◗ Provide patients with the information that they need about their condition and the health care system
● Tell patients what to expect from the system and the nurse, and explain what’s expected of them
● Tell them who has access to information about their condition
● Inform them of the unit rules
● Explain procedures and medications
● Provide the names of personnel associated with their care
◗ Empower patients
● Include them in care conferences
● Ask them what they think of the care plan, what they want the nurse to know about them, and what they expect from the nurse
◗ Anticipate patients’ needs
● Begin discharge planning when a patient enters care, and include signifi cant others in the planning
● Provide written materials; most patients are moderately anxious and comprehend only fragments of information at a time
● Allow for privacy and space needs
● Conserve patients’ energy for healing; don’t expect or require them to do more than is realistic
● Don’t wait for patients to tell you of their needs such as a need for pain medication; ask about their needs regularly
● Arrange for diversionary activities as patients recover
◗ Be accountable to patients
● Keep patients informed of care plans
● Ask them about care, and determine if they would like to change anything
Review questions
1. The nurse is assessing pain in a patient with appendicitis. Which initial statement or question will be most effective in eliciting information?
A. “Tell me how you feel.”
B. “Point to where you’re feeling pain.”
C. “Does your pain medication relieve your pain?”
D. “Coughing makes your pain worse, doesn’t it?”
Correct answer: A Asking the patient to describe how he’s feeling is an open-ended question, allowing for the widest range of responses. Asking the patient to point to his pain (Option B) may be an important follow-up question but is too limiting to be the nurse’s fi rst question. Asking if pain medication relieves his pain (Option C) is a closed question requiring only a yes-or-no response and should be avoided.
Option D is leading as well as closed. It suggests to the patient that coughing should make his pain worse.
2. When performing an abdominal assessment, the nurse should follow which examination sequence?
A. Auscultation, inspection, percussion, palpation B. Inspection, auscultation, percussion, palpation C. Palpation, auscultation, percussion, inspection D. Percussion, palpation, auscultation, inspection
Correct answer: B The correct sequence for abdominal assessment is inspection, auscultation, percus- sion, and palpation because this sequence prevents altering bowel sounds with palpation before ausculta- tion. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.
3. To maintain a therapeutic environment with a patient and his family, the nurse can use communication techniques such as clarifi cation. An example of clarifi cation is:
A. “How is it going?”
B. “You say you aren’t concerned, but you’ve asked me many questions on this same subject.”
C. “What do you mean when you say…?”
D. “For now, I would like to concentrate on…”
Correct answer: C Option C is an example of clarifi cation or seeking validation. Option A isn’t an example of clarifi cation but is instead an example of a broad-opening technique. Option B is an example of confrontation, which calls attention to discrepancies in what the patient is saying. Option D is an example of focusing or helping the patient direct his thoughts.
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Review questions ❍ 49
4. In the stages of death and dying as defi ned by Elisabeth Kübler-Ross, loss, grief, and intense sadness are symptoms of:
A. depression.
B. denial.
C. anger.
D. acceptance.
Correct answer: A Loss, grief, and intense sadness indicate depression. Denial (Option B) is indicated by the refusal to admit the truth or reality. Anger (Option C) is manifested by rage and resentment.
Acceptance (Option D) is evidenced by a gradual, peaceful withdrawal from life.
5. In the levels of basic human needs as defi ned by Abraham Maslow, which of the following levels is most basic?
A. Physiologic B. Safety and security
C. Love, affection, and belonging D. Esteem
Correct answer: A Physiologic needs (Option A) are the most basic needs and essential for sustaining life. Once physiologic needs are met, needs for safety and security (Option B) can be met, followed by love, affection, and belonging (Option C), and esteem (Option D).
6. According to the stages of development, what confl ict does the older adult experience?
A. Intimacy versus isolation B. Generativity versus stagnation C. Identity versus role confusion D. Integrity versus despair
Correct answer: D The key confl ict the older adult (age 66 and older) faces is integrity versus despair.
Intimacy versus isolation (Option A) is the key confl ict in young adulthood; generativity versus stagna- tion (Option B), the key confl ict in middle adulthood; and identity versus role confusion (Option C), the key confl ict of adolescence.
7. The nurse is caring for a patient who has just been diagnosed with a terminal illness. The patient says to her, “I can’t believe this! I feel…” and pauses. The nurse allows the patient time to gather his thoughts. What type of therapeutic communication is this?
A. Clarifi cation B. Empathy C. Refl ection D. Silence
Correct answer: D The nurse allows the patient time to gather his thoughts by using silence. Clarifi ca- tion (Option A) would be seeking validation for what the patient said. Empathy (Option B) would be the nurse placing herself temporarily in the patient’s position. Refl ection (Option C) would be paraphrasing what the patient said.
8. A patient becomes angry attending a treatment group and complains about it to the nurse. Which response could the nurse give that would best demonstrate clarifi cation?
A. “Can you tell me what about the treatment group made you angry?”
B. “Why are you upset? Attending the treatment group will help you get well.”
C. “It sounds like group today was pretty upsetting.”
D. “Treatment groups have been carefully planned by the staff to help patients.”
Correct answer: A Option A uses clarifi cation to seek validation of what the patient said. Using “why,”
as in Option B, is accusatory and can hinder self-disclosure. Option C is an example of empathy, and Option D is a destructive sentence that negates the patient’s importance.
9. Which of Piaget’s cognitive developmental stages takes place from ages 7 to 11?
A. Formal operations B. Concrete operations C. Preoperational D. Sensorimotor
Correct answer: B The concrete operations stage takes place between ages 7 and 11. The formal opera- tions stage (Option A) occurs at age 11 and above. The preoperational stage (Option C) takes place between ages 2 to 7, and the sensorimotor stage (Option D) occurs from birth to age 2 years.
10. Which interaction style describes a nurse who cannot clearly separate her own emotional responses from the patient’s needs and wants?
A. Holistic B. Defensive C. Sympathetic D. Silence
Correct answer: C A sympathetic interaction style occurs when the nurse can’t clearly separate her own emotional responses from the patient’s needs and wants. Nurses who use a holistic interaction style (Option A) have healthy ego boundaries and provide an atmosphere that promotes patient growth. Nurses who tend to blame their patients and feel frustrated when they do not “measure up”
have a defensive interaction style (Option B). Silence (Option D) is a type of therapeutic communication technique, not an interaction style.
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5
❖ Introduction
Skin, the body’s largest organ and the outer covering of the body, serves as a protective barrier against microorganisms
The skin is subject to injury from various external and internal factors
◆External factors include extremes of heat and cold, mechanical forces such as pressure and shearing, allergens, chemicals, radiation, and excretions and secretions (for instance, from an ostomy or draining wound)
◆Internal factors include emaciation, drugs, altered circulation and impaired oxygen transport, altered metabolic state, and infections
❖ Defi nitions
Angiogenesis is the formation of new granulation vessels Cellulitis is the infl ammation of cellular or connective tissue
Colonization refers to the presence of bacteria that cause no local or systemic indications of infection Dehiscence is the separation of the layers of a surgical wound
Eschar is thick, leathery, necrotic, devitalized tissue
Friction is the mechanical force exerted when skin rubs against a coarse surface such as bed linens Full thickness describes a wound that involves skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
Infection is the invasion and multiplication of microorganisms in body tissue in a suffi cient quantity (greater than 1 million organisms per gram of tissue) to overwhelm tissue defenses; an infection can pro- duce purulent exudate, odor, erythema, warmth, tenderness, edema, pain, fever, and an elevated white blood cell (WBC) count
Maceration is the softening of tissue by wetting or soaking; it can produce skin degeneration and disin- tegration if left uncontrolled
Partial thickness describes a wound that involves damage to epidermal and, possibly, dermal skin layers Sloughing is the separation of necrotic tissue from viable tissue
Shearing is trauma caused by tissue layers sliding against one another; it results in disruption or stran- gulation of blood vessels and can result in skin tear injuries
A wound is any disruption to the anatomic or physiologic function of tissue
❖ Types of wounds
An acute wound heals uneventfully within an expected time frame unless underlying systemic condi- tions interrupt the process; examples include surgical incisions and trauma wounds
A wound is chronic when underlying pathophysiology causes the wound or interferes with the course of healing; several types exist (see Characteristics of acute and chronic wounds, page 52)
Principles of wound care Principles of wound care
❖ Wound-healing process
A dynamic process that restores anatomic and functional integrity, wound healing works on a con- tinuum from injury to healing
◆In healing by primary intention, the wound is surgically closed (such as with sutures, staples, glue, or Steri-Strips), and healing occurs by fi brous adhesion; granulation tissue isn’t apparent, and there’s little or no scar tissue; examples include surgical wounds and superfi cial traumatic wounds
◆In healing by secondary intention, the wound’s edges are too far apart to be surgically closed, and there’s marked tissue loss; the wound is instead closed naturally by the formation and adhesion of granulation tissue and epithelialization; examples include pressure ulcers, dehisced surgical wounds, and traumatic injuries
◆In healing by tertiary intention, also known as delayed primary closure, there’s a delay in wound closure, resulting in granulation of the wound edges; later surgical closure results in more scar formation; these wounds are sometimes left open for several days to allow edema or infection to resolve or exudate to drain
Wound healing consists of several phases
◆The injury is a break in the skin’s integrity
◆Hemostasis is a brief period of vasoconstriction at the site of injury as the body attempts to prevent excessive bleeding
◆The infl ammatory phase starts right after the injury and lasts from 2 to 6 days; this defensive reaction to tissue injury involves increased blood fl ow and capillary permeability and aids in phagocytosis or auto- lytic debridement; it’s marked by increased heat, redness, swelling, and pain in the affected area
◆During the proliferative phase, granulation tissue forms and epithelialization begins
◗ Granulation tissue is a pink-to-red, moist tissue that contains new blood vessels, collagen, fi bro- blasts, and infl ammatory cells; the tissue fi lls the open deep wound and acts as a kind of scaffolding for the eventual migration of epithelial cells
◗ During epithelialization, epithelial cells migrate across the wound’s surface, forming a layer of new tissue; these cells look silvery and form a perimeter around the granulation tissue
◆As epithelial closure occurs, the wound contracts and begins to close
◆During the fi nal maturation phase, collagen reorganizes and strengthens, a process that continues for months and sometimes years; chronic wounds may regain 50% of their original tensile strength after 2 to 3 weeks, but they’ll ultimately regain only 70% to 75% of their original strength
The following chart summarizes the type and cause, location, related signs and symptoms, and appearance of acute and chronic wounds. Specifi c nursing measures vary with the type of wound.
Type and cause Location Related signs
and symptoms
Appearance Surgical wound
● Sterile incision, which is then closed with glue, staples, sutures, or Steri-Strips
● Heals by fi rst intention
● Anywhere on body
● Usually follows
integumentary cleavage line, which enhances healing
● Vary with type of surgery
● Even, sharp wound margins
● Clean, with no drainage or scab formation