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CHAPTER 41: CARING FOR CLIENTS WITH SPINAL CORD
CHAPTER 42: CARING FOR CLIENTS WITH NEUROLOGICAL
CHAPTER 43: MANAGING CLIENTS WITH SENSORY
CHAPTER 44: ASSESSING AND CARING FOR CLIENTS WITH EYE AND
CHAPTER 45: ASSESSING AND CARING FOR CLIENTS WITH
UNIT 11
CHAPTER 46: ASSESSMENT OF THE MUSCULOSKELETAL
CHAPTER 47: CARING FOR
CHAPTER 48: CARING FOR
CHAPTER 49: CARING FOR CLIENTS WITH INFLAMMATORY
CHAPTER 50: CARING FOR CLIENTS WITH DEGENERATIVE
UNIT 12
Nursing Care of Clients with Lymph, Immune, or Infectious
CHAPTER 51: ASSESSMENT OF LYMPH AND IMMUNE
CHAPTER 52: CARING
CHAPTER 53: CARING FOR
CHAPTER 54: CARING FOR CLIENTS WITH HYPERSENSITIVE
CHAPTER 55: CARING FOR CLIENTS WITH AUTOIMMUNE
UNIT 13
Nursing Care of Clients with Integumentary
CHAPTER 56: ASSESSMENT OF THE INTEGUMENTARY
CHAPTER 57: CARING FOR CLIENTS WITH INTEGUMENTARY
CHAPTER 58: CARING FOR CLIENTS WITH BURN
UNIT 14
Nursing Care of Clients with Reproductive and Sexual Health
CHAPTER 60: CARING FOR FEMALE CLIENTS WITH
CHAPTER 62: CARING FOR CLIENTS WITH BREAST
CHAPTER 63: CARING FOR MALE CLIENTS WITH REPRODUCTIVE
CHAPTER 64: ASSESSING AND CARING FOR CLIENTS
UNIT 15
CHAPTER 65: ASSESSING AND CARING FOR CLIENTS WITH MENTAL
CHAPTER 66: CARING
CHAPTER 67: CARING FOR
UNIT 16
UNIT 17
Special Considerations in
CHAPTER 70: EMERGENCY NURSING CARE PRINCIPLES
CHAPTER 71: APPLYING CRITICAL THINKING WITH MULTIPLE
CONTRIBUTORS
Fort Wayne, Indiana Chapter 12: IV Therapy Eric Mason, MSN, RN Chair, Assistant Professor of Nursing Department Rhodes State College Lima, Ohio.
REVIEWERS
PREFACE
ORGANIZATION OF THE TEXT
CONCEPTUAL APPROACH
Unit 10, Nursing Clients with Neurosensory Disorders, combines discussions of the neurological system disorders, combines discussions of the neurological system and sensory disorders. Unit 16, Nursing Care for Older Adult Clients, explains the assessment and nursing care of older adults.
FEATURES
The final chapter is distinct in that it presents several case studies that show how a disorder can affect multiple body systems.
Special Features
NEW TO THE THIRD EDITION
Chapter 1: Role of Medical-Surgical Nursing Chapter 2: Assessing Family Processes and Issues Chapter 3: Communicating with Clients with Personal
Chapter 67: Caring for Clients with Psychobiological Conditions
Chapter 69: Bioterrorism and Mass Casualty Care
EXTENSIVE TEACHING/
LEARNING PACKAGE
Instructor Resources
Suggested Answers to Chapter Case Studies: Throughout the book, students will find carefully crafted case studies with accompanying critical thinking questions. Suggested answers to these critical thinking questions are included herein to assist instructors in evaluating student responses.
Student Resources
To the reviewers, thank you for taking time out of your busy schedules to review the chapters in this text. Juliet Steiner, senior product manager, receives a special thanks for her expertise, guidance and dedication.
ACKNOWLEDGMENTS
Lois Elain Wacker White earned a degree in nursing from Memorial Hospital School of Nursing, Springfield, Illinois; an associate of science degree from Del Mar College, Corpus Christi, Texas; a bachelor of science in nursing from Texas A & I University–Corpus Christi, Corpus Christi, Texas; Master of Science in Education from Corpus Christi State University, Corpus Christi, Texas; and a Doctor of Philosophy in Educational Administration (community college) from the University of Texas, Austin. She has taught at Del Mar College, Corpus Christi, Texas, in both the nursing program and the professional nursing program.
ABOUT THE AUTHORS
White has served on the Nursing Education Advisory Committee (NEAC) of the Board of Nurse Examiners for the State of Texas and the Board of Vocational Nurse Examiners, which developed the competencies expected of graduates for each level of nursing. During her professional career, Gena has worked as a staff nurse, assistant charge nurse of a medical-surgical unit, continuing education instructor, associate professor in an LPN, LPN-RN, and ADN program, and director of an associate degree nursing program. .
HOW TO USE THIS BOOK
This provides a framework for understanding all the chapters in the unit as they relate to each other.
HOW TO USE THIS BOOK (Continued)
The nurse should try to include the client's Amish family in part of the care if possible. Director of care, caregiver, educator, and client advocate are the roles of the medical-surgical nurse.
UNIT 1
Role of Medical-Surgical Nursing
LEARNING OBJECTIVES
KEY TERMS
A standardized communication format used in health and nursing education to promote client safety is SBAR (situation, background, assessment and recommendation). Nurses use SBAR to organize and prioritize important client data when calling a nurse to receive orders and/or to update the nurse on a client's condition.
INTRODUCTION
They proposed this change because they discovered that several key components, such as the nurse identifying herself and the client when calling a provider, were missing from SBAR. Also added to SBAR is readback, where the nurse reads back the command given by the provider for clarity before terminating the communication.
CHARACTERISTICS OF THE MEDICAL-SURGICAL NURSE
Experienced nurses also have their own unique method of organizing their workload for the shift. Various names for this tool include "Med Minder", "Brain Sheet" or "Shift Organizer". New nurses can take this Brain Sheet tool into the clinical setting and use it to organize their client work.
Prioritization
Nurses will find it easier to prioritize care if they have an organized plan to manage their workload.
At the end of each shift, the nurse must complete a final checklist to ensure that all of the client's health needs have been met and communicated to the on-call nurse. Box 1-2 provides a tool for outlining essential elements to include in a shift-to-shift report.
Critical Thinker
Box 1-1 shows a useful tool that can serve as a check-and-balance approach at the end of a shift.
MEMORY TRICK
So why does it matter whether or not the client is allergic to morphine. Some nurses write a mixed reaction as an allergy to prevent distress to the client.
Innovative Problem Solver
The nurse must also be aware that significant others play a major role in the client's recovery process. The client's goal is the desired outcome that the client is working towards achieving.
CRITICAL THINKING
The goal of the nurse in the nursing process is to help the client achieve the best outcome. The nurse develops a plan with the client to help them reach their highest potential under the given circumstances.
Critical Thinking and Problem Solving
The nurse observes the client's husband and four young children and that the husband appears overwhelmed and often corrects the children for small indiscretions. The nurse decides to use the nursing diagnosis of ineffective coping related to a change in family dynamics, as evidenced by the client stating that the husband is usually very patient with the children.
Nursing Guideline to Critical Thinking
The nurse may suggest to the health care provider that a physical therapist and occupational therapist become involved in the client's morning care. The nurse will also encourage the client to look for new methods of performing daily activities.
Standards Related to Critical Thinking
At this point, the nurse stated that she would like to listen to the client's abdomen with a Doppler because it amplifies sounds. The client is admitted and the nurse reviews medications and places them on the nursing history.
ROLES OF THE MEDICAL- SURGICAL NURSE
Because critical thinking and problem solving require knowledge, the nurse must also involve other disciplines such as physicians, pharmacists, nurses who specialize in a particular area, dietitians, occupational therapists, physiotherapists and other resources. Critical thinking and problem solving involve a step-by-step process based on knowledge.
CASE STUDY
What are the important observations (assessment/data collection)?
Prioritize the information (significance)
What could be a possible nursing diagnosis?
What is the first thing the nurse should consider (plan)?
What plan should the nurse act on (implementation)?
What do you think the outcome would be (evaluation)?
Educator
Director of Care
Caregiver
For situations not covered in the policy and procedure manuals, the nurse is expected to exercise good judgment. If most nurses respond in a certain way to a certain situation, and so does the nurse in question, then the nurse is acting reasonably and sensibly.
CODE OF ETHICS
Nurses working in the facility are expected to follow the guidelines in the policy and procedure manuals. In nursing, this means that the nurse is expected to behave like other nurses at the same professional level and with the same amount of education or experience.
EVIDENCE-BASED PRACTICE
As the role of LPN/LVNs expands in the healthcare environment, it is essential to read and follow the LPN/LVN Standards of Practice. The practice standards provide guidelines for evaluating and measuring the quality of nursing care provided by the LPN/LVN.
Client Advocate
JOB OPPORTUNITIES
PROFESSIONAL AFFILIATIONS AND CERTIFICATIONS
STANDARDS OF PRACTICE
All areas of healthcare will soon implement the use of electronic medical records. According to Skiba (2010), nurses will have to become literate in informatics in order to function in the health care system.
GENETICS AND GENOMICS
In 2012, the Affordable Care Act will introduce a number of changes to standardize health care billing and will require health plans to adopt and implement rules for the secure and confidential exchange of electronic health information (White House, 2011). Healthcare institutions are preparing for this change from paper documentation to electronic computer records.
QUALITY AND SAFETY EDUCATION FOR NURSES
INFORMATICS
Clients with one TSER*2 allele have 38% more tumor shrinkage than those with two TSER*3 alleles (Kudzma & Carey, 2009). In these cases, genetic testing resulted in improved responses in clients with the TSER*2 allele and with two TSER*3 alleles.
CONCLUSION
The nurse ensures that the family understands the disorder, the consequences of the disorder, and the need for further care and treatment. Some clients and families may benefit from genetic counseling to discuss the disorder, mode of inheritance, risk factors for others in the immediate and extended family, diagnostic tests, treatment, and support for future decisions.
BESTPRACTICE
The nurse supports the client and refers him to community and Internet resources to face the sometimes overwhelming. An entire chapter on genetics, genomics, and their impact on nursing is available in the online resources that accompany this text.
Assessing Family
Processes and Issues
Recognizing the unique strength of a client's family can sometimes help the nurse use members to assist the client on the road to recovery. How a parent encourages a child to comply with treatment will most likely depend on the client's culture.
Intergenerational Families
Parents can even resort to time-outs where physical contact with parents is not allowed. Some parents may prefer to role model the behavior they want in their children.
DIVERSE FAMILIES ACROSS THE LIFE SPAN
Ochs describes the influence of multitasking on the family as “consistent (significant, substantial) on the structure of the family relationship” (Wallis, 2006, p. 2). The nurse can also share this research information with the client and family for consideration.
Nuclear Families
Her parents can provide continued economic support until she is able to finish her education and get a job. Parents can provide mature guidance, experienced parenting and a unique relationship with their grandchild.
Single-Parent Families
Sometimes families have three or four generations living and functioning as a family in the same house. Another example where an extended family arrangement can be helpful is when elderly parents need assistance.
Gay and Lesbian Families
For example, while it is common for Indian parents to arrange the marriages of their children, not all families in India follow this custom. Probably one of the greatest truths we can learn from exploring different cultures is that we all want to be treated with special attention to our individual needs.
Asian American Families
While most Americans want a diagnosis and prognosis regardless of the seriousness of each, someone from another culture may never want to be told they have a negative prognosis. Most Americans wouldn't ask a grandparent to make an important medical decision, but many cultures draw on the wisdom of previous generations to make decisions.
Grandparents Raising Grandchildren
The following section provides a brief overview of some important unique features of some subcultures found in our society. Most individuals do not mind being asked how they prefer things or how they feel about something if the question is asked respectfully.
Stepfamilies and Blended Families
CULTURAL VARIATIONS WITHIN FAMILIES
Nurses lose their sense of caring when they approach all clients the same way and ignore individual preferences.
Hispanic Families
African American Families
Native American Families
Amish Families
If hospitalized, a large group of family members may stay awake at the hospital to provide support for the client and the client's family.
Families of Middle Eastern Descent
FAMILY ROLES
Psychosocial Growth and Development
Economic Support
In fact, more and more families are without adequate health coverage and living paycheck to paycheck (U.S. Census Bureau, 2009). Hispanic and African American households fare the worst, while Asian households have the highest financial means (U.S. Census Bureau, 2010).
Health Promotion and Wellness
Spiritual and Personal Growth and Development
PARENTING STYLES
Authoritarian
Some believe that this form of parenting could work well for children with behavioral disorders. Children with a tendency to run amok may need the high level of structure and authority that this parenting style provides.
Authoritative
One disadvantage noted by opponents of this style is that children are not given enough opportunity to learn decision-making skills because decisions are made by the parents.
Permissive
CHARACTERISTICS FOUND IN HEALTHY FAMILIES
CHARACTERISTICS
OF DISTRESSED FAMILIES
POTENTIAL FAMILY CRISIS
26 UNIT 1 Introduction to Medical-Surgical Nursing person with responsibility in the family and the decision maker (U.S. Department of Education, 2010).
Domestic Violence
Family Member
Familial Genetic Disorders
Teen Pregnancy
Unplanned Pregnancy
Family Member with Cancer
28 UNIT 1 Introduction to Medical-Surgical Nursing Guilt, however irrational, often accompanies the myriad of emotions that arise when a loved one struggles with cancer. While this is wonderful, living in the shadow of a previous diagnosis with cancer can be difficult for both the cancer survivor and the family of the cancer survivor.
Guilty feelings of being healthy when a loved one is sick or feeling guilty that they could not prevent a loved one from experiencing cancer can occur.
Child Abuse
Divorce
PARENTAL STRESSORS
Management of Parental Stressors
Parents should be encouraged to use time off when others in the extended family are willing to help. The amount and type of resources available to families in communities across America varies greatly.
Communicating with Clients
Discuss the challenges the nurse may face when engaging in therapeutic communication with families or clients.
COMMUNICATIVE TRAITS OR TENDENCIES
IN DISTRESSED FAMILIES
COMMUNICATION WHEN PERSONAL OR FAMILY
IN HEALTHY FAMILIES
Sometimes honestly saying “I don't know how I would handle this” helps to recognize the meaning of what the client is experiencing. Many people feel uncomfortable imagining someone “feeling sorry for them.” If you indicate that what the person is experiencing is terrible and difficult to imagine, you may feel isolated and alone.
KEYS TO EFFECTIVE LISTENING
While it can be easier to provide support to clients if the nurse knows exactly what they are going through, this is not the only way to be supportive. Certainly, a nurse who has experienced a pregnancy loss will be in a better position to convey understanding to the client who has just suffered a miscarriage.
THERAPEUTIC COMMUNICATION
However, even when we have not personally experienced the same loss or level of emotional pain that our clients have, our words can communicate that we care about their loss or grief (Figure 3-2).
Divorced Families
PRODUCTIVE CONFRONTATION
SPECIAL COMMUNICATIVE CHALLENGES FOR NURSES
AREAS OF SPECIAL CHALLENGE FOR FAMILIES
Customer: I'm not saying that anyone is wrong; i just don't feel pregnant and i think i would know. Nurse: In the first weeks of pregnancy, women normally do not notice any major changes.
CHALLENGING COMMUNICATION
Families are different, and to be effective, the nurse shows acceptance of all types of family units. Productive confrontation can be an important part of the nurse-client communication process if this technique is used in a respectful, tactful, and nonthreatening manner.
UNIT SUMMARY
The nursing process is used to help guide the nurse in promoting optimal client outcomes, and is an ongoing process. A family crisis can mean the destruction of the family unit or the beginning of a pattern of using unhealthy defense mechanisms.
THEORY TO PRACTICE
- According to the text, the family can contribute to the growth of its members by promot- ing psychosocial development and growth, providing economic support, promoting health
- Economic support contributed to your growth as an individual
- Provision of security, acceptance, and love helped you develop into the person you are today
- Promotion of psychosocial development and growth shaped your values and beliefs
- Research health-related and educational resources for families that are available in your community. Bring your findings to the clinical postconference and share them with your
- List reasons some people may find productive confrontation difficult
- Think of a situation that you would like to address with productive confrontation. Write out the scenario using the productive confrontation examples presented in Chapter 3
The Human Genome Project that was completed in 2003 sequenced the genome, mapped the location of genes on all chromosomes, and increased our understanding of the human genome. The role of the nurse with a client who has a genetic disorder is to support the client and family, to state accurate facts about the genetic disorder, and to refer the client to reliable resources for help.
NCLEX-STYLE REVIEW QUESTIONS
- Which of the following is the priority when organiz- ing and prioritizing client care?
- Which of the following are steps in the nursing pro- cess that guide nurses when problem solving?
- Creativity, autonomy, application of proactive nurs- ing expertise, critical thinking, and effective leader-
- Using current best evidence that is supported by rel- evant valid research is an example of
- An example of a diverse family unit is the intergen- erational family. This type of family
- Characteristics of a healthy family include: (Select all that apply.)
- When assisting a client and her family through a cri- sis, the nurse can: (Select all that apply.)
- A mother is silently crying outside the room where her daughter is dying of leukemia. The nurse can
- Some common communicative challenges for nurses are: (Select all that apply.)
- Productive confrontation
- A parent sits down and talks with a preteen about the physical effects of smoking. Neither of the par-
- The most effective way for parents to respond to pa- rental stressors is to
- A teenager picks up the keys to his car and states he is going to pick up some printer paper so he can
- A young girl is sitting at a table when her brother approaches the chair next to her and starts to sit
A young girl is sitting at a table when her brother approaches the chair next to her and begins to sit, approaches the chair next to her and begins to sit. The girl says, "No, I want mom to sit next to me." The boy relented and said, "OK, I'll sit with dad." The girl immediately starts shouting to her father: "Dad, Dad, Dad." When he acknowledged her, she said, "Come sit here with me." This scenario is an example of what type of distressed family communication technique.
Evidence-based practice step by step—Igniting a spirit of inquiry: an essential foundation for evidence-based practice. Retrieved May 15, 2011, from http://www.blackpressusa .com/news/Article.asp?SID=3&Title=National+News&.
RESOURCES
When a nurse is caring for a medical-surgical client, it is important to see the client holistically. The nurse will assess the client's use of complementary and alternative forms of treatment, risk of infection and pain level.
Complementary
The Far East
India
LEGAL ASPECTS
HISTORIC FOUNDATION
Ancient Greece
The shaman uses special objects, such as power animals, fetishes and totems, as well as dances, ritual songs, food and clothing. Ritual songs, imagery, drumming and hallucinogenic drugs can be used to create a trance-like state through which the shaman contacts the spirit world.
CURRENT TRENDS
Mind/Body Research
Shamanistic Practices
Neuropeptides are released when neurotransmitters (chemicals produced by the body that facilitate the transmission of nerve impulses) signal emotions in the brain. Pert of the National Institutes of Health wrote in 1986 that “the more we know about neuropeptides, the more difficult it is to think in traditional mind-body terms.
Holism and Nursing
This complex, intertwined system of psyche and body chemistry is now called the bodymind, an inseparable connection and operation of thoughts, emotions, and physiological functions.
COMPLEMENTARY
AND ALTERNATIVE THERAPIES
Mind/Body Interventions
As the nurse on the health care team for this client, what interventions can be provided to promote support for this client during this time?
How can the nurse create a more informed health care team when clients ask about CT?
Therapies throughout the Life Span
This process is repeated for muscle groups all over the body until the client has reached a state of complete relaxation. The client is encouraged to use as many of the senses as possible to enhance the formation of vivid images.
Biofeedback
Nurses can use guided imagery with clients who are able to hear and understand the nurse's suggestions (Box 4-1). For example, show and explain a chart of the stages of bone healing to a client who has experienced a fracture and ask the client to imagine this sequential activity in his body.
Spiritual Therapies
Clients are instructed to focus on a specific area of the body (jaw, for example), tense the muscles for a count of 5, then relax the muscles for a count of 5. With guided imagery, the nurse can induce a sense of well- being with clients and helping them change their attitudes or behaviors about their illness, treatment and healing capacity, and providing them with guidance on using imagery as a self-help tool (Keegan, 2001 ).
CLIENT TEACHING
Many cultures recognize the inextricable link between the state of the soul (energy or life spirit) and the state of one's health. At the heart of spiritual or religious healing is the belief that practitioners must purify themselves and attain a state of oneness with God or a higher power before faith healing can occur.
Manipulative
Those who practice t'ai chi regularly believe it increases agility, endurance, and balance, as well as increasing energy and a sense of well-being. A full form of t'ai chi can take as little as 7 minutes or as long as an hour.
Energy Therapies
T'ai chi has been shown to increase muscle tone, endurance and flexibility and to improve balance, muscle mass, posture and strength in older people (NCCAM, 2011a). Chiropractic therapy is based on the principle that the brain sends vital energy to every organ in the body via the nerves that originate in the spine.
LIFE SPAN CONSIDERATIONS
The goal of chiropractic care is to awaken the client's own natural healing ability by correcting any area of the vertebral subluxation complex. If in doubt, the nurse should not touch until effective communication is established with the client.
CULTURAL CONSIDERATIONS
Although it was used for healing in all ancient cultures and shamanic traditions, the advent of scientific medicine and Puritanism led many healers away from the purposeful use of touch. The meaning of touch and the areas of the body that are acceptable to touch vary from culture to culture.
SAFETY
How can the nurse facilitate the use of massage therapy as a therapeutic regimen for this client’s com- fort and relaxation?
Many energy therapies are used by nurses today, such as touch, therapeutic massage, therapeutic touch, and healing touch. Therapeutic massage is the application of hand pressure and movement to improve the recipient's well-being.
Describe assessment measures that are used to determine the effectiveness of the massage therapy treatments
Reflexology is a non-invasive complementary modality in which pressure is applied by the practitioner's hands, fingers and thumb to the client's feet, hands and ears using specific thumb, finger and hand techniques. The reflexology theory states that disease is clearly visible as calcium deposits and acids in the corresponding part of the person's feet.
Biologically Based Therapies
Standard forms of horse chestnut include extract and tincture. Contraindicated for pregnancy, lactation and children. Assess use of alcohol, antidepressants, barbiturates, Parkinson's medications, benzodiazepines, sedatives, and CNS depressants.
Other Methodologies
Every culture and every generation within every culture has its own favorite type of music. Ask what type of music the customer prefers, or let the customer bring music.
CULTURAL CONSIDERATIONS
Some facilities allow clients to choose the type of music played during procedures such as cardiac catheterization. Pleasant sound and music can reduce stress, pain perception, anxiety and feelings of isolation.
EVIDENCED-BASED PRACTICE
In the hospice setting, it is common for family members to ask about comfort therapies that may be available for the client. Which evaluation measures can the nurse teach family members to determine if the complementary therapy provided is effective for the client.
Inflammation and Infection
List the chain of events that occur in an infectious process in the transmission of infection.
INFLAMMATION
Medical Management
Flora
Pathogenicity and Virulence
Bacteria
Viruses
INFECTION
Agent
Reservoir
Portal of Exit
Modes of Transmission
Fungi
Protozoa
Rickettsia
CHAIN OF INFECTION
It involves the transmission of an agent from an infected person to a host through direct contact with the infected person, indirect contact with the infected person by means of a fomite, or close contact with infected secretions (Figure 5-2). . Genitourinary tract, through contact with infected vaginal secretions or semen (as in sexually transmitted infections).
Portal of Entry
For example, a person with a common cold or superficial burns is at greater risk of infection due to the weakened state of the mechanisms of the body's systems. An older adult may be at increased risk of infection due to the normal aging process.
Between Reservoir and Portal of Exit
A germicide is a chemical that can be applied to both animate (living) and inanimate objects to eliminate pathogens. Autoclave sterilization, which uses moist heat or steam, is the most common sterilization technique used in the hospital setting.
BREAKING THE CHAIN OF INFECTION
The method of sterilization depends on the object to be sterilized and the type and amount of contamination. Boiling water is not an effective sterilization measure because some viruses and spores can survive boiling water.
Between Agent and Reservoir
COMMUNITY/HOME HEALTH CARE Disinfection
Between Portal of Exit and Mode of Transmission
Between Mode of Transmission and Portal of Entry
Between Portal of Entry and Host
Between Host and Agent
COMMUNITY/HOME HEALTH CARE Sterilization at Home
For example, the cilia of the respiratory tract trap mucus and microorganisms and propel them away from the lungs, reducing the risk of infection. Adequate levels of rest and sleep provide a restorative function necessary for physiological and psychological healing.
BODY DEFENSES
Nonspecific Immune Defense
Localized infections are confined to a specific area or single organ with symptoms similar to inflammation (redness, tenderness and swelling), such as a cold sore.
Incubation Stage
Prodromal Stage
Illness Stage
Convalescent Stage
ACQUIRED INFECTIONS
Hospital-Acquired Infections
Specific Immune Defense
TYPES AND STAGES OF INFECTIONS
The risk of developing a superinfection increases if the antibiotic used is high, if more than one antibiotic is used at the same time, or if broad-spectrum antibiotics are prescribed. Ways to manage a superinfection include discontinuing the current antibiotic and replacing it with an antibiotic to which the organism is sensitive, or culturing the infected area to identify the organism present (it may be a new organism) and, if necessary, giving another antibiotic that is effective against the new organism.
EMERGING INFECTIOUS DISEASES
Community-Acquired Infections
Superinfection
An elevated pH of the body fluids involved (gastric, urinary or vaginal secretions): evidence of the presence of microorganisms. Positive cultures of involved body fluids (blood, sputum, urine or other drainage): evidence of growth of microorganisms (Guyton & Hall, 2005).
Nursing Diagnosis
NURSING PROCESS
Data Collection
Implementation
Planning/Outcome Identification
What diagnostic tests would you expect to see as part of his medical orders?
What other orders would you expect to see on his chart?
Assessment data would include what specific information?
Are any measures necessary to protect his family, his school class, or his colleagues from the same in- fectious process as he has?
COMMUNITY/HOME HEALTH CARE Clients at Risk for Infection
SAMPLE NURSING CARE PLAN
The Client at Risk for Infection
Evaluation
Caring for Clients in Shock
In rare cases, fluid shifts resulting in hypovolemic shock are induced from infusion of a large volume of a hypotonic intravenous (IV) solution, such as 0.45% normal saline. The term mild hypovolemic shock is used when less than 20% of circulating blood volume is lost.
HYPOVOLEMIC SHOCK
Early signs of hypovolemic shock are subtle changes in the client's vital signs that are often missed until they become more pronounced and the client's body is less compensating. If hypovolemia is not corrected, the client may begin to experience severe tachycardias, arrhythmias, and chest pain.
Medical-Surgical Management
In hypovolemic shock, the client's systolic blood pressure falls below 90 mm Hg, or 40 mm Hg below the client's normal baseline blood pressure.
SAfeTy
The nurse should note that the use of any of these agents is secondary to fluid replacement because the primary treatment for hypovolemic shock is to restore the patient's circulating intravascular volume. Several medications may be used to help correct hypotension, low cardiac output (the amount of blood pumped from the left ventricle in a given time; usually expressed in liters per minute), oliguria, acidosis, and changes in breathing. associated with a cascade of shocks.
Nursing Management
The nurse will take a health history to assess for the symptoms the client is experiencing. Objective data the nurses assess for the client with hypovolemic shock are listed in Box 6-2.
Nursing diagnoses for a client in hypovolemic shock include the following
As the client's condition worsens, she may report worsening anxiety, shortness of breath, and chest pain (Garretson & Malberti, 2007). The assessment of the client with hypovolemic shock consists of collecting subjective and objective data to formulate nursing diagnoses for the client.
CLIeNT TEACHING
The client will maintain a normal serum osmolality and a systolic blood pressure of 90 mm Hg or greater. Insufficient fluid volume increases the risk of orthostatic hypotension, which increases the risk of falling during activity.
CARDIOGENIC SHOCK
If the client is alert, he is likely to be anxious and the nurse should provide emotional support. This includes information about the client's blood pressure and how she responds to medications.
SEPTIC SHOCK
Nursing diagnoses for a client in cardiogenic shock include the following
Finding and treating the cause of septic shock is essential to the client's long-term prognosis. As the client's condition worsens, the client may express feelings of foreboding and increasing anxiety.
Nursing diagnoses for a client in septic shock include the following
- Why would the physician order a fluid bolus to be given rather than go ahead and initiate a vasopres- sor right away for B.B.’s hypotension?
- If a vasopressor is started for B.B., what are the names of a few that might be appropriate in this situation?
- List a priority nursing diagnosis for this client
- What would be an appropriate plan/outcome for this client?
- List several nursing interventions with rationales for this client
- Write a potential evaluation statement pertaining to B.B’s attainment of the plan/outcome
The client tells the triage nurse that she took her blood pressure on her home monitor and noted that it was 88/46 mm Hg and that her heart rate was 110 just before she left home. Subjective data gathered by the nurse include reports of shortness of breath at rest that worsens with activity, the client stating that he has a productive cough with yellow-green sputum, and anterior chest pain with cough.
NEUROGENIC SHOCK
The physician orders the flow rate to be titrated according to the client's pulse oximetry. Subjective information collected by the nurse includes the client's level of understanding of the disorder and plan of care (Box 6-10).
MENTAL HEALTH CONNECTIONS
Another priority for the nurse is to maintain the client's safety and ensure stability of the client's neck and back during positional changes to prevent further spinal cord injury. Nursing process is the process in which the nurse caring for the client in neurogenic shock collects subjective and objective data about the client in order to formulate nursing diagnoses.
Nursing diagnoses for a client in neurogenic shock include the following
ANAPHYLACTIC SHOCK
According to the Center for Anaphylactic Support (2010), “For infants and very young children, the most common food allergies are to cow's milk and eggs.
COLLABORATIVECARE
Care of a client in anaphylactic shock includes obtaining subjective data and interviewing the client (Box 6-12). The client's response to the initial treatment provides the nurse with information to create a plan of care.
Nursing diagnoses for a client in anaphylactic shock include the following
The client is asked about the potential source of the allergen, if known, previous exposures, drug allergies and current symptoms. The client will verbalize an understanding of the basic physiology of her reaction and the likely antigen and will demonstrate appropriate use of an Epi-Pen.
Pain Assessment and Management
While other health care team members discuss pain management with clients, the nurse spends the most time with the client experiencing pain. Nurses are present 24 hours a day, administer the medication, assess the client's response and report the response to the physician.
DEFINITIONS OF PAIN
Regardless of the setting, including neonatal intensive care, intraoperative care, home care, or clinics, pain management can be challenging. For example, in an acute care setting, a physician orders analgesics (substances that relieve pain) for a client, but may spend only 10 to 15 minutes a day with that client.
NATURE OF PAIN
This chapter provides an overview of the complex phenomenon of pain, including definitions of pain, pain physiology, and pain assessment.
COMMON MYTHS ABOUT PAIN
Pain Categorized by Nature
TYPES OF PAIN
Pain Categorized by Origin
Chronic pain is usually defined as long-term (lasting 6 months or longer), persistent, near-constant or recurring pain that causes significant negative changes in the client's life. Chronic pain is the reason for more than 80% of all doctor visits (National Pain Foundation, 2009).
PHYSIOLOGY OF PAIN
Stimulation of Pain
PURPOSE OF PAIN
The Gate Control Theory
SAfety
FACTORS AFFECTING THE PAIN EXPERIENCE
Conduction of Pain Impulses
Previous Pain Experiences
Drug Abuse
Transduction
Modulation
LIfe SPAN CONSIDeRAtIONS
The first step in pain assessment is to collect subjective information about the client's pain. A client's pain tolerance is the intensity level or duration of pain that the client is able or willing to tolerate.
Cultural Norms
Pain as a fifth vital sign is assessed and recorded, along with the client's temperature, pulse, respiration, and blood pressure. The client's description of the pain includes several qualifiers, including location, onset and duration, quality, and medications.
JOINT COMMISSION STANDARDS
Ask the client how the pain feels and record the words used to describe the pain. The client can point to the location of the pain on the client's own body or locate it on a body diagram on a pain assessment tool.
CLIeNt TEACHING
Because of the motivational-affective components of the pain experience, the meaning of pain can have a major impact on how the client experiences the pain. The client's report of pain should be accepted and recorded, with pain management decisions based on that report.
Nursing Diagnoses
Step 2
- List factors that may indicate that C.S. is experiencing pain
- Identify factors that may be impacting C.S.’s pain experience
- Describe the nursing actions necessary to perform a comprehensive pain assessment of C.S
As the dose is gradually increased, the client develops tolerance (requiring higher and higher doses of the analgesic to achieve the same level of pain relief) to the side effects of the opioid. To teach simple relaxation techniques, the nurse instructs the patient to (a) take a deep breath and hold it, (b) exhale slowly and focus on the limp, and (c) start yawning (McCaffery & Pasero, 1999).
A nurse's personal perceptions of pain – how to express pain, the source of pain, and the management of pain – can influence their care of clients. Once a nurse evaluates personal thoughts and feelings about pain, they are better equipped to care for a client in pain.
Cancer
BMT) cachexia
PATHOPHYSIOLOGY
INCIDENCE
It is estimated that 80% of all cancers are related to environmental exposure and may be preventable if exposure is avoided. Approximately 3,000 non-smoking adults die each year from lung cancer from inhaling passive smoke (ACS, 2008).
Lifestyle Factors
The greater the dose or the longer the duration of exposure, the greater the risk of developing cancer.
RISK FACTORS
Environmental Factors
Occupational exposure to coal tar, creosote, arsenic compounds or radium is a risk factor for the development of skin cancer. Cervical cancer Multiple sexual partners Having sex at a young age Exposure to the human papillomavirus Smoking.
Genetic Factors
Food substances that may reduce the risk of cancer include cruciferous vegetables (cabbage, broccoli, cauliflower, Brussels sprouts, kohlrabi); possibly vitamins A, E and C; and selenium. Based on current knowledge, the ACS has offered dietary guidelines to reduce cancer risk.
Viral Factors
She tells you that there have been several cases of cancer diagnosed in family members, although none have been in her immediate family.
DETECTION
A woman age 30 or older with three normal test results in a row can be screened every 2 to 3 years with a conventional or liquid Pap smear. Alternatively, DNA tests and smear tests for human papillomavirus (HPV) can be performed every three years.
COMMON DIAGNOSTIC TESTS
These radiological tests are not described in detail in the following tables because they are described in different sections of the medical-surgical system chapters. Note if the client smokes or has an illness that will alter the results, such as hepatitis, cirrhosis, or colitis.
TREATMENT MODALITIES
Surgery
STAGING OF TUMORS
GRADING OF TUMORS
It can also be used to insert special access devices or to place enteral feeding tubes.
Radiation Therapy
They are best against rapidly reproducing cells, such as those in bone marrow, digestive tract, hair follicles and the eggs and sperm. Many of these drugs are given in combination with or after radiation or surgery to achieve maximum effect.
Chemotherapy
Because cells reproduce at their fastest rate at the beginning of the disease, the drugs work best against cancer in the earliest stages. Because most chemotherapy drugs are tissue irritants, extravasation is a potentially serious problem, especially if the drugs administered are vesical agents.
SAFETy
Recently, other methods have been introduced to increase local drug concentration at the tumor site, including intrathecal injection and intracavity delivery. Teaching clients and family members to monitor for side effects in the home environment is thus an essential function of the oncology nurse.
Hormone Therapy
The light stimulates the substance to destroy the cancer cells, but the surrounding healthy tissue is not harmed. An advantage of PDT is that the client can perform the procedure on an outpatient basis with light sedation and is relatively painless.
Targeted Cancer Therapy
Twenty-four to 48 hours after injecting the drug, low-power laser light is sent through a fiber optic guide via an endoscope to the cancerous tissue area. The client experiences sunburn, redness, and swelling when the skin and eyes are exposed to bright light or sunlight.
Biotherapy
COMMUNITy/HOME HEALTH CARE Home Care after Chemotherapy
Nutritional Alterations
Bone Marrow Transplantation
SYMPTOM MANAGEMENT
Bone Marrow Dysfunction
Frequent oral care helps to remove the taste of chemotherapy and increase the likelihood that the client will want to eat. Straws are useful because food is taken to the back of the mouth and swallowed.
BEsTPRACTICE
Stomatitis, or inflammation of the lining of the oral cavity, occurs in half of the cancer clients who receive treatment. If the client is receiving a chemotherapy agent known to cause stomatitis (eg, methotrexate), oral care is provided at least four times daily.
Alopecia
Odors
Fatigue
Ascites
Sexual Alterations
Dyspnea
Bowel Dysfunctions
Pathological Fractures
MEDICAL EMERGENCIES
HYPERCALCEMIA
CARDIAC TAMPONADE
MENTAl HEAlTH CONNECTIONs
SPINAL CORD COMPRESSION
SUPERIOR VENA CAVA SYNDROME
PSYCHOSOCIAL ALTERATIONS
The team ensures that the client's care plan is implemented and that family members receive adequate support. The client interview serves as a forum for determining the client's perception of the disease, treatment, and prognosis.
Nursing diagnoses for a client with cancer include the following