around joints. Arthritis is characterized by inflammation, pain, damage to joint cartilage, and/or stiffness (Arthritis Foundation, 2013b; Centers for Disease Control and Prevention [CDC], 2011). The most common type is osteoarthritis, also termed degenerative joint disease. Osteoarthritis is a noninflammatory, progressive disorder of movable joints, particularly weight-bearing joints, characterized by the deterioration of articular cartilage and pain with motion. Once the articular cartilage is damaged, bony deposits (bone spurs) may form in the joints, causing more pain with movement of the joint. p. 1046 p. 1047 Trauma to a joint may result in a sprain or a dislocation. A sprain occurs with the wrenching or twisting of a joint, resulting in a partial tear or rupture to its attachments. A dislocation is characterized by the displacement of a bone from a joint with tearing of ligaments, tendons, and capsules. Any condition restricting joint mobility has potentially crippling effects. Nurses caring for patients with joint problems work collaboratively with physicians, physical therapists, and other health care professionals to maintain joint mobility. Patient education is directed to the patient's mastery of an exercise and care program, which fosters tissue repair and maximal independence in ADLs. TRAUMA TO THE MUSCULOSKELETAL SYSTEM Injury to the musculoskeletal system can result in fractures and soft-tissue injuries. A fracture, a break in the continuity of a bone or cartilage, may result from a traumatic injury or some underlying disease process. Healing requires realignment of the bone fragment, immobilization, and restoration of the bone's function. Soft-tissue injuries include sprains, strains, and dislocations (sprains and dislocations are discussed in the previous section, Problems Affecting Joint Mobility). A strain, the least serious of these injuries, is a stretching of a muscle. Nurses need to be knowledgeable in first-aid measures for musculoskeletal trauma as well as in acute and rehabilitative care. PROBLEMS AFFECTING THE CENTRAL NERVOUS SYSTEM A problem in any of the principal parts of the brain or spinal cord involved with skeletal muscle control can affect mobility. The cerebral motor cortex assumes the major role of controlling precise, discrete movements. A cerebrovascular accident (stroke) or head trauma may damage the motor cortex and produce temporary or permanent voluntary motor impairment. Basal ganglia integrate semivoluntary movements such as walking, swimming, and laughing. In Parkinson disease, there is progressive degeneration of the basal ganglia of the cerebrum, thus affecting walking and coordination. Unnecessary skeletal movements result in tremors and muscle rigidity, which interfere with voluntary movement. The cerebellum assists the motor cortex and basal ganglia by making body movements smooth and coordinated. In multiple sclerosis, the myelin sheaths of neurons in the CNS deteriorate to hardened scars or plaques. Plaque formation in the cerebellum may produce lack of coordination, tremors, and/or weakness. The pyramidal pathways convey voluntary motor impulses from the brain through the spinal cord by way of two major pathways: (1) the pyramidal pathway and (2) the extrapyramidal pathway. With trauma to the spinal cord, transection (severing) of these motor pathways results in complete bilateral loss of voluntary movement below the level of the trauma. Patients with injury to the CNS often verbalize that no one talks with them (or with their families) about how the disease may progress and affect their functioning. Nurses caring for these patients need to be knowledgeable about the pathology and clinical course of these diseases to provide appropriate patient education and counseling. Problems Involving Other Body Systems The pathology of numerous other acute and chronic illnesses may also affect mobility. Chronic obstructive pulmonary disease and conditions such as ascites may alter posture. Any illnesses that interfere with oxygenation at the cellular level decrease the amount of oxygen available to the muscles for work and thus decrease activity tolerance. These illnesses include anemia, angina, cardiac arrhythmias, heart failure, and chronic obstructive pulmonary disease. Diseases characterized by a larger breakdown of protein than that which is manufactured leads to a negative nitrogen balance (e.g., anorexia nervosa and certain cancers) that results in muscle wasting and decreased physical energy for movement and work. Symptoms accompanying many illnesses, such as fatigue, muscle aches, and pain, may also lead to immobility. Bed rest is an important component of treatment for many diseases or trauma states, such as myocardial infarction, surgery, and fractures. Although rest is essential for the healing process, immobility associated with bed rest may cause its own problems. Table 32-4 outlines a comparison of the effects of immobility and exercise on body systems. Nurses need to be vigilant in determining the effects of any injury or illness on mobility and in providing care to facilitate optimal mobility as early as possible.

Mental Health A person's mental health influences body appearance and movement as much as the person's physical health. Body processes tend to slow down in depression, and there is a lack of visible energy and enthusiasm. Body posture also may be affected. For example, the person with depression often sits with head bowed and shoulders slumped, and may lack the energy to eat or even to use the toilet. Even facial movement may be decreased to the point at which the person's face registers no emotion (termed a flat affect). Conversely, people who are not depressed are more likely to have erect posture, animated facial features, and energy for routine activities. Lifestyle Many variables—including occupation, leisure activity preferences, and cultural influences—influence a person's lifestyle, whether active or sedentary. Many occupations are sedentary (e.g., computer technician). Therefore, people in sedentary occupations wishing to exercise regularly need to plan ahead for these leisure activities by preparing to exercise before or after work hours or during a lunch break. People may also participate in leisure activities that are sedentary in nature such as reading, debating, crafts, and watching television. In addition, a person's diet and smoking history are other lifestyle variables that influence mobility. Culture and gender may also play a role, encouraging or discouraging exercise. Nurses, particularly those involved in community health activities, need to consider appropriate forms of exercise and geographic location before making recommendations to patients from diverse cultures. For example, walking is a commonly prescribed exercise. However, walking may pose a threat to the person who only has access to walk in unsafe environments, such as high-crime areas. Identifying culturally acceptable physical activities is an important step in planning a program of physical activity. Physical activities that are congruent with overall lifestyle and cultural context will be easier to incorporate into daily living (Lee & Im, 2010). The nurse must talk with the patient and family members to determine preferred activities. While the nurse must avoid stereotyping, an exercise prescription for a Native American might include suggestions for exploring nearby mountain areas, hunting, or even participating in Native American dances as more acceptable methods for increasing activity level. Attitude and Values In some families, such as those who hike, swim, or play ball together, children learn early to value regular exercise. As these children mature, they often continue to value exercise and find new ways to incorporate regular exercise into their daily routine. On the other hand, children may be raised in families who are sedentary and in which watching sports is the closest anyone comes to exercise. Attitudes and values learned early may be internalized for a lifetime. Individual values also influence the exercise options people make. People who place a high value on physical attractiveness may be highly committed to regular exercise because it helps produce the body they want. Another person may exercise because of the desire for physical strength, relating strength with power. However, someone more disposed to intellectual pursuits may perceive body development as simply wasting time that could be better used to develop the mind. Sometimes, people view exercise as too much of a chore, thus avoid it. It is important to offer suggestions for how to incorporate exercise into the person's daily routine, making exercise less of a chore. Fatigue and Stress Chronic stress may deplete body energy to the point that fatigue makes even the thought of exercise overwhelming. Ironically, regular exercise is energizing and can better equip a person to deal with daily stresses. Excessive exercise, however, may stress the body and lead to injury as well as to fatigue. External Factors Many external factors can influence activity and mobility. Among these, weather probably exerts the greatest influence over outside exercise. A brisk, clear day is invigorating and invites increased activity. However, high humidity, very hot and very cold temperatures, rain, and snow discourage outdoor exercise. Sufficient financial resources for gym memberships, access to exercise equipment, safe outdoor parks and sports areas, the availability of malls for early-morning walkers, support people, and occupational or insurance rewards for exercise can all encourage regular exercise. Discouraging factors include lack of free time, insufficient financial resources for equipment purchase or gym membership, air pollution, unsafe neighborhoods, and lack of support and reinforcement.

Type of Artificial Airways

Oropharyngeal and nasopharyngeal airway Endotracheal tube Tracheostomy tube

A virus is the smallest of all microorganisms, visible only with an electron microscope. Viruses cause many infections, including the common cold, hepatitis B and C, and acquired immunodeficiency syndrome (AIDS). Antibiotics have no effect on viruses. However, there are some antiviral medications available that are effective with some viral infections. When given in the prodromal stage of certain viruses, these medications can shorten the full stage of the illness. Fungi, plant-like organisms (molds and yeasts) that also can cause infection, are present in the air, soil, and water. Some examples of infections caused by fungi include athlete's foot, ringworm, and yeast infections. These infections are treated with antifungal medications; however, many infections due to fungi are resistant to treatment. Parasites are organisms that live on or in a host and rely on it for nourishment. Malaria is a serious disease that occurs when a parasite infects a certain type of mosquito that then feeds on humans. Not all organisms to which a person is exposed cause disease. An organism's potential to produce disease in a person depends on a variety of factors, including: Number of organisms Virulence of the organism, or its ability to cause disease Competence of the person's immune system Length and intimacy of the contact between the person and the microorganism IDENTIFICATION OF INFECTIOUS AGENTS Identifying the type of infection and infectious agent is not always an easy process. Sometimes new diseases appear and health care workers race to identify them so that treatment can begin. This is the process that occurred with AIDS and with severe acute respiratory syndrome (SARS). Other times, a disease that is endemic or occurs with predictability in one specific region or population can appear in a different geographic location. For example, dengue fever that is endemic in Southeast Asia has the potential to emerge in the United States and pose a major public health problem (National Center for Biotechnology Information [NCBI], 2011). In cases like these, countries draw information from one another to learn about treatment options. COLONIZATION VERSUS INFECTION Under normal conditions, some organisms may not produce disease. Microorganisms that commonly inhabit various body sites and are part of the body's natural defense system are referred to as normal flora. However, if other factors intervene, a usually harmless organism may generate an infection. Bacteria that normally cause no problem but, with certain factors, may potentially be harmful in susceptible people are referred to as opportunists. For example, one type of Escherichia coli (E. coli) normally resides in the intestinal tract and causes no harm. However, if it migrates to the urinary tract, it can lead to urinary tract infection. Another example is one that occurs with the Clostridium difficile (C. difficile) organism. If the C. difficile organism resides in a person's body but there are no clinical signs of an infection, this is referred to as C. difficile colonization. An infection is present once the person exhibits specific manifestations of the disease. In both the E. coli and C. difficile situations, microscopic examinations reveal the presence of the bacteria. A person's defense mechanisms are either effective or ineffective in responding to the bacterial invasion. If ineffective, infection will result.

Reservoir The reservoir for growth and multiplication of microorganisms is the natural habitat of the organism. Possible reservoirs that support organisms pathogenic to humans include other people, animals, soil, food, water, milk, and inanimate objects. OTHER PEOPLE Some people act as reservoirs for the infectious agent and demonstrate signs and symptoms of the disease, while other people act as reservoirs for the infectious agent but do not exhibit any manifestations of the disease. These people are considered carriers. Carriers, although asymptomatic, can transmit the disease. For example, a person who has tested positive for the human immunodeficiency virus (HIV) antibody is probably infected with HIV. However, this person may not exhibit any signs and symptoms of the disease at the time of testing. Moreover, the signs and symptoms of AIDS may not occur for years. However, the person may transmit the virus to others, for example, by intimate sexual contact or by sharing a contaminated needle and syringe. An infected pregnant woman may transmit the virus to her child during pregnancy, birth, or breastfeeding. Children in daycare centers can spread E. coli from one child to another child. Nurses can also serve as reservoirs and inadvertently transfer pathogenic organisms to patients. For example, a nurse with artificial nails may harbor a large number and variety of microbes under the nails. Ineffective handwashing or improper glove use may result in exposing an immunocompromised patient to the risk of infection. OTHER RESERVOIRS Many other reservoirs exist and are encountered on a daily basis. The rabies virus is an example of a pathogen whose reservoir is various animals, notably dogs, squirrels, bats, and raccoons. A person contracts the rabies virus when bitten by an infected animal. The West Nile virus is another example of a pathogen whose reservoir is an animal, most frequently birds. Mosquitoes feed on infected birds, become infected and pass the infection on to people when feeding on their blood (CDC, 2011d; Overstreet, 2011). Unusual weather conditions have led to a significantly larger crop of mosquitoes, which has resulted in more cases than usual of West Nile virus. Soil also can act as a reservoir. For example, the organisms that cause gas gangrene and tetanus are examples of pathogens whose reservoir is soil. Water can harbor Giardia, E. coli 0157-H7, and Shigella. Drinking or swimming in contaminated water can begin the infectious cycle in a person. Food can also be a reservoir. Undercooked ground beef and fresh leafy vegetables have been identified as responsible for recent outbreaks of E. coli infections. CDC recommends that all ground beef be cooked until well done and new laws keep fruits and vegetables safer when they are grown, picked, and washed. Milk can contain Listeria unless it is pasteurized. A recent outbreak of foodborne illnesses caused by Listeria was traced to contaminated cantaloupe. Inanimate objects can also harbor organisms, such as the influenza virus, which may be spread if a person touches a contaminated article and then touches one's nose or eyes.

Maintaining Normal Voiding Habits

Schedule Urge to void Privacy Position Hygiene

Measurement of a Pressure Ulcer

Size of wound Depth of wound Presence of undermining, tunneling, or sinus tract

Transparent films (e.g., OpSite) are semipermeable membrane dressings that are adhesive and waterproof. These dressings are occlusive, decreasing the possibility of contamination, while allowing visualization of the wound. This type of dressing is often used over peripheral intravenous sites, central venous access device insertion sites, and noninfected healing wounds (Fig. 31-11). THINK back to Lucius Everly, the patient in the critical care unit. The nurse most likely would use a transparent dressing on his venous access sites, thereby allowing frequent assessment of the sites. When caring for open wounds and pressure ulcers, it is necessary to keep the wound tissue moist and the surrounding skin dry. Therefore, use dressings that continuously keep the wound moist, placing the moist dressing only on the wound surface and keeping the intact, healthy skin surrounding the ulcer dry because it is susceptible to damage. Select a dressing that absorbs exudate, if present, but still maintains a moist environment for healing. Use a skin sealant or moisture-barrier ointment on the surrounding skin and secure the dressing with the least amount of tape or other material to secure that is necessary. The presence of foreign matter and/or devitalized, injured, infected tissue in a wound may indicate the need for débridement to promote wound healing (Hess, 2013; Baranoski & Ayello, 2012; Beitz, 2012). Débridement can be accomplished through several different methods. Autolytic débridement uses occlusive dressings, such as hydrocolloids (Fig. 31-12) or transparent films, and uses the body's own enzymes and defense mechanisms to loosen and liquefy necrotic tissue. Biosurgical débridement involves the use of sterile fly larvae. The larvae secrete an enzyme that liquefies dead tissue, which is ingested by the larvae, clearing the wound of bacteria and infection. Enzymatic débridement involves the application of commercially prepared enzymes to speed up the body's autolytic process. Mechanical débridement uses external physical force to dislodge and remove debris and necrotic tissue. This could be achieved by wound irrigation with pulsed pressure lavage (washing), whirlpool therapy, ultrasound or laser treatment, or with surgical débridement. In the past, wet-to-dry gauze dressings have been used to débride wounds; this is no longer considered good practice. This type of dressing damages healthy wound bed tissue and can be painful (Baranoski & Ayello, 2012; Agency for Healthcare Research and Quality [AHRQ], 2011). Concern exists that complete drying of the gauze disrupts angiogenesis. However, despite concerns by wound care experts, these dressings are still prescribed by physicians for wound débridement.

There are many other wound care products/dressings available, each with distinctive actions, as well as indications, contraindications, advantages, and disadvantages. It is very important for the nurse to be aware of the products available in a particular facility and be familiar with the indications for, and correct use of, each type of dressing and wound care product. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. Table 31-5 outlines the purposes and uses for several wound dressing/product categories.

Positioning Patients in Bed Positioning that maintains correct body alignment and facilitates physiologic functioning contributes to the patient's psychological and physical well-being. The force of gravity pulls parts of the body out of alignment unless adequate support is provided. Various positions are, therefore, protective in nature only when the appropriate positions are maintained. COMMON DEVICES TO PROMOTE CORRECT ALIGNMENT Many devices can help maintain proper body alignment and muscle tonus while the patient is in bed and can alleviate discomfort or pressure on various parts of the body. Pillows. Pillows are used primarily to provide support or to elevate a body part. Pillows of different sizes are useful for different parts. Those intended for the head are usually full-sized or large-sized pillows. Small pillows are ideal for support or elevation of the extremities, shoulders, or incisional wounds. Specially designed heavy pillows are useful to elevate the upper part of the body when an adjustable bed is unavailable, such as at home. When placing the pillows, assess for proper alignment. For example, excess cervical flexion would not be comfortable or useful in maintaining adequate respiratory patterns. Mattresses. For a mattress to be comfortable and supportive, it must be firm but have sufficient "give" to permit proper body alignment. A patient who must remain in a bed with a nonsupportive mattress may complain of backache and other discomforts. Special mattresses, pads, and types of beds used to help prevent pressure ulcers are discussed in Chapter 31. Adjustable Beds. The nurse can elevate the head and foot of an adjustable bed to the desired degree. This positioning is discussed later in the chapter. Some adjustable beds allow the bed to be "broken," or gatched, so that the mattress is flexed at the level of the knees. This position is rarely recommended because it can cause pressure on the popliteal space behind the knee, resulting in impaired circulation to the lower extremity and an increased risk for clot formation. It is also possible to change the adjustable bed so that the distance from the bed to the floor can be altered. Position the bed at the height that will let the patient stand with the least amount of effort. Health care workers use the higher bed positions so that they do not strain their backs while providing bed care. However, a low bed position between treatments decreases the risk of injury if the patient were to fall out of bed. General guidelines for safe use of beds are discussed in Chapter 31. Many beds used in patient care environments have improvements to support transfer and repositioning of the patient. Some beds easily convert to a chair, bypassing the need for bed-to-chair transfers. Other beds are designed to align the patient's hip with the pivot point in the bed, minimizing slippage toward the foot of the bed when the head of the bed is raised and reducing the need to reposition the patient. Many new mattress surfaces are designed to eliminate the need for frequent repositioning by the nurse; some provide a cushion of air under the patient during movement, reducing friction; and others have surfaces that can rotate to move the patient as needed for care.

Trapeze Bar. A trapeze bar (Fig. 32-15) is a handgrip suspended from a frame near the head of the bed. A patient can grasp the bar with one or both hands and raise one's trunk from the bed. The trapeze makes moving and turning considerably easier for many patients and facilitates transfers into and out of bed. It can also be used when a patient needs to perform exercises that strengthen some muscles of the upper extremities (e.g., biceps). Additional Equipment. The greatest danger to the feet occurs when they are unsupported in the dorsiflexion position. The toes drop downward, and the feet are in plantar flexion. Because of the pull of gravity, this position of the feet occurs naturally when the body is at rest. If maintained for extended periods, plantar flexion can cause an alteration in the length of muscles, and the patient may develop a complication called footdrop. In this position, the foot is unable to maintain itself in the perpendicular position, heel-toe gait is impossible, and the patient experiences extreme difficulty in walking. The use of a foot support, such as a foot board, foot boot, or high-top sneakers, helps avoid this complication. Figure 32-16 demonstrates a foot in plantar flexion versus the dorsiflexion position maintained by wearing a high-top canvas sneaker. If top bedding must be kept off the patient's lower extremities, a device called a cradle is used. A cradle is usually a metal frame that supports the bed linens away from the patient while providing privacy and warmth. There are a number of sizes and shapes of cradles. If used, securely fasten the cradle to the bed so that it does not slide or fall on the patient. Sandbags, available in various sizes, can be used to immobilize an extremity and support body alignment. When properly filled, they should be pliable enough to be shaped to body contours to provide support. Avoid hard or firmly packed sandbags. Position a sandbag to avoid creating pressure on a bony prominence. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward. Figure 32-17 illustrates and describes how to use trochanter rolls. Properly placed pillows can also be used to help prevent the thighs from turning outward, but they tend to slip out of place and require frequent adjustment to be effective. If a patient is paralyzed or unconscious, hand-wrist splints or hand rolls may be necessary to provide a means for keeping the thumb in the correct position, that is, slightly adducted and in apposition to the fingers. A hand roll can be created by folding a washcloth, rolling it, and securing it in place with tape. Once placed against the palm of the hand, it can effectively keep the hand in a functional position (Fig. 32-18). A commercial plastic or aluminum splint also may be used to hold the thumb in place regardless of the hand position. Encourage patients who are not moving their fingers to do finger exercises, with special attention to having the thumb touch the tip of each finger. Side rails can assist the patient in rolling from one side to the other or to sitting up without calling for assistance. Using the side rails can help the patient retain or regain muscle efficiency. When using side rails, be sure to explain their use to patients and their families and follow the protocol of the health care agency. If a patient requests that side rails be raised for additional security, the patient must have the ability to raise and lower the side rails independently. Safe use of side rails is discussed in Chapter 26. PROTECTIVE POSITIONING Patients accustomed to an active lifestyle who generally use a bed only for sleep are often unaware of the importance of correct body alignment and regular position changes when on prescribed bed rest. Whenever possible, teach both the patient and family the following: Correct positioning techniques The need to change positions frequently, at least every 2 hours The importance of using the time allotted to position changes to exercise the extremities and to assess and massage pressure areas (reddened areas should not be massaged)

Breath Sounds

Vesicular: low-pitched, soft sound during expiration heard over most of the lungs Bronchial: high-pitched and longer, heard primarily over the trachea Bronchovesicular: medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area

Once a patient's risk has been identified, agencies use different approaches. Appropriate interventions are initiated based on the patient's identified risk. Many health care facilities use a special pressure ulcer assessment form. Documenting assessments is essential to ensure continuity of care, providing the foundation on which to develop the skin plan of care. All caregivers in the home or health care agency need to be aware of specific assessments, including assessment of mobility, nutritional status, and moisture and incontinence. MOBILITY Assessing a patient's mobility status includes evaluating the patient's ability to move, turn, and reposition the body. A patient who is confined to bed or a chair or has limited range of motion is at increased risk for a pressure ulcer. This assessment of activity status is done upon admission to the health care facility or during the initial home care interview. The use of any assistive devices to maintain mobility and activity is noted. Additional suggestions for gathering information about mobility are described in Chapter 32. NUTRITIONAL STATUS The importance of sound nutrition in the prevention and treatment of a pressure ulcer is well established. Older adults, in particular, need adequate nutrition for optimal health and wound healing. Nutritional assessment is described in Chapter 35. The following laboratory criteria indicate that a patient is nutritionally at risk for development of a pressure ulcer: Albumin level <3.2 mg/dL (normal, 3.5-5 mg/dL). Prealbumin <19 mg/dL (normal 16-40 mg/dL) Body weight decrease of 5% to 10% Additional laboratory tests to consider in patients at risk for or presenting with pressure ulcers include: Total lymphocyte count <1,800/mm3 (normal, 1,000-4,000/mm3) Hemoglobin A1C >8% (normal <6%) Glucose >120 mg/dL (normal 70-120 mg/dL) MOISTURE AND INCONTINENCE Many studies have documented that moisture makes the skin more susceptible to injury. Whether the moisture is from perspiration, wound drainage, urine, or stool, the skin is compromised. Moisture can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Chapters 36 and 37 have additional assessment information related to incontinence. APPEARANCE OF EXISTING PRESSURE ULCER Skin assessment for a pressure ulcer specifically includes inspection of the following (Baranoski & Ayello, 2012; NPUAP, 2012c; Hess, 2013): Location of any lesion or ulcer Identification of the stage (see Box 31-3, pp. 970-971) Size of the ulcer: length, width, depth (see Guidelines for Nursing Care 31-1, p. 975); presence of undermining, a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue Color and type of wound tissue Presence of any abnormal pathways in the wound, such as a sinus tract (a cavity or channel underneath the wound that has the potential for infection) or tunneling (a passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin). See Guidelines for Nursing Care 31-1. Visible necrotic tissue; necrotic tissue that is in the process of separating from viable portions of the body is referred to as slough. Presence of an exudate or drainage (amount and type) Presence of odor Presence or absence of granulation tissue Visible evidence of epithelialization Periwound skin condition The Pressure Ulcer Scale for Healing (PUSH Tool) was developed by the National Pressure Ulcer Advisory Panel (NPUAP, 2012c) as a quick, reliable tool to monitor the change in pressure ulcer status over time (Fig. 31-8). Graphing the PUSH Tool scores over time for each ulcer allows health care providers to "tell at a glance" whether the ulcer is healing, remains unchanged, or is deteriorating (NPUAP, 2012c). The RYB Wound Classification (red yellow black; see Box 31-4, p. 976) can also be used to aid in assessment and description of the pressure ulcer appearance.

Wound Care/Wound Management The goal of wound care is to promote tissue repair and regeneration so that skin integrity is restored. Wounds can be treated by leaving them open to air; no dressing (protective covering placed over a wound) is applied. Wounds left open to the air heal more slowly because wound drying produces a dried eschar or scab. If the scab is removed accidentally before healing is complete, reinjury occurs, and the new delicate cells are exposed. Wounds left open are exposed to more environmental factors and potential injury. Closed wound care uses dressings to keep the wound moist, promoting healing. A moist environment is best for wound healing. When a dressing is placed over a wound, the wound fluid keeps the surface of the wound moist. As a result, epidermal cells migrate more rapidly, maximizing healing. In addition, covered wounds can help patients cope with alterations in body image. Generally, an ideal dressing should maintain a moist environment, be absorbent, provide thermal insulation, act as a bacterial barrier, reduce or eliminate pain at the wound site, and allow for pain-free removal (Baranoski & Ayello, 2012; Wound Healing and Management Node Group, 2011). Many different types of dressings are available, but all have essentially the same purposes: Provide physical, psychological, and aesthetic comfort Prevent, eliminate, or control infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Protect the skin surrounding the wound Remove necrotic tissue, if appropriate There is no standard frequency for how often dressings should be changed. It depends on the amount of drainage, the primary practitioner's preference, the nature of the wound, and the particular wound care product being used. It is customary for the surgeon or other advanced practice professional to perform the first dressing change on a surgical wound, usually within 24 to 48 hours after surgery. CONSIDER the care needed by Lucius Everly, the patient in the critical care unit. Although he has multiple needs, performing incisional wound care cannot be overlooked; otherwise, his risk of infection may increase. Wound contamination occurs through a moist medium. Microorganisms can move from the external surface through the dressing to the wound if a dressing remains in place until it is saturated. Microorganisms can also move from the wound to the outer surface of a saturated dressing. For these reasons, always replace dressings with fresh dressings or reinforce the dressing with additional dressings before drainage causes saturation. Dressing changes provide an excellent opportunity for teaching, especially important when the patient will be changing dressings at home. Encourage the patient to help as much as possible, if appropriate. The sight of the wound may disturb a patient. Listen carefully to what the patient is saying and observe nonverbal communication as well. In some instances, the patient may not want to look at the wound, particularly with a wound that involves a change in normal body functions or appearance, such as a wound resulting from the removal of a breast, the amputation of an extremity, or the placement of a tube in a draining wound. With patience and emotional support, patients can learn to cope with and adapt to their wound. TYPES OF WOUND DRESSINGS The items needed for a dressing change may be gathered individually or may be packaged in a sterile dressing tray, depending on the health care setting. Wound care in the home may depend on the supplies provided by the patient or family. The number and type of dressings used depend on the location and size of the wound, type and depth of wound, the presence of infection, the need for débridement (removal of devitalized tissue and foreign material), and the amount and type of drainage. Dry gauze dressings can be used to cover wounds, commonly closed surgical wounds. These dressings come in various sizes (2 × 2 inches, 4 × 4 inches, 4 × 8 inches) and are commercially packaged as single units or in packs. Gauze dressings often consist of three layers. The first layer of dressing material applied directly to a draining wound is often nonabsorbent but hydrophilic (i.e., capable of carrying moisture). This type of material allows drainage from the wound to move into overlying absorbent layers of dressing, helping to prevent maceration and reinfection. Moreover, this type of dressing is less likely to stick to the wound, making dressing changes more comfortable for the patient. Material to absorb and collect drainage is then placed over the first layer of nonabsorbent material. This material acts as a wick, pulling drainage out by capillary action. Absorbent cotton has far greater capillarity than untreated cotton. Therefore, cotton-lined gauze sponges soak up more liquid than do unlined sponges. The number of gauze sponges used in the dressing depends on the amount of drainage. Loosely packed gauze, the threads of which act as numerous wicks, enhances capillarity and directs drainage upward and away from the wound. Fluffed and loosely packed dressings are more absorbent than tightly packed dressings. The top of the dressing may be further protected by surgical or abdominal pads, which are thick, absorbent pads that help to absorb profuse drainage (Fig. 31-9). Nonadherent gauzes include sterile petrolatum gauze and Telfa gauze. Telfa's shiny outer surface is applied to the wound. These dressings allow drainage to pass through and be absorbed by the outer absorbent layer but prevent outer dressings from adhering to the wound and causing further injury when removed. Special gauze dressings (e.g., Sof-Wick) are precut halfway to fit around drains or tubes (Fig. 31-10). Larger dressings (8 × 10 bandages, abdominal pads [ABDs], Surgi-Pads) are placed over the smaller gauze dressings and absorb drainage and protect the wound from contamination or injury.

DEEP BREATHING: INSTRUCT PT TO MAKE EACH BREATH DEEP ENOUGH TO MOVE BOTTOM RIBS

X

PTS CAN KEEP THEIR SECRETIONS THIN BY DRINKING 2-3 QUARTS OR 1.9-2.9L OF CLEAR FLUIDS DAILY

X

ch 36

urinary elimination

ch 24

vital signs

Disinfection destroys all pathogenic organisms except spores; sterilization destroys all microorganisms, including spores.

x

WHAT ARE THE 2 MAIN PT IDENTIFIERS PRIOR TO INSERTING A FOLEY NAME DOB also ask if they are allergic to iodine or shellfish

x

Cardiac Coronary Catheterization (Angiography)

A cardiac catheterization is an invasive study performed to evaluate coronary artery disease, visualize the coronary blood vessels, assess cardiac output, diagnose chest pain and complications of myocardial infarction, evaluate the need for coronary artery surgery, and assess the function of heart valves. Catheters are introduced into blood vessels of the right and left sides of the heart. Contrast dye is injected through the catheters and allows for x-ray visualization of the heart.

Benefits of Exercise to Cardiovascular System

Increased efficiency of the heart; the heart does not have to work as hard to perfuse the body when active Decreased heart rate and blood pressure Increased blood flow to all body parts...for example, increased urinary flow due to increased circulation Improved venous return Increased circulating fibrinolysin (substance that breaks up small clots) Hmmm, select all???

Effects of Applying Cold

constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort

when is alcohol rub not enough?

if there i C. difficile. Then we need to use soap and water to remove spores of C. difficile.

alcohol rub vs soap

oly use soap for c diff or if they are visibly soiled

ch 31

skin integrity and wound care

WHEN DO WE REMOVE TED HOSE? AT THE BATH! REMOVE DURING BATH or if they are soiled! or if u are assessing for edema

x

ch 30 hygiene

x

Nutritional Status Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and protein are necessary to rebuild cells and tissues. Vitamins A and C are essential for epithelialization and collagen synthesis. Zinc plays a role in proliferation of cells. Fluids are necessary for optimal function of cells. All phases of the wound healing process are slowed or inadequate in the patient with poor nutritional status and fluid balance. Some patients who are obese suffer from protein malnutrition, which interferes with healing. Patients who are undernourished may lack the nutritional stores to promote wound healing. Nutrition is further discussed in Chapter 35. Medications and Health Status Patients who are taking corticosteroid drugs or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection. The presence of a chronic illness (such as cardiovascular disease or diabetes mellitus) or impaired immune function can impair wound healing. Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including cells involved in wound healing. Prolonged antibiotic therapy increases a patient's risk for secondary infection and superinfection. Immunosuppression Suppression of the immune system as a result of disease (e.g., AIDS, lupus), medication (e.g., chemotherapy), or age (e.g., changes associated with advancing age) can delay wound healing. Wound Complications Wound complications include infection, hemorrhage, dehiscence, evisceration, and fistula. These complications increase the risk for generalized illness and death, lengthen the patient's need for health care interventions, and add to health care costs. INFECTION Wound infection results when the patient's immune system fails to control the growth of microorganisms. Microorganisms can invade a wound at the time of trauma, during surgery, or at any time after the initial wound occurs. A contaminated wound is more likely to become infected than one that is not contaminated. Additionally, the risk of infection is increased in a surgical wound created during a procedure involving the intestines because the risk for contamination with fecal material is high. Wound infections also occur as a result of hospital-acquired infections (HAIs). Symptoms of wound infection usually become apparent within 2 to 7 days after the injury or surgery; often, the patient is at home. Symptoms of infection include purulent drainage; increased drainage, pain, redness, and swelling in and around the wound; increased body temperature; and increased white blood cell count. Additional signs and symptoms include delayed healing and discoloration of granulation tissue in the wound (Baranoski & Ayello, 2012). In patients with infection in a chronic wound, pain and delayed healing may be the only symptoms (Baranoski & Ayello, 2012). Wound infections impair healing. Wound infections can lead to other complications, including development of chronic wounds, osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood or tissues). HEMORRHAGE Hemorrhage may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain. Check the dressing and the wound under the dressing, if possible, frequently during the first 48 hours after the injury, and no less than every 8 hours thereafter. If excessive bleeding does occur, additional pressure dressings or packing may be necessary, fluid replacement is probably necessary, and surgical intervention may be required. Internal hemorrhage causes the formation of a hematoma. If the bleeding leads to a large accumulation of blood, it can put pressure on surrounding blood vessels and cause tissue ischemia (deficiency of blood to an area). See Chapter 29 for more information about hemorrhage. DEHISCENCE AND EVISCERATION Dehiscence and evisceration (Fig. 31-2) are the most serious postoperative wound complications. Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Evisceration is the most serious complication of dehiscence (Hinkle & Cheever, 2014; Harvey, 2005). The wound completely separates, with protrusion of viscera through the incisional area. Patients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining (Hinkle & Cheever, 2014). An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The patient may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Dehiscence and evisceration of an abdominal incision is a medical emergency. Place the patient in the low Fowler's position and cover the exposed abdominal contents, as discussed previously. Do not leave the patient alone. Notify the primary care provider immediately. This situation is an emergency that requires prompt surgical repair

ISTULA FORMATION A fistula is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. Fistulas may be created purposefully; for example, an arteriovenous fistula is created surgically to provide circulatory access for kidney dialysis. However, fistula formation is often the result of infection that has developed into an abscess, which is a collection of infected fluid that has not drained. Accumulated fluid applies pressure to surrounding tissues, leading to the formation of the unnatural passage. Figure 31-3 illustrates an enterovaginal fistula, which is an abnormal connection between the rectum and vagina. The presence of a fistula increases the risk for delayed healing, additional infection, fluid and electrolyte imbalances, and skin breakdown.

ANATOMY AND PHYSIOLOGY OF OXYGENATION Oxygen Transport Click to Show Heart and Breath Sounds Click to Show Oxygenation of body tissues depends on several factors. One is the integrity of the airway system to transport air to and from the lungs. A properly functioning alveolar system in the lungs to oxygenate venous blood and to remove carbon dioxide from the blood is also important. A properly functioning cardiovascular system and blood supply to carry nutrients and wastes to and from body cells is a necessary component of oxygenation. Knowledge of the basic anatomy and physiology of the respiratory and cardiovascular systems and an understanding of the role of these systems in oxygenation of body tissues provides a foundation for assessing oxygenation in patients and for planning and implementing interventions to promote optimal oxygenation. This knowledge also helps nurses understand, interpret, and analyze assessment findings and provides the rationale for sound nursing interventions. Respiratory System Oxygen and carbon dioxide must move through the alveoli as part of the oxygenation process. Thus, an adequately functioning respiratory system is vital for the exchange of gases. Anatomy of the Respiratory System The airway, which begins at the nose and ends at the terminal bronchioles, is a pathway for the transport and exchange of oxygen and carbon dioxide. The airway is divided into the upper and the lower airways. The upper airway is composed of the nose, pharynx, larynx, and epiglottis. Its main function is to warm, filter, and humidify inspired air. The lower airway, known as the tracheobronchial tree, includes the trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles (Fig. 38-1). Its major functions are conduction of air, mucociliary clearance, and production of pulmonary surfactant. The airways are lined with mucus, which traps cells, particles, and infectious debris. This mucus covering also helps to protect the underlying tissues from irritation and infection. Cilia, which are microscopic hair-like projections, propel trapped material and accompanying mucus toward the upper airway so they can be removed by coughing. Removal is facilitated when mucus is watery in consistency. An adequate fluid intake is necessary for ciliary action and for the production of watery mucus normally present in the respiratory tract. The lungs, the main organs of respiration, are located within the thoracic cavity on the right and left sides (see Fig. 38-1). The lungs extend from the base at the level of the diaphragm to the apex (top), which is above the first rib. The heart lies between the right and left lung. Each lung is divided into lobes. The right lung has three lobes; the left has two. Each lobe is subdivided into segments or lobules. The main bronchus branches to each lung from the trachea. It immediately subdivides into secondary bronchi, one to each lobe. The bronchi subdivide again and again, becoming smaller and smaller as they branch through the lung. The smallest of these branches are the bronchioles, ending at the terminal bronchioles. The lungs are composed of elastic tissue that can stretch or recoil. At the end of the terminal bronchioles there are clusters of alveoli (singular, alveolus), small air sacs. The alveoli are the site of gas exchange. The wall of each alveolus is made of a single-cell layer of squamous epithelium (see Fig. 38-1). This thin wall allows for exchange of gases with the capillaries covering the alveoli. The average adult has more than 300 million alveoli. Surfactant, a detergent-like phospholipid, reduces the surface tension between the moist membranes of the alveoli, preventing their collapse. When surfactant production is reduced, the lung becomes stiff and the alveoli collapse. The lungs and thoracic cavity are lined with a serous membrane called the pleura. The visceral pleura covers the lungs, and the parietal pleura lines the thoracic cavity. These two membranes are continuous with each other and form a closed sac. The pleural space lies between the two layers. Pleural fluid between the membranes acts as a lubricant and as an adhesive agent to hold the lungs in an expanded position. A few milliliters of fluid between the pleural surfaces allows the lungs to move easily along the chest wall as they expand and contract. Without this fluid, filling and emptying of the lungs are difficult. p. 1398 p. 1399 Pressure within the pleural space (intrapleural pressure) is always subatmospheric (a negative pressure). This constant negative intrapleural pressure, along with the pleural fluid, holds the lungs in an expanded position.

Physiology of the Respiratory System Gas Exchange in Alveoli Click to Show Living cells require oxygen and the removal of carbon dioxide, a byproduct of oxidation. Gas exchange, the intake of oxygen and the release of carbon dioxide, is made possible by pulmonary ventilation, respiration, and perfusion. Pulmonary ventilation refers to the movement of air into and out of the lungs. Respiration involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries. Perfusion is the process by which oxygenated capillary blood passes through body tissues. PULMONARY VENTILATION Pulmonary ventilation (breathing) is the movement of air into and out of the lungs. The process of ventilation has two phases: inspiration (inhalation) and expiration (exhalation). Inspiration, the active phase, involves movement of muscles and the thorax to bring air into the lungs. Expiration, the passive phase, is the movement of air out of the lungs. During inspiration, the following events occur: the diaphragm contracts and descends, lengthening the thoracic cavity; the external intercostal muscles contract, lifting the ribs upward and outward; and the sternum is pushed forward, enlarging the chest from front to back. This combination of an increased lung volume and decreased intrapulmonic pressure allows atmospheric air to move from an area of greater pressure (outside air) into an area of lesser pressure (within the lungs). The relaxation, or recoil, of these structures then results in expiration. The diaphragm relaxes and moves up, the ribs move down, and the sternum drops back into position. This causes a decreased volume in the lungs and an increase in intrapulmonic pressure. As a result, air in the lungs moves from an area of greater pressure to one of lesser pressure and is expired (Fig. 38-2). Other physical factors contribute to airflow in and out of the lungs. These factors include the condition of the musculature, compliance of lung tissue, and airway resistance. The condition of the body's musculature can affect the process of respiration. Weakening of the muscles involved in respiration can contribute to less effective inhalation and exhalation. The accessory muscles of the abdomen, neck, and back are used to maintain respiratory movements at times when breathing is difficult. These muscles are used to facilitate breathing; the movement is called retraction. FIGURE 38-2. Pulmonary ventilation. p. 1399 p. 1400 FIGURE 38-3. Gas exchange in the alveolus. The greater pressure of the oxygen in the air inhaled into the alveoli causes the oxygen to move into the capillaries, which contain unoxygenated blood. The carbon dioxide in the returning venous blood moves from the capillaries (area of greater concentration) into the alveoli (area of lesser concentration). Lung compliance refers to the ease with which the lungs can be inflated. The compliance of lung tissue affects lung volume. The ability of the lungs to adequately fill with air during inhalation is achieved by the normal elasticity of lung tissue, aided by the presence of surfactant. The varying changes in lung pressure and resulting lung compliance can be compared to differences in blowing up a new, noncompliant balloon versus one that was inflated previously. A stiff, noncompliant lung (like a new balloon) requires a greater inspiratory effort to inflate it. Emphysema, a chronic lung condition, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which, in turn, decreases compliance. Airway resistance is the result of any impediment or obstruction that air meets as it moves through the airway. Any process that changes the bronchial diameter or width causes airway resistance. Obstruction in any part of the normal passageways impedes respiration. Obstruction can be caused by a foreign substance, such as a piece of food, a coin, or a toy, or by liquids, as in the case of a drowning victim. Obstruction can also result from secretions (e.g., excessive or thickened secretions) or tissues (e.g., tumors or edema of the respiratory tract). A decrease in the size of air passages resulting from constriction or poor neck positioning can also impede respiration. Bronchial constriction in asthma is an example of airway resistance related to a decrease in the size of air passages. Consider Tyrone Jacobs, the 12-year-old boy with suspected asthma. An understanding of the underlying pathophysiologic processes involved with this disorder would provide the basis for the nurse's actions to protect the child's airway. RESPIRATION Respiration, gas exchange, occurs at the terminal alveolar capillary system. Gases are exchanged between the air and blood via the dense network of capillaries in the respiratory portion of the lungs and the thin alveolar walls (see Fig. 38-1, p. 1398 and Fig. 38-3). Gas exchange occurs via diffusion. Diffusion is the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentration. In respiration, diffusion refers to the movement of oxygen and carbon dioxide between the air (in the alveoli) and the blood (in the capillaries). These gases move passively from an area of higher concentration to an area of lower concentration. The greater pressure of oxygen in the alveoli causes the oxygen to move from the alveoli into the capillaries containing the unoxygenated venous blood. Likewise, the carbon dioxide in the returning venous blood exerts a greater pressure than the carbon dioxide in the alveoli. Therefore, carbon dioxide diffuses across the capillary into the alveoli and ultimately is exhaled. Diffusion of gases in the lung is influenced by several factors, including changes in surface area available, thickening of alveolar-capillary membrane, and partial pressure. Any change in the surface area available for diffusion hinders diffusion. For example, removal of a lung or the presence of a disease that destroys lung tissue can decrease the surface area available, ultimately affecting gas exchange. Incomplete lung expansion or the collapse of alveoli, known as atelectasis, prevents pressure changes and the exchange of gas by diffusion in the lungs. Areas of the lung with atelectasis cannot fulfill the function of respiration. Examples of conditions that predispose a patient to atelectasis are obstructions of the airway by foreign bodies, mucus, airway constriction, external compression by tumors or enlarged blood vessels, and immobility. Any disease or condition that results in thickening of the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. The partial pressure, or pressure resulting from any gas in a mixture depending on its concentration, can also affect diffusion. If environmental oxygen is reduced, such as when a person is at higher altitudes or in the presence of toxic fumes, less oxygen is available for diffusion. When oxygen is administered, an increased amount of oxygen is available, resulting in greater diffusion across capillary membranes. PERFUSION Oxygenated capillary blood passes through the tissues of the body in the process called perfusion. The amount of blood flowing through the lungs is a factor in the amount of oxygen and other gases that are exchanged. The amount of blood present in any given area of lung tissue depends partially on whether the person is sitting, standing, or lying down. Perfusion is greater in dependent areas. The perfusion of lung tissue also depends on the person's activity level. Greater activity results in an increased need for cellular oxygen by the body's tissues and a subsequent increase in cardiac output and consequently in increased blood return to the lungs. In addition, perfusion to the body's tissues depends on an adequate blood supply and proper cardiovascular functioning to carry oxygen and carbon dioxide to and from the lungs (discussed later). Regulation of the Respiratory System The respiratory center is located in the medulla in the brainstem, immediately above the spinal cord. It is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. In addition, chemoreceptors in the aortic arch and carotid bodies are sensitive to the same arterial blood gas (measurement of blood pH, and arterial oxygen and carbon dioxide) levels and blood pressure, and can activate the medulla. Proprioceptors in the muscles and joints respond to body movements, such as exercise, and cause an increase in ventilation. Stimulation of the medulla increases the rate and depth of ventilation (both inspiration and expiration) to blow off carbon dioxide and hydrogen and increase oxygen levels (the patient is breathing faster and more deeply). The medulla sends an impulse down the spinal cord to the respiratory muscles to stimulate a contraction leading to inhalation. If a condition causes a chronic change in the oxygen and carbon dioxide levels, these chemoreceptors may become desensitized and not regulate ventilation adequately. Alterations in Respiratory Function If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. Anxiety, restlessness, confusion, and drowsiness also are common signs of hypoxia. Hypoxia is often caused by hypoventilation (decreased rate or depth of air movement into the lungs). Hypoxia can also be a chronic condition. The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Additional information related to alterations in respiratory function is discussed in Chapter 24.

RED FONT ON CLINICAL SKILLS PAGES ARE GAME FOR EXAM!!

SELECT ALL THAT APPLY ON BULLET POINTS IN POWERPOINTS ARE GAME!

Stages of pressure ulcers

Stage I: nonblanchable erythema of intact skin Stage II: partial-thickness skin loss Stage III: full-thickness skin loss; not involving underlying fascia Stage IV: full-thickness skin loss with extensive destruction Unstageable: base of ulcer covered by slough and/or eschar in wound bed

TECHNIQUES TO REDUCE STRESS: SPEREAD FEET SHOULDER WITDTH APART, KEEP WEIGHT TOWARDS BODY

should you push or pull eqip? look it up, i think its push..its push! you want to use ur strongest muscles! (?)

alcohol rub is 15 seconds

soap and water is 20 seconds

BEST DRESSING FOR DECUBITIS ULCERS

starts with C look it up! i think its colloidal

if person is incontinent, we need to put a barrier on them!

x

nails should be less than 0.25 inches long

x

best food sources for ppl with wounds?

protein with vit C

Heat Production The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise. When additional heat is required to maintain balance, epinephrine and norepinephrine (sympathetic neurotransmitters) are released to rapidly alter metabolism so that energy production decreases and heat production increases. Thyroid hormone, produced by the thyroid gland, also increases metabolism and heat production, but over a much longer time period. Shivering, a response that increases the production of heat, is initiated by the hypothalamus and results in muscle tremors, causing the production of heat. In addition, the contraction of pilomotor muscles of the skin, as occurs with shivering, causes piloerection, or "goose bumps," and reduces the surface area of skin available for heat loss. Physical exertion increases heat production through muscle movements. Heat Loss The skin is the primary site of heat loss. The circulating blood brings heat to the skin's surface, where small connections between the arterioles and the venules lie directly below the skin surface. These connections, called arteriovenous shunts, may remain open to allow heat to dissipate (e.g., during exercise in hot environmental temperatures) to the skin and then to the external environment, or they may close and retain heat in the body (e.g., when the body is exposed to cold environmental temperatures). The sympathetic nervous system controls the opening and closing of the shunts in response to changes in core body temperature and in environmental temperature (Grossman, 2014). Heat is transferred to the external environment through the physical processes of radiation, convection, evaporation, and conduction. These processes are defined and illustrated in Table 24-2. Other heat losses occur through evaporation of sweat, through warming and humidifying of inspired air, and through elimination of urine and feces. Factors Affecting Body Temperature A variety of factors affect body temperature. These factors include time of day (circadian rhythms), age, gender, physical activity, state of health, and environmental temperatures. Circadian Rhythms Many environmental and physiologic processes occur in repeated cycles of time. Some events in humans recur at 24-hour intervals, referred to as circadian (meaning nearly every 24 hours) rhythm. Predictable fluctuations in measurements of body temperature and blood pressure are examples of functions that have a circadian rhythm. For instance, body temperature is usually about 0.6°C (1° to 2°F) lower in the early morning than in the late afternoon and early evening. This variation tends to be somewhat greater in infants and children. The peak elevation of a person's temperature occurs in late afternoon and early evening, between 4 and 8 PM. Age and Gender Older adults lose some thermoregulatory control with aging; body temperatures in older adults may be lower than the average adult temperature (Lu, Leasure, & Dai, 2009). Both the very old and the very young are more sensitive to changes in environmental temperature. Older adults are at risk for harm from extremes of temperature due to impaired thermoregulatory responses. The body temperature of infants and children changes more rapidly in response to both hot and cold air temperatures.

radiation: The diffusion or dissemination of heat by electromagnetic waves ex: The body gives off waves of heat from uncovered surfaces. convection: The dissemination of heat by motion between areas of unequal density ex: An oscillating fan blows currents of cool air across the surface of a warm body. evaporation: The conversion of a liquid to a vapor ex: Body fluid in the form of perspiration and insensible loss is vaporized from the skin. conduction: The transfer of heat to another object during direct contact ex: The body transfers heat to an ice pack, causing the ice to melt.

how much soap?

1 teaspoon

when should an alcohol-based rub be used?

1. before direct pt contact 2. after direct pt contact 3. after contact with body fluids, mucous membranes, non-intact skin, wound dressings, and if hands are not visibly soiled 4. after removing gloves 5.before insreting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement 6. before donning sterile gloves prior to an invasive procedure. (catheter) 7. if moving from contaminated body site to a clean body site 8.after contact with objects (including equipment) located in the patient's environment

when are you supposed to wash your hands?

1. before touching a pt 2. after touching a pt 3. before a clean/aseptic technique 4. After a body fluid exposure risk 5. after touching pt surroundings 6. when they are visibly soiled

The tube is made of semi-flexible plastic (polyurethane or silicone), rigid plastic, or metal and is available in different sizes with varied angles. The condition and needs of the patient determine the selection of either a metal or plastic tracheostomy tube. Although metal tubes are more cost-effective for long-term use, most do not have an adapter at the neck plate that permits connection to respiratory therapy equipment (e.g., an oxygen delivery system, Ambu bag, or mechanical ventilator). A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place (Fig. 38-16). Many tubes also have inner cannulas that may or may not be disposable. The outer cannula remains in place in the trachea, and the inner cannula is removed for cleaning or replaced with a new one. Periodic cleaning or replacement of the inner cannula prevents airway obstruction from secretions that have accumulated on the tube's inner surface. A tube with an inner cannula is necessary when patients have excessive secretions or have difficulty clearing their secretions. It also may be recommended for a patient who will be discharged with a tracheostomy tube in place. Tracheostomy tubes may be either cuffed or cuffless (see Fig. 38-16). The inflated cuff seals the opening around the tube to create a tight fit in the trachea. This prevents air leakage and aspiration, and permits mechanical ventilation. Newer tracheal cuffs are low pressure, do not require deflating for short intervals every few hours, and can be maintained at lower than tracheal capillary pressure. If a cuffed tube is used, always deflate it before oral feeding unless the patient is at high risk for aspiration. If left cuffed, the balloon can cause pressure that extends through the trachea and onto the esophagus, possibly impeding swallowing or causing erosion of the tissue. A fenestrated tracheostomy tube has one large or several small openings or windows on its outer curve, has an inner cannula, and can be cuffed or cuffless. When the patient is being mechanically ventilated, the inner cannula is in place, blocking the small openings. After the patient is no longer connected to the ventilator, the inner cannula can be removed, the cuff deflated, and the tube plugged, allowing the patient to speak. Because the tube has these openings, it is not recommended for use in patients with a history of aspiration. The tracheostomy tube is held in place by twill tapes or a Velcro strip fastened around the patient's neck. When the tracheostomy is new, a sterile, square gauze pad that has been precut by the manufacturer may be placed between the skin and outer wings of the tube. This tracheostomy dressing must be kept dry to prevent infection and skin irritation. Regularly check cuff pressure, although some tubes have a pressure-release valve that prevents pressure from increasing to damaging levels. Also, because the tracheostomy tube bypasses the natural humidifying and heating mechanisms in the nose and mouth, administer heated, humidified oxygen to prevent secretions from becoming dry. Keep the tracheostomy tube free from foreign objects and nonsterile materials, such as cotton balls, loose threads from dressings, needles, and other small objects, to reduce the risk of obstruction and infection. Artificial noses, small pieces that attach over the end of the tracheostomy tube, are available to filter and warm the air before it enters the trachea. Preparation for emergency situations is an important part of nursing care for these patients. The tracheostomy is the patient's only airway, and measures to maintain its patency need to be readily available. Standard bedside equipment for emergency use should include the obturator from the current tube, suction equipment, oxygen, a spare tracheostomy tube of the same size, and one a size smaller (Freeman, 2011; Roman, 2005). Patients with tracheostomies frequently have an ineffective cough mechanism and copious secretions, which necessitate tracheal suctioning to remove secretions. Refer to the discussion related to tracheal suctioning later in the chapter. Tracheostomy Care: Providing Tracheostomy Care Using a Disposable Inner Cannula Click to Show Providing Tracheostomy Care. The nurse is responsible for replacing a disposable inner cannula or cleaning a nondisposable one. The inner cannula requires cleaning or replacement to prevent accumulation of secretions that can interfere with respiration and occlude the airway. Because soiled tracheostomy dressings place the patient at risk for the development of skin breakdown and infection, regularly change dressings and ties. Use gauze dressings that are not filled with cotton to prevent aspiration of foreign bodies (e.g., lint or cotton fibers) into the trachea. Clean the skin around a tracheostomy to prevent buildup of dried secretions and skin breakdown. Exercise care when changing the tracheostomy ties to prevent accidental decannulation or expulsion of the tube. Have an assistant hold the tube in place during the change or keep the soiled tie in place until a clean one is securely attached. Agency policy and patient condition determine specific procedures and schedules, but a newly inserted tracheostomy may require attention every 1 to 2 hours. Skill 38-5 outlines tracheostomy care. TRACHEAL SUCTIONING When performed correctly, suctioning provides comfort by relieving respiratory distress. When performed incorrectly, it can increase anxiety and pain and cause respiratory arrest. Tracheal suctioning may be performed by passing a sterile catheter through a tracheostomy or endotracheal tube. Suctioning to remove secretions is performed using the sterile technique as described in Chapter 23. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. The suction catheter should be small enough not to occlude the airway being suctioned but large enough to remove secretions. Several sizes of catheters are available. Wear gloves on both hands, goggles, and a mask—and a gown, if necessary—for protection from microorganisms. Tracheal suctioning is an uncomfortable procedure at minimum, and it can be a very painful and/or distressing experience. Therefore, anticipate assessing for the need for the administration of analgesic medication to a patient before suctioning (Arroyo-Novoa et al., 2008). However, only perform suctioning when clinically necessary because there are many potential risks. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. In the home setting, clean technique is used, as the patient is not exposed to disease-causing organisms that may be found in health care settings, such as hospitals (American Association for Respiratory Care [AARC], 1999). Closely assess the patient before, during, and after the procedure to limit negative effects. In order to prevent hypoxia, hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure (Hess, et al., 2012). Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis (Hess et al., 2012; Pate, 2004). Skill 38-6 describes suctioning a tracheostomy with an open system. The procedure is similar for an endotracheal tube. A closed airway suction system can be used to keep the airway patent for a patient with an endotracheal or tracheostomy tube who is receiving continuous mechanical ventilation, and reduce the risk of hypoxemia or, possibly, infection (Fig. 38-17). The catheter, encased in a plastic sleeve, remains connected to the patient's airway or ventilator tubing for up to 24 hours. This closed system is cost-effective because only one catheter is used daily, and the caregiver has additional protection from exposure to the patient's secretions. Some systems have an access valve, a safety feature that completely closes off access between the suction catheter and the endotracheal tube.

Administering Cardiopulmonary Resuscitation Cardiopulmonary resuscitation (CPR) is the combination of chest compressions, which circulate blood, and mouth-to-mouth breathing, which supplies oxygen to the lungs. After checking the victim for a response, activate the emergency response system, get an automated external defibrillator (AED) or defibrillator, and begin CPR with the CAB sequence: Chest Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation. Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter. Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each. Defibrillation: Apply the AED as soon as it is available. Start CPR in any situation in which either breathing alone or breathing and a heartbeat are absent. The brain is sensitive to hypoxia and will sustain irreversible damage after 4 to 6 minutes of no oxygen. The faster CPR is initiated, the greater the chance of survival. During CPR, standard precautions are followed even though contact with a patient's blood or body fluids does not always occur. Occupational Safety and Health Administration (OSHA) standards require health care facilities to provide an ample supply of ventilation masks along with other protective barriers for staff to use during resuscitation efforts. The automated external defibrillator (AED) has also proved effective in reducing deaths attributed to cardiac arrest. This easy-to-use, computer-based device is designed to deliver a shock to the heart muscle quickly to interrupt ventricular fibrillation, the most common initial rhythm occurring in cardiac arrest. The AED has the ability to analyze the heart's rhythm, direct the operator to deliver a shock when appropriate or deliver one automatically, and then reanalyze the rhythm to determine whether it has returned to normal (Fig. 38-20). Using the AED is an integral part of resuscitation. Most professional organizations recommend and support widespread efforts to teach CPR to laypeople and all health professionals. Mannequins for practice can be obtained from the AHA, the American Red Cross, and health agencies. The nurse is professionally responsible for maintaining proficiency in CPR skills. This necessitates periodic practice with mannequins (adult and infant). CPR must be administered quickly and accurately, without hesitation, when cardiac or pulmonary arrest occurs. In 2008, the AHA instituted changes in their suggestions regarding emergency interventions outside of health care facilities. Learning conventional CPR is still recommended. However, the AHA alternately recommends that when a teen or adult suddenly collapses, people near the victim should call 911 (activate the emergency response system) and push hard and fast in the center of the victim's chest. Studies of real emergencies that have occurred in homes, at work, or in public locations show that these two steps, called Hands-Only CPR, can be as effective as conventional CPR. Providing Hands-Only CPR to an adult who has collapsed from a sudden cardiac arrest can more than double or triple that person's chance of survival (AHA, 2012). Evaluating Evaluation is the final step of the nursing process; the accompanying concept map illustrates the nursing process for the care of Tyrone Jacobs. Evaluation is an ongoing and deliberate part of the nursing process that involves the nurse, patient, family, and other health care team members. It compares the patient's health status with previously defined expected outcomes and examines the patient's projected progress in meeting those outcomes. Everyone involved in the evaluation process needs to identify effective interventions and reasons for any failures in achieving the expected outcomes. Adjustments in the nursing plan of care are made accordingly. See Nursing Plan of Care 38-1 for Joan McEntyre.

Measuring Urine Output

Ask the patient to void into a bedpan, urinal, or specimen container in bed or bathroom (Nun's cap). Pour urine into the appropriate measuring device. Place the calibrated container on a flat surface and read at eye level. Note amount of urine voided and record on the appropriate form. Discard urine in the toilet unless specimen is needed...wear gloves when handling urine

EARLY MORNING CARE Shortly after the patient awakens, assist with toileting if necessary and then provide comfort measures to refresh the patient and prepare him or her for breakfast (or diagnostic tests). Nursing measures include washing the face and hands and providing mouth care. If needed, supplies necessary for morning care can be ordered at this time. Morning Care (AM care) After breakfast, complete morning care. Depending on the patient's self-care abilities, offer assistance with toileting, oral care, bathing, back massage, special skin care measures (e.g., pressure ulcer), hair care (includes shaving if indicated), cosmetics, dressing, and positioning for comfort. Cosmetics, if desired, can enhance morale in an ill patient. Agency policies are followed for refreshing or changing bed linens, and the patient's bedside area is tidied. When morning care is completed, the patient should feel refreshed and should be in a comfortable and safe environment. Morning care is often categorized as self-care, partial care, or complete care. Patients identified as self-care are capable of managing their personal hygiene independently once oriented to the bathroom. However, offer a back massage and spend time assessing the patient's day-to-day needs. Patients identified as partial care most often receive morning hygiene care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach. Patients identified as complete care require nursing assistance with all aspects of personal hygiene. A complete bed bath is done, or the patient is taken to the shower. Afternoon Care (PM care) Hospitalized patients frequently receive visitors in the afternoon or evening or use this time to rest when not scheduled for tests or therapies. Ensure the patient's comfort after lunch and offer assistance to nonambulatory patients with toileting, hand washing, and oral care. HOUR OF SLEEP CARE (HS CARE) Shortly before the patient retires, again offer assistance with toileting, washing of the face and hands, and oral care. Because many patients find that a back massage helps them to relax and fall asleep, offer one routinely. Change any soiled bed linens or clothing, and position the patient comfortably. Ensure that the call light and any other objects the patient desires (e.g., urinal, radio, water glass) are within easy reach. AS NEEDED CARE (PRN CARE) In addition to scheduled care, offer individual hygiene measures as needed. Some patients require oral care every 2 hours. Patients who are diaphoretic (sweating profusely) may need their clothing and bed linens changed several times a shift. At other times, a nurse may decide to forego hygiene measures because the patient's need for undisturbed rest may be a higher priority.

Assisting with Bathing and Skin Care Bathing serves a variety of purposes, including: Cleansing the skin Acting as a skin conditioner Helping to relax a restless person Promoting circulation by stimulating the skin's peripheral nerve endings and underlying tissues Serving as a musculoskeletal exercise through activity involved with bathing, thereby improving joint mobility and muscle tonus Stimulating the rate and depth of respirations Promoting comfort through muscle relaxation and skin stimulation Providing sensory input Helping to improve self-image Providing an excellent opportunity to strengthen the nurse-patient relationship, to thoroughly assess the patient's integumentary system, to observe the patient's physiologic and emotional status closely, to teach the patient as indicated, and to demonstrate care and interest in the patient's general welfare

Diseases Associated With Renal Problems

Congenital urinary tract abnormalities Polycystic kidney disease Urinary tract infection Urinary calculi Hypertension Diabetes mellitus Gout Connective tissue disorders

Reasons for Catheterization

Relieving urinary retention Obtaining a sterile urine specimen Obtaining a urine specimen when usual methods can't be used IE., a straight catheter Emptying bladder before, during, or after surgery Monitoring critically ill patients Increasing comfort for terminally ill patients

Equipment for Assessing Blood Pressure

Stethoscope and sphygmomanometer-make sure the cuff fits...BP can be altered if not the correct fit *higher when too tight *lower when too loose Doppler ultrasound-amplifies sound (Use this when a pulse can't be palpated) NOTE color & temp of site Electronic or automated devices-analyzes the sounds of blood flow & measures oscillations (fluctuations) in blood flow

Holter Monitor

This noninvasive study records the electric activity of the heart over a period of time, usually 24 to 48 hours, with an electronic recording device. It allows the patient to perform normal daily activities so that the response of the heart to these activities can be evaluated. It is also used to detect and evaluate dysrhythmias, evaluate chest pain and other symptoms, effectiveness of heart medications, and pacemaker function.

ch 32

activity

DO OLD PEOPLE NEED TO SHOWER EVERYDAY? SHOULD THEY USE HOT WATER?

NO

Oral temperature—37.0°C, 98.6°F Pulse rate—60 to 100 (80 average) Respirations—12 to 20 breaths/min Blood pressure—120/80

x

Collecting a Wound Culture If assessment of the wound indicates a possible infection, it is important to culture the wound. Culturing the wound allows identification of the infecting organism(s) and appropriate interventions. Skill 31-6 reviews the process for obtaining a wound culture.

HEAT AND COLD THERAPY The application of heat or cold is sometimes used as part of the treatment of wounds. The application of heat accelerates the inflammatory response to promote healing. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. The use of these therapies is discussed later in the chapter.

Endoscopic Studies

These involve direct visualization of a body cavity. A bronchoscope is used to examine the larynx, bronchi, and trachea. Bronchoscopy is used to view lesions, obtain a biopsy, improve drainage, remove foreign substances, evaluate trauma, and drain abscesses.

Oxygen Delivery Systems

Nasal cannula Nasopharyngeal catheter Transtracheal catheter Simple mask Partial rebreather mask Nonrebreather mask Venturi mask

Skin Tests

These determine antigen-antibody reactions and are used to identify exposure to diseases such as tuberculosis. In intradermal tests, antigens (to which the patient may have previously been exposed) are injected into the superficial layer of the skin with a needle and syringe to evaluate immune response.

Precautions for Oxygen Administration

Avoid open flames in the patient's room. Place "no smoking" signs in conspicuous places. Check to see that electrical equipment in the room is in good working order. Avoid wearing and using synthetic fabrics (builds up static electricity). Avoid using oils in the area (oils ignite spontaneously in oxygen).

Rate and Depth of Breathing

Changes in response to tissue demands Controlled by respiratory centers in the medulla and pons Activated by impulses from chemoreceptors Increase in carbon dioxide is the most powerful respiratory stimulant

Measures to Reduce Incidence of Nosocomial Infections

Constant surveillance by infection-control committees and nurse epidemiologists Written infection-prevention practices for all agency personnel (policies are written to be followed) This is beneficial in decreasing contamination Hand hygiene recommendations- wash with soap & water How long should you wash for? Which direction should your hands be in when rinsing? Infection control precaution techniques Keeping patient in best possible physical condition

Physical Assessment for Mobility

General ease of movement and gait/ are movements purposeful? Any tremors, tics, or chorea? Alignment/independent maintenance of correct alignment. Is there any spinal curvatures noted? Poor posture, trauma & nerve damage can lead to poor alignment Joint structure and function/absence of joint deformities, full ROM? Muscle mass, tone, and strength/adequate muscle mass, tone, & strength to accomplish work or movement Endurance/ ability to turn in bed, maintain correct alignment when sitting & standing

Devices to Apply Cold

Ice bags Cold packs Hypothermia blankets Cold compresses to apply moist cold

Tidal Volume (TV) Vital Capacity (VC) Forced Vital Capacity (FVC) Forced Expiratory Volume (FEV) Total Lung capacity (TLC) Residual Volume (RV) Peak Expiratory Flow Rate (PEFR)

Nursing Interventions Promoting Adequate Respiratory Functioning Teaching about a pollution-free environment Promoting optimal function Promoting comfort Promoting proper breathing Managing chest tubes Promoting and controlling coughing Suctioning the airway Meeting oxygenation needs with medications

Change in surface area available Thickening of alveolar-capillary membrane Partial pressure Solubility and molecular weight of the gas

Oxygen is carried in the body via plasma and red blood cells. Most oxygen (97%) is carried by red blood cells in the form of oxyhemoglobin. Hemoglobin also carries carbon dioxide in the form of carboxyhemoglobin. Internal respiration between the circulating blood and tissue cells must occur.

Helping Patients Ambulate Fortunately, for most patients, prolonged periods of bed rest are no longer considered necessary during most illnesses. Activity, even as mild as a short walk around the room, down the hall, from the bedroom to the living room, or out into the yard, is a protective measure for the body. PHYSICAL CONDITIONING TO PREPARE FOR AMBULATION Patients who are not confined to bed for long periods, who sleep well, and who experience possibly short periods of rest during the day may not require special considerations for increased physical activity in preparation for ambulation. However, others have to be prepared for the day when ambulation is resumed. Certain exercises that strengthen the overall efficiency of the musculoskeletal system can be done in bed. Check for physical activity restrictions or other contraindications before beginning any exercises. Quadriceps and Gluteal Setting Drills (Sets). Quadriceps drills are an isometric exercise—an exercise in which muscle tension occurs without a significant change in the length of the muscle. One of the most important muscle groups used in walking is the quadriceps femoris. This muscle group helps extend the leg and flex the thigh. To help reduce weakness and make first attempts at walking easier, encourage bedridden patients to contract this muscle group frequently. Following are techniques for quadriceps drills: Have the patient contract or tighten the muscles on the front of the thighs. The patient has the feeling of pushing the knees downward into the mattress and pulling the feet upward. Have the patient hold the position just described while counting slowly to four, and then relax the muscles for an equal count. Emphasize that relaxation is important to prevent muscle fatigue. Caution the patient not to hold the breath during these exercises to avoid straining the heart. Teach the patient to do quadriceps drills two or three times each hour, four to six times a day, or as ordered by the health care provider. Instruct the patient to stop the exercise short of muscle fatigue. p. 1074 p. 1075 The muscles in the buttocks can be exercised in the same way by pinching the buttocks together and then relaxing them. This is called gluteal setting. Tightening and holding the abdominal muscles for six seconds and then relaxing them also strengthens this muscle group to facilitate walking. Pushups. The muscles of the arms and shoulders may also need strengthening before the patient is ready to be out of bed. Exercises should improve the strength needed to hold onto or get into a chair and to move about with greater ease. They are part of the preparation for patients who must learn to walk on crutches. A trapeze attached to the bed of a patient who has limited use of the lower part of the body helps the patient to move about in bed and strengthens muscles in the upper part of the body. However, this does not strengthen the triceps, which is the muscle group necessary for crutch walking or for moving from a bed to a chair. More suitable exercises are pushups, which are done as follows: While sitting up in bed without support, the patient can do pushup exercises to strengthen the triceps. Instruct the patient to lift the hips off the bed by pushing down with the hands on the mattress. If the mattress is too soft, a block of books can be placed on the bed under the patient's hands. Pushups may also be done with the patient lying in bed on the abdomen. Instruct the patient to place the hands near the outstretched body at about shoulder level, with palms down on the mattress and elbows bent sharply. Then have the patient straighten the elbows to lift the head and shoulders off the bed. Pushups may also be done when the patient sits in an armchair or wheelchair. The patient places the hands on the arms of the chair and then raises the body out of the seat. Pushups should be done three or four times a day at first, with the number increased as upper body strength is increased. Remember Maggie Wyatt, the woman with a fracture being discharged? Due to bed rest, her physical conditioning may be less than what it was before the fracture. Therefore, exercises—such as quadriceps and gluteal setting exercises and pushups in bed—could help to improve Maggie's conditioning, allowing her to participate more fully in her care. These exercises will prepare Maggie for transferring from the bed to the chair or from the chair to the car. Dangling. Dangling refers to the position in which the person sits on the edge of the bed with legs and feet over the side of the bed. This exercise helps prepare patients for being out of bed. It is carried out as follows: Place the patient in the sitting position in bed for a few minutes. This will accustom the patient to this position and help prevent feelings of faintness. Place the bed in the low position or have a footstool handy on which the patient can rest the feet while dangling. Move the patient toward the side of the bed near you so that you do not stretch and strain while turning the patient. Pivot the patient a quarter of a turn by supporting the shoulders and legs. Swing the patient's legs over the side of the bed. The patient may place hands on your shoulders. Rest the patient's feet on the floor or on a footstool. This gives a sense of security, and lessens the likelihood that the patient will slide off the bed. Have the patient move the feet using an up-and-down, marching motion. This promotes circulation in the legs. Assess for lightheadedness or other signs of orthostatic hypotension (dizziness, nausea, tachycardia, or pallor). Remain with the patient and be ready to place the patient back to a lying position if feeling faint, to prevent falling out of bed. Daily Activities for Purposeful Exercise. Many activities can be carried out in ways that encourage patients to move and gain the benefit of exercise, improving physical conditioning. When patients understand the purpose, they often adopt other exercises for themselves. For example, position the bedside stand so that the patient must use shoulder and arm muscles to reach it, instead of placing it so that little effort is required to take things from it. Place the signal cord (call light) so that the patient must move either the arm or shoulder to reach it, as long as it is definitely within reach. Encourage patients to sit up and reach for the overbed table, to pull it close, and then to push it back in place. In addition, encourage patients to try to carry out self-care activities, including washing their back independently or putting on socks while still in bed. In a hospital setting, ADLs may be one of the few independent activities that a patient can perform. Allowing patients to do as much as they can independently is vital. Be sure to offer encouragement and praise. "Learned dependency," which often occurs with the older adult population, can lead to a decrease in self-esteem and depression. Collaborate with the occupational therapist when necessary to determine types of adaptive equipment that would help the patient achieve maximal functional independence. Box 32-2 provides examples of available adaptive equipment. Providing the necessary adaptive tools, coupled with encouraging independence, will create the optimal outcome. PROVIDING ASSISTANCE WITH WALKING Many patients who have been confined to bed for an extended period find that they must almost learn to walk all over again. Often, nurses play a major role in the patient's recovery, mental outlook, hope, and faith, especially when the patient must adhere to a rigid and often difficult schedule of re-educating muscle groups. Because muscle re-education is a major task, the patient needs the assistance of experts in physical medicine. However, nurses can assist patients out of bed and help them walk when a physical therapist is not present. Plan to walk with a patient who is walking for the first few times after a period of bed rest. Before getting the patient out of bed, do the following: Assess the patient's ability to walk and the need for assistance (one nurse, two nurses, walker, cane, walking belt, or crutches). Explain to the patient exactly what is to be done: transfer technique from bed to erect position, projected distance to be ambulated, assistance available, and the correct manner of using it. Instruct the patient to alert the nurse immediately if feeling dizzy or weak. Ensure that the patient has a clear path for ambulation. Provide skid-proof footwear. Assist the patient to an erect position for ambulation, pausing after the patient is seated at the edge of the bed and again after the patient first stands to ensure that the patient feels steady. Use a gait belt, if necessary, to prevent injury to the nurse and patient. Reinforce the need to stand erect and to hold the head high to achieve the full benefits of walking. Patients who are fearful of walking often tend to look at their feet. Remind the patient to take deep breaths to aerate the lungs while walking. Because patients who are walking for the first time after prolonged bed rest often feel faint or weak, plan ambulation for a short distance, gradually increasing the distance as tolerated. As this distance is increased, have chairs readily available should the patient need to rest. Should a patient faint or begin to fall while walking, stand with feet apart to create a wide base of support and rock the pelvis out on the side facing the patient. With arms under the patient's axillae and encircling the patient, slide the patient down one's body to the floor, carefully protecting the patient's head (Fig. 32-23A). If the patient is wearing a gait belt, use the belt to ease the patient backward against one's own body and gently ease the patient to the floor while protecting the patient's head. When two nurses are assisting a patient who starts to fall or faint, they both should use one hand to grasp the gait belt to support the patient and grasp the patient's hand or wrist with their other hand. After they have steadied the patient, they can slowly lower the patient to a chair or the floor (Fig. 32-23B). Practice these maneuvers before they are needed in an emergency situation.

One-Nurse Assist. Patients who require minimal nursing assistance may walk well with the nurse walking alongside. Provide support by standing at the patient's side and placing both hands at the patient's waist. Supporting the patient at the waist helps the patient to maintain an erect posture and prevents unintentionally pulling the patient to one side. Use of a gait belt snugly secured around the patient's waist also provides this type of support. Grasp the belt securely in the back, and walk behind and slightly to the side of the patient (Fig. 32-24). FIGURE 32-23. (A) One nurse guiding a patient to the floor. (B) Two nurses lowering a patient to the floor. p. 1076 p. 1077 FIGURE 32-24. Assistance with ambulation. The nurse stands on the patient's weaker side and grasps the gait belt. Frequently, it is necessary to assist the patient with intravenous (IV) therapy equipment to walk. Secure a portable IV pole that moves easily. The patient walks with the assistance of the nurse and the portable IV pole. Ensure that all the equipment is secure before walking and be alert for any tension or sudden action that might dislodge or interfere with the infusion. Also, consider reviewing this technique with family members who are assisting with ambulation and are unfamiliar with how to steady the patient, maneuver equipment, and navigate through crowded or narrow areas. When a patient has weakness or paralysis on one side, stand on the weaker or affected side and stabilize the patient by grasping the gait belt. Support the patient's weak arm by using one hand to support the patient's forearm and hand. Two-Nurse Assist. A two-nurse assist is the safer method to use when there is uncertainty about the patient's ability to walk. Use of a gait belt snugly secured around the patient's waist provides a safe method for the nurses to support the patient. Each nurse should grasp the belt securely with the hand nearest the patient at the handle on each side of the patient. Support the patient's near arm by holding the patient's lower arm or hand. Walk slightly behind and to the side of the patient.

Color Classification of Open Wounds

R = red—protect Y = yellow—cleanse B = black—débride Mixed wound—contains components of RY&B wounds

Effect of Nervous System on Muscle Contraction

The afferent nervous system conveys information to the CNS. Neurons conduct impulses from one part of the body to another. Information is processed by the CNS. The efferent system conveys a response from the CNS to skeletal muscles via the somatic nervous system.

Pulmonary ventilation: movement of air in and out of lungs Inhalation: breathing in Exhalation: breathing out Diffusion Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood Perfusion Exchange of oxygen and carbon dioxide between circulating blood and tissue cells

x

MECHANICAL AIDS FOR WALKING Various devices can assist a patient with walking. These devices enhance the patient's balance and ability to bear weight. The most common are walkers, canes, braces, and crutches. Typically, a patient is fitted for a device and instructed in its use in the department of physical medicine or physical therapy. In this instance, the nurse's concern is chiefly to reinforce the teaching the patient has received and to ensure that the patient continues to use the device properly to assist in safe ambulation. In some health care settings, however, nurses may be responsible for fitting patients with the device and teaching them the appropriate way to use the device. Whenever you assess a patient who has been using a walker, cane, brace, or crutches for a period of time, determine whether the device is still needed, whether it continues to meet the patient's needs, and whether the patient continues to use it properly. Some older patients consider the use of a mobility aid a visible symbol of weakness or an indication of decline in capabilities and loss of independence. Many patients refuse to use them and keep them out of sight. If the mobility aid is intended for short-term use (e.g., after hip replacement surgery), the response is usually more positive. Be sensitive to a patient's perspective regarding these devices and focus on the meaning the aid has for the patient, rather than simply emphasizing how to use it. Allow patients some control over their mobility decisions while still ensuring a safe environment. General guidelines for helping patients who need the assistance of a walker, cane, brace, or crutches include the following: Whenever possible, instruct the patient and family members in the correct use of the device before it is needed (e.g., before surgery). If family members are knowledgeable, they can reinforce the teaching as needed. When ready to begin walking with the new device, make sure the patient is wearing rubber-soled, well-fitting shoes and that there is a clear path for ambulation (clean, flat, dry, well lit). Use a gait belt, especially if the patient is at high risk for falls. Before moving, make sure the patient is steady on the feet when standing; instruct the patient to stand erect, looking straight ahead. The nurse should walk behind and slightly to one side of the patient (in cases of hemiparesis or hemiparalysis, walk on the patient's affected side). Should the patient lose balance, be prepared to grasp the patient's shoulder and the gait belt to steady the patient. Walker. A walker is a lightweight metal frame (usually aluminum) with four legs (see Fig. 32-25A). Walkers improve balance by increasing the patient's base of support, enhancing lateral stability, and supporting the patient's weight. The walker provides a sense of security and support. There are several types of walkers, specified according to the arm strength and balance of the patient. Most walkers have four legs with rubber tips. Some walkers have wheels on the front legs. These walkers are best for patients with a gait that is too fast for a walker without wheels and for patients who have difficulty lifting a walker. Because lifting repeatedly is not required, energy expenditure and stress to the back and upper extremities is lower than with a standard walker (Mayo, 2011c). Walkers also are available with wheels on all four legs. Patients who require a larger base of support and do not rely on the walker to bear weight can use these. If full body weight is applied to this type of walker, it could roll away, resulting in a fall. Wheeled walkers are best for patients who need minimal weight bearing from the walker. Walkers often prove to be difficult to maneuver through doorways and congested areas. They should not be used on stairs (Mayo). FIGURE 32-25. Mechanical aids to walking. (A) A walker is a lightweight metal frame with a broad, four-point base of support. The walker should be adjusted to the height of the patient's hip joint so that the patient's elbows are flexed about 30 degrees. (B) Three types of canes. Single-ended canes with half-circle handles are recommended for patients requiring minimal support. Single-ended canes with straight handles are recommended for patients with hand weakness. Three- or four-prong canes are recommended for patients with poor balance. When the patient stands between the back legs of the walker with arms relaxed at the side, the top of the walker should line up with the crease on the inside of the patient's wrist. When the patient's hands are placed on the grips, elbows should be flexed about 30 degrees (Mayo, 2011c). The walker's rubber tips should be intact to prevent slipping. Generally, patients lift the walker without wheels ahead of themselves and step into it. Instruct a patient using a walker to do the following: Wear nonskid shoes or slippers. When rising from a seated position, use the chair arms for support. Once standing, place one hand at a time on the walker and move forward into it. Begin by pushing the walker forward, keeping the back upright. Place one leg inside the walker, keeping the walker in place. Then, step forward with the remaining leg into the walker, keeping the walker still. Repeat the process by moving the walker forward again. Caution the patient to avoid pushing the walker out too far in front and leaning over it. Patients should always step into the walker, rather than walking behind it, staying upright as they move (Mayo, 2011c). Never attempt to use a walker on stairs. Canes. Canes widen a person's base of support, providing increased balance (Nolen, Liu, Liu, McGee, & Grando, 2010). Canes come in three variations (see Fig. 32-25B): single-ended canes with half-circle handles (recommended for patients requiring minimal support and those who will be using stairs frequently), single-ended canes with straight handles (recommended for patients with hand weakness because the handgrip is easier to hold, but not recommended for patients with poor balance), canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support (recommended for patients with poor balance). Many canes are adjustable; fit them so that when the patient stands with the cane's tip 4 inches (10 cm) to the side of the foot, the cane extends from the floor to the patient's hip joint. The elbow should be flexed 30 degrees when holding the cane. Rubber tips on the cane prevent slipping and accidents. Inspect these regularly to ensure that they are intact. Teach patients to stand erect when walking with a cane and not to lean out over the cane. When walking with a cane, instruct patients to hold the cane in the opposite hand from the leg with the most severe deficit (Mayo, 2011c). Ambulation proceeds in the following fashion: The patient stands with weight evenly distributed between the feet and the cane. The cane is held on the patient's stronger side and is advanced 4 to 12 inches (10-30 cm). Supporting weight on the stronger leg and the cane, the patient advances the weaker foot forward, parallel with the cane. Supporting weight on the weaker leg and the cane, the patient next advances the stronger leg forward ahead of the cane (heel slightly beyond the tip of the cane). The weaker leg is moved forward until even with the stronger leg, and the cane is once again advanced as in step 2. When less support is required from the cane, the patient can advance the cane and weaker leg forward while the stronger leg supports the patient's weight. Teach patients to position their canes within easy reach when they sit down so that they can rise easily. Braces. Braces that support weakened leg muscles are available in many variations. Nursing responsibilities include knowing when the brace is to be worn and the correct technique for applying the brace, monitoring to ensure correct use of the brace by the patient, and observing for any untoward problems the brace might cause (e.g., skin irritation). Muscle changes such as those occurring with growth and development or brought about by illness (atrophy) may require the brace to be refitted to maintain its effectiveness. FIGURE 32-26. Axillary (left) and forearm (right) support crutches. Crutches. Sometimes it is necessary for patients to use crutches for a time to avoid using one leg or to help strengthen one or both legs. The two types of crutches most commonly used are axillary crutches and forearm crutches (Fig. 32-26). Forearm crutches are used for patients requiring long-term support for ambulation (Mincer, 2007). A supportive frame extends beyond the handgrip for the lower arm to help guide the crutch. These crutches are more likely to be used by patients who have permanent limitations and will always need crutch assistance for ambulation. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. These crutches require significant upper body and arm strength to use. The procedure for crutch walking is usually taught by a physical therapist, but it is important for the nurse to be knowledgeable about the patient's progress and the gait being taught. Be prepared to guide the patient at home or in the hospital after the initial teaching is completed. Remind the patient that the support of body weight should come primarily on the hands and arms while using the crutches, not in the axillary areas, where pressure may damage nerves and cut off circulation. Also, the crutches should not be forced into the axillae each time the body moves forward. Teaching Tips 32-1 summarizes the important content to reinforce regarding crutch walking. Promoting Exercise

x

TYMPANIC

99.5°F

Cardinal Signs of Acute Infection

Redness Heat Swelling Pain Loss of function

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oxygenation and perfusion

Guidelines for Obtaining a Nursing History

-Determine why the patient needs nursing care. -Determine what kind of care is needed to maintain a sufficient intake of air. -Identify current or potential health deviations. -Identify actions performed by the patient for meeting respiratory needs. -Make use of aids to improve intake of air and effects on patient's lifestyle and relationship with others.

Lung Scan

A lung scan is the recording on a photographic plate of the emissions of radioactive waves from a substance injected into a vein as it circulates through the lung. A perfusion scan (Q scan) is done to measure integrity of pulmonary blood vessels and evaluate blood flow abnormalities (e.g., pulmonary emboli). A ventilation scan (V scan) is done to detect ventilation abnormalities (especially in patients with emphysema). Both scans used together provide greater and more accurate diagnostic information than either test used alone.

Wound Classification Wounds are classified in many different ways, including intentional or unintentional (based on how they were acquired), open or closed, and acute or chronic (based on the length of time the patient has had the wound). Wounds may also be classified as partial-thickness (all or a portion of the dermis is intact), full-thickness (the entire dermis and sweat glands and hair follicles are severed), or complex (the dermis and underlying subcutaneous fat tissue are damaged or destroyed). Intentional Wounds and Unintentional Wounds An intentional wound is the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes. Examples of intentional wounds include those that result from surgery, intravenous therapy, and lumbar puncture. The wound edges are clean, and bleeding is usually controlled. Because the wound was made under sterile conditions with sterile supplies and skin preparation, the risk for infection is decreased, and healing is facilitated. Unintentional wounds are accidental. These wounds occur from unexpected trauma, such as from accidents, forcible injury (such as a stabbing or a gunshot), and burns. Because the wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors create a high risk for infection and a longer healing time. Open and Closed Wounds An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions. A closed wound results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas.

Acute and Chronic Wounds Acute wounds, such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. Acute wounds usually move through the healing process without difficulty. Chronic wounds, in contrast, do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed. Chronic wounds remain in the inflammatory phase of healing (discussed in the next section). Chronic wounds include any wound that does not heal along the expected continuum, such as wounds related to arterial or venous insufficiency, and pressure ulcers.

Cardiovascular System Oxygen and carbon dioxide must move through the alveoli and be carried to and from body cells by the blood. Thus, an adequately functioning cardiovascular system is vital for exchange of gases. Anatomy of the Cardiovascular System The cardiovascular system is composed of the heart and the blood vessels. The heart is the main organ of circulation, the continuous one-way circuit of blood through the blood vessels, with the heart as the pump (Taylor & Cohen, 2013). The heart lies in the thoracic cavity between the lungs, in the center and somewhat to the left of the body's midline (Fig. 38-4). The heart is a cone-shaped, muscular pump, divided into four hollow chambers. The upper chambers, the atria (singular, atrium), receive blood from the veins (the superior and inferior vena cava and the left and right pulmonary veins). The lower chambers, the ventricles, force blood out of the heart through the arteries (the left and right pulmonary arteries and the aorta). One-way valves that direct blood flow through the heart are located at the entrance (tricuspid and mitral valves) and exit (pulmonary and aortic valves) of each ventricle (Fig. 38-5). The blood vessels form a closed circuit of tubes that carry blood between the heart and the body cells. Arteries and arterioles conduct blood away from the ventricles to the capillaries and the venules and veins, and return blood from the capillaries to the atria. Capillaries function in the exchange of substances between the blood and the body cells. Blood is squeezed through the heart and out into the body by contractions starting in the atria, followed by contraction of the ventricles, with a subsequent resting of the heart. Deoxygenated blood (low in oxygen, high in carbon dioxide) is carried from the right side of the heart to the lungs, where oxygen is picked up and carbon dioxide is released, and then returned to the left side of the heart. This oxygenated blood (high in oxygen, low in carbon dioxide) is pumped out to all other parts of the body and back again (Fig. 38-6). The quantity of blood forced out of the left ventricle with each contraction is called the stroke volume (SV). The cardiac output (CO) is the amount of blood pumped per minute, which averages from 3.5 L/min to 8.0 L/min in a healthy adult (Grossman & Porth, 2014). This volume is determined by using the following formula: cardiac output = stroke volume × heart rate. Thus, the cardiac output of an adult with a stroke volume of 70 mL and a heart rate of 70 beats/min is 4.9 L/min. Cardiac output increases during physical activity and decreases during sleep; it also varies depending on body size and metabolic needs. Oxygen is carried via plasma and red blood cells. It is dissolved in plasma, but because oxygen is insoluble in liquids, little oxygen is carried in this way. The majority of oxygen is carried by the red blood cells. The hemoglobin in red blood cells has a strong affinity for oxygen. Therefore, most oxygen (97%) is carried in the body by red blood cells as part of hemoglobin in the form of oxyhemoglobin. Hemoglobin also carries carbon dioxide easily in the form of carboxyhemoglobin. Once the red blood cells reach the tissues, internal respiration must occur. Internal respiration is the exchange of oxygen and carbon dioxide between the circulating blood and the tissue cells. Any abnormality in the blood's components affects internal respiration. For example, hemorrhage or loss of blood can cause a decrease in cardiac output. A decrease in cardiac output causes a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Alternately, exercise can improve the transport of oxygen. Regular exercise contributes to more effective pumping of the heart muscle, and improved oxygen transport to cells. Regulation of the Cardiovascular System Electrical impulses produced in and carried over specialized tissue within the heart control contraction of the muscles of the heart. These tissues make up the heart's conduction system (Fig. 38-7). The sinoatrial (SA) node is a mass of tissue in the upper right atrium, just below the opening of the superior vena cava. This node initiates the transmission of electrical impulses, causing contraction of the heart at regular intervals. It is also referred to as the pacemaker. After initiation, the electrical impulse travels throughout the muscle of each atrium, causing contraction of the atrium. The impulse also travels at the same time to the atrioventricular (AV) node, located at the bottom of the right atrium. When the impulse reaches the AV node, it enters a group of fibers called the atrioventricular bundle, or bundle of His. This bundle divides into right and left branches. Smaller conduction myofibers (Purkinje fibers) branch off, traveling throughout the ventricles. The right branch extends to the walls of the right ventricle and the left branch travels through the left ventricle. The electrical impulse continues through the atrioventricular bundle and the Purkinje fibers, causing contraction of the ventricles. The contraction of the ventricles, which occurs just a moment after the atrial contractions, completes a cardiac cycle, or singe heartbeat. The heart rests a moment, and another cycle begins almost immediately. Many things can influence the function of the heart. A person's heart rate can be modified by the nervous system based on the needs of the body. Stimulation of the SA and AV nodes by the sympathetic nerves increases the heart rate and force of contraction in response to increased activity, and as part of the response to real or perceived threats. Parasympathetic stimulation of the SA and AV nodes by the vagus nerve decreases the heart rate. The balance between the parasympathetic and sympathetic effects on the heart is maintained with the help of input from the medulla in the brainstem. Hormones and other chemicals made by the body, as well as drugs, also affect heart action. Blood Flow to the Cardiovascular System The muscles of the heart have their own blood vessels that provide oxygen and nourishment and remove waste products. The main blood vessels that provide coronary circulation are the right and left coronary arteries, which branch off the aorta. They encircle the heart and branch out to all regions of the heart. The coronary arteries fill with blood during relaxation of the ventricles. The blood returns to the right atrium after passing through the heart muscle via the cardiac veins.

Alterations in Cardiovascular Function If a problem exists in the cardiovascular system, alterations in function of the heart may occur, leading to impaired oxygenation. A dysrhythmia or arrhythmia is a disturbance of the rhythm of the heart. Dysrhythmias are caused by an abnormal rate of electrical impulse generation from the SA node, or from impulses originating from a site or sites other than the SA node. They can also be caused by the abnormal conduction of electrical impulses through the heart. They can occur with heart disease, hypertension, damage to the heart, in the presence of various drugs, with decreased oxygenation of the heart tissues, and with trauma. Dysrhythmias cause disturbances of the heart rate, heart rhythm, or both, and can affect the pumping action of the heart, interfering with circulation, leading to alterations in oxygenation. Symptoms vary, depending on the cause and type of dysrhythmia. Symptoms may include decreased blood pressure, dizziness, palpitations (awareness of throbbing heart beats), weakness, and fainting. Myocardial ischemia, decreased oxygen supply to the heart caused by insufficient blood supply, can lead to impaired oxygenation of tissues in the body. It is most commonly caused by atherosclerosis, the accumulation of fatty substances and fibrous tissue in the lining of arterial blood vessel walls, creating blockages and narrowing the vessels, reducing blood flow. Angina and myocardial infarction can result from myocardial ischemia. Stable angina is a temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles. Myocardial infarction, one type of acute coronary syndrome characterized by the death of heart tissue due to lack of oxygen, is also known as a heart attack. Myocardial ischemia causes disturbances of the heart rate, heart rhythm, or both, and can affect the pumping action of the heart, interfering with circulation, leading to alterations in oxygenation. Symptoms vary, based on the problem, but include pain, anxiety, nausea, vomiting, indigestion, and shortness of breath. Heart failure occurs when the heart is unable to pump a sufficient blood supply, resulting in inadequate perfusion and oxygenation of tissues. It can be the result of many heart conditions, including chronic hypertension, coronary artery disease, and disease of the heart valves. Symptoms include shortness of breath, edema (swelling), and fatigue. Additional information related to alterations in cardiovascular function is discussed in Chapter 24.

When the patient is unable to change position independently, use a turn schedule, posted at the bedside to assist with and document the rotation of positions. Table 32-6 describes common bed positions and nursing measures to prevent complications associated with these positions. Fowler's Position. The semi-sitting position, or Fowler's position, calls for the head of the bed to be elevated 45 to 60 degrees. This position is often used to promote cardiac and respiratory functioning because abdominal organs drop in this position, providing maximal space in the thoracic cavity. This is also the position of choice for eating, conversation, and urinary and intestinal elimination. Variations of Fowler's position include high Fowler's and low Fowler's or semi-Fowler's position. In the high Fowler's position, the head of the bed is elevated 90 degrees. When a bedside table with a pillow on top of it is placed in front of the patient in high Fowler's position, the patient can lean forward and rest the arms on the pillow, assuming a posture that allows for maximal lung expansion. In low Fowler's or semi-Fowler's position, the head of the bed is elevated only 30 degrees. In Fowler's position, the buttocks bear the main weight of the body. In this position, the heels, sacrum, and scapulae are at risk for skin breakdown and require frequent assessment. See Table 32-6 for information about correct positioning and nursing actions to prevent complications associated with this position. Supine or Dorsal Recumbent Position. In the supine position, the patient lies flat on the back with the head and shoulders slightly elevated with a pillow unless contraindicated, such as spinal anesthesia or surgery on the spinal vertebrae. Correct alignment in the supine position is illustrated in Table 32-6. Side-Lying or Lateral Position. In the side-lying position, the patient lies on the side and the main weight of the body is borne by the lateral aspect of the lower scapula and the lateral aspect of the lower ilium. Because many people routinely fall asleep in the side-lying position, this is a comfortable alternative to the supine position for the patient on bed rest. Although it relieves pressure on the scapulae, sacrum, and heels and allows the legs and feet to be comfortably flexed, support pillows are needed for correct positioning (see Table 32-6). The oblique position, a variation of the side-lying position, is recommended as an alternative to the side-lying position because it places significantly less pressure on the trochanter region. The patient turns toward the side with the hip of the top leg flexed at a 30-degree angle and the knee flexed at 35 degrees. The calf of the upper leg is positioned slightly behind the body's midline. Pillows support the patient's back and calf of the top leg (Fig. 32-19).

Another variation of the lateral position is Sims' position. In this position, the patient again lies on the side, but the lower arm is behind the patient and the upper arm is flexed at both the shoulder and the elbow. In this position, the main body weight is borne by the anterior aspects of the humerus, clavicle, and ilium. Thus, the major pressure points differ from those in the lateral and other bed-lying positions (see Table 32-6). Prone Position. In the prone position, the person lies on the abdomen with the head turned to the side. The body is straight in the prone position because the shoulders, head, and neck are in an erect position, the arms are easily placed in correct alignment with the shoulder girdle, the hips are extended, and the knees can be prevented from flexing or hyperextending. When patients on bed rest use this position periodically, it helps to prevent flexion contractures of the hips and knees. However, the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine. The position is thus contraindicated for people with spinal problems. The pull of gravity on the feet may result in plantar flexion unless the legs and feet are positioned carefully (see Table 32-6). Using Graduated Compression Stockings and Pneumatic Compression Devices Venous stasis and the development of venous thrombosis are potential complications of immobility. Graduated compression stockings and pneumatic compression devices are passive interventions prescribed to aid in the prevention of these common complications of inactivity. GRADUATED COMPRESSION STOCKINGS Graduated compression stockings are often used for patients at risk for deep vein thrombosis, pulmonary embolism, and to help prevent phlebitis (described in Chapter 29). Manufactured by several companies, they are made of elastic material and are available in either knee-high or thigh-high length. By applying pressure, graduated compression stockings increase the velocity of blood flow in the superficial and deep veins and improve venous valve function in the legs, promoting venous return to the heart. By preventing pooling of the blood, clot formation is less likely. An order is required from the patient's primary care provider for their use. When assisting with graduated compression stockings, follow these general nursing guidelines: Measure the patient's legs to determine the proper size of stocking. Each leg should have a correct fitting stocking; if measurements are different, then two different sizes of stocking need to be ordered to ensure correct fitting on each leg (Walker & Lamont, 2008). The manufacturer whose stockings are being used gives directions for measuring. Some stockings fit either leg; others are designated right or left. An improperly fitting stocking is uncomfortable and ineffective and possibly even harmful (Miller, 2011). Assess the skin condition and neurovascular status of the legs. Report abnormalities before continuing with the application of the stockings. Be prepared to apply the stockings in the morning before the patient is out of bed and while the patient is supine. If the patient is sitting or has been up and about, have the patient lie down with legs and feet elevated for at least 15 minutes before applying the stockings. Otherwise, the leg vessels are congested with blood, reducing the effectiveness of the stockings. Do not massage the legs. If a clot is present, it may break away from the vessel wall and circulate in the bloodstream. Check the legs regularly for redness, blistering, swelling, and pain. Some recommend checking the legs at least once every 8 hours; others recommend twice a day. Remove the stockings completely once a day to bathe the legs and feet. Launder the stockings as necessary, but at least every 3 days. Soiled stockings irritate the skin. Dry the stockings on a flat surface to prevent them from stretching. If using a clothes dryer, set on low heat and remove as soon as the cycle is complete. The patient may need two pairs of stockings to wear one pair while the second pair is being cleaned. Always remove graduated compression stockings during morning care and inspect the legs. Then reapply the stockings before the patient is out of bed, as shown in Skill 32-1.

ENDURANCE When assessing endurance, evaluate the patient's ability to turn in bed, maintain correct alignment when sitting or standing, ambulate, and perform self-care activities. When a physical or psychological factor is believed to be affecting endurance, evaluate the following: Vital signs while the patient is at rest Ability to perform the activity (e.g., ambulation) Patient's response during and after the activity Vital signs immediately after the activity Vital signs after the patient has rested for 3 minutes Significant findings indicating that a person's exercise tolerance has been reached include noticeably increased pulse, respirations, and blood pressure; shortness of breath; dyspnea; weakness; pallor; confusion; and vertigo.

Application of Body Mechanics to Prevent Injury Providing patient care places demands on the nurse's musculoskeletal system. These demands are a result of the movements required and use of equipment necessary to provide patient care, as well as the handling of patients. Nurses lift, carry, push, pull, and move objects and people routinely in the course of their work. Performing these actions correctly is necessary to avoid musculoskeletal strain and injury. Body mechanics include proper body movement in daily activities, the prevention and correction of problems associated with posture, and the enhancement of coordination and endurance. The following guidelines for good body mechanics are important to anyone, including nurses, who are engaged in physical activity both at home and at work. Overexertion injuries to workers' necks, shoulders, and backs are the most costly work-related injury for health care facilities (June & Cho, 2011; OSHA, 2012). Techniques to prevent back stress that should be included routinely in injury-prevention programs include the following: Develop a habit of erect posture (correct alignment). Slouching can strain neck and back muscles. When sitting, use the chair back to support the whole spine, keeping shoulders back but relaxed. Balance the head over the shoulders, avoid leaning forward, and hold in the stomach muscles. Use the longest and the strongest muscles of the arms and the legs to help provide the power needed in strenuous activities. The muscles of the back are less strong and more easily injured when used improperly. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. Figure 32-6 illustrates the internal girdle. Work as closely as possible to an object that is to be lifted or moved. This brings the body's center of gravity close to that of the object being moved, permitting most of the burden to be borne by the leg and arm muscles, rather than the back. Figure 32-7 illustrates a proper and an improper way to pick up an object. Face the direction of your movement. Avoid twisting your body. Use the weight of the body as a force for pulling or pushing, by rocking on the feet or leaning forward or backward. This reduces the amount of strain placed on the arms and the back. Slide, roll, push, or pull an object, rather than lift it, to reduce the energy needed to lift the weight against the pull of gravity. Use the weight of the body to push an object by falling or rocking forward and to pull an object by falling or rocking backward. Push rather than pull equipment when possible. Keep arms close to your body and push with your whole body, not just your arms. Begin activities by broadening your base of support. Spread the feet to shoulder width. Make sure that the surface is dry and smooth when moving an object to decrease the effects of friction. Rough, wet, or soiled surfaces can contribute to increased friction, increasing the amount of effort required to move an object. Flex the knees, put on the internal girdle, and come down close to an object that is to be lifted. Break up heavy loads into smaller loads. The National Institute for Occupational Safety and Health (NIOSH) recommends manual load lifting limits of 35 pounds (Waters, 2007). Take breaks from lifting or moving to relax and recover.

Applying Heat Heat is applied by both dry and moist methods. Hot water bags, electric heating pads, aquathermia pads, or chemical heat packs provide local dry heat by conduction. Hot compresses or packs, sitz baths, or soaks provide moist heat by conduction.

Applying Cold Cold is applied by both dry and moist methods. Dry cold is provided with ice bags, cold packs, or a hypothermia blanket (or pad). Cold compresses are a method of applying moist cold. DRY COLD Ice Bags. An ice bag, like its counterpart hot water bottle or bag, is a relatively easy and inexpensive method for applying cold to an area. It has essentially the same disadvantages as the hot water bag. When using an ice bag, follow these recommendations: Fill the bag with small pieces of ice to about two-thirds full. This makes the bag lightweight. Using ice chips, rather than cubes, makes it easier to mold the bag to the body part. Remove air from the ice bag in the same manner as removing air from a hot water bag. After securing the cap, test the ice bag for leaks and wipe off excess moisture. Place a cover on the ice bag to provide comfort and to absorb moisture that may accumulate on the outside of the bag. Apply an ice bag for 30 minutes, then remove it for about an hour before reapplying it. This technique prevents the effects of prolonged exposure to cold (Fig. 31-21). In the home setting, a bag of frozen vegetables (such as peas) makes a good substitute for an ice bag.

Assess wounds for the approximation of the wound edges (edges meet) and signs of dehiscence or evisceration. Assess the color of the wound and surrounding area. Note the presence of drains, tubes, staples, and sutures. The edges of a healthy healing surgical wound appear clean and well approximated, with a crust along the wound edges. Initially, the edges are reddened and slightly swollen. After approximately 1 week, the skin is closer to normal in appearance, with wound edges healing together. The skin surrounding the wound may at first be bruised, but this too returns to normal as blood is reabsorbed. When infection is present, the wound is swollen and deep red. It feels hot on palpation, and drainage is increased and possibly purulent. If dehiscence is impending or present, the wound edges are separated. If the wound edges have separated and the wound is open, describe the type of tissue in the wound: granulation, slough, or eschar (see Box 31-4). Assess for the presence of odor, but only after the wound has been cleaned. The presence of odor can be indicative of certain types of bacteria. DRAINAGE The inflammatory response results in the formation of exudate, which then drains from the wound. The exudate is composed of fluid and cells that escape from blood vessels and are deposited in or on tissue surfaces. This exudate is called wound drainage and is described as serous, sanguineous, serosanguineous, or, if infected, purulent. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

Assess the amount, color, odor, and consistency of wound drainage. The amount and color depend on the wound location and size. Typically, larger wounds have more drainage than do smaller wounds. Assess wound drainage on the wound, on the dressings, in drainage bottles or reservoirs, or—depending on the location of the wound and the amount of drainage—under the patient. SUTURES AND STAPLES Skin sutures are used to hold tissue and skin together. Sutures may be black silk, synthetic material, or fine wire. Sutures are removed when enough tensile strength has developed to hold the wound edges together during healing. The time frame varies depending on the patient's age, nutritional status, and wound location. Frequently, after skin sutures are removed, small wound-closure strips of adhesive are applied across the wound to give additional support as it continues to heal. Figure 31-6 shows an example of an incision with sutures. Retention sutures are used to provide extra support for patients who are obese and for wounds with an increased risk for dehiscence. Pressure Ulcer Assessment Most pressure ulcers can be prevented (Black et al., 2011). It is a nursing priority to perform a comprehensive assessment in all settings and identify patients at risk for pressure ulcers, predisposing factors, or evidence of actual pressure ulcers. RISK ASSESSMENT An aggressive approach to prevent a pressure ulcer or manage the care of a patient who already has impaired skin integrity begins with a risk assessment form, which should be simple to use, reliable, and cost effective. Use the assessment tool in conjunction with nursing judgment to ensure implementation of the most appropriate patient care (Braden, 2012). Several different scales are available to assess risk, such as the Norton scale (physical condition, mental condition, activity, mobility, incontinence) and the Braden scale (mental status, continence, mobility, activity, nutrition; Fig. 31-7). With these tools, a numeric score is assigned to each assessment area. The degree of risk is based on the patient's total score. Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk (Braden & Maklebust, 2005). Patients may have additional risk factors and/or other health problems not measured by the chosen assessment scale. Therefore, good nursing judgment may reveal the need for a higher intensity of preventive intervention than what may be identified by the scale alone (Braden, 2012).

Certain drugs cause urine to change color, including the following: Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine. The antidepressant amitriptyline (Elavil) or B-complex vitamins can turn urine green or blue-green. Levodopa (L-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.

Assessing A comprehensive nursing assessment of the functioning of a patient's urinary system includes the following: Collection of data about the patient's voiding patterns, habits, and difficulties and a history of current or past urinary problems Physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; and examination of the urine Correlation of these findings with the results of diagnostic tests and procedures for examining the urine and the urinary tract

Activities of Daily Living The presence of an acute or chronic wound or pressure ulcer can have an impact on the ability of the patient to perform activities of daily living. Physical, financial, and medical restrictions can result in limitations on a patient's ability to perform things normally done in daily living including any daily activity related to self-care (such as feeding oneself, bathing, dressing, grooming), work, homemaking, and leisure, restricting the patient's life. Changes in Body Image Body image reflects a person's view of oneself as a whole entity. When the skin and tissues are traumatized, that image is changed, requiring the person to adapt and reformulate the concept of self. Wounds and scars that are visible to others, especially on the face, can result in feelings of conspicuousness, ugliness, and diminished self-worth. Large scars, such as from removal of a breast or from creation of a colostomy opening, can seriously affect the person's sexuality, social relationships, and self-concept. Referral to support groups or counselors may be necessary to facilitate coping and acceptance of changes in body structure or function. See the Focused Critical Thinking Guide 31-1. In addition, Chapter 40 contains more information about self-concept.

Assessing The patient's health history is an essential component for assessing the patient's integumentary status and identification of risk factors for problems with the skin. This information can be obtained from either the patient or a family member. The nursing examination combined with laboratory findings can provide information to identify a patient's strengths, the nature of any problems, their course, related signs and symptoms, and their onset, frequency, and effects on activities of daily living. The nurse decides, based on these findings, what problems can be treated independently by nursing. Other problems are referred to a physician and/or other collaborative professionals for decisions on treatment. Skin Assessment Skin assessment should be an integral part of every patient's care. Physical assessment of the skin is included as part of the initial database collection. Skin assessment provides needed information for developing an appropriate plan of care. The inspection and palpation skills used to assess the integumentary system are described in detail in Chapter 25. Be sure to inspect the skin systematically in a head-to-toe fashion, including bony prominences, on admission and then at regular intervals for all at-risk patients. Reassessment is recommended (NPUAP, 2012a), as follows: Acute care setting: On admission, then reassessed at least every 24 hours or if the patient's condition changes. Reassess stable patients in intensive care units daily; reassess unstable patients every shift. Long-term care setting: On admission, then reassess weekly for 4 weeks, then quarterly and whenever the resident's condition changes Home health care: On admission, then reassess at every visit Early detection and treatment of skin problems are important nursing functions. It is important to provide patients with a proactive strategy for skin care. Many conditions and wounds, particularly pressure ulcers, can be prevented or minimized with early interventions. Interventions to promote skin health are discussed in Chapter 30. Wound Assessment Wound assessment involves inspection (sight and smell) and palpation for appearance, drainage, odor, and pain. Wound assessment determines the status of the wound, identifies barriers to the healing process, and identifies signs of complications. Accurate assessment provides essential baseline data and information to judge the effectiveness of treatment and wound healing progression. Skin integrity and wound assessment are performed at regular intervals, based on the nature of the wound and facility policy. APPEARANCE OF THE WOUND Note the location of the wound. Location is described in relation to the nearest anatomic landmark, such as bony prominences. Document the size of the wound. Measurements are taken in millimeters or centimeters, measuring length, width, and depth. Refer to Guidelines for Nursing Care 31-1 for details on measuring a wound.

MASSAGING THE BACK A backrub generally follows the patient's bath. A backrub acts as a general body conditioner and can relieve muscle tension and promote relaxation. Some nurses forego giving backrubs to patients due to time constraints. However, giving a backrub allows the nurse to observe the skin for signs of breakdown. A backrub improves circulation; can decrease pain, distress, and anxiety; can improve sleep quality; and provides a means of communication with the patient through the use of touch. Because some patients may consider the backrub a luxury and be reluctant to accept it, be sure to communicate its importance and value to the patient. An effective backrub should take 4 to 6 minutes to complete. If a lotion is used, warm it before use. Be aware of the patient's medical diagnosis when considering giving a backrub. A backrub is contraindicated, for example, if the patient has had back surgery or has fractured ribs. Position the patient on the abdomen or, if this is contraindicated, on the side. Recommended techniques for administering a backrub are outlined in Skill 34-1.

Assisting with Oral Hygiene The mouth requires care even during illness, but sometimes care must be modified to meet a patient's needs. Adequate oral hygiene care is imperative to promote the patient's sense of well-being and prevent deterioration of the oral cavity. Poor oral hygiene is reported to lead to the colonization of the oropharyngeal secretions by respiratory pathogens. Diligent oral hygiene care can improve oral health and limit the growth of pathogens in the oropharyngeal secretions, decreasing the incidence of aspiration pneumonia, community-acquired pneumonia, ventilator-associated pneumonia, and other systemic diseases, such as diabetes, heart disease, and stroke (Tada & Miura, 2012; CDC, 2011a; Durgude & Cocks, 2011; AACN, 2010). An oral assessment tool can assist with assessment of the status of the oral cavity, as well as help to determine the frequency and procedure for oral care. If the patient can assist with mouth care, provide the necessary materials (Skill 30-2, pp. 938-940). Physical limitations, such as those associated with aging, often lead to less than adequate oral hygiene. The dexterity required for adequate brushing and flossing may decrease with age or illness. Older patients may be dependent on caregivers for oral hygiene. Patients with cognitive impairment, such as dementia, are also at risk for inadequate oral hygiene (Jablonski, Therrien, & Kolanowski, 2011). If the patient is unable to perform oral hygiene, make certain that the mouth receives care as often as necessary to keep it clean and moist, as often as every 1 or 2 hours if necessary. This is especially important for patients who cannot drink or are not permitted fluids by mouth. Refer to Box 30-3 for suggestions to meet the oral hygiene needs for patients with cognitive impairments. Skill 30-3 gives techniques for administering oral hygiene to dependent patients. Moisten the mouth with water, if allowed, and lubricate the lips often enough to keep the membranes well moistened. Following the steps for cleaning the mouth thoroughly is more important than the agent used. This supports the personal experience of many people that no mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning of the oral cavity. The use of chlorhexidine gluconate as part of oral hygiene has been integrated into oral hygiene regiments and is available in an oral spray and dental gel (Ames et al., 2011; Kelly, Timmis, & Twelvetree, 2010). The use of chlorhexidine gluconate as part of protocols for systematic oral care for critically ill patients has been shown to reduce the incidence of health care-associated pneumonia (Ames et al., 2011).

Providing Environmental Care A person's environment can improve or detract from the patient's sense of well-being. The patient's environment can consist of a room in a facility, such as a hospital, one or more rooms in the patient's home or apartment, or something in-between. Regardless of the setting, ensure that this area is clean and clutter-free, safe, and pleasant. The patient's environment in a hospital or other facility consists of the bedside unit and the furnishings and equipment in the space around the bed. Basic furniture includes the bed, overbed table, bedside stand, and chairs. Standard equipment in the health care environment includes the call light, oxygen, suction, and electrical outlets; light fixtures; bath basin; emesis basin; bedpan or urinal; water pitcher and glass; and bed linens. One nursing responsibility is ensuring that necessary equipment and items are in their proper place and functioning properly. Patients usually store personal items in the bedside stand. Always request permission from alert patients or family members before opening the stand to obtain the bath basin, lotion, or other items. When assisting with hygiene, respecting the patient's right to privacy and ownership of personal goods decreases the patient's sense of powerlessness. Before leaving the bedside, get into the habit of saying to the patient, "Is there anything else I can do to make you more comfortable?" Checking with the patient communicates genuine caring and can correct for any oversights. In the case of manipulative patients, set limits regarding what comfort and hygiene measures can be performed. Good ventilation in patient rooms is imperative to limit pathogens and unpleasant odors associated with body secretions and excretions, for example, urine, stool, vomitus, draining wounds, or body odors. Decrease odors by emptying bedpans, urinals, and emesis basins promptly. When the waste receptacle in the patient's room is used to dispose of soiled dressings or anything with a strong odor, be sure to remove the trash before leaving the room. Dispose of the trash according to facility policy. Room deodorizers may need to be used. Patient preferences for room temperature often vary widely. Whenever possible, respect the patient's preference when determining the room temperature. In general, the room temperature should be between 68°F-74°F (20°C and 23°C). Many patients find it difficult to sleep in a health care facility. Patients are often disturbed frequently for assessment or treatment purposes. Care should be taken to reduce harsh lighting and noises whenever possible, although adequate lighting is necessary for all nursing procedures. Whenever possible, avoid carrying on conversations immediately outside the patient's room. Many patients find this stressful because the noise disturbs them and because they believe whatever is being said involves them.

BED SAFETY AND COMFORT Many people who are ill and hospitalized or are being cared for at home spend a large portion of the day—if not the entire day—in bed, so the bed is an important part of the patient's environment. Nursing responsibilities include ensuring a safe and comfortable bed. The typical hospital bed has a motorized metal frame in three sections, which allows the height of the bed to be raised or lowered and the head and foot to be adjusted. Know how to operate the bed and be ready to explain it to the patient. Bed positions are described in Chapter 33. Hospital beds can also be ordered for use in the home. Because certain positions may be harmful to some patients, instruct the patient and family about advisable bed positions and the use of the bed controls. Historically, hospital beds have been generally 26 inches (66 cm) from the floor. This is higher than most beds at home, enabling the nurse or caregiver to reach the patient without undue musculoskeletal strain. However, many manufacturers are making low-height beds available to health care facilities. These beds have a minimum height of 7 to 15 inches from the floor. Side rails are used to provide assistance with moving in bed, and access to bed controls is often on the side rails. See Chapter 26 for additional discussion about the use of side rails. Use side rails when indicated and according to facility policy. Also, lock the wheels or casters on the hospital bed whenever the bed is stationary to prevent the bed from moving when the patient is moving from the bed to an upright position or being transferred. The headboard of most hospital beds is removable to allow close patient contact in an emergency situation. Nurses are responsible for ensuring the safety and comfort of the patient at the bedside. To promote bed safety while maintaining patient comfort, ensure the following before leaving the patient's bedside: The bed is in its lowest position. The bed position is safe for the patient. The bed controls are functioning (bed is electrically safe). The call light is functioning and always within reach. Side rails are raised if indicated. The wheels or casters are locked.

Applying a New Dressing. Apply a skin protectant or barrier to the healthy skin around the wound. This is particularly important if there is drainage from the wound. The skin protectant prevents skin irritation and excoriation from tape, adhesives, and wound drainage. The nurse should be familiar with and follow the manufacturer's guidelines for the specific dressing in use. General guidelines for applying a new dressing include (Hess, 2013): Check the wound care order or nursing care plan. Perform hand hygiene. Use standard precautions; use appropriate transmission-based precautions when indicated. Check the patient's identification. Explain what you are going to do to the patient. Provide privacy by closing the door to the room and pulling the bedside curtain. Put on gloves. Cleanse the wound, and periwound skin, as prescribed. Apply a skin barrier, such as Skin Prep, to the areas of skin where the dressing adhesive or tape will be placed and to areas around the wound where drainage may come in contact with skin. Gently place the dressing at the wound center and extend it at least 1 inch beyond the wound in each direction. Alternately, follow the manufacturer's directions for application. Remove gloves when the dressing is in place, before handling tape, if used. Do not apply tape under tension to prevent blisters and skin shearing. Perform hand hygiene. Some wounds require packing with dressing material as part of treatment. It is important to be familiar with and follow the manufacturer's guidelines for the specific product in use. To pack a wound: Check the wound care order or nursing care plan. Perform hand hygiene. Use standard precautions; use appropriate transmission-based precautions when indicated. Check the patient's identification. Explain what you are going to do to the patient. Provide privacy by closing the door to the room and pulling the bedside curtain. Cleanse the wound and periwound skin, as prescribed. Apply a skin barrier, such as Skin Prep, to the areas of skin where the dressing adhesive or tape will be placed and to areas around the wound where drainage may come in contact with skin. Moisten packing material as necessary and as indicated by the manufacturer's directions or medical orders. Loosely pack the wound cavity just until the wound surfaces and edges are covered. If tunneling is present, pack the tunneling area first, then the base of the wound. Alternately, follow the manufacturer's directions for application. Ensure that all wound surfaces are covered and kept moist. Do not allow packing to overlap the wound edges; maceration of surrounding tissues could occur. Cover with appropriate top dressing. Skill 31-1 describes the process for cleaning a wound and applying a dry sterile dressing. Skill 31-2 describes cleaning a wound and applying a saline-moistened dressing. Skill 31-3 presents the technique for irrigating a wound. Securing Wound Dressings. Many dressings are self-adhesive, thus no further material is needed to secure the dressing in place over the wound. However, other wound dressings require additional materials to hold the dressings in place, including tape, bandages and binders, and Montgomery straps. Tape can be used to secure dressings in place. Tape comes in a wide variety of sizes and types, ranging in width from 1 to 4 inches (1-inch-wide tape is the most commonly used). Take care to protect the skin surrounding the wound from injury-related irritation or shearing, or tearing of the skin during tape removal. Table 31-6 summarizes the types and purposes of different tapes.

Bandages and binders are used to secure dressings, apply pressure, and support the wound. Bandages are strips of cloth, gauze (e.g., roller gauze, Kerlix, Kling), or elasticized material (e.g., ACE bandages) used to wrap a body part. They come packaged in rolls and vary in width from 1 to 6 inches. Binders are designed for a specific body part and include slings, abdominal binders, chest binders, and T-binders. They may be made of cloth (flannel, muslin) or of an elasticized material that fastens together with Velcro. The Guidelines for Nursing Care 31-4 highlights important principles for applying bandages and binders. A roller bandage is a continuous strip of material wound on itself to form a cylinder or roll. Plain gauze, elastic webbing, and stretchable roller bandages are made in various widths and lengths. Begin applying the bandage to the distal part of the area. The free end is held in place with one hand while the other hand passes the roll around the body part. After the bandage is anchored, the roll is passed or rolled around the body part, taking care to exert equal tension in all turns and rolling toward the heart, to avoid causing venous stasis and resulting edema. Apply the bandage using a circular turn, spiral turn, or figure-of-eight turn (Fig. 31-13). For each technique, keep tension equal by unwinding the bandage gradually and only with as much length as is required. Evenly overlap one-half to two-thirds the width of the bandage with each turn, except for the circular turn. A circular turn is used primarily to anchor a bandage. In a circular turn, wrap the bandage around the body part, completely overlapping the previous bandage turn. Once the circular turn anchors the bandage, application continues, ascending in a spiral manner using a spiral turn. Each turn overlaps the preceding one by one-half or two-thirds the width of the bandage. The spiral turn is useful for the wrist, fingers, and trunk. The figure-of-eight turn consists of making oblique overlapping turns that ascend and descend alternately. It is effective for use around joints, such as the knee, elbow, ankle, and wrist. When removing a roller bandage, cut the bandage with bandage scissors to prevent excessive manipulation of the part. Cut on the side opposite the injury or the wound, from one end to the other, so that the bandage can be folded open for its entire length. If the bandage is to be reused, it may be unwound by keeping the loose ends together and passing it as a ball from one hand to the other while unwinding it. When applying a recurrent bandage, make a few circular turns to anchor the bandage, and place the initial end of the bandage at the center of the body part being bandaged, well back from the tip to be covered. Pass the bandage back and forth over the tip, first on the one side and then on the other side of the centerpiece of the bandage. Figure 31-13 shows how to apply a recurrent bandage to a residual limb, using the figure-of-eight turn to finish the bandage. Recurrent bandages are used for fingers, for the head, and for a residual limb. Of the many different kinds of binders, those used most commonly include straight binders, T-binders, and slings. A straight binder is a straight piece of material, usually about 15 to 20 cm (6 to 8 inches) wide and long enough to more than circle the torso. It is used for the chest and the abdomen. Straight binders may be pinned or, more commonly, fastened with Velcro. A T-binder might be used to secure dressings on the rectum and perineum and in the groin. The single T-binder is used for female patients, the double T-binder for male patients. Pass the belt around the waist and secure it, then pass the tails between the legs and fasten them to the belt. A sling is used to support an arm. Most health care agencies use commercial strap slings or sleeve slings. In the home, a large piece of cloth folded into a triangle can be used as a sling (see Fig. 31-13). Montgomery straps use ties attached to an adhesive backing to hold dressings in place. Protect the patient's skin with a skin barrier, such as Skin Prep, or a hydrocolloid dressing, prior to applying the Montgomery straps. Apply the adhesive backing to the skin adjacent to the wound, with the ties extending over the wound area. When the dressing is changed, untie the strips and turn them back to allow for wound care. After applying the new dressing, tie the straps over the dressing to hold it in place (Fig. 31-14). Montgomery straps can be useful in preventing skin irritation and damage due to constant retaping with dressing changes. Change Montgomery straps only when they become moist or soiled.

Promoting Normal Urination Nursing care to promote normal urination includes interventions to support normal voiding habits, fluid intake, strengthening of muscle tone, stimulating urination and resolving urinary retention, and assisting with toileting. Nurses working with patients to promote appropriate behaviors related to urine elimination should examine their own behaviors as factors in the success of the plan. Nurses who role model good health behaviors are more effective teachers. Use the display, Promoting Health 36-1, for yourself before using it with others. MAINTAINING NORMAL VOIDING HABITS If the patient's voiding habits are adequate, provide care or teach the patient to maintain these habits to ensure comfort and satisfactory urine output. Attention to the following variables is helpful: Schedule: Some patients report urinating on demand in no apparent pattern. Others have inflexible patterns that have developed over the years and become anxious if these are interrupted. Some patients need assistance to urinate and may experience urgency. Nursing actions should support the patient's usual urinating pattern as much as possible. Urge to void: Assist the patient to void when the patient first feels the urge to void. Routinely delaying urination may result in difficulty initiating a stream and/or urinary stasis. Urinary stasis can contribute to the development of urinary tract infections. Privacy: Many adults and children cannot urinate in the presence of another person. Unless the patient is extremely weak and requires assistance, provide privacy in the health care facility and in the home. Position: Helping patients assume their usual voiding position may be all that is necessary to resolve an inability to urinate. Some male patients cannot use a urinal while lying down or sitting; encourage them to void while standing at the bedside unless this is contraindicated. Similarly, some female patients cannot void easily on a bedpan but respond favorably with a bedside commode. Hygiene: Patients who are confined to bed find it difficult to perform their usual genital hygiene. Careful cleansing of the perineal and genital areas is needed for patient comfort and to prevent infection. This is easily accomplished for patients on bedrest by using warmed, moistened disposable washcloths and skin cleanser or by pouring warm, soapy water over the perineal area while the patient is still on the bedpan, followed by clear water. Families providing care for ill members at home may be taught this technique.

Because people customarily wash their hands after toileting, offer patients confined to bed a moistened towelette or soap and water to wipe their hands after removing the bedpan or urinal. Specific recommendations for urinary elimination problems that affect older adults are listed in the accompanying Focus on the Older Adult box . Recall Anna Galinski, the frail older woman in the long-term care facility. Ideally, before the charge nurse had inserted the catheter into Mrs. Galinski, strategies to promote normal urinary elimination should have been attempted to determine their effectiveness in promoting urinary elimination. In addition, when advocating for the patient, the nurse would strongly urge incorporating strategies to promote normal urinary elimination into the patient's plan of care to determine their effectiveness, ultimately substantiating that catheterization was not necessary. PROMOTING FLUID INTAKE Many people routinely drink less fluid than is optimal to promote healthy urinary functioning. Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (eight to ten 8-oz glasses) of fluid daily. A common misperception is that drinking this much fluid causes water retention and contributes to weight gain. If a good proportion of the daily fluid intake is water, the kidneys and urinary structures are well flushed, and waste products, including potentially harmful bacteria, are removed. Monitor fluid intake for excessive amounts of caffeine-containing beverages, high-sodium beverages, and high-sugar beverages. Provide fresh water, juices, and fluids of preference to patients confined to bed. Remind children and patients who are confused to drink. Fluid restrictions may be ordered for patients with certain diseases. For others, forced fluids (above-average intake of fluids) are prescribed. Incorporate this information in the plan of care and explain it to the patient. STRENGTHENING MUSCLE TONE Weakening of the pelvic floor muscles is a common cause of urinary continence problems in women and men (Perry, 2011). Pelvic floor muscle training (PFMT) can improve voluntary control of urination and significantly reduce or eliminate problems with stress incontinence (involuntary loss of urine related to an increase in intra-abdominal pressure) by strengthening perineal and abdominal muscle tone (Huebner et al., 2011). PFMT, more commonly called Kegel exercises, targets the inner muscles that lie under and support the bladder. These muscles can be toned, strengthened, and actually made larger by a regular routine of tightening and relaxing. Often patients have difficulty determining which muscles to exercise. These are the same muscles that the patient contracts to stop urinating in midstream or to control defecation. Instruct patients to contract the pelvic floor muscles for 10 seconds and to relax them for 10 seconds. Encourage the patient to perform Kegel exercises without involving the muscles in the abdomen, inner thigh, and buttocks. When the patient is familiar with these sensations, these exercises should be performed multiple times a day for at least 3 months, and possibly longer, depending on the response (Perry; Huebner et al.). The exercises can be done anywhere. Assist patients to incorporate them into their daily activities.

The following are clinical situations when an alcohol-based handrub can be used to decontaminate hands:

Before direct contact with patients After direct contact with patient's skin After contact with body fluids, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled After removing gloves Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement Before donning sterile gloves prior to an invasive procedure (e.g., inserting a central intravascular catheter) If moving from a contaminated body site to a clean body site during patient care After contact with objects (including equipment) located in the patient's environment (IHI, 2011).

Factors Affecting Wound Healing A variety of factors affect wound healing. Local factors, those occurring directly in the wound, include pressure, desiccation (dehydration), maceration (overhydration), trauma, edema, infection, excessive bleeding, necrosis (death of tissue), and the presence of biofilm (a thick grouping of microorganisms). Systemic factors, those occurring throughout the body, include age, circulation to and oxygenation of tissues, nutritional status, wound condition, health status, immunosuppression, and medication use (Huether & McCance, 2012; Hess, 2013; Grossman, 2014). LOCAL FACTORS Factors occurring local to the wound itself can prolong wound healing. These factors are discussed in the following sections. Pressure Pressure disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing. Desiccation Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. Wounds that are kept moist (not wet) and hydrated experience enhanced epidermal cell migration, which supports epithelialization (epithelial cell migration to the wound bed; Hess, 2013). Maceration Maceration, softening and breakdown of skin, results from prolonged exposure to moisture. Overhydration of cells related to urinary and fecal incontinence can also lead to maceration and impaired skin integrity. This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin. Trauma Repeated trauma to a wound area results in delayed healing or the inability to heal. Edema Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue. Infection Bacteria in a wound increase stress on the body, requiring increased energy to deal with the invaders. Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death. Excessive Bleeding Excessive bleeding results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood is an excellent place for growth of bacteria and promotes infection (Huether & McCance, 2012). Necrosis Dead tissue present in the wound delays healing. Dead tissue appears as slough—moist, yellow, stringy tissue—and eschar appears as dry, black, leathery tissue. Healing of the wound will not take place with necrotic tissue in the wound. Removal of the dead tissue must occur for healing to begin (Hess, 2013; Beitz, 2012).

Biofilm Wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). The bacteria also produce a protective matrix that attaches the biofilm to the wound surface. Biofilms impair wound healing and contribute to chronic wound inflammation (Baranoski & Ayello, 2012). SYSTEMIC FACTORS Factors not related to the wound location itself also can prolong wound healing. These factors are discussed in the following sections. Age The major skin layers arise from different embryologic origins, resulting in poor adherence between the epidermis and the dermis. This loose binding between the layers causes the layers to separate easily during an inflammatory process, placing infants and small children at risk for impaired skin integrity. Epidermal stripping, the unintentional removal of the epidermis with tape removal, is one type of such injury. Care should be taken to minimize tension, traction, and wrinkles on the skin when using tape on these young patients. Children and healthy adults, however, heal more rapidly than do older adults, in whom physiologic changes caused by aging result in diminished fibroblastic activity and circulation. Older adults are more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. See the accompanying Focus on the Older Adult display for other age-related factors affecting wound healing. Circulation and Oxygenation Adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing. Certain physical conditions, because of their effect on circulation and oxygenation, can affect wound healing. Circulation may be impaired in older adults and in people with peripheral vascular disorders, cardiovascular disorders, hypertension, or diabetes mellitus. Oxygenation of tissues is decreased in people with anemia or chronic respiratory disorders and in those who smoke.

Administering Inhaled Medications

Bronchodilators: open narrowed airways Nebulizers: disperse fine particles of liquid medication into the deeper passages of the respiratory tract Meter-dose inhalers: deliver a controlled dose of medication with each compression of the canister Dry powder inhalers: breath-activated delivery of medications

EXAM 1 RECAP SOURCES OF SOAP RECOMMENDED WHEN DECREASING SPREAD OF CONTAMINATION FOR EX BAR OF SOAP VS LIQUID PUMP SOAP OR HAND SANITIZER WHEN DO YOU HAVE TO ACTUALLY USE SOAP AND WATER TO CLEANSE YOUR HANDS IS THERE A LIMIT TO HOW MANY TIMES YOU CAN USE HAND SANITIZER BEFORE OYOU HAVE TO heartACTUALLY WASH YOUR HANDS WITH SOAP AND WATER? HOW FAR UP THE WRIST DO U WASH? _________________________________ CH 24 VS: 1.CORE TEMPS: RECTAL 2. ORAL THERMOMETER CONTRAINDICATIONS: UNCONSCIOUS PATIENT, CHILD 3. AGITATED PT AND OBTAINING TEMPERATURES CONSIDERATIONS: USE AXILLARY ROUTE 4. BP CUFF SIZE CONSIDERATIONS IF IT IS TOO BIG YOU WON'T GET A GOOD READING, IT HAS TO BE LINED UP WITH THE BRACHIAL ARTERY....BIG CUFF IS TOO LOW, SMALL CUFF IS TOO HIGH 5. OTHER FACTORS AFFECTING INCORRECT BP READING: IF PT WAS JUST WALKING BRISKLY, MEDICATIONS, GENDER (MALE IS HIGHER), CIRCADIAN RHYTHM, CAFFEINE, OBESITY, ATE A BIG MEAL, ANGRY/UPSET, AGE, WHAT POSITION YOU ARE IN IF YOU ARE AT HEART LEVEL, HOW NOISY IT IS YOU MAY NOT HEAR IT RIGHT, WHAT IF YOU DIDNT CALIBRATE IT CORRECTLY (TEST ANSWER), DEHYDRATION, 6. TYMPANIC TEMP OF THE ADULT: PULL EAR UP AND BACK FOR ADULT, FOR CHILD PULL IT DOWN. EAR WAX DOESNT MAKE A DIFFERENCE 7. BEARING DOWN AND EFFECT ON VS: SIMULATES VAGAL RESPONSE THAT CAN SIGNIFICANTLY DECREASE HEART RATE 8.PAIN AND HEART RATE: PAIN CAN DRIVE UP THE HEART RATE, DEPENDING ON SEVERITY OF PAIN 9. SOB AND HEART RATE, HEART RATE GOES UP WITH SOB 10. FEVER AND HEART RATE....FEVER MAKES HEART RATE GO UP! 11. ASSESSING ORTHOPNEA: TELLL HOW WE WE HAD TO ASK HOW MANY PILLOWS THEY USE AT HOME FOR SLEEPING. FIRST THOUGHT HOW STRANGE? ARE THEY SURVERYING HOW MANY ARE NEEDED ON EACH UNIT? NO!! IF YOU ARE SLEEPING WITH 6 PILLOWS TO SIT U UP, PROBABALY U HAVE A BREATHING PROBLEM. SOME PATIENTS SLEEP IN A CHAIR ALL THE TIME, THEY CANT SLEEP IN A BED 12. WHEN YOU GET 2 DIFF BLOOD PRESSURE READINGS, GO WITH THE HIGHER ONE 13. CARDIAC PTS AND RECTAL TEMPS, DIGITAL IMPACTION REMOVAL AND THE HEART RATE WHAT DOES THIS ACTIVATE? VAGAL RESPONSE!! 14. PULSE DEFICIT? DIFERENCE BETWEEN HEART RATE AND PULSE RATE? REMEMEBER NOT ALL THE BEATS GO TO THE PERIPHERY, SOME OF THEM DONT HAVE A PEDAL PULSE FOR EXAMPLE

CH 23 ASEPSIS WHEN SHOUDL YOUR HANDS BE CLEANSED? BEFORE AND AFTER EVERY PATIENTS, AFTER USING BATHROOM, MUST USE SOAP WITH CDIFF PATIENTS!! WHEN ELSE SHOULD U WASH UR HANDS WITH SOAP BEFORE MEALS, VISIBLY SOILED MINIMAL LENGTH OF TIME TO WASH HANDS, DOES THIS ALWAYS APPLY IF THEY ARE HEAVILY SOILED? NO, U HAVE TO WASH LONGER! FRICTION CONSIDERATIONS? MOVE HANDS IN CIRCULAR MOTION WATER TEMP TO DECREASE CONTAMINATION: 110-115 AMOUTN OF SOAP REQUIRED FOR HAND WASHING: TEASPOON HAND SANITIZER VS ACTUAL HAND WASHING: SOURCES OF SOAP RECOMMENDED WHEN DECREASING SPREAD OF CONTAMINATION (FOR EXAMPLE BAR OF SOAP VS LIQUID PUMP SOAP OR HAND SANITIZER): WHEN DO YOU HAVE TO ACTUALLY USE SOAP AND WATER TO CLEANSE YOUR HANDS?? HOW FAR UP WRIST? ONE INCH ABOVE ARE OF CONTAMINATION IS THERE A LIMIT TO HOW MANY TIMES YOU CAN USE HAND SANIZER BEFORE OU HAVE TO ACTUALLY WASH UR HANDS WITH SOAP AND WATER HOW FAR DO U DROP UR STERILE ITEMS ONTO THE STERILE FIELD? 6 INCHES! STERLILE GLOVES AND STERILE DRAPE, ONLY TOUCH ONE INCH BORDER WITHOUT GLOVES, EVEN WITH GLOVES ONCE U PUT IT DOWN DONT TOUCH THAT ONE INCH BORDER!!!!! (JUST KNOW THE 1 INCH BORDER CANT BE TOUCHED WITH OR WITHOUT GLOVES) WHAT PART OF THE STERILE PACKAGING IS CONSIDERED CONTAMINATED AND WHEN? DO YOU CONSIDER THE STERILE DRAP ONE INCH BODRDER OCONTAMINATED WHEN YOU HAVE PLACE IT ON ITS INTENDED SURFACE? YES! CROSSING THE STERILE FIELD: NO OPENING A STERILE PACKAGE: AWAY FROM YOU, SIDE TO SIDE, AND THEN THE FRONT AWAY FROM YOU!!! KNO ITS SIDE TO SIDE AND THEN FRONT AWAY!! DURING POSITIONING U CAN TOUCH STERILE DRAP E WITH STERILE GLOVES BECAUSE STERILE TO STERILE IS OK MAINTAINE STERILE TECHNIQUE HWILE DONNING GLOVES: HAVE TABLE BE AT WAIST LEVEL POSISITIONING A STERILE DRAPE WITH STERILE GLOVES: STERILE TO STERILE CAN TOUCH, BUT PACKAGING HAS TO BE OPEN ALREADY HOW DO YOU FACE YOUR STERILE FIELD, CANT TURN UR BACK TO IT WHAT HEIGHT SHOULD U APPLY STERILE GLOVES AT WHERE SHOULD THE CUFF END OF GLOVES BE AT? TOWARDS YOU FOLEY INSERTION CONSIDERATIONS... MALES : 8 inches urethra FEMALES: 1.5-2.5 inches urethra WHAT ARE THE 2 MAIN PT IDENTIFIERS PRIOR TO INSERTING A FOLEY NAME DOB WHAT STEPS ARE NEEDED BEFORE CONTAMINATING THE NON-DOMINANY HAND WHNE CLEANSING THE MEATUS? LUBE HAS TO BE DONE CLEANING HAS TO BE DONE ISOLATION PRECAUTION.... STANDARD PRECAUTIONS: TRANSMISSION-BASED PRECAUTIONS: AIRBORNE/DROPLET...FOR MASK USE A RESPIRATOR MASK WITH NEGATIVE PRESSURE ROOM DROPLET PRECAUTIONS CONTACT PRECAUTIONS

Caring for Patients with Wound Drains A variety of drains, catheters, or tubes may be inserted into or near a wound when it is anticipated that a collection of fluid in a closed area would delay healing. After a surgical procedure, the surgeon places one end of the tube or drain in or near the area to be drained and passes the other end through the skin, either directly through the incision or through a separate opening called a stab wound. Wound drains are either open systems that drain into dressings or closed systems that drain into a suction device. Drains and tubes may or may not be sutured in place. OPEN DRAINAGE SYSTEMS A Penrose drain is soft and flexible. This drain does not have a collection device. It empties into absorptive dressing material. It promotes drainage passively, with the drainage moving from the area of greater pressure, in the wound or surgical site, to the area of less pressure, the dressing. It is not sutured in place. A sterile, large safety pin is often attached to the outer portion to prevent the drain from slipping back into the incised area (Fig. 31-15). Care is necessary to ensure that these drains are not dislodged during dressing changes. Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, and cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as

CLOSED DRAINAGE SYSTEMS Closed drainage systems consist of a drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir to maintain constant low suction. Examples include Jackson-Pratt drainage tubes (Fig. 31-16) and Hemovacs (Fig. 31-17). These tubes are usually sutured to the skin. The closed drainage system prevents microorganisms from entering the wound from saturated dressings. Closed drainage systems also allow accurate measurement of drainage. Be sure to know which type of drain or tube was inserted during surgery to ensure accurate assessments and interventions. These systems must be emptied and the suction reestablished according to the directions for each device. This usually involves compressing the container while the port is open, then closing the port after the device is compressed. Skills 31-4 and 31-5 outline the procedures for caring for Jackson-Pratt and Hemovac drains. Wear gloves when emptying the drainage and do not touch the open port to avoid contaminating the port.

PFMT can also be accomplished by using vaginal weights. The patient inserts a small weighted cone into her vagina. She then contracts her pelvic floor musculature to prevent the cone from falling out. The cones can be gradually increased in weight as the muscles are strengthened. ASSISTING WITH TOILETING The amount of assistance provided to a patient in relation to toileting varies, depending on the patient's abilities and health status. Toilet. Even when the patient can use the bathroom toilet, the nurse may be responsible for noting any abnormalities of urinary elimination. In some instances, patients may be taught to report abnormalities to the nurse and instructed not to flush the toilet until the nurse checks the urine. In other instances, when the urine volume is to be calculated, the patient may need to urinate in a bedpan or a specimen hat placed in the toilet so that the urine can be measured before it is discarded. Although many patients can easily be taught to measure their urine output, the nurse is responsible for observing urine at least once during a shift and more frequently if warranted. Assist weakened patients to the bathroom. If there is any danger of the patient falling, remain in attendance. Never lock the bathroom door. Also, ensure that a signal bell is within easy reach so that the patient can summon help easily if feeling weak and needing assistance. A handrail near the toilet also is helpful. Commode. Commodes are chairs—straight-back chairs or wheelchairs with open seats and a shelf or a holder underneath that holds a bedpan or bucket (Fig. 36-9). They can be used for patients who can get out of bed but cannot use the bathroom toilet. The commode can be placed adjacent to the bed, and the patient can be assisted to it with minimal exertion. If the patient has a roommate, any visitors may be asked to exit the room while the patient uses the commode. Remember to pull the curtain in the room and close the door to provide for patient privacy. Bedpan and Urinal. Male patients confined to bed usually use the urinal for voiding and the bedpan for defecation; female patients use the bedpan for both (see Fig. 36-5, p. 1274). Many patients find it embarrassing and difficult to use the bedpan and/or the urinal. When a patient uses a bedpan or urinal, maintain the patient's privacy. FIGURE 36-9. Bedside commode. A special bedpan called a fracture bedpan is frequently used by people with fractures of the femur or lower spine. Smaller and flatter than the ordinary bedpan, it is helpful for patients who cannot easily raise themselves onto the regular bedpan. Very thin or elderly patients often find it easier and more comfortable to use the fracture bedpan. Skills 36-2 and 36-3 show how to assist a patient with using a bedpan and urinal.

Caring for Patients with Urinary Tract Infections Urinary tract infections (UTIs) are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals (Edward et al., 2007; Klevans et al., 2007 in AACN, 2011). UTIs are the leading cause of systemic infections in older adults. Women are especially vulnerable to UTIs because the female urethra is shorter and in closer proximity to the vagina and rectum. UTIs can affect both the upper urinary tract, involving the kidneys and ureters (pyelonephritis) and lower urinary tract, involving the bladder and urethra (cystitis). Escherichia coli, bacteria commonly found in the gastrointestinal tract, are the most common causal organism (National Kidney Foundation [NKF], 2010). RISK FACTORS Those at greatest risk for a UTI include the following: Sexually active women: During intercourse, perineal bacteria can migrate into the urethra and bladder. Women who use diaphragms for contraception: The spermicide used with a diaphragm decreases the amount of normally protective vaginal flora. Postmenopausal women: Urinary stasis, which is common at this age, provides an optimal environment for bacteria to multiply; in addition, decreased estrogen contributes to loss of protective vaginal flora. People with an indwelling urinary catheter in place: Up to 80% of UTIs are associated with the presence of an indwelling urinary catheter (Apisarnthanark et al., 2007 in AACN, 2011). A catheter-associated urinary tract infection (CAUTI) increases hospital cost and is associated with increased morbidity and mortality. CAUTIs are considered by the Centers for Medicare and Medicaid Services to represent a reasonably preventable complication of hospitalization. As such, no additional payment is provided to hospitals for CAUTI treatment-related costs (Klevans et al., 2007 in AACN, 2011; Wald & Kramer, 2007, in AACN, 2011; CMS, 2012). Although a break in sterile technique during placement can lead to an infection, most pathogens are introduced via handling of the catheter and drainage device after placement. People with diabetes mellitus: Glucose in the urine acts as an excellent medium for bacteria to proliferate. Older adults: The physiologic changes associated with aging (listed earlier in the chapter) predispose older people to the development of UTIs. In addition, enlargement of the prostate as men age can contribute to the development of UTIs in older men (NKF, 2013).

TYPES OF CATHETERS Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. Intermittent catheterization should be considered as an alternative to short-term or long-term indwelling urethral catheterization to reduce catheter-associated UTIs (Hooton et al., 2012). Intermittent catheterization is becoming the gold standard for the management of bladder-emptying dysfunctions and following surgical interventions. Certain advantages to intermittent catheterization, including the lower risks of catheter-associated UTI and complications, may make it a more desirable and safer option than indwelling catheterization (Herter & Wallace Kazer, 2010, pp. 343-344). Intermittent catheterization, performed by the patient or a caregiver in the home, may be necessary for patients with spinal cord injuries or other neurologic conditions. Although the risk for UTI is always present, most research supports the use of clean, rather than sterile, technique in this environment. Patients can be taught to insert and remove intermittent catheters themselves. The procedure for self-catheterization is essentially the same as that used by the nurse to catheterize a patient. Initially, a female patient may use a mirror to locate the meatus, but eventually she can learn to insert the catheter using just touch. Self-catheterization is recommended at regular intervals to prevent overdistention of the bladder and decreased blood flow through the wall of the bladder (Hinkle & Cheever, 2014). Intermittent catheters and catheterization are discussed in Guidelines for Nursing Care 36-2. Box 36-4 outlines important information related to patient self-catheterization. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. The indwelling urethral catheter is designed so that it does not slip out of the bladder. A balloon is inflated to ensure that the catheter remains in the bladder once it is inserted. Indwelling catheters are used for the gradual decompression of an overdistended bladder, for intermittent bladder drainage and irrigation, and for continuous bladder drainage. Several types of indwelling catheters are available, but the principles on which they operate are similar. The indwelling catheter has more than one lumen (open tube) within the catheter. In a double-lumen catheter, one lumen is connected directly to the balloon, which is inflated with sterile water; the other is the lumen through which the urine drains. The triple-lumen catheter provides an additional lumen for the instillation of irrigating solution. Figure 36-10 illustrates a triple-lumen, double-lumen, and straight catheter. A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area (Fig. 36-11). Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised the flow of urine through the urethra. A suprapubic catheter is often preferred over indwelling urethral catheters for long-term urinary drainage. Suprapubic catheters are associated with decreased risk of contamination with organisms from fecal material, elimination of damage to the urethra, a higher rate of patient satisfaction, and lower risk of catheter-associated UTIs (Rew & Smith, 2011; Hooton et al., 2010). The drainage tube is secured with sutures or tape. Care of the patient with a suprapubic catheter includes skin care around the insertion site; care of the drainage tubing and drainage bag is the same as for an indwelling catheter (see Caring for Patients With an Indwelling Catheter).

Caring for a Patient With a Urinary Diversion Obstructions or tumors in the urinary tract may require some patients to have urinary flow diverted surgically. Urinary diversions may also be used as part of the treatment for patients with a neurogenic bladder, radiation cystitis, or congenital anomalies of the lower urinary tract. An ileal conduit is a type of incontinent cutaneous urinary diversion. An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. This separated section of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma, a surgically created opening on the body surface. Figure 36-14 shows how the ureters are diverted in an ileal conduit. A cutaneous ureterostomy is another type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin. These cutaneous diversions are usually permanent, and the patient wears an external appliance to collect the urine because elimination of the urine from the stoma cannot be controlled voluntarily. Another option for diversion of urine is a continent urinary reservoir (e.g., the Indiana pouch and the Kock pouch). Figure 36-15 shows how the ureters are diverted into a segment of ileum and cecum in an Indiana pouch. This is a surgical alternative that uses a section of the intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma. The external stoma or outlet must be catheterized at regular intervals to drain the urine that has collected in this reservoir.

DIAGNOSTIC EVALUATION In addition to the nursing history and physical examination, laboratory findings can identify the presence of a UTI. A urine sample from a clean-catch or sterile specimen should be sent to the laboratory for a culture and sensitivity (C&S) test. A C&S is positive if it shows at least 100,000 organisms per milliliter of urine. Lower counts may be considered clinically significant if the patient has signs and symptoms of a UTI (Van Leeuwen, Poelhuis-Leth, & Bladh, 2011). The presence of bacteria in a clean-catch midstream or sterile urine specimen, accompanied by symptoms (e.g., dysuria, urinary frequency or urgency, or cloudy urine with a foul odor), indicates a UTI. Red blood cells and nitrates also may be present in the urine. TREATMENT Various protocols are used to treat UTIs. A short-course antibiotic regimen (1 large dose vs. 3 or 7 days of smaller doses) usually eradicates infections of the lower urinary tract; longer antimicrobial therapy is required for upper UTIs. Patient education can help prevent UTI recurrence. Teaching the patient about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. Instruct the patient to: Drink eight to ten 8-oz glasses of water daily. Observe the urine for color, amount, odor, and frequency. Report any sign of infection to your health care provider. Dry the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum. Drink two glasses of water before and after sexual intercourse and void immediately after intercourse. Take showers rather than baths. Wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Drink 10 oz of cranberry or blueberry juice daily. These juices contain chemicals that may help prevent bacteriuria (bacteria in the urine) by inhibiting bacteria from adhering to the bladder wall and urinary catheters (NKF, 2010). Daily cranberry juice should not be recommended for patients with a personal or family history of kidney stones (MedlinePlus, 2013). Nursing interventions to prevent UTIs for a patient with an indwelling catheter are discussed later in the chapter.

Caring for an Incontinent Patient Urinary incontinence, any involuntary leakage of urine, is widely underreported and underdiagnosed. It is one of the most common chronic health problems. However, it is not an inevitable result of growing old or bearing children. Many people self-manage this life-altering condition for many years before seeking assistance from a health care provider. Urinary incontinence is more prevalent in women and increases with age. It is a special problem for older adults who may experience decreasing control over urination and who may find it more difficult to reach a toilet in time to void because of mobility problems or dexterity problems in undressing. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing the individual to feel like a social outcast. Age-related changes do affect urinary function, but urinary incontinence can be treated and individualized interventions can help the patient lead a normal life. Of those who seek treatment, 80% are cured or have their symptoms improved notably. Patients frequently turn to absorbent products for protection when they are incontinent of urine if they have not had this condition properly diagnosed and treated. These products absorb or contain urine leakage. Many types of disposable and reusable products are available, including perineal pads or liners, protective underwear, guards and drip collection pouches, and adult briefs. When used improperly, such products may cause skin breakdown and place the patient at risk for a UTI. Long-term use of these products is not recommended until the following factors have been considered and discussed with a health care provider: Functional disability of the patient Type and severity of incontinence Gender Availability of caregivers Failure of previous treatment programs Patient preference

Administering Cardiopulmonary Resuscitation (CAB)

Chest Compressions: Check the pulse. If the victim has no pulse, initiate chest compressions to provide artificial circulation. Airway: Tilt the head and lift the chin; check for breathing. The respiratory tract must be opened so that air can enter. Breathing: If the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1 second each. Defibrillation: Apply the AED as soon as it is available.

Crackles: intermittent sounds occurring when air moves through airways that contain fluid Classified as fine, medium, or coarse Wheezes: continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors Classified as sibilant or sonorous

Common Diagnostic Methods to Assess Cardiopulmonary Function Cardiac coronary catheterization Cardiac exercise stress testing Echocardiogram Endoscopic studies Holter monitor Lung scan Skin tests Radiography

Echocardiogram

Echocardiography is a noninvasive ultrasound test used to evaluate abnormal heart sounds; size of the heart; size and function of the heart's structures; direction and speed of blood flow through the heart; and presence of abnormalities, such as tumors.

Very thin and very obese people are more susceptible to skin injury. Fluid loss during illness causes dehydration. Skin appears loose and flabby. Excessive perspiration during illness predisposes skin to breakdown. Jaundice causes yellowish, itchy skin. Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care.

Desiccation (dehydration), a process of drying up Maceration (over hydration), a prolonged exposure to moisture as occurs with urinary & fecal incontinence Trauma (repeated trauma to a wound area) for example, picking a scab over & over Edema (interferes with blood supply, oxygen & nutrients) Infection (bacteria creates increased stress & requires a lot of energy to fight the bacteria, which leaves decreased which reserves for healing. Also, toxins are released from bacteria Excessive bleeding (results in large clots which take up space & decreases 02 diffusion) Necrosis (death of tissue) Presence of biofilm (thick grouping of microorganisms)

Functions of the Skin and Mucous Membranes The skin has multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination. See Table 31-1 for details of each of these functions. Mucous membranes line body cavities that open to the outside of the body, joining with the skin. They can also be found in the digestive tract, the respiratory passages, and the urinary and reproductive tracts. Epithelium covers the mucous membrane surfaces and contains cells that secrete mucus. Mucous membranes have receptors that offer the body protection. For example, an irritating substance in the upper respiratory tract causes a person to sneeze, and food caught in the larynx or trachea causes a person to cough. Sneezing and coughing are protective mechanisms that help rid the body of foreign materials. Mucous membranes are insensitive to temperature, except in the mouth and rectum, but are sensitive to pressure. Mucous membranes also function to absorb substances from their surface. For example, digested food is absorbed through the mucous membrane in the small intestine. Factors Affecting Skin Integrity Basic principles related to integrity of the skin and mucous membranes include the following: Unbroken and healthy skin and mucous membranes serve as the first lines of defense against harmful agents. Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissues, and illness conditions. Adequately nourished and hydrated body cells are resistant to injury. The better nourished the cell is, the better able it is to resist injury and disease. Adequate circulation is necessary to maintain cell life. When circulation is impaired for any reason, cells receive inadequate nourishment and cannot remove wastes efficiently.

Developmental Considerations Specific characteristics of the skin are associated with different developmental stages. Hygiene practices at every age have a direct influence on the status and appearance of the skin. In children younger than 2 years, the skin is thinner and weaker than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to and infection of the skin and mucous membranes. A child's skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. In older adults, the maturation of epidermal cells is prolonged, leading to thin, easily damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure. Changes that occur in the skin with aging are discussed in Focus on the Older Adult .

FACTORS AFFECTING CARDIOPULMONARY FUNCTIONING AND OXYGENATION Asthma Click to Show A variety of factors affect adequate cardiopulmonary function, leading to impaired oxygenation. Important factors are discussed in the following sections. Level of Health Acute and chronic illnesses can affect a person's cardiopulmonary function dramatically. For example, people with renal or cardiac disorders often have compromised respiratory functioning because of fluid overload and impaired tissue perfusion. People with chronic illnesses often have muscle wasting and poor muscle tone. These problems affect all the muscles, including those of the respiratory system. Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration, as well as inadequate functioning of the heart. Anemia can result in impaired respiratory function. As discussed previously, anemia may lead to an inadequate supply of oxygen to the tissues of the body. Because hemoglobin also carries carbon dioxide to the lungs, anemia results in diminished carbon dioxide exchange. Myocardial infarction causes a lack of blood supply to the heart muscle. Damage to the heart muscle interferes with effective contractions of the heart muscle, leading to decreased perfusion of tissues and decreased gas exchange. Physical changes such as scoliosis (curvature of the spine) influence breathing patterns and may cause air trapping. Research reveals a statistically significant correlation between obesity and chronic bronchitis. Moreover, people who are obese are often short of breath during activity, ultimately leading to less participation in exercise. As a result, the alveoli at the base of the lungs are rarely stimulated to expand fully. Recall Yan Kim, the 57-year-old patient who developed respiratory failure from complications associated with pulmonary surgery. The acuity of the situation played a major role in the patient's current condition. The pulmonary surgery most likely reduced his respiratory function. The effects of anesthesia on his lungs and subsequently the development of complications compounded his situation.

Developmental Considerations There are many age-related developmental considerations affecting respiratory function. Table 38-1 summarizes respiratory variations in the life cycle. Age-related variations in pulse rate and blood pressure can be found in Chapter 24, Table 24-1. Infants The normal infant's chest is small, the airways are short, and aspiration is a potential problem. The respiratory rate is more rapid in infants than at any other age (see Table 38-1). As the alveoli increase in number and size, adequate oxygenation is accomplished at lower respiratory rates. Surfactant is formed in utero between 34 and 36 weeks. An infant born before 34 weeks may not have produced sufficient surfactant, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli. Infants are at risk for upper respiratory tract infections and asthma as a result of exposure to secondhand smoke. Respiratory activity is primarily abdominal in infants. The pulse rate is more rapid in infancy than in adulthood, limiting the infant's ability to increase cardiac output by increasing the heart rate (Kyle & Carman, 2013). Toddlers, Preschoolers, School-Aged Children, and Adolescents The preschool child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections decreases until the child enters daycare or school and is exposed more frequently to pathogens. Young children who are not placed in daycare usually have not had the opportunity to develop antibodies for the variety of viruses and bacteria they may encounter in a school setting. Encourage good hand hygiene and tissue etiquette. Most children at this age have colds or upper respiratory infections, but some have more serious problems of otitis media, bronchitis, and pneumonia. Children in this age group are also at risk for asthma as a result of exposure to secondhand smoke. By the end of late childhood and during adulthood, the immune system is prepared to protect the person from most infections. A child's blood vessels widen and increase in length over time. The blood pressure increases over time, reaching the adult level in adolescence. Older Adults Specific physical changes occur in older adults that are unrelated to any pathology. Refer to the Focus on the Older Adult Box . The tissues and airways of the respiratory tract (including the alveoli) become less elastic. The power of the respiratory and abdominal muscles is reduced, therefore the diaphragm moves less efficiently. The chest is unable to stretch as much, resulting in a decline in maximum inspiration and expiration. Airways collapse more easily. These alterations increase the risk for disease, especially pneumonia and other chest infections. Think back to Joan McIntyre, the 72-year-old woman who is having an exacerbation of her chronic COPD. The nurse needs to incorporate information about age-related changes when planning the patient's care. The nurse also needs to consider that some of these age-related changes may be intensifying some of her symptoms and contributing to her decreased ability to care for herself. The normal aging heart can maintain adequate cardiac output under ordinary circumstances, but may have a limited ability to respond to situations that cause physical or emotional stress (Hinkle & Cheever, 2014). Decreased physical activity, physical deconditioning, decreased elasticity of the blood vessels, and stiffening of the heart valves can lead to a decrease in the overall function of the heart. Medication Considerations Many medications affect the function of the cardiopulmonary system. Patients receiving drugs that affect the central nervous system need to be monitored carefully for respiratory complications. For example, opioids are chemical agents that depress the medullary respiratory center. As a result, the rate and depth of respirations decrease. Be alert for the possibility of respiratory depression or arrest when administering any narcotic or sedative. Other medications decrease heart rate, with the potential to alter the flow of blood to body tissues.

Factors Influencing Mobility

Developmental considerations-age & degree of neuromuscular movement IE., older adult may have convex spine & arthritic joint changes Physical health-illness or trauma may hinder physical health, promote self-care activities. Optimize independence & functioning as a goal Mental health-influences body appearance IE., a depressed person may have limited energy & enthusiasm Lifestyle-active or sedentary IE., sedentary job, watching TV, crafting, sewing; can increase activity such as walking Attitude and values-IE., families who bike together Fatigue and stress-chronic stress depletes energy External factors-weather is a big factor

ORAL CAVITY A physical assessment of the oral cavity involves inspection of the oral cavity and surrounding structures with attention to any unusual odors. When performing the physical assessment of the oral cavity, examine the following: Lips: color, moisture, lumps, ulcers, lesions, and edema Buccal mucosa: color, moisture, lesions, nodules, and bleeding Color of the gums and surface of the gums: lesions, bleeding, edema, and exudate Teeth: any loose, missing, or carious (decayed) teeth. Note the presence of dentures or other orthodontic devices. Tongue: color, symmetry, movement, texture, and lesions Hard and soft palates: intactness, color, patches, lesions, and petechiae Oropharynx: movement of the uvula and condition of tonsils, if present Also, note unusual mouth odors and assess the adequacy of mastication and swallowing. Refer to Chapter 25 for further description of nursing assessment of the oral cavity. When inspecting the oral cavity, observe for any oral problems. These problems may be benign or only mildly annoying to patients, but they may also be life threatening. Identifying the problem and its cause and initiating appropriate treatment are imperative. This may require consultation with a dentist or physician. Dental Caries. The decay of teeth with the formation of cavities is called caries. Caries result from failure to remove plaque, an invisible, destructive, bacterial film that builds up on everyone's teeth and eventually leads to the destruction of tooth enamel. A successful plaque-fighting program includes limiting sweet snacks such as soft drinks, candy, gum, jams, and jellies between meals; thorough cleansing of the teeth; and regular dental checkups. The use of antiplaque fluoride toothpastes, mouth rinses, and flossing also help prevent dental caries. Periodontal Disease. The major cause of tooth loss in adults older than 35 years of age is gum disease. Gingivitis is an inflammation of the gingiva, the tissue that surrounds the teeth. Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums; swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the teeth and gums; pus that appears when gums are pressed; and loose teeth. If unchecked, plaque builds up and, along with dead bacteria, forms hard deposits called tartar at the gum lines. The tartar attacks the fibers that fasten teeth to the gums and eventually attacks bone tissue. The teeth then loosen and fall out. Halitosis, a strong mouth odor or a persistent bad taste in the mouth, may be the first indication of periodontal disease. Regular treatment by a dentist is imperative. Other Oral Problems. Other oral problems that may be observed when inspecting the oral cavity include the following: Stomatitis, an inflammation of the oral mucosa, has numerous causes, such as bacteria, virus, mechanical trauma, irritants, nutritional deficiencies, and systemic infection. Symptoms may include heat, pain, increased flow of saliva, and halitosis. Glossitis, an inflammation of the tongue, can be caused by deficiencies of vitamin B12, folic acid, and iron. Cheilosis, an ulceration and dry scaling of the lips with fissures at the angles of the mouth, is most often caused by vitamin B complex deficiencies (especially riboflavin). Dry oral mucosa may simply be related to dehydration or may be caused by mouth breathing, an alteration in salivary functioning, or certain medications (e.g., anticholinergic drugs). Oral malignancies, appearing as lumps or ulcers, must be distinguished from benign mouth problems because early detection may lead to cure; later detection can lead to radical surgery or death. Teach patients to see their dentist immediately if they notice white or red patches, persistent sores, swelling, bleeding, numbness, or pain in the mouth.

Diagnosing A careful assessment of the adequacy of a patient's hygiene practices and the assessment of the skin, mucous membranes, and other body areas may lead to the development of one or more nursing diagnoses related to alterations in hygiene. Each nursing diagnosis statement identifies a patient problem and suggests expected patient outcomes. The etiology of the problem directs nursing interventions. Problems concerning deficient hygiene are categorized as self-care deficits. Self-Care Deficit diagnoses address specific activities necessary to meet daily needs: feeding, bathing, dressing, and toileting. It is important to identify the cause of these problems correctly. If hygiene is deficient because of insufficient knowledge, health education may quickly remedy the problem. If, however, hygiene is viewed as a low priority by the individual or the person lacks the physical ability to perform hygiene measures, these problems must be addressed before health education can be effective. The following are examples of appropriate nursing diagnoses: Bathing Self-Care Deficit related to postoperative weakness Ineffective Health Maintenance: dental caries related to deficient oral hygiene practices Impaired Oral Mucous Membrane related to malnutrition and dehydration Impaired Social Interaction related to negative body image: acne Examples of these diagnoses, etiologic factors, and defining characteristics appear in Examples of NANDA-I Nursing Diagnoses: Hygiene. In certain situations, a wellness nursing diagnosis may be appropriate as the patient progresses toward an increased level of health awareness and wellness. An example of a wellness diagnosis may be Readiness for Enhanced Self-Care related to oral hygiene practices. Data collected during the nursing assessment may also lead to the identification of a collaborative problem. For example, a patient receiving intravenous chemotherapy is at risk for developing phlebitis, a complication requiring a collaborative approach. Therefore, when caring for a patient receiving intravenous chemotherapy, checking the infusion site every shift is a priority based on the nurse's knowledge that this complication can occur. In addition, careful preparation and administration of the drug according to the manufacturer's instructions, adherence to nursing protocols for the maintenance of intravenous infusions, and ongoing nursing assessment are crucial to help reduce the risk for phlebitis. If redness, warmth, tenderness, or swelling is noted, immediate collaborative intervention is indicated. Similarly, a nurse may notice a 1.5-cm mole with an irregular border on a patient's back during a bath. Prompt reporting of this finding to the physician may lead to the detection and early, successful treatment of the medical diagnosis of malignant melanoma.

Effects of Applying Heat

Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity and increases capillary permeability Reduces muscle tension Helps relieve pain

Effects of Medications on Urine Production and Elimination

Diuretics: prevent reabsorption of water and certain electrolytes in tubules Cholinergic medications: stimulate contraction of detrusor muscle, producing urination Analgesics and tranquilizers: suppress CNS, diminish effectiveness of neural reflex

USING OXYGEN AT HOME

Do not smoke or use open flames within 10 feet of the oxygen source. Do not use electrical equipment near oxygen administration set (e.g., space heaters, blow dryers). Use caution with gas or electric appliances. Ground oxygen concentrators. Secure the oxygen tank in a holder and away from direct sunlight or heat. Allow adequate airflow around the oxygen concentrator (avoid placing flush against the wall). Notify local fire department of the oxygen in the home.

Isotonic exercise involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling. Potential benefits include increased muscle mass, tone, and strength; improved joint mobility; increased cardiac and respiratory function; increased circulation; and increased osteoblastic or bone-building activity. These benefits do not occur when the nurse or family member performs passive range-of-motion exercises for a patient because the patient's muscles do not exert effort. Therefore, although still beneficial, the overall potential benefits are reduced. p. 1049 p. 1050 Isometric exercise involves muscle contraction without shortening (i.e., there is no movement or only a minimum shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as what occurs when holding a Yoga pose. Potential benefits are increased muscle mass, tone, and strength; increased circulation to the exercised body part; and increased osteoblastic activity. Nurses should encourage both isotonic and isometric exercises for hospitalized patients with limited mobility. Isokinetic exercise involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device, which has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights. Using the device, the person takes the muscles and joint through a complete range of motion without stopping, meeting resistance at every point. A continuous passive motion (CPM) device used postoperatively after joint surgery (knee replacement, anterior cruciate ligament [ACL] repair) performs these same type exercises passively for the patient.

Effects of Exercise on Major Body Systems The human body was designed for motion, and regular exercise is necessary for its healthy functioning. The effects of regular exercise on major body systems are explored in the following sections and outlined in Table 32-4. People differ in the benefits they receive from exercise based on the patient's age and overall health status. People who choose inactive lifestyles or who are forced into inactivity by illness or injury are at high risk for serious health problems (see Effects of Immobility on the Body section starting). Cardiovascular System To meet the demand for oxygen created by the rhythmic contraction and relaxation of skeletal muscle groups, the supply of oxygenated blood to skeletal muscle needs to be increased. The cardiovascular system meets this challenge by increasing the heart rate, increasing the contractile strength of the myocardium, and increasing stroke volume (volume of blood ejected), thus increasing cardiac output. Arterial (systolic) blood pressure is increased, and blood is shunted from the nonexercising tissues to the heart and muscles. Exercise also improves venous return because the contracting muscles compress superficial veins and push blood back to the heart against gravity. Over time, regular exercise results in cardiovascular conditioning and produces the following benefits: Increased efficiency of the heart Decreased heart rate and blood pressure Increased blood flow to all body parts Improved venous return Increased circulating fibrinolysin (substance that breaks up small clots) Respiratory System The respiratory and cardiovascular systems work together to make increased oxygen available to the muscles. During exercise, the depth of respiration, respiratory rate, gas exchange at the alveolar level, and rate of carbon dioxide excretion are increased. Over time, regular exercise leads to improved pulmonary functioning. Improvements in pulmonary function include: Improved alveolar ventilation Decreased work of breathing Improved diaphragmatic excursion p. 1050 p. 1051 Musculoskeletal System The rhythmic contraction and relaxation of muscle groups during exercise result in increased muscle mass, tone, strength, and increased joint mobility. The more a person exercises, the more strength the individual has to exercise or work in the future. Regular exercise produces the following benefits: Increased muscle efficiency (strength) and flexibility Increased coordination Reduced bone loss Increased efficiency of nerve impulse transmission Regular exercise is also believed to slow the effects of aging. For example, exercise has been shown to help prevent osteoporosis (the process of bone demineralization) associated with aging. Exercise has also been associated with minimizing bone loss during chemotherapy.

The hospital mattress is firm and generally covered with a water-repellent material that can be easily wiped with a bactericidal solution between patients. A variety of therapeutic beds and mattresses are available to reduce or relieve the effects of pressure on the skin (Fig. 30-9). These are discussed in more detail in Chapter 31. Facility policies usually dictate the availability and use of bed linens. Bed linens include mattress covers, sheets, incontinence pads, pillowcases, blankets, bedspreads, and bath blankets. Changing the bed linen is often not the nurse's responsibility and is delegated. The nurse is responsible for coordinating with assistive personnel to ensure patient comfort. To promote bed comfort, ensure the following before leaving a patient: Linens are clean and free of crumbs and wrinkles. The patient feels comfortably warm. Pressure areas are protected from rough sheets, hem edges, and water-repellent material. This is especially important for patients with a nursing diagnosis of Risk for Impaired Skin Integrity.

Evaluating Performing or assisting with the performance of hygiene measures provides a means of at least daily contact with the patient to determine whether the patient is achieving outcomes related to hygiene and skin care. Indicators that can be used to determine outcome achievement include the following: Level of patient's participation in hygiene program Elimination of, reduction in, or compensation for factors interfering with the patient's independent execution of hygiene measures, for example, weakness, decreased motivation, and lack of knowledge Changes related to specific skin problems, for example, healing of skin lesions, elimination or reduction in causative factors, and independent patient management of the prescribed treatment program

Ensuring Safe Patient Handling and Movement Safe patient handling and transfers involve the use of patient assessment criteria, algorithms for patient handling decisions, and proper use of patient handling equipment. Keep the patient in good alignment and protect the patient from injury while being moved. SAFE PATIENT TRANSFER Follow these recommended guidelines when moving and lifting patients: Assess the patient. Know the patient's medical diagnosis, capabilities, and any movement not allowed. Apply braces or any device the patient wears before helping from bed. Assess the patient's ability to assist with the planned movement. Encourage patients to assist in their own transfers. Encouraging patients to perform tasks that are within their capabilities promotes independence. It is important to eliminate or reduce unnecessary tasks to reduce the risk of injury and increase the patient's self-esteem and mobility levels. Assess the patient's ability to understand instructions and cooperate with the staff to achieve the movement. Box 32-1 outlines general guidelines to consider related to mobility and safe handling of people with dementia. Use an assessment tool to aid in patient assessment and decision-making regarding safe patient handling and movement. An example of a tool can be found in Figure 32-8 . During any patient-transferring task, if any caregiver is required to lift more than 35 pounds of a patient's weight, consider the patient to be fully dependent and use assistive devices for the transfer. Ensure that enough staff is available and present to safely move the patient. See the Reflective Practice box at the beginning of the chapter. Assess the area for clutter, accessibility to the patient, and availability of devices. Remove any obstacles that may make moving and lifting inconvenient. Decide which equipment to use. Step-by-step protocols or algorithms are available to aid decision making to prevent injury to staff and patients (Fig. 32-9). Use handling aids, transfer equipment, and assistive devices (discussed later) whenever possible to help reduce risk of injury to yourself and the patient. Plan carefully what you will do before moving or lifting a patient. Assess the mobility of attached equipment. You may injure the patient or yourself if you have not planned well. If necessary, enlist the support of another caregiver. This reduces the strain on everyone involved. Communicate the plan with staff and the patient to ensure coordinated movement.

Explain to the patient what you plan to do. Then use what abilities the patient has to assist you. This technique often decreases the effort required and the possibility of injury to you. If the patient is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the patient to participate in the move more comfortably. Elevate the bed as necessary so that you are working at a height that is comfortable and safe for you. Lock the wheels of the bed, wheelchair, or stretcher so that they do not slide while you are moving the patient. Be sure the patient is in good body alignment while being moved and lifted to protect the patient from strain and muscle injury. Support the patient's body properly. Avoid grabbing and holding an extremity by its muscles. Avoid friction on the patient's skin during moving. Use friction-reducing devices whenever possible, especially during lateral transfers. Move your body and the patient in a smooth, rhythmic motion. Jerky movements tend to put extra strain on muscles and joints and are uncomfortable for the patient. Use mechanical devices such as lifts, slides, transfer chairs, or gait belts for moving patients. Be sure that you understand how the device operates and that the patient is properly secured and informed of what will occur. If you are not comfortable with the operation of the equipment, obtain assistance from a caregiver who is. Patients who do not understand or are afraid may be unable to cooperate and may cause injury to the staff as well as suffer injury as a result. Ensure that the equipment used meets weight requirements. Bariatric patients (BMI >50) require bariatric transfer aids and equipment. Bariatric transfer aids and equipment are designed to be used with people who are obese.

Postural Reflexes Postural reflexes are the group of reflexes (automatic movements) that maintain body position and equilibrium, whether at rest or during movement. Integrated functioning of the musculoskeletal and nervous systems is essential for body alignment and balance. Postural tonus, the sustained contraction of select skeletal muscles that keeps the human body in an upright position against the force of gravity, depends on the functioning of several postural reflexes: Labyrinthine sense: The sensory organs in the inner ear provide this sense of position, orientation, and movement. Body movement (e.g., changes in head position) stimulates the sensory organs, which then transmit these impulses to the cerebellum. Proprioceptor or kinesthetic sense: This informs the brain of the location of a limb or body part as a result of joint movements stimulating special nerve endings in muscles, tendons, and fascia. Visual or optic reflexes: Visual impressions contribute to posture by alerting the person to spatial relationships with the environment (nearness of ceilings, walls, furniture, condition of floor, etc.). Extensor or stretch reflexes: When extensor muscles are stretched beyond a certain point (e.g., when knees buckle under), their stimulation causes a reflex contraction that aids a person to reestablish erect posture (e.g., straighten the knee).

FACTORS AFFECTING MOVEMENT AND ALIGNMENT Numerous factors, including growth and development, physical health, mental health, lifestyle variables, attitude and values, fatigue and stress, and external factors such as weather, influence a person's posture, movement, and daily activity level. Developmental Considerations A person's age and degree of neuromuscular development markedly influence body proportions, posture, body mass, movements, and reflexes. To promote neuromuscular development in patients of all ages and to facilitate each patient's use of the body to perform self-care activities, nurses need to be familiar with developmental variations in body proportions and neuromuscular development. These variations are presented in Table 32-3 with related nursing assessment priorities and nursing interventions.

HYGIENE PRACTICES Hygienic practices include caring for the skin, hair, nails, mouth, teeth, and perineal area. There are strong links between good hygiene practices and a person's health. Inadequate hygiene practices can contribute to alterations in a person's health. The skin, or integument, is the largest organ of the body and has multiple functions. The integumentary system is made up of the skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including the hair and nails. Chapter 31 provides a description of the anatomy and physiology of the integumentary system and factors that affect skin integrity. Hair is an accessory structure of the skin. Good general health is essential for attractive hair and skin, and cleanliness is a positive influence. Illness affects the hair, especially when endocrine abnormalities, increased body temperature, poor nutrition, or anxiety and worry are present. Changes in the color or condition of the hair shaft are related to changes in hormonal activity or to changes in the blood supply to hair follicles. The nails are an accessory structure of the skin composed of epithelial tissue. Healthy nailbeds are pink, convex, and evenly curved. With certain pathologic conditions, and to some extent with aging, the nails become ridged and areas become concave. Hygienic care includes keeping the nails trimmed and clean. A person's general health influences the health of that person's mouth and teeth, and proper care of the mouth and teeth lends to overall health. There is an established relationship between healthy teeth and a diet sufficient in calcium and phosphorus, along with vitamin D, which is necessary for the body to make use of these minerals. Maintaining good oral hygiene and dental care has several benefits. There is esthetic value in having a clean and healthy mouth. Having one's own teeth in good condition contributes to an intact body image. In addition, the beginning of the digestive process and tasting pleasure are enhanced when the mouth and teeth are in good condition. The perineal area is dark, warm, and often moist, providing conditions that favor bacterial growth. The patient who cannot clean the perineal area needs the nurse's assistance for this important part of personal hygiene. Neglecting perineal cleaning for the patient who cannot provide self-care often results in physical and psychological discomfort for the patient, skin breakdown, and offensive odors.

FACTORS AFFECTING PERSONAL HYGIENE Hygiene activities and practices can protect health and prevent disease. However, hygiene practices vary widely among groups and people. It is important to respect differences in patient hygiene practices and provide care and information in a nonjudgmental manner. The following factors may influence personal hygiene behaviors. Culture It is important to identify cultural variations that could affect a patient's personal hygiene preferences, such as typical bathing habits, and behaviors, such as use of various hygiene-related products. For example, people from some cultures place a high value on personal cleanliness and feel unclean unless they shower or bathe at least once daily. Many consider bathing incomplete without the use of products to reduce or mask normal body odors. Other people often find a weekly bath sufficient and may feel no need to mask normal body odors. Culture may also influence whether bathing is a private or communal activity. Socioeconomic Class A person's socioeconomic class and financial resources often define the hygiene options available to that person. For example, someone renting a room in a boarding house may have limited or no access to a tub or shower and may have limited finances to buy soap, shampoo, shaving cream, and deodorant. Homeless people, who often carry all their belongings in a car or shopping cart, may welcome the warm running water and soap available in roadside or public restrooms. Spiritual Practices Spiritual practices, including religious beliefs, may dictate ceremonial washings and purifications, sometimes as a prelude to prayer or eating. For example, in the Orthodox Jewish tradition, ritual baths are required for women after childbirth and menstruation. In some religions, contact with a deceased person or a deceased animal may make a person "unclean." Other religions dictate that no modern facilities be installed in homes. This would prohibit some people from having running water and toilets in their homes. As a result, they may bathe infrequently. Developmental Level Children learn hygiene practices while growing up. Family practices often dictate hygiene habits, such as morning or evening baths; the frequency of shampooing, tooth brushing, and clothing changes; feelings about nudity; and so on. As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. Bathing frequency commonly decreases as a person ages, possibly due to limitations in mobility and the natural tendency toward drier skin with age. Older adults may experience an increase in skin conditions or problems, increasing the need for education related to hygiene and skin care (Cowdell, 2011). Health State Disease, surgery, or injury may reduce a person's ability to perform hygiene measures or motivation to follow usual hygiene habits. Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash the lower extremities. Illness may also create a demand for new or modified hygiene measures. For example, peripheral vascular complications that often accompany diabetes mellitus require meticulous foot care. The presence of pain with an acute condition or chronic pain can affect a person's ability to perform and/or tolerate personal hygiene measures. Personal Preferences People have different preferences with regard to hygiene practices such as taking a shower versus a tub bath, using bar soap versus liquid soap, and washing to wake oneself or to relax before sleep. A person's self-concept and sexuality also influence personal hygiene practices. For example, in an effort to promote a positive self-image, older adults may use skin care products advertised to prevent wrinkles and diminish signs of aging. Women who are sexually active may use a variety of hygiene products following intercourse to promote cleanliness.

Frequency of Urination The frequency of urination depends on the amount of urine being produced. The more urine produced, the more often voiding is necessary. Except when fluid intake is very large, most healthy people do not void during normal sleeping hours. The first voided urine of the day is usually more concentrated than other urine excreted during the day. Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output, this urine may or may not be used as a specimen for certain tests. Some people normally void small amounts at frequent intervals because they habitually respond to the first early urge to void. This habit usually is meaningless and is not necessarily an indication of disease. On the other hand, if this pattern occurs as a change in urination routine, it may indicate illness. Other people have habits of infrequent voiding. For example, some people go 8 to 12 waking hours or longer without urinating. A habitual low fluid intake or a decrease in the sensation of thirst associated with aging may be one reason. The inaccessibility of toilet facilities owing to travel, work circumstances, or illness, as well as limitations in mobility, can also lead to infrequent urination. People who habitually urinate infrequently develop more urinary tract infections and kidney disorders than those who urinate at least every 3 to 4 hours. The reason for this is believed to be stagnation of urine in the bladder, which serves as a good medium for bacterial growth. Newly occurring infrequent voiding can also indicate a decreased production of urine caused by a kidney or circulatory disorder. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse.

FACTORS AFFECTING URINATION Numerous factors affect the amount and quality of urine produced by the body and the manner in which it is excreted. Developmental Considerations Infants are born without voluntary control of urination and with little ability to concentrate urine. An infant's urine is usually very light in color and without odor. At about 6 weeks of age, the infant's nephrons are able to control reabsorption of fluids in the tubules and effectively concentrate urine. As a child grows, the bladder gradually enlarges, with an increase in capacity. Most children develop urinary control between the ages of 2 and 5 years. Daytime control precedes nighttime control, and girls generally develop control earlier than boys. Older children and adults control urination voluntarily. They seldom wake to void at night because their kidneys are able to concentrate urine and produce less urine at night as a result of decreased renal blood flow. Toilet Training Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function. Toilet training usually begins at about 2 to 3 years of age. Toilet training should not begin until the child is able to: Hold urine for 2 hours Recognize the feeling of bladder fullness Communicate the need to void and control urination until seated on the toilet The child's desire to gain control is also important. Wanting to be like a parent or older sibling often provides adequate motivation. Lifelong attitudes toward urination, the body, and cleanliness may develop during the time of toilet training. Cultures approach toilet training differently. In some cultures, toilet training begins before the child is 1 year old; in other cultures, it may not be considered until the child is near 5 years of age. It is important to recognize cultural influences on this parenting responsibility while promoting flexibility. Reassure parents that any regression of toileting skills that occurs during a child's hospitalization is to be expected and is usually short-lived. Occasional daytime incontinence of urine in a child is usually not a cause for concern. Continued incontinence of urine past the age of toilet training is termed enuresis. Nocturnal enuresis (nighttime bedwetting) usually subsides by 6 years of age (Kyle & Carman, 2013). Effects of Aging Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the following: The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Decreased bladder contractility may lead to urine retention and stasis, which increases the likelihood of urinary tract infection. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Medications prescribed for other health problems in the older adult may interfere with bladder function. For example, diuretics cause increased urine production, resulting in the need for increased urination and possibly urge incontinence (the involuntary loss of urine that occurs soon after feeling an urgent need to void). Sedatives and tranquilizers may diminish awareness of the need to void. People who view themselves as old, powerless, and neglected may cease to value voluntary control over urination and simply find toileting too much bother no matter what the setting. Incontinence may be the result. Consider Midori Morita's 70-year-old husband who has been experiencing urinary problems since his last hospitalization. The nurse would need to keep in mind age-related changes during assessment of Mr. Morita in order to determine if he is experiencing urinary problems related to these changes or if they are due to another cause. Food and Fluid Intake When the body is functioning well, the kidneys help the body maintain a careful balance of fluid intake and output, which should be about equal. When the body is dehydrated, the kidneys reabsorb fluid. The urine produced is more concentrated and is decreased in amount. Conversely, with fluid overload, the kidneys excrete a large quantity of dilute urine. Alcohol produces a diuretic effect by inhibiting the release of antidiuretic hormone, increasing urine production. Foods high in water may increase urine production. Foods and beverages with high sodium content cause sodium and water reabsorption and retention, thereby decreasing urine formation. Certain foods may affect the odor of the urine (asparagus, onions) or its color (beets). Psychological Variables Many individual, family, and sociocultural variables influence a person's normal voiding habits. For some people, voiding is a personal and private act—something one does not talk about. Needing assistance with a bedpan or urinal provokes great embarrassment and anxiety, especially when the bedpan is offered by a nurse of the opposite gender. For others, voiding is a natural act that does not cause embarrassment; these people readily excuse themselves to void whenever the urge presents. Some people who experience stress void smaller amounts of urine at more frequent intervals. Stress can also interfere with the ability to relax the perineal muscles and the external urethral sphincter. When this happens, the person may feel an urge to void, but emptying the bladder completely becomes difficult or impossible. Activity and Muscle Tone Among the many benefits of regular exercise are increased metabolism and optimal urine production and elimination. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma. Pathologic Conditions Certain renal or urologic problems can affect both the quantity and the quality of urine produced. Diseases associated with renal problems include congenital urinary tract abnormalities, polycystic kidney disease, urinary tract infection, urinary calculi (kidney stones), hypertension, diabetes mellitus, gout, and certain connective tissue disorders. Renal failure is a condition in which the kidneys fail to remove metabolic end products from the blood and are unable to regulate fluid, electrolyte, and pH balance. Acute renal failure is a sudden decline in kidney function, and may be caused by conditions such as severe dehydration, anaphylactic shock, pyelonephritis, and ureteral obstruction. Chronic kidney disease is the end result of irreparable damage to the kidneys, developing slowly over many years. Chronic renal failure is caused by conditions such as diabetes, hypertension, and glomerulonephritis. Diseases that reduce physical activity or lead to generalized weakness, such as arthritis, Parkinson's disease, and degenerative joint disease, may interfere with toileting. Cognitive deficits and certain psychiatric problems can interfere with a person's ability or desire to control urination voluntarily. Fever and diaphoresis (profuse perspiration) result in body fluid conservation by the kidneys. Urine production is decreased, and the urine is highly concentrated. Other pathologic conditions, such as congestive heart failure, may lead to fluid retention and decreased urine output. High blood glucose levels, such as with diabetes mellitus, may lead to an increase in urine output secondary to an osmotic diuretic effect. Medications Medications have numerous effects on urine production and elimination. Of gravest concern are the many prescription and nonprescription drugs known to be nephrotoxic (capable of causing kidney damage). Abuse of analgesics, such as aspirin or ibuprofen (Advil), can cause nephrotoxicity; some antibiotics, such as gentamicin, can be nephrotoxic. Diuretics, which commonly are used in the treatment of hypertension and other disorders, prevent the reabsorption of water and certain electrolytes in the tubules. Depending on their strength, they cause moderate to severe increases in production and excretion of dilute urine. Cholinergic medications stimulate contraction of the detrusor muscle and produce urination. Some analgesics and tranquilizers suppress the central nervous system, interfering with urination by diminishing the effectiveness of the neural reflex.

Pressure Ulcers A pressure ulcer is a wound with a localized area of injury to the skin and/or underlying tissue. A pressure ulcer may be an acute wound or a chronic wound. The underlying cause is pressure. Most pressure ulcers develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction (Hess, 2013; National Pressure Ulcer Advisory Panel [NPUAP], 2012a). The terms decubitus ulcer, pressure sore, and bedsore are also used to refer to this type of wound. The term pressure ulcer is considered the most appropriate term because pressure is the most prominent underlying cause. Pressure ulcers are costly in terms of patient discomfort, disfigurement, decreased quality of life, and health care expenditures (Hess, 2013; Baranoski & Ayello, 2012; O'Tuathall & Taqi, 2011). Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. Other significant at-risk populations include people with spinal cord injuries, traumatic brain injuries, or neuromuscular disorders. When pressure ulcers occur, aggressive intervention and treatment can spare the patient unnecessary pain and discomfort, prevent further tissue deterioration, hasten wound healing, and save millions of health care dollars. Factors in Pressure Ulcer Development Pathologic changes at a pressure ulcer site result from blood vessel collapse caused by pressure, usually from body weight. Necrosis eventually occurs, leading to the characteristic ulcer. Two mechanisms contribute to pressure ulcer development: (1) external pressure that compresses blood vessels and (2) friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin. EXTERNAL PRESSURE Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue to cushion damage to the skin. Common sites for pressure ulcers are illustrated in Figure 31-4. Of the susceptible areas, most pressure ulcers occur over the sacrum and coccyx, followed by the trochanter and the calcaneus (heel). The major predisposing factor for a pressure ulcer is external pressure applied over an area, which results in occluded blood capillaries and poor circulation to tissues. Insufficient circulation deprives tissues of oxygen and nutrients, which leads to ischemia (deficiency of blood in a particular area), hypoxia (inadequate amount of oxygen available to cells), edema, inflammation, and, ultimately, necrosis and ulcer formation. A pressure ulcer may form in as little as 1 to 2 hours if the patient has not moved or been repositioned to allow circulation to flow to dependent areas. Patients with casts, orthopedic devices, or support stockings require routine assessment of areas where inadequate circulation may be a contributing factor to the development of a pressure ulcer.

FRICTION AND SHEAR Friction occurs when two surfaces rub against each other. The injury, which resembles an abrasion, also can damage superficial blood vessels directly under the skin. A patient who lies on wrinkled sheets is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often is injured due to friction when patients lift and help move themselves up in bed with the use of their arms and feet. Friction burns can also occur on the back when patients are pulled or slid over sheets while being moved up in bed or transferred onto a stretcher. Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Figure 31-5 illustrates how shearing forces occur. Patients who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from shearing forces. A patient who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a patient who sits in a chair but slides down. Risks for Pressure Ulcer Development In addition to pressure, friction, and shear, a combination of causes contributes to ulcer development. These include immobility, nutrition and hydration, skin moisture, mental status, and age; these factors are addressed here. Additional risk factors are outlined in Box 31-2 . IMMOBILITY Patients who spend long periods of time in bed or seated without shifting their body weight properly are at great risk for developing a pressure ulcer (Hess, 2013). People who are ambulatory usually do not develop this type of injury because no part of the body experiences prolonged pressure. In addition, when asleep, healthy people tend to move about in bed freely. Patients who are unconscious and paralyzed, those with cognitive impairments, or those with other physical limitations such as a fracture, are subject to pressure ulcers if they are allowed to remain in any one position for an extended period. People who are emotionally depressed ordinarily do not move around much, placing them at risk for pressure ulcer formation. Additional factors that cause immobility and may result in this serious problem include surgery and the use of tranquilizers or sedatives.

Hypoxia: inadequate amount of oxygen available to the cells Dyspnea: difficulty breathing Hypoventilation: decreased rate or depth of air movement into the lungs Pt.'s with: Gillian Barre', MD, & COPD at risk Vital for exchange of gases Composed of the heart and the blood vessels The heart is a cone shaped, muscular pump, divided into four hollow chambers The upper chambers, the atria (singular, atrium), receive blood from the veins (the superior and inferior vena cava and the left and right pulmonary veins). The lower chambers, the ventricles, force blood out of the heart through the arteries (the left and right pulmonary arteries and the aorta). alterations in the cardiovascular system include" Dysrhythmia or arrhythmia Myocardial ischemia Angina Myocardial infarction Heart failure

Factors Affecting Cardiopulmonary Functioning and Oxygenation Level of health Developmental considerations Medication considerations Lifestyle considerations Environmental considerations Psychological health considerations

Teaching Wound Care at Home GENERAL GUIDELINES With the increase in ambulatory surgery and earlier discharge of patients from inpatient settings to home care, teaching patients and their families about wound care is important. Although a nurse may be needed to change dressings and provide wound care in complex situations, family members often are taught how to perform the procedure. To provide the continuity of care that is necessary to prevent infection and promote healing, be sure to include teaching about wound care as part of discharge planning and in interactions with home care patients and families. A summary of teaching content is outlined in Teaching Tips 31-1: Wound Care and Healing.

Figure B. Removing staples. p. 993 p. 994 TEACHING TIPS 31-1 WOUND CARE AND HEALING Health Topic Teaching Tip Why is This Important? Supplies Methods for obtaining dressing supplies such as purchasing from pharmacies, drug stores, discount stores, and medical supply stores Considerations for costs and ease of use Investigation about reimbursement by insurance company or other source of health care financing for supplies Patients need to be able to obtain appropriate supplies in order to perform prescribed care. Wound care will not be completed if patient cannot obtain supplies due to financial limitations, inability to obtain supplies, or if wound care plan is complex or not within patient's level of understanding. Infection prevention Signs and symptoms of infection to be immediately reported to the health care provider Need to watch for increased body temperature, flu-like symptoms, red or separated wound edges, increased pain in the wound, and increased drainage that is thick and has a foul odor Wearing of disposable gloves when changing the dressing Hand hygiene before putting on and after removing the gloves Proper methods for disposal of old dressing, such as wrapping old dressing in several layers of newspaper or putting it in a plastic bag before disposal in a trash container Early detection of possible complications promotes early intervention and prevention of further complications. Reduces transmission of microorganisms. Wound healing Importance of eating well-balanced meals that are high in protein and vitamins Need to drink 6 to 8 glasses of fluids each day Rest periods during the day Modifications in activities of daily living and exercise until healing is complete and approval is given by health care provider Promotes optimal healing. PRESSURE ULCER PREVENTION AND CARE Teaching patients and caregivers how to prevent pressure ulcers requires a comprehensive, organized educational effort. Initially, the health care provider presents basic information that explains the terminology, identifies risk factors, explains where and how pressure ulcers develop, and describes various prevention strategies and options. Illustrated instructions written at the level of the learner are a valuable resource. The protocols listed in the Guidelines for Nursing Care boxes serve as a model for development of a teaching plan that incorporates basic principles and targets individuals at risk. As new information becomes available, education for prevention of pressure ulcers requires updating. Involve the patient and caregivers in the plan of care and provide them with a good understanding about causative factors for the pressure ulcer. Instruct them in proper hand hygiene techniques and how to identify the signs and symptoms of infection. Provide the patient and caregivers with simple, easy-to-read instructions. Encourage frequent consultation with the primary health care provider about the progress of wound healing and products used. In addition, ensure that the patient, family, or caregivers understand the need for adequate nutrition to aid in wound healing. Assess the patient's nutritional status and suggest consultation with a dietitian for dietary deficiencies, if necessary. If dressing changes or wound care is painful, teach the patient to use pain medication as prescribed 30 to 60 minutes before the procedure. Reinforce the importance of hand hygiene before and after the dressing change. Documenting Wound Care Documentation related to wound care is an important nursing responsibility. Clear and accurate documentation is essential for communication of wound status and tracking of the progression of healing. Precise documentation contributes to continuity of care, accurate evaluation of care, and appropriate changes in wound care, if necessary. Use a skin and wound assessment tool to accurately record assessment findings and treatment interventions. Photographs of a wound contribute to accurate assessment documentation and measurement of changes over time (Hess, 2013). Figure 31-19 shows an example of a paper skin and wound assessment/documentation tool. Figure 31-20 shows an example of an electronic documentation tool.

Physical Assessment Physical assessment of mobility status includes an assessment of general ease of movement and gait; alignment, joint structure, and function; muscle mass, tone, and strength; and endurance. Table 32-5 provides normal findings and significant alterations. During this assessment, direct attention to both structure and function. The patient's ability to stand, walk, sit up, and grasp are important because these enable the patient to wash, dress, and feed oneself and perform other basic ADLs. Older adults make up an increasingly larger part of the general population. Functional decline (inability to care for oneself by bathing, dressing, toileting, eating, transferring, and/or maintaining continence) in older adults can have severe consequences. Changes in mobility status contribute to this functional decline. Assessment of an older patient's ability to care for oneself is an important part of a mobility assessment. This assessment can provide clues to changes in health and prevent, or prevent further, functional decline. Refer to the accompanying Research in Nursing display regarding functional decline and nursing care. See the accompanying Focus on the Older Adult for an example of a tool to use to measure the older adult's capacity to care for oneself and assist nurses to detect subtle changes in health and prevent functional decline.

GENERAL EASE OF MOVEMENT AND GAIT Begin the physical assessment of an ambulatory patient the moment the patient walks into the room. Voluntarily controlled, fluid, and coordinated body movements are keys to the integrated functioning of the skeletal, muscular, and nervous systems. Note whether the patient's body movements are quick and sure or slow and deliberate. These observations communicate both a sense of the person's emotional status and self-care abilities. Common involuntary movements that may be observed include tremors (continuous quivering of whole muscles or major portions of a muscle) and tics (irregularly occurring spasmodic movements such as winking, grimacing, or shoulder shrugging). Note the gait of the patient who is ambulatory. The patient's movements while walking should be coordinated and the posture well balanced. The arms should swing freely in a rhythm alternating with the legs. Figure 32-4 illustrates stance and swing, the two phases of the normal gait. The heel of the right foot strikes the ground (stance), while the toe of the left foot pushes off and leaves the ground, moving the leg from behind to in front of the body (swing). While one leg is in the stance phase, the other is in the swing phase. Detection of gait abnormalities is important because gait abnormalities may place the person at risk for injury and may indicate a neuromuscular disorder or intoxication. Note whether the patient uses any assistive devices such as a wheelchair, brace, cane, walker, or crutches to aid in ambulation. Also, determine whether the assistive device is meeting the patient's needs, if it is required for mobility, and if it is being used safely. ALIGNMENT Correct body alignment permits optimal musculoskeletal balance and operation, and promotes optimal physiologic functioning. Deviations in body alignment may result from chronic poor posture, trauma, muscle damage, or nerve dysfunction. Pain, fatigue, and a person's mental and emotional status may also influence alignment. Observe alignment when a patient is standing, sitting, or lying (Fig. 32-5). Note whether the patient is able to maintain correct alignment independently. A patient's body is in correct body alignment in the standing position when: The head is held erect and in the midline The face is in the forward position, in the same direction as the feet The chest is held upward and forward The spinal column is upright, and the curves of the spine are within normal limits The abdominal muscles are held upward, with the abdomen comfortably tucked in and the buttocks downward The arms hang comfortably at the sides The knees are extended in a slightly flexed position—not bent or hyperextended in the knee-locked position The feet are at right angles to the lower legs The line of gravity goes through the midline, from the middle of the forehead to a midpoint between the feet; laterally the line of gravity runs vertically from the middle of the skull to the posterior of the foot The base of support is on the soles of the feet, and weight is distributed through the soles and heels Correct body alignment when sitting is similar to correct alignment when standing except that the hips are flexed, the knees are flexed and not crossed, and the base of support is on the buttocks and upper thighs. The weight is distributed evenly on the buttocks and thighs. The thighs are parallel and the popliteal area should be free of the edge of the chair to prevent circulatory stasis and possible nerve injury. The patient's forearms are supported either on the armrests, lap, or on a flat surface in front of the chair.

Using Personal Protective Equipment and Supplies

Gloves. Gloves, not a substitute for good hand hygiene, are worn only once and discarded appropriately according to agency policy. Then hands are thoroughly decontaminated with meticulous hand hygiene. When nursing care activities do not involve the possibility of soiling the hands with body fluids, gloves are not necessary. Activities such as turning a patient, feeding a patient, taking vital signs, and changing IV fluid bags do not require the use of gloves as long as the potential contact with body fluids is not present. However, when there is a possibility of soiling the hands with body fluids, gloves must be worn. Each patient interaction requires a clean pair of gloves. Some care activities for an individual patient may necessitate changing gloves more than once. Gloves should always be changed prior to moving from a contaminated task to a clean one. While wearing gloves, never leave the patient's room (unless transporting a contaminated item or a patient requiring transmission-based precautions), never write in the patient's chart, and never use the computer keyboard or telephone in the nurses' station. Also, health care workers should not touch their pagers or cell phones without performing good hand hygiene first. Wearing gloves does not eliminate the need for proper hand hygiene. In reality, the warmth and moisture inside gloves create an ideal environment for bacteria to multiply, making it even more important to perform good hand hygiene before and after using gloves. Research also indicates that gloving does not guarantee complete protection from infectious organisms. Gloves provide a barrier but are not impenetrable. It has been shown that many times glove-barrier failure goes undetected by the health care worker. Double gloving (putting on two gloves on one hand) is recommended if the health care worker is involved in a procedure during which exposure to blood or body fluids is expected, such as in an OR setting. Approximately 2% to 17% of health care workers and less than 1% of the general population are sensitized to traditional latex, with reactions ranging from local skin reactions to urticaria (hives) to systemic anaphylaxis, an exaggerated allergic reaction that can result in death (Behrman & Schraga, 2011; Altrich, 2012). The cornstarch powder or talc used to make gloves easier to put on is a major causative factor in any latex allergy. The powder binds with the latex protein and becomes airborne, where it can remain for 5 to 12 hours after health care workers don or remove gloves. Powder particles may be inhaled or absorbed into skin or mucous membranes or enter the bloodstream. Repeated exposures have been shown to lead to a latex sensitivity. If the person continues to be exposed to latex after a sensitivity has developed, the person may demonstrate signs of a latex allergy. At present, there is no cure for a latex allergy. The National Institute for Occupational Safety and Health (NIOSH) recommends that nonlatex gloves or powder-free, low-allergen latex gloves (if latex gloves are used) be available for use. Research has indicated that using powder-free latex gloves resulted in a significant reduction in latex sensitivity and there was also a 25% reduction in latex sensitivity when latex gloves were replaced with nonlatex gloves (Kelly et al., 2011). Also, according to the OSHA Bloodborne Pathogens Standard, employers must provide alternative gloves if necessary. Because a totally "latex-free" environment is considered unattainable given the ubiquitous nature of latex, a "latex-safe" health care environment is essential for patients and health care providers with a latex allergy. All health care facilities are required to have a written policy that identifies how to deal with latex-sensitive employees and patients. Awareness of an allergy to latex is also important for safe home care. Nurses need to ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. Box 23-3 summarizes information on latex allergy for health care personnel and patients.

Devices to Apply Heat

Hot water bags or bottles---dontmicrowave!! Electric heating pads Aquathermia pads Hot packs Moist heat Sitz baths Warm soaks

Phases of Wound Healing The wound healing process can be divided into three or four phases, depending on the reference. In this chapter, four phases will be discussed: hemostasis, inflammation, proliferation, and maturation. These four phases systematically lead to repair of the injury (Baranoski & Ayello, 2013; Hess, 2013). If three stages are identified, hemostasis is included as part of the inflammatory stage. HEMOSTASIS Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing.

INFLAMMATORY PHASE The inflammatory phase follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. PROLIFERATION PHASE The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. Fibroblasts form fibrin that stretches through the clot. A thin layer of epithelial cells forms across the wound, and blood flow across the wound is reinstituted. The new tissue, called granulation tissue, forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily. In wounds that heal by first intention, epidermal cells seal the wound within 24 to 48 hours, thus the granulation tissue is not visible. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. Depending on the size of the wound, collagen deposit continues for several weeks or even years. By the end of the second week following the injury, the majority of white blood cells have left the wound area, and the wound is lighter in color. The systemic symptoms now typically disappear. During this phase, adequate nutrition and oxygenation, as well as prevention of strain on the suture line, are important patient care considerations. Wounds that heal by secondary intention eventually follow the same process but take longer to heal and form more scar tissue (Grossman, 2014). Granulation tissue fills the wound and is then covered by skin cells that grow over the granulation tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of granulation tissue formed. MATURATION PHASE The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses the blood vessels in the healing wound, so that the scar, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line. Scar tissue is less elastic than uninjured tissue. The strength of the scar tissue remains less than that of normal tissue, even many years following injury and it is never fully restored (Baranoski & Ayello, 2012, p. 91). Wounds that heal by secondary intention take longer to remodel and form a scar smaller than the original wound. If the scar is over a joint or other body structure, it may limit movement and cause disability.

SHAMPOOING THE HAIR The hair, which is exposed to the same dirt and oil as the skin, requires washing as often as necessary to keep it clean. Wash the comb and brush each time the hair is washed and as frequently as necessary between shampoos. Many health agencies have beauticians and barbers to assist with hair care, including shampooing, but this does not relieve the nurse of the responsibility. Before shampooing the hair, brush or have the patient brush and comb the hair well to stimulate the scalp and undo tangled hair. The patient may then shampoo the hair while showering, if able. In some settings, a medical order is required for shampooing a patient's hair. For patients on bed rest—whether at home or in the hospital—who are unable to shampoo their own hair, use the following as a guide: Prepare several pitchers of water of a suitably warm temperature for a thorough washing and rinsing, shampoo, one or two towels for drying, and a receptacle to receive wash and rinse water. Place a protective pad and a plastic hair-washing tray if one is available (Fig. 30-6) under the head. Place the patient in a position over the pad so that water drainage is directed into the receptacle. Wet the hair, apply shampoo, and massage the scalp well while washing the hair. Rinse the hair and reapply shampoo for a second washing, if indicated. Rinse the hair thoroughly. Apply conditioner if requested or if the scalp appears dry. Dry the hair as quickly as possible to prevent the patient from becoming chilled, and arrange the hair according to the patient's preference.

If regular shampooing is inappropriate or is contraindicated by the patient's condition, other products for use at the bedside are available. Products for use at the bedside do not require rinsing and are available as foams, concentrates, and dry powders. After application of a foam or concentrate cleaner, lather the product and then towel-dry the hair. Comb and style the hair as per the patient's preference. Keep the head covered with a towel until the hair dries to help minimize chilling of the patient. Alternately, shampoo caps are available, and are being used with increasing frequency (Figure 30-7). These commercially prepared, disposable caps contain a rinseless shampoo product. Warm the cap in the microwave or store it in a warmer until use. Place the cap on the patient's head and massage the hair and scalp through the cap, to lather the shampoo. After shampooing for the manufacturer's suggested length of time, remove and discard the cap. Finally, towel dry the patient's hair and style it according to the patient's preference. SHAVING Grooming of body hair other than hair on the head can be an important part of a patient's self-esteem and well-being. Patients with beards or mustaches may require nursing assistance to keep the beard and mustache clean. Never trim or shave a patient's beard or mustache without the patient's consent. Female patients may require assistance with shaving underarm and leg hair, depending on the patient's personal preference and abilities. Blade razors tend to give a closer shave than do electric razors, but many patients find electric razors more convenient and practical. Electric shavers are usually recommended when the patient is receiving anticoagulant therapy or has a bleeding disorder and are especially convenient for ill and bedridden patients. Shaving after a warm bath or shower softens the hair, making the process easier. The technique for shaving patients who cannot shave themselves is described in Guidelines for Nursing Care 30-1

Benefits of Exercise to Respiratory System

Improved alveolar ventilation Decreased work of breathing Improved diaphragmatic excursion

Aseptic Technique

Includes all activities to prevent or break the chain of infection Two categories Medical asepsis: clean technique-clean catch urinalysis specimen Surgical asepsis: sterile technique-inserting an indwelling Foley catheter

Benefits of Exercise to Musculoskeletal System

Increased muscle efficiency (strength) and flexibility Increased coordination people who do yoga tend to fall better & not break as many bones as people who do not do yoga Reduced bone loss-keeps the calcium in the bones Increased efficiency of nerve impulse transmission

Factors Essential to Normal Functioning of the Respiratory System

Integrity of the airway system to transport air to and from lungs Properly functioning alveolar system in lungs Oxygenates venous blood Removes carbon dioxide from blood Properly functioning cardiovascular and hematologic systems Carry nutrients and wastes to and from body cells

Bones Classified by Shape Long bones: upper and lower extremities Short bones: wrist and ankle Flat bones: ribs and skull bones Irregular bones: spinal column and jaw

Joint Movements Abduction-lateral movement away from midline IE., arm moved away from body Adduction-lateral movement toward from midline IE., arm moved toward the body Circumduction-circular motions Flexion-state of being bent Extension-state of being in a straight line Hyperextension-exaggerated extension IE., looking at the ceiling Dorsiflexion-backward extension of the hand or foot IE., toes pointing toward knee Plantar flexion-flexion of the foot IE., drop foot

Respiratory Activity in the Infant

Lungs are transformed from fluid-filled structures to air-filled organs. The infant's chest is small, airways are short, and aspiration is a potential problem. Respiratory rate is rapid and respiratory activity is primarily abdominal. Synthetic surfactant can be given to the infant to reopen alveoli. Crackles heard at the end of deep respiration are normal.

JOINT STRUCTURE AND FUNCTION Use inspection and palpation to examine joints, their range of motion, and the surrounding tissue. Range of motion is the maximum degree of movement of which a joint is normally capable. (Skill 32-6 on pp. 1105-1113 illustrates the range of motion of selected joints.) When assessing joint mobility, note the following: Size, shape, color, and symmetry of joints: note any masses, deformities, or muscle atrophy Range of motion of each joint Any limitation in the normal range of motion or any unusual increase in the mobility of a joint (instability); range of motion varies among people and decreases with aging Muscle strength when performing range-of-motion exercises against resistance Any swelling, heat, tenderness, pain, nodules, or crepitation (palpable or audible crunching or grating sensation produced by motion of the joint) Comparison of findings in one joint with those of the opposite joint

MUSCLE MASS, TONE, AND STRENGTH Adequate skeletal muscle mass, tone, and strength are prerequisites to appropriate body movement and work performance. Mass refers to muscle size. Assess muscle mass throughout the body and compare one muscle group to another using tape measurements. Hypertrophy refers to increased muscle mass resulting from exercise or training. Atrophy describes muscle mass that is decreased through disuse or neurologic impairment. Patients experiencing muscle wasting as a result of a chronic disease process such as cancer may report visible changes in muscle mass. The slight residual tension that remains in a resting normal muscle with an intact nerve supply is termed muscle tone. Assess muscle tone by flexing and extending the elbow or knee and noting the degree of resistance to these movements. Decreased tone, also known as hypotonicity or flaccidity, results from disuse or neurologic impairments, and is described as a weakness or paralysis of the involved area. Spasticity, or hypertonicity, increased tone that interferes with movement, is also caused by neurologic impairments, and is often described as a stiffness, tightness, or pulling of the muscle. Muscle strength varies greatly from one person to another and even within the same person, and is affected by muscle use. Test muscle strength by asking the patient to move actively against resistance. For example, instruct the patient to push the examiner's palms apart or to push the foot against the examiner's palm. When comparing muscle groups, remember that a person's dominant side tends to be stronger. Impaired muscle strength or weakness is termed paresis. The absence of strength secondary to nervous impairment is called paralysis. Hemiparesis refers to weakness of one half of the body, and hemiplegia is paralysis of one half of the body. Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs. Assess whether the patient's muscle strength is adequate for the performance of tasks the patient deems necessary. For example, a patient whose primary means of ambulation is a wheelchair requires upper body strength.

Turning the Patient in Bed Frequently, a patient cannot turn in bed without assistance. Nurses need to use their knowledge of correct alignment to turn the patient from the back onto the side, from the back onto the abdomen, and from the abdomen onto the back. A suggested decision-making strategy is outlined in Figure 32-9 (VISN 8, 2009). If the patient is unable to assist with movement, a full-body sling and two or more caregivers are required. When turning the patient, the bed should be at the height of the caregivers' elbows to ensure a comfortable working height. The technique for turning a patient in bed is described and illustrated in Skill 32-2. Mastering this turning technique helps nurses adhere to an every-2-hour turn schedule for an immobile patient. CONSIDER Mrs. Nguyen, the older woman who will be caring for her husband at home, and Kelsi Lester, the 10-year-old girl who is unconscious. Teaching Mrs. Nguyen how to properly turn her husband in bed and assist him to get out of bed will be crucial to minimize stress and strain on her back and legs. Turning Kelsi every 2 hours would be essential to prevent alterations in her skin integrity. Moving a Patient Up in Bed A suggested decision-making strategy is outlined in Figure 32-9 (VISN 8, 2009). The first decision point is whether the patient can assist. If the patient is fully able, caregiver assistance is not needed and the patient may or may not use a positioning aid. If the patient is fully able to assist in moving up in the bed, allow the patient to complete the movement independently, with safe supervision. The patient assists movement either by pushing with the feet flat against the bed or by using an overbed trapeze. If only partially able, encourage the patient to assist using a positioning aid or cues. If the patient is less than 200 pounds, use a friction-reducing device and two to three caregivers. If the patient is over 200 pounds, use a friction-reducing device and at least three caregivers. If the patient is not able to assist, use a full-body sling lift and two or more caregivers. Friction-reducing sheets or other devices should be used to minimize shearing forces and work effort. A technique used to move a patient up in bed when the patient is partially able to assist and two caregivers are available is described and illustrated in Skill 32-3. Moving a Patient From Bed to Stretcher Considerable care must be taken when moving a patient from a bed to a stretcher, or vice versa, to prevent injury to the patient and caregivers. A suggested decision-making strategy is outlined in Figure 32-20 (VISN 8, 2009).If the patient is fully able to assist in the transfer, allow the patient to complete the movement independently, with supervision for safety. If the patient is partially able or not able to assist at all and weighs less than 200 pounds, use a friction-reducing device. If the patient weighs more than 200 pounds, a friction-reducing device and three caregivers are required. If the patient is unconscious or weakened, additional nurses are needed to support the extremities and the head. These actions are described in Skill 32-4. When returning the patient to the bed from the stretcher, the same techniques are used.

Moving a Patient From Bed to Chair Safety and comfort are key concerns when assisting the patient out of bed. Preliminary assessment of vital signs provides baseline data; subsequent recordings determine the effect of this activity on the patient. The position of the nurse when preparing to move the patient and during placement of the chair are critical elements in the transfer. The patient's apparel should be sufficient to prevent embarrassment and provide warmth yet not impede movement. Assess the patient's ability to bear weight when determining the appropriate method for transfer and the appropriate transfer aid. Patients who are unable to bear partial weight or full weight or who are uncooperative should be transferred using a full-body sling lift with two caregivers. The technique for assisting a patient to transfer from bed to chair is described in Skill 32-5. Recall Maggie Wyatt, the woman being discharged with an external fixation device in place. In assessing the situation, the nurse would need to determine how much Maggie can help with the transfer. From there, the nurse would then determine if another person is needed to help transfer Maggie. Realizing that the device is heavy and cumbersome, the nurse would determine that most likely two persons are needed. Logrolling a Patient When a patient has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the patient. Two or three nurses can accomplish this safely by logrolling a patient (Fig. 32-21). Do not try to logroll the patient without enough help. Do not twist the patient's head, spine, shoulders, knees, or hips while logrolling. Refer to the accompanying Guidelines for Nursing Care 32-1: Logrolling a Patient. Assisting with Range-of-Motion Exercises Range of motion is the complete extent of movement of which a joint is normally capable. Engaging in routine tasks—such as bathing, eating, dressing, and writing—helps use muscle groups that keep many joints in effective range of motion. When all or some of one's normal ADLs are impossible, it is important to give attention to the joints not being used or to those that are limited in their use. FIGURE 32-21. Logrolling by two or three nurses aids in turning a patient with a spinal injury. One nurse stands on the side, holding the drawsheet taut. The patient is moved toward the other two nurses on a predetermined signal. Unless contraindicated, encourage active, active-assistive, or passive range-of-motion exercises regularly and include them in the patient's plan of care. In active exercise, the patient independently moves joints through their full range of motion (isotonic exercise). In active-assistive exercise, the nurse may provide minimal support, whereas in passive exercise, the patient is unable to move independently, and the nurse moves each joint through its range of motion. Both active and passive exercises improve joint mobility and increase circulation to the affected part, but only active exercise increases muscle mass, tone, and strength and improves cardiac and respiratory functioning. Thus, exercises should be as active as the patient's physical condition permits. It is also helpful to teach isometric exercises to patients to increase muscle mass, tone, and strength. Include directives in the nursing plan of care for range-of-motion exercises, specifying what, how, and when, so that all who care for the patient observe the same routine. In some institutions, nurses work closely with physiotherapists in designing and implementing exercise programs. Refer to Table 32-2 for an explanation of terms related to movement

The strength and flexibility of the skeletal system also depend on ligaments, tendons, and cartilage. Ligaments are tough, fibrous bands of connective tissue that bind joints together and connect bones and cartilage. Tendons are strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone. Cartilage is hard, nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx. Cartilage in joints functions as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. Fat may also provide padding at joints. Muscular System The muscular system is composed of three types of muscles: (1) skeletal, (2) cardiac, and (3) smooth or visceral muscles. Muscle tissue produces movement by contraction of its cells. Skeletal muscle works with tendons and bones to move the body. Cardiac muscle forms the bulk of the heart and produces the contractions that create the heartbeat. Smooth muscle forms the walls of the hollow organs (such as the stomach and intestines), and is in the walls of blood vessels and other hollow tubes (such as ureters) that connect internal organs. Skeletal muscle is discussed here in relation to the topic of activity. The skeletal muscle system includes the skeletal muscle tissue and connective tissue that comprise individual muscle organs, such as the biceps. Bones and joints provide form to the body and serve as the levers and fulcrums that make body movement possible. Movement results from a skeletal muscle contracting and exerting force on a tendon, which, in turn, pulls on a bone. Muscles have two differing points of attachment: (1) the attachment of a muscle to the more stationary bone is called the point of origin, and (2) the attachment to the more movable bone is the point of insertion. Between these two points is the fleshy "belly" of the muscle. The excitability, contractility, extensibility, and elasticity of muscles enable them to perform four important functions for the body through contraction: Motion: Skeletal muscle contractions pull on tendons and move the bones, creating movements as simple as extending the arm to as highly coordinated as swimming or skiing. Maintenance of posture: Skeletal muscle contractions hold the body in stationary positions. Support: Skeletal muscles support soft tissues in the abdominal wall and floor of the pelvic cavity. Heat production: Skeletal muscle contractions produce heat and help maintain body temperature.

Nervous System The skeletal and muscular systems cannot produce purposeful movement without a functioning nervous system. Nerve impulses stimulate muscles to contract. More specifically: Nerve cells called neurons conduct impulses from one part of the body to another. The afferent neurons convey information from receptors in the periphery of the body to the central nervous system (CNS; e.g., light pressure on nose). This information is processed by the CNS, leading to a response (e.g., "There is a fly on my nose. I want to brush it off."). The efferent neurons convey the response from the CNS to skeletal muscles by way of the somatic nervous system (e.g., muscles in the arm, wrist, and hand contract, and the fingers brush the fly from the nose). Normal Movement and Alignment The following concepts are an important part of normal movement and musculoskeletal functioning, and contribute to a person's overall well-being. Body Alignment or Posture Good posture, or proper body alignment, is the alignment of body parts that permits optimal musculoskeletal balance and operation, and promotes healthy physiologic functioning. A person in correct alignment is experiencing no undue strain on the joints, muscles, tendons, or ligaments while balance is maintained.

Managing Chest Tubes Patients with fluid ( pleural effusion), blood ( hemothorax), or air ( pneumothorax) in the pleural space require a chest tube to drain these substances and allow the compressed lung to re-expand. A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted in the pleural space. Once inserted, the tube is secured with a suture and tape, covered with an airtight dressing, and attached to a drainage system that may or may not be attached to suction. Other components of the system may include a closed water-seal drainage system that prevents air from re-entering the chest once it has escaped and a suction control chamber that prevents excess suction pressure from being applied to the pleural cavity. The suction chamber may be a water-filled or a dry chamber. A water-filled suction chamber is regulated by the amount of water in the chamber, whereas dry suction has a one-way mechanical valve system that allows air to leave the chest and prevents air from moving back into the chest and is automatically regulated to changes in the patient's pleural pressure. Most health care agencies use a molded plastic, three-compartment disposable chest drainage unit for management of chest tubes (Fig. 38-14). There are also portable drainage systems that utilize gravity for drainage. Table 38-6 compares different types of chest drainage systems. The type of drainage determines the placement of the chest tube. When air is to be drained, the tube is placed higher in the chest. If fluid needs to be drained, the tube is inserted lower in the lung because fluids settle at the base of the lung. Nursing responsibilities include assisting with insertion and removal of a chest tube. Once the tube is in place, monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system. Guidelines for monitoring a patient with a chest tube are shown in Guidelines for Nursing Care 38-3. FIGURE 38-14. A chest drainage system attached to a patient. (Photo by Rick Brady.) Removal of chest tubes can be a painful and stressful process for patients. Whenever possible, administer analgesics prior to the tube removal, at a sufficient interval to allow for the medication to take effect, based on the medication prescribed. The application of cold to the chest prior to removal has also been shown to decrease patient discomfort during chest tube removal. Refer to the accompanying Research in Nursing box. Nursing responsibilities related to chest tube removal also include providing emotional support for the patient, as well as monitoring the patient's status after removal. Monitor the patient's respiratory status, vital signs, pain, and site dressing.

OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS An oropharyngeal or nasopharyngeal airway is a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth (oro) or nose (naso) in a patient who is breathing spontaneously. The oropharyngeal airway is used to keep the tongue clear of the airway. It is often used for postoperative patients until they regain consciousness. Once the patient regains consciousness, remove the oropharyngeal airway. Do not use tape to hold the airway in place because the patient should be able to expel the airway once he or she becomes alert. A nasopharyngeal airway is inserted through the nare and protrudes into the back of the pharynx. The nasal trumpet allows for frequent nasotracheal suctioning without trauma to the nasal passageway. This airway may be left in place, without much discomfort, in the patient who is alert and conscious. Techniques to use when inserting an artificial airway are outlined in Guidelines for Nursing Care 38-4. ENDOTRACHEAL TUBE An endotracheal tube is a polyvinylchloride airway that is inserted through the nose or mouth into the trachea, using a laryngoscope as a guide. It is used to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstructions (e.g., tongue or tracheal edema). Although uncomfortable and easy to manipulate with the tongue, orotracheal insertion is often the method of choice, especially in an emergency, because insertion is easier and a larger tube can be used, making ventilation easier. Placement of the tube through the nasotracheal route, although tolerated better by patients, is more difficult and requires the use of a narrower tube. Most commonly, a cuffed endotracheal tube is used (Fig. 38-15). This type of tube prevents air leakage and bronchial aspiration of foreign material while allowing more precise control of oxygen and mechanical ventilation. However, careful monitoring of cuff pressure is necessary to decrease the risk for tracheal necrosis. The smallest amount of air that results in an airtight seal between the trachea and the tube is desirable and less likely to result in complications. Patients with endotracheal tubes often require suctioning via the endotracheal tube to remove secretions from the airway. Refer to the discussion related to tracheal suctioning later in the chapter. Routine oral suctioning to aspirate secretions that accumulate above the cuff of the tube is also necessary to reduce the risk of pneumonia (Sole, Penoyer, Bennett, Bertrand, & Talbert, 2011). Consider Mr. Kim, the 57-year-old man receiving oxygen therapy and mechanical ventilation via an endotracheal tube. When developing the patient's plan of care, the nurse needs to assess him closely and frequently for signs and symptoms indicating an increase in secretions. If secretions increase, the nurse needs to suction the patient to maintain a patent airway and minimize his risk for hypoxemia and infection. TRACHEOSTOMY A tracheostomy tube is inserted for a variety of reasons. It may be used to replace an endotracheal tube, to provide a method for mechanical ventilation of the patient, to bypass an upper airway obstruction, or to remove tracheobronchial secretions. Tracheostomy Procedure and Tubes. A tracheostomy is an artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring. A curved tube, called a tracheostomy tube, is inserted through the opening. It is inserted in the operating room or intensive care unit under sterile conditions using local anesthesia, and can be temporary or permanent.

OXYGEN DELIVERY SYSTEMS Oxygen can be administered by many different delivery systems: nasal cannula, nasopharyngeal catheter, transtracheal catheter, simple mask, partial rebreather mask, nonrebreather mask, Venturi mask, and tent. Table 38-5 compares several oxygen delivery systems. Administering Oxygen via Nasal Cannula Click to Show Nasal Cannula. A nasal cannula, also called nasal prongs, is the most commonly used oxygen delivery device. The cannula is a disposable plastic device with two protruding prongs that are inserted into the nostrils. The cannula is connected to an oxygen source with a flow meter and, many times, a humidifier. The cannula does not impede eating or speaking and is used easily in the home. Disadvantages of this system are that it can be dislodged easily and can cause dryness of the nasal mucosa. In addition, if a patient breathes through the mouth, it is difficult to determine the amount of oxygen the patient is actually receiving. Skill 38-3 describes oxygen administration by nasal cannula. Nasopharyngeal Catheter. A nasopharyngeal catheter is another efficient means for administering oxygen, but it is infrequently used because it is uncomfortable for the patient and may cause trauma to respiratory mucous membranes. It is inserted into the nose through one nostril, with the end of the catheter resting in the oropharynx. It is important to remove the catheter for cleaning and change it to the other nostril every 12 to 24 hours (Eastwood, Gardner, & O'Connell, 2007). Gastric distention often occurs because the gas flow can be misdirected into the stomach. Face masks. Disposable and reusable face masks are available. Fit the mask carefully to the patient's face to avoid leakage of oxygen. It should be comfortably snug but not tight against the face. The most commonly used types of masks are the simple face mask, the partial rebreather mask, the nonrebreather mask, and the Venturi mask. Skill 38-4 describes the actions and rationales involved in using face masks. The simple face mask is connected to oxygen tubing, a humidifier, and a flow meter, just like the nasal cannula. This mask has vents on its sides that allow room air to leak in at many places, thereby diluting the source oxygen. The vents also allow exhaled carbon dioxide to escape. Often a simple mask is used when an increased delivery of oxygen is needed for short periods (e.g., less than 12 hours). The mask should fit closely to the face to deliver this higher concentration of oxygen effectively. Patients may have difficulty keeping the mask in position over the nose and mouth, and because of this pressure and the presence of moisture, skin breakdown is a possibility. Eating or talking with the mask in place can be difficult. Because of the risk of retaining carbon dioxide, never apply the simple face mask with a delivery flow rate of less than 5 liters per minute. The partial rebreather mask is similar to a simple face mask, but is equipped with a reservoir bag for the collection of the first part of the patient's exhaled air. The remaining exhaled air exits through vents. The air in the reservoir is mixed with 100% oxygen for the next inhalation. Thus, the patient rebreathes about one-third of the expired air from the reservoir bag. This type of mask permits the conservation of oxygen. An additional advantage is that the patient can inhale room air through openings in the mask if the oxygen supply is briefly interrupted. The disadvantages are those of any mask: eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. Monitor the reservoir bag carefully. It should deflate slightly with inspiration; if it deflates completely, the flow rate should be increased until only a slight deflation is noted. The nonrebreather mask delivers the highest concentration of oxygen via a mask to a spontaneously breathing patient. It is similar to the partial rebreather mask except that two one-way valves prevent the patient from rebreathing exhaled air. The reservoir bag is filled with oxygen that enters the mask on inspiration. Exhaled air escapes through side vents. A malfunction of the bag could cause carbon dioxide buildup and suffocation. This mask can also be used to administer other gases, such as heliox. Heliox is a mixture of helium and oxygen, used to reduce the work of breathing, deliver aerosols, and reduce fear and anxiety for patients in respiratory distress. Helium has a very low density that allows it to flow easily into narrow or twisty air passages, delivering nebulized medications into the lower airways. In addition, carbon dioxide diffuses through helium at four to five times the rate it diffuses through room air, thus it can exit the body faster and easier (Hess, MacIntyre, Mishoe, Galvin, & Adams, 2012; Pruitt, 2007a). The Venturi mask gets its name from the Venturi effect, which allows the mask to deliver the most precise concentrations of oxygen. This mask has a large tube with an oxygen inlet. As the tube narrows, the pressure drops, causing air to be pulled in through side ports. These ports are adjusted according to the prescription for oxygen concentration. Be sure that the ports are always open. If these are occluded by linens, clothing, or a patient rolling on the mask, the oxygen delivered might be at an unsafe (too high or too low) concentration. Oxygen Tent. Oxygen also can be administered by way of an oxygen tent. An oxygen tent is a light, portable structure made of clear plastic and attached to a motor-driven unit. The motor helps to circulate and cool the air in the tent. The cooling device functions like an electric refrigeration unit. A thermostat in the unit keeps the tent at the temperature considered most comfortable for the patient. The tent fits either over the top part of the bed so that the patient's head and thorax are inside, or over the entire bed. It has side openings through which nursing care can be administered. An oxygen tent is commonly used with children who need a cool and highly humidified airflow (e.g., children with pneumonia). Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, it is rarely used with other patients. In addition, it is difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50% (Kyle & Carman, 2013). The humidified airflow quickly creates moisture, leading to damp clothing and linens, and, possibly, hypothermia. Therefore, frequent assessment of the child's temperature, pajamas, and bedding is necessary.

OXYGEN THERAPY IN THE HOME Liquid oxygen and oxygen concentrators, rather than cylinders, are used more commonly in the home setting. Liquid oxygen is kept inside a small thermal container that can be refilled from a larger storage tank kept in the home. An oxygen concentrator removes nitrogen from the room air and concentrates the oxygen left in the air. The oxygen concentrator needs a power source such as an electrical outlet or battery pack. Oxygen concentrators are portable, cost-effective, and easy to use but cannot deliver oxygen flow at greater than 5 L/min (fraction of inspired oxygen [FiO2] of about 40%; Stoller, 2011). Patients using continuous supplemental oxygen therapy in the home have another alternative: transtracheal oxygen delivery (Fig. 38-13). With this type of delivery system, a small catheter is inserted into the trachea under local anesthesia, then the catheter is attached to the oxygen source. A transtracheal catheter does not interfere with talking, eating, or drinking and delivers oxygen throughout the respiratory cycle rather than just at inspiration. The patient or family must assume responsibility for daily catheter care. Patients usually report improved mobility, comfort, and appearance, and lower cost with this delivery system.

Urinary Functioning as the Problem Nursing diagnoses that specifically address problems in urinary functioning include problems of incontinence, pattern alteration, and urinary retention. Sample defining characteristics for these diagnoses appear in the accompanying Examples of NANDA-I Nursing Diagnoses box . Urinary Functioning as the Etiology Difficulty with urination or changes in normal voiding patterns may affect other areas of human functioning. Examples of nursing diagnoses related to urinary problems include the following: Caregiver Role Strain related to incontinence of family member Impaired Skin Integrity (Actual, Risk for) related to incontinence Acute Pain related to bladder spasms, dysuria, urinary retention, cancer of the bladder, diagnostic procedures Disturbed Body Image related to urinary diversion Disturbed Sleep Pattern related to nocturia Toileting Self-Care Deficit related to parent's lack of knowledge or motivation to toilet train child, neuromuscular impairment or musculoskeletal disorders, immobility, trauma or surgical procedures, confusion, disorientation

Outcome Identification and Planning When the patient is ambulatory and not experiencing difficulties with the urinary system, normal voiding is usually not a problem. Trauma or illness, however, may result in the patient's need for nursing assistance with voiding. Nursing interventions should support planned patient outcomes. The patient will: Produce urine output about equal to fluid intake Maintain fluid and electrolyte balance Empty the bladder completely at regular intervals Report ease of voiding Maintain skin integrity

DEEP BREATHING When hypoventilation occurs, a decreased amount of air enters and leaves the lungs. However, deep-breathing exercises can be used to overcome hypoventilation. Instruct the patient to make each breath deep enough to move the bottom ribs. Unless the patient has a nasal condition that prohibits or prevents normal breathing, have the patient start slowly taking deep ventilations nasally and then expiring slowly through the mouth. Breathing through the nose warms, filters, and humidifies the air. The patient's respiratory status, motivation, and general clinical condition dictate the timing of this exercise, which should be done hourly while awake or four times daily. USING INCENTIVE SPIROMETRY Incentive spirometry provides visual reinforcement for deep breathing by the patient. An incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration. The gauge on the spirometer allows the patient to measure one's own progress, providing immediate positive reinforcement. It encourages the patient to maximize lung inflation and prevent or reduce atelectasis. Optimal gas exchange is supported and secretions can be cleared and expectorated. Before using incentive spirometry equipment, the patient needs instructions on using the equipment properly. Validate the patient's correct use of this equipment in both health care and home environments. See Guidelines for Nursing Care 38-1 for information regarding teaching patients to use this device. PURSED-LIP BREATHING Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing. Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration. Prolonged expiration is thought to result in decreased airway narrowing during expiration and prevent the collapse of small airways. This results in improved air exchange and decreased dyspnea. Pursed-lip breathing also helps the patient to control the rate and depth of respiration, helping to reduce feelings of dyspnea. It also encourages relaxation, which aids the patient to gain control of dyspnea and reduce feelings of panic. Encourage patients with COPD to try this breathing technique to help manage their daily activities (Corbridge, Wilken, Kapella, & Gronkiewicz, 2012; Hinkle & Cheever, 2014). While sitting upright, the patient inhales through the nose while counting to three, then exhales slowly and evenly against pursed lips while tightening the abdominal muscles. During exhalation, the patient counts to seven. To purse the lips, the patient should position the lips as though sucking through a straw or whistling. When walking and using pursed-lip breathing, the patient should inhale while taking two steps and then exhale through pursed lips while taking the next four steps, then repeat the cycle. DIAPHRAGMATIC BREATHING Many people with COPD breathe in a shallow, rapid, and exhausting pattern. Teach the patient with COPD to change this type of upper chest breathing to another form, diaphragmatic breathing. Diaphragmatic breathing reduces the respiratory rate, increases alveolar ventilation, and sometimes helps expel as much air as possible during expiration (Hinkle & Cheever, 2014). To do this, the patient places one hand on the stomach and the other on the middle of the chest. The patient breathes in slowly through the nose, letting the abdomen protrude as far as it will go, then breathes out through pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen. The patient repeats these steps for 1 minute, followed by a rest for 2 minutes. Encourage the patient to practice this breathing pattern several times during the day, so that eventually it becomes automatic. Promoting and Controlling Coughing A cough is a cleansing mechanism of the body. It is a means of helping to keep the airway clear of secretions and other debris. A cough that is dry is termed a nonproductive cough. A cough that produces respiratory secretions is termed a productive cough. The respiratory secretion expelled by coughing or clearing the throat is called sputum. When there are excessive fluids or secretions in an organ or body tissue, the patient is said to be congested. Thus, a person with secretions or fluid in the lungs is said to have congested lungs. If the cough is dry, the patient is said to be congested with a nonproductive cough. If the cough produces sputum, the patient is said to be congested with a productive cough. Thick respiratory secretions are sometimes called phlegm. A patient who is coughing and does not have any congestion or secretions produced is said to be noncongested with a nonproductive cough. A series of events produce a cough. The cough mechanism (Fig. 38-10) consists of an initial irritation; a deep inspiration; a quick, tight closure of the glottis together with a forceful contraction of the expiratory intercostal muscles; and an upward push of the diaphragm. This causes an explosive movement of air from the lower to the upper respiratory tract. To be effective, a cough should have enough muscle contraction to force air to be expelled and to propel a liquid or a solid on its way out of the respiratory tract. Coughing is most effective when the patient is sitting upright with feet flat on the floor. Coughing can be voluntary or involuntary. FIGURE 38-10. (A) A cough begins with a deep inspiration, distending the trachea and hyperinflating the lungs. (B) After inspiration, the glottis closes while intercostal and abdominal muscles contract forcibly. (C) When intrathoracic pressure reaches a high level, the glottis opens slightly, and the diaphragm is pushed up, producing an explosive movement of air. VOLUNTARY COUGHING When a cough does not occur as a result of reflex stimulation of the cough-sensitive areas, it can be induced voluntarily. Teaching the patient to cough voluntarily is an important aspect of preoperative and postoperative care. Coughing is more effective when combined with deep breathing. Although teaching a patient to cough and deep breathe is relatively easy, experience has shown that it is difficult to motivate patients to follow through and perform coughing on their own. Refer to Guidelines for Nursing Care 29-2: Effective Coughing,, for detailed instructions for teaching this intervention. Frequently remind patients to perform effective coughing throughout the day. Develop a specific schedule for coughing on the patient's plan of care. Coughing early in the morning after rising removes secretions that have accumulated during the night. Coughing before meals improves the taste of food and oxygenation. At bedtime, coughing removes any buildup of secretions and improves sleep patterns. For a patient who is unable to cough voluntarily, manual stimulation over the trachea and prolonged exhalation can be helpful. If neither of these methods is successful, mechanical endotracheal suctioning with a catheter may be necessary. If the patient has a neuromuscular disorder and is unable to cough physically, an assisted cough may be used. For an assisted cough, firm pressure is placed on the abdomen below the diaphragm in rhythm with exhalation. This pressure is similar to the Heimlich maneuver, but with less force. This pressure is used to substitute for the weakened or paralyzed abdominal muscles. INVOLUNTARY COUGHING Involuntary coughing often accompanies respiratory tract infections and irritations. Many times respiratory infections lead to the production of respiratory secretions. These secretions can trigger the cough mechanism. When the cough is productive, it helps clear the airway. However, when the cough is nonproductive, it can be fatiguing and irritating. Medications may control involuntary coughing. Refer to the next section, Cough Suppressants. Observation of the patient's breathing and coughing characteristics is necessary to determine the appropriate type of medication. USING COUGH MEDICATIONS Various medications can be used to promote coughing, aiding in the movement of mucus through the respiratory tract, and in controlling coughing to allow the patient to rest. Expectorants. Expectorants are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions. Patients with extremely tenacious (thick) secretions may need the secretions liquefied for their cough to be effective. In that way, the nonproductive cough of a person with lung congestion can become productive. Use of an expectorant by a person without congestion is inappropriate. Guaifenesin is widely used as an expectorant in cold and cough medications (e.g., Robitussin). Some health care providers consider adequate fluid intake and air humidification as effective expectorants. Cough Suppressants. Suppressants are drugs that depress a body function—in this case, the cough reflex. Codeine, which is present in many cough preparations, is generally considered the preferred cough suppressant ingredient. However, codeine can be addictive, and because of possible abuse, most states require a prescription for its use. Drowsiness is a side effect, thus it may not be safe to use codeine when the person must remain alert, such as when driving a car. A suppressant that is not addictive is dextromethorphan, which can be found in many over-the-counter cold and cough remedies. An irritating, nonproductive cough in people without congestion may be treated appropriately with suppressants. Suppression of the productive cough is usually not recommended unless the patient is trying to sleep. If a productive cough is suppressed, secretions can be retained, leading to a pulmonary infection. Lozenges. Cough lozenges can often relieve mild, nonproductive coughs in people without congestion. A lozenge is a small, solid medication intended to be held in the mouth until it dissolves. Lozenges generally control coughs by the local anesthetic effect of benzocaine. The local anesthetic acts on sensory and motor nerves, controlling the primary irritation and inhibiting afferent and efferent impulses. Teaching about Cough Medications. Cough medications are readily available, and people who purchase them are usually eager for relief. Often, consumers take excessive amounts of more than one type. Teach about the appropriate choice of expectorants and suppressants and about misuse of cough mixtures. For example, cough syrups with a high sugar or alcohol content can disturb the metabolic balance of patients with diabetes mellitus or can trigger a relapse for recovering alcoholics. Preparations containing antihistamines have an anticholinergic action, which can cause serious problems for people with glaucoma or cause urinary retention in men with prostate enlargement. Other cough preparations can be detrimental to people with hypertension or thyroid or cardiac diseases. In addition, prolonged use of self-prescribed cough preparations can conceal more serious health problems. If a cough lasts more than 7 days, urge the person to contact the primary care provider. In addition, encourage the person to increase fluid intake if the secretions become too thick to expectorate.

Performing Chest Physiotherapy Chest physiotherapy helps loosen and mobilize secretions, increasing mucous clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough. Chest physiotherapy includes percussion, vibration, and postural drainage. PERCUSSION Percussion of lung areas involves the use of a cupped palm to loosen pulmonary secretions so that they can be expectorated with greater ease. With the hand held in a rigid, dome-shaped position (Fig. 38-11), strike the area over the lung lobes to be drained in a rhythmic pattern. Position the patient in a lateral, supine, or prone position, based on the lobes to be treated. Proper hand and patient positioning will ensure that the patient does not experience any pain with this procedure. Percussion is never done on bare skin or performed over surgical incisions, below the ribs, or over the spine or breasts because of the danger of tissue damage. Typically, each area is percussed for 30 to 60 seconds several times a day. If the patient has tenacious secretions, the area may be percussed for up to 3 to 5 minutes several times per day. Patients may learn how to percuss the anterior surfaces of their own chest wall. In addition, it is a good idea to teach family members how to percuss posterior surfaces. Mechanical devices as well as manual handheld cupping devices also are available for percussion on the chest wall. VIBRATING Vibration uses manual compression and tremor on the patient's chest wall to help loosen respiratory secretions. Loosened secretions can be expectorated more easily. The practitioner uses rhythmic contraction and relaxation of arm and shoulder muscles while holding the hands flat on the patient's chest wall as the patient exhales. Vibration can be done for several minutes, several times a day. To avoid causing patient discomfort, vibration is never done over the patient's breasts, spine, sternum, and lower rib cage. Vibration (see Fig. 38-11) can also be taught to family members or accomplished using a mechanical device. FIGURE 38-11. (A) The cupping position and action of the hand on manual percussion of the lung area. (B) The position and action of the hands necessary to use vibration to loosen respiratory secretions in the lungs. (Photos by B. Proud.) PROVIDING POSTURAL DRAINAGE Postural drainage makes use of gravity to drain secretions from the lungs. Position the patient in a way that promotes the drainage of secretions from smaller pulmonary branches into larger ones, where they can be removed by coughing (Fig. 38-12). Vibration, percussion, or both often precede postural drainage. When implementing postural drainage, have tissues and an emesis basin close at hand for the patient to use when coughing and expectorating secretions. Place the patient in an appropriate position to promote drainage from the lobes of the lungs. Postural drainage should be done two to four times a day for 20 to 30 minutes. Discontinue the drainage if the patient begins to feel weak or faint. Delay postural drainage for 1 to 2 hours after meals to avoid provoking vomiting. Appropriate positioning to achieve postural drainage is as follows: Use high Fowler's position to drain the apical sections of the upper lobes of the lungs. Place the patient in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs. Place the patient lying on the left side with a pillow under the chest wall to drain the right lobe of the lung. Place the patient in the Trendelenburg position to drain the lower lobes of the lungs. Suctioning the Airway Oxygenation: Nasopharyngeal Suctioning Click to Show Suctioning of the pharynx is indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning of the oropharynx or nasopharynx may be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. Refer to Skill 38-2. The frequency of suctioning varies with the amount of secretions present but should be done often enough to keep ventilation effective and as effortless as possible. If the patient is unable to raise secretions from the airways, tracheal suctioning may be indicated. Tracheal suctioning is discussed later in the chapter. Suctioning irritates the mucosa and removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). Thus, it is important to preoxygenate the patient before suctioning. This is accomplished by applying or increasing supplemental oxygen and having the patient take several deep breaths before inserting the catheter. When performed correctly, suctioning provides comfort by relieving respiratory distress. When performed incorrectly, it can increase anxiety and pain and cause respiratory arrest. At minimum, it is an uncomfortable procedure and it can be a very painful and/or distressing experience. Individualized pain management must be performed in response to the patient's needs (Arroyo-Novoa et al., 2008). Anticipate the administration of analgesic medication to a patient who has had surgery or other trauma before suctioning, because the cough reflex will be stimulated. Possible complications of suctioning include infection, cardiac arrhythmias, hypoxia, mucosal trauma, and death. FIGURE 38-12. Postural drainage. Shown are four positions that use the force of gravity to assist the drainage of secretions from the smaller bronchial airways into the main bronchi and trachea to enable the patient to cough them up. Wear gloves on both hands, goggles, and a mask—and a gown, if necessary—for protection from microorganisms. Continuously monitor the patient's color and heart rate and the color, amount, and consistency of secretions. If cyanosis, an excessively slow or rapid heart rate, or suddenly bloody secretions are noted, stop suctioning immediately, administer oxygen, and notify the physician. Cyanosis and a change in heart rate can indicate hypoxemia. Blood can indicate damage to the mucosa. Meeting Oxygenation Needs With Medications Although treating patients with medications is a dependent nursing intervention, monitoring the patient's response and development of side effects to medications is an independent nursing action. Table 38-4 lists some common medications for improving respiratory functioning, their side effects, and nursing implications. Many of the drugs used to dilate bronchial airways interact with caffeine. Encourage patients to avoid caffeine, which may potentiate the side effects of bronchodilators. ADMINISTERING INHALED MEDICATIONS Inhaled medications may be administered to open narrowed airways ( bronchodilators), to liquefy or loosen thick secretions (mucolytic agents), or to reduce inflammation in airways (corticosteroids). These medications typically are administered via nebulizer, metered-dose inhaler, or dry powder inhaler. Refer to Guidelines for Nursing Care 28-8 for pictures of these devices. Nebulizers disperse fine particles of liquid medication into the deeper passages of the respiratory tract, where absorption occurs. The treatment continues until all the medication in the nebulizer cup has been inhaled. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. Common mistakes that patients make when using MDIs include the following: Failing to shake the canister Holding the inhaler upside down Inhaling through the nose rather than the mouth Inhaling too rapidly Stopping the inhalation when the cold propellant is felt in the throat Failing to hold their breath after inhalation Inhaling two sprays with one breath To use an MDI, the patient must activate the device while continuing to inhale. For some patients, especially young children and older adults, a spacer or extender device may be necessary to aid delivery of medication by the inhalation route. The spacer acts as a reservoir. When the MDI is compressed, the medication is deposited in the reservoir, and the patient then inhales the medication from the spacer device. This makes administration less complicated, the dose more predictable, and enhances the delivery of medication to the lungs. Dry powder inhalers (DPI) are another type of delivery method for inhaled medications. DPIs are breath activated. A quick deep breath by the patient activates the flow of medication, eliminating the need to coordinate activating the inhaler (spraying the medicine) while inhaling the medicine at the same time. DPIs require less manual dexterity than do MDIs. DPIs are actuated by the patient's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. Many types of DPIs are available with distinctive operating instructions. Some have to be loaded with a dose of medication each time they are used. Some hold a preloaded number of doses. It is important to understand the particular instructions for the medication being used. One disadvantage of DPIs is that the medication in DPIs will clump if exposed to humidity. Remember Tyrone, the 12-year-old boy with suspected asthma. During this acute attack, the nurse would anticipate administering bronchodilators via a nebulizer. The physician may order bronchodilators to be administered at home using a nebulizer or possibly an MDI with a spacer, or dry powder inhaler.

NUTRITION AND HYDRATION Protein-calorie malnutrition predisposes a person to pressure ulcer formation because poorly nourished cells are damaged easily. Protein deficiency leading to a negative nitrogen balance, electrolyte imbalances, and insufficient caloric intake also predisposes the skin to injury. Other deficiencies can increase risk. For example, vitamin C deficiency causes capillaries to become fragile, with resultant poor circulation to the area. The condition of the teeth or fit of dentures may also exacerbate the problem of inadequate dietary intake. Dehydration as well as edema can interfere with circulation and subsequent cell nourishment. MOISTURE Primary sources of skin moisture include perspiration, urine, feces, and drainage from wounds (Voegeli, 2012). Prolonged moisture on the skin reduces the skin's resistance to trauma, particularly damage from friction and shear. When skin is damp, less friction is required to blister and abrade skin. Additionally, the moisture associated with urinary and fecal incontinence is believed to increase the risk for skin damage due to the chemical irritation from the ammonia in the urine. Ammonia also raises the alkalinity of the skin pH, altering the function of the normally acidic skin. A more alkaline pH promotes premature shedding of skin cells and decreases the skin's defense against bacteria, which results in enhanced growth of pathogens, such as yeast and staphylococci. MENTAL STATUS The more alert a person is, the more likely the individual is to protect skin integrity by relieving pressure periodically and maintaining adequate skin hygiene. Apathy, confusion, or a comatose state can diminish these self-care abilities and increase the likelihood of skin breakdown. AGE Older adults are at a greater risk for pressure ulcer formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure ulcer development in older adults. Pressure Ulcer Staging The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. This ischemia makes the skin appear paler than in areas where circulation is adequate. When pressure is relieved, ischemia is rapidly followed by hyperemia. Reactive hyperemia is a blanchable reddening of the skin that occurs when pressure is removed. The body literally floods the area with blood to nourish and remove wastes from the cells. The area appears red and feels warm, but blanches when slight pressure is applied. Reactive hyperemia is not a pressure ulcer. After a patient who has been lying supine for 2 hours is repositioned onto the side, any reddened area due to reactive hyperemia should fade within 60 to 90 minutes. In patients with darkly pigmented skin, it may be best to assess for hyperemia by touch; the skin feels warm. Also, assess for some change in color relative to the surrounding skin. If the pressure continues after ischemia occurs, circulation is further impaired and a pressure ulcer develops. Appropriate intervention depends on early recognition of the stage of development of the pressure ulcer. Pressure ulcers are commonly classified according to six stages (four numbered and two unnumbered)—suspected deep-tissue injury, stage I,stage II, stage III, stage IV, and unstageable (NPUAP, 2012a). See the accompanying Research in Nursing box, which highlights the importance of the nurse's role in accurate assessment of pressure ulcers, essential to providing appropriate and effective wound care. Suspected deep-tissue injury presents as a purple or maroon, localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. It may initially present as a painful, firm, mushy, boggy, warmer, or cooler area as compared to adjacent tissue (NPUAP, 2012a). A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue (NPUAP, 2012a). A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer (NPUAP). A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling (NPUAP). Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

Pressure ulcers are classified as unstageable when the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Eschar is a thick, leathery scab or dry crust that is necrotic (dead tissue) and must be removed before the stage can be determined accurately. However, stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed (NPUAP, 2012a). Detailed descriptions of these stages and a visual representation are presented in Box 31-3 . Psychological Effects of Wounds and Pressure Ulcers Because the skin is a sensory organ and plays a major role in communication with others and self-image, wounds and pressure ulcers require emotional as well as physical adaptation. Although stress and adaptation vary greatly among people, actual and potential emotional stressors are common in all patients with wounds. These stressors impact the quality of life of the patient and caregivers and include pain, anxiety, fear, activities of daily living, and changes in body image. Pain Pain is part of almost any trauma, from a small cut on the finger to a large incision made during abdominal surgery or a chronic arterial ulcer. Although pain can be considered a physical complication, it also has a large psychological component. Pain from wounds is often increased by activities such as ambulating, coughing, moving in bed, and dressing changes. The actual pain might be worsened by the patient's apprehension about such activities. Nursing interventions to reduce pain can greatly reduce emotional stress. See Chapter 34 for a more in-depth discussion of pain. Anxiety and Fear Anxiety and fear are common responses to a wound. Patients are apprehensive about the possibility of the wound opening, how much privacy will be lost as the wound is being cared for, and how they and others will react to the appearance and smell of the wound. When caring for patients with wounds, demonstrating acceptance and empathy, encouraging the expression of feelings, answering questions accurately and honestly, and avoiding excessive exposure of body parts when giving wound care are essential.

Act of Urination (Micturition, Voiding)

Process of emptying the bladder Detrusor muscle contracts, internal sphincter relaxes, urine enters posterior urethra Muscles of perineum and external sphincter relax Muscle of abdominal wall contracts slightly Diaphragm lowers, micturition occurs

Outcome Identification and Planning When caring for patients with an alteration in oxygenation, nursing measures support the following general expected outcomes. The patient will: Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain and a pulse oximetry reading more than 95% Relate the causative factors, if known, and demonstrate a method of coping with these factors Preserve cardiopulmonary function by maintaining an optimal level of activity Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems When the patient's physical, psychosocial, and spiritual dimensions contribute to alterations in oxygenation, individualized expected outcomes are developed with the patient's input (e.g., "By March 15, the patient will be able to walk up one flight of steps at home without dyspnea."). Implementing Oxygen deficits, particularly in older people, impair all aspects of daily living. Going to get the mail or cleaning the house may become a monumental task for people with oxygen deficits. Nursing interventions related to oxygenation aim to promote optimal functioning of the cardiopulmonary systems, to promote comfort, and to promote and control coughing. Nurses may also need to intervene by performing chest physiotherapy, suctioning the airway, meeting respiratory needs with medications, providing supplemental oxygen, managing chest tubes, using artificial airways, clearing an obstructed airway, and administering CPR.

Promoting Optimal Function Healthy lifestyle choices and behaviors are an important part of preventing and managing cardiopulmonary diseases, which can have an impact on level of health and oxygenation. Vaccination is an important part of preventing respiratory infections. Teaching patients with problems of oxygenation about pollution-free environments is an important part of respiratory management. Many people with altered oxygenation experience anxiety as a result of their symptoms and the actual or potential loss of independence. It is important to minimize anxiety in patients with alterations in oxygenation in order to promote optimal functioning. Promoting good nutrition is another vital part of promoting optimal cardiopulmonary functioning. Teach patients about their health conditions and provide information and support to improve patient health literacy. Refer to the accompanying Promoting Health Literacy box. HEALTHY LIFESTYLE Patients who practice good health-related behaviors can reduce their risk for many cardiopulmonary diseases. Explain that beneficial behaviors should be incorporated into their daily and weekly activities. Encourage patients to eat a healthy diet (see discussion later in the chapter). Encourage patients to maintain a healthy weight. Regular exercise should also be part of a patient's daily activities. Current recommendations suggest 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week (CDC, 2011a). Teach patients to monitor their cholesterol, triglyceride, lipoprotein (HDL) and low-density lipoprotein levels, (LDL), as well as their blood pressure. Encourage patients to limit alcohol intake and stop smoking (see discussion later in the chapter). VACCINATION Influenza. Influenza (the flu) is a contagious respiratory illness that causes mild to severe illness, and even death. People at high risk for serious flu complications include young children; pregnant women; people with chronic health conditions like asthma, diabetes, or heart and lung disease; and people 65 years and older. The best way to prevent the flu is by getting vaccinated. All people 6 months of age and older should be vaccinated each year (CDC, 2012). Pneumococcal Disease. Pneumococcal disease is an infection caused by a type of bacteria called pneumococcus. There are different types of pneumococcal disease, such as pneumococcal pneumonia, meningitis, and otitis media. Pneumococcal disease can be fatal. In some cases, it can result in long-term problems, like brain damage, hearing loss, and limb loss. Pneumococcal vaccine is very good at preventing severe disease, hospitalization, and death. Pneumococcal vaccine is recommended for all children less than 59 months of age. Children aged more than 24 months who are at high risk for pneumococcal disease and adults with risk factors should receive this vaccine. Risk factors for children and adults include those with long-term health problems, with a disease or condition that lowers the body's resistance to infection, or who are taking a drug or undergoing a treatment that lowers the body's resistance to infection. All adults 65 years of age and older, any adult 19 through 64 years of age who is a smoker or has asthma, and residents of long-term care facilities should also receive this vaccine (CDC, 2011b). TEACHING ABOUT POLLUTION-FREE ENVIRONMENTS A pollution-free environment is particularly important for people with cardiopulmonary problems. Teach the patient to assess the environment and make adjustments, whenever possible, to factors that impair respiratory functioning ("triggers"). The patient must actively plan to prevent exposure to pollutants and triggers. This might involve a job change, use of protective equipment, requesting enforcement of laws by government agencies, or subcontracting jobs. In order to minimize triggers in the home, dusting and vacuuming the office and home must be done at least twice per week. In some situations, the patient may be asked to wear a mask to prevent some symptoms of respiratory distress. Explain to the patient that exposure to industrial or occupational hazards (e.g., paint, varnish, gaseous fumes, asbestos) must also be restricted. In the United States, fine pollutants—including carbon monoxide, sulfur dioxide, total suspended particulates, ozone, and nitrogen dioxide—that pose a hazard to health are monitored closely. On days when pollutant levels are elevated significantly, morbidity and mortality rates among people with pre-existing pulmonary disease are increased greatly. Thus, on days when pollution alerts are announced, people with altered respiratory function should reduce their activities, stay indoors, and use an air conditioner, electronic air cleaner, or air filter. If pollen alters the patient's respiratory function, the same principles apply. Cigarette smoking is a major risk factor in cardiopulmonary diseases. The inhalation of cigarette smoke increases airway resistance, reduces ciliary action, increases mucus production, causes thickening of the alveolar-capillary membrane, and causes bronchial walls to thicken and lose their elasticity. Smoking is the most common cause of chronic obstructive pulmonary disease (COPD), and increases the risk for many types of cancer, including cancers of the oral cavity, esophagus, lung, urinary bladder, and kidneys. In addition, cigarette smoking causes reduced circulation by narrowing the blood vessels (arteries). Smoking causes coronary heart disease, the leading cause of death in the United States, and causes a much greater risk for stroke, peripheral vascular disease, and abdominal aortic aneurysm (abnormal dilation of blood vessels). These effects occur in both smokers and nonsmokers (children and adults) who live with smokers (CDC, 2010). Habitual smokers usually have great difficulty quitting or reducing their smoking and need much encouragement. The American Lung Association and the American Heart Association (AHA) offer many free educational materials to aid and support patients who are trying to stop smoking. Their addresses and phone numbers are listed in local telephone directories; both agencies offer extensive information online. As a nurse, it is important to play a key role in presenting accurate information about the effects of smoking. Encourage the decision to never start smoking or to stop smoking. Provide appropriate information, counseling, support, and resources to assist patients to be successful with smoking cessation. REDUCING ANXIETY It is important to create an environment that is likely to reduce anxiety. Help institute measures to alleviate discomfort immediately. Use effective listening skills and accurate observation to display a caring attitude. Attempt to understand the patient's life experiences and habits without judging them. Patients with harmful health habits often fear they will be judged, which impedes the use of nursing interventions. Patients who believe nurses are genuinely concerned about them and their families are more willing to work toward achieving mutually desirable outcomes. Think back to Joan McIntyre, the woman requesting to be "let go" if she should stop breathing. The nurse needs to provide support to the patient, showing genuine concern for her welfare. In addition, the nurse needs to act ethically and legally to ensure the patient's rights. MAINTAINING GOOD NUTRITION Beneficial behaviors, such as a healthy diet, should be incorporated into a patient's daily activities. Encourage patients to eat a diet that includes foods low in saturated fat and cholesterol, low in sodium (salt), and high in fiber. This diet can help patients reduce their risk for chronic disease such as cardiopulmonary diseases, improve health, and reduce the prevalence of overweight and obesity (U.S. Department of Agriculture [USDA], 2012). Patients with cardiovascular diseases, such as hypertension, benefit from eating a diet rich in fruit, vegetables, low-fat dairy products, and nuts and legumes, with reduced amounts of fat, red meat, sweets, and beverages with sugar. This diet provides a high intake of potassium, magnesium, calcium, protein, and fiber, along with a low intake of saturated fat, sodium, cholesterol, total fat, and extra sugars. People who work hard at breathing often do not have much energy for eating. Many of the medications used for treatment can cause anorexia and nausea. However, maintaining an adequate nutritional intake is crucial. Interventions should focus on ensuring an adequate intake of proteins, vitamins, and minerals. Consider the use of six small meals distributed over the course of the day instead of the usual three larger meals. Provide frequent oral hygiene and rest periods before eating to help improve the patient's intake. Encourage patients to eat their meals 1 to 2 hours after breathing treatments and exercises. Patients who have COPD require a high-protein/high-calorie diet to counter malnutrition. Encourage obese patients to lose weight using a calorie-controlled diet. Diets should be 40% to 55% carbohydrates, 30% to 40% fat, and 12% to 20% protein. A diet rich in antioxidants, vitamins A and C, and the B vitamins is important. If supplemental oxygen is used, reinforce the importance of wearing the cannula during and after meals. Eating and digestion require energy, which causes the body to use more oxygen. Promoting Comfort Interventions to promote patient comfort are an important part of nursing care for patients with alterations in cardiopulmonary function. Promoting proper positioning, adequate fluid intake, humidification of inspired air, and appropriate breathing techniques are used to maximize the patient's sense of well-being. In addition, encourage the patient to pace physical activities and schedule frequent rest periods to conserve energy. POSITIONING Proper positioning is important to ease respirations. A proper position for breathing is a position that allows free movement of the diaphragm and expansion of the chest wall. Alternately, sitting in a slumped position permits the abdominal contents to push upward on the diaphragm, decreasing lung expansion during inspiration. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Research has demonstrated that, in patients with pulmonary disease who are acutely ill, turning to the prone position on a regular basis promotes oxygenation (Dirkes et al., 2012; Rickelmann, 2012). In this position, the posterior dependent sections of the lungs are better ventilated and perfused. MAINTAINING ADEQUATE FLUID INTAKE Patients can help keep their secretions thin by drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum that the patient's health state can tolerate. Increased fluids are needed by patients who have an elevated temperature, who are breathing through the mouth, who are coughing, or who are losing excessive body fluids in other ways. However, encourage patients with heart failure and low sodium levels to limit their fluid intake to 1.5 L/day (Dudek, 2014). PROVIDING HUMIDIFIED AIR Inspiring dry air removes the normal moisture in the respiratory passages that protect against irritation and infection. This is especially troublesome for patients who cannot breathe through their nose. When air humidity is low, it may be necessary to humidify the air with room humidifiers or vaporizers. Electric vaporizers that produce steam or cool mist are also useful, but neither device has been demonstrated to have greater therapeutic value than the other. Although a cool-mist vaporizer reduces the danger of burns because it does not generate heat or hot water, it can be a medium for pathogen growth if it is not cleaned adequately. A steam vaporizer does not present this risk for infection because the heat kills most pathogens. Promoting Proper Breathing Many people, both well and ill, have breathing habits that are not conducive to maximal respiratory functioning. Some people develop a pattern of shallow breathing or walk with a posture that makes the chest wall appear caved in, affecting chest expansion. Ill people may limit their respiratory efforts to compensate for disease symptoms or an illness. Breathing exercises are designed to help patients achieve more efficient and controlled ventilations, to decrease the work of breathing, and to correct respiratory deficits. The accompanying box, Examples of Nursing Intervention and Nursing Outcome Classifications (NIC/NOC), lists standardized nursing interventions and corresponding outcomes related to maximizing oxygen and carbon dioxide exchange in the lungs. Descriptions of specific techniques follow.

bed bath Some patients must remain in bed as a part of their therapeutic regimen but can still bathe themselves. Other patients are not on bed rest but require total or partial assistance with bathing in bed due to physical limitations, such as fatigue or limited range of motion. Implement the following nursing measures to help patients take a bath in bed: Provide the patient with articles for bathing and a basin of water that is a comfortable and safe temperature. Place these items conveniently for the patient on a bedside stand or overbed table.

Provide privacy for the patient. Make sure the call device is within reach. Remove the top linens from the patient's bed and replace them with a bath blanket. Place cosmetics in a convenient place for the patient. Provide a mirror, a good light, and hot water for patients who wish to shave with a razor. Assist patients who cannot bathe themselves completely. For example, some patients can wash only the upper parts of the body. Nursing personnel then complete the remainder of the bath. Bathing procedures for patients who require total nursing assistance vary among health agencies. Skill 30-1 offers one example as a guide. It assumes that the patient can be raised or lowered in bed and that, although the patient may have limited movement, the nurse can manage the patient alone.

TOOTH BRUSHING AND FLOSSING Brush and floss teeth twice a day and rinse the mouth after meals. A soft-bristled toothbrush should be small enough to reach all teeth. Clean and dry all brushes between uses. Bacteria do most damage directly after eating, so make sure the patient brushes the teeth immediately after eating or drinking. In addition, clean the tongue with the toothbrush. Use a toothbrush even when the patient has no or few teeth. It is the only effective way to remove plaque and debris. Automatic toothbrushes, electric or battery operated, are simple to use and are as good as manual brushes for removing debris and plaque. These devices are very useful for patients with arthritis or other conditions that make it difficult to brush effectively (Mayo Foundation for Medical Education and Research [MFMER], 2011d). Pressurized water spray units are available to assist with oral hygiene. However, if too much water pressure is used, particles of debris may be forced into tissue pockets, leading to gum damage. Therefore, discuss their use with a dentist. The toothbrush cannot reach areas between the teeth where food lodges, so flossing twice a day is recommended. Flossing removes the debris that the toothbrush cannot and helps to break up colonies of bacteria. Toothpastes and powders aid the brushing process and usually have a pleasant taste that encourages brushing, especially by children. Most dentifrices are safe to use, but those containing harsh abrasives may scratch the enamel of the teeth, thus are not recommended. Salt and sodium bicarbonate are far less expensive than proprietary products on the market and just as effective for short-term use. However, these products lack fluoride and should not be used exclusively. Dentifrices containing stannous fluoride and antitartar agents, as well as antiplaque rinses, decrease dental caries and thus are recommended by many dentists. MOUTHWASHES An offensive breath odor (halitosis) is often systemic in nature. For example, the odor of onions and garlic on the breath comes from the lungs, where the oils are being removed from the bloodstream and eliminated with respiration. A mouthwash cannot remove halitosis when odors are being eliminated by respiration. If the cause of halitosis is poor oral hygiene, cleaning reduces the odor. Commercial mouthwashes may also be helpful. Therapeutic mouth rinses that reduce bacteria can help reduce plaque, gingivitis, and bad breath. Anticavity rinses with fluoride help protect tooth enamel and are often used with children (American Dental Association [ADA], 2012). If concentrated mouthwashes are used frequently in debilitated patients, however, they may injure oral tissue. DENTURE CARE Failing to wear dentures for a long period allows the gum line to change, thus affecting the fit of the dentures. If the patient has been instructed to remove dentures while sleeping, a disposable denture cup is convenient and easy to use. Advise the patient not to wrap dentures in toilet tissue or disposable wipes because these are likely to be thrown away. Patients with dentures are more likely to keep them in the mouth if they are kept clean. If the patient cannot care for them, the nurse must ensure that the dentures are clean. Use care when handling a patient's dentures because they represent a considerable financial investment, and replacement for damage or loss is expensive. Brush dentures twice a day; remove and rinse dentures and mouth after meals. When cleaning dentures, put on gloves and hold them over a basin of water or a sink lined with a washcloth or soft towel (Fig. 30-3) so that if they slip from your grasp, they will not fall onto a hard surface and break. If necessary, grasp the dentures with a 4" × 4" piece of gauze to help prevent them from slipping out of your gloved hands. Use cool or lukewarm water to cleanse them. Hot water may warp the plastic material of which most dentures are made. Use a soft toothbrush and toothpaste. Dentures may be soaked in commercial preparations to help remove stains and hardened particles and then rinsed well after cleaning. Give the patient the opportunity to brush the gums and tongue and rinse the mouth before the dentures are replaced. Assist the patient with care as necessary. Store dentures in cold water when not in the patient's mouth. Leaving dentures to dry can cause warping, leading to discomfort when worn.

Providing Eye Care Normally, the eyes are kept clean with lacrimal secretions. During illness, the eyes may produce more secretions than normal and may appear glass-like. Use the following techniques when secretions adhere to the eyelashes and become dry and crusty or when discharge is present: Wear gloves during the cleaning procedure. Use water or normal saline and cotton balls or a clean washcloth or compress to clean the eyes. Never use soap to clean the eyes because soap is irritating to eye tissues. Position the patient on the same side as the eye to be cleaned so that solution and debris do not run across the bridge of the nose and contaminate the other eye. Dampen a washcloth or cotton ball with the solution of choice and wipe once while moving the cotton ball from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. Turn the washcloth and use a different section for each stroke. Alternately, discard the used cotton ball. Continue this technique, using a different section of the washcloth or one cotton ball for each stroke, until the eye is clean. Turn the patient to the opposite side and clean the other eye in the same manner. Wipe the lashes dry with a paper tissue or a clean washcloth, exposing a clean area of the tissue or cloth with each stroke. If the eyelashes are matted with secretions or debris that cannot be removed by wiping, apply a warm, wet compress to the closed eye for 3 to 5 minutes to loosen the secretions so that they may be removed in a painless manner.

Providing Fingernail Care The following are recommended techniques for the care of fingernails: File the nails straight across, then round the tips in a gentle curve. Do not trim so far down on the sides that the skin and cuticle are injured. Remove hangnails, which are broken pieces of cuticle, by cutting them off. Avoid injury to tissue with the cuticle scissors. Gently push cuticles back off the nail when soft and pliable after washing in warm water. Push back cuticles with a blunt instrument or a terry cloth. Apply an emollient to the cuticle to help prevent hangnails. Clean under the nails with a blunt instrument, being careful not to injure the area where the nail is attached to the underlying tissue. Splitting and peeling of the nails are usually caused by dryness. Teach the patient to avoid contact with soap and water as much as possible, use a good hand cream frequently, and avoid using polish remover with acetone, which tends to dry the nails (MFMER, 2011c).

Providing Foot Care Proper foot care is important at any age. It becomes even more so with aging and when conditions such as circulatory disturbances or diabetes mellitus are present. Guidelines for Nursing Care 30-2 highlights the appropriate techniques related to foot care. Cut toenails straight across the toes. Discourage patients with conditions such as diabetes and peripheral vascular diseases from doing nail care at home (Lyman & Vlahovic, 2010). Encourage patients with these diseases to see a podiatrist for treatment related to bunions, corns, or calluses (MFMER, 2012a).

Providing Ear Care Other than cleaning the outer ears, little intervention is needed for routine hygiene of the ear. After the ears are washed, dry them carefully with a soft towel so that water and cerumen (wax) are removed by capillary action. Forcing the towel into the ear for drying or using a cotton-tipped applicator may aid in the formation of wax plugs. Using bobby pins, hairpins, paper clips, or fingernails to remove wax from the ear is extremely dangerous because these may injure or puncture the eardrum. If the patient uses a hearing aid, check the batteries routinely and clean the earpieces or ear mold daily with mild soap and water. A whistling sound that is audible when the hearing aid is held in the hand with the power on and the volume high indicates that the battery is functioning properly. Refer to Chapter 20 for strategies nurses can use to promote communication with a hearing-impaired patient. If hearing loss is mild and the patient is not using a hearing aid, the following suggestions may help to improve hearing and should be included in any patient teaching: Avoid noisy places for conversation. Choose well-lit places where it is easier to look at the speaker's face, lips, and hands for cues to the conversation. Cup your hand behind your ear. Ask people to face you when they are speaking to you. Ask people to repeat what they said, if it was not clear to you, and to speak slowly. Consider buying amplitude devices so that you can hear your television and radio without turning up the sound.

Providing Nose Care The best way to clean the nose is to blow it gently. Both nostrils should be open while doing this. Closing one nostril adds to the danger of forcing debris into the eustachian tubes. Irrigations are usually contraindicated because of the danger of forcing material into the sinuses. If the external nares are crusted, applying a warm, moist compress helps to soften and remove the crusts. Disposable paper tissues are recommended for nasal secretions. A cotton-tipped applicator may be used to clean the nares, but with great care to avoid injury. Never introduce the applicator into the nares. Providing Hair Care Daily brushing of the hair helps keep it clean and distributes oil along the shaft of each hair. Brushing also stimulates blood circulation in the scalp. Hair that becomes entangled is difficult to comb. Combing tiny sections of hair at a time may be necessary if a patient's hair has not been combed for even 1 day. The best way to protect long hair from matting and tangling is to ask the patient for permission to braid it. Patients usually consent to the procedure if it increases their comfort. Parting the hair in the middle on the back of the head and making two braids, one on either side, prevents the discomfort of lying on one heavy braid on the back of the head. When braiding a patient's hair, ensure that the hair is not pulled too tightly. Occasionally, a patient's hair is almost hopelessly matted, and cutting the hair may be necessary. Before a patient's hair is cut, usually the patient signs a written consent. Also, as appropriate, discuss with a member of the patient's immediate family the necessity of cutting the hair. Tightly curled (kinky) hair usually requires special attention. It is normally dry and curly and becomes matted and tangled easily. Use a comb with wide-spaced teeth and work the hair through from the neckline upward toward the forehead. Some people have their hair straightened, but even after this process, it may be difficult to untangle the hair when the person is confined to bed. Some African Americans style their hair in small braids. The braids are not undone for shampooing and may need to have a lubricant or oil applied daily to prevent hair strands from breaking. Demonstrate cultural consideration by grooming the patient's hair in the style preferred by the patient.

Providing Perineal Care Perineal cleaning is performed in a matter-of-fact and dignified manner. If this approach is followed, patients generally do not find care by a person of the opposite gender to be offensive or embarrassing. In some cases, a sitz bath may be used to clean and soothe the perineal and anal areas. The procedure associated with administering a sitz bath is discussed in Chapter 31. Perineal care may be carried out while the patient remains in bed. When performing perineal care, follow these guidelines: Assemble supplies, and provide for privacy. Explain the procedure to the patient, perform hand hygiene, and put on disposable gloves. Wash and rinse the groin area (both male and female patients). Use a small amount of mild, unscented soap and water. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area to prevent carrying organisms from the anal area back over the genital area (Fig. 30-8). Always proceed from the least contaminated area to the most contaminated area. Use a clean portion of the washcloth for each stroke. Rinse the washed areas well with plain water. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area (Fig. 30-8). Always proceed from the least contaminated area to the most contaminated area. Rinse the washed areas well with plain water. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis. Pull the uncircumcised male patient's foreskin back into place over the glans penis to prevent constriction of the penis, which may result in edema and tissue injury. It is not recommended to retract the foreskin for cleaning during infancy and childhood, as injury and scarring could occur (MedlinePlus, 2012b). Wash and rinse the male patient's scrotum. Handle the scrotum, which houses the testicles, with care because the area is sensitive. Dry the cleaned areas and apply an emollient as indicated. Avoid the use of powder. Powder may become a medium for the growth of bacteria. Turn the patient on his or her side and continue with cleansing the anal area. Continue in the direction of least contaminated to most contaminated area. In the female, cleanse from the vagina toward the anus. In both female and male patients, change the washcloth with each stroke until the area is clean. Rinse and dry the area. Remove gloves and perform hand hygiene. Continue with additional care as necessary If the patient has an indwelling catheter and the agency recommends daily care for the catheter, this is usually done after perineal care. Care of an indwelling catheter is discussed in Chapter 36. Incontinent patients require special attention to perineal care. Patients with urinary or fecal incontinence are at risk for perineal skin damage. This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of perineal skin from friction on moist skin. Skin care for these patients should include measures to reduce overhydration (excess exposure to moisture), contact with ammonia and bacteria, and friction. Remove soil and irritants from the skin during routine hygiene, and clean the area when the skin becomes exposed to irritants. Avoid using soap and excessive force for cleaning. The use of perineal skin cleansers, moisturizers, and barriers is recommended for skin care for the incontinent patient. These products help promote healing and prevent further skin damage. Incontinence, and nursing care of the patient with incontinence, is discussed further in Chapters 31, 36, and 37.

Providing Vaginal Care Vaginal mucous secretions are odor free until they combine with air and perspiration. Thus, for vaginal care, using plain soap and water is the most effective means to control odor. In normal, healthy women, daily douching is believed to be unnecessary and unwise because it tends to remove normal bacterial flora from the vagina, and an acidic solution may irritate or injure normal cells. Douching has also been linked to vaginal irritation, bacterial vaginosis, and pelvic inflammatory disease. Although douching is occasionally ordered to treat a vaginal infection, it is not recommended as a routine hygiene measure. Deodorants to control odor around the vaginal orifice are unnecessary. No therapeutic benefit from their use has been proven to date. Use of these special deodorants is not a substitute for keeping the area clean; female patients often require teaching on this subject. If patients insist on using them explain that, although these deodorants do not contain aluminum salts, which are irritating to the mucous membrane, they are intended for external use only. They should not be placed on sanitary napkins or tampons. Some sprays have been reported as possibly harmful when sprayed into the vagina. Repeated use is not generally recommended because of reported irritation and rashes. In addition, the sprays should not be used on broken skin areas.

Advertisements for adult disposable undergarments have increased public awareness about urinary incontinence, but they fail to mention possible treatment strategies (see Focused Critical Thinking Guide 36-1). Review the scenario at the beginning of the chapter describing Midori Morita and her husband. The nurse should assess the feelings of Midori and her husband related to the problems associated with his urinary dribbling and incontinence. Midori may be feeling overwhelmed and possibly upset or angry. Her husband most likely would be feeling embarrassed and possibly disgusted. Helping them resolve these feelings is essential for effective care. TYPES OF URINARY INCONTINENCE The National Association for Continence (NAFC, 2013a) and the U.S. Department of Health and Human Services (USDHHS, 2010) identify numerous types of urinary incontinence. Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by treatable factors, such as confusion secondary to acute illness, infection, and as a result of medical treatment, such as the use of diuretics or intravenous fluid administration. Stress incontinence (discussed earlier in the chapter) occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities. Childbirth, menopause, obesity, or straining from chronic constipation can also result in urine loss. The leakage usually does not occur when the person is supine. Urge incontinence is the involuntary loss of urine that occurs soon after feeling an urgent need to void (urgency). These patients experience a loss of urine before getting to the toilet and an inability to suppress the need to urinate. A diagnosis of mixed incontinence indicates that there is urine loss with features of two or more types of incontinence. Overflow incontinence, or chronic retention of urine, is the involuntary loss of urine associated with overdistention and overflow of the bladder. The signal to empty the bladder may be underactive or absent, the bladder fills, and dribbling occurs. It may be due to a secondary effect of some drugs, fecal impaction, or neurologic conditions. Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, loss of memory, or disorientation. Patients with reflex incontinence experience emptying of the bladder without the sensation of the need to void. Spinal cord injuries may lead to this type of incontinence. Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation. Urination cannot be controlled due to an anatomic abnormality. Urinary incontinence is treatable. Appropriate interventions can significantly reduce the symptoms of urinary incontinence and even prevent its occurrence.

REASONS FOR URINARY CATHETERIZATION Common reasons for urinary catheterization include: Relieving urinary retention. Retention is often temporary and is common after surgery involving the lower abdomen, pelvis, bladder, or urethra, especially if ambulation is delayed, fluid intake is minimal, or epidural analgesia is used for pain control. Any mechanical obstruction, such as swelling at the meatus, which can occur after childbirth, or an enlarged prostate in men, may cause retention. Some patients who are unable to use any other bladder management method, such as those with neurogenic bladder dysfunction related to a disability (e.g., spinal cord injury), require long-term use of an indwelling catheter. Obtaining a sterile urine specimen Obtaining a urine specimen when a specimen cannot be secured satisfactorily by other means. Examples include collecting an uncontaminated specimen from a woman who is menstruating or from an incontinent patient. Emptying the bladder before, during, or after surgery and before certain diagnostic examinations. Monitoring renal function of critically ill patients Increasing comfort for terminally ill patients

Radiography

Radiography is an x-ray examination of the lungs and the thoracic cavity. Radiographic examinations of the lungs are done to help diagnose pulmonary diseases and to determine the progress or development of disease.

changing the dressing Prepare the patient for the dressing change before starting the procedure by explaining what will be done. If wound care is uncomfortable, administer a prescribed analgesic 30 to 45 minutes before changing the dressing. Also, plan to change the dressing midway between meals so that the patient's appetite and mealtimes are not disturbed. Provide privacy by properly screening the patient; close the room door and curtain. Then help the patient into a position that is comfortable and also convenient for changing the dressing. Expose only the area necessary to perform the wound care while maintaining proper draping. Using appropriate aseptic techniques when changing the dressing is crucial. Be especially vigilant in performing hand hygiene thoroughly before and after changing dressings and in adhering to standard precautions and transmission-based precautions, when necessary. Among the most common causes of hospital-acquired infections is carelessness in practicing asepsis during dressing changes. Surgical wounds that have dehisced require the use of sterile technique. Pressure ulcers are nonsterile wounds. There is no need to use sterile dressings on these wounds, and nonsterile gloves can be used for wound care (Pegram & Bloomfield, 2010).

Removing a Dressing. Remove any dressing currently in place: Use standard precautions; use appropriate transmission-based precautions when indicated. Perform hand hygiene and put on clean (nonsterile) gloves. Remove tapes and dressings in the direction of hair growth to minimize trauma to the skin. Use a push-pull method; lift a corner of the dressing away from the skin, then gently push the skin away from the dressing. Carefully lift the adhesive barrier from the surrounding skin. If there is resistance, use a silicone-based adhesive remover, as this allows for the easy, rapid, and painless removal without the associated problems of skin stripping (Denyer, 2011; Benbow, 2011). Slowly remove the dressing, noting the amount, type, color, and odor of the drainage. Discard the dressing according to facility policy. Remove gloves and perform hand hygiene. Cleaning the Wound. Perform wound cleaning to remove microorganisms and debris with as little chemical and mechanical force as possible and protect healthy granulation tissue. Normal saline solution (0.9% sodium chloride) is usually the agent of choice, particularly when cleaning pressure ulcer wounds. There are also commercially prepared cleansing sprays available for use. Wounds are cleaned initially and before applying any new dressing. Guidelines for Nursing Care 32-3 outlines the techniques for cleaning a wound with approximated edges, such as a surgical incision, and for cleaning a wound with unapproximated edges, to remove cellular debris and drainage. It is also used to apply local heat or an antiseptic to an area. Wound irrigation is a directed flow of solution over tissues. Sterile equipment and solutions are required for irrigating an open wound, even in the presence of an existing infection. Sterile 0.9% sodium chloride or sterile water, a commercially prepared wound cleanser, an antiseptic, or an antibiotic solution may be used, depending on the condition of the wound and the primary practitioner's order. A sterile, large-volume syringe is used to direct the flow of the solution. After irrigation, open wounds may be packed with appropriate dressing materials to absorb additional drainage and allow healing by secondary intention to take place. Nonsterile solutions are generally used to clean the skin surface if the wound edges are approximated.

PATIENT EDUCATION Patient education is essential for independence in self-care. As the patient assumes responsibility for self-care, teach the patient how to make the necessary observations, to be aware of indications of problems, and to recognize when to seek assistance. For these goals to be met, the patient and/or family member needs to be able to do the following: Explain the reason for the urinary diversion and the rationale for treatment. Demonstrate self-care behaviors that effectively manage the diversion. Describe follow-up care and existing support resources. Report where supplies may be obtained in the community. Verbalize related fears and concerns. Demonstrate a positive body image.

Role of Skeletal System in Movement Supports the soft tissues of the body Protects crucial components of the body Furnishes surfaces for the attachment of muscles, tendons, and ligaments Provides storage areas for minerals and fat Produces blood cells

SKIN Question the patient about any past or current problems (e.g., rashes, lumps, itching, dryness, lesions). When skin problems are present, ask the patient the following: How long have you had this problem? Does it bother you? How does it bother you? Does it itch? Have you found anything that helps relieve these symptoms? When documenting the nursing history, be specific, clearly describing the patient's typical hygiene practices and any complaints. The following are two examples of documentation of patients' personal practices related to hygiene and skin care: Hygiene: "Showers twice daily, once in the morning and after working out in the evening. Skin tends to be very dry, and moisturizing creams are used daily. Aveeno® Oilated baths as needed. Allergic to deodorant soaps." Integument: "History of athlete's foot since high school days with outbreaks every 2 to 3 months. Knowledgeable about appropriate foot care. Uses antifungal agent such as terbinafine hydrochloride (Lamisil DermaGel) or tolnaftate (Tinactin cream), a topical fungicidal agent."

SKIN The inspection and palpation skills used to assess the integumentary system are described in detail in Chapters 25 and 31. Assisting patients with basic hygiene measures provides an excellent opportunity for examining a patient's skin. Many people are unaware that they have skin lesions, such as precancerous moles, that if untreated could prove fatal. Early detection and treatment of skin problems are important nursing functions. When examining the skin, pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and any lesions. Follow these general guidelines for assessing the skin: Proceed systematically in a head-to-toe fashion. Use a good source of light, preferably daylight. Compare bilateral parts for symmetry. Use standard terminology to report and record findings. Allow data obtained in the nursing history to direct the skin assessment. Identify any variables known to cause skin problems, such as deficient self-care abilities, immobility, malnutrition, decreased hydration, decreased sensation, sun exposure, vascular problems (altered tissue perfusion or venous return), or the presence of irritants (body secretions or excretions on the skin, other chemicals, mechanical devices). Because lifestyle factors, changes in health state, illness, and certain diagnostic and therapeutic measures may adversely affect the skin, be alert for patients who may be at high risk for skin problems, and perform the appropriate skin assessment. Assessment may reveal dry skin, acne, or skin rashes. Table 30-1 summarizes recommended treatments for these skin problems. When documenting a physical assessment of the skin, describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings. The following are two examples of documentation of the physical assessment of the skin: "Skin is light brown, even tone, warm, dry, and elastic; no petechiae, lesions, or excoriation; multiple moles of small size and regular border and surface." "Red, macular rash generalized over trunk and thighs; semi-confluent lesions measure 1 to 2 mm; abrupt onset."

PHYSIOLOGY OF MOVEMENT AND ALIGNMENT Purposeful, coordinated movement of the body and maintenance of alignment require the integrated functioning of the musculoskeletal and nervous systems. The following sections review concepts related to movement and alignment. Skeletal System The framework of bones, the joints between them, and cartilage that protects our organs and allows us to move is called the skeletal system. Functions of this system include: Supporting the soft tissues of the body (maintains body form and posture) Protecting crucial components of the body (brain, lung, heart, spinal cord) Furnishing surfaces for the attachments of muscles, tendons, and ligaments, which, in turn, pull on the individual bones and produce movement Providing storage areas for minerals (such as calcium) and fat Producing blood cells (hematopoiesis) The 206 bones in the human body are classified by their shape. Long bones, found in the upper and lower extremities (e.g., humerus and femur), contribute to height and length. Short bones, located in the wrist and ankle, contribute to movement. Flat bones are relatively thin (e.g., ribs and several of the skull bones) and contribute to shape (structural contour). Irregular bones are all those bones not included in the preceding classifications (e.g., bones of the spinal column and jaw). Bones are too rigid to bend without damage. Therefore, all movements that change the positions of the bony parts of the body occur at joints. The terms articulation and joint refer to the area where a bone meets another bone. Joints are classified according to the amount of movement they permit and on the basis of the material between the adjoining bones. Types of joints are outlined in Table 32-1 . Diarthroses or synovial joints, joints in which there is a potential space containing lubricating synovial fluid between the articulating bones, are freely moving joints. Freely movable joints are discussed here in relation to the topic of activity.

Several types of freely movable joints are found in the body. These include: Ball-and-socket joint: The rounded head of one bone fits into a cuplike cavity in the other; flexion-extension, abduction-adduction, and rotation can occur (e.g., shoulder and hip joints). Condyloid joint: The oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur (e.g., wrist joint and joints connecting fingers to palm). Gliding joint: Flat surfaces of the bone slide over one another; flexion-extension and abduction-adduction can occur (e.g., carpal bones of wrist and tarsal bones of feet). Hinge joint: A spool-like (rounded) surface of one bone fits into a concave surface of another bone; only flexion-extension can occur (e.g., elbow, knee, ankle joints). Pivot joint: A ring-like structure that turns on a pivot; movement is limited to rotation (e.g., joints between the atlas and axis of the neck and between the proximal ends of the radius and the ulna at the wrist). Saddle joint: Bone surfaces are convex on one side and concave on the other; movements include flexion-extension, adduction-abduction, circumduction, and opposition (e.g., joint between the trapezium and metacarpal of the thumb). Movements possible at diarthrodial joints include abduction, adduction, flexion, extension, and rotation. Special movements of the forearm, ankle, and clavicle include supination, pronation, inversion, and eversion. The thumb is the only joint that can perform opposition. These movements are defined in Table 32-2 and illustrated in Skill 32-6.

Patients at Risk for UTIs

Sexually active women Women who use diaphragms for contraception Postmenopausal women Individuals with indwelling urinary catheter Individuals with diabetes mellitus Older adults

Respiratory Activity in the Child

Some subcutaneous fat is deposited on the chest wall, making landmarks less prominent. Eustachian tubes, bronchi, and bronchioles are elongated and less angular. The average number of routine colds and infections decreases until children enter daycare or school. Good hand hygiene and tissue etiquette are encouraged. By the end of late childhood, the immune system protects from most infections.

Evaluating Evaluation of wound and pressure ulcer care involves reassessment at regular intervals to monitor response to the treatment, determine the effectiveness of the treatment, and allow for necessary changes in the plan of care. The plan of care for the patient with a wound is evaluated based on the expected outcomes. Evaluation is ongoing throughout the care of the patient, with the plan being effective if no complications have occurred during wound healing, wound is progressing through the healing stages, and the patient or family has the knowledge and skill necessary for wound care at home, if appropriate. When evaluating the effectiveness of a plan of care designed to prevent the development of pressure ulcers or to treat pressure ulcers or other wounds already present, the nurse uses each nurse-patient interaction to determine if the patient has met the individualized expected outcomes in the plan of care. Nursing care is considered effective if the patient, family member, or caregiver expresses satisfaction with prevention and treatment measures and is able to accomplish the following: Participate effectively in preventive and treatment regimens Prevent development of any additional areas of skin breakdown Demonstrate progressive healing of pressure ulcer or other wound Improve overall physical condition (including nutritional state and mobility status) Remain free of infection at any pressure ulcer or other wound site Communicate the need for additional support (environmental, physical, psychosocial)

THE NURSING PROCESS FOR HEAT AND COLD THERAPY Assessing Before initiating heat or cold therapy, assess the patient's physical and mental status, the condition of the body area to be treated with heat or cold, and the condition of the equipment to be used. Carefully evaluate factors influencing the patient's ability to tolerate heat and cold applications. These factors are the basis for the following considerations: How long will the heat or cold be applied? Prolonged exposure increases tolerance, and rebound effects are undesirable. What body part is involved? Some body areas, such as the neck, perineum, and inner aspects of the wrist and forearm, are more sensitive to thermal changes. Is the skin intact? Open tissue or abraded skin is more sensitive to thermal changes. How large is the area? Applications of heat or cold to large areas of the body cause systemic responses and lower tolerance of temperature change. What is the patient's age? Infants, children, and older adults do not tolerate temperature changes as well as adults. What is the patient's physical condition? Patients with certain alterations in health, such as those with cardiovascular or peripheral vascular diseases, might have reduced response to or tolerance of thermal changes. Assessing Overall Status Assessing the patient's overall status includes obtaining a health history and completing a physical examination. A history of cardiovascular or peripheral vascular impairment, sensory impairment, and alterations in mental status, such as confusion or decreased level of consciousness, indicates the need for caution when using heat or cold because of the danger of tissue damage. Assessments include response to stimuli (sharp and dull), color and appearance of body tissues, circulation (pulses, blanching sign, temperature, color), level of consciousness, and orientation. Do not apply heat to an open wound immediately after the trauma; during hemorrhage; over noninflammatory edema; to an acutely inflamed area, a localized malignant tumor, the testes, or the abdomen of a pregnant woman; or over metallic implants. Conversely, do not use cold for open wounds or for patients with impaired peripheral circulation or allergy to cold. Assessing the Area of Application Perform baseline assessments to ensure safety and to evaluate the outcomes of therapy. The risk for damage to tissues is increased if the area is traumatized or has altered integrity. Assess for open lesions, blisters, wounds, edema, bleeding, or drainage or evidence of altered circulation such as changes in color, temperature, pulses, and sensation. As with any assessment, compare body parts bilaterally for changes. Tissues with decreased or absent pulses, those that appear pale or cyanotic, and those that feel cold to the touch indicate a decrease in circulation. Subsequently, the risk for injury from heat and cold applications increases. When the heat or cold is applied, make ongoing assessments to ensure patient safety and comfort. When heat is applied, assess the patient for undesired responses, including localized redness, blistering, and pain (symptoms of burning), along with possible systemic responses, such as hypotension and changes in consciousness. When cold is applied, assess for localized responses, including pallor, cyanosis, numbness, and pain.

Lifestyle Considerations Activity levels and habits can dramatically affect a person's cardiopulmonary status. For example, sedentary activity patterns do not encourage the expansion of alveoli and the development of pulmonary exercise patterns (deep breathing). People who exercise (e.g., aerobics, walking, swimming) three to six times per week can better respond to stressors to respiratory health. Regular physical activity provides many health benefits, including increased heart and lung fitness, improved muscle fitness, and reducing the risk of heart disease. Cultural influences can also play a role in a person's lifestyle, encouraging or discouraging healthy choices. Culture is a strong force in the determinants of health and behavior change. An understanding of a patient's cultural background is necessary to promote health and disease prevention in any population (Ritter & Hoffman, 2010). For example, consider the implications of the use of traditional methods for health restoration, such as cupping by patients of Chinese descent to treat lung congestion (Spector, 2009). An important part of care would be to assess the impact of this practice and belief on a patient's readiness to participate in the proposed plan of care related to the treatment of pneumonia. Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress, heart disease, and lung cancer. Cigarette smoking is the most important risk factor for chronic COPD (Macnee, 2007). Smoking causes coronary heart disease, the leading cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2010). Nurses working with patients to initiate changes in health habits that affect oxygenation must also examine themselves as a factor in the success of the plan. Nurses who role model good health behaviors are more effective teachers. Use the display, Promoting Health 38-1: Oxygenation, for yourself before using it with others. Environmental Considerations Although it is impossible to pinpoint all the effects of air pollution, researchers have demonstrated a high correlation between air pollution and cancer and lung diseases. For example, a person with adequate respiratory functioning who is exposed to air pollution may experience stinging of eyes and nasal passages, coughing, choking, headache, and dizziness. Occupational exposure to asbestos, silica, or coal dust, as well as environmental pollution, can lead to chronic pulmonary disease. Chronic exposure to radon, radiation, asbestos, and arsenic can lead to lung cancer. Additionally, people who have experienced an alteration in respiratory functioning in the past often have difficulty continuing to perform self-care activities in a polluted environment. Psychological Health Considerations Many psychological factors and conditions can affect the respiratory system. People responding to stress may sigh excessively or exhibit hyperventilation (increased rate and depth of ventilation, above the body's normal metabolic requirements). Hyperventilation can lead to a lowered level of arterial carbon dioxide. Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of bronchial asthma. In addition, patients with respiratory problems often develop some anxiety as a result of the hypoxia caused by the respiratory problem. Think back to Tyrone Jacobs, the young boy described at the beginning of the chapter. The patient is gasping for breath, which is extremely frightening and anxiety producing. In addition, his parents are frantic; this would increase Tyrone's anxiety level, further limiting his ability to breathe. The nurse needs to incorporate an understanding of this situation and plan interventions that promote oxygenation while reducing anxiety in both Tyrone and his parents.

THE NURSING PROCESS FOR OXYGENATION Assessing The patient's health history is an essential component for assessing the patient's cardiopulmonary function and ability to maintain adequate oxygenation. This information can be obtained from either the patient or a family member. The nursing examination combined with laboratory findings can provide information to identify a patient's strengths; the nature of any problems; their course; related signs and symptoms; and onset, frequency, and effects on activities of daily living. The nurse decides, based on these findings, what problems can be treated independently by nursing. Other problems are referred to a physician and/or other collaborative professionals for decisions on treatment. Nursing History The nursing history, an important clinical tool in the early steps of the nursing process, always includes a cardiopulmonary component. The information gained provides data about why the patient needs nursing care and what kind of care is required to maintain sufficient oxygenation of tissues. Interview questions help identify current or potential health deviations, actions performed by the patient for meeting cardiopulmonary needs, and the effects of such actions. They also help identify any contributing factors, the use of any aids to improve oxygenation, and effects of health problems on the patient's lifestyle and relationships with others. Before starting the interview, make certain that the patient is not in acute distress. If the patient is experiencing any respiratory distress, initiate appropriate actions immediately to help relieve symptoms. Enlist the aid of family members or others to help answer questions. Interview the patient at a later point, when the patient is able, to expand the initial database. If no emergency interventions are necessary for the patient's clinical condition, obtain a comprehensive history at this time. When a health deviation is noted during the data collection, collect as much descriptive information as possible, including whether the problem evolved suddenly or slowly. The accompanying Focused Assessment Guide 38-1 provides some appropriate questions for health history assessment related to oxygenation.

Ensuring Bedside Safety

The bed is in its lowest position. The bed position is safe for the patient. The bed controls are functioning (bed is electrically safe). Call light is functioning and always within reach Side rails are raised if indicated. The wheels or casters are locked. Hmmmm???? An opportunity for select all that apply

Remittent fever

The body temperature does not return to normal and fluctuates a few degrees up or down.

Planning: Expected Outcomes

The client will demonstrate improved gas exchange in lungs by absence of cyanosis or chest pain and a pulse oximetry reading >95% within 5-10 min of receiving bronchodilator. Relate the causative factors and demonstrate adaptive method of coping. Preserve pulmonary function by maintaining an optimal level of activity. Demonstrate self-care behaviors that provide relief from symptoms and prevent further problems.

Inspiration: the active phase of ventilation Involves movement of muscles and the thorax to bring air into the lungs Expiration: the passive phase of ventilation Movement of air out of the lungs Note: It takes one full inhalation and one full exhalation to comprise a full breath

The diaphragm contracts and descends, lengthening the thoracic cavity. The external intercostal muscles contract, lifting the ribs upward and outward. The sternum is pushed forward, enlarging the chest from front to back Increased lung volume and decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lungs) to lesser pressure (inside lungs). The relaxation of these structures results in expiration.

Cardiac Exercise Stress Testing

This procedure is a noninvasive way to evaluate the response of the cardiovascular system to physical stress, helping to identify the presence of coronary artery disease, the cause of chest pain, the functional capacity of the heart, the effectiveness of some cardiac medications, and evaluate dysrhythmias that occur during exercise. The patient exercises on a treadmill or pedals a stationary bicycle while the patient's electrocardiogram and blood pressure are monitored. The study is performed in a series of stages, gradually increasing the speed or resistance, until the patient reaches 85% of the maximum heart rate, becomes symptomatic, or displays changes on the electrocardiogram consistent with ischemia.

Commonly Measured Values from Pulmonary Function Tests

Tidal volume (TV): Total amount of air inhaled and exhaled with one breath Vital capacity (VC): Maximum amount of air exhaled after maximum inspiration Forced vital capacity (FVC): Maximum amount of air that can be forcefully exhaled after a full inspiration Forced expiratory volume (FEV): The amount of air exhaled in the first second after a full inspiration; can also be measured at 2 or 3 seconds Total lung capacity (TLC): The amount of air contained within the lungs at maximum inspiration Residual volume (RV): The amount of air left in the lungs at maximal expiration Peak expiratory flow rate (PEFR): The maximum flow attained during the FVC

MEASURING URINE OUTPUT Measuring the patient's fluid intake and output is an important nursing responsibility. Accuracy of the total fluid intake and output from all sources aids in identifying potential alterations in fluid balance and is essential for planning the patient's nursing and medical care. The measurement of fluid intake and output is described further in Chapter 39. Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. Goggles also are worn whenever there is a concern of urine splashing. The measurement of fluid intake and output may be delegated to unlicensed personnel. However, the nurse is responsible for ensuring that staff members understand the required procedures, and the nurse must validate the accuracy of the measurements. Measuring Urine Output in Patients Who Are Continent. Patients who have self-control over urination are continent. The procedure for measuring the urine output of a patient who is continent and voiding is as follows: 1. Ask the patient to void into a bedpan, urinal, or specimen hat, either in bed or in the bathroom. Urinary devices used to collect or measure urine are shown in Figure 36-5 . 2. Pour the urine from the collection device into the appropriate measuring device provided by the agency. The devices are calibrated in milliliters. Collection devices may be calibrated for measurement, eliminating the need for an additional measuring device. 3. Place the calibrated container on a flat surface, such as a shelf, for an accurate reading. Reading at eye level, note the amount of urine voided and record it in the patient's electronic record. Record the total amount voided during each shift. The total for the 24-hour period is usually calculated by the electronic record computer software. Alternately, the information may be recorded in a paper form at the bedside. Figure 36-6 shows a paper form used for recording urine output. 4. Discard the urine in the toilet unless a specimen is required. If a specimen is required, pour the urine into an appropriate specimen container.

To ensure that all voided urine is measured, be sure to tell ambulatory patients when their urine output is to be measured and recorded. A specimen hat is a valuable device that can be placed under the toilet seat to collect and measure voided urine for ambulatory patients (see Fig. 36-5). Patients who are willing and able can be taught to measure and record their own output. Measuring Urine Output in Patients Who Are Incontinent. Urinary incontinence is the involuntary or uncontrolled loss of urine from the bladder. It is difficult to accurately measure urinary output for incontinent patients. Note the number of times the patient is incontinent and any notable urine characteristics, such as color and odor. Additional nursing interventions are required to collect urine for measurement. Use of scheduled toileting (assisting the patient to the toilet to attempt to void on a regular basis, such as every 2 hours) can assist in obtaining urine for measurement, for required laboratory specimens, and prevent incontinence. Urinary incontinence is discussed in more detail later in the chapter. Measuring Urine Output in Patients With an Indwelling Catheter. For patients with an indwelling catheter, the procedure for measuring urine output is as follows: 1. Put on clean gloves. 2. Place a calibrated measuring device beneath the urine collection bag at the bedside. To prevent the spread of infection, patients should have their own calibrated measuring device. 3. Place the drainage spout from the collection bag above, but not touching, the calibrated measuring device, and open the clamp. 4. Allow the urine to flow from the collection bag into the measuring device. 5. Reclamp the drainage tube, wipe the spout of the tube with an alcohol pad, and replace the tube into the slot on the drainage bag. Proceed with measurement of urine as described earlier.

EQUIPMENT AND ASSISTIVE DEVICES Many devices and equipment are available to aid in transferring, repositioning, and lifting patients. It is important to use the right equipment and appropriate device based on patient assessment and desired movement. Gait Belts. A gait belt is a device used for transferring patients and assisting with ambulation (Fig. 32-10). The belt, which often has handles, is placed around the patient's waist and secured by Velcro fasteners. The handles can be placed in a variety of configurations so that the caregiver can have better access to, improved grasp of, and control of the patient. Some belts are hand-held slings that go around the patient, providing a firm grasp for the caregiver and facilitating the transfer. The gait belt is used to help the patient stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. Do not use gait belts on patients with abdominal or thoracic incisions (OSHA, 2009). Stand-Assist and Repositioning Aids. Some patients need minimal assistance to stand up. With an appropriate support to grasp, they can lift themselves. Many types of devices can help a patient to stand. These devices can be freestanding or attached to the bed or wheelchair. Other aids have a pull bar to assist the patient to stand, and then a seat unfolds under the patient. After the patient sits on the seat, the device can be wheeled to the toilet, chair, shower, or bed. Lateral-Assist Devices. Lateral-assist devices reduce patient-surface friction during side-to-side transfers. Roller boards, slide boards, transfer boards, inflatable mattresses, and friction-reducing lateral-assist devices are examples of these devices, which make transfers safer and more comfortable for the patient. For example, an inflatable lateral-assist device is a flexible mattress that is placed under the patient. An attached, portable air supply then inflates the mattress, which provides a layer of air under the patient. This air cushion allows nursing staff to perform the move with much less effort (Baptiste, Boda, Nelson, Lloyd, & Lee, 2006), but has been found to place the care providers at an increased risk of injury because of the horizontal reach required, posture adopted during transfer, and lack of handles (Nelson & Baptiste, 2004). Another example is a transfer board, usually made of smooth, rigid, low-friction material (such as coated wood or plastic). The board, which is placed under the patient, provides a slick surface for the patient during transfers, reducing friction and the force required to move the patient. A third type of lateral sliding aid is made of a special fabric that reduces friction. Some devices have long handles that reduce reaching by staff to improve safety and make the transfer easier (Fig. 32-11). Friction-Reducing Sheets. Friction-reducing sheets can be used under patients to prevent skin shearing when moving patients in bed and when assisting with lateral transfers. Their use reduces friction and the force required to move patients. Mechanical Lateral-Assist Devices. Mechanical lateral-assist devices include specialized stretchers and eliminate the need to slide the patient manually. Some devices are motorized, whereas others use a hand crank. A portion of the device moves from the stretcher to the bed, sliding under the patient, bridging the bed and stretcher (Fig. 32-12). The device is then returned to the stretcher, effectively moving the patient without any pulling by staff members.

Transfer Chairs. Chairs that can convert into stretchers are available. These are useful with patients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the patient. Some of these chairs have built-in mechanical aids to perform the patient transfer, as detailed previously. Powered Stand-Assist and Repositioning Lifts. These devices can be used with patients who can bear weight on at least one leg, can follow directions, and are cooperative. A simple sling is placed around the patient's back and under the arms. Some devices come with breathable slings that can remain under the patient, reducing the risk for the nurse in turning the patient to position the sling. The patient rests the feet on the device's footrest and places the hands on the handle. The device mechanically assists the patient to stand, without any assistance from the nurse (Fig. 32-13). Once the patient is standing, the device can be wheeled to a chair, the toilet, or bed. Some devices have removable footrests and can be used as a walker. Some have scales incorporated into the device that can be used to weigh the patient. Powered Full-Body Lifts. These devices are used with patients who cannot bear any weight to move them out of bed, into and out of a chair, and to a commode or stretcher. A full-body sling is placed under the patient's body, including head and torso, then the sling is attached to the lift (Fig. 32-14). As mentioned previously, some of these slings are made to stay under the patient to decrease strain on the staff during placement. The device slowly lifts the patient. Some devices can be lowered to the floor to pick up a patient who has fallen. These devices are available on portable bases and ceiling-mounted tracks.

Types of Urinary Incontinence

Transient: appears suddenly and lasts 6 months or less Mixed: urine loss with features of two or more types of incontinence Overflow: overdistention and overflow of bladder Functional: caused by factors outside the urinary tract Reflex: emptying of the bladder without sensation of need to void Total: continuous, unpredictable loss of urine

Managing Chest Tubes ONLY assist with insertion and removal of the chest tube....in other words, do not pull one independently. Monitor the patient's respiratory status and vital signs. Check the dressing. Maintain the patency and integrity of the drainage system. Measure and mark output q shift Note the type of drainage ALWAYS have a hemostat & Vaseline gauze at the bedside

Types of Cough Medications Cough suppressants Expectorants Lozenges Promoting Comfort Positioning Maintaining adequate fluid intake Providing humidified air Performing chest physiotherapy Maintaining good nutrition Pacing physical activities

Nursing History In the nursing history, question the patient (or caregiver) about usual voiding habits and any current or past voiding difficulties. Box 36-1 lists some additional terms that can be used to describe several urinary problems. When interacting with patients, use terminology that the patient and/or the caregiver understands. The accompanying Focused Assessment Guide 36-1 lists elements of a urinary elimination history that should be incorporated into the initial nursing assessment. With infants, assess the number of wet diapers per day that the infant produces. Newborns should have six to eight wet diapers per day (Kyle & Carman, 2013). With young children, assess whether the child has achieved bladder control during both day and nighttime. Be sure to indicate on the nursing history and care plan the words that the child uses to indicate the need to void. With older adults, decreased bladder tone may be a problem. Note on the nursing history any problems, how the person normally handles these problems, and your judgment of the adequacy of the solution. Patients with urinary diversions may have established individualized personal care routines. A urinary diversion involves the surgical creation of an alternate route for excretion of urine and is discussed later in the chapter. Assess the procedures and equipment used by patients to make sure they follow accepted guidelines and do not predispose themselves to infection or other risk. Record in both the history and the nursing plan of care any special routine, equipment, or supplies the patient uses for urinary elimination. When a patient (or caregiver) reports a problem with voiding, explore its duration, severity, and precipitating factors. Also, note the patient's perception of the problem and the adequacy of the patient's self-care behaviors. Physical Assessment The physical assessment of urinary functioning includes an examination of the urinary bladder, if indicated, urethral meatus, skin, and urine. The kidneys are normally well protected by considerable fat and connective tissue, making palpation difficult. Palpation of the kidneys is usually performed as part of a more detailed assessment. This technique requires deep palpation and is generally assessed by advanced health care professionals, such as an advanced practice nurse or physician. BLADDER Assessment of the bladder may be indicated when patients experience difficulty voiding or other alterations in elimination. The bladder is normally positioned below the symphysis pubis and cannot be palpated or percussed when empty. When the bladder is distended, it rises above the symphysis pubis and may reach to just below the umbilicus (Fig. 36-4). Before palpating the bladder, always ask when the patient voided last. Observe the lower abdominal wall, noting any swelling, and palpate this area for tenderness. Note the smoothness and roundness of the bladder. Measure the height of the edge of the bladder above the symphysis pubis. A bedside scanner is another way to assess the bladder. These portable bladder ultrasound devices create an image of the patient's bladder and calculate urine volume present in the bladder. This method is noninvasive and painless. A bladder scan can be performed at the bedside, poses no risk for infection, and is a safer alternative to catheterization to determine bladder urine volume. Results are most accurate when the patient is in the supine position during the scanning. Skill 36-1 outlines the procedure for assessing bladder volume using an ultrasound bladder scanner.

URETHRAL ORIFICE Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor. In females, the urethral meatus is a slit-like opening below the clitoris and above the vaginal orifice. Place female patients in the dorsal recumbent position with the inner labia retracted for good visualization of the meatus. In males, the meatus is at the tip of the penis. If the male patient is uncircumcised, retract the foreskin to visualize the meatus. SKIN INTEGRITY AND HYDRATION Because problems with urinary functioning may result in disturbances in hydration and excretion of body wastes, assess the skin carefully for color, texture, and turgor. Assess the integrity of the skin in the perineal area. Problems with incontinence may result in severe excoriation (abrasion of the epidermis). Urine Characteristics Assess the patient's urine for color, odor, clarity, and the presence of any sediment. Note any abnormalities. In select patients, monitor the pH and specific gravity of the urine (which is a measure of the density of urine compared with the density of water) and check the urine for abnormal constituents such as protein, blood, glucose, ketone bodies, and bacteria (see the section entitled Point of Care Urine Testing on p. 1277). The normal characteristics of urine are detailed in Table 36-1. Special Assessment Techniques In addition to the nursing history and physical examination, the nurse gathers data about urinary elimination through the following assessment measures: measuring urine output, collecting urine specimens, performing point of care urine testing, and assisting with diagnostic procedures. These are discussed in the following sections.

Factors Affecting the Skin

Unbroken and healthy skin and mucous membranes defend against harmful agents. Resistance to injury is affected by age, amount of underlying tissues, and illness. Adequately nourished and hydrated body cells are resistant to injury. Adequate circulation is necessary to maintain cell life.

Variables Leading to Back Injury in Health Care Workers

Uncoordinated lifts Manual lifting and transferring of patients without assistive devices Lifting when fatigued or after recent back injury recovery Repetitive movements such as lifting, transferring, and repositioning patients Standing for long periods of time Transferring patients Transferring/repositioning uncooperative or confused patients

Included in the targeted infections are four categories that are responsible for a majority of HAIs in the acute care hospital setting. These include:

Urinary tract infections Surgical site infections Bloodstream infections Pneumonia (USDHHS, 2012b)

Catheterized patients who are acutely ill may require hourly measurements of urine. This is facilitated by using a special collection bag that has a built-in calibrated measuring chamber called a urimeter (see Fig. 36-5). After assessing and recording the amount of urine produced hourly, tilt the measuring chamber so that this urine flows into the general collection bag. This empties the measuring chamber, making it ready to collect the next hour's urine. COLLECTING URINE SPECIMENS Different techniques are used for collecting urine specimens. The nurse needs to understand the rationale for the specific test ordered, as well as the correct collection procedure associated with the required test in order to ensure obtaining the appropriate urine sample. Routine Urinalysis. A sterile urine specimen is not required for a routine urinalysis. Collect urine by having the patient void into a clean bedpan, urinal, or receptacle (e.g., a specimen hat in the toilet bowl). Take care to avoid contamination with feces. If a woman is menstruating when a urine sample is obtained, note this on the laboratory slip because red blood cells may appear in the urine. When patients are voiding into a bedpan or collection device on the toilet, instruct them not to place toilet tissue into the urine because this makes analysis more difficult. Using aseptic technique, pour the urine into an appropriate container; label it with the patient's name, date, and time of collection; package it appropriately; and send it to the laboratory for examination. Do not leave urine standing at room temperature for a long period before sending it to the laboratory because this may alter both the appearance and chemistry of the urine. Clean-Catch or Midstream Specimen. A clean-catch specimen of urine is required in some situations. Most health care agencies specify that a clean-catch specimen be collected during midstream. This means that the patient voids and discards a small amount of urine; continues voiding in a sterile specimen container to collect the urine; stops voiding into container; removes container and continues voiding; then discards the last amount of urine in the bladder. The first small amount of urine voided helps to flush away any organisms near the meatus because the findings may be inaccurate if these organisms enter the specimen. Additionally, it is generally thought that urine voided at midstream is most characteristic of the urine the body is producing. p. 1274 p. 1275 FIGURE 36-6. An example of a paper form used for recording intake and output. Concept Mastery Alert A clean-catch midstream urine specimen is considered a sterile specimen. A patient who can carry out the technique properly may collect one's own clean-catch midstream urine specimen and often prefers to do so. The nurse provides the appropriate equipment and instructions for the procedure. Refer to Guidelines for Nursing Care 36-1: Obtaining a Clean-Catch or Midstream Urine Specimen . Sterile Specimen. Sterile urine specimens may be obtained by catheterizing the patient's bladder or by taking the specimen from an indwelling catheter already in place. (Refer to the Catheterizing the Patient's Bladder discussion and Guideline 36-2.) When it is necessary to collect a urine specimen from a patient with an indwelling catheter, always obtain it from the catheter itself using the special port for specimens. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and possibly a clamp. The size of the syringe for the specimen depends on the specific laboratory test. A urine culture requires about 3 mL, whereas routine urinalysis requires at least 10 mL of urine. Also, check the catheter to determine if an access port for specimen removal is present. Wearing gloves protects the nurse from any contact with the specimen. If urine is not present in the tube, clamp the tube below the access port briefly (not to exceed 30 minutes) to allow urine to accumulate. Clean the access port with an antiseptic swab, and carefully attach the syringe to the port (Fig. 36-7). Aspirate urine into the syringe, remove the syringe, release the clamp if one was used, and transfer the specimen to the appropriate container. Label the specimen with the patient's name, date, and time of collection; then package and transport the specimen according to facility policy.

Urine Specimens from a Urinary Diversion. Urine specimens can be obtained from urinary diversions. Clean urine specimens can be obtained from a urinary diversion appliance into a clean container for a routine urinalysis (Williams, 2012). If a urine sample is needed for culture and sensitivity, it can be obtained by two methods. The preferred method is to catheterize the stoma. Remove the stoma appliance and clean the stoma site with warm water. Using sterile technique, insert the urinary catheter into the stoma site and advanced 2 to 2.25 inches. If there is resistance, rotate the catheter gently until it slides forward. If there is continued resistance, do not force the catheter any further (Williams). After collection of a sufficient amount of urine, remove the catheter and reapply the stoma appliance. 24-Hour Urine Specimens. For some laboratory studies, 24-hour specimen collection is required. The patient and the entire nursing team must understand the importance of collecting all the urine voided in a 24-hour period. Post a sign on the patient's bathroom door as a helpful reminder not to discard urine. Initiate a collection at a specific time (which is recorded) by asking the patient to empty the bladder. Discard this urine and then collect all urine voided for the next 24 hours. At the end of the 24 hours, ask the patient to void. Add this urine to the previously collected urine, and then send the entire specimen to the laboratory. Depending on the type of examination, the urine from each voiding may be kept in a separately marked container and the time of each voiding recorded, or all urine voided may be collected in a common receptacle. The laboratory usually specifies whether a preservative is used to retard decomposition and whether the specimen is to be refrigerated or kept on ice. In some situations, the patient may be required to collect the specimen at home. Many laboratories have a transport service that picks up specimens from a patient's home and returns them to the laboratory within the appropriate time frame. FIGURE 36-7. Obtaining a urine specimen from an indwelling urinary catheter. (A) Use an antiseptic swab to clean the access port. (B) Attach syringe and aspirate urine into the syringe. (Photos by B. Proud.) FIGURE 36-8. Disposable urine collection device for infants and young children. Specimens From Infants and Children. Plastic disposable collection bags are available for collecting urine specimens from infants and young children who have not achieved voluntary bladder control (Fig. 36-8). Follow the manufacturer's instructions and take care when applying and removing the bag to avoid irritating the sensitive perineal skin.

State of Health The state of a person's health and therapeutic treatments have a direct effect on the condition of the skin. Proper nutrition, adequate circulation, and good overall health are important for healthy skin. Very thin and very obese people tend to be more susceptible to skin irritation and injury. Fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body. This is termed dehydration and makes the skin appear loose and flabby. Excessive moisture such as perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. Excessive moisture may also occur as a result of incontinence of urine and/or stool. Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry; patients with jaundice are more likely to scratch their skin and cause an open lesion, with the potential for infection. Diseases of the skin such as eczema and psoriasis may have a genetic predisposition and often cause lesions that require special care.

WOUNDS AND PRESSURE ULCERS A wound is a break or disruption in the normal integrity of the skin and tissues. That disruption may range from a small cut on a finger to a third-degree burn covering almost all of the body. Wounds may result from mechanical forces (such as surgical incisions) or physical injury (such as a burn). Examples of types of wounds and their causes are highlighted in Table 31-3.

Kidneys and Ureters The kidneys are located on either side of the vertebral column behind the peritoneum, in the upper abdominal cavity. One of the more significant functions of the kidneys is to help maintain the composition and volume of body fluids. About once every 30 minutes, the body's total blood volume passes through the kidneys for waste removal. The kidneys filter and excrete blood constituents that are not needed and retain those that are. Despite varying kinds and amounts of food and fluids ingested, body fluids remain relatively stable if the kidneys are functioning properly. Urine, the waste product excreted by the kidneys, contains organic, inorganic, and liquid wastes. The nephron is the basic structural and functional unit of the kidneys. There are about 1 million nephrons in each kidney. Each nephron consists of a complicated system of arterioles, capillaries, and tubules. Nephrons remove the end products of metabolism, such as urea, creatinine, and uric acid from the blood plasma and form urine. The nephrons maintain and regulate fluid balance through the mechanisms of selective reabsorption and secretion of water, electrolytes, and other substances. Once formed, urine from the nephrons empties into the pelvis of each kidney. From each kidney, urine is transported by rhythmic peristalsis through the ureters to the urinary bladder. The ureters enter the bladder obliquely. A fold of membrane in the bladder closes the entrance to the ureters so that urine is not forced up the ureters to the kidneys when pressure exists in the bladder. Figure 36-1 shows the male and female urinary systems and the position of the kidneys and ureters in the abdomen.

lateral view of the male urinary tract (right). p. 1266 p. 1267 Bladder The urinary bladder is a smooth muscle sac that serves as a temporary reservoir for urine. It is composed of three layers of muscle tissue: the inner longitudinal layer, the middle circular layer, and the outer longitudinal layer. These three layers are called the detrusor muscle. At the base of the bladder, the middle circular layer of muscle tissue forms the internal, or involuntary, sphincter, which guards the opening between the urinary bladder and the urethra. The urethra conveys urine from the bladder to the exterior of the body. The urinary bladder muscle is innervated by the autonomic nervous system. The sympathetic system carries inhibitory impulses to the bladder and motor impulses to the internal sphincter. These impulses cause the detrusor muscle to relax and the internal sphincter to constrict, retaining urine in the bladder. The parasympathetic system carries motor impulses to the bladder and inhibitory impulses to the internal sphincter. These impulses cause the detrusor muscle to contract and the sphincter to relax. The urinary bladder is shown in Figure 36-2. The bladder normally contains urine under very little pressure. As the volume of urine increases, the pressure increases only slightly. The bladder wall is able to adapt to this pressure because of the muscle tissue in the bladder. This makes it possible for urine to continue to enter the bladder from the ureters against low pressure. When the pressure becomes sufficient to stimulate nerves in the bladder wall (stretch receptors), the person feels a desire to empty the bladder. Urethra The urethra's function is to transport urine from the bladder to the exterior of the body. The anatomy of the urethra differs in males and females. The male urethra functions in the excretory system and the reproductive system. It is about 5 1/2″ to 6 1/4″ (13.7 to 16.2 cm) long and consists of three parts: the prostatic, the membranous, and the cavernous portions (Fig. 36-3). The external urethral sphincter consists of striated muscle and is located just beyond the prostatic portion of the urethra. The external sphincter is under voluntary control. In contrast, the female urethra is about 1 1/2″ to 2 1/2″ (3.7 to 6.2 cm) long. The external, or voluntary, sphincter is located in the middle of the urethra. No portion of the female urethra is external to the body, as in the male, although the muscle at the meatus is usually called the external sphincter. Act of Urination The process of emptying the bladder is known as urination, micturition, or voiding. The nerve centers for urination are situated in the brain and the spinal cord. Urinating, or voiding, is largely an involuntary reflex act, but its control can be learned. The voluntary control of urination develops as the higher nerve centers develop after infancy. Until that time, voiding is purely a reflex action. People whose bladders are no longer controlled by the brain because of injury or disease also void by reflex only. This is called autonomic bladder. Stretch receptors in the bladder are stimulated as the urine collects. The person feels a desire to void, usually when the bladder fills to about 150 to 250 mL in an adult. The pressure within the bladder is many times greater during urination than it is during the time the bladder is filling. When urination is initiated, the detrusor muscle contracts, the internal sphincter relaxes, and urine enters the posterior urethra. The muscles of the perineum and the external sphincter relax, the muscle of the abdominal wall contracts slightly, the diaphragm lowers, and urination occurs. The act of urination is normally painless. The voluntary control of voiding is limited to initiating, restraining, and interrupting the act. Restraint of voiding is thought to occur subconsciously when the volume of urine in the bladder is small. If voiding is delayed, however, the bladder continues to fill. Discomfort may then be felt when undue distention occurs, and the urgency to void becomes paramount. Sometimes, increased abdominal pressure—such as occurs during coughing and sneezing—forces an involuntary escape of urine. This is a particular problem for some women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence. Urinary incontinence is discussed in detail later in the chapter. Strong psychological factors, such as marked fear, may also result in involuntary urination. Alternately, in certain conditions, it may be difficult for a person to relax the restraining muscles sufficiently to void, such as when a shy or embarrassed person needs to give a urine specimen.

AUSCULTATION Change in Breathing Sounds Click to Show Auscultation of the lungs assesses air flow through the respiratory passages and lungs. Listen for normal and abnormal lung sounds. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Auscultate as the patient breathes slowly through an open mouth. Breathing through the nose can produce falsely abnormal breath sounds. In addition to air flow, listen for adventitious sounds (extra, abnormal sounds of breathing), such as wheezing or crackles. Abnormal lung sounds can occur as a result of alterations in the respiratory and cardiovascular systems and lead to impaired oxygenation. Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. They are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. They are often heard in patients with asthma, tumors, or a buildup of secretions. Auscultation of the heart assesses function of the heart, heart valves, and blood flow. Listen for normal and abnormal heart sounds. Listen to the rhythm of the beat and the characteristic "lub-dub." The first sound, the lub, is followed by the second sound, the dub, with a pause before the next lub-dub. These sounds are made by the closure of valves in the heart during the cardiac cycle. The lub correlates with the beginning of systole, the contraction of the ventricles, and is called S1. The dub correlates with the end of systole and the beginning of diastole, the relaxation of the ventricles, and is called S2. In addition to S1 and S2, listen for extra and abnormal heart sounds. Abnormal heart sounds occur as a result of alterations in the cardiovascular system that may lead to impaired oxygenation. Refer to Chapter 25 for a detailed discussion of auscultation as part of the assessment of the respiratory and cardiovascular systems.

x

Assess for perineal or vaginal problems and related treatments. Perform a physical assessment of male and female genitalia...(If indicated) Perform perineal care in matter-of-fact and dignified manner according to procedure. Cleanse vaginal area with plain soap and water. Wipe from front to back

x

ASSESSING BLOOD PRESSURE AT THE BRACHIAL ARTERY It is recommended that blood pressure should be checked in both arms at the first examination. It has been shown that most individuals have differences in blood pressure readings between arms. When there is a consistent interarm difference, the arm with the higher pressure should be used (Pickering et al., 2004). A brachial artery blood pressure assessment should not be taken on an arm with an intravenous line or with an arteriovenous fistula or shunt. Blood pressure assessment should also be avoided in the arm on the side of an axillary node dissection or mastectomy because the pressure may increase the risk of lymphedema developing in the affected arm. Skill 24-4 describes how to assess the blood pressure using the brachial artery. Table 24-10 describes the common causes associated with blood pressure assessment errors.

ASSESSING BLOOD PRESSURE AT THE POPLITEAL ARTERY When the patient's brachial artery is inaccessible and/or the use of the upper arm is contraindicated, the nurse can assess the blood pressure using the popliteal artery in the leg. The systolic pressure is normally 10 to 40 mm Hg higher at this site, although the diastolic pressure is the same. The technique for assessment is outlined in Guidelines for Nursing Care 24-7.

Factors Affecting Blood Pressure

Age- older adults have decreased elasticity of the arteries, which increase BP D/T increased peripheral resistance Gender- women usually have lower BP then men until menopause Race-is a factor that affects BP. African American men & women are at risk for hypertension Circadian rhythm-Normal fluctuations occur Food intake-BP increases after meals Exercise-SBP increases with activity

Practicing Basic Principles of Surgical Asepsis

Allow only a sterile object to touch another sterile object. Unsterile touching sterile means contamination has occurred. Open sterile packages so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile surface touching unsterile clothing. The outside of the sterile package is considered contaminated. Opening a sterile package is shown and described in Skill 23-3. Avoid spilling any solution on a cloth or paper used as a field for a sterile setup. The moisture penetrates through the sterile cloth or paper and carries organisms by capillary action to contaminate the field. A wet field is considered contaminated if the surface immediately below it is not sterile. Hold sterile objects above the level of the waist. This will ensure keeping the object within sight and preventing accidental contamination. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. Never walk away from or turn your back on a sterile field. This prevents possible contamination while the field is out of the worker's view. Keep all items sterile that are brought into contact with broken skin, or used to penetrate the skin to inject substances into the body, or to enter normally sterile body cavities. These items include dressings used to cover wounds and incisions, needles for injection, and tubes (catheters) used to drain urine from the bladder. Use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile. Consider the edge (outer 1 inch) of a sterile field to be contaminated. Consider an object contaminated if you have any doubt as to its sterility.

Immune Response

Another defense system is the immune response. The immune response involves specific body responses to an invading foreign protein, such as bacteria, or in some cases, to the body's own proteins. The complex mechanisms that constitute the immune response occur as the body attempts to protect and defend itself. The foreign material is called an antigen, and the body commonly responds to the antigen by producing an antibody. This antigen-antibody reaction, also known as humoral immunity, is one component of the overall immune response. The other component that also helps the body defend against invaders is a cell-mediated defense, or cellular immunity. It involves an increase in the number of lymphocytes (white blood cells) that destroy or react with cells the body recognizes as harmful. Although these complicated chemical and mechanical responses are not completely understood, it is known that they help to defend the body specifically against bacterial, viral, and fungal infections, as well as malignant cells.

Bacteria. Two types of bacterial flora are normally found on the hands: transient bacteria and resident bacteria (Table 23-2). Transient bacteria, although usually easily removed by thorough handwashing, have the potential to adjust to the environment of the skin when they are present in large numbers over a long period and become resident bacteria. If pathogenic organisms become resident bacteria on the skin, the hands then become carriers of the particular organism. Therefore, to help prevent transient bacteria from becoming resident bacteria, it is important to clean the hands promptly when they are visibly soiled, after each contact with contaminated materials, and after removing gloves. (See the accompanying PICO in Practice box.) In addition, the CDC Guideline for Hand Hygiene in Health-Care Settings (2002) specifies that health care personnel involved in patient care should not wear artificial nails because they are more likely to be associated with higher bacterial counts. In fact, wearing artificial nails in the operating room (OR) is a citable offense during The Joint Commission accreditation process. Natural nails should be less than one quarter (1/4) of an inch long.

Cleansing Agents. Various hand hygiene products are available. Soaps and detergents, also referred to as nonantimicrobial agents, are considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganisms. They help remove soil because they lower surface tension and act as emulsifying agents. Bar, liquid, leaflet, and powdered soaps are all effective. Use of a particular type in a health care agency often depends on personnel or agency preference. Using handwashing products that contain an antimicrobial or antibacterial ingredient is recommended in any setting where the risk for infection is high. When present in certain concentrations, these agents can kill bacteria or suppress their growth. Numerous studies have documented that alcohol-based handrubs, in most situations, more effectively reduce bacterial and viral counts on the hands of health care personnel than antimicrobial soap does (Institute for Healthcare Improvement [IHI], 2011). Alcohol-based handrubs have an alcohol concentration between 60% and 95% and are available as foam, gel, or lotions. Techniques. If the health care worker's hands are not visibly soiled, alcohol-based handrubs are recommended because they save time, are more accessible and easy to use, and reduce bacterial count on the hands.

When used repeatedly, alcohol-based handrubs cause less dryness and skin irritation than soap products do. Those who have sensitive skin may benefit from use of an alcohol-based product that contains lotion. See Guidelines for Nursing Care 23-1 for directions on how to use an alcohol-based handrub.

Controversy does exist regarding the use of alcohol-based handrubs when C. difficile organisms have been identified. C. difficile is a gram-positive, anaerobic, spore-forming bacterium that is a common cause of diarrhea affecting children, adults, and older adults. The morbidity and mortality associated with C. difficile infections (CDI) has motivated health care providers to improve prevention strategies. Alcohol does not kill C. difficile spores. In fact, soap and water is considered more effective at removing C. difficile spores from the hands of health care providers when an outbreak of C. difficile occurs (Jabbar et al., 2010). Therefore, soap and water is the preferred hand hygiene method. However, additional information seems to confirm that glove use is the best preventative measure to control this infection

If patient goals have been met and evaluative criteria have been satisfied, the patient will accomplish the following:

Correctly use techniques of medical asepsis Identify health habits and lifestyle patterns that promote health State the signs and symptoms of an infection Identify unsafe situations in the home environment

Equipment Body temperature, measured in degrees, may be assessed with a variety of devices—electronic and digital thermometers, tympanic membrane thermometers, disposable single-use thermometers, temporal artery thermometers, and automated monitoring devices. Figure 24-1 illustrates several different types of thermometers. No matter which type of thermometer is used, it is very important to follow the manufacturer's instructions to ensure an accurate measurement. Body temperature is documented in either Celsius or Fahrenheit degrees. Table 24-4 provides equivalent Celsius and Fahrenheit values as well as a method for conversion. Glass thermometers with mercury-filled bulbs have been used in the past for measuring body temperature. They are not used in health care institutions, based on federal safety recommendations (U.S. Environmental Protection Agency [EPA], 2012). However, patients may still have mercury thermometers at home and may be continuing to use them. Nurses should encourage patients to use alternative devices to measure body temperature and include patient teaching as part of nursing care. Bulb-type glass thermometers containing liquids other than mercury are available. This type of thermometer is prone to breakage and should never be used to take a temperature for a person who is unconscious or irrational, or for infants and young children. ELECTRONIC AND DIGITAL THERMOMETERS Electronic and digital thermometers measure oral, rectal, or axillary body temperature over a time period from 1 to 60 seconds, depending on the site and product used. These battery-operated devices provide a numerical temperature display. The devices also have disposable probe covers to reduce the risk of infection transmission. Some models also provide the last measurement, a full 60-second pulse timer, and automatic conversion from the Fahrenheit to the Celsius scale. TYMPANIC MEMBRANE THERMOMETERS Tympanic membrane thermometers use infrared sensors to detect heat given off by the tympanic membrane. The probe is covered with a probe cover and inserted into the ear canal tightly enough to seal the opening. The reading takes from 1 to 3 seconds, depending on the product. Studies conflict regarding the accuracy of this method (Davie & Amoore, 2010; Jensen, 2011; Lawson et al., 2007). As such, it is important to use proper technique and adhere to manufacturer's guidelines for use.

DISPOSABLE SINGLE-USE THERMOMETERS Disposable single-use thermometers are nonbreakable and register the temperature within seconds. Because they are used only once, they eliminate the danger of cross-infection and are sometimes used for patients requiring transmission-based precautions. Temperature-sensitive patches or tape, commonly applied to the abdomen or forehead, change color at different temperature ranges. These devices may be used to screen the temperature of a toddler or young child. A thermometer should be used to reassess the temperature if the color on the tape or patch indicates that the temperature is out of the normal average range. TEMPORAL ARTERY THERMOMETERS Temporal artery thermometers measure body temperature by capturing the heat emitted by the skin over the temporal artery. These devices are battery operated and have a temperature display. Lawson et al. (2007) found oral and temporal artery measurements more accurate and precise than those taken by the axillary and tympanic routes. AUTOMATED MONITORING DEVICES Automated monitoring devices are used in various health care settings to measure body temperature, pulse, respirations, and blood pressure simultaneously. They require less of the nurse's time, especially when these assessments are required frequently.

PULSE The peripheral pulse is a throbbing sensation that can be palpated over a peripheral artery, such as the radial artery or the carotid artery. Peripheral pulses are palpable when blood is ejected as the left ventricle contracts and pumps blood into the vascular system. As the heart contracts to eject blood into an already full aorta, smooth muscle in the arteries expands to compensate for the increase in pressure of the blood. This rhythmic distention of the arterial walls is the result of surges of blood as the heart beats. The distention of the arteries moves along the arterial system until it reaches the capillaries, where vessel walls lack elasticity and peripheral resistance to blood flow. The peripheral pulses may be felt wherever an artery passes over a solid structure, such as bone or cartilage. Characteristics of the peripheral pulse, including rate, quality (strong or weak), rhythm, and volume of blood ejected with each heartbeat (also referred to as stroke volume), are indicators of the effectiveness of the heart as a pump and the adequacy of peripheral blood flow. The heart rate affects the amount of blood ejected by the heart with each beat by determining the frequency with which the ventricle contracts. The quality and rhythm affect how much blood is ejected and whether the beat is regular in rhythm. Further information about the control and mechanisms involved with blood flow and stroke volume is provided later with the discussion of blood pressure. An apical pulse may also be auscultated (listened to) over the apex of the heart as the heart beats. Heart sounds, which are produced by closure of the valves of the heart, are characterized as "lub-dub." The apical pulse is the result of closure of the mitral and tricuspid valves ("lub") and aortic and pulmonic valves ("dub"). The combination of the two sounds is counted as one beat. Further information related to the characteristics of pulses is discussed later in this chapter. Physiology of the Pulse The pulse is regulated by the autonomic nervous system through the sinoatrial (SA) node (the pacemaker) of the heart. Parasympathetic stimulation of the SA node via the vagus nerve decreases the heart rate, and sympathetic stimulation of the SA node increases the heart rate and force of contraction. Additional information about the conduction system and function of the heart is discussed in Chapter 38. The pulse rate is the number of pulsations felt over a peripheral artery or heard over the apex of the heart in 1 minute. This rate normally corresponds to the same rate at which the heart is beating.

Decreased Pulse Rate Bradycardia is a pulse rate below 60 beats/min in an adult. The pulse rate is normally slower during sleep in men and in people who are thin. It slows during hypothermia as metabolic processes decrease. The pulse also tends to become slower with aging. Some medications, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output. Sinus bradycardia results when the SA node generates a slower-than-normal impulse rate. This type of bradycardia occurs at times when metabolic needs are decreased (e.g., during sleep, in hypothermia, in trained athletes at rest); from certain medications, such as beta blockers; from vagal stimulation (e.g., from bearing down to have a bowel movement), during suctioning of respiratory secretions, with severe pain, and in increased intracranial pressure and MI. The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, decreased blood pressure, ECG changes, and angina (heart pain). Emergency treatment consists of administering atropine intravenously to block vagal stimulation and to restore normal heart rate. Pulse Amplitude and Quality The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flow through the vessel. The amplitude of each pulse beat is normally strong at all areas where an artery can be palpated. There are several systems for grading the amplitude of arterial pulses. Nurses should be familiar with the system in use at their facility or institution. Table 24-5 presents a scale often used to describe and document pulse amplitude. In addition, the peripheral pulse may be described and documented as full and bounding when it is forceful or weak and thready when it is feeble. Pulse Rhythm Pulse rhythm is the pattern of the beats and the pauses between them. Pulse rhythm is normally regular; the beats and the pauses between occur at regular intervals. An irregular pulse rhythm occurs when the beats and pauses between beats occur at unequal intervals. An irregular pattern of heartbeats is called a dysrhythmia. Report any irregularity in the heartbeat immediately.

Normal Respiratory Rate Under normal conditions, healthy adults breathe about 12 to 20 times each minute; infants and young children breathe more rapidly (see Table 24-1, p. 581). Normal, unlabored respiration is called eupnea. The relationship of one respiration to four heartbeats is fairly consistent in healthy people. THINK back to Noah Shoolin, the 2-year-old brought to the emergency department. The nurse would anticipate that the child's respiratory rate would be increased most likely as a result of his screaming and emotional upset. Increased Respiratory Rate Tachypnea, an increased respiratory rate, may occur in response to an increased metabolic rate, such as when a person has a fever. Cells require more oxygen at this time and produce more carbon dioxide that must be removed. The rate increases as much as 4 breaths/min with every 0.6°C (1°F) that the temperature rises above normal. Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood increases the rate and depth of respirations, hyperventilation. Respiratory diseases such as acute pneumonia or may cause tachypnea or hyperventilation.

Decreased Respiratory Rate Bradypnea, a decrease in respiratory rate, occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in irregular or shallow breathing, slow breathing, or both. Certain drugs, such as opioids (e.g., morphine, hydromorphone), can depress the respiratory rate. Respiratory Depth and Rhythm The depth of respirations normally varies from shallow to deep. The depth of each respiration is about the same when resting or sleeping. Periodically, each person automatically inhales deeply (sighs), filling the lungs with more air than with the usual depth of respiration. Certain terms are used to describe the nature and depth of respirations. Apnea refers to periods during which there is no breathing. If apnea lasts longer than 4 to 6 minutes, brain damage and death might occur. Dyspnea is difficult or labored breathing. A dyspneic patient usually has rapid, shallow respirations and appears anxious. Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm. This gives the lungs more room for expansion within the chest, allowing the intake of more air with each breath. Table 24-6 describes and illustrates various respiratory patterns.

Assessing Blood Pressure To accurately assess blood pressure, the nurse must know the appropriate equipment to use, how to describe the sounds that are heard, and which site to choose. Equipment Blood pressure may be assessed with different types of devices. Most commonly, nurses assess blood pressure by using a stethoscope and sphygmomanometer. Auscultation is the preferred method of obtaining blood pressure readings in children older than one year (NHLBI, 2005; Ogedegbe & Pickering, 2010). Blood pressure may also be estimated with a Doppler ultrasound stethoscope (described in the discussion of the pulse), estimated by palpation, and assessed with electronic or automated devices. SPHYGMOMANOMETER A sphygmomanometer is used to assess blood pressure. The sphygmomanometer consists of a cuff and the manometer (Fig. 24-4). The cuff contains an airtight, flat, rubber bladder covered with cloth. Selecting a cuff of the proper width (ranging from neonate to adult thigh) is essential to obtain an accurate blood pressure reading. The correct cuff should have a bladder length that is 80% of the arm circumference and a width that is at least 40% of the arm circumference, with a length-to-width ratio of 2:1. The bladder inside the cuff should enclose a child's entire limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery. This occurs, for example, when an average-sized cuff is used on an obese person. If a cuff is too wide (e.g., using an adult cuff on the arm of a child), the reading may be erroneously low because pressure is dispersed over a disproportionately large surface area. Recommendations by the AHA for the selection of an appropriately sized cuff are given in Table 24-8.

Depending on the product, cuffs may be disposable or reusable. They are closed around the limb with contact closures, such as nylon fabric that can be fastened to itself with Velcro® or hooks. Some long cuffs are applied by encircling the arm several times. Two tubes are attached to the bladder within the cuff. One is connected to a manometer and the other is attached to a bulb used to inflate the bladder. The bladder is inflated enough to obstruct the flow of blood through the artery. A needle valve on the bulb allows the cuff to be deflated while the pressure is being read. AUTOMATED BLOOD PRESSURE MONITORS Automated, electronic blood pressure monitors determine blood pressure by analyzing the sounds of blood flow or measuring oscillations (fluctuations) in blood flow (Fig. 24-5). The machine can be set to take and record blood pressure readings at preset intervals. Irregular heart rates, excessive patient movement, and environmental noise can interfere with the readings. Because electronic equipment is more sensitive to outside interference, and the monitors require routine validation of accuracy, these readings are susceptible to error. There is some evidence to suggest that these devices should not be used in some specific circumstances, such as in management of hypertension, with patients who have experienced trauma, or where there is significant potential for deterioration in the patient's condition. Blood pressure should be measured using an auscultatory device in these situations (Skirton, Chamberlain, Lawson, Ryan, & Young, 2011). When using an automatic blood pressure monitor for serial readings, check the cuffed limb frequently. Incomplete deflation of the cuff between measurements can lead to inadequate arterial perfusion and venous drainage, compromised the circulation in the limb (Bern et al., 2007; Pickering, Hall, & Appel, 2004). These devices may also provide measurements of pulse rate, pulse oximetry, and/or temperature. DOPPLER ULTRASOUND Blood pressure may be taken with a Doppler ultrasound device, which amplifies sounds. This device is especially useful if the sounds are indistinct or are inaudible with a regular stethoscope. This method only provides an estimate of systolic blood pressure. See Guidelines for Nursing Care 24-6 for assessment technique. DIRECT ELECTRONIC MEASUREMENT It is possible to measure blood pressure directly through the insertion of a thin catheter into an artery (an arterial line). The tip of the catheter senses the pressure and transmits this information to a machine that displays the systolic and diastolic pressure in a waveform. This technique is used primarily in intensive care areas. Korotkoff Sounds The series of sounds for which the nurse listens when assessing the blood pressure are called Korotkoff sounds, described and illustrated in Table 24-9. These sounds are only heard when using a stethoscope to assess blood pressure. In some adults, each of these sounds is distinct, whereas in others only the beginning and ending sounds are heard. It is important to determine agency policy for recording blood pressure sounds and to be consistent in taking and documenting the readings. The blood pressure is most commonly recorded with two numbers, written as a fraction. The first sound heard through the stethoscope, which is the onset of phase I, represents the systolic pressure. It is recorded as the first number in the fraction—for example, if the blood pressure reading is 120/80 mm Hg, 120 is the systolic pressure. The second number, which represents the diastolic pressure (in this case, 80), notes the level at which the sounds disappear completely. There has been discussion in the past as to using phase IV or V of the Korotkoff sounds for recording diastolic pressure, but there is now a general consensus that phase V should be used (Jarvis, 2012; Pickering et al., 2004). In situations in which sounds were heard all the way down to zero—for example, in pregnant women and patients with arteriovenous fistulas—the blood pressure recording would include phase IV (112/62/0). Blood pressure readings for children are recorded in the same manner (Kyle, 2012).

Categories of Antihypertensive Medications

Diuretics (to decrease fluid volume) Beta-adrenergic blockers (to block sympathetic stimulation and decrease cardiac output) Vasodilators and calcium channel blockers (to relax smooth muscles of arterioles and decrease peripheral vascular resistance) ACE inhibitors (to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production)

Physical Activity Physical exertion increases body temperature. Increased metabolism resulting from muscle activity results in the production of heat. The nurse should consider whether the patient has participated in physical activity when evaluating temperature measurements. State of Health Alterations in a person's health can contribute to variations in body temperature. The presence of certain disease conditions and other health problems may result in alterations in body temperature. Refer to the Increased Body Temperature and Decreased Body Temperature discussions later in this section.

Environmental Temperature Most of us respond to changes in environmental temperature by wearing clothing that either allows increased heat loss when it is hot or retains heat when it is cold. When one is exposed to extreme cold without adequate protective clothing, heat loss may be increased to the point of hypothermia (low body temperature). Similarly, if one is exposed to extremes of heat for long periods of time, hyperthermia (high body temperature) may result. Both hypothermia and hyperthermia may cause serious illness or death.`

Standard Precautions (Tier 1)

Follow hand hygiene techniques. Wear clean nonsterile gloves when touching blood, body fluids, excretions or secretions, contaminated items, mucous membranes, and nonintact skin. Change gloves between tasks on the same patient as necessary and remove gloves promptly after use. Wear personal protective equipment such as mask, eye protection, face shield, or fluid-repellent gown during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. Use gown to protect skin and prevent soiling of clothing. Follow respiratory hygiene/cough etiquette. Any patients, family members, and visitors with undiagnosed, transmissible respiratory infections require education to cover their mouth and nose with a tissue when coughing and promptly dispose of the tissue. During periods of increased occurrence of respiratory infections, offer a surgical mask to coughing patients and other symptomatic people upon entry to the health care facility or office. Encourage the coughing patient to maintain more than a 3-foot separation from other people in the health care facility or office. Avoid recapping used needles. If you must recap, never use two hands. Use a needle-recapping device or the one-handed scoop technique. Place needles, sharps, and scalpels in appropriate puncture-resistant containers after use. Use safe injection practices including single-dose vials when possible; use disposable needles and syringes for each injection, and prevent contamination of injection equipment and medication. Wear face mask if placing a catheter or injecting material into the spinal or epidural space. Handle used patient care equipment that is soiled with blood or identified body fluids, secretions, and excretions carefully to prevent transfer of microorganisms. Clean and reprocess items appropriately if used for another patient. Use adequate environmental controls to ensure that routine care, cleaning, and disinfection procedures are followed. Review room assignments carefully. Place patients who may contaminate the environment in private rooms (such as an incontinent patient).

Prodromal Stage A person is most infectious during the prodromal stage. Early signs and symptoms of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. This period lasts from several hours to several days. During this phase, the patient often is unaware of being contagious. As a result, the infection spreads.

Full Stage of Illness The presence of specific signs and symptoms indicates the full stage of illness. The type of infection determines the length of the illness and the severity of the manifestations. Symptoms that are limited or occur in only one body area are referred to as localized symptoms, whereas symptoms manifested throughout the entire body are referred to as systemic symptoms.

Performing Hand Hygiene

Hand hygiene is the most effective way to help prevent the spread of infectious agents. There is general consensus that most health care-associated pathogens are transmitted via the contaminated hands of health care workers. According to the CDC, each year approximately 2 million patients or nearly 1 in 20 people get a hospital-acquired infection (CDC, 2011a). The CDC issued the initial guidelines for hand hygiene in health care settings in 2002. The term hand hygiene applies to either handwashing with plain soap and water, use of antiseptic handrubs including waterless alcohol-based products, or surgical hand antisepsis. Although there is agreement that hand hygiene is the most important procedure for preventing infections, this procedure is still not performed consistently in health care settings. Compliance rates are generally below 50% and less than 41% when gloves are used (Fuller et al., 2011). The Joint Commission Center for Transforming Healthcare (2012a) cites some of the factors that contribute to poor compliance with hand hygiene practices: Dispensers or sinks are placed in inappropriate locations. Hand hygiene compliance data is collected or reported inaccurately. There is a lack of accountability. There is a failure to stress the importance of hand hygiene for all staff. Education regarding hand hygiene is ineffective or insufficient. Hands are full with equipment or supplies. The belief may exist that hand hygiene is not required when gloves are worn. Inattentiveness or other factors can distract health care workers.

Factors Affecting the Risk for Infection The susceptibility of the host depends on various factors: Integrity of skin and mucous membranes, which protect the body against microbial invasion pH levels of the gastrointestinal and genitourinary tracts, as well as the skin, which help to ward off microbial invasion Integrity and number of the body's white blood cells, which provide resistance to certain pathogens Age, sex, race, and hereditary, which influence susceptibility. Neonates and older adults appear to be more vulnerable to infection. (See the accompanying box, Focus on the Older Adult.) Immunizations, natural or acquired, which act to resist infection Level of fatigue, nutritional and general health status, the presence of preexisting illnesses, previous or current treatments, and certain medications, which play a part in the susceptibility of a potential host Stress level, which if increased, may adversely affect the body's normal defense mechanisms Use of invasive or indwelling medical devices, which provide exposure to and entry for more potential sources of disease-producing organisms, particularly in a patient whose defenses are already weakened by disease

Health habits that promote wellness can reduce potential risk factors, thus decreasing the susceptibility of a host. Sensible nutrition, adequate rest and exercise, stress-reduction techniques, and good personal hygiene habits can help maintain optimum bodily function and immune response. Unsafe sex practices and sharing intravenous (IV) needles are potentially dangerous, providing an opportunity for pathogens to enter a host and cause an infection.

Stages of Infection An understanding of the stages in the development of an infection is necessary to intervene and disrupt the infection cycle. An infection progresses through the following phases: Incubation period Prodromal stage Full stage of illness Convalescent period The course and severity of the infection, as well as the patient's response, influence the type and extent of nursing care provided.

Incubation Period The incubation period is the interval between the pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, the organisms are growing and multiplying. The length of incubation may vary. For example, the common cold has an incubation period of 1 to 2 days, whereas tetanus has an incubation period ranging from 2 to 21 days.

An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body. An infection occurs as a result of a cyclic process, consisting of six components, as shown in Figure 23-1 . These components are: Infectious agent Reservoir Portal of exit Means of transmission Portals of entry Susceptible host

Infectious Agent Some of the more prevalent agents that cause infection are bacteria, viruses, and fungi. Bacteria, the most significant and most commonly observed infection-causing agents in health care institutions, can be categorized in various ways. They are categorized by shape as spherical (cocci), rod shaped (bacilli), or corkscrew shaped (spirochetes). Bacteria can be categorized as either gram positive or gram negative, based on their reaction to the Gram stain. For example, gram-positive bacteria have a thick cell wall that resists decolorization (loss of color) and are stained violet. However, gram-negative bacteria have chemically more complex cell walls and can be decolorized by alcohol. Thus, gram-negative bacteria do not stain. This information is crucial for physicians when prescribing the most appropriate antibiotic therapy because antibiotics are classified as specifically effective against only gram-positive organisms or as broad spectrum and effective against several groups of microorganisms. Another distinguishing characteristic of (or way of categorizing) bacteria is their need for oxygen. Most bacteria require oxygen to live and grow and are, therefore, referred to as aerobic. Those that can live without oxygen are anaerobic bacteria.

Sustained or Continuous

The body temperature remains above normal with minimal variations.

Intermittent fever

The body temperature returns to normal at least once every 24 hours.

Relapsing or Recurrent:

The body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days.

Assessing Blood Pressure

Listening for Korotkoff sounds with stethoscope First sound is systolic pressure. Change or cessation of sounds occurs—diastolic pressure. The brachial artery and popliteal artery are commonly used.

Gowns. Gowns are usually worn to prevent soiling of the health care worker's clothing by the patient's blood and body fluids. They provide barrier protection and are donned immediately before entering the patient's room. Individual gown technique is recommended. This technique involves wearing a gown only one time and then discarding it appropriately according to agency policy. A waterproof or impervious gown is used if there is an increased likelihood of contact with the patient's blood or body fluids. If a gown becomes heavily soiled or moistened with blood or body fluids when caring for a patient, remove it, perform thorough hand hygiene, and put on a clean gown. There is no single special technique for applying a gown used as a barrier, but recommended practices for removing a soiled gown are described in Skill 23-2.

Masks. Masks help prevent the wearer from inhaling large-particle aerosols, which usually travel short distances (about 3 feet), and small-particle droplet nuclei, which can remain suspended in the air and travel longer distances. They also protect the patient from the respiratory secretions of the health care worker. Masks discourage the wearer from touching the eyes, nose, and mouth, thus limiting contact of organisms with mucous membranes. Various mask practices are used. In some instances, all personnel and all the patient's visitors wear masks; in other situations, a patient requiring specific precautions wears the mask when transported outside his or her room to protect health care personnel and other patients from any exposure to pathogens. A mask is worn only once and never lowered around the neck and then brought back over the mouth and nose for reuse. How long one can wear one mask while caring for one patient is the subject of debate. Regardless of the time worn, a mask must be changed before it becomes damp from the wearer's exhalations. (See Skill 23-2, pp. 561-564 for the recommended practice for applying and removing a mask.) The serious increase in the number of multidrug-resistant tuberculosis cases prompted new guidelines to prevent the transmission of this disease. According to CDC guidelines, either a high-efficiency particulate air (HEPA) filter respirator or N95 respirator certified by NIOSH must be worn when entering the room of a patient with known or suspected tuberculosis, SARS, or influenza. The respirators filter inspired air, whereas surgical masks filter only expired air. Caregivers have expressed difficulty wearing the HEPA-style respirator for extended periods of time, but the N95 respirator, which is designed to filter out particles as small as 1 mcm with 95% efficiency, fits more comfortably against the face (Fig. 23-3). The elastic straps on these respirators provide more protection and a better fit than the ties on regular surgical masks.

Portal of Exit The portal of exit is the point of escape for the organism from the reservoir. The organism cannot extend its influence unless it moves away from its original reservoir. Usually, each type of microorganism has a primary exit route. In humans, common portals of exit or escape routes include the respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin. Blood and tissue can also be portals of exit for pathogens.

Means of Transmission An organism may be transmitted from its reservoir by various means or routes. Some organisms can be transmitted by more than one route. Organisms can enter the body by way of the contact route, either directly or indirectly. Direct contact involves proximity between the susceptible host and an infected person or a carrier, such as through touching, kissing, or sexual intercourse. Health care workers have the potential to directly transmit organisms to susceptible people through touching. The indirect contact route involves personal contact with an inanimate object, such as touching a contaminated instrument. Recent research indicated that pathogenic bacteria were found on more than 60% of nurses' scrubs (Guolette, 2012). Proper hand hygiene and glove use can interrupt the transmission of dangerous bacteria from nurses to patients. Paper has also been identified as a surface where bacteria can survive; pathogens can possibly be transferred from a paper document to a health care worker's hands to the patient (Hubner, Hubner, Kramer, & Assadian, 2011). Contaminated blood, food, water, or inanimate objects (fomites) are vehicles of transmission. Vectors, such as mosquitoes, ticks, and lice, are nonhuman carriers that transmit organisms from one host to another by injecting salivary fluid when a human bite occurs. Microorganisms can also be spread through the airborne route when an infected host coughs, sneezes, or talks, or when the organism becomes attached to dust particles. Another means of transmission is through droplets. Droplet transmission is similar to airborne transmission. However, airborne particles are less than 5 mcm, and droplet particles are greater than 5 mcm. Table 23-1 summarizes the means of transmission for several organisms, their reservoirs, and examples of diseases they transmit.

The World Health Organization (WHO) clearly defined the "Five Moments for Hand Hygiene." These include:

Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3 - After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings

Evaluating

Nurses as primary caregivers can intervene in and positively affect a patient's outcome. By assessing the person at risk, selecting appropriate nursing diagnoses, planning, and intervening to maintain a safe environment, the nurse can reduce a patient's potential for developing an infection (see the accompanying concept map for an example). Evaluation of the plan of care determines whether the person's need for safety is being met effectively. Ongoing systematic evaluation is crucial for nurses who strive to maintain a secure environment for their patients as well as themselves

Use of Surgical Asepsis

Operating room, labor and delivery areas Certain diagnostic testing areas Patient bedside For example, for procedures that involve insertion of urinary catheter, sterile dressing changes, or preparing and injecting medicine

The CDC recommends the following to prevent CDI:

Prescribe antibiotics cautiously. Use contact precautions for patients confirmed or suspected of having CDI. This includes a private room, as well as use of gown and gloves when entering the room and during patient care. Use effective hand hygiene (discussed earlier in this chapter). Have room and nondisposable equipment cleaned with bleach or other appropriate disinfectant. Upon transfer out of the facility, notify the new facility about the C. difficile infection (Splete, 2012).

If a health care worker's hands are visibly soiled or contaminated with blood or body fluids, washing the hands with either antimicrobial soap or nonantimicrobial soap and water is required. Handwashing is also required before eating and after using the restroom. Effective handwashing requires at least a 20-second scrub with plain soap or disinfectant and warm water. Hands that are visibly soiled need a longer scrub. Recommended hand-washing techniques for medical asepsis are listed in Skill 23-1. Hand antisepsis before assisting with a surgical procedure involves a more lengthy scrub, reducing resident and transient flora from the forearms and hands. This procedure, known as surgical hand scrub, incorporates surgical asepsis and is described in texts that deal with operating and delivery room procedures. The CDC guideline recommends using an antimicrobial soap or alcohol-based surgical hand scrub product with persistent activity for surgical hand antisepsis. Scrub time is also reduced significantly when alcohol-based scrub agents are used.

Preventing Health Care-Associated Infections For various reasons and sometimes despite best efforts, certain patients in health care agencies develop health care-associated infections (HAIs) during the course of treatment for other conditions that were not present in this patient on admission. The term nosocomial is used specifically to indicate something originating or taking place in a hospital. The source of infection may be either exogenous or endogenous. An infection is referred to as exogenous when the causative organism is acquired from other people. An endogenous infection occurs when the causative organism comes from microbial life harbored in the person. An infection is referred to as iatrogenic when it results from a treatment or diagnostic procedure. Not all nosocomial infections are iatrogenic. Prevention of HAIs is a major challenge for health care providers. In the United States, HAIs account for tens of thousands of deaths and $28 billion to $33 billion dollars of additional health care costs annually (Agency for Healthcare Research and Quality [AHRQ], 2010). A patient who is hospitalized for a medical or surgical condition and acquires an HAI requires, on average, a 19-day longer hospital stay (Keefe, 2011). The cost of the additional hospital care days necessary to treat an HAI is staggering, particularly in light of the efforts to control spiraling health care expenses. With its focus on patient safety, The Joint Commission mandated that death or serious injury caused by an infection-related event must be reported as a sentinel event (see Chapter 26 for a discussion of sentinel events; Joint Commission, 2012). Effective October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for preventable hospital-acquired conditions in ten categories. Urinary tract infections from improper use of catheters, vascular catheter-associated infections, and certain surgical site infections are included in the list. In order to comply with this ruling, hospitals must report whether these conditions existed when the patients were admitted to their facility (CMS, 2012). Though this is an evolving process, there is potential that the critical impact that nurses have on decreasing the number of HAIs will be recognized and more easily verified. Healthy People 2020 (2012) has included a "disproportionate nurse-to-patient ratio" as an issue that may have an impact on HAIs. Staffing takes into account registered nurse-to-patient ratios, level of RN education and experience, and the use of temporary workers. Failure to perform appropriate hand hygiene can occur when a nurse has a heavy patient load or when an inexperienced nurse is overwhelmed with her assignment. Based on the premise that most HAIs are preventable, the U.S. Department of Health and Human Services (USDHHS), in conjunction with multiple other federal agencies, has formed a Steering Committee that is committed to coordinating strategies to reduce the transmission of HAIs. Nine targets have been identified and goals have been established for each target. Progress is measured annually, moving toward a 5-year completion date for the current action plan

Major Classifications of Hypertension

Primary (essential) Characterized by an increase above normal in both systolic and diastolic pressures No known cause Secondary Caused by another disease conditions Common causes include kidney disease, adrenal cortex disorders, and aorta disorders

Appropriate Times to Measure Vital Signs!

Screenings at health fairs and clinics In the home Upon admission to any health care agency Based on agency or institutional policy and procedure When medications are given that affect cardiac rate & rhythm & or respiratory function Before and after invasive diagnostic and surgical procedures Any time there is a change in the client's condition In emergency situations

Using Surgical Asepsis

Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the patient's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. For example, the needle for an injection must be handled so that it is sterile when inserted into a patient. Sterile forceps or gloves are used to handle sterile dressings to protect against contamination. The basic principles of surgical asepsis are listed in Box 23-6. When observing medical asepsis, areas are considered contaminated if they bear or are suspected of bearing pathogens; whereas when following surgical asepsis, areas are considered contaminated if they are touched by any object that is not also sterile. One of the most important aspects of surgical and medical asepsis is that the effectiveness of both depends on faithful and conscientious practice by those carrying them out. It is far better to err on the side of safety when using surgical asepsis than to take the slightest chance of possible contamination. Being a patient advocate requires vigilant aseptic technique and a willingness to speak up if the patient's safety has been compromised by improper procedures. Explaining the surgical asepsis procedure to patients facilitates their cooperation. Inform the patient about which objects and areas may not be touched, and direct the patient to avoid sudden movements that might contaminate the equipment. This helps the patient assist in maintaining the sterility of the procedure.

Portal of Entry The portal of entry is the point at which organisms enter a new host. The organism must find a portal of entry to a host or it may die. The entry route into the new host often is the same as the exit route from the prior reservoir. The urinary, respiratory, and gastrointestinal tracts and the skin are common portals of entry.

Susceptible Host Microorganisms can continue to exist only in a source that is acceptable (a host) and only if they overcome any resistance mounted by the host's defenses. Susceptibility is the degree of resistance the potential host has to the pathogen. Hospital patients are often in a weakened state of health because of illness and have less resistance. Thus, they are more susceptible for infection. Many factors influence a host's susceptibility; these are discussed later in the chapter.

Convalescent Period The convalescent period is the recovery period from the infection. Convalescence may vary according to the severity of the infection and the patient's general condition. The signs and symptoms disappear, and the person returns to a healthy state. However, depending on the type of infection, there may be a temporary or permanent change in the patient's previous health state even after the convalescent period. A person may continually pass through the four phases with the same infectious process, such as with herpes simplex. Although there may have been only one infectious exposure, the infection may continue to cycle through the phases.

The Body's Defense Against Infection One of the first lines of defense against infection is the body's normal flora. Flora helps to keep potentially harmful bacteria from invading the body. In addition to the normal flora that inhabit various body sites, other defense systems help a person combat infection. These include the inflammatory response and immune response.

Inflammatory Response

The inflammatory response is a protective mechanism that eliminates the invading pathogen and allows for tissue repair to occur. Inflammation helps the body to neutralize, control, or eliminate the offending agent and to prepare the site for repair (Smeltzer, Bare, Hinkle, & Cheever, 2010). In addition to infection, the inflammatory response also occurs in response to injury. It is either an acute or chronic process. The cardinal signs of acute infection are redness, heat, swelling, pain, and loss of function, usually appearing at the site of the injury or inflammation. The vascular and cellular stages are the main components of the inflammatory process; these physiologic processes are responsible for the appearance of the cardinal signs. Initially, in the vascular stage, small blood vessels constrict in the area followed by vasodilatation of arterioles and venules that supply the area. This increase in blood flow results in redness and heat in the area. Histamine also is released, leading to an increased permeability of vessels, which allows protein-rich fluid to pour into the area. At this point, swelling, pain, and loss of function can occur. During the cellular stage, white blood cells (leukocytes) move quickly into the area. Neutrophils, the primary phagocytes, engulf the organism and consume cell debris and foreign material. Exudate composed of fluid, cells, and inflammatory byproducts is released from the wound. The exudate may be clear (serous), contain red blood cells (sanguinous), or contain pus (purulent). The amount of exudate depends on the size and location of the wound. The damaged cells then are repaired by either regeneration (replacement with identical cells) or the formation of scar tissue (Porth, 2011). Refer to Chapters 31 and 41 for additional discussion of the inflammatory response.

Hypertension, one of the most common health problems, is blood pressure that is above normal for a sustained period. A diagnosis of hypertension is made when the systolic pressure is 140 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher. The AHA (2012) estimates that 76.4 million adults in the United States have been diagnosed with hypertension. Of this number, the prevalence of hypertension is greater in African American adults than in White or Hispanic American adults. Its prevalence is also greater in older adults. This trend can be expected to continue with the aging of the "baby boomers," as the number of people with hypertension increases with aging. In addition, overweight and obesity is on the rise in youth younger than 18 years old. As a result, prehypertension and high blood pressure are also becoming more common in this age group. African American and Mexican American youth are more likely to have high blood pressure and prehypertension than White youth. Also, boys are at higher risk for high blood pressure than girls (National Heart Blood and Lung Institute [NHBLI], 2011). Hypertension is a major risk factor for heart disease and is the most important risk factor associated with stroke. It is often called "the silent killer" because there are few symptoms beyond increased blood pressure. The NHBLI has outlined standards for diagnosing hypertension (see Table 24-7).

The two major classifications of hypertension are primary hypertension and secondary hypertension. Primary hypertension (also called essential hypertension) has no known cause. It is characterized by an increase above normal in both the systolic and diastolic pressures. Secondary hypertension, which is much less common than primary hypertension, is caused by another disease condition. Some of the common causes of secondary hypertension are kidney disease, disorders of the adrenal cortex, and disorders of the aorta. The basis for hypertension is thought to be dysfunction of the neurohormonal system. Overactivation of both angiotensin and aldosterone result in an increase in blood pressure. Over time, this sustained increase results in a permanent remodeling and thickening of the blood vessels. As a result, there is increased peripheral resistance and a back-up of pressure to organs affected by the vascular system, such as the brain, heart, and kidneys. Disorders resulting from hypertension include thickening of the myocardium, enlargement of the ventricles, congestive heart failure, MI, stroke, and kidney damage. There are many risk factors for the development of hypertension. Significant risks are a family history of hypertension, race, aging, and metabolic disorders such as type 2 diabetes mellitus, obesity, and high cholesterol. Lifestyle risk factors include a sedentary lifestyle; high dietary intake of salt, fats, and calories; use of oral contraceptives in women; and sleep apnea. Other high-risk factors include cigarette smoking and regular alcohol consumption. REMEMBER Mrs. Renfrow, the wife of a man who is overweight and diagnosed with hypertension? The nurse would need to incorporate information about various risk factors for developing hypertension as well as information about risk related to hypertension in the teaching plan for Mrs. Renfrow. Hypertension can be controlled by medications and lifestyle changes. The categories of antihypertensive medications include diuretics (to decrease fluid volume), beta-adrenergic blockers (to block sympathetic stimulation and decrease cardiac output), vasodilators and calcium channel blockers (to relax smooth muscles of arterioles and decrease peripheral vascular resistance), and angiotensin-converting enzyme (ACE) inhibitors (to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production). Lifestyle changes include following a low-calorie, low-fat diet; losing excess weight and maintaining weight loss; limiting alcohol intake; eliminating smoking; reducing salt intake; and engaging in regular physical activity. Nurses can influence the health of the public through screenings, education, and referrals. See Promoting Health Literacy in Patients With Hypertension for more information.

Standard precautions: precautions used in the care of all hospitalized patients regardless of their diagnosis or possible infection status. These precautions apply to blood, all body fluids, secretions, and excretions except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes. Additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures.

Transmission-based precautions: precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. The 2007 guidelines include a directive to don personal protective equipment (PPE) when entering the room of a patient on contact or droplet precautions. Previously, PPE was only required when the nurse was delivering care within 3 feet of the patient. These categories recognize that a disease may have multiple routes of transmission.

Contact Precautions

Use these for patients who are infected or colonized by a multidrug-resistant organism (MDRO). Place the patient in a private room, if available. Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Change gloves after having contact with infective material. Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. Limit movement of the patient out of the room. Avoid sharing patient-care equipment.

Airborne Precautions

Use these for patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), rubeola (measles), and possibly SARS (severe acute respiratory syndrome). Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside or monitored filtration if air is recirculated. Keep door closed and patient in room. Wear a mask or respirator when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Consult CDC Guidelines for additional prevention strategies for tuberculosis.

Droplet Precautions M-RAD!

Use these for patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Use a private room, if available. Door may remain open. Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Transport patient out of room only when necessary and place a surgical mask on the patient if possible. Keep visitors 3 feet from the infected person.

Following are examples of medical asepsis practices recommended in the home:

Washing hands before preparing food and before eating Preparing foods at temperatures high enough to ensure that they are safe to eat (e.g., preparation of fresh meat) Washing hands, cutting boards, and utensils with hot, soapy water before and after handling raw poultry and meat Keeping foods refrigerated, especially those containing mayonnaise Washing raw fruits and vegetables before serving them Using pasteurized milk and fruit juices Washing hands after using the bathroom Using individual personal care items, such as washcloths, towels, and toothbrushes, rather than sharing

Factors Affecting Blood Pressure

Weight-usually BP higher in obese people vs thin people Emotional state-anger, fear, excitement, & pain can increase BP Body position-prone, or supine can lower BP Drugs/medications-oral contraceptives can increase BP

What type of soap should be used?

any type of antibacterial soap is recommended. Actually alcohol-based rubs (60-95% alcohol concentration) are more effective in reducing bacterial and viral counts, and are available as foam, gel, or lotions. *so if the healthcare worker's hands are not visibly soiled, then alcohol-based handrubs are recommended because they save time, are more accessible and easy to use and reduce bacterial count on hands.*

bundles

are evidence-based best practices that have proven positive outcomes when implemented together to prevent infection

RESPIRATIONS Respiration involves ventilation, diffusion, and perfusion. Ventilation (or breathing) is movement of gases in and out of the lungs; inspiration (or inhalation) is the act of breathing in, and expiration (or exhalation) is the act of breathing out. Unlike heart rate, which is controlled by the autonomic nervous system, ventilation has both autonomic and voluntary control. Diffusion is the exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood. Perfusion is the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells. Although nurses assess the manifestations of changes in all of these respiratory events, the component that is measured as a vital sign is ventilation, more commonly called respirations. Respiratory system assessment is described further in Chapter 25. Measuring respirations allows for baseline assessment of respiratory function. Respiratory rate can give early indications of physiologic deterioration (Parkes, 2011). Physiology of Respirations The rate and depth of breathing can change in response to tissue demands. These changes are brought about by the inhibition or stimulation of the respiratory muscles by the respiratory centers in the brain. Activation of the respiratory centers occurs via impulses from chemoreceptors located in the aortic arch and carotid arteries, via stretch and irritant receptors in the lungs, and via receptors in muscles and joints. An increase in carbon dioxide is the most powerful respiratory stimulant, causing an increase in respiratory depth and rate. The cerebral cortex of the brain allows voluntary control of breathing, such as when singing or playing a musical instrument. See Chapter 38 for a further discussion of respiratory physiology.The rate and depth of inhalation and exhalation are normally smooth, effortless, and without conscious effort. However, factors such as environmental changes and pathophysiologic alterations in various body systems may result in increases or decreases in respiratory rate and depth.

increases in carbon dioxide is the strongest respiratory stimulant

how high should u wash ur hands ?

wash atleast 1 inch above area of contamination, if hands are not visibly soiled, wash 1 inch above the wrists

Clostridium difficile. While rates of some HAIs have declined in recent years, C. difficile infection (CDI) rates and associated deaths have risen. It is considered responsible for about 14,000 deaths annually in the United States; this infection costs the health care system billions of dollars each year (CDC, 2012b). Health care experts are concerned that the number of deaths caused by C. difficile may actually be considerably higher since the CDC data is based on death certificates. Often, one of the complications of C. difficile may be listed as the cause of death and the infection is not listed. Those most at risk are older adults who are receiving medical care and taking antibiotics. Hospital-acquired CDI rates have also increased significantly in children, but the severity of those cases has remained constant. Both symptomatic and asymptomatic people serve as reservoirs for C. difficile, as do any surfaces or objects contaminated with feces. This organism normally resides in the intestinal tract. When antibiotics are prescribed or taken for a prolonged period of time, particularly broad-spectrum ones, helpful bacteria are destroyed and C. difficile bacteria can grow out of control, creating a bacterial imbalance. Watery diarrhea, fever, and mild abdominal cramping are some of the more common signs and symptoms (Snow, 2011). When antibiotics are discontinued, 20% of the cases of CDI resolve but 80% of those diagnosed with this infection require further antibiotic therapy

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Eupnea: normal, unlabored respiration; one respiration to four heartbeats Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate Bradypnea: decreased respiratory rate; occurs in some pathologic conditions Apnea: periods when no breathing occurs Dyspnea: difficult or labored breathing Orthopnea: difficulty breathing when lying down

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Johnson, Kaehler, Siska, Lecy, and O'Neil (2011) express the need to focus attention on a cultural change generated by an institution-wide commitment to compliance with hand hygiene recommendations. The Joint Commission Center for Transforming Healthcare (2012b) has initiated a campaign inviting all Joint Commission accredited organizations to improve patient safety and lower the cost of health care. The Hand Hygiene Project takes advantage of their Targeted Solutions ToolTM (TST) that facilitates a "step-by-step process to accurately measure an organization's actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers." The initial group of eight major health care organizations who participated in this project demonstrated significant gains in performance of hand hygiene. Compliance rates that initially were less than 50% have improved to 82%; this level has been maintained over an 8-month period. The CDC also encourages consumers to help prevent infections by a personal commitment to practicing hand hygiene and a reminder to insist on hand hygiene measures from all health care staff involved in their care. (Refer to the accompanying Research in Nursing box for a discussion of hand hygiene in the community setting.)

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Method Selection. Various factors influence the choice of sterilization and disinfection methods, including the following: Nature of organisms present: The CDC recommends that all supplies, linens, and equipment in a health care setting should be treated as if the patient were infectious. Some organisms are easily destroyed, whereas others can withstand certain common sterilization and disinfection methods. Number of organisms present: The more organisms present on an item, the longer it takes to destroy them. Type of equipment: Equipment with small lumens, crevices, or joints requires special care. Certain articles that may be damaged by various sterilization and disinfection methods require special handling. Intended use of equipment: The need for medical or surgical asepsis influences the preparation and cleaning of equipment. In the home, it may be safe to use equipment and supplies that are clean, but most health care agencies use sterilized articles for patient care. Available means for sterilization and disinfection: The choice of chemical or physical means of sterilization and disinfection depends on the nature and number of organisms, the type and intended use of the equipment, and the availability and practicality of the means. (Table 23-3 lists the types of methods for sterilization and disinfection.) Time: Time is a key factor when sterilizing or disinfecting articles. Failure to follow the recommended time periods is grossly negligent.

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OPENING A STERILE PACKAGE AND PREPARING A STERILE FIELD Commercially prepared sterile items may be sealed in paper or packaged in plastic containers. Sterile packages may be opened on a flat surface or while held in the hands. Skill 23-3 illustrates how to open a sterile package and prepare a sterile field. A sterile item should be covered if it is not used immediately. Reapply the cover by touching only the outside of the wrapper and reversing the opening order. POURING STERILE SOLUTIONS Care is necessary when pouring sterile liquids onto a sterile dressing or into a sterile basin. The outer surfaces of the bottle and cap are considered unsterile, whereas the inside areas and the solution are considered sterile. After a solution has been opened, the outer bottle should be labeled with date and time if it is to be reused. Most solutions are considered sterile for 24 hours after they are opened. When pouring from a bottle, grasp the bottle so that the label is in the palm of your hand. This action prevents any of the liquid from running over the label and making it illegible. Avoid splashing the liquid since this would contaminate the sterile field (see Skill 23-3, p. 564-569). ADDING STERILE SUPPLIES TO A STERILE FIELD After establishing a sterile field, it may be necessary to add items such as instruments or additional supplies to the sterile field. Item 6 in Skill 23-3 demonstrates this technique. Once a sterile field is established, objects on a field may be handled only by using sterile forceps or with hands wearing sterile gloves. PUTTING ON STERILE GLOVES Sterile gloves are donned in a way that allows only the inside of the gloves to come in contact with the hands. Skill 23-4 describes the proper technique for putting on sterile gloves. After the gloves are on, only sterile items may be handled with the sterile-gloved hands. Careful removal of the gloves reduces any hand contact with contaminated materials. Good hand hygiene technique before and after putting on sterile gloves is imperative. POSITIONING A STERILE DRAPE The sterile drape, which ideally is waterproof, may be used to extend the sterile working area. Using sterile gloves allows the nurse to handle the entire drape surface. For protection when positioning, fold the upper edges of the drape over the sterile-gloved hands (Fig. 23-4). When sterile gloves are not worn, the nurse can touch only the outer 1 inch (2.5 cm) of the drape. Use caution when gently shaking the drape open so as not to touch one's clothing or an unsterile object. Hold the drape by the 1-inch upper edge and position the drape over the desired area. Do not reach over the drape because this would contaminate a sterile area.

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Outcome Identification and Planning The nurse develops appropriate patient outcomes after reviewing the assessment data, considering the cycle of events resulting in an infection, and incorporating the principles of infection control. Planning outcomes that prevent infection or interfere with the infection cycle is an exciting challenge, providing an opportunity to see the positive results from one's efforts, that is, effective nursing interventions aimed at controlling or preventing infection. The following examples of expected patient outcomes are appropriate for preventing infection and using infection control techniques. The patient will: Demonstrate effective hand hygiene and good personal hygiene practices Identify the signs of an infection Maintain adequate nutritional intake Demonstrate proper disposal of soiled articles Use appropriate cleansing and disinfecting techniques Demonstrate an awareness of the necessity of proper immunizations Demonstrate stress-reduction techniques Verbalize an understanding of health risks associated with a latex allergy

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Teaching About Infection Control Teaching about medical asepsis and infection control is a challenging nursing responsibility. Patients need to be aware of techniques that prevent the spread of infection. Use of the nursing process in infection control protects both the patient and the nurse. Medical asepsis techniques are appropriate for most procedures in the home, except for self-injection technique and venous catheter care, which require surgical asepsis. The patient frequently must make adjustments and improvise with the resources and supplies available for his or her use. In addition, the nurse emphasizes effective hand hygiene and other hygiene practices that interrupt the infection cycle. To satisfy OSHA requirements, many home care agencies have either a full-time or part-time infection preventionist. Teach patients to use basic principles of asepsis at home and in public facilities. These involve the activities of daily living (see Chapter 30 for a discussion of personal hygiene).

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VRE is spread via contact with the feces, urine, or blood of an infected or colonized person. Health care providers have the potential to spread VRE on their hands from one patient to another. Medical equipment and environmental surfaces can also harbor this organism. Appropriate hand hygiene and contact precautions can halt the spread of VRE. Careful assessment, intervention, and evaluation of high-risk patients and situations by nurses helps to minimize infection and reduce the unnecessary suffering imposed on patients.

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if a healthcare worker's hands are soileed, or contaminated with blood or body fluids, washing the hands with soap and water is required. it is also required after eating and after using the restroom

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